Ascending Aorta Aneurysm and Blood Group A among Iranian Patients

Thrombosis Research 131 (2013) e51–e53

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Ascending Aorta Aneurysm and Blood Group A among Iranian Patients Maryam Sotoudeh Anvari a, Mohammad Ali Boroumand a, Saeed Shoar a, b, c,⁎, 1, Mohammad Naderan a, b, c, Payvand Bina c a b c

Department of Surgical and Clinical Pathology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Department of Research, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran

a r t i c l e

i n f o

Article history: Received 29 September 2012 Received in revised form 8 November 2012 Accepted 22 November 2012 Available online 20 December 2012 Keywords: Ascending Aortic Aneurysm ABO Blood Group Risk factor

a b s t r a c t Background: Ascending aortic aneurysm is a life threatening conditions leading to surgery in many cases. Demonstrating risk factors for this disease is essential for development of screening strategies for high-risk populations. Blood group although described as a potential risk factor for abdominal aortic aneurysm, has not been addressed in patients with aneurysm of the ascending aorta. Objectives: Our study aimed to demonstrate the prevalence of ABO blood groups among one of the largest Iranian population with diagnosed aneurysm of the ascending aorta. Methods: A retrospective study was conducted in Tehran Heart Center in Tehran, Iran reviewing profile of 24,433 patients admitted to the cardiac surgery ward between January 2005 and February 2012 to extract data of 96 patients with confirmed diagnosis of ascending aortic aneurysm (AAA). Frequency of blood groups was determined and risk factors and AAA-related complications and mortality were compared between different blood groups. Results: Of ninety six patients with AAA, 38 patients (39.58%) had blood group A, followed by 16 patients with blood group B (16.66%), 12 blood group AB (12.5%), and 30 patients (30.25%) with blood group O. Cerebrovascular accident (CVA), peripheral vascular disease (PVD), and AAA-related mortality were more frequent in patients with blood group A. However, it did not reveal statistically significant difference (p>0.05). Conclusion: Our study showed that risk factors for developing vascular disease are more prevalent in patients with blood group A and this blood group is associated with higher complication and mortality in AAA. © 2012 Elsevier Ltd. All rights reserved.

Introduction Aortic aneurysms involve the ascending portion of aorta more frequently with less prevalence in the abdominal aorta [1–6]. Regardless of the site of origin, ascending aortic aneurysm occurs as a result of weakened aortic wall due to connective tissue diseases [7,8], aortic valve abnormalities [5], or genetic disorders [6,8,9]. Although some limited studies have recently addressed the potential role of blood groups in vascular diseases [10–12] including recent reports on abdominal aortic aneurysm [13], no single study has discussed yet about the role of this entity in aneurysmal dilations of ascending aorta. With attention to the higher mortality related to dissection of aortic aneurysm and open surgical approach in emergency setting [14], screening for development of aortic aneurysm and identifying those at higher risk for complicated dissections are the key points in decreasing lethal consequences of this degenerative diseases. As it has been shown that

⁎ Corresponding author at: Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. Tel.: +98 913 362 0932; fax: +98 361 5426532. E-mail addresses: [email protected], [email protected] (S. Shoar). 1 Address: No 54, Boostan e Qods (Shilat) Dormitory, Shahed Alley, Qods Street, Keshavarz Boulevard, Tehran, Iran. 0049-3848/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.thromres.2012.11.023

low socioeconomic status and uninsured individuals are associated with higher mortality rate [2,9], establishing risk factors in a low income country is close to this purpose. Our study aimed to demonstrate the prevalence of blood groups among one of the largest Iranian population with already diagnosed ascending aorta aneurysm. The results of the current study will be applicable in developing screening and preventive strategies for aorta aneurysm. Methods Through a retrospective descriptive study between January 2005 and February 2012 in Tehran Heart Center, the referral center for heart disease in Tehran, Iran, profiles of 24,433 patients admitted to the cardiac surgery wards of the hospital were reviewed to detect data of patients with diagnosed ascending aortic aneurysm (AAA). AAA patients were admitted to the department of Cardiac Surgery for emergent or elective surgical repair or for follow-up visits. The diagnosis of aneurysm was done based on Computed Tomography (CT) Angiography and Echocardiography and confirmed with histopathologic evaluation. ABO blood group typing was performed for each patient as a routine lab study before the surgery and related data were then obtained

