Risk assessment and disease burden of extreme precipitation on hospitalizations for acute aortic dissection in a subtropical coastal Chinese city.

Background: Extreme precipitation events are becoming more frequent due to climate change. The present study aimed to explore the impacts of extreme precipitation on hospitalizations for acute aortic dissection (AAD) and to identify susceptible populations and quantify the corresponding disease burden. Methods: The present study used a distributed lag nonlinear model (DLNM) with a quasi-Poisson function to investigate the association between extreme precipitation (≥95th percentile) and the risk of hospitalizations for AAD from 2015 to 2020 in Shantou, Guangdong Province, China. Results: The significant adverse effects of extreme precipitation (relative to no precipitation) on daily AAD hospitalizations lasted from lag 5 [relative risk (RR): 1.0318, 95% confidence interval (CI): 1.0067-1.0575] to lag 9 (RR: 1.0297, 95% CI: 1.0045-1.0555) and reached its maximum at lag 7 (RR: 1.0382, 95% CI: 1.0105-1.0665). Males and older adult individuals (≥60 years) were more susceptible to extreme precipitation. A total of 3.68% (118 cases) of AAD hospitalizations were due to extreme precipitation. Conclusion: Extreme precipitation was significantly correlated with AAD hospitalizations. Government departments should actively implement extreme precipitation intervention measures to strengthen the protection of males and the older adult (≥60 years) and effectively reduce AAD hospitalizations.

Oral fluoroquinolones and risk of aortic aneurysm or dissection: A nationwide population-based propensity score-matched cohort study.

STUDY OBJECTIVE: To investigate risk of aortic aneurysm or dissection in patients using oral fluoroquinolones compared to those using macrolides in real-world clinical practice among a large US general population. DESIGN: Retrospective cohort study design. DATA SOURCE: MarketScan commercial and Medicare supplemental databases. PATIENTS: Adults patients with at least one prescription fill for fluoroquinolone or macrolide antibiotics. INTERVENTION: Fluoroquinolone or macrolide antibiotics. MEASUREMENTS AND MAIN RESULTS: The primary outcome was estimated incidence of aortic aneurysm or dissection associated with the use of fluoroquinolones compared with macrolides during a 60-day follow-up period in a 1:1 propensity score-matched cohort. We identified 3,174,620 patients (1,587,310 in each group) after 1:1 propensity score matching. Crude incidence of aortic aneurysm or dissection was 1.9 cases per 1000 person-years among fluoroquinolone users and 1.2 cases per 1000 person-years among macrolide users. In multivariable Cox regression, compared with macrolides, the use of fluoroquinolones was associated with an increased risk of aortic aneurysm or dissection (aHR: 1.34; 95% CI: 1.17-1.54). The association was primarily driven by a high incidence of aortic aneurysm cases (95.8%). Results of sensitivity (e.g., fluoroquinolone exposure ranging from 7 to 14 days (aHR: 1.47; 95% CI: 1.26-1.71)) and subgroup analyses (e.g., ciprofloxacin (aHR: 1.26; 95% CI: 1.07-1.49) and levofloxacin (aHR: 1.44; 95% CI: 1.19-1.52)) remained consistent with main findings. CONCLUSIONS: Fluoroquinolone use was associated with a 34% increased risk of aortic aneurysm or dissection compared with macrolide use among a general US population.

The impact of hospital size on national trends and outcomes in isolated open proximal aortic surgery.

OBJECTIVE: To determine the impact of hospital size on national trend estimates of isolated open proximal aortic surgery for benchmarking hospital performance. METHODS: Patients age >18 years who underwent isolated open proximal aortic surgery for aneurysm and dissection from 2002 to 2014 were identified using the National Inpatient Sample. Concomitant valvular, vessel revascularization, re-do procedures, endovascular, and surgery for descending and thoracoabdominal aorta were excluded. Discharges were stratified by hospital size and analyzed using trend, multivariable regression, propensity-score matching analysis. RESULTS: Over a 13-year period, 53,657 isolated open proximal aortic operations were performed nationally. Although the total number of operations/year increased (∼2.9%/year increase) and overall in-hospital mortality decreased (∼4%/year; both P < .001 for trend), these did not differ by hospital size (P > .05). Large hospitals treated more sicker and older patients but had shorter length of stay and lower hospital costs (both P < .001). Even after propensity-score matching, large hospital continued to demonstrate superior in-hospital outcomes, although only statistically for major in-hospital cardiac complications compared with non-large hospitals. In our subgroup analysis of dissection versus non-dissection cohort, in-hospital mortality trends decreased only in the non-dissection cohort (P < .01) versus dissection cohort (P = .39), driven primarily by the impact of large hospitals (P < .01). CONCLUSIONS: This study demonstrates increasing volume and improving outcomes of isolated open proximal aortic surgeries nationally over the last decade regardless of hospital bed size. Moreover, the resource allocation of sicker patients to larger hospital resulted shorter length of stay and hospital costs, while maintaining similar operative mortality to small- and medium-sized hospitals.

