This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (327)  • Contact me when this article is cited  Related Content  • Related article  • Similar articles in JAMA

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).

RELATED ARTICLE

February 16, 2000
JAMA. 2000;283(7):943-944.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

A 48-Year-Old Man With Paralysis and Hypotension
Johnson et al.
Chest 2008;134:862-865.
FULL TEXT  

The Role of False Lumen Size in Prediction of In-Hospital Complications After Acute Type B Aortic Dissection
Chang et al.
J Am Coll Cardiol 2008;52:1170-1176.
ABSTRACT | FULL TEXT  

Endovascular Management of Complicated Acute Type B Aortic Dissection
Chan and Cheng
Asian Cardiovasc. Thorac. Ann. 2008;16:272-273.
FULL TEXT  

Complicated Acute Type B Dissection: Is Surgery Still the Best Option?: A Report From the International Registry of Acute Aortic Dissection
Fattori et al.
J Am Coll Cardiol Intv 2008;1:395-402.
ABSTRACT | FULL TEXT  

Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection.
Szeto et al.
Ann. Thorac. Surg. 2008;86:87-94.
ABSTRACT | FULL TEXT  

Combining Classic Surgery With Descending Stent Grafting for Acute DeBakey Type I Dissection.
Jakob et al.
Ann. Thorac. Surg. 2008;86:95-101.
ABSTRACT | FULL TEXT  

Acute aortic dissection mimicking an acute coronary syndrome through occlusion of the right coronary artery
Dorman and Barry
Emerg. Med. J. 2008;25:462-463.
ABSTRACT | FULL TEXT  

Aortic Dissection With Aortic Side Branch Compromise: Impact of Malperfusion on Patient Outcome
Oderich et al.
PERSPECT VASC SURG ENDOVASC THER 2008;20:190-200.
ABSTRACT  

Preliminary experience with the smooth muscle troponin-like protein, calponin, as a novel biomarker for diagnosing acute aortic dissection
Suzuki et al.
Eur Heart J 2008;29:1439-1445.
ABSTRACT | FULL TEXT  

Resident's knowledge on thoracic aortic dissection
Meenakshisundaram and Thirumalaikolundusubramanian
Postgrad. Med. J. 2008;84:278-278.
FULL TEXT  

Heart Failure Due to Severe Supravalvular Aortic Stenosis in Painless Type A Aortic Dissection
Sakamoto et al.
Ann. Thorac. Surg. 2008;85:1441-1443.
ABSTRACT | FULL TEXT  

Pre-operative N-terminal pro-brain natriuretic peptide predicts outcome in type A aortic dissection.
Sodeck et al.
J Am Coll Cardiol 2008;51:1092-1097.
ABSTRACT | FULL TEXT  

Endovascular Management of Thoracic Dissections
Swee and Dake
Circulation 2008;117:1460-1473.
FULL TEXT  

EMQ answers
Emerg. Med. J. 2008;25:121-121.
FULL TEXT  

Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology
Rapezzi et al.
Eur Heart J 2008;29:277-278.
FULL TEXT  

Aortic Dissection
Reece et al.
Card Surg Adult 2008;3:1195-1222.
FULL TEXT  

Endovascular Therapy for the Treatment of Thoracic Aortic Disease
Moffatt-Bruce and Mitchell
Card Surg Adult 2008;3:1299-1308.
FULL TEXT  

Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts
Svensson et al.
Ann. Thorac. Surg. 2008;85:S1-S41.
ABSTRACT | FULL TEXT  

D-dimer in ruling out acute aortic dissection: a systematic review and prospective cohort study
Sodeck et al.
Eur Heart J 2007;28:3067-3075.
ABSTRACT | FULL TEXT  

Fate of the Residual Distal and Proximal Aorta After Acute Type A Dissection Repair Using a Contemporary Surgical Reconstruction Algorithm
Geirsson et al.
Ann. Thorac. Surg. 2007;84:1955-1964.
ABSTRACT | FULL TEXT  

Degree of fusiform dilatation of the proximal descending aorta in type B acute aortic dissection can predict late aortic events.
Marui et al.
J. Thorac. Cardiovasc. Surg. 2007;134:1163-1170.
ABSTRACT | FULL TEXT  

Partial Thrombosis of the False Lumen in Aortic Dissection
Takagi et al.
NEJM 2007;357:1868-1869.
FULL TEXT  

Aortic Dilatation and Dissection in Turner Syndrome
Matura et al.
Circulation 2007;116:1663-1670.
ABSTRACT | FULL TEXT  

