Magnitude of Soluble ST2 as a Novel Biomarker for Acute Aortic Dissection

Aging aggravates aortic aneurysm and dissection via miR-1204-MYLK signaling axis in mice

The mechanism by which aging induces aortic aneurysm and dissection (AAD) remains unclear. A total of 430 participants were recruited for the screening of differentially expressed plasma microRNAs (miRNAs). We found that miR-1204 is significantly increased in both the plasma and aorta of elder patients with AAD and is positively correlated with age. Cell senescence induces the expression of miR-1204 through p53 interaction with plasmacytoma variant translocation 1, and miR-1204 induces vascular smooth muscle cell (VSMC) senescence to form a positive feedback loop. Furthermore, miR-1204 aggravates angiotensin II-induced AAD formation, and inhibition of miR-1204 attenuates β-aminopropionitrile monofumarate-induced AAD development in mice. Mechanistically, miR-1204 directly targets myosin light chain kinase (MYLK), leading to the acquisition of a senescence-associated secretory phenotype (SASP) by VSMCs and loss of their contractile phenotype. MYLK overexpression reverses miR-1204-induced VSMC senescence, SASP and contractile phenotypic changes, and the decrease of transforming growth factor-β signaling pathway. Our findings suggest that aging aggravates AAD via the miR-1204-MYLK signaling axis.

Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis

STUDY OBJECTIVE

Acute aortic syndrome is a life-threatening emergency condition. Previous systematic reviews of D-dimer diagnostic accuracy for acute aortic syndrome have been contradictory and based on limited data, but recently published studies offer potential for a more definitive overview. We aimed to perform a systematic review and meta-analysis to determine the diagnostic accuracy of D-dimer for diagnosing acute aortic syndrome.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library from inception to February 2024. Additionally, the reference lists of included studies and other systematic reviews were thoroughly searched. All diagnostic cohort studies (prospective or retrospective) that assessed the use of D-dimer for diagnosing acute aortic syndrome compared with a reference standard test (eg, computed tomographic angiography (CTA), ECG-gated CTA, echocardiography, magnetic resonance angiography, operation, or autopsy) were included. Two independent reviewers completed study selection, data extractions and quality assessment using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Data were synthesized using a bivariate meta-analysis model.

RESULTS

Of 2017 potentially relevant citations, 25 cohort studies met the inclusion criteria, and 18 reporting the 500 ng/mL threshold were included in the primary meta-analysis. Risk of bias domains were mostly unclear due to limited study reporting. The summary sensitivity was 96.5% (95% credible interval [CrI] 94.8% to 98%) and summary specificity was 56.2% (95% CrI, 48.3% to 63.9%). Study specificity varied markedly from 33% to 86%, indicating substantial heterogeneity. Sensitivity analysis including the 7 studies reporting other thresholds showed summary sensitivity of 95.7% (95% CrI, 93.2% to 97.5%) and summary specificity of 57.5% (95% CrI, 50.1% to 64.6%).

CONCLUSION

D-dimer concentration has high sensitivity (96.5%) and moderate specificity (56.2%) for acute aortic syndrome, with some uncertainty around estimates due to risk of bias and heterogeneity. Previous meta-analysis reporting higher specificity may be explained by inclusion of case-control studies that may overestimate accuracy.

Diagnostic and prognostic values of serum Selenoprotein P and soluble St2 levels in pulmonary embolism

AIM

Pulmonary Thromboembolism (PTE) occurs as a result of occlusion of one or more of the pulmonary artery branches by thrombus and is an important cause of right heart failure and pulmonary hypertension. Selenoprotein P (SePP) and soluble suppression of tumorigenicity 2 protein (sST2) are two new biomarkers that have previously been the subject of various studies in heart failure. The aim of this study was to determine the diagnostic and prognostic potential of SePP and soluble sST2 levels in patients with acute PTE.

MATERIALS AND METHODS

The study included 135 patients diagnosed with acute non-massive PTE and 43 healthy volunteers. Clinical, laboratory, and radiological patient data were recorded. SePP and sST2 levels were measured in the patient and control groups. Patients were followed at 1, 3, and 6 months of treatment via the death notification system and telemedicine.

RESULTS

SePP and sST2 levels were significantly lower in the patient group compared with the control group (SePP: 17.65 ng/ml vs. 43.06 ng/ml and sST2: 10.86 ng/ml vs. 16.20 ng/ml, both p < 0.001). No correlation was found at 1, 3, and 6 months of follow-up with prognosis and mortality.

CONCLUSION

SePP and sST2 values were significantly lower in patients with acute PTE compared with the control group. Low levels of these biomarkers may be diagnostically valuable.

The diagnostic value of tenascin-C in acute aortic syndrome

OBJECTIVES

Misdiagnosis of acute aortic syndrome (AAS) significantly increases mortality. Tenascin-C (TN-C) is an extracellular matrix glycoprotein related to cardiovascular injury. The elevation of TN-C in AAS and whether it can discriminate sudden-onset of acute chest pain in Chinese remains unclear.

METHODS

We measured the plasma concentration of TN-C by ELISA in a cohort of 376 patients with chest or back pain. Measures to discriminate AAS from acute coronary syndrome (ACS) were compared and calculated.

RESULTS

From October 2016 to September 2021, 376 undiagnosed patients with chest or back pain were enrolled. 166 of them were finally diagnosed as AAS, 100 were ACS and 110 without cardiovascular diseases (NCV). TN-C was significantly elevated in AAS at 18.18 ng/mL (IQR: 13.10-27.68) compared with 7.51 ng/mL (IQR: 5.67-11.38) in ACS (P < 0.001) and 3.68 ng/mL (IQR: 2.50-5.29) in NCV (P < 0.001). There was no significant difference in TN-C level among the subtypes of AAS. Of the 166 AAS patients, the peaked level of TN-C was at acute stage (P = 0.012), then a slight of decrease was observed at subacute stage. The area under receiver operating characteristic curve for AAS patients versus NCV was 0.979 (95% CI: 0.964-0.994) for TN-C. At a cutoff level of 11.474 ng/mL, TN-C has a sensitivity of 76.0%, specificity of 85.5%, accuracy of 82.0%, positive predictive value (PPV) of 76.0%, negative predictive value (NPV) of 85.5%. Diagnostic performance of TN-C was superior to D-dimer and hs-cTnT.

CONCLUSIONS

The concentration of serum TN-C in AAS patients was significantly higher than that in ACS patients and NCV. TN-C could be a new biomarker to distinguish AAS patients in the early stage after symptoms onset from other pain diseases.

