Does implementation of a diagnostic pathway for acute aortic syndrome including D-dimer increase the usage of D-dimer and computed tomography?



The Canadian clinical practice guidelines propose a novel diagnostic pathway incorporating a clinical decision tool and D-dimer to aid in risk stratifying patients for acute aortic syndrome. The objective of this study was to assess if implementation of a diagnostic pathway incorporating D-dimer would increase the usage of D-dimer and computed tomography (CT) in a tertiary care emergency department.


Prospective single centre before and after study-recruiting patients over a 6-week period from a tertiary care emergency department. Intervention: multi model implementation of a diagnostic pathway for acute aortic syndrome incorporating D-dimer. Outcome: proportion of patients receiving D-dimer testing/CT in the 2 weeks before and after implementation.


We included 982 patients (Female 55%, Age mean 51.9, N = 492 pre intervention and N = 490 post intervention). The proportion that received a D-dimer test increased from 6.9 to 10.4% (p < 0.051), while the number of CT aortas remained stable (0.6% vs. 0.6%; p = 0.60). Documentation of pretest probability assessment increased from 1 to 3%, (p < 0.009) following the intervention. In the post intervention cohort, the tool was applied correctly in all cases (N = 17).


This single centre study found that a diagnostic pathway for acute aortic syndrome including D-dimer could be implemented without a significant increase in test ordering during this first 2 weeks after implementation. This study adds to the argument for use of D-dimer to help risk stratify patients for the diagnosis of acute aortic syndrome. Future studies are needed to confirm the diagnostic accuracy of this pathway and the long-term impact on resource utilization.



Les guides de pratique clinique canadiens proposent une nouvelle voie de diagnostic intégrant un outil de décision clinique et du D-dimère pour aider à stratifier le risque chez les patients atteints du syndrome aortique aigu. L’objectif de cette étude était d’évaluer si la mise en place d’une voie diagnostique intégrant le dimère-D augmenterait l’utilisation du dimère-D et de la tomodensitométrie (TDM) dans un service d’urgence de soins tertiaires.


Centre unique prospectif avant et après l'étude - recrutement de patients sur une période de 6 semaines à partir d'un service d'urgence de soins tertiaires. Intervention : mise en œuvre multi-modèle d’une voie diagnostique pour le syndrome aortique aigu intégrant le D-dimère. Résultat : Proportion de patients ayant subi un test des D-dimères/TDM dans les deux semaines précédant et suivant la mise en œuvre.


Nous avons inclus 982 patients (femmes 55 %, âge moyen 51,9, N = 492 avant l’intervention et N = 490 après l’intervention). La proportion de personnes ayant reçu un test D-dimère est passée de 6,9 % à 10,4 % (p < 0,051), tandis que le nombre d’aortes CT est demeuré stable (0,6 % contre 0,6 %; p = 0,60). La documentation de l'évaluation de la probabilité avant le test est passée de 1 % à 3 % (p<0,009) après l'intervention. Dans la cohorte post-intervention, l'outil a été appliqué correctement dans tous les cas (n = 17).


Cette étude menée auprès d’un seul centre a révélé qu’une voie diagnostique pour le syndrome aortique aigu, y compris le D-dimère, pourrait être mise en œuvre sans qu’il y ait une augmentation significative de l’ordre des tests au cours des deux premières semaines suivant la mise en œuvre. Cette étude renforce l'argument en faveur de l'utilisation du D-dimère pour aider à stratifier les risques des patients pour le diagnostic du syndrome aortique aigu. De futures études sont nécessaires pour confirmer la précision du diagnostic de cette voie et l'impact à long terme sur l'utilisation des ressources.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA J Am Med Assoc. 2002;287(17):2262–72.

    Article  Google Scholar 

  2. 2.

    Ohle R, Anjum O, Bleeker H, Wells G, Perry JJ. Variation in emergency department use of computed tomography for investigation of acute aortic dissection. Emerg Radiol. 2018;2018:1–6.

    Google Scholar 

  3. 3.

    Ohle R, Um J, Anjum O, Bleeker H, Luo L, Wells G, Perry JJ. High risk clinical features for acute aortic dissection: a case–control study. Acad Emerg Med. 2018;25(4):378–87.

    Article  Google Scholar 

  4. 4.

    Watanabe H, Horita N, Shibata Y, Minegishi S, Ota E, Kaneko T. Diagnostic test accuracy of D-dimer for acute aortic syndrome: systematic review and meta-analysis of 22 studies with 5000 subjects. Sci Rep. 2016;6:26893.

    CAS  Article  Google Scholar 

  5. 5.

    Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current evidence and future implications. J Cont Edu Health Prof. 2004;24(S1):S31–7.

    Article  Google Scholar 

  6. 6.

    Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ Can Med Assoc J. 1995;153(10):1423.

    CAS  Google Scholar 

  7. 7.

    Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK. The International registry of acute aortic dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.

    CAS  Article  Google Scholar 

  8. 8.

    Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol. 2010;55(14):e27–129.

    Article  Google Scholar 

  9. 9.

    Erbel R, Aboyans V, Boileau C, Bossone E, Di Bartolomeo R, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J. 2014;35(41):2873–926.

    Article  Google Scholar 

  10. 10.

    Diercks DB, Promes SB, Schuur JD, Shah K, Valente JH, Cantrill SV. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015;65(1):32-42.e12.

    Article  Google Scholar 

  11. 11.

    Nazerian P, Mueller C, Soeiro AD, Leidel BA, Salvadeo SA, Giachino F, Vanni S, Grimm K, Oliveira MT Jr, Pivetta E, Lupia E. 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):250–8.

    CAS  Article  Google Scholar 

  12. 12.

    Grzywacz JG, Fuqua J. The social ecology of health: Leverage points and linkages. Behav Med. 2000;26(3):101–15.

    CAS  Article  Google Scholar 

Download references

Author information




RO was responsible for study design, analysis and manuscript preparation. NF, OM, AR and OB were responsible for data extraction. CD was responsible for manuscript editing, formatting and co-writing. RO acts as guarantor for accuracy and integrity of the manuscript.

Corresponding author

Correspondence to Robert Ohle.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 580 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ohle, R., Fortino, N., McIsaac, S. et al. Does implementation of a diagnostic pathway for acute aortic syndrome including D-dimer increase the usage of D-dimer and computed tomography?. Can J Emerg Med (2021).

Download citation


  • Acute aortic syndrome
  • D-dimer
  • Computed tomography