The clinical utility of laboratory tests in patients with aortic dissection_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHOU Sangyu , LIU Yanxiang , ZHANG Bowen , WANG Luchen , XIE Mingxin ,  SUN Xiaogang

Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P. R. China;

Corresponding author：

SUN Xiaogang, Email: xiaogangsunl@163.com

Keywords：

Aortic dissection; D-dimer; brain natriuretic peptide; cardiac troponin I; C-reactive protein; procalcitonin; review

DOI：

10.7507/1007-4848.202304005

Video：

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Aortic dissection is a life-threatening cardiovascular disease with devastating complications and high mortality. It requires rapid and accurate diagnosis and a focus on prognosis. Many laboratory tests are routinely performed in patients with aortic dissection including D-dimer, brain natriuretic peptide, cardiac troponin I, C-reactive protein, and procalcitonin. D-dimer showed vital performance in the diagnosis of aortic dissection, and brain natriuretic peptide, cardiac troponin I, C-reactive protein, and procalcitonin exhibited important value in risk stratification and prognostic effect in aortic dissection patients. Our review summarized the clinical utility of these laboratory tests in patients with aortic dissection, aiming to provide advanced and comprehensive evidence for clinicians to better understand these laboratory tests and help their clinical practice.

1.	Harris KM, Nienaber CA, Peterson MD, et al. Early mortality in type A acute aortic dissection: Insights from the international registry of acute aortic dissection. JAMA Cardiol, 2022, 7(10): 1009-1015.
2.	Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the international registry of acute aortic dissection: A 20-year experience of collaborative clinical research. Circulation, 2018, 137(17): 1846-1860.
3.	Morello F, Santoro M, Fargion AT, et al. Diagnosis and management of acute aortic syndromes in the emergency department. Intern Emerg Med, 2021, 16(1): 171-181.
4.	Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 146(24): e334-e482.
5.	Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(41): 2873-2926.
6.	Bossone E, Czerny M, Lerakis S, et al. Imaging and biomarkers in acute aortic syndromes: Diagnostic and prognostic implications. Curr Probl Cardiol, 2021, 46(3): 100654.
7.	Johnson ED, Schell JC, Rodgers GM. The D-dimer assay. Am J Hematol, 2019, 94(7): 833-839.
8.	Weitz JI, Fredenburgh JC, Eikelboom JW. A test in context: D-dimer. J Am Coll Cardiol, 2017, 70(19): 2411-2420.
9.	Xu Z, Wei M, Guo X, et al. Changes of serum D-dimer, NT-proBNP, and Troponin I levels in patients with acute aortic dissection and the clinical significance. Evid Based Complement Alternat Med, 2022, 2022: 8309505.
10.	Wang D, Chen J, Sun J, et al. The diagnostic and prognostic value of D-dimer in different types of aortic dissection. J Cardiothorac Surg, 2022, 17(1): 194.
11.	Suzuki T, Distante A, Zizza A, et al. Diagnosis of acute aortic dissection by D-dimer: The international registry of acute aortic dissection substudy on biomarkers (IRAD-Bio) experience. Circulation, 2009, 119(20): 2702-2707.
12.	Li W, Huang B, Tian L, et al. Admission D-dimer testing for differentiating acute aortic dissection from other causes of acute chest pain. Arch Med Sci, 2017, 13(3): 591-596.
13.	Yao J, Bai T, Yang B, et al. The diagnostic value of D-dimer in acute aortic dissection: A meta-analysis. J Cardiothorac Surg, 2021, 16(1): 343.