Differential gene expression patterns in ST-elevation Myocardial Infarction and Non-ST-elevation Myocardial Infarction

The ST-elevation Myocardial Infarction (STEMI) and Non-ST-elevation Myocardial Infarction (NSTEMI) might occur because of coronary artery stenosis. The gene biomarkers apply to the clinical diagnosis and therapeutic decisions in Myocardial Infarction. The aim of this study was to introduce, enrich and estimate timely the blood gene profiles based on the high-throughput data for the molecular distinction of STEMI and NSTEMI. The text mining data (50 genes) annotated with DisGeNET data (144 genes) were merged with the GEO gene expression data (5 datasets) using R software. Then, the STEMI and NSTEMI networks were primarily created using the STRING server, and improved using the Cytoscape software. The high-score genes were enriched using the KEGG signaling pathways and Gene Ontology (GO). Furthermore, the genes were categorized to determine the NSTEMI and STEMI gene profiles. The time cut-off points were identified statistically by monitoring the gene profiles up to 30 days after Myocardial Infarction (MI). The gene heatmaps were clearly created for the STEMI (high-fold genes 69, low-fold genes 45) and NSTEMI (high-fold genes 68, low-fold genes 36). The STEMI and NSTEMI networks suggested the high-score gene profiles. Furthermore, the gene enrichment suggested the different biological conditions for STEMI and NSTEMI. The time cut-off points for the NSTEMI (4 genes) and STEMI (13 genes) gene profiles were established up to three days after Myocardial Infarction. The study showed the different pathophysiologic conditions for STEMI and NSTEMI. Furthermore, the high-score gene profiles are suggested to measure up to 3 days after MI to distinguish the STEMI and NSTEMI.

Biomarkers in aortic dissection: Diagnostic and prognostic value from clinical research

ABSTRACT

Aortic dissection is a life-threatening condition for which diagnosis mainly relies on imaging examinations, while reliable biomarkers to detect or monitor are still under investigation. Recent advances in technologies provide an unprecedented opportunity to yield the identification of clinically valuable biomarkers, including proteins, ribonucleic acids (RNAs), and deoxyribonucleic acids (DNAs), for early detection of pathological changes in susceptible patients, rapid diagnosis at the bedside after onset, and a superior therapeutic regimen primarily within the concept of personalized and tailored endovascular therapy for aortic dissection.

Biomarkers for Risk Stratification in Patients With Type A Acute Aortic Dissection

Type A acute aortic dissection (AAD) is a fatal disease and thus, accurate and objective risk stratification is essential. In this study, we evaluated the prognostic value of readily available and assessable biomarkers in patients with type A AAD. This was a retrospective, multicenter, observational study. A total of 703 patients with type A AAD diagnosed using contrast-enhanced computed tomography were included. Therapeutic strategies were left to the physician's discretion in a real-world clinical setting. The prognostic value for in-hospital mortality was examined in 15 circulating biomarkers on admission, which are routinely available in clinical practice. Of the 703 patients, 126 (17.9%) died during the hospitalization. Of the 15 biomarkers, the multivariable analysis identified positive cardiac troponin, a low total bilirubin (T-Bil) level, and increased levels of brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) as significant predictors of in-hospital death. The receiver operating characteristics curve analysis showed that these 4 biomarkers had an independent additive prognostic value. With the cut-off values of T-Bil, BNP, and LDH, in combination with positive troponin, the increase in the number of positive biomarkers was progressively associated with higher in-hospital mortality from 1.3% to 9.8%, 20.5%, 36.4%, and 75.0% (p <0.001). In conclusion, in patients with type A AAD, positive cardiac troponin, a low T-Bil level, and increased levels of BNP and LDH on admission were related to higher in-hospital mortality, with an incremental prognostic value, suggesting that the readily available and assessable biomarkers can aid in decision-making in therapeutic strategies.

Plasma soluble suppression of tumorigenesis 2 measured in the emergency department for diagnosis and outcome prediction of sepsis: A single-center prospective study

BACKGROUND AND AIMS

The diagnostic and prognostic performance of soluble Suppression of Tumorigenicity 2 (sST2) in suspected septic patients presenting to the Emergency Department (ED) is largely unknown.

MATERIALS AND METHODS

Patients were included in this prospective study if there was high suspicion of sepsis. The plasma level of sST2 was measured during initial ED evaluation. Outcomes were the evaluation of (1) sST2 diagnostic performance (alone and in combination with procalcitonin [PCT]), and (2) sST2 ability to predict 30-day and 90-day all-cause mortality.

RESULTS

Among 569 patients included, 481 (84.5 %) had sepsis or septic shock. Plasma sST2 levels were more elevated in septic patients (159 [71-331] vs 50 [31-103] ng/mL, P < 0.001). The AUC of sST2 for sepsis diagnosis was lower than the AUC of PCT (0.76 vs 0.85, P = 0.03). The best cut-off for sST2 was 61.7 ng/mL, with a sensitivity of 79.9 % and a specificity of 70.6 %. sST2 was able to correctly reclassify septic patients with PCT <0.5 (NRI 28.9 % [P = 0.02]). sST2 level was an independent predictor of 30-day mortality in a model including clinical variables (aHR 2.03 [1.24-3.33], C-index 0.69).

CONCLUSION

sST2 could be a useful adjunct in diagnosing sepsis and in all-cause mortality prediction.

Diagnostic potential of soluble ST2 and D-dimer for Stanford Type B aortic dissection and intramural aortic hematoma

OBJECTIVE

Type B aortic dissection (TBAD) and intramural aortic hematoma (IMH) are common manifestations of Acute Aortic Syndrome (AAS), exhibiting overlapping clinical features. The timely and accurate diagnosis and differentiation between TBAD and IMH are critical for appropriate management. Tumorigenicity 2 (sST2) and D-dimer have been shown to elevate levels in both TBAD and IMH, making them valuable as "rule-out" markers. Hence, we aimed to assess the diagnostic utility of sST2 and D-dimer in distinguishing TBAD from IMH.

METHODS

In this retrospective study, we analyzed serum levels of sST2 and D-dimer in 182 AAS patients, comprising 90 TBAD cases, 92 IMH cases, and 90 non-AAS cases. Serial measurements were taken at 1 h, 6 h, 12 h, 24 h, and 72 h post-admission. Comparative analyses were conducted between TBAD and non-AAS cases, IMH and non-AAS cases, and TBAD and IMH cases. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic accuracy of sST2 and D-dimer in identifying TBAD or IMH cases.

