Gender-related differences in acute aortic dissection

Methods: Patients with AAA referred to vascular surgeons at 93 UK hospitals were entered into the UK Small Aneurysm Trial. For this study, 1743 patients were monitored for changes in AAA diameter by ultrasonography over a mean follow-up of 1.9 years. Results: Mean initial AAA diameter and growth rates were 43 mm (range 28 to 85 mm) and 2.6 mm/year (95% range, ⫺1.0 to 6.1 mm/year), respectively. Baseline diameter was strongly associated with growth, suggesting that AAA growth accelerates as the aneurysm enlarges. The AAA growth rate was lower in those with low ankle/brachial pressure index and diabetes but higher for current smokers (all p⬍0.001). No other factor (including lipids and blood pressure) was associated with AAA growth. Intervals of 36, 24, 12 and 3 months for aneurysms of 35, 40, 45 and 50 mm, respectively, would restrict the probability of breaching the 55-mm limit at rescreening to below 1%. Conclusions: The authors concluded that annual, or less frequent, surveillance intervals are safe for all AAAs ⱕ45 mm in diameter. Smoking increases AAA growth, but atherosclerosis appears to play a minor role. Perspective: Evidence from several clinical trials indicate that medical surveillance is a safe, cost-effective management of small AAAs. A strategy to reduce cardiovascular risk factors of those enrolled in surveillance programs appears reasonably likely to improve patient survival, but this study demonstrates that, with the exception of smoking cessation, such a strategy is unlikely to slow AAA growth. Smoking cessation must be aggressively targeted, because smoking appears to be the only modifiable factor associated with AAA expansion. The authors also provide a rational basis for determining appropriate rescreening intervals for those enrolled in surveillance programs. DM

abrupt onset of pain than were males (p⫽0.004); otherwise, presenting symptoms were similar. Pulse deficits were more common in males than in females (31.7% vs. 19.2%; p⬍0.001), whereas altered mental status was more common in females (13% vs. 9%; p⫽0.05). A widened mediastinum was more common in males (62.7% vs. 55.1%; p⫽0.02). Considering type A AoD, more males than females were referred for surgical repair (86.8% vs. 70.6%; p⬍0.001). Hospital complications were similar in the two groups, with a trend toward a greater incidence of mental status changes and coma (8.7% vs. 5.4%; p⫽0.06), hypotension (34.1% vs. 23.9%; p⫽0.001) and cardiac tamponade (16.5% vs. 10.5%; p⫽0.007) in women. Limb ischemia was more prominent in males (11.8% vs. 7.4%; p⫽0.04). Overall mortality was higher in females (30.1% vs. 21%; p⫽0.001), which was predominantly due to excess mortality in Type A dissection (38.2% vs. 26.2%; p⫽0.002). When analyzed by age, the excess mortality seen in females was exclusively attributed to the age group 66 –75 yrs where mortality was 36% vs. 16% for males. Conclusions: There are subtle gender-related differences in presenting symptoms for patients who have AoD, as well as differences in outcome, with a higher overall mortality in females than in males. Perspective: This substudy from IRAD sheds further light on the clinical presentation of patients with acute AoD. As with other forms of cardiovascular disease, including acute ischemic syndromes, gender-based differences in presenting symptoms and complication rates were noted. Of importance, there was an “insignificant” increase in the time from onset of symptoms to presentation noted in female patients (4.7 h), which, although not statistically significant, may have clinical relevance in an entity with a high early mortality such as AoD. WA

Gender-Related Differences in Acute Aortic Dissection

Comparison of Aortic Dissection in Patients With and Without Marfan’s Syndrome (Results From the International Registry of Aortic Dissection)

Nienaber CA, Fattori R, Mehta R, et al. Circulation 2004;109: 3014 –21.

Januzzi JL, Marayati F, Mehta RH, et al. Am J Cardiol 2004;94: 400 –2.

Study Question: To investigate gender-related differences in presentation and outcome in acute aortic dissection (AoD). Methods: This is a substudy from the International Registry of Acute Aortic Dissection (IRAD) in which presenting symptoms, diagnostic imaging and hospital outcomes were analyzed based on gender. Results: The IRAD Registry contained 1078 patients, 346 of whom were female (32%). Broken down by age, the percentage of females was 20%, 23%, 36% and 51% for ages ⬍50, 50 – 65, 66 –76 and ⬎75 yrs. Type A dissection was seen in 61% of male and 65.9% of females; females were more likely to have a history of hypertension. Dissection was noted during pregnancy only in two patients. There was a trend (p⫽0.2) to a longer duration from onset to presentation for women compared to men (21.5⫾51.4 h vs. 16.8⫾43.6 h). Female patients were less likely to have

Study Question: Investigators assessed the prevalence of Marfan syndrome (MS) among a large contemporary cohort of patients with aortic dissection (AD) and systematically compared the clinical characteristics of patients who had AD with and without MS. Methods: All patients enrolled in IRAD from January 1, 1996, to December 31, 2000, were included for the purpose of this analysis. Acute type A AD was defined as any dissection that involved the ascending aorta with presentation within 14 days of symptom onset. Type B AD was defined as any in which the dissection did not involve the ascending aorta. Variables of interest included demographics, history, physical examination, imaging results, management strategies and outcomes. Patients were then divided

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