14.	Nitta K, Imamura H, Kashima Y, et al. Impact of a negative D-dimer result on the initial assessment of acute aortic dissection. Int J Cardiol, 2018, 258: 232-236.
15.	Koch V, Biener M, Müller-Hennessen M, et al. Diagnostic performance of D-dimer in predicting venous thromboembolism and acute aortic dissection. Eur Heart J Acute Cardiovasc Care, 2020, 2048872620907322.
16.	Kaito D, Yamamoto R, Nakama R, et al. D-dimer for screening of aortic dissection in patients with ST-elevation myocardial infarction. Am J Emerg Med, 2022, 59: 146-151.
17.	Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation, 2010, 121(13): e266-369.
18.	Nazerian P, Mueller C, Soeiro AM, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: The ADvISED prospective multicenter study. Circulation, 2018, 137(3): 250-258.
19.	Tsutsumi Y, Tsujimoto Y, Takahashi S, et al. Accuracy of aortic dissection detection risk score alone or with D-dimer: A systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care, 2020, 9(3_suppl): S32-S39.32-39.
20.	Bima P, Pivetta E, Nazerian P, et al. Systematic review of aortic dissection detection risk score plus D-dimer for diagnostic rule-out of suspected acute aortic syndromes. Acad Emerg Med, 2020, 27(10): 1013-1027.
21.	Deng L, Xia Q, Diao L, et al. Aortic dissection detection risk score and D-dimer for acute aortic syndromes in the chinese population: Exploration of optimal thresholds and integrated diagnostic value. J Cardiovasc Transl Res, 2023. [Epub ahead of print.
22.	Morello F, Bima P, Pivetta E, et al. Development and validation of a simplified probability assessment score integrated with age-adjusted D-dimer for diagnosis of acute aortic syndromes. J Am Heart Assoc, 2021, 10(3): e018425.
23.	Bergler-Klein J. NT-proBNP as a cornerstone for prognosis in valve disease: All we need is blood. J Am Coll Cardiol, 2020, 75(14): 1673-1675.
24.	Mueller C, McDonald K, de Boer RA, et al. Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. Eur J Heart Fail, 2019, 21(6): 715-731.
25.	Wen D, Jia P, Du X, et al. Value of N-terminal pro-brain natriuretic peptide and aortic diameter in predicting in-hospital mortality in acute aortic dissection. Cytokine, 2019, 119: 90-94.
26.	Vrsalovic M, Vrsalovic Presecki A, Aboyans V. N-terminal pro-brain natriuretic peptide and short-term mortality in acute aortic dissection: A meta-analysis. Clin Cardiol, 2020, 43(11): 1255-1259.
27.	Luo C, Zhou J, Xiong S, et al. N-terminal pro-B-type natriuretic peptide and outcomes in type B aortic dissection in China: A retrospective multicentre study. BMJ Open, 2019, 9(9): e029885.
28.	Yola ML, Atar N. Development of cardiac troponin-I biosensor based on boron nitride quantum dots including molecularly imprinted polymer. Biosens Bioelectron, 2019, 126: 418-424.
29.	Bonaca MP, Reece TB. The prognostic implications of cardiac troponin in Type A aortic dissection and the challenge of understanding therapeutic consequences. Eur Heart J Acute Cardiovasc Care, 2022, 11(8): 607-608.
30.	Gong M, Wu Z, Guan X, et al. Comparison of prognostic ability of perioperative myocardial biomarkers in acute type A aortic dissection. Medicine (Baltimore), 2019, 98(43): e17023.
31.	Liu S, Song C, Bian X, et al. Elevated cardiac troponin I and short-term mortality in patients with acute type A aortic dissection. Eur Heart J Acute Cardiovasc Care, 2022, 11(8): 597-606.
