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      Population-Based Study of Incidence and Outcome of Acute Aortic Dissection and Premorbid Risk Factor Control : 10-Year Results From the Oxford Vascular Study

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          Abstract

          Background—

          Acute aortic dissection is a preventable life-threatening condition. However, there have been no prospective population-based studies of incidence or outcome to inform an understanding of risk factors, strategies for prevention, or projections for future clinical service provision.

          Methods and Results—

          We prospectively determined incidence and outcomes of all acute aortic dissections in a population of 92 728 in Oxfordshire, United Kingdom, from 2002 to 2012. Among 155 patients with 174 acute aortic events, 54 patients had 59 thoracoabdominal aortic dissections (52 incident events: 6/100 000, 95% confidence interval, 4–7; 37 Stanford type A, 15 Stanford type B; 31 men, mean age=72.0 years). Among patients with type A incident events, 18 (48.6%) died before hospital assessment (61.1% women). The 30-day fatality rate was 47.4% for patients with type A dissections who survived to hospital admission and 13.3% for patients with type B dissections, although subsequent 5-year survival rates were high (85.7% for type A; 83.3% for type B). Even though 67.3% of patients were on antihypertensive drugs, 46.0% of all patients had at least 1 systolic BP ≥180 mm Hg in their primary care records over the preceding 5 years, and the proportion of blood pressures in the hypertensive range (>140/90 mm Hg) averaged 56.0%. Premorbid blood pressure was higher in patients with type A dissections that were immediately fatal than in those who survived to admission (mean/standard deviation pre-event systolic blood pressure=151.2/19.3 versus 137.9/17.9; P <0.001).

          Conclusions—

          Uncontrolled hypertension remains the most significant treatable risk factor for acute aortic dissection. Prospective population-based ascertainment showed that hospital-based registries will underestimate not only incidence and case fatality, but also the association with premorbid hypertension.

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          Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study).

          P M Rothwell, A Coull, L Silver … (2005)
          Acute coronary, cerebrovascular, and peripheral vascular events have common underlying arterial pathology, risk factors, and preventive treatments, but they are rarely studied concurrently. In the Oxford Vascular Study, we determined the comparative epidemiology of different acute vascular syndromes, their current burdens, and the potential effect of the ageing population on future rates. We prospectively assessed all individuals presenting with an acute vascular event of any type in any arterial territory irrespective of age in a population of 91 106 in Oxfordshire, UK, in 2002-05. 2024 acute vascular events occurred in 1657 individuals: 918 (45%) cerebrovascular (618 stroke, 300 transient ischaemic attacks [TIA]); 856 (42%) coronary vascular (159 ST-elevation myocardial infarction, 316 non-ST-elevation myocardial infarction, 218 unstable angina, 163 sudden cardiac death); 188 (9%) peripheral vascular (43 aortic, 53 embolic visceral or limb ischaemia, 92 critical limb ischaemia); and 62 unclassifiable deaths. Relative incidence of cerebrovascular events compared with coronary events was 1.19 (95% CI 1.06-1.33) overall; 1.40 (1.23-1.59) for non-fatal events; and 1.21 (1.04-1.41) if TIA and unstable angina were further excluded. Event and incidence rates rose steeply with age in all arterial territories, with 735 (80%) cerebrovascular, 623 (73%) coronary, and 147 (78%) peripheral vascular events in 12 886 (14%) individuals aged 65 years or older; and 503 (54%), 402 (47%), and 105 (56%), respectively, in the 5919 (6%) aged 75 years or older. Although case-fatality rates increased with age, 736 (47%) of 1561 non-fatal events occurred at age 75 years or older. The high rates of acute vascular events outside the coronary arterial territory and the steep rise in event rates with age in all territories have implications for prevention strategies, clinical trial design, and the targeting of funds for service provision and research.
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            Epidemiology and clinicopathology of aortic dissection.