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Table 1 Demographics and primary characteristics of patients. Blood Group

A

B

AB

O

Total Number Age (mean ± SD) Gender Female Male Rh Antigen RhRh+ Risk Factors Current Smoking Opium Addiction DM HTN Dyslipidemia Renal Failure Family History Mean ± SD Levels FBS (mg/dl) TG (mg/dl) LDL (mg/dl) HDL (mg/dl) Cholesterol (mg/dl) VLDL(mg/dl)

38 (39.58%) 58.03 ± 13.54

16 (16.66%) 48.88 ± 20.64

12 (12.5%) 57.83 ± 13.82

30 (31.25%) 53.17 ± 17.47

P Value

8 (8.33%) 30 (31.25%)

4 (4.16%) 12 (12.5%)

1 (1.04%) 11 (11.45%)

5 (5.20%) 25 (26.04%)

6 (6.25%) 32 (33.33%)

1 (1.04%) 15 (15.62%)

1 (1.04%) 11 (11.45%)

3 (3.12%) 27 (28.12%)

12 (12.5%) 2 (2.08%) 7 (7.29%) 21 (21.87%) 16 (16.66%) 4 (4.16%) 12 (12.5%)

4 (4.16%) 0 (0%) 3 (3.12%) 4 (4.16%) 3 (3.12%) 1 (1.04%) 6 (6.25%)

7 (7.29%) 0 (0%) 1 (1.04%) 6 (6.25%) 6 (6.25%) 0 (0%) 1 (1.04%)

12 (12.25%) 0 (0%) 1 (1.04%) 14 (14.58%) 9 (9.37%) 4 (4.16%) 4 (4.16%)

0.421 0.229 0.232 0.241 0.242 0.565 0.098

105.82 ± 36.15 119.12 ± 53.29 102.42 ± 43.31 45.06 ± 21.13 163.60 ± 58.82 25.69 ± 16.25

94.36 ± 40.12 144.84 ± 97.04 92.30 ± 25.62 45.30 ± 13.99 159.23 ± 31.56 30.64 ± 19.34

99.16 ± 28.81 155.33 ± 79.20 103.16 ± 37.96 37 ± 9.49 168.75 ± 40.25 31.06 ± 15.84

101.19 ± 21.8 117.84 ± 38.5 100.63 ± 46.21 38.23 ± 11.78 159.76 ± 50.08 23.56 ± 7.69

0.76 0.21 0.89 0.025 0.95 0.35

0.232 0.156

0.727

along with demographic and other clinical characteristics from the hospital central research data base. Research and ethic committee of Tehran Heart Center approved the study protocol without pertaining informed consent in this retrospective data base review. Data were analyzed using statistical package for social sciences (SPSS, Chicago, Inc) version 16. Descriptive analysis and chi square test was employed. The values are presented as number (%) and considered significant at p b 0.05.

Results Of ninety six patients with ascending aortic aneurysm (AAA) in this study, 19 patients (20%) were female and 77 patients (80%) were male. Mean ± SD age of patients was 54.74 ± 16.16 years. Also, mean ± SD weight and height were 72.95 ± 13.27 kg and 168.80 ± 10.31 cm, respectively. Frequency of ABO blood group was as follows: 38 patients had blood group A (39.58%), 16 patinets had blood group B (16.66%), 12 patients had blood group AB (12.5%), and 30 patients had blood group O (30.25%). In terms of Rh antigen, 11 patients were Rh negative (11.45%) while 85 patients were Rh positive (88.54%). Primary clinical characteristics and risk factors for vascular disease are summarized in Table 1. Patients’ outcomes according to the ABO blood group are presented in Table 2. As the table shows, cerebrovascular accident (CVA), peripheral vascular disease (PVD), and mortality have the highest frequency in blood group A; however, it did not reveal statistically significant difference (p>0.05). Moreover, there was no significant difference between O and non-O blood group nor there was any significant difference between A and non-A blood group in terms of PVD, CVA, and mortality (p> 0.05) (Table 2). Similarly Table 3 demonstrates that 4 patient (36.4%) with Rh – blood group and 18 patients (21.2%) with Rh + group died of AAA. However, the mortality rate was not significantly different (p > 0.05).