RESULTS

Both TBAD and IMH patients displayed elevated levels of sST2 and D-dimer compared to non-AAS cases. Notably, sST2 levels were significantly higher in TBAD patients than in IMH patients, whereas D-dimer levels exhibited moderate differences. TBAD patients tended to exhibit elevated levels of either sST2 or D-dimer, with a modest correlation between the two (Pearson correlation coefficient = 0.3614). In contrast, IMH patients showed elevations in both markers, with a positive correlation between them (Pearson correlation coefficient = 0.6814). The ROC analysis revealed that both sST2 (AUC, 0.657; 95 % CI, 0.552-0.753; cutoff value, 27.54 ng/ml) and D-dimer (AUC, 0.695; 95 % CI, 0.591-0.787, cutoff value, 1.215 ng/ml) demonstrated favorable diagnostic performance for TBAD. sST2 exhibited a sensitivity of 80.92 % and a specificity of 75.00 %, while D-dimer showed a sensitivity of 80.92 % and a specificity of 75.00 %. For the diagnosis of IMH, the combined assessment of sST2 and D-dimer (AUC, 0.674; 95 % CI, 0.599-0.768; sensitivity, 69.20 %; specificity, 80.00 %) proved effective.

CONCLUSIONS

Our results indicate that both sST2 and D-dimer show diagnostic potential for TBAD. Elevated levels of either serve as an indicator of TBAD onset. However, concurrent elevation of both markers seems to be indicative of IMH. The combination of increased sST2 and D-dimer levels demonstrates strong diagnostic performance in identifying IMH cases.

Diagnostic biomarkers and aortic dissection: a systematic review and meta-analysis

BACKGROUND

Aortic dissection (AD) is a serious and fatal vascular disease. The earlier the condition of AD patients can be assessed precisely, the more scientifically controlled the patient's condition will be. Therefore, timely and accurate diagnosis is significant for AD. Blood biomarker testing as a method of liquid biopsy can improve the diagnostic efficiency of AD. This study conducted a systematic review of the current blood diagnostic biomarkers of AD.

METHODS

The PubMed, Cochrane Library, Web of Science, and Embase electronic databases were systematically searched from inception to January 1, 2023, using the terms "aortic dissection", "serum", "plasma" and "diagnosis". Stata 12.0 software was used to perform Random effects meta-analysis was performed using Stata 12.0 software to determine the effect sizes and corresponding 95% confidence intervals. Then, a summary receiver operator characteristic (SROC) curve was drawn, and the area under the ROC curve (AUC) was calculated.

RESULTS

D-dimer had the best sensitivity and AUC for AD, with values of 0.96 (95% CI: 0.93-0.98) and 0.95 (95% CI: 0.93-0.97), respectively. The sensitivity and AUC values for D-dimer with a cut-off value of 500 ng/mL were 0.97 (95% CI: 0.95-0.99) and 0.94 (95% CI: 0.92-0.96), respectively. In contrast, microRNA had a better specificity value for AD, at 0.79 (95% CI: 0.73-0.83).

CONCLUSIONS

D-dimer and microRNA have good accuracy in the diagnosis of AD, but the specificity of D-dimer is worse, and studies of microRNA are insufficient. The combination of different biomarkers can improve the diagnostic accuracy. Other blood biomarkers are related to the pathological progression of AD and can be selected according to pathological progress.

Analytical performances of a new rapid assay of soluble ST2 for cardiac and inflammatory diseases and establishment of the reference intervals for children and adolescence in China

Background

sST2 has emerged as a potential disease biomarker of cardiac and inflammatory diseases in pediatrics. This study aimed to evaluate the performance of the new Pylon sST2 assay and establish the reference intervals of sST2 in children and adolescence in China.

Methods

The experiments on precision, linearity, effects of interferents and sample stability were carried out to evaluate the analytical performances. A total of 240 healthy participants, aged from 2 to 17 years were enrolled. The nonparametric method was used to calculate the age- and sex-specified reference intervals. sST2 levels were measured in children with different diseases to evaluate the assay's diagnostic performance.

Results

The repeatability and within-laboratory imprecision CVs of the assay were 6.0% and 7.6% at 19.5 ng/ml, and 3.1% and 5.9% at 289.8 ng/ml, respectively. The method showed linearity between 2.5 and 918.5 ng/ml. It was also noteworthy that the sST2 level was not affected in the presence of hemoglobin (2 mg/ml), triglyceride (30 mg/ml), bilirubin (0.3 mg/ml) and cholesterol (5 mg/ml). sST2 was found stable for 5 days at 4 °C in serum sample. The reference interval was determined as 2.1-21.0 ng/ml in general. No significant variation was observed by sex. However, sST2 increased constantly with age, especially in male. Increased sST2 was found in patients of systemic lupus erythematosus, sepsis, Crohn's diseases, respiratory failure and post cardiac surgery.

Conclusions

The Pylon sST2 assay showed good analytical performances. The reference intervals were established in children and adolescence and sST2 showed potential clinical values in several diseases in pediatrics.

Serum Sema7A is increased in patients with acute aortic dissection

BACKGROUND

To observe the level of serum Sema7A in acute aortic dissection (AAD) and its diagnostic value for AAD.

RESEARCH DESIGN AND METHODS

Patients with sudden chest pain including AAD, acute myocardial infarction (AMI) or pulmonary embolism (PE) were enrolled. Patients without chest pain or cardiovascular diseases were included as the controls. Serum Sema7A and plasma D-dimer were detected and compared in each group.

RESULTS

85 AAD patients, 55 AMI patients, 15 PE patients, and 30 controls were enrolled. The concentration of Serum Sema7A in the AAD group was significantly higher than that in the control, AMI and PE group. Serum Sema7A was positively correlated with D-dimer. In AAD patients who underwent invasive intervention therapy, serum Sema7A levels were significantly decreased after the intervention. Serum Sema7A was an independent risk factor for the presence of AAD. The areas under the ROC curve of Sema7A and D-dimer for differential diagnosis of AAD from other chest pain disorders were 0.842 (0.776, 0.909) and 0.788 (0.714, 0.862), respectively.

CONCLUSIONS

Sema7A is highly expressed in patients with AAD. Sema7A might be a valuable biomarker for the early diagnosis of AAD and has the potential to differentiate AAD from AMI and PE.

Global trends in research of acute type a aortic dissection: A bibliometric analysis from 2002 to 2022

Background

Acute type A aortic dissection (ATAAD) is life-threatening and needs urgent and highly invasive surgery. So far, there is no comprehensive review of the status quo of ATAAD studies. Therefore, this study aimed to quantify and identify the global trends of ATAAD research over the past two decades through bibliometric analysis and to provide reference for clinical practice, research funding allocation, and decision-making.

Methods

The original research articles and reviews related to ATAAD research were downloaded from the Web of Science Core Collection on March 19, 2023. CiteSpace (6.2.1) and VOSviewer (1.6.18) were used for bibliometric analysis of the number of publications by each country, institution, and authors and the establishment of knowledge maps. The raw data collected were examined using the Online Analysis Platform of Bibliometric to assess the collaboration of countries in the field.