Acute Type B Aortic Dissection: Does Aortic Arch Involvement Affect Management and Outcomes?: Insights From the International Registry of Acute Aortic Dissection (IRAD)
Tsai et al.
Circulation 2007;116:I-150-I-156.
ABSTRACT | FULL TEXT  

Aortic Diameter >=5.5 cm Is Not a Good Predictor of Type A Aortic Dissection: Observations From the International Registry of Acute Aortic Dissection (IRAD)
Pape et al.
Circulation 2007;116:1120-1127.
ABSTRACT | FULL TEXT  

Three-dimensional Contrast-enhanced MR Angiography of Aortic Dissection: A Pictorial Essay
Liu et al.
RadioGraphics 2007;27:1311-1321.
ABSTRACT | FULL TEXT  

Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations
Geirsson et al.
Eur. J. Cardiothorac. Surg. 2007;32:255-262.
ABSTRACT | FULL TEXT  

Partial Thrombosis of the False Lumen in Patients with Acute Type B Aortic Dissection
Tsai et al.
NEJM 2007;357:349-359.
ABSTRACT | FULL TEXT  

Surgical and long-term mortality in 2634 consecutive patients operated on the proximal thoracic aorta
Olsson et al.
Eur. J. Cardiothorac. Surg. 2007;31:963-969.
ABSTRACT | FULL TEXT  

Ascending aorta cannulation in acute type A aortic dissection
Inoue et al.
Eur. J. Cardiothorac. Surg. 2007;31:976-979.
ABSTRACT | FULL TEXT  

Stent Graft Management of Stable, Uncomplicated Type B Aortic Dissection
Kahn and Dake
PERSPECT VASC SURG ENDOVASC THER 2007;19:162-169.
ABSTRACT  

Commentary on "Stent Graft Management of Stable, Uncomplicated Type B Aortic Dissection"
Nienaber and Ince
PERSPECT VASC SURG ENDOVASC THER 2007;19:170-173.
 

What Is the Optimal Management of Late-Presenting Survivors of Acute Type A Aortic Dissection?
Davies et al.
Ann. Thorac. Surg. 2007;83:1593-1602.
ABSTRACT | FULL TEXT  

Proximal Reoperations After Repaired Acute Type A Aortic Dissection
Estrera et al.
Ann. Thorac. Surg. 2007;83:1603-1609.
ABSTRACT | FULL TEXT  

Case 8-2007 -- A 48-Year-Old Man with Chest Pain Followed by Cardiac Arrest
Lewis et al.
NEJM 2007;356:1153-1162.
FULL TEXT  

Endovascular Repair of Acute Type B Aortic Dissection: Long-Term Follow-Up of True and False Lumen Diameter Changes
Schoder et al.
Ann. Thorac. Surg. 2007;83:1059-1066.
ABSTRACT | FULL TEXT  

Central cannulation is safe in acute aortic dissection repair
Reece et al.
J. Thorac. Cardiovasc. Surg. 2007;133:428-434.
ABSTRACT | FULL TEXT  

Preoperative predictive factors for mortality in acute type A aortic dissection: an institutional report on 217 consecutives cases
Chavanon et al.
ICVTS 2007;6:43-46.
ABSTRACT | FULL TEXT  

Diagnosis and management of patients with aortic dissection
Ince and Nienaber
Heart 2007;93:266-270.
FULL TEXT  

Neurological Symptoms in Type A Aortic Dissections
Gaul et al.
Stroke 2007;38:292-297.
ABSTRACT | FULL TEXT  

Simple Risk Models to Predict Surgical Mortality in Acute Type A Aortic Dissection: The International Registry of Acute Aortic Dissection Score
Rampoldi et al.
Ann. Thorac. Surg. 2007;83:55-61.
ABSTRACT | FULL TEXT  

The fate of the distal aorta after repair of acute type A aortic dissection
Halstead et al.
J. Thorac. Cardiovasc. Surg. 2007;133:127-135.
ABSTRACT | FULL TEXT  

Thoracic Aortic Aneurysm and Dissection: Increasing Prevalence and Improved Outcomes Reported in a Nationwide Population-Based Study of More Than 14 000 Cases From 1987 to 2002
Olsson et al.
Circulation 2006;114:2611-2618.
ABSTRACT | FULL TEXT  

Long-Term Survival in Patients Presenting With Type B Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection
Tsai et al.
Circulation 2006;114:2226-2231.
ABSTRACT | FULL TEXT  

Is Surgery Always Mandatory for Type A Aortic Dissection?
Centofanti et al.
Ann. Thorac. Surg. 2006;82:1658-1664.
ABSTRACT | FULL TEXT  

