Indexing ascending aortopathy (AA) to height better identifies patients, especially women, who could benefit from earlier surgery rather than absolute diameters, according to a recent study published in JACC: Advances.

Milind Y. Desai, MD, MBA, et al., included 11,083 patients (68 ± 13 years, 79% men, 28% with bicuspid aortic valve) diagnosed via echocardiography with AA (4-5 cm) between 2010 and 2023 – 2,196 patients underwent aortic surgery and 8,887 did not. Key measurements were maximum AA diameter, AA height index (AHI) and AA cross-sectional area-to-height index (CSAH), and the primary outcome was mortality.

Mean AA diameter was 4.4 ± 0.2 cm, AHI was 2.53 ± 0.3 cm/m, and CSAH was 8.8 ± 1 cm²/m. There was a mortality rate of 8.3% in the surgery group and 11.9% in the non-surgical group, over the course of a 6 ± 4 year follow-up period.

Among patients in the nonsurgical group, an increased risk of mortality was observed in women with AA diameter ≥4.5 cm and in all patients with AHI ≥2.5 cm/m or CSAH ≥9 cm²/m. An additional analysis with a separate cohort of 5,000 patients confirmed the associations between AHI and CSAH with higher long-term mortality (p < 0.05 for both).

"[Our study] represents one of the largest contemporary AA cohorts with comprehensive echocardiographic and tomographic imaging, combined with extended long-term follow-up," write the authors. "The substantial female representation allowed for robust sex-specific analyses, confirming that indexed aortic measurements outperform absolute diameter in identifying high-risk women."

An accompanying editorial comment, authored by Joseph Meyer, MD, and Eric M. Isselbacher, MD, MSc, states that the study authors "provide compelling evidence that AHI and CSAH are clinically useful measures for risk stratification in patients with root and ascending aortic aneurysms... but before such tools can be adopted into routine clinical practice, further validation is required."