Ann Thorac Surg 2004;77:1622-1628
© 2004 The Society of Thoracic Surgeons
Original article: cardiovascular
Acute type B aortic dissection in elderly patients: clinical features, outcomes, and simple risk stratification rule
Rajendra H. Mehta, MD, MSa*,
Eduardo Bossone, MDa,
Arturo Evangelista, MDa,
Patrick T. O'Gara, MDa,
Dean E. Smith, PhDa,
Jeanna V. Cooper, MSa,
Jae K. Oh, MDa,
James L. Januzzi, MDa,
Stuart Hutchison, MDa,
Dan Gilon, MDa,
Linda A. Pape, MDa,
Christoph A. Nienaber, MDa,
Eric M. Isselbacher, MDa,
Kim A. Eagle, MDa International Registry of Acute Aortic Dissection (IRAD) Investigators
a Department of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
Accepted for publication October 20, 2003.
* Address reprint requests to Dr Mehta, University of Michigan, Cardiology 111A 7E, 2215 Fuller Rd, Ann Arbor, MI 48105, USA
e-mail: rmehta{at}umich.edu
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Abstract
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BACKGROUND: The clinical features and outcomes of elderly patients with acute type B aortic dissection (ABAD) are less well known. Accordingly, we sought to evaluate the clinical features and outcomes and derive a simple risk stratification rule for elderly with ABAD.
METHODS: We categorized 383 patients with ABAD enrolled in the International Registry of Acute Aortic Dissection into two strata (aged less than 70 years and aged 70 years or more) and compared their clinical features and in-hospital outcomes. Further, we developed a clinical decision rule to risk-stratify elderly with ABAD.
RESULTS: Forty-two percent (161 of 383) of patients with ABAD were aged 70 years or more. Hypertension, diabetes, history of prior aortic aneurysm, and arteriosclerosis were more common in the elderly patients, whereas Marfan syndrome and cocaine abuse were less common. The in-hospital complication of hypotension/shock was more common among elderly, and malperfusion of a visceral organ less frequent among elderly patients. In-hospital mortality was higher in the elderly cohort compared with the younger patients (16% versus 10%, p = 0.07). A classification tree identified that elderly patients with hypotension/shock had the highest risk of death (56%). In absence of this, any branch vessel involvement was associated with the next highest mortality rate (28.6%) followed by presence of periaortic hematoma (10.5%). In contrast, elderly patients without any of these three risk factors had an extremely low mortality rate (1.3%).
CONCLUSIONS: Our study highlights important differences between older and younger patients with ABAD in their clinical characteristics, management, and outcomes. We also propose a simple decision rule that allows stepwise risk-stratification in elderly patients with ABAD.
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Introduction
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The majority of patients with acute aortic dissection are in their sixth decade of their life or older, particularly those with acute type B dissection [1–8]. Prior investigations have shown that compared with younger patients, elderly patients with acute type B dissection have a greater propensity of aneurysm expansion leading to aortic rupture as well as a higher risk of in-hospital and long-term mortality among medically as well as surgically treated patients [7–13]. Yet, despite the greater incidence of acute type B dissection and the associated higher morbidity and mortality among elderly patients, no study has evaluated the clinical characteristics of elderly patients compared with the younger cohort among a large group of patients with this disease entity. With the aging of the global population, the number of patients presenting with acute type B dissection would be expected to increase. As such, a better understanding of the clinical features, imaging findings, management, and outcomes of the elderly cohort with acute type B aortic dissection should allow physicians a better understanding of how these characteristics correlate with their outcomes. Improved risk-stratification of elderly patients with acute type B dissection may allow physicians to better educate patients and their families with regard to the risk of their disease and its treatment.
Accordingly, we studied patients with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD) [3, 14] to evaluate the differences in the clinical manifestations, imaging findings, management, and in-hospital outcomes between patients 70 years of age or older versus patients less than 70 years of age. Additionally, we also attempted to stratify elderly patients into varying risk categories.
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Material and methods
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Study population
We examined data on all patients with acute type B aortic dissection in IRAD enrolled from January 1, 1996, to December 31, 2001. The rationale and methodology of IRAD have been previously published [3, 14]. Acute type B dissection was defined as any dissection that involved the descending aorta (without any tear in the ascending aorta) with presentation within 14 days of symptom onset [3, 4, 15]. Patients were categorized into two age-based groups: less than 70 years old and 70 or more years old. The Institutional Review Board for research at all IRAD sites approved the study protocol.