Emergency Surgery for Acute Type A Aortic Dissection in Octogenarians
Shiono et al.
Ann. Thorac. Surg. 2006;82:554-559.
ABSTRACT | FULL TEXT  

Complications after endovascular repair of acute symptomatic and chronic expanding Stanford type B aortic dissections.
Bockler et al.
J. Thorac. Cardiovasc. Surg. 2006;132:361-368.e4.
ABSTRACT | FULL TEXT  

Diagnostic Accuracy of Transesophageal Echocardiography, Helical Computed Tomography, and Magnetic Resonance Imaging for Suspected Thoracic Aortic Dissection: Systematic Review and Meta-analysis.
Shiga et al.
Arch Intern Med 2006;166:1350-1356.
ABSTRACT | FULL TEXT  

Long-Term Survival in Patients Presenting With Type A Acute Aortic Dissection: Insights from the International Registry of Acute Aortic Dissection (IRAD)
Tsai et al.
Circulation 2006;114:I-350-I-356.
ABSTRACT | FULL TEXT  

Role and Results of Surgery in Acute Type B Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection (IRAD)
Trimarchi et al.
Circulation 2006;114:I-357-I-364.
ABSTRACT | FULL TEXT  

Which suture technique is better in acute type A aortic dissection?
Ates
Eur. J. Cardiothorac. Surg. 2006;30:199-199.
FULL TEXT  

Management of Type A Aortic Dissection and a Large Pheochromocytoma: A Surgical Dilemma
Bowen et al.
Ann. Thorac. Surg. 2006;81:2296-2298.
ABSTRACT | FULL TEXT  

Atypical presentation of aortic dissection secondary to a gunshot wound.
Domingo et al.
Emerg. Med. J. 2006;23:e38-e38.
ABSTRACT | FULL TEXT  

Acute aortic syndrome: pathology and therapeutic strategies.
Ahmad et al.
Postgrad. Med. J. 2006;82:305-312.
ABSTRACT | FULL TEXT  

Coma Might Not Preclude Emergency Operation in Acute Aortic Dissection
Pocar et al.
Ann. Thorac. Surg. 2006;81:1348-1351.
ABSTRACT | FULL TEXT  

Aortic dissection and hypothermic arrest in a Jehovah's Witness patient: a case for recombinant factor VIIa?: [Dissection aortique et asystolie sous hypothermie chez un Temoin de Jehovah : un cas pour le facteur VIIa recombinant ?].
Ballen et al.
Canadian J. Anesthesia 2006;53:353-356.
ABSTRACT | FULL TEXT  

Survival and quality of life after repair of acute type A aortic dissection in patients aged 75 years and older justify intervention
Santini et al.
Eur. J. Cardiothorac. Surg. 2006;29:386-391.
ABSTRACT | FULL TEXT  

Suspected Aortic Dissection and Other Aortic Disorders: Multi-Detector Row CT in 373 Cases in the Emergency Setting
Hayter et al.
Radiology 2006;238:841-852.
ABSTRACT | FULL TEXT  

Endovascular stent-graft placement in aortic dissection: a meta-analysis
Eggebrecht et al.
Eur Heart J 2006;27:489-498.
ABSTRACT | FULL TEXT  

Role of the Media in Vascular Injury: Atherosclerosis and Dissection
Boor et al.
Toxicol Pathol 2006;34:33-38.
ABSTRACT | FULL TEXT  

Acute Aortic Syndromes
Tsai et al.
Circulation 2005;112:3802-3813.
FULL TEXT  

Delayed visceral malperfusion in aortic dissection--successful surgical revascularization using a saphenous vein graft
Kipfer et al.
Eur. J. Cardiothorac. Surg. 2005;28:903-905.
ABSTRACT | FULL TEXT  

Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes
Swap and Nagurney
JAMA 2005;294:2623-2629.
ABSTRACT | FULL TEXT  

Aortic Dissection with Pseudo-Aortic Regurgitation and Transient Myocardial Ischemia: A Case Report
Zreiqat et al.
ANGIOLOGY 2005;56:781-784.
ABSTRACT  

Aortic Emergencies
FURLOW
radtech 2005;77:41-49.
ABSTRACT | FULL TEXT  

How to Guide Stent-Graft Implantation in Type B Aortic Dissection?: Comparison of Angiography, Transesophageal Echocardiography, and Intravascular Ultrasound
Koschyk et al.
Circulation 2005;112:I-260-I-264.
ABSTRACT | FULL TEXT  

Acute Aortic Dissection Presenting With Congestive Heart Failure: Results From the International Registry of Acute Aortic Dissection
Januzzi et al.
J Am Coll Cardiol 2005;46:733-735.
FULL TEXT  

