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New Insights Into an Old Disease

Peter G. Hagan, MB; Christoph A. Nienaber, MD; Eric M. Isselbacher, MD; David Bruckman, MS; Dean J. Karavite; Pamela L. Russman, BS; Arturo Evangelista, MD; Rossella Fattori, MD; Toru Suzuki, MD; Jae K. Oh, MD; Andrew G. Moore, MD; Joseph F. Malouf, MD; Linda A. Pape, MD; Charlene Gaca, RN; Udo Sechtem, MD; Suzanne Lenferink, MD; Hans Josef Deutsch, MD; Holger Diedrichs, MD; Jose Marcos y Robles, MD; Alfredo Llovet, MD; Dan Gilon, MD; Sugata K. Das, MD; William F. Armstrong, MD; G. Michael Deeb, MD; Kim A. Eagle, MD

JAMA. 2000;283:897-903.

Context  Acute aortic dissection is a life-threatening medical emergency associated with high rates of morbidity and mortality. Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this setting.

Objective  To assess the presentation, management, and outcomes of acute aortic dissection.

Design  Case series with patients enrolled between January 1996 and December 1998. Data were collected at presentation and by physician review of hospital records.

Setting  The International Registry of Acute Aortic Dissection, consisting of 12 international referral centers.

Participants  A total of 464 patients (mean age, 63 years; 65.3% male), 62.3% of whom had type A dissection.

Main Outcome Measures  Presenting history, physical findings, management, and mortality, as assessed by history and physician review of hospital records.

Results  While sudden onset of severe sharp pain was the single most common presenting complaint, the clinical presentation was diverse. Classic physical findings such as aortic regurgitation and pulse deficit were noted in only 31.6% and 15.1% of patients, respectively, and initial chest radiograph and electrocardiogram were frequently not helpful (no abnormalities were noted in 12.4% and 31.3% of patients, respectively). Computed tomography was the initial imaging modality used in 61.1%. Overall in-hospital mortality was 27.4%. Mortality of patients with type A dissection managed surgically was 26%; among those not receiving surgery (typically because of advanced age and comorbidity), mortality was 58%. Mortality of patients with type B dissection treated medically was 10.7%. Surgery was performed in 20% of patients with type B dissection; mortality in this group was 31.4%.

Conclusions  Acute aortic dissection presents with a wide range of manifestations, and classic findings are often absent. A high clinical index of suspicion is necessary. Despite recent advances, in-hospital mortality rates remain high. Our data support the need for continued improvement in prevention, diagnosis, and management of acute aortic dissection.

Author Affiliations: University of Michigan, Ann Arbor (Drs Hagan, Das, Armstrong, Deeb, and Eagle, Messrs Bruckman and Karavite, and Ms Russman); Massachusetts General Hospital, Boston (Dr Isselbacher), and University of Massachusetts, Worcester (Dr Pape and Ms Gaca); Hospital General Universitari Vall d'Hebron, Barcelona (Dr Evangelista), and Hospital 12 de Octubre, Madrid (Drs Marcos y Robles and Llovet), Spain; University Hospital S Orsola, Bologna, Italy (Dr Fattori); University of Tokyo, Tokyo, Japan (Dr Suzuki); Mayo Clinic, Rochester, Minn (Drs Oh, Moore, and Malouf); University Hospital Eppendorf, Hamburg (Dr Nienaber), Robert-Bosch Krankenhaus, Stuttgart (Drs Sechtem and Lenferink), and University of Cologne, Cologne (Drs Deutsch and Diedrichs), Germany; and Hadassah University Hospital, Jerusalem, Israel (Dr Gilon).

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