Data collection
Data were collected on a standard questionnaire form and included information on patient demographics, history, clinical presentation, imaging findings, management, and hospital clinical events including mortality. Completed data forms were forwarded to the IRAD coordinating center at the University of Michigan where they were entered into an Access database.
Statistical analysis
Summary statistics of the two age groups were presented as frequencies and percentages and mean ± standard deviation. In all cases, missing data were not defaulted to negative and denominators reflect cases reported. Univariate associations among the age groups for nominal variables were compared using the Pearson 
2 test or, when appropriate, the two-sided Fisher's exact test, while the two-tailed Student's t test was used for continuous variables. Iterative logistic regression modeling was performed to derive independent predictors of hospital mortality and adjusted estimates for the odds ratios of in-hospital mortality for the older patients using likelihood ratio tests. Initial modeling used variables marginally suggestive of unadjusted association to in-hospital death (p < 0.20). Variables were reviewed for clinical significance before testing. Diagnostic routines (the Hosmer-Lemeshow test for lack of fit and likelihood ratio test) were used for the final model selection. The c-index was calculated to evaluate model discrimination. Estimates of survival in patients with type B dissection less than 70 years of age and 70 or more years of age were determined by the Kaplan-Meier survival method and compared using the log-rank test. Finally, we used a classification tree to identify clinical variables among elderly patients that allowed identification of individuals with acute type B dissection at low risk. Beginning with the factor associated with worse outcome (mortality), this method splits the data successively in a manner that maximally distinguishes the response variable in the left and right branch [16]. For all analyses, SAS Version 8.2 (SAS Institute, Cary, NC) was utilized.
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Results
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Clinical features, diagnostic imaging findings, and in-hospital management
Of 383 patients with acute type B dissection in IRAD, 42% were 70 or more years of age (10.5% were 80 years old or older). Age of the overall population ranged from 20 to 93 years (interquartile range, 56 to 74). Median length of stay for all patients with type B dissection was 28 days (interquartile range, 8.0 to 30) and was similar for the two groups. Although both groups had male predominance, the proportion of female patients with acute type B dissection almost doubled in the elderly cohort (Table 1). Nearly two thirds of patients in both groups were transferred from other hospitals to IRAD sites. While the time intervals from symptom onset to surgery, symptom onset to diagnosis, and diagnosis to surgery were all shorter for the younger cohort, these were statistically not significantly different.
A history of hypertension was present in a majority of patients with type B dissection and was more common (nonsignificant trend) among elderly patients than among the younger cohort. While arteriosclerosis, diabetes, and prior aortic aneurysm were more common among the elderly, Marfan syndrome and cocaine abuse were seen only in the younger group. Other etiologies and comorbid conditions and presenting symptoms and signs were not significantly different in the two groups with the exception of a lower incidence of pulse deficits in the older patients (Tables 1 and 2).
Chest x-ray films were more likely to demonstrate pleural effusions and mediastinal widening in elderly patients with acute type B dissection, whereas electrocardiographic abnormalities of Q waves and ST deviations did not differ between the two groups. Elderly patients were less likely to undergo transesophageal echocardiography and aortography with a trend toward lower use of magnetic resonance imaging. The presence of a patent false lumen on diagnostic imaging was significantly less common among the elderly, whereas there was a trend for a greater proportion of the elderly patients having an aortic diameter 6 cm or greater or periaortic hematoma (Table 2). The prevalence of intramural hematoma, while higher among elderly, was not statistically different.
Compared with younger patients, elderly patients with acute type B dissection were more frequently managed medically rather than with surgery or percutaneous stents or fenestrations. Appropriate medical therapies (particularly ß-blockers) did not differ between the two groups (Table 3).
The indications for surgical management in IRAD were as follows: recurrent or refractory pain 42%, limb ischemia 16%, extension of dissection 40%, hypertension refractory to medical management leading to persistence of pain and or extension of dissection 18%, and refractory hypotension or shock 10% (reasons not mutually exclusive). Percutaneous fenestrations or stents, or both, were performed for organ malperfusion or for patients deemed high risk for surgery by the treating physician.