Results

The number of documents on ATAAD research increased continuously. A total of 1,943 publications published from 2002 to 2022 from 66 countries/regions were identified: 637 (32.78%) were conducted in China and 360 (18.53%) in the United States; 152 (cited frequency 941) were conducted by Capital Medical University and 107 (cited frequency 370) by Fujian Medical University. The Journal of Cardiac Surgery was the most frequently published journal (143 publications, cited frequency 695). The highest citation and co-cited journal was the Annals of Thoracic Surgery (cited frequency 3,888, co-cited frequency 6,224). We identified 8,050 authors among which Lizhong Sun (61 publications, cited frequency 721) had the largest number of publications, and Nienaber Christoph A (cited frequency 1,536, co-cited frequency 392) was co-cited most often. Meanwhile, the most common keywords were acute type A aortic dissection (occurrences, 1,211), surgery (occurrences, 657), repair (occurrences, 404), and management (occurrences, 386). The earliest and latest used keywords were "axillary artery" (average publication year: 2011.23) and "inflammation" (average publication year: 2019.09), respectively. The keyword "surgical treatment" (strength 12.31) and the co-cited reference "Evangelista A, 2018, Circulation" (strength 28.55) had the highest citation bursts. The keywords "impact" and "acute kidney injury" remained high citation bursts. The co-cited references with the largest and smallest size clusters were "cerebral protection" (#0, size = 126) and "pregnancy" (#12, size = 11). The reference "Hagan PG, 2000, JAMA" (cited frequency, 350) had the highest co-citations.

Conclusions

The bibliometric and visualized analysis generated objective evidence for a comprehensive understanding and evaluation of ATAAD research.

Relationship Between Soluble ST2 Level and Chronic Thromboembolic Pulmonary Hypertension (CTEPH) in Acute Pulmonary Embolism (PE) Patients

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease characterized by right heart failure following recurrent pulmonary embolism (PE). It is important to know the predictors of the development of CTEPH after PE as it is a treatable cause of pulmonary arterial hypertension. Soluble ST2 is a biomarker closely associated with heart failure and the inflammatory process. The aim of this study was to investigate the relationship between sST2 level and the development of CTEPH in patients with PE.

METHODOLOGY

Baseline characteristics, electrocardiographic findings, laboratory findings, transthoracic echocardiography (TTE) findings, location, and extent of involvement in CT pulmonary angiography were recorded in 100 patients with acute PE included in our prospective study. Treatment modalities and treatment durations were followed. Ventilation-perfusion scintigraphy was performed in patients with a systolic pulmonary artery pressure (sPAP) of 35 mmHg or more on TTE and residual thrombus on CT pulmonary angiography after at least three months of anticoagulant use. In the case of findings compatible with CTEPH in these examinations, patients were diagnosed with CTEPH by right heart catheterization. The sST2 levels obtained from all patients at admission were evaluated between the groups of patients with and without CTEPH.

RESULTS

CTEPH was observed in 11 of the 100 patients who participated in the trial, with a median follow-up of 284 ± 60 days. The mean age of the 11 patients with CTEPH was 67 ± 10 years; five were males and six were females. The mean age of 89 patients without CTEPH was 65 ± 18 years, 36 were males and 53 were females. The sST2 values of the group with CTEPH were found to be statistically significantly higher than those of patients without CTEPH [193.7 (184.3-244.7) vs 58.6 (29.5-122.9) p=0.020]. This receiver operating characteristic (ROC) curve shows that the optimal cutoff point of sST2 levels in the prediction of CTEPH was > 157.4 with specificity of 83.7% and sensitivity of 81.8% (area under the curve = 0.783; 95% CI, 1.005-1.027; p < 0.001).

CONCLUSION

In acute PE patients, sST2 levels may be a useful biomarker to predict the development of CTEPH.

The ST2/IL-33 Pathway in Adult and Paediatric Heart Disease and Transplantation

ST2 is a member of interleukin 1 receptor family with soluble sST2 and transmembrane ST2L isoforms. The ligand of ST2 is IL-33, which determines the activation of numerous intracytoplasmic mediators following the binding with ST2L and IL-1RAcP, leading to nuclear signal and cardiovascular effect. Differently, sST2 is released in the blood and works as a decoy receptor, binding IL-33 and blocking IL-33/ST2L interaction. sST2 is mainly involved in maintaining homeostasis and/or alterations of different tissues, as counterbalance/activation of IL-33/ST2L axis is typically involved in the development of fibrosis, tissue damage, inflammation and remodeling. sST2 has been described in different clinical reports as a fundamental prognostic marker in patients with cardiovascular disease, as well as marker for the treatment monitoring of patients with heart failure; however, further studies are needed to better elucidate its role. In this review we reported the current knowledge about its role in coronary artery disease, heart failure, heart transplantation, heart valve disease, pulmonary arterial hypertension, and cardiovascular interventions.

Anzhen Risk Evaluation System for Acute Aortic Syndrome (AZSCORE-AAS): protocol for a multicentre prospective cohort study in northern China

INTRODUCTION

Acute aortic syndrome (AAS) is a group of acute and critical conditions, including acute aortic dissection (AAD), acute intramural haematoma and penetrating aortic ulcer. High mortality and morbidity rates result in a poor patient prognosis. Prompt diagnoses and timely interventions are paramount for saving patients' lives. In recent years, risk models for AAD have been established worldwide; however, a risk evaluation system for AAS is still lacking in China. Therefore, this study aims to develop an early warning and risk scoring system in combination with the novel potential biomarker soluble ST2 (sST2) for AAS.

METHODS AND ANALYSIS

This multicentre, prospective, observational study will recruit patients diagnosed with AAS at three tertiary referral centres from 1 January 2020 to 31 December 2023. We will analyse the discrepancies in sST2 levels in patients with different AAS types and explore the accuracy of sST2 in distinguishing between them. We will also incorporate potential risk factors and sST2 into a logistic regression model to establish a logistic risk scoring system for predicting postoperative death and prolonged intensive care unit stay in patients with AAS.

ETHICS AND DISSEMINATION

This study was registered on the Chinese Clinical Trial Registry website (http://www. chictr. org. cn/). Ethical approval was obtained from the human research ethics committees of Beijing Anzhen Hospital (KS2019016). The ethics review board of each participating hospital agreed to participate. The final risk prediction model will be published in an appropriate journal and disseminated as a mobile application for clinical use. Approval and anonymised data will be shared.

TRIAL REGISTRATION NUMBER

ChiCTR1900027763.