Discussion Despite advances in surgical and endovascular techniques for repair of aortic aneurysms, little improvement has occurred in aortic aneurysmrelated mortality [1,2]. Although risk factors for AAA rupture have been well described [1–4, 8, 13, 15], determining more risk factors including blood groups increases the probability to identify those patients needing preventive car. Association of blood groups with vascular disease has been proposed for a long time [10,11]; however, there is not sufficient studies to investigate the role of blood groups in development and complications of AAA. Wu et al. in a meta - analysis showed that non-O blood groups are associated with vascular diseases such as coronary artery disease CAD, CVA, PVD, and venous thromboembolism [11]. Also they confirmed the previously reported relationship between non-O blood groups and Von willebrand serum levels as the highest von Willebrand factor was detected in individuals with the lowest expression of O (H) blood group antigen. Similarly, our results showed that vascular disease and mortality are more frequent in AAA patients with blood group A followed by blood groups O, B, and AB. In contrast, our previous study demonstrated that CAD are more prevalent among Iranian patients with blood group O [12]. This discrepancy may simply occur as a result of variations between studied populations with different blood group proportions. ABO blood group and abdominal aortic aneurysm have also been related in a study [13]. Mahmoodi et al. in their retrospective review comparing 499 patients with abdominal aortic aneurysm and 499 patients with PAD showed that non-O blood groups are risk factors for vascular diseases. Although they have studied patients with abdominal aortic aneurysm, their findings are comparable to our results on AAA. While their study supports the role of non-O blood group in developing vascular disease such as abdominal aortic aneurysm, our study showed that blood group A is more prevalent in patients with AAA and associated with higher mortality rate.

Table 2 Patients’ outcome according to ABO blood group.

PVD CVA Mortality

A (n)

B (n)

AB (n)

O (n)

P Value

Non-O (n)

P Value

Non-A (n)

P Value

2 (3.1%) 4 (4.2%) 10 (10.4%)

1(1%) 0 4 (4.2%)

1 (1%) 0 2 (2.1%)

2 (2.1%) 1 (1%) 6 (6.3%)

0.516 0.181 0.874

4 (4.2%) 4 (4.2%) 18 (18.8%)

0.794 0.705 0.540

4 (4.2%) 1 (1%) 14 (14.6%)

0.709 0.106 0.671

M.S. Anvari et al. / Thrombosis Research 131 (2013) e51–e53

Conflict of Interest Statement

Table 3 Patients’ outcome according to Rh antigen. Rh

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Rh-

Rh+

P Value

1 (9.1%) 1 (9.1%) 4 (36.4%)

5 (6%) 4 (4.8%) 18 (21.2%)

0.863 0.779 0.259

There are no conflicts of interest.

Outcomes PVD CVA Mortality

To the best of our knowledge, this is the first study addressing the association of blood groups with AAA and related mortality. In our study, Rh- patients although not significantly, had less mortality compared to patients with Rh+ blood group. However, there is no single study in the literature addressing the role of Rh antigen in AAA to be compared with this finding. Clark et al. investigated the relationship between blood groups and vascular diseases showing that an association is present between non-O antigens and thrombosis mainly mediated by von Willebrand factor [16]. Additionally, they find a trend in the literature supporting the modest and consistent effect of ABO (H) on PVD. However, the evidences are heterogeneous and there is need to future prospective population - based studies to clarify the role of blood groups on vascular diseases [11,13,16]. Despite advances in the management of aortic aneurysm, morbidity and mortality remain considerable [8] necessitating effective screening and preventive action plans which is never achieved without concise exploration of all the risk factors. Our study although discussed the possible role of blood groups in AAA and associated complications was not able to show a significant role for this potential risk factor in AAA probably due to small sample size. Moreover, retrospective feature of our study limits extrapolation of its findings to the general population. On the other hand, some of the risk factors for vascular disease such as serum levels of von Willebrand and factor VIII could not be retrieved in our review as these parameters were not routinely measured in our clinical settings. Nevertheless, this study was the first one addressing the role of blood groups in AAA and pave the way for future investigations to define the role of blood groups in such a morbidly disease. Conclusion Our study showed that risk factors for developing vascular disease are more prevalent in patients with blood group A and this blood group is associated with higher complication and mortality rate in patients with ascending aortic aneurysm.