Compared with patients treated medically, the patients who underwent surgery were more likely to be younger and male, and to have hypertension, diabetes, a neurologic deficit on presentation in hospital, periaortic hematoma, wider aortic diameter, any branch vessel involvement with evidence of malperfusion, in-hospital shock (data not shown). Similarly, compared with patients treated medically, those treated with percutaneous stents or fenestrations were more likely to be younger, more likely to be transferred to IRAD sites from community hospitals, and more likely to have prior cardiac surgery, periaortic hematoma, wider aortic diameter, and any branch vessel involvement with evidence of malperfusion (data not shown).
In-hospital outcomes
Elderly patients showed a trend toward lower in-hospital adverse events of limb ischemia or malperfusion. In contrast, elderly patients had a greater propensity for hypotension or shock. In-hospital mortality was 1.7-fold higher in the elderly compared with younger patients (p = 0.07; Table 4).
The 30-day survival was lower among the elderly regardless of treatment type (Fig 1).
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Fig 1. Survival curves for death due to type B dissection by age group and management strategies. Kaplan-Meier survival curves for patients with acute type B aortic dissection aged 70 years or more versus those less than 70 years of age stratified by treatment types. Log rank test p = 0.10 for older versus younger patients managed medically, and p = 0.13 for the two age groups managed with surgery.
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Multivariate logistic regression analysis identified hypotension or shock, any branch vessel involvement and periaortic hematoma to be independent predictors of in-hospital death in the elderly patients (Table 5).
Age as a continuous variable when entered into the model in Table 5 resulted in overfitting although it was a significant predictor. However, when age was entered as a dichotomous variable, age less than 80 years versus age 80 years or more, there was a trend toward higher in-hospital death in patients 80 or more years of age (20% versus 15%; adjusted odds ratio 4.59, 95% confidence interval 0.95 to 22.08, p = 0.057).
The classification tree identified three clinical factors useful for stratifying the risk of in-hospital death among the elderly patients with acute type B dissection: hypotension or shock, peripheral branch vessel involvement, and periaortic hematoma. As seen in Figure 2,
elderly patients with hypotension or shock had the highest risk of in-hospital death (56%). Patients without any of the three risk factors (approximately 60%) had very low in-hospital mortality (1.3%). Elderly patients with one or more of these risk factors (high-risk group) had a trend toward higher mortality compared with the high-risk younger patients (34.5% versus 20.0%, p = 0.052; Fig 3).
No difference was seen between the two age groups without any of these risk factors (low-risk group, 1.8% versus 1.3%; p = not significant).
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Fig 2. Classification tree for the risk of in-hospital death in elderly patients ( 70 years) with acute type B aortic dissection. Please note that patients with hypotension or shock have the highest risk of death (56.0%). In absence of this, any branch vessel involvement is associated with the next highest mortality rate (28.6%), followed by presence of periaortic hematoma (10.5%). Elderly patients without any evidence of these three factors have the lowest mortality rate (1.3%).
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Fig 3. In-hospital mortality in low- and high-risk groups: mortality rate for patients aged less than 70 years versus those aged 70 years or more with acute type B aortic dissection stratified into low- and high-risk categories. High-risk patients are those with hypotension or shock, any branch vessel involvement, or periaortic hematoma. Low-risk patients are those without these three risk factors.
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Comment
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Our investigation represents the largest report to date examining the clinical features, management, and outcomes of elderly patients compared with younger patients with acute type B aortic dissection. Besides providing a global perspective on clinical features and outcomes among a large number of unselected elderly patients with acute type B aortic dissection, we also made an attempt to provide a simple decision rule to stratify risk of in-hospital death in these patients. Such information is particularly important for physicians in the view of the fact that the elderly constitute a significant proportion of patients with type B dissection (42% in IRAD). This number is expected to increase substantially with the aging of the population.
Our study found that like many other cardiovascular diseases [17], the clinical features, management, and outcomes of the elderly with type B dissection differed from younger patients. The greater proportion of females among the elderly with acute type B dissection may be a result of the longer lifespan of females than males. Not surprisingly, factors associated with generalized arteriosclerosis such as hypertension and diabetes were more common in elderly patients with type B dissection. In contrast, there was a virtual absence of dissections associated with genetic diseases such as Marfan syndrome as well as those associated with cocaine abuse in the elderly cohort. Thus, treatment of hypertension, diabetes, and other atherosclerotic risk factors may have an important role in decreasing the risk of acute type B aortic dissection in elderly patients. Interestingly, unlike other cardiovascular conditions such as acute myocardial infarction, where elderly are more likely to present with atypical symptoms and signs [17], these clinical presenting features did not differ between the younger and the older patients with acute type B aortic dissection.