Incidence and natural history of isolated abdominal aortic dissection: A population-based assessment from 1995 to 2015.

BACKGROUND: Isolated abdominal dissection (IAD) is an uncommon clinical problem that is less well-understood than thoracic aortic dissection (AD). We performed a population-based assessment of the incidence, natural history, and treatment outcomes of IAD to better characterize this disease. METHODS: We used the Rochester Epidemiology Project to identify all Olmsted County, MN residents with a diagnosis of AD, intramural hematoma or penetrating ulcer (1995-2015). Diagnostic imaging of all patients was reviewed to confirm the diagnosis of IAD for inclusion. Presentation, treatment, and outcomes were reviewed. Survival of IAD patients was compared to age- and sex-matched population controls 3:1. RESULTS: Of 133 residents with aortic syndrome (AD, intramural hematoma, or penetrating ulcer), 23 were initially diagnosed with IAD. Nine were reclassified as having a penetrating aortic ulcer and were excluded, leaving 14 patients for review (10 male [71%]; mean age, 71 years). Three patients (21%) were symptomatic (abdominal pain, back pain, hypertension) and none had malperfusion or rupture. Prior aortic dilatation was present in eight patients (57%) and Marfan syndrome in one (7%). Two patients (14%) had iatrogenic IAD. Initial management was medical in 13 and endovascular aneurysm repair in one (symptomatic subacute, infrarenal dissection with small aneurysm). The median clinical and imaging follow-up was 6.7 years (range, 0-17 years). An abdominal aortic aneurysm occurred in eight (six at the time of IAD diagnosis, one at 2.9 years, and one at 5.2 years after diagnosis). The average growth in the entire cohort was 0.9 ± 0.4 cm, which translated to an average growth rate of 0.09 cm/year. Subsequent intervention was performed in two patients; for severe aortic stenosis with claudication in one (infrarenal aortic stenting) and increasing aortic size in one (open repair). One patient required reintervention (thrombolysis and stenting for endovascular aneurysm repair limb thrombosis). Survival for IAD at 1, 3, and 5 years was 93%, 85%, and 76%, respectively, compared with population controls at 98%, 85%, and 71%, respectively (long rank P = .38). Mortality was due to cardiovascular causes in three patients (21%) and no deaths were aortic related. Major adverse cardiac events occurred in five patients (36%) owing to heart failure. CONCLUSIONS: IAD is rare. The initial management for asymptomatic patients is medical. The aortic growth rate is slow, with no aortic-related mortality and a low rate of aortic intervention. The overall mortality is similar to population controls. Heart failure and cardiac-related death are prevalent, suggesting that close cardiovascular care is needed in this patient population.

Epidemiology and management of aortic disease: aortic aneurysms and acute aortic syndromes.

The aorta is the 'greatest artery', through which oxygenated blood is delivered from the left ventricle to end organs with each cardiac cycle (200 million litres of blood transported in an average lifetime). The aorta can be affected by a wide spectrum of acute factors (such as cocaine use, weight lifting and trauma) and chronic acquired and/or genetic conditions (such as systemic arterial hypertension and phaeochromocytoma), which variously lead to increased aortic wall stress. The medial layer of the aorta can also be subject to abnormalities (such as Marfan syndrome, bicuspid aortic valve, inflammatory vasculitis, atherosclerosis and infections). Despite important advances in diagnostic and therapeutic interventions, data derived from registries and population-based studies highlight that the burden of aortic diseases remains high. Therefore, specific resources need to be allocated to design and implement preventive strategies (healthy lifestyles, modifications to cardiovascular risk factors, and educational and screening programmes) at individual and community levels. In this Review, we discuss the epidemiology, management and outcomes of the most common aortic diseases, namely, aortic aneurysms and acute aortic syndromes.

Population-Based Assessment of Aortic-Related Outcomes in Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer.