Soluble ST2 in Patients with Carotid Artery Stenosis-Association with Plaque Morphology and Long-Term Outcome

Interleukin (IL-33) and the ST2 receptor are implicated in the pathogenesis of atherosclerosis. Soluble ST2 (sST2), which negatively regulates IL-33 signaling, is an established biomarker in coronary artery disease and heart failure. Here we aimed to investigate the association of sST2 with carotid atherosclerotic plaque morphology, symptom presentation, and the prognostic value of sST2 in patients undergoing carotid endarterectomy. A total of 170 consecutive patients with high-grade asymptomatic or symptomatic carotid artery stenosis undergoing carotid endarterectomy were included in the study. The patients were followed up for 10 years, and the primary endpoint was defined as a composite of adverse cardiovascular events and cardiovascular mortality, with all-cause mortality as the secondary endpoint. The baseline sST2 showed no association with carotid plaque morphology assessed using carotid duplex ultrasound (B 0.051, 95% CI -0.145-0.248, p = 0.609), nor with modified histological AHA classification based on morphological description following surgery (B -0.032, 95% CI -0.194-0.130, p = 0.698). Furthermore, sST2 was not associated with baseline clinical symptoms (B -0.105, 95% CI -0.432-0.214, p = 0.517). On the other hand, sST2 was an independent predictor for long-term adverse cardiovascular events after adjustment for age, sex, and coronary artery disease (HR 1.4, 95% CI 1.0-2.4, p = 0.048), but not for all-cause mortality (HR 1.2, 95% CI 0.8-1.7, p = 0.301). Patients with high baseline sST2 levels had a significantly higher adverse cardiovascular event rate as compared to patients with lower sST2 (log-rank p < 0.001). Although IL-33 and ST2 play a role in the pathogenesis of atherosclerosis, sST2 is not associated with carotid plaque morphology. However, sST2 is an excellent prognostic marker for long-term adverse cardiovascular outcomes in patients with high-grade carotid artery stenosis.

Mammalian sterile 20-like kinase 1 acts as a candidate biomarker of mortality of emergency surgical repair for acute type a aortic dissection

BACKGROUND

Acute type A aortic dissection (ATAAD) is a life-threatening pathological change of the aorta. Patients who have undergone aortic surgery are usually at high risk of mortality.

AIM

We investigated the predictive value of serum Mammalian sterile 20-like kinase 1 (MST1) as a biomarker for the risk of mortality of ATAAD patients.

METHODS

In this retrospective cohort study, we analyzed 160 consecutive ATAAD patients who had undergone emergency surgery from July 2016 to April 2017. Medical records and blood samples were collected and analyzed. ELISA assays were performed to detect the concentrations of several proteins including MST1. The relationship between these potential biomarkers and the primary endpoint of death was evaluated using Cox proportional hazard regression analysis.

RESULTS

Compared with a low level (< 1330.8 ng/L), high serum MST1 level (≥ 1330.8 ng/L) was positively associated with the 30-day mortality (OR = 5.233, 95%CI, 1.843-14.862, P < 0.01) and retained predictive after adjustment for sex, age, BMI, nasopharyngeal temperature and deep hypothermia circulatory arrest time (OR = 4.628 95% CI, 1.572-13.625, P < 0.01). A pre-existing basic clinical prediction model was improved with the inclusion of preoperative serum MST1. Specifically, the area under the ROC curve for base model (history of cerebrovascular disease, creatinine, time of operation) was 0.708 (95%CI, 0.546-0.836) and markedly increased to 0.823 when taking MST1 into consideration (95%CI, 0.700-0.912, P = 0.02).

CONCLUSION

Our study suggests that high preoperative circulating MST1, with a concentration greater than 1330.8 ng/L, was correlated with the 30-day mortality of ATAAD patients who underwent emergency surgery.

Recent advancements of nanomodified electrodes - Towards point-of-care detection of cardiac biomarkers

The increasing number of deaths from cardiovascular diseases has become a substantial concern in both developed and underdeveloped countries. Rapid and on-site monitoring of this disease is urgently important to control, prevent and make awareness of public health. Recently, a lot of focus has been placed on nanomaterials and modify these nanomaterials have been explored to detect cardiac biomarkers. By implementing biosensors that are modified with novel recognition elements and more stable nanomaterials, the use of electrochemistry for point-of-care devices is more realistic every day. This review focuses on the current state of nanomaterials conjugated biorecognition elements (enzyme integrated with nanomaterials, antibody conjugated nanomaterials and aptamer conjugated nanomaterials) for electrochemical cardiovascular disease detection. Specifically, a lot of attention has been given to the trends toward more stable biosensors that have increased the potential to be used as point-of-care devices for the detection of cardiac biomarkers due to their high stability and specificity. Moreover, the recent progress on biomolecule-free electrochemical nanosensors for cardiovascular disease detection has been considered. At last, the possibility and drawbacks of some of these techniques for point-of-care cardiac device development in the future have been discussed.

Fast and Sensitive Detection of Protein Markers Using an All-Printing Photonic Crystal Microarray via Fingertip Blood

With the demand for point-of-care testing (POCT) in cardiovascular diseases, the detection of biomarkers in trace blood samples is of great significance in emergency medicine settings. Here, we demonstrated an all-printed photonic crystal microarray for POCT of protein markers (named "P4 microarray"). The paired nanobodies were printed as probes to target the soluble suppression of tumorigenicity 2 (sST2) as a certified cardiovascular protein marker. Benefiting from photonic crystal-enhanced fluorescence and integrated microarrays, quantitative detection of sST2 is 2 orders of magnitude lower than that of a traditional fluorescent immunoassay. The limit of detection is down to 10 pg/mL with the coefficient of variation being less than 8%. Detection of sST2 via fingertip blood is achieved in 10 min. Moreover, the P4 microarray after 180 days of storage at room temperature showed excellent stability for detection. This P4 microarray, as a convenient and reliable immunoassay for rapid and quantitative detection of protein markers in trace blood samples, has high sensitivity and strong storage stability, which hold great potential to advance cardiovascular precision medicine.

Acute aortic dissection: evidence, uncertainties, and future therapies

Remarkable progress has become especially apparent in aortic medicine in the last few decades, leading to essential changes in how thoracic aortic dissection is understood and treated. This state-of-the-art review article addresses the mechanisms of acute aortic dissection, explaining the role of its primary entry location, proximal, and distal dissection extension in their clinical presentation and impact on the decision-making process towards the best treatment approach. The latest evidence on novel treatment methods for acute aortic syndromes is presented, and the diverse dissection classification systems that remain uncertain are discussed, which reveals the need for shared terminology and more clarity. Finally, future aspects are discussed in treating acute aortic dissection, such as the endovascular treatment of aortic dissection Type A and biomarkers for acute aortic syndromes.