A semi-invasive or invasive test such as transesophageal echocardiography or aortography was performed less often in the elderly patients, most likely because of the physician's perception of an increased risk of such procedures in the elderly. Consistent with prior studies, elderly patients in our investigation often tended to have the diameter of their dissecting aneurysm larger than 6 cm in diameter, a factor known to be associated with increased risk of rupture [9, 10]. The greater propensity of rupture in the elderly may also account for the increased frequency of pleural effusions and periaortic hematomas seen among the elderly with acute type B dissection in our study.
Elderly patients with acute type B aortic dissection were frequently managed medically as opposed to an invasive strategy such as surgery or percutaneous stenting or fenestration. This may again be related to the physician's perception of increased risk with invasive strategy among the elderly patients. Interestingly, the presence of a patent false lumen was seen less frequently among the elderly cohort. The presence of a large or expanding patent false lumen is considered an important indication for surgery or stents or fenestrations. This relationship may also have played a role in the less aggressive approach adopted for the elderly. Most notably, medical management (including the use of ß-blockers by nearly 80% of patients without hypotension) was similar in the two groups, suggesting that at least in these large tertiary referral centers, appropriate medical therapy is utilized in most patients. Management strategies in IRAD were not mandated by a particular protocol and were dictated by the treating physicians at various centers. These limitations preclude any inference regarding the efficacy of any given management strategy.
Complications of acute type B aortic dissection were also different between the two cohorts. Hypotension or shock occurred with a greater frequency among the elderly, again most probably indicating rupture or impending rupture. In contrast, malperfusion of vital organs was less likely to occur in the elderly compared with younger patients. It is possible that the elderly may have more localized dissection resulting in a lower incidence of malperfusion, yet may have a greater propensity for rupture of this localized aortic tear resulting in greater incidence of hypotension and shock. As reported by other investigators [7–13], older age was associated with increased mortality in patients with acute type B aortic dissection.
Hypotension or shock and periaortic hematoma generally indicate a rupture or impending rupture of the aorta in type B aortic dissection, a complication which frequently leads to death. Similarly, involvement of celiac-mesenteric, spinal, and limb circulation often culminates in organ hypoperfusion, leading to increased mortality. Thus, it is not surprising that these factors were found to be strongest independent predictors of mortality among the elderly patients.
We used these variables to create a decision tree to help physicians define an elderly patient's risk of mortality with acute type B aortic dissection. Although elderly patients who have hypotension and shock have a more than 50% chance of in-hospital death, elderly patients who are hemodynamically stable, do not have any branch vessel involvement, and do not have periaortic hematoma have a mortality rate that is extremely low, about 1%. The group of patients without these three risk factors makes up approximately 60% of the elderly population. Thus, our study helps to identify a significant portion of the elderly population that has an extremely low risk of death in-hospital. This decision rule may allow physicians to make an educated choice regarding surgical or medical management in elderly patients with acute type B aortic dissection.
Currently, surgery in acute type B dissection is indicated for patients with persistent symptoms despite medical treatment, extension of the dissection tear, a large rapidly expanding false lumen, an impending rupture/rupture, or major organ malperfusion [4, 18]. Factors identified by our decision rule that correlates with high-risk includes signs of rupture or impending rupture (hypotension, shock, and periaortic hematoma) or organ malperfusion (any branch vessel involvement). Thus, we believe that surgery should be considered for elderly patients with type B dissection who are at high risk based on our decision rule. Interestingly, similar proportions of elderly and young patients have one or more of these risk factors (43.4% versus 42.9%, p = 0.93). Elderly patients without any of these risk factors have a very low mortality rate and are best managed with medical therapy (ie, aggressive control of blood pressure, use of ß-blockers to reduce the dP/dT, and modification of the atherosclerotic risk factors). In IRAD, 42.4% of the elderly in the high-risk group were managed surgically or with stents or fenestrations versus 61.2% of younger patients with these risk factors (p = 0.03). It is possible that more aggressive management of the high-risk elderly patients (similar to that of the younger age group) may have resulted in better outcomes of these patients. Alternatively, the more recently available and less invasive percutaneous catheter-based techniques of fenestration or stents may provide potential benefit with less risk in this group of patients [4, 19–21]. These procedures were performed in only 11 elderly patients with type B aortic dissection enrolled in our registry. Hence, effectiveness of this treatment strategy cannot be assessed from our data.