BACKGROUND: The aim of the study was to analyze aortic-related outcomes after diagnosis of aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) from a population-based approach. METHODS: Retrospective review of an incident cohort of AD, IMH, and PAU patients in Olmsted County, Minnesota from 1995 to 2015. Primary end point was aortic death. Secondary end points were subsequent aortic events (aortic intervention, new dissection, or rupture not present at presentation) and first-time diagnosis of an aortic aneurysm. Outcomes were compared with randomly selected population referents matched for age and sex in a 3:1 ratio using Cox proportional hazards regression adjusting for comorbidities. RESULTS: Among 133 patients (77 AD, 21 IMH, and 35 PAU), 57% were males, and mean age was 71.8 years (standard deviation, 14). Median follow-up was 10 years. Of 73 deaths among AD/IMH/PAU patients, 23 (32%) were aortic-related. Estimated freedom from aortic death was 84%, 80%, and 77% at 5, 10, and 15 years. There were no aortic deaths among population referents (adjusted hazard ratio [HR] for aortic death in AD/IMH/PAU, 184.7; 95% confidence interval [95% CI], 10.3-3,299.2; P < 0.001). Fifty (38%) AD/IMH/PAU patients had a subsequent aortic event (aortic intervention, new dissection, or rupture), whereas there were 8 (2%) aortic events among population referents (all elective aneurysm repairs; adjusted HR for any aortic event and aortic intervention in AD/IMH/PAU patients, 33.3; 95% CI, 15.3-72.0; P < 0.001 and 31.5; 95% CI, 14.5-68.4; P < 0.001, respectively). After excluding aortic events/interventions ≤14 days of diagnosis, AD/IMH/PAU patients remained at increased risk of any aortic event (adjusted HR, 10.8; 95% CI, 3.9-29.8; P < 0.001) and aortic intervention (adjusted HR, 9.6; 95% CI, 3.4-26.8; P < 0.001). Among those subjects with available follow-up imaging, the risk of first-time diagnosis of aortic aneurysm was significantly increased for AD/IMH/PAU patients when compared with population referents (adjusted HR, 10.9; 95% CI, 5.4-21.7; P < 0.001 and 8.3; 95% CI, 4.1-16.7; P < 0.001 for thoracic and abdominal aneurysms, respectively) and remained increased when excluding aneurysms that formed within 14 days of AD/IMH/PAU (adjusted HR, 6.2; 95% CI, 1.8-21.1; P = 0.004 and 2.8; 95% CI, 1.0-7.6; P = 0.040 for thoracic and abdominal aneurysms, respectively). CONCLUSIONS: AD/IMH/PAU patients have a substantial risk of aortic death, any aortic event, aortic intervention, and first-time diagnosis of aortic aneurysm that persists even when the acute phase (≤14 days after diagnosis) is uncomplicated. Advances in postdiagnosis treatment are necessary to improve the prognosis in these patients.

Economic Burden and Healthcare Resource Use for Thoracic Aortic Dissections and Thoracic Aortic Aneurysms-A Population-Based Cost-of-Illness Analysis.

Background Thoracic aortic dissections (TADs) and thoracic aortic aneurysms (TAAs) are resource intensive. We sought to determine economic burden and healthcare resource use to guide health policy. Methods and Results Using universal healthcare coverage data for Ontario, Canada, from 2003 to 2016, a cost-of-illness analysis was performed. From a single-payer's perspective, direct costs (hospitalization, reinterventions, readmissions, rehabilitation, extended care, home care, prescription drugs, and imaging) were assessed in 2017 Canadian dollars. Controls without TADs or TAAs were matched 10:1 on age, sex, and socioeconomic status to cases with TADs or TAAs to compare posthospital service use to the general population. Linear and spline regression were used for cost trends. Total hospital costs increased from $9 M to $20.7 M for TADs (P<0.0001) and $13 M to $18 M for TAAs (P<0.001). Costs cumulated to $587 M for 17 113 cases. Median hospital costs for TADs were $11 525 ($6102 medical, $26 896 endograft, and $30 372 surgery) with an increase over time (P=0.04). For TAAs, median costs were $16 683 ($7247 medical, $11 679 endograft, and $22 949 surgery) with a decrease over time (P=0.03). Home care was the most used posthospital service (TADs 44%, TAAs 38%), but rehabilitation had the highest median cost (TADs $11.9 M, TAAs $11 M). Men had increased median costs for indexed hospitalizations relative to women, yet women used more posthospital services with higher service costs. Conclusions Total yearly costs have increased for TADs and TAAs. Median hospital costs have increased for TADs yet decreased for TAAs. Women use posthospital healthcare services more often than men.

