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Management and outcomes in acute aortic dissection patients with shock
Letter to the Editor
Management and outcomes in acute aortic dissection patients with shock To the Editor: With great interest and appreciation, we have read the article by Bossone et al 1 titled “Shock complicating type A acute aortic dissection: Clinical correlates, management, and outcomes.” The study showed that shock was common in type A acute aortic dissection patients and was associated with higher rates of in-hospital adverse events and mortality. However, no differences in long-term mortality were observed between type A acute aortic dissection survivors with or without shock. The study was based on a registry conducted at 25 aortic centers with a large sample size and focused specifically on shock. Results from this study should be interpreted with the following considerations. First, when running multivariable binary logistic regression analysis to investigate the relationship between shock and in-hospital mortality, the authors did not state clearly what variables they put into the model to adjust for confounding factors. Therefore, this conclusion is less convincing. Second, the similar long-term survival rate may be due to more aggressive medical treatment implemented in patients with shock. At discharge, angiotensin-converting enzyme inhibitors, angiotensin receptor blocker, and statins were more frequently used in patients with shock. However, no further analysis was conducted to investigate the relationship between specific medications and long-term mortality. Third, the mortality for patients without shock decreased significantly throughout the years. However, for patients with shock, in-hospital mortality elevated in later years (2008-2013) and almost reached the level in late 1990s. In our opinion, this might be related to different onset of shock which happened preoperatively or postoperatively. Recent studies confirmed that preoperative hemodynamic instability is associated with higher in-hospital mortality. 2,3 However, in the present study, information about different causes of shock was not presented. Further analyses are urgently needed to confirm this hypothesis. In addition, there are limited studies focusing on instable hemodynamics of type B acute aortic dissection (TBAAD). In our study, we retrospectively studied hypotension in 131 patients (31 women, 23.6%; 97 men, 76.4%) undergoing endovascular therapy for TBAAD from January to December 2012 in our hospital and followed up to 2.1 years. 4 Of the 131 patients, 12 (9.2%) presented with hypotension. No differences were observed in age, gender, smoking history, hypertension,
Marfan syndrome, and in-hospital myocardial infarction between hypotensive and nonhypotensive patients. The incidence of cardiac tamponade, hypoxemia, acute renal dysfunction, and limb ischemia as well as rate of medical treatment was higher in hypotensive patients (Table). In-hospital mortality is 66.7% and 4.2% for patients with and without hypotension, respectively (P b .001). Long-term mortality is 37.5% for hypotensive patients and 7.9% for nonhypotensive patients (P = .031). Well-designed trials with large samples are needed to investigate the association between hypotension and acute aortic dissection.
Am Heart J 2016;1–2. 0002-8703 http://dx.doi.org/10.1016/j.ahj.2016.08.014
Chen Chen, MD Department of Cardiology West China Hospital Sichuan University Chengdu, China Dongze Li, MBBS Department of Emergency Medicine West China Hospital Sichuan University Chengdu, China E-mail: [email protected] Lixia Deng, MD Department of Cardiology West China Hospital Sichuan University Chengdu, China
References 1. Bossone E, Pyeritz RE, Braverman AC, et al. Shock complicating type A acute aortic dissection: clinical correlates, management, and outcomes. Am Heart J 2016;176:93-9. 2. Chien TM, Li WY, Wen H, et al. Stable haemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg 2013;16:158-65. 3. Long SM, Tribble CG, Raymond DP, et al. Preoperative shock determines outcome for acute type A aortic dissection. Ann Thorac Surg 2003;75:520-4. 4. Zeng R, Li D, Deng L, et al. Hypoalbuminemia predicts clinical outcome in patients with type B acute aortic dissection after endovascular therapy. Am J Emerg Med 2016. [Epub ahead of print].
American Heart Journal Month Year
2 Chen et al
Table. Comparison of demographical data, clinical presentations, and treatment between TBAAD patients with and without hypotension Variable Age (y) Male, n (%) Smoking history, n (%) Hypertension, n (%) Marfan syndrome, n (%) In-hospital complications Myocardial infarction, n (%) Cardiac tamponade, n (%) Hypoxemia, n (%) Acute renal dysfunction, n (%) Limb ischemia, n (%) Heart rate (beats/min) SBP (mm Hg) DBP (mm Hg) Treatment Endovascular therapy, n (%) Medication, n (%)
Hypotension (n = 12)
Nonhypotension (n = 119)
P
51 ± 9 9 (75.0) 6 (50.0) 11 (91.7) 0 (0.0)
51 ± 14 88 (73.9) 50 (42.0) 95 (79.8) 1 (0.8)
.138 .937 .594 .461 .999
2 (16.7) 2 (16.7) 7 (58.3) 5 (41.7) 4 (33.3) 95 ± 23 160 ± 47 97 ± 22
3 (2.5) 0 (0.0) 20 (16.8) 8 (6.7) 6 (5.0) 85 ± 16 149 ± 28 90 ± 23
.066 .008 .003 .002 .006 .037 .036 .830
2 (16.7) 9 (75.0)
88 (73.9) 27 (22.7)
b.001 b.001
Abbreviations: SBP, Systolic blood pressure at admission; DBP, diastolic blood pressure at admission.
