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Respiratory Medicine CME 4 (2011) 91e92

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Respiratory Medicine CME

journal homepage: www.elsevier .com/locate/rmedc

Case Report

Elevated D-dimer is not always pulmonary embolism

Vikas Pathak*, Iliana Samara Hurtado Rendon, Padmini MuthyalaInternal Medicine, St. Barnabas Hospital, Bronx, NY 10457, United States

a r t i c l e i n f o

Article history:Received 18 April 2010Accepted 5 May 2010

Keywords:D-dimerAcute aortic dissection

* Corresponding author. Tel.: þ1 5712304087.E-mail address: drvikaspathak@gmail.com (V. Path

1755-0017/$36.00 � 2010 Elsevier Ltd. All rights resedoi:10.1016/j.rmedc.2010.05.006

a b s t r a c t

Serum D-dimer is elevated in several chest emergencies, including Acute Coronary Syndrome (ACS),Venous Thromboembolism (VTE) and Acute Aortic Dissection (AAD). Because of its simplicity and easyavailability its use beyond the exclusion of VTE has grown in recent years. There is an increasing trendtowards using the test to exclude AAD, where there are no other sensitive screening tests.

We present a patient suspected to have pulmonary embolism (PE) based on chest pain and elevatedD-dimer, gets a computed tomography with angiogram (CTA) and turns out to have an AAD.

� 2010 Elsevier Ltd. All rights reserved.

1. Introduction

Serum D-dimer is elevated in several chest emergencies,including Acute Coronary Syndrome (ACS), Venous Thromboem-bolism (VTE) and Acute Aortic Dissection (AAD). Because of itssimplicity and easy availability its use beyond the exclusion of VTEhas grown in recent years. There is an increasing trend towardsusing the test to exclude AAD, where there are no other sensitivescreening tests.

We present a patient suspected to have pulmonary embolism(PE) based on chest pain and elevated D-dimer, gets a computedtomography with angiogram (CTA) and turns out to have an AAD.

2. Case

A 49 year old African American male with history of hyperten-sion came with the complaints of centrally located chest pain since1 day, pain was 8/10 in intensity, pressure like, without any radia-tion and therewas no aggravating or relieving factor. Patient deniedany shortness of breath, palpitation, cough or fever. Patient wasa known hypertensive and was not taking any hypertensivemedicine for last 6 months. Clinical examinationwas unremarkableexcept that his blood pressure was 172/101. Routine blood testsincluding cardiac enzymes were normal and there were no acutechanges in the electrocardiogram (EKG) or chest x-ray. Echocar-diogram showed normal ejection fraction, dilated left atrium,normal aortic and mitral valve and mild concentric hypertrophy ofthe left ventricle. Mildly dilated right atrium and ventricle with

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trace anterior and posterior pericardial effusion was also noted.Patient was admitted to the chest pain unit with the impression ofchest pain rule out ACS, rule out PE. Plan was to check D-dimer andanother set of cardiac enzyme/EKG in 6 h. In the mean time patientwas started on Aspirin, Beta-blockers, Nitroglycerine drip andMorphine.

D-dimer was found to be elevated; 3.88 (normal< 1.6), so hewas sent for computed tomography with angiogram (CTA) to ruleout pulmonary embolism but turned out to have an aortic dissec-tion. Stanford type A aortic dissection with associated mediastinaland pericardial hematoma was reported. Patient was evaluated byvascular surgery and emergency surgical repair was planned(Fig. 1).

3. Discussion

In 2003 there were 6.1 million initial Emergency Department(ED) visits due to non-injury-related chest pain, which accountedfor 6% of all initial ED visits.

Most of the time acute coronary syndrome is thought to be theculprit and it is effectively ruled out with a simple blood test and anEKG.

AAD can easily mimic ACS, Pericarditis and PE and as per TheInternational Registry of Acute Aortic Dissection (IRAD). 30% ofthese patients are later found to have AAD.1

Classically they present with severe central chest pain.2 Physicalexamination reveals pulse and blood pressure differentials butthese findings are present only in a minority of patients.1,3

These patients usually have the history of hypertension, which isfound to have in 70% of the patients.1 As for diagnostic work up,chest radiography has a sensitivity of only 64% and a specificity of86% for aortic disease.4 This shows the limited value of chest

Fig. 1. CT chest: Formatted sagittal and coronal view showing acute aortic dissection.

V. Pathak et al. / Respiratory Medicine CME 4 (2011) 91e9292

radiography for diagnosing the acute aortic syndrome, particularlyfor conditions confined to the ascending aorta.4

Imaging modalities that can help diagnose the condition areeither time-consuming or not available in ED settings (CTA or MRI).All these uncertainties call for a simple and reliable blood testwhich can help detect presence of AAD, but so far no specific serummarker has been found. D-dimer is one such test which can helprule out AAD.

D-dimer, the final product of plasmin-mediated degradation offibrin-rich thrombi has been a subject of great interest for the EDphysicians and investigators looking for the reliable blood testwhich can be used as screening test for patients with potentialAAD.

Weber et al.5 reported 24 patients with AAD in whom D-dimerwas tested as a part of the initial diagnostic strategy. All patientswith AAD had elevated levels of D-dimer (sensitivity 100%). Incontrast, only 31% of control group patients who had chest pain ofother origin had increased D-dimer concentrations (specificity67%). Based on this observation, it was suggested that D-dimer beused for the initial evaluation of the patient who present with chestpain, as the negative test makes the presence of the diseaseunlikely.

Sodeck and colleagues had similar findings and they too rec-ommended the routine use of dimer in the patients suspected tohave AAD.6

But the wide spread use of D-dimer assay to screen AAD hasbeen limited, partly because the studies that support its utility inAAD had small patient numbers and partly because of its retro-spective nature.

But given that the delayed diagnosis caries a very high mortalityrate (1% per hour during the first 48 h),7 it does not hurt to useD-dimer as a screening test for AAD.

4. Conclusion

Acute Aortic dissection is a serious and life-threatening condi-tion with high mortality, early diagnosis is essential for survival.

Elevated D-dimer, although not specific for AAD is a highlysensitive marker of the condition.

D-dimer has high negative predictive value and likely rules outAAD. High index of suspicion should be maintained for the patientswith chest pain in ED and D-dimer should be used as screening testto rule out AAD.

Conflict of interest statement

Neither the author nor any of the co-author has any financial orpersonal relationships with other people or organizations thatcould inappropriately influence (bias) our work.

References

1. Hagan PG, Nienaber CA, Isselbacher EM. The International Registry of AcuteAortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897e903.

2. Spittell PC, Spittell Jr JA, Joyce JW, et al. Clinical features and differential diag-nosis of aortic dissection: experience with 236 cases (1980 through 1990). MayoClin Proc 1993;68:642e51.

3. Kodolitsch YV, Schwartz AG, Nienaber CA. Clinical prediction of acute aorticdissection. Arch Intern Med 2000;160:2977e82.

4. Kodolitsch YV, Nienaber CA, Dieckmann C, et al. Chest radiography for thediagnosis of acute aortic syndrome. Am J Med 2004;116:273e7.

5. Weber T, Hogler S, Auer J, et al. D-dimer in acute aortic dissection. Chest2003;123:1375e8.

6. Sodeck G, Domanovits H, Schillinger M, et al. D-dimer in ruling out acute aorticdissection: a systemic review and prospective cohort study. Eur Heart J 2007;28:3067e75.

7. Hirst A, Johns V, Kime S. Dissecting aneurysms of the aorta: a review of 505cases. Medicine 1958;37:217e79.