Chronologic and Climatic Factors of Acute Aortic Dissection: Study of 1642 Patients in Two Continents

Patterns in acute aortic dissection and a connection to meteorological conditions in Germany

Acute type A aortic dissection (ATAAD) is a dramatic emergency exhibiting a mortality of 50% within the first 48 hours if not operated. This study found an absolute value of cosine-like seasonal variation pattern for Germany with significantly fewer ATAAD events (Wilcoxon test) for the warm months of June, July, and August from 2005 to 2015. Many studies suspect a connection between ATAAD events and weather conditions. Using ERA5 reanalysis data and an objective weather type classification in a contingency table approach showed that for Germany, significantly more ATAAD events occurred during lower temperatures (by about 4.8 K), lower water vapor pressure (by about 2.6 hPa), and prevailing wind patterns from the northeast. In addition, we used data from a classification scheme for human-biometeorological weather conditions which was not used before in ATAAD studies. For the German region of Berlin and Brandenburg, for 2006 to 2019, the proportion of days with ATAAD events during weather conditions favoring hypertension (cold air advection, in the center of a cyclone, conditions with cold stress or thermal comfort) was significantly increased by 13% (Chi-squared test for difference of proportions). In contrast, the proportion was decreased by 19% for conditions associated with a higher risk for patients with hypotension and therefore a lower risk for patients with hypertension (warm air advection ahead of warm fronts, conditions with no thermal stress or heat stress, in the center of a cyclone with thermal stress). As many studies have shown that hypertension is a risk factor for ATAAD, our findings support the hypothesized relation between ATAAD and hypertension-favoring weather conditions.

Chronobiology discrepancies between patients with acute type a aortic dissection complicated with and without sleep apnea syndrome: a single-center seven-year retrospective study

BACKGROUND

The present study aimed to investigate the differences in chronobiology and prevention between patients with acute type-A aortic dissection (ATAAD) complicated with sleep apnea syndrome (SAS) and without sleep apnea syndrome (non-SAS).

METHODS

We retrospectively analyzed the clinical information of ATAAD patients using hospital medical records and regional meteorological and chronological information between January 2013 and December 2019.

RESULTS

An early mortality rate of 16.9% (196 out of 1160 cases) was observed, comprising 95 cases of aortic rupture before surgery and 101 surgery-related deaths. Eighty-one of the 964 survivors were screened for SAS using complete morphological characteristics. Of these patients, 291 (33.0%) suffered from SAS, while 590 (67.0%) had no SAS. Based on a Circular Von Mises distribution analysis, the non-SAS patients experienced a significant morning peak in the occurrence of ATAAD at 10:04 (r1 = 0.148, p < 0.01). In contrast, the SAS patients experienced a significantly different (non-SAS vs. SAS, U2 = 0.947, p < 0.001) nighttime peak at 23:48 (r2 = 0.489, p < 0.01). Moreover, both non-SAS (Z = 39.770, P < 0.001) and SAS (Z = 55.663, P < 0.001) patients showed a comparable peak during January (non-SAS vs. SAS, U2 = 0.173, p > 0.05). Furthermore, SAS patients experienced a peak on Fridays (χ2 = 36.419, p < 0.001), whereas there was no significant difference in the weekly distribution in non-SAS patients (χ2 = 11.315, p = 0.079).

CONCLUSIONS

The analyses showed that both SAS and non-SAS patients showed distinct rhythmicity in ATAAD onset. These findings highlight the chronobiological triggers within different ATAAD subpopulations and may contribute to the prevention of this potentially fatal occurrence.

Rhythm of Acute Aortic Syndrome in Northeastern China

Acute aortic syndromes (AAS) are a series of life-threatening conditions of the aorta. To improve predictability and prevention, we investigated the daily, weekly, monthly, and seasonal variations in the onset of AAS in Liaoning Province, Northeast China.We collected the clinical data of 1,197 patients treated for AAS at the General Hospital of Northern Theater Command between June 2002 and June 2021. Chi-square goodness-of-fit testing was used to determine whether AAS uniformly occurred.The average age was 54.93 ± 12.32 years, and 614 patients (51.29%) aged below or equal to 55 years. Nine-hundred-and-five patients (75.61%) were male. The proportions of patients comorbid with hypertension and diabetes were 80.37% and 4.09%, respectively. The peak time of the day for the onset of AAS was between 12:00 and 17:59 (P < 0.001). Furthermore, we found that patients with hypertension had obvious circadian rhythm. AAS had a weekly distribution (P = 0.032), with Sunday and Monday being two troughs. The incidence rate of AAS was low in warmer periods, such as July and August in summer (P < 0.001). The correlation analysis revealed a negative association between the incidence of AAS and the monthly average temperature (P < 0.05).Our results revealed that AAS displayed circadian and seasonal rhythms in northeast China. AAS peaked between 12:00 and 17:59. Patients with AAS with hypertension had obvious circadian rhythm. Summer was trough season for the onset of AAS. The incidence rate of AAS was negatively correlated with the monthly average temperature.