ADAMTS-7 deficiency attenuates thoracic aortic aneurysm and dissection in mice

Thoracic aortic aneurysm and dissection (TAAD) is a life-threatening cardiovascular disease with severe extracellular matrix (ECM) remodeling that lacks efficient early stage diagnosis and nonsurgical therapy. A disintegrin and metalloproteinase with thrombospondin motif 7 (ADAMTS-7) is recognized as a novel locus for human coronary artery atherosclerosis. Previous work by us and others showed that ADAMTS-7 promoted atherosclerosis, postinjury neointima formation, and vascular calcification. However, whether ADAMTS-7 is involved in TAAD pathogenesis is unknown. We aimed to explore the alterations in ADAMTS-7 expression in human and mouse TAAD, and investigate the role of ADAMTS-7 in TAAD formation. A case-control study of TAAD patients (N = 86) and healthy participants (N = 88) was performed. The plasma ADAMTS-7 levels were markedly increased in TAAD patients within 24 h and peaked in 7 days. A TAAD mouse model was induced with 0.5% β-aminopropionitrile (BAPN) in drinking water. ELISA analysis of mouse plasma, Western blotting, and immunohistochemical staining of aorta showed an increase in ADAMTS-7 in the early stage of TAAD. Moreover, ADAMTS-7-deficient mice exhibited significantly attenuated TAAD formation and TAAD rupture-related mortality in both male and female mice, which was accompanied by reduced artery dilation and inhibited elastin degradation. ADAMTS-7 deficiency caused repressed inflammatory response and complement system activation during TAAD formation. An increase in plasma ADAMTS-7 is a novel biomarker for human TAAD. ADAMTS-7 deficiency attenuates BAPN-induced murine TAAD. ADAMTS-7 is a potential novel target for TAAD diagnosis and therapy. KEY MESSAGES: A case-control study revealed increased plasma ADAMTS-7 is a risk factor for TAAD. ADAMTS-7 was elevated in plasma and aorta at early stage of mouse TAAD. ADAMTS-7 knockout attenuated mouse TAAD formation and mortality in both sexes.

A fluorescent nano vector for early diagnosis and enhanced Interleukin-33 therapy of thoracic aortic dissection

Thoracic aortic dissection (TAD) is the most devastating complication of vascular disease. The accuracy of the clinical diagnosis and treatment of TAD at the early stage is still limited. Herein, we report a nano-delivery strategy for early diagnosis and the first case of interleukin-33 (IL-33) based therapy for the effective intervention of TAD. A targeted fluorescent nano vector (FNV) is designed to co-assemble with IL-33, which protects IL-33 and prolongs its half-life. With specific targeting ability to the thoracic aorta, FNV can diagnose TAD at its early stage through fluorescent imaging. FNV@IL-33 nanocomplex presents better therapeutic effects on mice TAD progression compared with that of IL-33 alone by reducing smooth muscle apoptosis. Administration of FNV@IL-33 two weeks before onset, the development of TAD is greatly intervened. Our study provides a novel approach for early diagnosis and effective IL-33 therapy of TAD, which opens attractive opportunities for clinical prevention of cardiovascular diseases.

Development and validation of nomogram models to discriminate between acute aortic syndromes and non-ST-elevation myocardial infarction during troponin-blind period

Background

Blood-test-based methods of distinguishing between acute aortic syndromes (AASs) and non-ST-elevation myocardial infarction (NSTEMI) during the troponin-blind period of <2-3 h of symptom onset have not been studied previously. We aimed to explore whether routine biomarkers might facilitate differential diagnosis.

Methods

Data were retrospectively collected from 178 patients with AASs and 460 patients with NSTEMI within 3 h of onset. Differential risk factors related to AASs were identified by univariate and multivariate logistic regression analyses for patients with onset <2 h and onset ≥2 h, respectively, in the cardiac troponin (cTn) cohort. Nomograms were established in the cTn cohort as a training set and validated in the high-sensitivity cTn cohort. To assess the utility of the models in clinical practice, decision curve analyses were performed.

Results

D-dimer, fibrinogen, and age were identified as differential risk factors for AASs with the onset of <2 h. D-dimer at an optimal cutoff level of 281 ng/mL for AASs had a sensitivity of 86.4% and a specificity of 91.3%. A nomogram was developed and validated with areas under the curve (AUC) of 0.934 (95% CI: 0.880-0.988) and 0.952 (95% CI: 0.874-1.000), respectively. D-dimer, neutrophil, bilirubin, and platelet were the differential risk factors for AASs with the onset of ≥2 h. D-dimer at an optimal cutoff level of 385 ng/mL has a sensitivity of 91.8% and a specificity of 91.3%. The AUC of the second nomogram in the training set and the validation set were 0.965 (95% CI: 0.942-0.988) and 0.974 (95% CI: 0.944-1.000), respectively.

Conclusion

Time-dependent quality of D-dimer should be considered for discriminating AASs from NSTEMI. Both nomogram models may have a clinical utility for evaluating the probability of AASs.

Targeting endothelial tight junctions to predict and protect thoracic aortic aneurysm and dissection

AIMS

Whether changes in endothelial tight junctions (TJs) lead to the formation of thoracic aortic aneurysm and dissection (TAAD) and serve as an early indicator and therapeutic target remains elusive.

METHODS AND RESULTS

Single-cell RNA sequencing analysis showed aberrant endothelial TJ expressions in the thoracic aortas of patients with TAAD. In a β-aminopropionitrile (BAPN)-induced TAAD mouse model, endothelial TJ function was disrupted in the thoracic aortas at an early stage (5 and 10 days) as observed by a vascular permeability assay, while the intercellular distribution of crucial TJ components was significantly decreased by en face staining. For the non-invasive detection of endothelial TJ function, two dextrans of molecular weights 4 and 70 kDa were conjugated with the magnetic resonance imaging (MRI) contrast agent Gd-DOTA to synthesize FITC-dextran-DOTA-Gd and rhodamine B-dextran-DOTA-Gd. MRI images showed that both probes accumulated in the thoracic aortas of the BAPN-fed mice. Particularly, the mice with increased accumulated signals from 5 to 10 days developed TAAD at 14 days, whereas the mice with similar signals between the two time points did not. Furthermore, the protease-activated receptor 2 inhibitor AT-1001, which seals TJs, alleviated the BAPN-induced impairment of endothelial TJ function and expression and subsequently reduced TAAD incidence. Notably, endothelial-targeted ZO-1 conditional knockout increased TAAD incidence. Mechanistically, vascular inflammation and edema were observed in the thoracic aortas of the BAPN-fed mice, whereas these phenomena were attenuated by AT-1001.

CONCLUSION

The disruption of endothelial TJ function is an early event prior to TAAD formation, herein serving as a potential indicator and a promising target for TAAD.

Prognostic value of interleukin-33, sST2, myeloperoxidase, and matrix metalloproteinase-9 in acute aortic dissection

Background and purpose

Acute aortic dissection (AAD) is a life-threatening cardiovascular emergency. Both neutrophil granzyme and interleukin (IL)-33/ST2 systems have proven to be effective diagnostic markers for AAD. This study aimed to investigate the relationship between plasma IL-33, soluble suppression of tumorigenesis-2 (sST2), myeloperoxidase (MPO), and matrix metalloproteinase (MMP)-9 levels at admission and all-cause mortality in patients with AAD.