32.	Zhao K, Zhu H, Zhang L, et al. Elevated admission cardiac Troponin I predicts adverse outcomes of acute type B aortic dissection after endovascular treatment. Front Surg, 2022, 9: 789954.
33.	Butler CC, Gillespie D, White P, et al. C-reactive protein testing to guide antibiotic prescribing for COPD exacerbations. N Engl J Med, 2019, 381(2): 111-120.
34.	Mac Giollabhui N, Ellman LM, Coe CL, et al. To exclude or not to exclude: Considerations and recommendations for C-reactive protein values higher than 10 mg/L. Brain Behav Immun, 2020, 87: 898-900.
35.	Liu J, Yang Y, Liu X, et al. Macrophage-biomimetic anti-inflammatory liposomes for homing and treating of aortic dissection. J Control Release, 2021, 337: 224-235.
36.	Vrsalović M, Vrsalović Presečki A. Admission C-reactive protein and outcomes in acute aortic dissection: A systematic review. Croat Med J, 2019, 60(4): 309-315.
37.	Erdolu B, As AK. C-reactive protein and neutrophil to lymphocyte ratio values in predicting inhospital death in patients with stanford type A acute aortic dissection. Heart Surg Forum, 2020, 23(4): E488-E492.
38.	Song M, Deng L, Shen H, et al. Th1, Th2, and Th17 cells are dysregulated, but only Th17 cells relate to C-reactive protein, D-dimer, and mortality risk in Stanford type A aortic dissection patients. J Clin Lab Anal, 2022, 36(6): e24469.
39.	Chen X, Zhou J, Fang M, et al. Procalcitonin, interleukin-6 and C-reactive protein levels predict renal adverse outcomes and mortality in patients with acute type A aortic dissection. Front Surg, 2022, 9: 902108.
40.	Sakakura K, Kubo N, Ako J, et al. Peak C-reactive protein level predicts long-term outcomes in type B acute aortic dissection. Hypertension, 2010, 55(2): 422-429.
41.	Wirz Y, Meier MA, Bouadma L, et al. Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: A patient-level meta-analysis of randomized trials. Crit Care, 2018, 22(1): 191.
42.	Ruan L, Chen GY, Liu Z, et al. The combination of procalcitonin and C-reactive protein or presepsin alone improves the accuracy of diagnosis of neonatal sepsis: A meta-analysis and systematic review. Crit Care, 2018, 22(1): 316.
43.	Jeeha R, Skinner DL, De Vasconcellos K, et al. Serum procalcitonin levels predict acute kidney injury in critically ill patients. Nephrology (Carlton), 2018, 23(12): 1090-1095.
44.	Clementi A, Virzì GM, Muciño-Bermejo MJ, et al. Presepsin and procalcitonin levels as markers of adverse postoperative complications and mortality in cardiac surgery patients. Blood Purif, 2019, 47(1-3): 140-148.
45.	Kupiec A, Adamik B, Kozera N, et al. Elevated procalcitonin as a risk factor for postoperative delirium in the elderly after cardiac surgery: A prospective observational study. J Clin Med, 2020, 9(12): 3837.
46.	Chakravarthy M, Kavaraganahalli D, Pargaonkar S, et al. Elevated postoperative serum procalcitonin is not indicative of bacterial infection in cardiac surgical patients. Ann Card Anaesth, 2015, 18(2): 210-214.
47.	Liu H, Luo Z, Liu L, et al. Inflammatory biomarkers to predict adverse outcomes in postoperative patients with acute type A aortic dissection. Scand Cardiovasc J, 2020, 54(1): 37-46.
48.	Zheng GZ, Chen XF, Chen LW, et al. Thyroid hormone, cortisol, interleukin-2, and procalcitonin regulate postoperative delirium in acute type A aortic dissection patients. BMC Cardiovasc Disord, 2022, 22(1): 503.
49.	Liu H, Luo Z, Liu L, et al. Early kinetics of procalcitonin in predicting surgical outcomes in type A aortic dissection patients. Chin Med J (Engl), 2017, 130(10): 1175-1181.