Short-term effects of air pollution and weather changes on the occurrence of acute aortic dissection in a cold region

Background

Air pollution and severe weather conditions can adversely affect cardiovascular disease emergencies. Nevertheless, it remains unclear whether air pollutants and low ambient temperature can trigger the occurrence of acute aortic dissection (AAD) in cold regions.

Methods

We applied a retrospective analysis to assess the short-term effects of air pollution and ambient temperature on the occurrence of AAD in Harbin, China. A total of 564 AAD patients were enrolled from a major hospital in Harbin between January 1, 2017, and February 5, 2021. Weather condition data and air pollutant concentrations, including fine particulate matter smaller than 10 μm (PM10) and 2.5 μm in diameter (PM2.5), nitrogen dioxide (NO2), sulfur dioxide (SO2), carbon monoxide (CO), and ozone (O3), were collected every day. Conditional logistic regressions and correlation analysis were applied to analyze the relationship of environmental and atmospheric parameters with AAD occurrence at lags of 0 to 7 days. Specifically, we appraised the air quality index, CO, NO2, SO2, O3, PM10, PM2.5, temperature, dew point temperature, atmospheric pressure, and cloud amount.

Results

A total of 1,496 days at risk were assessed, of which 564 patients developed AAD. Specifically, AAD did not occur on 1,043 (69.72%) days, while 1 or more cases occurred on 453 (30.28%) days. Several pollution and weather predictors for AAD were confirmed by multilevel modeling. The air quality index (p = 0.0012), cloud amount (p = 0.0001), and concentrations of PM2.5 (p = 0.0004), PM10 (p = 0.0013), NO2 (p = 0.0007) and O3 (p = 0.0001) predicted AAD as early as 7 days before the incident (lag of 7 days) in the study period. However, only concentrations of the air pollutants NO2 (p = 0.0468) and O3 (p = 0.011) predicted the occurrence of AAD after the COVID-19 outbreak. Similar predictive effects were observed for temperature, dew point temperature, and atmospheric pressure (all p < 0.05) on all days.

Conclusion

The risk of AAD is closely related to air pollution and weather characteristics in Harbin. While causation was not determined, the impact of air pollutants on the risk of AAD was reduced after the COVID-19 outbreak.

The intervention seasons of thoracic endovascular aortic repair impacted the outcomes for patients with type B aortic dissection

Purpose

The objective of this research was to investigate whether seasonal variations influence the outcomes of type B aortic dissection (TBAD) patients with thoracic endovascular aortic repair (TEVAR).

Patients and methods

From 2003 to 2020, a retrospective cohort study was performed, which included 1,123 TBAD patients who received TEVAR. Medical records were used to gather data on baseline characteristics. Outcomes including all-cause mortality and aortic-related adverse events (ARAEs) were tracked and analyzed.

Results

Of the 1,123 TBAD patients in this study, 308 received TEVAR in spring (27.4%), 240 cases in summer (21.4%), 260 cases in autumn (23.2%), and 315 cases in winter (28.0%). Patients in the autumn group had a significantly lower risk of 1-year mortality than those in the spring group (hazard ratio: 2.66, 95% confidence interval: 1.06-6.67, p = 0.037). Kaplan-Meier curves revealed that patients who underwent TEVAR in autumn had a lower risk of 30-day ARAEs (p = 0.049) and 1-year mortality (p = 0.03) than those in spring.

Conclusion

This study confirmed that TEVAR operated in autumn for TBAD was associated with a lower risk of 30-day ARAEs and 1-year mortality than in spring.

Low temperature and temperature decline increase acute aortic dissection risk and burden: A nationwide case crossover analysis at hourly level among 40,270 patients

Background

Acute aortic dissection (AAD) is a life-threatening cardiovascular emergency with high mortality, so identifying modifiable risk factors of AAD is of great public health significance. The associations of non-optimal temperature and temperature variability with AAD onset and the disease burden have not been fully understood.