            István Mészáros, József Mórocz, József Szlávi … (2000)
            To determine the incidence and mortality as well as to analyze the clinical and pathologic changes of aortic dissection. A population-based longitudinal study over 27 years on a study population of 106,500, including 66 hospitalized and 18 nonhospitalized consecutively observed patients. Analysis of data from the medical, surgical, and autopsy records of patients with aortic dissection. Altogether, 86 cases of aortic dissection were found in 84 patients, corresponding to a 2.9/100,000/yr incidence. Sixty-six of the 84 patients (79%) were admitted to the hospital, and 18 patients (21%) died before admission. Their ages ranged from 36 to 97 years, with a mean of 65. 7 years. The male/female ratio was 1.55 to 1. A total of 22.7% of the hospitalized patients died within the first 6 h, 33.3% within 12 h, 50% within 24 h, and 68.2% within the first 2 days after admission. Six patients were operated on, with a perioperative mortality of two of six patients and a 5-year survival of two of six patients. All patients who were not operated on died. Pain was the most frequent initial symptom. Every patient had some kind of cardiovascular and respiratory sign. Neurologic symptoms occurred in 28 of 66 patients (42%). Five patients presented with clinical pictures of acute abdomen and two with acute renal failure. Trunk arteries were affected in 33 of the 80 autopsied cases (41%), and rupture of aorta was seen in 69 cases (86%). In five cases, spontaneous healing of dissection was also found. The ratio of proximal/distal dissections was 5.1 to 1. All 18 prehospital cases were acute. Fifty-nine cases (89.4%) were acute at admission, and 7 cases (10.6%) were chronic dissections. Hypertension and advanced age were the major predisposing factors. Aortic dissection was the initial clinical impression in only 13 of the 84 patients (15%). Thus, 85% of the patients did not receive immediate appropriate medical treatment. For this reason, these late-recognized and/or unrecognized cases may be regarded as an untreated or symptomatically treated group, whose course may resemble the natural course of aortic dissection.
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              Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture.

              W Clouse, John W Hallett, Hartzell V Schaff … (2004)
              To ascertain whether acute aortic dissection (AAD) remains the most common aortic catastrophe, as generally believed, and to detect any improvement in outcomes compared with previously reported population-based data. We determined the incidence, operative intervention rate, and long-term survival rate of Olmsted County, Minnesota, residents with a clinical diagnosis of AAD initially made between 1980 and 1994. The incidence of degenerative thoracic aortic aneurysm (TAA) rupture was also delineated. We compared these results with other population-based studies of AAD, degenerative TAA, and abdominal aortic aneurysm (AAA) rupture. During a 15-year period, we identified 177 patients with thoracic aortic disease. We focused on 39 patients with AAD (22% of the entire cohort) and 28 with TAA rupture (16%). The annual age- and sex-adjusted incidences were 3.5 per 100,000 persons (95% confidence interval, 2.4-4.6) for AAD and 3.5 per 100,000 persons (95% confidence interval, 2.2-4.9) for TAA rupture. Thirty-three dissections (85%) involved the ascending aorta, whereas 6 (15%) involved only the descending aorta. Nineteen patients (49%) underwent 22 operations for AAD, with a 30-day case fatality rate of 9%. Among all 39 patients with AAD, median survival was only 3 days. Overall 5-year survival for those with AAD improved to 32% compared with only 5% in this community between 1951 and 1980. In other studies, the annual incidences of TAA rupture and AAA rupture are estimated at approximately 3 and 9 per 100,000 persons, respectively. This study indicates that AAD and ruptured degenerative TAA occur with similar frequency but less commonly than ruptured AAA. Although timely recognition and management remain problematic, these new data suggest that recent diagnostic and operative advances are improving long-term survival in AAD.
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                Author and article information

                Journal
                Title: Circulation
                Abbreviated Title: Circulation
                Publisher: Ovid Technologies (Wolters Kluwer Health)
                ISSN (Print): 0009-7322
                ISSN (Electronic): 1524-4539
                Publication date Created: May 21 2013
                Publication date (Print): May 21 2013
                Volume: 127
                Issue: 20
                Pages: 2031-2037
                Affiliations
                [1 ]From the Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); and Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (J.P.).
                Article
                DOI: 10.1161/CIRCULATIONAHA.112.000483
                PMC ID: 6016737
                PubMed ID: 23599348
                SO-VID: 1609812b-be46-4bfb-b087-13b9ad5e8f1c
                Copyright © © 2013
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