1. Harris KM, Nienaber CA, Peterson MD, et al. Early mortality in type A acute aortic dissection: Insights from the international registry of acute aortic dissection. JAMA Cardiol, 2022, 7(10): 1009-1015.
2. Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the international registry of acute aortic dissection: A 20-year experience of collaborative clinical research. Circulation, 2018, 137(17): 1846-1860.
3. Morello F, Santoro M, Fargion AT, et al. Diagnosis and management of acute aortic syndromes in the emergency department. Intern Emerg Med, 2021, 16(1): 171-181.
4. Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 146(24): e334-e482.
5. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(41): 2873-2926.
6. Bossone E, Czerny M, Lerakis S, et al. Imaging and biomarkers in acute aortic syndromes: Diagnostic and prognostic implications. Curr Probl Cardiol, 2021, 46(3): 100654.
7. Johnson ED, Schell JC, Rodgers GM. The D-dimer assay. Am J Hematol, 2019, 94(7): 833-839.
8. Weitz JI, Fredenburgh JC, Eikelboom JW. A test in context: D-dimer. J Am Coll Cardiol, 2017, 70(19): 2411-2420.
9. Xu Z, Wei M, Guo X, et al. Changes of serum D-dimer, NT-proBNP, and Troponin I levels in patients with acute aortic dissection and the clinical significance. Evid Based Complement Alternat Med, 2022, 2022: 8309505.
10. Wang D, Chen J, Sun J, et al. The diagnostic and prognostic value of D-dimer in different types of aortic dissection. J Cardiothorac Surg, 2022, 17(1): 194.
11. Suzuki T, Distante A, Zizza A, et al. Diagnosis of acute aortic dissection by D-dimer: The international registry of acute aortic dissection substudy on biomarkers (IRAD-Bio) experience. Circulation, 2009, 119(20): 2702-2707.
12. Li W, Huang B, Tian L, et al. Admission D-dimer testing for differentiating acute aortic dissection from other causes of acute chest pain. Arch Med Sci, 2017, 13(3): 591-596.
13. Yao J, Bai T, Yang B, et al. The diagnostic value of D-dimer in acute aortic dissection: A meta-analysis. J Cardiothorac Surg, 2021, 16(1): 343.
14. Nitta K, Imamura H, Kashima Y, et al. Impact of a negative D-dimer result on the initial assessment of acute aortic dissection. Int J Cardiol, 2018, 258: 232-236.
15. Koch V, Biener M, Müller-Hennessen M, et al. Diagnostic performance of D-dimer in predicting venous thromboembolism and acute aortic dissection. Eur Heart J Acute Cardiovasc Care, 2020, 2048872620907322.
16. Kaito D, Yamamoto R, Nakama R, et al. D-dimer for screening of aortic dissection in patients with ST-elevation myocardial infarction. Am J Emerg Med, 2022, 59: 146-151.
17. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation, 2010, 121(13): e266-369.
18. Nazerian P, Mueller C, Soeiro AM, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: The ADvISED prospective multicenter study. Circulation, 2018, 137(3): 250-258.
19. Tsutsumi Y, Tsujimoto Y, Takahashi S, et al. Accuracy of aortic dissection detection risk score alone or with D-dimer: A systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care, 2020, 9(3_suppl): S32-S39.32-39.
20. Bima P, Pivetta E, Nazerian P, et al. Systematic review of aortic dissection detection risk score plus D-dimer for diagnostic rule-out of suspected acute aortic syndromes. Acad Emerg Med, 2020, 27(10): 1013-1027.
21. Deng L, Xia Q, Diao L, et al. Aortic dissection detection risk score and D-dimer for acute aortic syndromes in the chinese population: Exploration of optimal thresholds and integrated diagnostic value. J Cardiovasc Transl Res, 2023. [Epub ahead of print.
22. Morello F, Bima P, Pivetta E, et al. Development and validation of a simplified probability assessment score integrated with age-adjusted D-dimer for diagnosis of acute aortic syndromes. J Am Heart Assoc, 2021, 10(3): e018425.
23. Bergler-Klein J. NT-proBNP as a cornerstone for prognosis in valve disease: All we need is blood. J Am Coll Cardiol, 2020, 75(14): 1673-1675.
24. Mueller C, McDonald K, de Boer RA, et al. Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. Eur J Heart Fail, 2019, 21(6): 715-731.
25. Wen D, Jia P, Du X, et al. Value of N-terminal pro-brain natriuretic peptide and aortic diameter in predicting in-hospital mortality in acute aortic dissection. Cytokine, 2019, 119: 90-94.
26. Vrsalovic M, Vrsalovic Presecki A, Aboyans V. N-terminal pro-brain natriuretic peptide and short-term mortality in acute aortic dissection: A meta-analysis. Clin Cardiol, 2020, 43(11): 1255-1259.
