Low D-dimer in acute coronary syndrome and heart failure: Screening for large vessel diseases in patients with chest symptoms.

BACKGROUND: Distinguishing between large-vessel diseases such as acute aortic syndrome (AAS) and pulmonary embolism (PE), and non-large-vessel diseases, such as acute coronary syndrome (ACS), heart failure (HF), and neurogenic diseases, in patients presenting with chest symptoms remains a challenge, which can result in a significant number of misdiagnoses. Simultaneously distinguishing both AAS and PE is essential because large-vessel diseases require angio-computed tomography (CT) during initial presentation whereas, non-large-vessel diseases do not. This study aimed to determine the optimal method for differentiating between large-vessel and non-large-vessel diseases using D-dimer, troponin I, and pretest probability scores.

METHODS: From the 11683 patients who presented with chest symptoms including chest pain, discomfort, or dyspnea, this retrospective observational study included 1817 patients who had complete data for essential biomarkers; 105 with AAS, 139 with PE, 1093 with ACS, 451 with HF, and 83 with neurogenic diseases.

RESULTS: D-dimer, D-dimer/troponin I ratio (DT ratio), and troponin I results distinguished the 2 groups: D-dimer (>2.38 μg/mL), AUC 0.935; DT ratio, AUC 0.827; and troponin I, AUC 0.653. For predicting AAS, the performances of D-dimer level and aortic dissection detection risk score (ADD-RS) were AUCs of 0.915 (p < 0.0001) and 0.67 (p = 0.0004), respectively; for predicting PE, the AUCs of D-dimer level and modified Wells score were 0.95 (p = 0.0001) and 0.857 (p < 0.0001), respectively.

CONCLUSIONS: The D-dimer levels proved to be a crucial discriminator for identifying AAS and PE, even when compared with the ADD-RS and modified Wells scores. Moderately elevated D-dimer levels suggest the need to consider AAS and PE diagnoses via angio-CT for patients with chest symptoms.