Management and outcomes in acute aortic dissection patients with shock To the Editor: With great interest and appreciation, we have read the article by Bossone et al 1 titled “Shock complicating type A acute aortic dissection: Clinical correlates, management, and outcomes.” The study showed that shock was common in type A acute aortic dissection patients and was associated with higher rates of in-hospital adverse events and mortality. However, no differences in long-term mortality were observed between type A acute aortic dissection survivors with or without shock. The study was based on a registry conducted at 25 aortic centers with a large sample size and focused specifically on shock. Results from this study should be interpreted with the following considerations. First, when running multivariable binary logistic regression analysis to investigate the relationship between shock and in-hospital mortality, the authors did not state clearly what variables they put into the model to adjust for confounding factors. Therefore, this conclusion is less convincing. Second, the similar long-term survival rate may be due to more aggressive medical treatment implemented in patients with shock. At discharge, angiotensin-converting enzyme inhibitors, angiotensin receptor blocker, and statins were more frequently used in patients with shock. However, no further analysis was conducted to investigate the relationship between specific medications and long-term mortality. Third, the mortality for patients without shock decreased significantly throughout the years. However, for patients with shock, in-hospital mortality elevated in later years (2008-2013) and almost reached the level in late 1990s. In our opinion, this might be related to different onset of shock which happened preoperatively or postoperatively. Recent studies confirmed that preoperative hemodynamic instability is associated with higher in-hospital mortality. 2,3 However, in the present study, information about different causes of shock was not presented. Further analyses are urgently needed to confirm this hypothesis. In addition, there are limited studies focusing on instable hemodynamics of type B acute aortic dissection (TBAAD). In our study, we retrospectively studied hypotension in 131 patients (31 women, 23.6%; 97 men, 76.4%) undergoing endovascular therapy for TBAAD from January to December 2012 in our hospital and followed up to 2.1 years. 4 Of the 131 patients, 12 (9.2%) presented with hypotension. No differences were observed in age, gender, smoking history, hypertension,
Marfan syndrome, and in-hospital myocardial infarction between hypotensive and nonhypotensive patients. The incidence of cardiac tamponade, hypoxemia, acute renal dysfunction, and limb ischemia as well as rate of medical treatment was higher in hypotensive patients (Table). In-hospital mortality is 66.7% and 4.2% for patients with and without hypotension, respectively (P b .001). Long-term mortality is 37.5% for hypotensive patients and 7.9% for nonhypotensive patients (P = .031). Well-designed trials with large samples are needed to investigate the association between hypotension and acute aortic dissection.
Am Heart J 2016;1–2. 0002-8703 http://dx.doi.org/10.1016/j.ahj.2016.08.014
Chen Chen, MD Department of Cardiology West China Hospital Sichuan University Chengdu, China Dongze Li, MBBS Department of Emergency Medicine West China Hospital Sichuan University Chengdu, China E-mail: [email protected] Lixia Deng, MD Department of Cardiology West China Hospital Sichuan University Chengdu, China
References 1. Bossone E, Pyeritz RE, Braverman AC, et al. Shock complicating type A acute aortic dissection: clinical correlates, management, and outcomes. Am Heart J 2016;176:93-9. 2. Chien TM, Li WY, Wen H, et al. Stable haemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg 2013;16:158-65. 3. Long SM, Tribble CG, Raymond DP, et al. Preoperative shock determines outcome for acute type A aortic dissection. Ann Thorac Surg 2003;75:520-4. 4. Zeng R, Li D, Deng L, et al. Hypoalbuminemia predicts clinical outcome in patients with type B acute aortic dissection after endovascular therapy. Am J Emerg Med 2016. [Epub ahead of print].
American Heart Journal Month Year
2 Chen et al
Table. Comparison of demographical data, clinical presentations, and treatment between TBAAD patients with and without hypotension Variable Age (y) Male, n (%) Smoking history, n (%) Hypertension, n (%) Marfan syndrome, n (%) In-hospital complications Myocardial infarction, n (%) Cardiac tamponade, n (%) Hypoxemia, n (%) Acute renal dysfunction, n (%) Limb ischemia, n (%) Heart rate (beats/min) SBP (mm Hg) DBP (mm Hg) Treatment Endovascular therapy, n (%) Medication, n (%)
Hypotension (n = 12)
Nonhypotension (n = 119)
P
51 ± 9 9 (75.0) 6 (50.0) 11 (91.7) 0 (0.0)
51 ± 14 88 (73.9) 50 (42.0) 95 (79.8) 1 (0.8)
.138 .937 .594 .461 .999
2 (16.7) 2 (16.7) 7 (58.3) 5 (41.7) 4 (33.3) 95 ± 23 160 ± 47 97 ± 22
3 (2.5) 0 (0.0) 20 (16.8) 8 (6.7) 6 (5.0) 85 ± 16 149 ± 28 90 ± 23
.066 .008 .003 .002 .006 .037 .036 .830
2 (16.7) 9 (75.0)
88 (73.9) 27 (22.7)
b.001 b.001
Abbreviations: SBP, Systolic blood pressure at admission; DBP, diastolic blood pressure at admission.