Editorial comment
Westaby
Eur. J. Cardiothorac. Surg. 2005;27:632-633.
FULL TEXT  

Outcome of Medical and Surgical Treatment in Patients With Acute Type B Aortic Dissection
Hsu et al.
Ann. Thorac. Surg. 2005;79:790-794.
ABSTRACT | FULL TEXT  

Endovascular stent-graft treatment of aortic dissection: determinants of post-interventional outcome
Eggebrecht et al.
Eur Heart J 2005;26:489-497.
ABSTRACT | FULL TEXT  

Acute Intramural Hematoma of the Aorta: A Mystery in Evolution
Evangelista et al.
Circulation 2005;111:1063-1070.
ABSTRACT | FULL TEXT  

Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection
Estrera et al.
J. Thorac. Cardiovasc. Surg. 2005;129:277-285.
ABSTRACT | FULL TEXT  

Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients
Chiappini et al.
Eur Heart J 2005;26:180-186.
ABSTRACT | FULL TEXT  

Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience
Trimarchi et al.
J. Thorac. Cardiovasc. Surg. 2005;129:112-122.
ABSTRACT | FULL TEXT  

Branch vessel complications are increased in aortic dissection patients with renal insufficiency
Beckman et al.
Vasc Med 2004;9:267-270.
ABSTRACT  

Differences in Clinical Presentation, Management, and Outcomes of Acute Type A Aortic Dissection in Patients With and Without Previous Cardiac Surgery
Collins et al.
Circulation 2004;110:II-237-II-242.
ABSTRACT | FULL TEXT  

Evolving Strategies for Treatment of Acute Aortic Dissection Type A
Kallenbach et al.
Circulation 2004;110:II-243-II-249.
ABSTRACT | FULL TEXT  

Secondary surgical interventions after endovascular stent-grafting of the thoracic aorta
Grabenwoger et al.
Eur. J. Cardiothorac. Surg. 2004;26:608-613.
ABSTRACT | FULL TEXT  

Surgery for acute type a aortic dissection: is advanced age a contraindication?
Chiappini et al.
Ann. Thorac. Surg. 2004;78:585-590.
ABSTRACT | FULL TEXT  

Aortic Dissection: A Dreaded Disease with Many Faces
Kasher et al.
J CARDIOVASC PHARMACOL THER 2004;9:211-218.
ABSTRACT  

Gender-Related Differences in Acute Aortic Dissection
Nienaber et al.
Circulation 2004;109:3014-3021.
ABSTRACT | FULL TEXT  

Acute dissection of the descending aorta: noncommunicating versus communicating forms
Srichai et al.
Ann. Thorac. Surg. 2004;77:2012-2020.
ABSTRACT | FULL TEXT  

Atherosclerotic Vascular Disease Conference: Writing Group V: Medical Decision Making and Therapy
Creager et al.
Circulation 2004;109:2634-2642.
FULL TEXT  

Acute aortic dissection versus aortic root aneurysm: comparison of indications for valve sparing aortic root reconstruction
Kallenbach et al.
Eur. J. Cardiothorac. Surg. 2004;25:663-670.
ABSTRACT | FULL TEXT  

Late outcome of patients with aortic dissection: study of a national database
Yu et al.
Eur. J. Cardiothorac. Surg. 2004;25:683-690.
ABSTRACT | FULL TEXT  

Acute type B aortic dissection in elderly patients: clinical features, outcomes, and simple risk stratification rule
Mehta et al.
Ann. Thorac. Surg. 2004;77:1622-1628.
ABSTRACT | FULL TEXT  

Case 12-2004 - A 38-Year-Old Woman with Acute Onset of Pain in the Chest
O'Gara et al.
NEJM 2004;350:1666-1674.
FULL TEXT  

Management strategies for type A dissection complicated by peripheral vascular malperfusion
Girardi et al.
Ann. Thorac. Surg. 2004;77:1309-1314.
ABSTRACT | FULL TEXT  

Abdominal CT Angiography Before Surgery as a Predictor of Postoperative Death in Acute Aortic Dissection
Vernhet et al.
Am. J. Roentgenol. 2004;182:875-879.
ABSTRACT | FULL TEXT  

Characterizing the young patient with aortic dissection: results from the international registry of aortic dissection (IRAD)
Januzzi et al.
J Am Coll Cardiol 2004;43:665-669.
ABSTRACT | FULL TEXT  

Can the principles of evidence-based medicine be applied to the treatment of aortic dissections?
Myrmel et al.
Eur. J. Cardiothorac. Surg. 2004;25:236-242.
ABSTRACT | FULL TEXT