27. Luo C, Zhou J, Xiong S, et al. N-terminal pro-B-type natriuretic peptide and outcomes in type B aortic dissection in China: A retrospective multicentre study. BMJ Open, 2019, 9(9): e029885.
28. Yola ML, Atar N. Development of cardiac troponin-I biosensor based on boron nitride quantum dots including molecularly imprinted polymer. Biosens Bioelectron, 2019, 126: 418-424.
29. Bonaca MP, Reece TB. The prognostic implications of cardiac troponin in Type A aortic dissection and the challenge of understanding therapeutic consequences. Eur Heart J Acute Cardiovasc Care, 2022, 11(8): 607-608.
30. Gong M, Wu Z, Guan X, et al. Comparison of prognostic ability of perioperative myocardial biomarkers in acute type A aortic dissection. Medicine (Baltimore), 2019, 98(43): e17023.
31. Liu S, Song C, Bian X, et al. Elevated cardiac troponin I and short-term mortality in patients with acute type A aortic dissection. Eur Heart J Acute Cardiovasc Care, 2022, 11(8): 597-606.
32. Zhao K, Zhu H, Zhang L, et al. Elevated admission cardiac Troponin I predicts adverse outcomes of acute type B aortic dissection after endovascular treatment. Front Surg, 2022, 9: 789954.
33. Butler CC, Gillespie D, White P, et al. C-reactive protein testing to guide antibiotic prescribing for COPD exacerbations. N Engl J Med, 2019, 381(2): 111-120.
34. Mac Giollabhui N, Ellman LM, Coe CL, et al. To exclude or not to exclude: Considerations and recommendations for C-reactive protein values higher than 10 mg/L. Brain Behav Immun, 2020, 87: 898-900.
35. Liu J, Yang Y, Liu X, et al. Macrophage-biomimetic anti-inflammatory liposomes for homing and treating of aortic dissection. J Control Release, 2021, 337: 224-235.
36. Vrsalović M, Vrsalović Presečki A. Admission C-reactive protein and outcomes in acute aortic dissection: A systematic review. Croat Med J, 2019, 60(4): 309-315.
37. Erdolu B, As AK. C-reactive protein and neutrophil to lymphocyte ratio values in predicting inhospital death in patients with stanford type A acute aortic dissection. Heart Surg Forum, 2020, 23(4): E488-E492.
38. Song M, Deng L, Shen H, et al. Th1, Th2, and Th17 cells are dysregulated, but only Th17 cells relate to C-reactive protein, D-dimer, and mortality risk in Stanford type A aortic dissection patients. J Clin Lab Anal, 2022, 36(6): e24469.
39. Chen X, Zhou J, Fang M, et al. Procalcitonin, interleukin-6 and C-reactive protein levels predict renal adverse outcomes and mortality in patients with acute type A aortic dissection. Front Surg, 2022, 9: 902108.
40. Sakakura K, Kubo N, Ako J, et al. Peak C-reactive protein level predicts long-term outcomes in type B acute aortic dissection. Hypertension, 2010, 55(2): 422-429.
41. Wirz Y, Meier MA, Bouadma L, et al. Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: A patient-level meta-analysis of randomized trials. Crit Care, 2018, 22(1): 191.
42. Ruan L, Chen GY, Liu Z, et al. The combination of procalcitonin and C-reactive protein or presepsin alone improves the accuracy of diagnosis of neonatal sepsis: A meta-analysis and systematic review. Crit Care, 2018, 22(1): 316.
43. Jeeha R, Skinner DL, De Vasconcellos K, et al. Serum procalcitonin levels predict acute kidney injury in critically ill patients. Nephrology (Carlton), 2018, 23(12): 1090-1095.
44. Clementi A, Virzì GM, Muciño-Bermejo MJ, et al. Presepsin and procalcitonin levels as markers of adverse postoperative complications and mortality in cardiac surgery patients. Blood Purif, 2019, 47(1-3): 140-148.
45. Kupiec A, Adamik B, Kozera N, et al. Elevated procalcitonin as a risk factor for postoperative delirium in the elderly after cardiac surgery: A prospective observational study. J Clin Med, 2020, 9(12): 3837.
46. Chakravarthy M, Kavaraganahalli D, Pargaonkar S, et al. Elevated postoperative serum procalcitonin is not indicative of bacterial infection in cardiac surgical patients. Ann Card Anaesth, 2015, 18(2): 210-214.
47. Liu H, Luo Z, Liu L, et al. Inflammatory biomarkers to predict adverse outcomes in postoperative patients with acute type A aortic dissection. Scand Cardiovasc J, 2020, 54(1): 37-46.
48. Zheng GZ, Chen XF, Chen LW, et al. Thyroid hormone, cortisol, interleukin-2, and procalcitonin regulate postoperative delirium in acute type A aortic dissection patients. BMC Cardiovasc Disord, 2022, 22(1): 503.
49. Liu H, Luo Z, Liu L, et al. Early kinetics of procalcitonin in predicting surgical outcomes in type A aortic dissection patients. Chin Med J (Engl), 2017, 130(10): 1175-1181.

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