Methods

We conducted a time-stratified case-crossover study using a nationwide registry dataset from 1,868 hospitals in 313 Chinese cities. Conditional logistic regression and distributed lag models were used to investigate associations of temperature and temperature changes between neighboring days (TCN) with the hourly AAD onset and calculate the attributable fractions. We also evaluated the heterogeneity of the associations.

Findings

A total of 40,270 eligible AAD cases were included. The exposure-response curves for temperature and TCN with AAD onset risk were both inverse and approximately linear. The risks were present on the concurrent hour (for temperature) or day (for TCN) and lasted for almost 1 day. The cumulative relative risks of AAD were 1.027 and 1.026 per 1°C lower temperature and temperature decline between neighboring days, respectively. The associations were significant during the non-heating period, but were not present during the heating period in cities with central heating. 23.13% of AAD cases nationwide were attributable to low temperature and 1.58% were attributable to temperature decline from the previous day.

Interpretation

This is the largest nationwide study demonstrating robust associations of low temperature and temperature decline with AAD onset. We, for the first time, calculated the corresponding disease burden and further showed that central heating may be a modifier for temperature-related AAD risk and burden.

Funding

This work was supported by the National Natural Science Foundation of China (92043301 and 92143301), Shanghai International Science and Technology Partnership Project (No. 21230780200), the Medical Research Council-UK (MR/R013349/1), and the Natural Environment Research Council UK (NE/R009384/1).

Once after a full moon: acute type A aortic dissection and lunar phases

OBJECTIVES

Acute type A aortic dissection (ATAAD) is a rare but severe condition, routinely treated with emergent cardiac surgery. Many surgeons have the notion that patients with ATAAD tend to come in clusters, but no studies have examined these observations. This investigation was undertaken to study the potential association between the lunar cycle and the incidence of ATAAD.

METHODS

We collected information on 2995 patients who underwent ATAAD surgery at centres from the Nordic Consortium for Acute Type A Aortic Dissection collaboration. We cross-referenced the time of surgery with lunar phase using a case-crossover design with 2 different definitions of full moon (>99% illumination and the 7-day full moon period).

RESULTS

The period when the moon was illuminated the most (99% definition) did not show any significant increase in incidence for ATAAD surgery. However, when the full moon period was compared with all other moon phases, it yielded a relative risk of 1.08 [95% confidence interval (CI) 1.00-1.17, P = 0.057] and, compared to waxing moon, only the relative risk was 1.11 (95% CI 1.01-1.23, P = 0.027). The peak incidence came 4-6 days after the moon was fully illuminated.

CONCLUSIONS

This study found an overrepresentation of surgery for ATAAD during the full moon phase. The explanation for this is not known, but we speculate that sleep deprivation during full moon leads to a temporary increase in blood pressure, which in turn could trigger rupture of the aortic wall. While this finding is interesting, it needs to be corroborated and the clinical implications are debateable.

Low ambient temperature and temperature drop between neighbouring days and acute aortic dissection: a case-crossover study

AIMS

The incidence of acute aortic dissection (AAD) has been shown to have seasonal variation, but whether this variation can be explained by non-optimum ambient temperature and temperature change between neighbouring days (TCN) is not clear.

METHODS AND RESULTS

We performed a time-stratified case-crossover study in the Registry of Aortic Dissection in China covering 14 tertiary hospitals in 11 cities from 2009 to 2019. A total of 8182 cases of AAD were included. Weather data at residential address were matched from nearby monitoring stations. Conditional logistic regression model and distributed lag nonlinear model were used to estimate the associations of daily temperature and TCN with AAD, adjusting for possible confounders. We observed an increase of AAD risk with lower temperature cumulated over lag 0-1 day and this association became statistically significant when daily mean temperature was below 24°C. Relative to the referent temperature (28°C), the odds ratios (ORs) of AAD onset at extremely low (-10°C) and low (1°C) temperature cumulated over lag 0-1 day were 2.84 [95% confidence interval (CI): 1.69, 4.75] and 2.36 (95% CI: 1.61, 3.47), respectively. A negative TCN was associated with increased risk of AAD. The OR of AAD cumulated over lag 0-6 days was 2.66 (95% CI: 1.76, 4.02) comparing the extremely negative TCN (-7°C) to no temperature change. In contrast, a positive TCN was associated with reduced AAD risk.

CONCLUSION

This study provides novel and robust evidence that low ambient temperature and temperature drop between neighbouring days were associated with increased risk of AAD onset.

KEY QUESTION

Incidence of acute aortic dissection (AAD) was reported to have seasonal trends, but it remains unclear whether non-optimum ambient temperature and temperature change between neighbouring days (TCN) is associated with AAD onset.

