Presenting Systolic BP and Outcomes in Acute Aortic Dissection

Study Questions:

What is the association of presenting systolic blood pressure (SBP) with in-hospital outcomes, specifically all-cause mortality, in acute aortic dissection (AAD)?

Methods:

The investigators included 6,238 consecutive patients (4,167 with type A and 2,071 with type B AAD) enrolled in the International Registry of Acute Aortic Dissection. Patients were stratified in four groups according to presenting SBP: SBP >150 mm Hg, SBP 101-150 mm Hg, SBP 81-100 mm Hg, or SBP ≤80 mm Hg. Risk adjustment was performed to determine the association of presenting SBP with in-hospital mortality using a multivariable logistic regression model using a backward stepwise method.

Results:

The relationship between presenting SBP and in-hospital mortality displayed a J-curve association, with significantly higher mortality rates in patients with very high SBP (26.3% for SBP >180 mm Hg in type A AAD, 13.3% for SBP >200 mm Hg in type B AAD; p = 0.005 and p = 0.018, respectively) as well as in those with SBP ≤100 mm Hg (29.9% in type A, 22.4% in type B; p = 0.033 and p = 0.015, respectively). This relationship was mainly due to increased rates of in-hospital complications (acute renal failure, coma, and mesenteric ischemia/infarction in patients with SBP >150 mm Hg; stroke, coma, cardiac tamponade, and acute renal failure in patients with SBP ≤80 mm Hg). Notably, presenting SBP ≤80 mm Hg was independently associated with in-hospital mortality in both type A (p = 0.001) and type B AAD (p = 0.003).

Conclusions:

The authors concluded that presenting SBP showed a J-curve relationship with in-hospital mortality in AAD patients.

Perspective:

This registry study reports a J-shaped relationship between presenting SBP and in-hospital all-cause mortality, which showed significantly higher mortality rates in patients with very high SBP levels as well as in those with SBP ≤100 mm Hg. However, the association of presenting SBP with mortality did not remain significant for higher SBP after adjustment for differences in baseline confounders. In contrast, in both type A and type B AAD, presenting SBP ≤80 mm Hg was found to be independently associated with in-hospital mortality when adjusting for other well established predictors of in-hospital death. Additional studies are indicated to assess whether outcomes of patients with AAD presenting with either very low or high SBP could be improved by targeted treatment to normalize SBP with or without definitive corrective surgical or endovascular repair.

Clinical Topics: Heart Failure and Cardiomyopathies, Pericardial Disease, Prevention, Vascular Medicine

Keywords: Acute Kidney Injury, Aneurysm, Dissecting, Blood Pressure, Cardiac Tamponade, Coma, Dissection, Endovascular Procedures, Hospital Mortality, Infarction, Ischemia, Outcome Assessment (Health Care), Primary Prevention, Risk Adjustment, Stroke, Systole, Vascular Diseases


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