Trends in mortality from aortic dissection analyzed from the World Health Organization Mortality Database from 2000 to 2017

https://doi.org/10.1016/j.ijcard.2022.05.043Get rights and content

Highlights

  • In 2000-2017, mortality from aortic dissection decreased in Australia, the USA, and many European countries.

  • Increasing mortality was seen in Austria, the Czech Republic, Germany, Hungary, Israel, with the largest increase in Japan.

  • In 2017, the highest mortality rates were in Japan and the lowest in Kyrgyzstan.

  • The age-standardized death rates in 2017 were higher for men than women.

Abstract

Background

We assessed trends in aortic dissection (AD) death rates in 23 countries from 2000 to 2017.

Methods

We extracted AD mortality data for countries with high usability data from the World Health Organization (WHO) Mortality Database and from the Center for Disease Control (CDC) WONDER Database for the United States of America (USA). Age Standardized Death Rates (ASDRs) per 100,000 population were computed. Trends were assessed by locally weighted scatter plot smoother (LOWESS) regression.

Results

Between 2000 and 2017, ASDRs from AD decreased in Australia, Belgium, Croatia, Denmark, France, Italy, New Zealand, Norway, Sweden, the United Kingdom, and the USA for both sexes. Increasing AD mortality was observed in Austria, Czech Republic, Germany, Hungary, Israel, and Japan for both sexes. The largest absolute increases in ASDR were in Japan for men (+1.59) and women (+1.11). The largest percentage decreases were in Norway for men (−0.91) and in New Zealand (−0.6) for women. In 2017, the highest mortality rates were in Japan for both sexes (3.22 and 2.09, respectively). The lowest ASDR was in Kyrgyzstan for both sexes (0.16 and 0.10, respectively). ASDRs for AD in 2017 were higher for men than women in all countries included. Spain had the greatest difference between the gender's mortality rates with a 2.71-fold higher mortality average rate in men.

Conclusion

We identified an overall decrease in AD mortality in most included countries, while an increase was noted in other countries including Israel and Japan.

Introduction

Aortic dissection (AD) is a life-threatening condition caused by a tear in the intimal layer of the aorta or bleeding from the vasa vasorum within the aortic wall, resulting in the dissection of the layers of the aortic wall and propagation of a false lumen within the wall of the aorta [1]. AD is the most common lethal event affecting the aorta, with a similar incidence to ruptured aortic aneurysms in Western populations [2]. Ascending aortic dissection (Stanford type A) is almost twice as common as descending aortic dissection (Stanford type B) [3]. Data from the International Registry of Acute Aortic Dissection (IRAD) published in 2018 revealed that 67% of patients presented with type A AD, with the remaining 33% being type B, where two-thirds of patients were men having a mean age of 63 years [4]. In AD, blood flow in the false lumen can cause complications such as aortic rupture, malperfusion of aortic branch arteries, and pericardial tamponade. Stanford type A dissections usually mandate urgent open surgical repair of the ascending aorta, while Stanford type B dissections are usually treated by endovascular repair of the descending thoracic aorta with a stent graft and/or medical therapy [5,6].

Compromise of aortic integrity underlies AD, and this can be caused by inherited wall weakness (inherited connective tissue disease such as Marfan, Ehlers-Danlos, and Loeys-Deitz syndromes) or acquired wall weakness (atherosclerosis, trauma, aneurysm, inflammation and infection, aortic instrumentation or surgery) [7]. Hypertension increases pressure on the aortic wall, triggering an intimal tear [8].

During the last 20 years, the diagnosis has been optimized through the use of computed tomography in addition to the presenting symptoms (chest pain, back pain) and physical findings. The mainstay of management for type A AD is open surgical repair (OSR), with almost 90% of patients receiving OSR. Accordingly, overall in-hospital mortality from type A AD has been steadily declining, mainly due to a decline in surgical mortality. Conversely, in-hospital mortality remains unchanged for type B AD, despite the increasing use of minimally invasive endovascular surgery and improved medical optimization of blood pressure to reduce hemodynamic stress on the damaged aortic wall [5].

Previous articles have discussed mortality trends from AD in several countries. Sidloff and colleagues have shown that aortic dissection mortality demonstrates variability, however, is mainly declining from 1994 to 2010 in most of the eighteen countries studied worldwide [9]. On the other hand, Sampson and colleagues have concluded that the burden of aortic dissection from 1990 to 2010 increased in developing regions [10]. In the state of São Paulo, Brazil, an increasing trend in age-standardized death rates from AD was observed in men and women from 1985 to 2009 [11].

To our knowledge, no up-to-date analysis has been published presenting global trends in AD mortality. The objective of this study was to describe mortality rates due to AD in countries with high usability data based on the WHO Mortality Database, and in the United States of America (USA) based on the Centers for Disease Control and Prevention (CDC) WONDER database, between 2000 and 2017.

Section snippets

Data sources

Aortic dissection mortality data for countries with high usability data, as defined by the WHO, were extracted from the WHO Mortality Database for the years 2000–2017 inclusive. “Usability” is the percentage of the total number of deaths that are registered with valid cause-of-death information [12]. The WHO evaluates data quality and ensures reliability by providing details of reporting and comparability. For inclusion in the WHO Mortality Database, birth and population recording must exceed

Results

Data for analysis meeting inclusion criteria were available in 23 countries: Australia, Austria, Belgium, Croatia, Czech Republic, Denmark, France, Germany, Hungary, Israel, Italy, Japan, Kyrgyzstan, Lithuania, Netherlands, New Zealand, Norway, Romania, Spain, Switzerland, the UK, and the USA. Four countries were excluded owing to missing data (72% in Estonia, 61% in Ireland, 67% in Mauritius, and 33% in Moldova), and three others had populations of less than one million citizens (Iceland,

Discussion

In this observational study assessing trends in AD mortality in 23 countries with high usability data over 18 years, decreases in both sexes were seen in Norway, Croatia, New Zealand, the UK, Sweden, France, Italy, Denmark, Australia, and Belgium, whereas increases in both sexes were observed in the Czech Republic, Japan, Germany, Israel, Austria, and Hungary. There was a discrepancy between men and women in Kyrgyzstan, Lithuania, and Romania (increasing AD mortality in men, decreasing in

Conclusions

In conclusion, AD mortality trends were decreasing in Australia, the USA, and most European countries, mirroring a decrease in atherosclerotic diseases, possibly due to common risk factors. However, an increase in AD mortality and a discrepancy between sexes was noted in the remaining countries which warrants further investigation.

Author statement

Nour Abdallah: Conception and Design Analysis, Interpretation, Data Collection, Writing, Christian Mouchati: Conception and Design Analysis, Interpretation, Data Collection, Writing, Conor Crowley: Statistical analysis, Critical Revision, Lydia Hanna: Writing, Critical Revision, Richard Goodall: Conception and Design Analysis, Interpretation.

Justin Salciccioli: Statistical analysis, Critical Revision, Dominic Marshall: Conception and Design Analysis, Interpretation, Critical Revision, Richard

Declaration of Competing Interest

Authors disclose no conflict of interests.

Acknowledgments

N.A. and C.M. contributed equally to this article. The medical data research collaborative (MDR Collab) provided infrastructure support for this work. The authors declare no conflict of interest. This research did not receive any specific grant.

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