KEY FINDING

Daily mean temperature lower than 24°C was significantly associated with increased risk of AAD at lag 0-1 day. A negative TCN (temperature drop) was associated with increased risk of AAD, whereas a positive TCN was associated with decreased risk.

TAKE HOME MESSAGE

This multi-centre, case-crossover study provides novel and robust evidence that low ambient temperature and temperature drop between neighbouring days were associated with increased AAD risk.

Safety and efficacy of alcohol septal ablation in adolescents and young adults with hypertrophic obstructive cardiomyopathy

INTRODUCTION

Data regarding alcohol septal ablation (ASA) in young patients with hypertrophic obstructive cardiomyopathy (HOCM) are scarce. The purpose of our study is to evaluate the safety and efficacy of ASA in patients ≤ 25 years.

METHODS AND RESULTS

All ASAs between 2002 and 2020 at our institution were assigned to a group of patients 14-25 years of age (group 1) and a reference group > 25 years (group 2). 1,264 procedures were analysed in group 2 (58.6 ± 13.5 years) and 41 procedures in group 1 (20.9 ± 3.3 years). The baseline interventricular septal diameter (IVSD) was higher in group 1 (26.0 ± 6.5 mm vs. 21.3 ± 4.4 mm; p < 0.0001). There was no difference in baseline left ventricular outflow tract gradient (LVOTG) (group 1: 54.4 ± 24.4 mmHg; group 2: 52.4 ± 36.6 mmHg; p = n.s.). A previous cardiac device was more often observed in group 1 (31.7% vs. 9.0%; p < 0.0001). Symptoms were improved after 6 months (group 1: mean NYHA class 2.5 at baseline and 1.3 at FU; p < 0.0001; group 2: mean NYHA class 2.7 at baseline and 1.4 at FU; p <0 .0001). IVSD (group 1: 20.3 ± 8.2 mm; group 2: 16.8 ± 5.7 mm; p < 0.0001 for each group compared to baseline) and LVOTG improved during FU (group 1: 25.5 ± 20.0 mmHg; group 2: 22.1 ± 21.7 mmHg; p < 0.0001 for each group). Intrahospital mortality was 0.0% in patients 14-25 years and 0.9% in the reference group. Persistent AV-block was observed in 12.2% of the group 1 and 15.9% of the group 2 patients (p = n.s.).

CONCLUSION

ASA is safe and effective in HOCM patients 14-25 years of age in experienced centres.

Age-related differences in acute aortic dissection

OBJECTIVE

The present study investigated the differences in clinical characteristics, treatments, and outcomes of patients with acute aortic dissection (AAD) in different age groups.

METHODS

The present single-center retrospective study was conducted from August 2014 to August 2020. The patients were divided into three groups: age <45 years (young group), age 45 to 59 years (middle-age group), and age >59 years (elderly group). Type A (TAAD) and type B (TBAD) aortic dissection were evaluated separately using the latest definitions.

RESULTS

The mean age at onset was 52.4 years in our cohort of 602 patients. The young group included a large proportion of male patients (86%). The body mass index and body surface area were higher in the young group. The proportion of non-true lumen blood supply of branches on the abdominal aorta in the young group (27%-55%) was greater than that in the others. In the young group, the distal extent of dissection in 84% of TAAD and 89% of TBAD exceeded the abdominal aortic branch cluster (AABC) compared with 36% of TAAD and 58% of TBAD in the elderly group. The multivariate analysis revealed that age <45 years (odds ratio, 5.15; P < .001) and D-dimer level (odds ratio, 1.05; P = .001) were risk factors for intimal flap tear exceeding the AABC. The proportion of visceral and lower limb malperfusion increased from 4.8% to 36.9% as the intimal flap tear exceeded the AABC.

CONCLUSIONS

Compared with middle-age and elderly patients, young patients with AAD had two characteristics (ie, obesity and an intimal flap that had frequently exceeded the branches of the aorta). These two factors resulted in a greater proportion of non-true lumen blood supply, increased visceral and lower limb malperfusion, and an increase in potential associated risks.

Prevalence, Clinical Features, and In-hospital Outcome of Fatty Liver Disease in Acute Aortic Dissection: A Single-Center Retrospective Study

Background and Aims: Fatty liver disease (FLD) has emerged as a major public issue in China. We aim to investigate prevalence, clinical features, and in-hospital outcome of FLD in acute aortic dissection (AAD) patients.

