Survival improved over time in acute aortic dissection
NEW ORLEANS — Since 1996, survival in patients with acute aortic dissection has increased, according to data from the IRAD registry presented at the American College of Cardiology Scientific Session.
In addition, endovascular therapy is now performed in more than 30% of patients with type B acute aortic dissection, according to the researchers.
Kim A. Eagle, MD, MACC, director of the Samuel and Jean Frankel Cardiovascular Center, Albion Walter Hewlett Professor of Internal Medicine and professor of health management and policy at the University of Michigan, and colleagues analyzed 9,000 patients (mean age, 62 years; 66% men) with acute aortic dissection from 55 centers in 13 countries enrolled in the IRAD registry between 1996 and 2019.
The patients were stratified into tertiles based on time of enrollment. Approximately two-thirds had type A dissection and the rest had type B dissection. Over time, patients were more likely to have hypertension and less likely to have atherosclerosis (P for trend < .001 for both) and nearly one-third were smokers.
The predominant method of diagnosis was CT scan, which rose in use from 66.5% in the earliest tertile to 90.6% in the latest tertile (P for trend < .001), Eagle said during his presentation.
Type A dissection
Most patients with type A dissection were managed with open surgery, which increased over time (earliest tertile, 85%; latest tertile, 88.6%; P for trend = .001), and fewer patients in this group over time had preoperative coma or stroke (earliest tertile, 7.4%; latest tertile, 3.9%; P for trend < .001), according to the researchers.
In those with type A dissection, in-hospital mortality declined over time (earliest tertile, 26.2%; latest tertile, 16.3%; P for trend < .001), driven by improved mortality in those who had open surgery (earliest tertile, 21.1%; latest tertile, 13%; P for trend < .001), Eagle said.
Kaplan-Meier estimates of 5-year survival in patients with type A dissection improved slightly over time (earliest tertile, 81.9%; latest tertile, 88.5%; P = .672), he said, noting that those managed surgically had higher survival rates than those managed medically.
Predictors of 5-year mortality in type A dissection included age 70 years or older (HR = 2.945; 95% CI, 2.229-3.891), postprocedure stroke (HR = 3.242; 95% CI, 2.222-4.73) and postprocedure cardiac tamponade (HR = 1.718; 95% CI, 1.068-2.764), according to the researchers.
Type B dissection
In patients with type B aortic dissection, endovascular treatment rose over time (earliest tertile, 19.5%; latest tertile, 31.2%; P for trend < .001), whereas surgical and medical management both declined (P for trend for both < .001), Eagle said.
“Continued evolution of endovascular therapies for type A and type B dissection offers potential for less invasive and potentially more efficacious treatments for patients requiring an intervention,” he said.
In-hospital mortality in type B aortic dissection declined overall (earliest tertile, 10.2%; latest tertile, 7.4%; P for trend = .027), but there was no significant decline in any of the three management types, according to the researchers.
Five-year survival in in type B aortic dissection rose over time (earliest tertile, 74%; latest tertile, 83.7%; P < .001), driven by improved survival in patients managed medically (earliest tertile, 71.8%; latest tertile, 82.7%; P = .001).
Predictors of 5-year mortality in type B dissection included age 70 years or older (HR = 3.24; 95% CI, 2.226-4.718), spinal cord ischemia (HR = 3.5; 95% CI, 1.38-8.882), renal failure (HR = 1.683; 95% CI, 1.074-2.637) and history of chronic obstructive pulmonary disease (HR = 1.932; 95% CI, 1.265-2.949), according to the researchers.
Time from admission to diagnosis declined over time in type B dissection (from 3.3 to 2.5 hours; P for trend = .002) but not in type A dissection, the researchers found.
“Delays in time to diagnosis and time to surgery for type A dissection remain substantial,” Eagle said. “Most patients dissect at an aortic diameter below current recommendations for prophylactic repair. Genetic testing along with aortic biomarkers offer possible inroads to identifying at-risk patients earlier, before dissection.” – by Erik Swain
Eagle KA, et al. Featured Clinical Research III. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.
Disclosures: The study was funded in part by Medtronic, Terumo and W.L. Gore and Associates. Eagle reports he received research grants from Medtronic and W.L. Gore and Associates.