Use in adults presenting with acute chest, back or abdominal pain, syncope or signs of perfusion deficit when acute aortic syndrome (AAS) is a realistic differential.

ADD-RS allocates 1 point for each of three high-risk feature categories (predisposing conditions, pain features, examination findings) drawn from 2010 ACCF/AHA guideline items, giving a total score of 0–3 and classifying patients into low (0), intermediate (1) or high (2–3) clinical probability strata for AAS.

Original evidence signal (IRAD)

In the 2011 IRAD study, the score was applied to 2,538 patients with confirmed acute aortic dissection in the International Registry of Acute Aortic Dissection (IRAD). Most patients had at least one guideline-listed high-risk marker, and ADD-RS values were distributed as follows:

ADD-RS	Risk category	IRAD proportion of confirmed dissections
0	Low	108/2,538 (4.3%)
1	Intermediate	927/2,538 (36.5%)
2–3	High	1,503/2,538 (59.2%)

Confirmed dissections therefore still occurred with ADD-RS 0 and 1, so the score highlights higher-risk presentations but does not rule out AAS on its own.

ADD-RS with D-dimer

The prospective multicentre ADvISED study of 1,850 emergency department patients with suspected AAS (prevalence about 13%) evaluated strategies combining ADD-RS with D-dimer (negative if <500 ng/mL). In this cohort, strategies of ADD-RS 0 plus negative D-dimer, or ADD-RS ≤1 plus negative D-dimer, each had reported failure rates around 0.3%, but nearly half of participants did not undergo definitive imaging and adjudication relied on 14-day follow-up.

Meta-analyses and guideline context

A 2024 systematic review and meta-analysis of ADD-RS alone and with D-dimer found that ADD-RS >0 alone provided high sensitivity (around 95%) but low specificity (around 35%), while combinations such as ADD-RS >0 or D-dimer above a 500-unit cut-off increased sensitivity towards 100% at the cost of very low specificity. Other assessed combinations traded modestly lower sensitivity for higher specificity.

The 2022 ACC/AHA guideline incorporates ADD-RS-based pre-test probability assessment into diagnostic pathways for suspected AAS. In low-prevalence emergency populations, and where not all patients undergo definitive imaging, miss rates and specificity for ADD-RS±D-dimer strategies remain uncertain, so results should be integrated with haemodynamic status, imaging availability and local protocols rather than used as stand-alone rule-out tests.

Aortic Dissection Detection Risk Score (ADD-RS)