From Tear to Fear: Posttraumatic Stress Disorder in Patients With Acute Type A Aortic Dissection.

Background Acute type A aortic dissection presents with abrupt onset of pain that requires emergency surgery. However, minimal research exists on posttraumatic stress disorder (PTSD) in survivors. We aimed to quantify the prevalence and describe characteristics of PTSD in patients following dissection. Methods and Results A total of 295 adult survivors of surgical dissection with an email on file were administered a cross-sectional online survey about their dissection experience; 137 returned questionnaires, and 129 (94%) responded to the 4-item Primary Care PTSD portion of the survey that was part of a larger lifestyle survey designed to study survivors of aortic dissection and surgery. In addition to the PTSD screening, it inquired about current sexual activity, exercise habits, and employment within the preceding 30 days. At a median of 6.8 years (quartile 1=2.6, quartile 3=8.9 years) after dissection, 23% of patients (30/129) screened positive for PTSD, with 44% (57/129) stating that within the past month they felt constantly on guard or watchful or were easily startled. Of those who screened positive and matched to their electronic medical record (n=27), only 2 (7.4%) had been tested and clinically diagnosed with PTSD. Patients who screened positive for PTSD were more likely to report limited current sexual activity than those who did not (odds ratio, 5.3; 95% CI, 1.9-15 [P=0.0006]). Conclusions PTSD is an important mental health consideration in aortic dissection survivors. Physicians should screen these patients for PTSD at follow-up visits to identify those who test positive and refer them for further testing and treatment, such as trauma-focused psychotherapy or medication.

Cost and Utility of Routine Contrast-Enhanced Neck MRA in a Pediatric MRI Stroke Evaluation Protocol.

BACKGROUND AND PURPOSE: Cervical arterial dissection is one of the frequent causes of pediatric arterial ischemic stroke. Out of concern for missing cervical arterial dissection in patients in whom pediatric stroke is suspected, our tertiary children's hospital added contrast-enhanced 3D neck MR angiography to every pediatric stoke work-up. This research investigated whether the routine use of contrast-enhanced neck MRA in our MR imaging stroke protocol ever detected a cervical arterial abnormality when the DWI, SWI/gradient recalled-echo, or circle of Willis MRA findings from the brain MR imaging were reported as normal. MATERIALS AND METHODS: The institutional PACS data base was searched for stroke protocol MRIs that included DWI, gradient recalled-echo or SWI, circle of Willis MRA, and 3D contrast-enhanced neck MRA in patients younger than 18 years of age with examinations performed between September 2010 and June 2017. RESULTS: In only a single case (0.15%) were the DWI, SWI/gradient recalled-echo, or circle of Willis MRA findings all separately reported as normal and the contrast-enhanced neck MRA findings reported as abnormal. To reach these findings, we screened 681 patients, which would have resulted in an estimated >$200,000 in Medicare charges and $80,000 in of out-of-pocket cost to patients. CONCLUSIONS: In our large series, the addition of a routine contrast-enhanced neck MRA to our pediatric stroke MR imaging protocol was of extremely low yield. We believe the use of neck MRA should reasonably be limited to cases in which abnormalities are initially detected on standard brain sequences or to patients with atypical presentation or recurrent pathology.

Association of Aortic Aneurysms and Dissections With Subarachnoid Hemorrhage.

Background It is uncertain whether aortic diseases, such as aneurysm and dissection, are associated with intracranial aneurysm formation and aneurysmal subarachnoid hemorrhage (SAH). Methods and Results We used data on claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. Our exposure variable was hospitalization with an unruptured or ruptured aortic aneurysm or aortic dissection. The outcome was nontraumatic SAH. Variables were ascertained by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnosis codes. Survival statistics were used to calculate incidence rates. Cox proportional hazards analysis was used to examine the association between aortic aneurysm/dissection and SAH while adjusting for demographics, vascular risk factors, and Charlson comorbidities. Among 1 781 917 beneficiaries, 32 551 (1.8%) had a documented aortic aneurysm or dissection. During 4.6±2.2 years of follow-up, 2538 patients (0.14%) developed a nontraumatic SAH. The incidence of SAH was 9 (95% CI, 7-11) per 10 000 patients per year in those with aortic aneurysm/dissection compared with 3 (95% CI, 3-3) per 10 000 patients per year in those without aortic aneurysm/dissection. After adjustment for demographics, stroke risk factors, and Charlson comorbidities, patients with aortic aneurysm/dissection faced an increased risk of SAH (hazard ratio, 1.4; 95% CI, 1.02-1.9; P=0.04). Conclusions In a nationally representative sample of Medicare beneficiaries, aortic aneurysm/dissection was associated with an increased risk of nontraumatic SAH.

