Trends in mortality from aortic dissection analyzed from the World Health Organization Mortality Database from 2000 to 2017
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.
References (41)
- et al.
Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture
Mayo Clin. Proc.
(2004 Feb) - et al.
Global and regional burden of aortic dissection and aneurysms: mortality trends in 21 world regions, 1990 to 2010
Glob. Heart
(2014 Mar) Metabolic syndrome update
Trends Cardiovasc. Med.
(2016 May)- et al.
Epidemiology and clinicopathology of aortic dissection
Chest.
(2000 May) - et al.
Acute aortic dissection
Lancet.
(2008 Jul 5) - et al.
Should triple rule-out CT angiography be used in patients with suspected acute coronary artery disease, aortic dissection, or pulmonary embolus?
Ann. Emerg. Med.
(2015 Feb) - et al.
The role of imaging in aortic dissection and related syndromes
JACC Cardiovasc. Imaging
(2014 Apr) - et al.
The ascending aortic image quality and the whole aortic radiation dose of high-pitch dual-source CT angiography
J. Cardiothorac. Surg.
(2013 Dec 12) - et al.
National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality
Ann. Thorac. Surg.
(2013 May) - et al.
Acute type a aortic dissection in the United Kingdom: surgeon volume-outcome relation
J. Thorac. Cardiovasc. Surg.
(2017 Aug)
Less invasive quick replacement for octogenarians with type a acute aortic dissection
J. Thorac. Cardiovasc. Surg.
Impact of a multidisciplinary acute aortic dissection program: improved outcomes with a comprehensive initial surgical repair strategy
J. Vasc. Surg.
Long-term follow up of patients with acute aortic syndromes: relevance of both aortic and non-aortic events
Eur. J. Vasc. Endovasc. Surg.
A global assessment of civil registration and vital statistics systems: monitoring data quality and progress
Lancet.
Aortic dissection
Nat. Rev. Dis. Primers
Surgical indications for thoracic aortic disease: beyond the “magic numbers” of aortic diameter
G Ital. Cardiol. (Rome).
Insights from the international registry of acute aortic dissection: a 20-year experience of collaborative clinical research
Circulation.
Pathophysiology, diagnosis, and management of aortic dissection
Ther. Adv. Cardiovasc. Dis.
Endovascular stent-graft placement for the treatment of acute aortic dissection
N. Engl. J. Med.
Aortic dissection
Cited by (7)
EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ
2024, Annals of Thoracic SurgeryPrognostic impact of branch vessel involvement on organ malperfusion and mid-term survival in patients with acute type A aortic dissection
2023, International Journal of CardiologyEACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ
2024, European Journal of Cardio-thoracic SurgeryHotspots and development frontiers of postoperative complications of AD: Bibliometric analysis - A review
2023, Medicine (United States)
- 1
Equal authorship contribution.
- 2
This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.