Methods

A total of 155 patients with AAD were enrolled from the Prospective Evaluation of Acute Chest Pain (PEACP) study. Plasma concentrations of IL-33, sST2, and MMP-9 were measured using an enzyme-linked immunosorbent assay, and MPO was detected using a chemiluminescence immunoassay. Aortic anatomical parameters were measured using CT radiography. The primary endpoint was all-cause mortality rate.

Results

The median age of the patients was 55 years, and 96 (61.9%) were diagnosed with type A-AAD. After adjusting for confounding factors, the highest tertiles of IL-33, sST2, MPO, and MMP-9 had hazard risks of 0.870 (95% CI: 0.412-1.836, P = 0.714), 3.769 (95% CI: 1.504-9.446, P = 0.005), 4.689 (95% CI: 1.985-11.076, P < 0.001), and 4.748 (95% CI: 1.763-12.784, P = 0.002), respectively, compared to the lowest tertile. Pearson's correlation analysis revealed a significant correlation between these markers (P < 0.001). Moreover, sST2, MPO, and MMP-9 levels had a significant positive correlation with aortic diameter and pseudolumen area (P < 0.001).

Conclusion

The biomarkers sST2, MPO, and MMP-9 were independently associated with mortality in patients with AAD. The significant correlation between these biomarkers suggests a pathogenic role for the IL-33/ST2/neutrophil granzyme system in patients with AAD.

Alcoholic Liver Disease Is Associated with Elevated Plasma Levels of Novel Advanced Glycation End-Products: A Preliminary Study

Elucidating the biochemical mechanisms associated with the progression of alcoholic liver disease (ALD) to more advanced stages such as alcoholic hepatitis (AH) remains an important clinical and scientific challenge. Several hypotheses point to the involvement of advanced glycation end-products (AGEs) in alcohol-associated liver injuries. Recently, we determined the structure of a synthetic, melibiose-derived AGE (MAGE), which was an analog of the novel AGE subgroup AGE10. The primary objective of our study was to determine whether AGE10 was associated with alcoholic hepatitis. The secondary objective was to provide a diagnostic accuracy of AGE10 in AH. To achieve this objective, we examined the plasma levels of AGE10 in 65 healthy individuals and 65 patients with AH. The AGE10 level was measured using a competitive ELISA. Our study confirmed that patients with AH had significantly higher plasma concentrations of AGE10 compared with healthy controls (184.5 ± 71.1 μg/mL and 123.5 ± 44.9 μg/mL, respectively; p < 0.001). In addition, AGE10 showed an acceptable performance as a diagnostic marker of AH, with an AUC of 0.78. In conclusion, AH was associated with elevated levels of novel advanced glycation end-product AGE10.

Acute aortic syndromes: An internist's guide to the galaxy

Acute aortic syndromes (AASs) are severe conditions defined by dissection, hemorrhage, ulceration or rupture of the thoracic aorta. AASs share etiological and pathophysiological features, including long-term aortic tissue degeneration and mechanisms of acute aortic damage. The clinical signs and symptoms of AASs are unspecific and heterogeneous, requiring large differential diagnosis. When evaluating a patient with AAS-compatible symptoms, physicians need to integrate clinical probability assessment, bedside imaging techniques such as point-of-care ultrasound, and blood test results such as d-dimer. The natural history of AASs is dominated by engagement of ischemic, coagulative and inflammatory pathways at large, causing multiorgan damage. Medical treatment, multiorgan monitoring and outcome prognostication are therefore paramount, with internal medicine playing a key role in non-surgical management of AASs.

Plasma Siglec-5 and CD163 as Novel Biomarkers for Fulminant Myocarditis

Fulminant myocarditis (FM) is the severest type of myocarditis and requires timely diagnosis and treatment. However, effective biomarkers for early diagnosis of FM are limited. First, 12 common inflammatory cytokines levels in the plasma of patients with FM were measured using human cytokine 12-Plex assay. Then, enzyme-linked immunosorbent assay (ELISA) was used to detect the plasma levels of another eight cytokines that we previously reported on. Moreover, a Spearman correlation test was employed to investigate the correlations between the plasma cytokine levels and the clinical parameters of patients with FM. Finally, receiver operating characteristic (ROC) curve analyses were performed to assess the diagnostic performance of plasma cytokine levels for the detection of FM. Five of the twelve common inflammation cytokines were significantly altered in patients with FM, but none of them was correlated with the severity of FM. Six of the eight significantly changed cytokines that we previously reported on were validated by ELISA. Among these, sST2, Siglec-5, and CD163 were negatively correlated with ejection fraction values. Furthermore, plasma Siglec-5 and CD163 levels were found to be associated with the severity of FM. Finally, both plasma Siglec-5 and CD163 showed outstanding diagnostic performance for FM. The current study identified plasma Siglec-5 and CD163 as valuable novel biomarkers for the early diagnosis of FM.

Current Understanding of Aortic Dissection

The aorta is the largest artery in the body, delivering oxygenated blood from the left ventricle to all organs. Dissection of the aorta is a lethal condition caused by a tear in the intimal layer of the aorta, followed by blood loss within the aortic wall and separation of the layers to full dissection. The aorta can be affected by a wide range of causes including acute conditions such as trauma and mechanical damage; and genetic conditions such as arterial hypertension, dyslipidaemia, and connective tissue disorders; all increasing the risk of dissection. Both rapid diagnostic recognition and advanced multidisciplinary treatment are critical in managing aortic dissection patients. The treatment depends on the severity and location of the dissection. Open surgical repair is the gold standard of treatment for dissections located to the proximal part of the aorta and the arch, while endovascular interventions are recommended for most distal or type B aortic dissections. In this review article, we examine the epidemiology, pathophysiology, contemporary diagnoses, and management of aortic dissection.

Diagnostic and prognostic value of serum soluble suppression of tumorigenicity-2 in heart failure with preserved ejection fraction: A systematic review and meta-analysis

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) is a growing public health burden, with mortality and rehospitalization rates comparable to HF with reduced ejection fraction (HFrEF). The evidence for the clinical usefulness of soluble suppression of tumorigenicity 2 (sST2) in HFpEF is contradictory. Therefore, we conducted the following systematic review and meta-analysis to assess the diagnostic and prognostic value of serum sST2 in HFpEF.

Methods

PubMed and Scopus were searched exhaustively from their inception until March 15, 2022. In diagnostic analysis, we compared the diagnostic value of serum sST2 in HFpEF to NT pro-BNP. We separately pooled the unadjusted and multivariate-adjusted hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) in prognostic analysis.