Methods: Data of 379 AAD patients from 2017 to 2019 at Renmin hospital of Wuhan University was retrospectively collected and divided according to age and FLD absence. Propensity score matching was used for minimal confounding. We compared their physical environmental parameter of onset, clinical features, and in-hospital outcome.

Results: The mean age was 52.0 ± 11.5 years in type A and 55.1 ± 11.4 in type B. 25.0% of type A and 19.2% of type B AAD patients had FLD. Logistic regression indicated a negative association between FLD and age, both in type A [unadjusted odds ratio (OR) 0.958 (per 1 year), 95% confidence interval (CI) 0.930–0.988, p = 0.0064] and type B [unadjusted OR 0.943 (per 1 year), 95% CI 0.910–0.978, p = 0.0013]. After matching, type A with FLD had onset with a lower air quality index (AQI) of 68.5 [interquartile range (IQR) 46.0–90.0] and a lower Pm 2.5 concentration of 36.0 μg/m³ (IQR 23.0–56.0) compared with non-FLD group. In Kaplan-Meier estimation, FLD was associated with higher risk of in-hospital mortality in type B AAD (p = 0.0297).

Conclusion: The prevalence of FLD in AAD decrease with age, both in type A and type B AAD. Type A AAD patients with FLD had onset with better air quality parameters compared with non-FLD group. FLD was associated with higher risk of in-hospital mortality in type B AAD.

Association of Daily Mean Temperature and Temperature Variability With Onset Risks of Acute Aortic Dissection

Background The association between ambient temperature and cardiovascular diseases has been well established, but evidence of temporal changes in the risk of acute aortic dissection (AAD) onset is lacking. Methods and Results We conducted an 8-year time-series study based on data from 2120 patients diagnosed with AAD at Tongji Hospital (Wuhan, China). Daily meteorological parameters were measured in the study area. Spearman's rank correlation analysis was applied to measure the associations between daily meteorological data and air pollution indicators. A distributed lag nonlinear model following quasi-Poisson regression was used to express the nonlinear exposure-response relationships and lag effects of daily mean temperature and temperature variability on the occurrence of AAD. Considering a 25-day lag effect, lower or higher temperatures with reference to 25°C did not alter the onset risk of AAD. The lag effect of daily mean temperature on the incidence of AAD is statistically significant within 2 days, and the impact of daily mean temperature on the risk is most influential on the day. The exposure-response curve between daily mean temperature and onset risks of AAD at lag 0 showed that the extremely cold temperature (2.5th percentile, 0.5°C) significantly increased the AAD risk for the total (relative risk, 1.733; 95% CI, 1.130-2.658) and type A dissection (relative risk, 3.951; 95% CI, 1.657-9.418). Temperature variability within 1 week did not affect the onset risks of AAD for the total. Conclusions We confirmed that extremely cold temperatures significantly increased the AAD risk, which could contribute to early prevention and timely diagnosis of the disease.

Chronobiological patterns of acute aortic dissection in central China

BACKGROUND

Acute aortic dissection (AAD) is a life-threatening emergency with poor clinical outcomes. Understanding the chronological patterns of AAD onset would be helpful for identifying the triggers of AAD and preventing this catastrophic event.

METHODS

We collected data from 2048 patients diagnosed with AAD at Tongji Hospital (Wuhan, China) from 2011 to 2018. The χ2 test was used to determine whether a specific period had significantly different seasonal/weekly distributions from other periods. Fourier models were used to analyse the rhythmicity in monthly/circadian distribution.

RESULTS

The mean age was 53.4±10.9 years, and 1161 patients (56.7%) were under 55 years. One thousand six hundred fifty-seven patients (80.9%) were male, and 935 cases (45.7%) were type A dissections. The proportions of patients with comorbid hypertension/diabetes were 60.3% (1234 cases) and 1.8% (36 cases), respectively. A peak was identified in colder periods (winter/December) and a trough in warmer periods (summer/June). No significant variation was observed in weekly distribution. Fourier analysis showed a statistically significant circadian variation (p<0.001) with a nocturnal trough in 2:00-3:00, a morning peak in 9:00-10:00, and an afternoon peak in 16:00-17:00. Subgroup analyses identified circadian rhythmicity in all subgroups except for the female group and younger group (younger than 55 years).

CONCLUSION

Our results confirmed that the onset of AAD exhibits significant seasonal, monthly and circadian patterns. Patients with AAD with different Stanford-type dissections, sexes, ages and hypertension statuses could present different circadian variations. These findings may provide novel perspectives for identifying the triggers of AAD and better preventing this catastrophic event.