References [1] Heller JA, Weinberg A, Arons R, Krishnasastry KV, Lyon RT, Deitch JS, et al. Two decades of abdominal aortic aneurysm repair: Have we made any progress? J Vasc Surg 2000;32:1091–100. [2] Wainess RM, Dimick JB, Cowan Jr JA, Henke PK, Stanley JC, Upchurch Jr GR. Epidemiology of surgically treated abdominal aortic aneurysms in the United States, 1988 to 2000. Vascular 2004;12:218–24. [3] Wanhainen A, Bylund N, Björck M. Outcome after abdominal aortic aneurysm repair in Sweden 1994–2005. Br J Surg 2008;95:564–70. [4] Forsdahl S, Singh K, Solberg S, Jacobsen B. Risk factors for abdominal aortic aneurysms: A 7-year prospective study: The Tromso Study, 1994–2001. Circulation 2009;119: 2202–8. [5] Tadros T, Klein M, Shapira O. Ascending aortic dilatation associated with bicuspid aortic valve: Pathophysiology, molecular biology, and clinical implications. Circulation 2009;119:880–90. [6] Cozijnsen L, Braam RL, Waalewijn RA, Schepens MA, Loeys BL, van Oosterhout MF, et al. What is new in dilatation of the ascending aorta? Review of current literature and practical advice for the cardiologist. Circulation 2011;121:924–8. [7] Judge D, Dietz H. Marfan's syndrome. Lancet 2005;366:1965–76. [8] Lavall D, Schäfers H, Böhm M, Laufs U. Aneurysms of the ascending aorta. Dtsch Arztebl Int 2012;109(13):227–33. [9] Boxer LK, Dimick JB, Wainess RM, Cowan JA, Henke PK, Stanley JC, et al. Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States. Surgery 2003;134:142–5. [10] Garrison R, Havlik R, Harris R, Feinleib M, Kannel W, Padgett S. ABO blood group and cardiovacular disease: The Framingham study. Atherosclerosis 1976;25: 311–8. [11] Wu O, Bayoumi N, Vickers M, Clark P. ABO(H) blood groups and vascular disease: A systematic review and meta-analysis. J Thromb Haemost 2008;6:62–9. [12] Anvari MS, Boroumand MA, Emami B, Karimi A, Soleymanzadeh M, Abbasi SH, et al. ABO Blood Group and Coronary Artery Diseases in Iranian Patients Awaiting Coronary Artery Bypass Graft Surgery: A Review of 10,641 Cases. Lab Med September 1 2009;40(9):528–30. [13] Mahmoodi B, Nijsten M, Wijsman J, Matthews A, van der Laan L. ABO-blood groups and risk of abdominal aortic aneurysm and peripheral obstructive artery disease: Two sides of the same coin. Thromb Res 2012;129(1):89–90. [14] Masuda Y, Yamada Z, Morooka N, Watanabe S, Inagaki Y. Circulation Nov 1991;84(5 Suppl):III7–III13. [15] Blankensteijn J, de Jong S, Prinssen M, van der Ham A, Buth J, van Sterkenburg S, et al. Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005;352:2398–405. [16] Clark P, Wu O. ABO blood groups and thrombosis: A causal association, but is there value in screening? Future Cardiol Mar 2011;7(2):191–201.