Case series have described aortic dissection and rupture in pregnancy. Few population-based data exist to support an association.
We performed a cohort-crossover study using data on all emergency ...department visits and acute care hospitalizations at nonfederal healthcare facilities in California, Florida, and New York. We included women ≥12 years of age with labor and delivery or abortive pregnancy outcome between 2005 and 2013. Our outcome was a composite of aortic dissection or rupture. Based on the timing of reported aortic complications during pregnancy, we defined the period of risk as 6 months before delivery until 3 months after delivery. We compared each patient's likelihood of aortic complications during this period with an equivalent 270-day period exactly 1 year later. Incidence rates and incidence rate ratios were computed using conditional Poisson regression with robust standard errors.
Among 6 566 826 pregnancies in 4 933 697 women, we identified 36 cases of aortic dissection or rupture during the pregnancy or postpartum period and 9 cases during the control period 1 year later. The rate of aortic complications was 5.5 (95% confidence interval, 4.0-7.8) per million patients during pregnancy and the postpartum period, in comparison with 1.4 (95% confidence interval, 0.7-2.9) per million during the equivalent period 1 year later. Pregnancy was associated with a significantly increased risk of aortic dissection or rupture (incidence rate ratio, 4.0; 95% confidence interval, 2.0-8.2) in comparison with the control period 1 year later.
The risk of aortic dissection or rupture is elevated during pregnancy and the postpartum period.
Hereditary thoracic aortic disease: How to save lives Roman, Mary J.; De Backer, Julie
The Journal of thoracic and cardiovascular surgery,
January 2022, 2022-Jan, 2022-01-00, 20220101, Volume:
163, Issue:
1
Journal Article
Thoracic aortic dilatation requires accurate and timely detection to prevent progression to thoracic aortic aneurysm and aortic dissection. The detection of thoracic aortic dilatation necessitates ...the availability of cut-off values for normal aortic diameters. Tools to evaluate aortic dimension above the root are scarce and inconsistent regarding age groups. The aim of this study was to provide reference values for aortic root and ascending aortic diameters on the basis of transthoracic echocardiographic measurements in a large cohort of children and adults. Diameters at the level of the sinuses of Valsalva (SoV) and ascending aorta (AA) were assessed with transthoracic echocardiography in 849 subjects (453 females, age range 1 to 85 years, mean 40.1 ± 21.3 years) and measured according to published guidelines. Linear regression analysis was applied to create nomograms, as well as equations for upper limits of normal and z-scores. SoV and AA diameters were strongly correlated with age, body surface area (BSA), and weight (r = 0.67 to 0.79, p <0.001 for all). Male subjects had significantly larger aortic dimensions at all levels in adulthood, even after BSA correction (p ≤0.004 for all age intervals). Gender-, age-, and BSA-specific upper limits of normal and z-score equations were developed from a multivariate regression model, which strongly predicts SoV and AA diameters (adjusted R2 for SoV = 0.84 and 0.67 and for AA = 0.82 and 0.74, for male and female subjects, respectively). In conclusion, this study provides widely applicable reference values for thoracic aortic dilatation screening purposes. Age, BSA, and gender must be taken into account when assessing an individual patient.
Nomograms to predict normal aortic root diameter for body surface area (BSA) in broad ranges of age have been widely used but are limited by lack of consideration of gender effects, jumps in upper ...limits of aortic diameter among age strata, and data from older teenagers. Sinus of Valsalva diameter was measured by American Society of Echocardiography convention in normal-weight, nonhypertensive, nondiabetic subjects ≥15 years old without aortic valve disease from clinical or population-based samples. Analyses of covariance and linear regression with assessment of residuals identified determinants and developed predictive models for normal aortic root diameter. In 1,207 apparently normal subjects ≥15 years old (54% women), aortic root diameter was 2.1 to 4.3 cm. Aortic root diameter was strongly related to BSA and height (r = 0.48 for the 2 comparisons), age (r = 0.36), and male gender (+2.7 mm adjusted for BSA and age, p <0.001 for all comparisons). Multivariable equations using age, gender, and BSA or height predicted aortic diameter strongly (R = 0.674 for the 2 comparisons, p <0.001) with minimal relation of residuals to age or body size: for BSA 2.423 + (age years × 0.009) + (BSA square meters × 0.461) − (gender 1 = man, 2 = woman × 0.267), SEE 0.261 cm; for height 1.519 + (age years × 0.010) + (height centimeters × 0.010) − (gender 1 = man, 2 = woman × 0.247), SEE 0.215 cm. In conclusion, aortic root diameter is larger in men and increases with body size and age. Regression models incorporating body size, age, and gender are applicable to adolescents and adults without limitations of previous nomograms.
Abstract Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are associated with increased mortality, largely as a consequence of cardiovascular disease. Increased cardiovascular ...morbidity and mortality in patients with RA and SLE cannot be entirely explained by traditional risk factors, suggesting that the systemic inflammation that characterizes these diseases may accelerate atherosclerosis. We used carotid ultrasonography to investigate the prevalence and correlates to preclinical atherosclerosis in patients with RA and SLE. Because atherosclerosis is a systemic disease, assessment of carotid plaque by ultrasonography provides a robust, direct measure of systemic atherosclerosis. We observed a substantially increased prevalence of carotid plaque in RA and SLE patients compared with age- and sex-matched controls, which remained after adjustment for traditional risk factors. The presence of carotid atherosclerosis was associated with disease duration in both RA and SLE and damage in SLE. These data support the hypothesis that inflammation associated with RA and SLE contributes to accelerated atherosclerosis and argue that RA and SLE disease activity should be more aggressively managed.