Poor management of hypertension is an important precipitating factor for the development of acute aortic dissection.

Hypertension is considered a key risk factor for acute aortic dissection (AAD). However, there is limited evidence demonstrating if hypertension management affects AAD development. The objective of this study was to investigate the role of hypertension management in AAD development in a Chinese population. A total of 825 AAD patients and 3300 age- and sex-matched controls were included. The authors analyzed data on demographics, chronic comorbidities, and hypertension management of all participants. Multiple logistic regression analysis was used to estimate the adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for the relationship between chronic comorbidities, as well as the management of hypertension and AAD risk. After adjusting for other related factors, multivariate logistic regression identified hypertension, chronic kidney disease, Marfan syndrome, history of cardiovascular surgery, and history of smoking as risk factors for AAD. Among the identified risk factors, hypertension was an important and controllable risk factor for AAD development. Thus, the authors further evaluated how hypertension management affects AAD development. A total of 848 controls and 585 AAD patients with hypertension were enrolled in this part of the study. Hypertensive patients with AAD had a longer history, higher stage, poorer medication compliance, and poor control rates of blood pressure, among which poor medication compliance (Irregular vs Regular P < 0.001; Never treated vs Regular P < 0.001) and uncontrolled hypertension (P < 0.001) significantly increased the risk of AAD development. In conclusion, uncontrolled hypertension and poor medication compliance are important precipitating and controllable factors for AAD development.

Hospital Incidence and In-Hospital Mortality of Surgically and Interventionally Treated Aortic Dissections: Secondary Data Analysis of the Nationwide German Diagnosis-Related Group Statistics From 2006 to 2014.

Background Population-based data about the incidence and mortality of patients with aortic dissections ( ADs ) are sparse. Therefore, the hospital incidence and in-hospital mortality of patients undergoing open or endovascular surgery for type A ADs ( TAADs ) and type B ADs ( TBADs ) in Germany were analyzed on a nationwide basis between 2006 and 2014. Methods and Results A secondary data analysis of the nationwide diagnosis-related group statistics, compiled by the German Federal Statistical Office, was performed for patients who were surgically/interventionally treated for AD ( International Classification of Diseases, Tenth Revision, German Modification [ ICD -10- GM] codes I71.00-I71.07; n=20 533). By using specific procedure codes, a distinction between TAAD (n=14 911/72.6%) and TBAD (n=5622/27.4%) could be made. The standardized hospital incidence of surgically/interventionally treated AD was 2.7/100 000 per year, comprising 2.0/100 000 per year for TAAD and 0.7/100 000 per year for TBAD . The in-hospital mortality of TAAD was 19.5%; and of TBAD, 9.3%. Both the incidence and in-hospital mortality increased over the 9-year period. The share of endovascularly treated TBAD increased steadily during the same time interval. A multilevel multivariable analysis revealed that, for TAAD , age and comorbidity were significantly associated with a higher mortality risk. The latter was also true for TBAD . Sex was not significantly associated with mortality. A significant association between higher annual center volume and mortality was found for TAAD , but not for TBAD . Conclusions This is the first report on hospital incidence and mortality for surgically/interventionally treated AD on a nationwide basis. Overall, in Germany, hospital incidence and mortality of TAAD and TBAD increased over time. In addition, TAAD is performed more safely in high-volume centers.

Medication adherence patterns in aortic dissection survivors.

