Aortic Dissection Detection Risk Score (ADD-RS)

ADD-RS Calculator
Risk Conditions (Marfan syndrome, family history, known aortic valve disease, recent aortic manipulation, known thoracic aortic aneurysm)
Pain Features (abrupt onset, severe intensity, or ripping/tearing quality)
Exam Features (pulse deficit, systolic BP difference, focal neurological deficit, aortic diastolic murmur, hypotension/shock)
ADD-RS Score: 0
Low Risk
ADD-RS 0: Low risk for aortic dissection. Consider alternative diagnoses. D-dimer may be used to further risk-stratify.
Rules out aortic dissection.

Why Use

May reduce misdiagnosis of AAS. May reduce over-testing for AAS (avoiding radiation and cost associated with definitive imaging).

When to Use

Low to moderate risk patients for whom acute aortic syndromes (AAS) are in the differential diagnosis.

Formula

Addition of the selected points: Finding Points Any high risk condition Marfan syndrome 1 point Family history of aortic disease Known aortic valve disease Recent aortic manipulation Known thoracic aortic aneurysm Any high risk pain feature Chest, back, or abdominal pain described as any of the following: Abrupt onset Severe intensity Ripping or tearing 1 point Any high risk exam feature Evidence of perfusion deficit (pulse deficit, systolic BP differential, or focal neurological deficit in conjunction with pain) 1 point New murmur of aortic insufficiency (with pain) Hypotension or shock state

Pearls / Pitfalls

The Aortic Dissection Detection Risk Score (ADD-RS) in combination with D-dimer has been proposed and internally validated as a diagnostic algorithm. There are significant caveats: Algorithm has not been externally validated. Half of the patients in the study did not get definitive imaging and follow up was only 14 days, raising the question of possible missed cases. The American College of Emergency Physicians’ (ACEP) 2014 Clinical Policy advises against using D-dimer alone to rule out AAS, though based on Level C evidence. ADD-RS and D-dimer are not meant to diagnose AAS, but rather, to provide guidance in risk stratification for who merits imaging. Consider using this risk stratification algorithm in patients considered low risk for aortic dissection but with uncertainty that the diagnosis can be ruled out. ADD-RS scores range from 0-3, as patients can only get one point from each category (predisposing conditions, pain features, exam findings). Thus, the score does not account for a patient that may have 2 points in a given category. Patients with multiple points in a given category may not be appropriate for the algorithm.

Management

For ADD-RS >1, consider proceeding directly to CTA or other conclusive imaging. For ADD-RS ≤1, proceed to D-dimer testing. If D-dimer FEU <500 ng/mL, consider stopping workup of dissection; if D-dimer FEU ≥500 ng/mL, consider CTA.

Critical Actions

Use in conjunction with other diagnostics to address other emergent, more common causes of chest pain. In patients with high pretest probability of AAS, consider empirically treating hypertension/tachycardia if there is any delay in getting conclusive imaging.

Advice

This study D-dimer threshold assumes D-dimer is reported in fibrinogen equivalent units (FEU). If your institution utilizes D-dimer units (DDU) to report D-dimer levels, please convert accordingly. More information on D-dimer use in the emergency department can be found in this ACEP Clinical Policy .

More Information

Interpretation: ADD-RS Recommendation >1 Consider proceeding directly to CTA or other conclusive imaging. ≤1 Proceed to D-dimer testing. If D-dimer FEU <500 ng/mL, consider stopping workup of dissection, if D-dimer FEU ≥500 ng/ml, consider CTA.

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