We found that two thirds of the elderly patients were transferred for further management to the IRAD sites from other referring hospitals. The decision rule derived in our study could help physicians to identify low risk patients with acute type B aortic dissection and may allow for medical treatment to be carried out at smaller hospitals for this low-risk group, preventing otherwise routine transfer of such patients. This approach may have implications on reducing health care resource utilization. The efficacy and safety of this simple decision rule in risk stratification, its value in making decisions regarding management, as well as its impact on reducing the otherwise routine transfer of such patients to tertiary care centers and improving outcomes in the high-risk elderly cohort, remain to be proven in future prospective studies.
Limitations
All patients in our study had acute type B aortic dissection and were managed at tertiary care hospitals. Thus, our findings may not be applicable for those with chronic stable dissection or those who are treated at hospitals that lack the surgical expertise for the management of these patients. Data were collected retrospectively through voluntary participation of IRAD centers and thus were subject to incomplete or missing information. Further, treatments at various sites were not protocol driven and varied at different centers, limiting our ability to provide any meaningful insight into the efficacy of the different treatment strategies in the elderly cohort. Validation of our decision rule was not performed. Long-term outcomes were not evaluated, and an effort is ongoing to evaluate long-term outcomes.
Conclusions
Our study highlights important differences in the demographics, clinical features, management, and outcomes of elderly compared with younger patients with acute type B aortic dissection. Additionally, we provide a simple decision rule for risk stratification that may aid physicians not only in their choice of treatment strategies (medical therapy for low-risk patients versus surgical therapy for high-risk patients), but also in educating patients and families regarding their perceived risk of in-hospital mortality. Appendix
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Acknowledgments
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This work was supported by the University of Michigan Faculty Group Practice and Varbedian Fund for Aortic Research, Ann Arbor, MI.
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Appendix
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International registry of acute aortic dissection (IRAD) investigators
Coprincipal investigators
Kim A. Eagle, MD, University of Michigan, Ann Arbor, Michigan; Eric M. Isselbacher, MD, Massachusetts General Hospital, Boston, Massachusetts; and Christoph A. Nienaber, MD, University of Rostock, Rostock, Germany.
Coinvestigators
Eduardo Bossone, MD, National Research Council, Brindisi, Italy; Arturo Evangelista, MD, Hospital General Universitari Vall d'Hebron, Barcelona, Spain; Rossella Fattori, MD, University Hospital S. Orsola, Bologna, Italy; Dan Gilon, MD, Hadassah University Hospital, Jerusalem, Israel; Steve Goldstein, MD, Washington Heart Center, Washington, DC; Stuart Hutchison, MD, St. Michael's Hospital, Toronto, Ontario, Canada; James L. Januzzi, MD, Massachusetts General Hospital, Boston, Massachusetts; Alfredo Llovet, MD, Hospital Universitario "12 de Octubre," Madrid, Spain; Rajendra H. Mehta, MD, MS, University of Michigan, Ann Arbor, Michigan; Truls Myrmel, MD, Tromsø University Hospital, Tromsø, Norway; Patrick O'Gara, MD, and Joshua Beckman, MD, Brigham and Women's Hospital, Boston, Massachusetts; Jae K. Oh, MD, Mayo Clinic, Rochester, Minnesota; Linda A. Pape, MD, University of Massachusetts Hospital, Worcester, Massachusetts; Marc Penn, MD, Cleveland Clinic Foundation, Cleveland, Ohio; Udo Sechtem, MD, Robert-Bosch Krankenhaus, Stuttgart, Germany; and Toru Suzuki, MD, University of Tokyo, Tokyo, Japan.
Data management and biostatistical support
Jeanna V. Cooper, MS, Jianming Fang, MS, and Dean E. Smith, PhD, University of Michigan, Ann Arbor, Michigan.
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Abstract
Introduction