BACKGROUND & OBJECTIVES: Beta-blockers have been shown to improve survival in both type A and type B acute aortic dissection (AAD) patients. Calcium channel blockers have been shown to selectively improve survival only in type B AAD patients. There is a lack of data on medication adherence in AAD survivors. The purpose of this study was to assess medication adherence in patients who survived an AAD. METHODS: This was a cross-sectional survey-based study of individuals from a single medical centre which was part of the larger International Registry of Acute Aortic Dissection (IRAD). Patients with type A or B AAD who survived to discharge were included in this study. Individuals who were deceased based on the results of an online Social Security Death Index were excluded from the study. Data were obtained from both a survey and also from abstraction from the local academic institution's IRAD registry. A survey packet was sent to patients. One section of this survey was dedicated to assessing medication adherence using the 4-item Morisky scale. RESULTS: Eighty two completed surveys were returned; 74 patients completed the section of the survey pertaining to medication adherence (response rate 38%). Morisky score was ≥1.0 for 27 (36%) patients and 0 for 47 (64%) patients. Thirty three patients reported yes to 'forget to take medications' and eight reported yes to 'careless with medications.' Medication non-adherence (defined as a score of ≥1.0 on Morisky) was associated with increased follow up recurrence of chest pain at one year of follow up. Only two patients stopped their antihypertensive on their own and did not cite a reason for doing this. INTERPRETATION & CONCLUSIONS: The medication adherence rate for patients who survived an AAD was 64 per cent at a median (Q1, Q3) of 7.1 yr (5.6, 11.5) after discharge, as per the Morisky scale. The clinicians should educate their patients on the importance of antihypertensive therapy and assess for forgetfulness and carelessness at each clinic visit, as well as understand patients' beliefs about drug therapy, all of which have been shown to increase medication adherence.

Epidemiology and management of thoracic aortic dissections and thoracic aortic aneurysms in Ontario, Canada: A population-based study.

OBJECTIVES: To determine hospital incidence, mortality, and management for thoracic aortic dissections and aneurysms. METHODS: A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of thoracic aortic dissections and aneurysms were identified between 2002 and 2014. Treatment and mortality trends were assessed. RESULTS: There were 5966 aortic dissections (Type A n = 2289 [38%] and Type B n = 3632 [61%]). Overall incidence proportion for aortic dissections was 4.6 per 100,000. There were 9392 thoracic aortic aneurysms with an overall incidence proportion of 7.6 per 100,000. The incidence for both dissections and aneurysms significantly increased over the 12-year study. Only 53% (1204 out of 2289) of Type A dissections underwent surgery. Type B dissection treatment was 83% (3000 out of 3632) medical, 10% (370 out of 3632) surgery, and 7% (262 out of 3632) endovascular. Thoracic aortic aneurysm treatment was 53% (4940 out of 9392) surgery, 44% (4129 out of 9392) medical, and 3% (323 out of 9392) endovascular. Thirty-five percent of known descending thoracic aortic aneurysms (323 out of 924) received a stent graft. Cardiac surgeons performed 87% of the open surgical repairs. Vascular surgeons performed 91% of the endovascular procedures. All-cause 3-year mortality significantly decreased for both aortic dissections (44% to 40%) and aneurysms (30% to 22%). All-cause hospital mortality also decreased. Women had worse outcomes than men. CONCLUSIONS: The incidence of thoracic aortic dissections and aneurysms increased over time but all-cause hospital and late outcomes improved. Gender differences exist. Men incur more disease but women have higher hospital mortality. Surgery was primarily referred to cardiac surgeons. Endovascular therapy was primarily referred to vascular surgeons.

Unrecognized Cardiovascular Emergencies Among Medicare Patients.

Importance: The Institute of Medicine described diagnostic error as the next frontier in patient safety and highlighted a critical need for better measurement tools. Objectives: To estimate the proportions of emergency department (ED) visits attributable to symptoms of imminent ruptured abdominal aortic aneurysm (AAA), acute myocardial infarction (AMI), stroke, aortic dissection, and subarachnoid hemorrhage (SAH) that end in discharge without diagnosis; to evaluate longitudinal trends; and to identify patient characteristics independently associated with missed diagnostic opportunities. Design, Setting, and Participants: This was a retrospective cohort study of all Medicare claims for 2006 to 2014. The setting was hospital EDs in the United States. Participants included all fee-for-service Medicare patients admitted to the hospital during 2007 to 2014 for the conditions of interest. Hospice enrollees and patients with recent skilled nursing facility stays were excluded. Main Outcomes and Measures: The proportion of potential diagnostic opportunities missed in the ED was estimated using the difference between observed and expected ED discharges within 45 days of the index hospital admissions as the numerator, basing expected discharges on ED use by the same patients in earlier months. The denominator was estimated as the number of recognized emergencies (index hospital admissions) plus unrecognized emergencies (excess discharges). Results: There were 1 561 940 patients, including 17 963 hospitalized for ruptured AAA, 304 980 for AMI, 1 181 648 for stroke, 19 675 for aortic dissection, and 37 674 for SAH. The mean (SD) age was 77.9 (10.3) years; 8.9% were younger than 65 years, and 54.1% were female. The proportions of diagnostic opportunities missed in the ED were as follows: ruptured AAA (3.4%; 95% CI, 2.9%-4.0%), AMI (2.3%; 95% CI, 2.1%-2.4%), stroke (4.1%; 95% CI, 4.0%-4.2%), aortic dissection (4.5%; 95% CI, 3.9%-5.1%), and SAH (3.5%; 95% CI, 3.1%-3.9%). Longitudinal trends were either nonsignificant (AMI and aortic dissection) or increasing (ruptured AAA, stroke, and SAH). Patient characteristics associated with unrecognized emergencies included age younger than 65 years, dual eligibility for Medicare and Medicaid coverage, female sex, and each of the following chronic conditions: end-stage renal disease, dementia, depression, diabetes, cerebrovascular disease, hypertension, coronary artery disease, and chronic obstructive pulmonary disease. Conclusions and Relevance: Among Medicare patients, opportunities to diagnose ruptured AAA, AMI, stroke, aortic dissection, and SAH are missed in less than 1 in 20 ED presentations. Further improvement may prove difficult.

