Trends in Thoracic Aortic Aneurysms and Dissection

Abstract

Editorial 2267I n this issue of Circulation, Sidloff and colleagues 1 have presented their findings that, among 18 World Health Organization member states over a period of 16 years (1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010), there has been a reduction in the age-standardized mortality from both thoracic aortic aneurysm and dissection. If one considers the United States, the United Kingdom, and Sweden, 3 countries that have published extensively on the prevalence and mortality of thoracic aortic disease, the trends are quite favorable: Mortality from thoracic aortic aneurysm has declined by ≈5% to 10% among men and 3% to 6% among women, and mortality from aortic dissection has declined by ≈2% to 3% among men and 1% to 2% among women. However, and not surprisingly, the investigators discovered heterogeneity among mortality trends by country. For example, for men with thoracic aortic aneurysms, although there was a statistically significant reduction in mortality over time in 13 of the 18 countries, in 3 countries, there was instead an increase in mortality. Similarly, for men suffering from aortic dissection, although there was again a statistically significant reduction in mortality over time in 13 of the 18 countries, in 1 country, there was a significant rise in mortality. Japan and Romania were the 2 countries with the most consistent increases in mortality. Article see p 2287The investigators then considered the impact of changing prevalence of risk factors on the changing mortality from thoracic aortic disease. In all of the countries studied, there was a decline in systolic blood pressure of up to 6% over time, and there was a linear relationship between systolic blood pressure and mortality from both thoracic aortic aneurysm and dissection. This makes good mechanistic sense given the known association between hypertension and both aneurysms and dissection.In all countries but Japan, there was a decline in cholesterol levels over time, and the investigators also found a linear relationship between cholesterol and mortality from thoracic aortic aneurysm. At first, it may seem logical that a reduction in cholesterol would result in a reduction in death caused by thoracic aortic disease because hyperlipidemia is a well-known cardiovascular risk factor. Moreover, atherosclerosis has been found to be strongly associated with abdominal aortic aneurysms, although whether this association is causative remains unclear.2 However, the evidence actually indicates that atherosclerosis is negatively rather than positively associated with thoracic aortic aneurysms.3 So how might the apparent association between the downward trends in both cholesterol and thoracic aortic aneurysm mortality be explained? One possibility, albeit unlikely, is that, despite the negative association between atherosclerosis and thoracic aneurysms, there is an independent and positive association with cholesterol itself and thoracic aortic aneurysm. An alternative, and far more plausible...

Regional Practice Patterns and Outcomes of Surgery for Acute Type A Aortic Dissection

“…It is clear that at least some of the impact on improving survival is related to these factors (18, 19). The overall operative mortality rate of 18.9% in this cohort, is consistent with the current literature (6–9, 16–18, 20–22). Mody et al demonstrated significant improvement in 30-day mortality for Medicare patients from 30.7% in 2000 to 21.4% in 2011, similar to an IRAD analysis where in-hospital mortality decreased from 25.0% in an era starting in 1996 to 18.4% currently (7, 8).…”

“…The current literature is replete with contemporary outcomes from high volume hospitals or consortiums of aortic centers reporting improving outcomes with mortalities of 5–19% (3–5, 7, 9, 16, 17). These analyses suffer from the simple fact that their aortic teams, high volume aortic surgeons, and surgical and intensive care infrastructure may not be representative of the resources available to a majority of patients suffering TAAD.…”

The River of no Return: Acute Aortic Dissection with Catastrophic Outcome

“…Type-B AD is usually managed medically with aggressive blood pressure control. Patients with AD tend to be 60 to 80-years-old-men [5][6][7][8][9][10]. In a review of 4428 patients from the International Registry of Acute Aortic Dissection (IRAD), 66% were men with mean age of 63-years [6].…”

Árangur aðgerða við ósæðargúlp í rishluta ósæðar á Íslandi 2000-2014

“…Heilablóðfall greindist hjá tveimur sjúklingum (1,9%) en aðrir tveir sjúklingar létust innan 30 daga frá aðgerð (1,9% Tilviljanagreiningum hefur fjölgað á Vesturlöndum samhliða fjölgun myndrannsókna vegna óskyldra sjúkdóma í brjóstholi, til daemis við leit að aexlum í lungum eða við tölvusneiðmyndatöku á kransaeðum. 10 Ef rof eða flysjun (dissection) verður á gúlpnum er 30 daga dánarhlutfall allt að 25% hjá þeim sem ná lifandi í aðgerð, en rof er jafnframt langalvarlegasti fylgikvilli sjúkdómsins. 11,12 Því er reynt að gera skurðaðgerð á aeðargúlp áður en hann rofnar.…”