Pressure measured with a cuff and sphygmomanometer in the brachial artery is accepted as an important predictor of future cardiovascular risk. However, systolic pressure varies throughout the ...arterial tree, such that aortic (central) systolic pressure is actually lower than corresponding brachial values, although this difference is highly variable between individuals. Emerging evidence now suggests that central pressure is better related to future cardiovascular events than is brachial pressure. Moreover, anti-hypertensive drugs can exert differential effects on brachial and central pressure. Therefore, basing treatment decisions on central, rather than brachial pressure, is likely to have important implications for the future diagnosis and management of hypertension. Such a paradigm shift will, however, require further, direct evidence that selectively targeting central pressure, brings added benefit, over and above that already provided by brachial artery pressure.
The risk of pregnancy-associated vascular complications in Marfan syndrome (MFS) is uncertain because of ascertainment bias, prepartum lack of knowledge of diagnosis, and insufficient peripartum ...imaging data. Furthermore, U.S. and European guidelines differ in pregnancy recommendations in MFS.
This study describes a single-center experience of 169 MFS women to address these gaps.
Clinical, imaging, and pregnancy history were compared in never vs ever-pregnant MFS women, and pregnancy-associated vascular complications were described.
A total of 74 ever-pregnant women had 112 live births. Elective aortic root replacement occurred at a younger age in never-pregnant women (33 years vs 42 years; P = 0.0026). Although aortic dissection prevalence did not differ between never-pregnant vs ever-pregnant women (23% vs 31%; P = 0.25), it tended to occur at an earlier age in the former group (38 years vs 45 years; P = 0.07). Of observed “sanctioned” pregnancies with prepartum diameters ≤4.5 cm, mean pregnancy-related aortic diameters remained stable. In total, 5 dissections were associated with pregnancy: 2 type A in women unaware of their diagnosis; and 2 type B and 1 isolated coronary artery dissection in women aware of their diagnosis. Dissection rates were 5-fold higher in the pregnancy vs nonpregnancy period.
Pregnancy-related type A dissection only occurred in patients unaware of their diagnosis. Type B dissection remains an unpredictable complication. Although there were baseline differences between the never- and ever-pregnant groups, no difference in dissection risk was observed outside the peripartum period. Those with prepartum aortic diameters between 4.0 and 4.5 cm demonstrated stable aortic dimensions throughout pregnancy. These findings provide a rationale to update existing U.S. guidelines for the management of pregnancy in MFS.
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Aortic Dissection Risk in Marfan Syndrome Roman, Mary J.; Devereux, Richard B.
Journal of the American College of Cardiology,
03/2020, Volume:
75, Issue:
8
Journal Article
In conclusion, numerous studies have documented a superior relation of central over brachial BP to intermediate cardiovascular phenotypes or cardiovascular target organ damage. In general, PP has ...been more strongly related to vascular disease, whereas systolic pressure seems to be a more important determinant of LVH. The similarity of findings in a wide variety of patient-based and population-based studies as well as a broad range of ethnicities supports the robust nature of this phenomenon. Although data regarding the superiority of central over brachial PP with regard to LV diastolic dysfunction are preliminary, the importance of LVH, female sex, and aging as underlying risk factors for HFPEF suggests that more extensive evaluation is likely to reveal a stronger relation of central than peripheral BP with this additional measure of target organ involvement. Finally, limited data suggesting a more important impact of reversing hypertensive cardiovascular hypertrophy by lowering central pressure for a given brachial pressure require confirmation in larger, longitudinal intervention studies.
We previously demonstrated stronger relations of central vs. brachial blood pressure, particularly pulse pressure, to carotid artery hypertrophy and extent of atherosclerosis. Data regarding the ...relative impacts of central and brachial pressures on left ventricular hypertrophy and geometry are limited.
Echocardiography and radial applanation tonometry were performed in American Indian participants in the 4th Strong Heart Study examination. Left ventricular mass was calculated using an anatomically validated formula and adjusted for height. Brachial blood pressure was measured according to a standardized protocol. Central pressures were derived using a generalized transfer function.
Of 2585 participants in the analysis, 60% were women, 21% had diabetes and 33% were hypertensive; the mean age was 40 +/- 17 years. All blood pressure variables were significantly related to left ventricular absolute and relative wall thicknesses and left ventricular mass index (all P < 0.001), with considerable variation in correlation coefficients (r = 0.135-0.432). Central and brachial systolic pressures were uniformly more strongly related to left ventricular wall thicknesses, diastolic diameter and mass index than their respective pulse pressures (all P < 0.005 by z statistics). Left ventricular relative wall thickness and mass index were more strongly related to central than brachial pressures.
Left ventricular hypertrophy is more strongly related to systolic pressure than to pulse pressure. Furthermore central pressures are more strongly related than brachial pressures to concentric left ventricular geometry. These data suggest that absolute (systolic) pressure is more important in stimulating left ventricular hypertrophy and remodeling, whereas pulsatile stress (pulse pressure) is more important in causing vascular hypertrophy and atherosclerosis.
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