Sex Differences in Phenotypes of Bicuspid Aortic Valve and Aortopathy: Insights From a Large Multicenter, International Registry.

BACKGROUND: This large multicenter, international bicuspid aortic valve (BAV) registry aimed to define the sex differences in prevalence, valve morphology, dysfunction (aortic stenosis/regurgitation), aortopathy, and complications (endocarditis and aortic dissection). METHODS AND RESULTS: Demographic, clinical, and echocardiographic data at first presentation of 1992 patients with BAV (71.5% men) were retrospectively analyzed. BAV morphology and valve function were assessed; aortopathy configuration was defined as isolated dilatation of the sinus of Valsalva or sinotubular junction, isolated dilatation of the ascending aorta distal to the sinotubular junction, or diffuse dilatation of the aortic root and ascending aorta. New cases of endocarditis and aortic dissection were recorded. There were no significant sex differences regarding BAV morphology and frequency of normal valve function. When presenting with moderate/severe aortic valve dysfunction, men had more frequent aortic regurgitation than women (33.8% versus 22.2%, P<0.001), whereas women were more likely to have aortic stenosis (34.5% versus 44.1%, P<0.001). Men had more frequently isolated dilatation of the sinus of Valsalva or sinotubular junction (14.2% versus 6.7%, P<0.001) and diffuse dilatation of the aortic root and ascending aorta (16.2% versus 7.3%, P<0.001) than women. Endocarditis (4.5% versus 2.5%, P=0.037) and aortic dissections (0.5% versus 0%, P<0.001) occurred more frequently in men. CONCLUSIONS: Although there is a male predominance among patients with BAV, men with BAV had more frequently moderate/severe aortic regurgitation at first presentation compared with women, whereas women presented more often with moderate/severe aortic stenosis compared with men. Furthermore, men had more frequent aortopathy than women.

White blood cell and platelet count as adjuncts to standard clinical evaluation for risk assessment in patients at low probability of acute aortic syndrome.

AIMS: Pre-test probability assessment is key in the approach to suspected acute aortic syndromes (AASs). However, most patients with AAS-compatible symptoms are classified at low probability, warranting further evaluation for decision on aortic imaging. White blood cell count, platelet count and fibrinogen explore pathophysiological pathways mobilized in AASs and are routinely assayed in the workup of AASs. However, the diagnostic performance of these variables for AASs, alone and as a bundle, is unknown. We tested the hypothesis that white blood cell count, platelet count and/or fibrinogen at presentation may be applied as additional tools to standard clinical evaluation for pre-test risk assessment in patients at low probability of AAS. METHODS AND RESULTS: This was a retrospective observational study conducted on consecutive patients managed in our Emergency Department from 2009 to 2014 for suspected AAS. White blood cell count, platelet count and fibrinogen were assayed during evaluation in the Emergency Department. The final diagnosis was obtained by computed tomography angiography. The pre-test probability of AAS was defined according to guidelines. Of 1210 patients with suspected AAS, 1006 (83.1%) were classified at low probability, and 271 (22.4%) were diagnosed with AAS. Within patients at low probability, presence of at least one alteration among white blood cell count >9*103/µl, platelet count <200*103/µl and fibrinogen <350 mg/dl was associated with a sensitivity of 95.5% (89.7-98.5%) and a specificity of 18.3% (15.6-21.2%). In patients at low probability, white blood cell count >9*103/µl and platelet count <200*103/µl were found as independent predictors of AAS beyond established clinical risk markers. Within patients at low probability, the estimated risk of AAS based on the number of alterations amongst white blood cell count >9*103/µl and platelet count <200*103/µl was 2.7% (1.2-5.7%) with zero alterations, 11.3% (8.8-14.3%) with one alteration and 31.9% (24.8-40%) with two alterations ( p<0.001). CONCLUSION: In addition to standard clinical evaluation, white blood cell count and platelet count may be used in patients at low pre-test probability to fine-tune risk assessment of AAS.

