Fractured aorta with magnifying glass, symbolizing diagnostic accuracy in aortic dissection.

Aortic Dissection Detection: Is the Risk Score Missing the Mark?

Mira Elwood in Health & Wellness June 2025 • 4 min read.

"Specificity Concerns in Low Prevalence Populations"

In the fast-paced environment of emergency medicine, time is of the essence, especially when dealing with life-threatening conditions such as acute aortic syndrome (AAS). Acute aortic syndrome, a spectrum of aortic catastrophes including aortic dissection, requires prompt diagnosis and treatment to improve patient outcomes. Given the high stakes, clinicians often rely on risk stratification tools like the Aortic Dissection Detection Risk Score (ADD-RS) to aid in decision-making.

The ADD-RS, proposed by the American Heart Association (AHA), aims to reduce the rate of missed diagnoses and accelerate time to diagnosis. However, recent research has raised concerns about its effectiveness in populations where AAS is less common. The challenge lies in the potential for reduced specificity, which could lead to increased imaging rates, unnecessary radiation exposure, and higher healthcare costs. The big question: Does the ADD-RS maintain its diagnostic accuracy in low-prevalence settings?

A recent study sought to answer this question by evaluating the specificity of the ADD-RS in a low-prevalence population. The study's findings shed light on the limitations of the ADD-RS and underscore the importance of cautious interpretation when applying it in diverse clinical settings.

ADD-RS: A Closer Look

Fractured aorta with magnifying glass, symbolizing diagnostic accuracy in aortic dissection.

The Aortic Dissection Detection Risk Score (ADD-RS) is designed to categorize patients into different risk strata based on predisposing conditions, pain characteristics, and physical findings. These factors help clinicians assess the likelihood of acute aortic syndrome (AAS). Ideally, this score assists in promptly identifying high-risk patients who require immediate diagnostic imaging, while avoiding unnecessary interventions for those at lower risk. The ADD-RS considers:

The ADD-RS score is calculated based on several factors. The main components involves are the following:

Predisposing Conditions: Includes history of Marfan syndrome, family history of aortic disease, known aortic valve disease, recent aortic manipulation, and known thoracic aortic aneurysm.
Pain Features: Focuses on abrupt onset, severe intensity, and ripping or tearing quality of pain.
Physical Findings: Assesses pulse asymmetry, systolic blood pressure differential, focal neurological deficit, new murmur of aortic insufficiency, and shock state or hypotension.

The study revealed a notable decrease in specificity when the ADD-RS was applied to a low-prevalence population. This means that a higher number of patients were falsely identified as being at risk for AAS, leading to unnecessary imaging and potential overtreatment. The implications are particularly significant, as low specificity not only increases healthcare costs but also exposes patients to avoidable radiation and incidental findings. These outcomes highlight a critical need for refining the application of the ADD-RS to improve its accuracy in different clinical settings.

Implications for Clinical Practice

The study's findings serve as a reminder of the importance of understanding the limitations of clinical decision tools like the ADD-RS. While risk scores can be valuable aids in the diagnostic process, they should not replace clinical judgment. Clinicians need to be aware of the potential for reduced specificity in low-prevalence populations and adjust their approach accordingly. Further research is needed to refine risk stratification strategies and develop more accurate methods for identifying patients at risk for AAS. By standardizing clinical suspicion and improving the accuracy of diagnostic tools, healthcare providers can optimize patient care and resource utilization in the evaluation of acute aortic syndrome.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1111/acem.13634, Alternate LINK

Title: What Is The Specificity Of The Aortic Dissection Detection Risk Score In A Low Prevalence Population?

Subject: Emergency Medicine

Journal: Academic Emergency Medicine

Publisher: Wiley

Authors: Robert Ohle, Omar Anjum, Helena Bleeker, Sarah Mcisaac

Published: 2018-10-12

Everything You Need To Know

What is the Aortic Dissection Detection Risk Score (ADD-RS) and how is it used in emergency medicine?

The Aortic Dissection Detection Risk Score (ADD-RS) is a tool designed to categorize patients into different risk levels for acute aortic syndrome (AAS). It considers predisposing conditions like Marfan syndrome or aortic valve disease, pain characteristics such as abrupt onset and tearing quality, and physical findings like pulse asymmetry. The score helps clinicians decide if immediate diagnostic imaging is necessary.

What does "specificity" mean in the context of the Aortic Dissection Detection Risk Score (ADD-RS), and why is it important?

Specificity refers to the ability of the Aortic Dissection Detection Risk Score (ADD-RS) to correctly identify patients who do not have acute aortic syndrome (AAS). A decrease in specificity means the ADD-RS incorrectly identifies more patients as high-risk, leading to unnecessary imaging and potential harm. This is particularly concerning in low-prevalence populations where false positives can outweigh true positives.

How do the various components of the Aortic Dissection Detection Risk Score (ADD-RS) – predisposing conditions, pain features, and physical findings – contribute to a patient's overall risk assessment?

The Aortic Dissection Detection Risk Score (ADD-RS) incorporates predisposing conditions (e.g., Marfan syndrome, aortic valve disease), pain features (e.g., abrupt onset, ripping/tearing), and physical findings (e.g., pulse asymmetry, neurological deficits). If a patient has a history of Marfan syndrome, experiences abrupt, severe, ripping pain, and exhibits pulse asymmetry, their ADD-RS will be higher, indicating a greater risk of acute aortic syndrome (AAS).

What did the study reveal about the accuracy of the Aortic Dissection Detection Risk Score (ADD-RS) in low-prevalence populations, and what are the potential consequences?

The study found that the Aortic Dissection Detection Risk Score (ADD-RS) has reduced specificity in low-prevalence populations. This means that in settings where acute aortic syndrome (AAS) is rare, the ADD-RS is more likely to incorrectly flag patients as high-risk. This leads to unnecessary imaging, increased radiation exposure, and higher healthcare costs. This highlights that the ADD-RS results should be considered carefully in conjunction with clinical judgement.

What are the broader implications of this study for clinical practice and the use of the Aortic Dissection Detection Risk Score (ADD-RS) in emergency care settings?

The implications of the study's findings are significant for emergency care. Clinicians need to recognize that the Aortic Dissection Detection Risk Score (ADD-RS) may not be as accurate in populations where acute aortic syndrome (AAS) is uncommon. Over-reliance on the ADD-RS could result in unnecessary imaging and potential harm to patients, as well as increased healthcare costs. Further research is needed to refine risk stratification strategies and improve diagnostic accuracy, ensuring that clinical judgement remains paramount.