Trends in the Diagnosis and Outcomes of Traumatic Carotid and Vertebral Artery Dissections among Medicare Beneficiaries.

BACKGROUND: Early identification of carotid and vertebral artery dissections has been advocated to reduce stroke among trauma patients. We sought to characterize trends in the diagnosis of traumatic carotid and vertebral artery dissections and association changes in stroke rate among Medicare beneficiaries. METHODS: Using Medicare claims, we created a cohort of 5,961 beneficiaries admitted with a new traumatic carotid or vertebral artery dissection from 2001 to 2012. We calculated rates of stroke during hospitalization and 90 days of discharge. We calculated rates of carotid imaging using computed tomography-angiography, carotid duplex, and plain angiography index hospitalization. To study concurrent secular trends, we created a secondary cohort of patients admitted after any traumatic injury from 2001 to 2012 and determined rates of stroke and carotid imaging within this cohort. RESULTS: From 2001 to 2012, incidence of traumatic carotid dissection increased 72% among Medicare beneficiaries (1.1-1.76 per 100,000 patients; rate ratio [RR], 1.72; 95% CI, 1.6-1.9, P < 0.001). Among patients diagnosed with traumatic carotid or vertebral artery dissections, the combined in-hospital and 90-day stroke rate did not change significantly (4.9% in 2001; 5.2% in 2012; RR, 1.06; 95% CI, 0.93-1.20; P = 0.094). Likewise, there was little change in mortality (10.3%; RR, 1.01; 95% CI, 0.95-1.06; P = 0.88). Among all trauma patients, the use of computed tomography angiography has increased 16-fold (2-35 per 100,000 patients; RR, 16.7; 95% CI, 13-19; P < 0.0001). CONCLUSIONS: Despite increased diagnosis of carotid or vertebral artery dissection, there has been little change in stroke risk among trauma patients. Efforts to more effectively target imaging and treatment for these patients are necessary.

Global cardiac risk assessment in the Registry Of Pregnancy And Cardiac disease: results of a registry from the European Society of Cardiology.

AIMS: To validate the modified World Health Organization (mWHO) risk classification in advanced and emerging countries, and to identify additional risk factors for cardiac events during pregnancy. METHODS AND RESULTS: The ongoing prospective worldwide Registry Of Pregnancy And Cardiac disease (ROPAC) included 2742 pregnant women (mean age ± standard deviation, 29.2 ± 5.5 years) with established cardiac disease: 1827 from advanced countries and 915 from emerging countries. In patients from advanced countries, congenital heart disease was the most prevalent diagnosis (70%) while in emerging countries valvular heart disease was more common (55%). A cardiac event occurred in 566 patients (20.6%) during pregnancy: 234 (12.8%) in advanced countries and 332 (36.3%) in emerging countries. The mWHO classification had a moderate performance to discriminate between women with and without cardiac events (c-statistic 0.711 and 95% confidence interval (CI) 0.686-0.735). However, its performance in advanced countries (0.726) was better than in emerging countries (0.633). The best performance was found in patients with acquired heart disease from developed countries (0.712). Pre-pregnancy signs of heart failure and, in advanced countries, atrial fibrillation and no previous cardiac intervention added prognostic value to the mWHO classification, with a c-statistic of 0.751 (95% CI 0.715-0.786) in advanced countries and of 0.724 (95% CI 0.691-0.758) in emerging countries. CONCLUSION: The mWHO risk classification is a useful tool for predicting cardiac events during pregnancy in women with established cardiac disease in advanced countries, but seems less effective in emerging countries. Data on pre-pregnancy cardiac condition including signs of heart failure and atrial fibrillation, may help to improve preconception counselling in advanced and emerging countries.