Results

A total of 16 publications from 2008 to 2021 were examined. The results of this analysis were as follow: Firstly, compared with NT pro-BNP, sST2 obtains poor diagnostic performance in independently identifying HFpEF from healthy controls, hypertensive patients, and HFrEF patient. Nevertheless, it may provide incremental value to other biomarkers for diagnosing HFpEF and deserves further investigation. Secondly, log sST2 was independently associated with adverse endpoints on multivariable analysis after adjusting for variables such as age, sex, race, and NYHA class. Per log unit rise in sST2, there was a 2.76-fold increased risk of all-cause death [HR:2.76; 95% CI (1.24, 6.16); p = 0.516, I² = 0%; P = 0.013] and a 6.52-fold increased risk in the composite endpoint of all-cause death and HF hospitalization [HR:6.52; 95% CI (2.34, 18.19); p = 0.985, I² = 0%; P = 0.000]. Finally, the optimal threshold levels of serum sST2 need further determined.

Conclusions

Higher sST2 was strongly linked to an increased risk of adverse outcomes in HFpEE. Especially, log sST2 independently predicted all-cause death and the composite endpoint of all-cause death and HF hospitalization. However, prospective and multicenter studies with large-sample and extended follow-up periods are required to validate our results due to limitations in our research.

Soluble ST2 as a Potential Biomarker for Abdominal Aortic Aneurysms-A Single-Center Retrospective Cohort Study

The maximal aortic diameter is the only clinically applied predictor of abdominal aortic aneurysm (AAA) progression and indicator for surgical repair. Circulating biomarkers resulting from AAA pathogenesis are attractive candidates for the diagnosis and prognosis of aneurysmal disease. Due to the reported role of interleukin 33 in AAA development, we investigated the corresponding circulating receptor molecules of soluble suppression of tumorigenesis 2 (sST2) in AAA patients regarding their marker potential in diagnosis and prognosis. We conducted a single-center retrospective cohort study in a diagnostic setting, measuring the circulating serum sST2 protein levels of 47 AAA patients under surveillance, matched with 25 peripheral artery disease (PAD) patients and 25 healthy controls. In a prognostic setting, we analyzed the longitudinal monitoring data of 50 monitored AAA patients. Slow versus fast AAA progression was defined as a <2 or ≥2 mm increase in AAA diameter over 6 months and a <4 or ≥4 mm increase over 12 months. Additionally, the association of circulating serum sST2 and AAA growth was investigated using a specifically tailored log-linear mixed model. Serum sST2 concentrations were significantly increased in AAA patients compared with healthy individuals: the median of AAA patient cohort was 112.72 ng/mL (p = 0.025) and that of AAA patient cohort 2 was 14.32 ng/mL (p = 0.039) versus healthy controls (8.82 ng/mL). Likewise, PAD patients showed significantly elevated sST2 protein levels compared with healthy controls (the median was 12.10 ng/mL; p = 0.048) but similar concentrations to AAA patients. Additionally, sST2 protein levels were found to be unsuited to identifying fast AAA progression over short-term periods of 6 or 12 months, which was confirmed by a log-linear mixed model. In conclusion, the significantly elevated protein levels of sST2 detected in patients with vascular disease may be useful in the early diagnosis of AAA but cannot distinguish between AAA and PAD or predict AAA progression.

Identification and validation of differentially expressed chromatin regulators for diagnosis of aortic dissection using integrated bioinformatics analysis and machine-learning algorithms

Background: Aortic dissection (AD) is a life-threatening disease. Chromatin regulators (CRs) are indispensable epigenetic regulators. We aimed to identify differentially expressed chromatin regulators (DECRs) for AD diagnosis.

Methods: We downloaded the GSE52093 and GSE190635 datasets from the Gene Expression Omnibus database. Following the merging and processing of datasets, bioinformatics analysis was applied to select candidate DECRs for AD diagnosis: CRs exertion; DECR identification using the “Limma” package; analyses of enrichment of function and signaling pathways; construction of protein–protein interaction (PPI) networks; application of machine-learning algorithms; evaluation of receiver operating characteristic (ROC) curves. GSE98770 served as the validation dataset to filter DECRs. Moreover, we collected peripheral-blood samples to further validate expression of DECRs by real-time reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Finally, a nomogram was built for clinical use.

Results: A total of 841 CRs were extracted from the merged dataset. Analyses of functional enrichment of 23 DECRs identified using Limma showed that DECRs were enriched mainly in epigenetic-regulation processes. From the PPI network, 17 DECRs were selected as node DECRs. After machine-learning calculations, eight DECRs were chosen from the intersection of 13 DECRs identified using support vector machine recursive feature elimination (SVM-RFE) and the top-10 DECRs selected using random forest. DECR expression between the control group and AD group were considerably different. Moreover, the area under the ROC curve (AUC) of each DECR was >0.75, and four DECRs (tumor protein 53 (TP53), chromobox protein homolog 7 (CBX7), Janus kinase 2 (JAK2) and cyclin-dependent kinase 5 (CDK5)) were selected as candidate biomarkers after validation using the external dataset and clinical samples. Furthermore, a nomogram with robust diagnostic value was established (AUC = 0.960).

Conclusion: TP53, CBX7, JAK2, and CDK5 might serve as diagnostic DECRs for AD diagnosis. These DECRs were enriched predominantly in regulating epigenetic processes.

A Novel Serum Biomarker Model to Discriminate Aortic Dissection from Coronary Artery Disease

Background

The misdiagnosis of aortic dissection (AD) can lead to a catastrophic prognosis. There is currently a lack of stable serological indicators with excellent efficacy for the differential diagnosis of AD and coronary artery disease (CAD). A recent study has shown an association between AD and iron metabolism. Thus, we investigated whether iron metabolism could discriminate AD from CAD.

Methods

This retrospective and multicenter cross-sectional study investigated the efficacy of biomarkers of iron metabolism for the differential diagnosis of AD. We collected biomarkers of iron metabolism, liver function, kidney function, and other biochemistry test, and further, logistic regression analysis was applied.

Results

Between Oct. 8, 2020, and Mar. 1, 2021, we recruited 521 patients diagnosed with AD, CAD, and other cardiovascular diseases (OCDs) with the main symptoms of chest and back pain and assigned them to discovery set (n = 330) or validation set (n = 191). We found that six serum biomarkers, including serum iron, low-density lipoprotein, uric acid, transferrin, high-density lipoprotein, and estimated glomerular filtration rate, can serve as a novel comprehensive indicator (named FLUTHE) for the differential diagnosis of AD and CAD with a sensitivity of 0.954 and specificity of 0.905 to differentially diagnose AD and CAD more than 72 h past symptom onset.

Conclusion

Our findings provide insight into the role of iron metabolism in diagnosing and distinguishing AD, which might in the future be a key component in AD diagnosis. Furthermore, we establish a novel model named "FLUTHE" with higher efficiency, safety, and economy, especially for patients with chest pain for more than 72 h.

Study on Proteomics-Based Aortic Dissection Molecular Markers Using iTRAQ Combined With Label Free Techniques

Background: Aortic dissection refers to the separation of aortic media and extension along the long axis to form the true and false chambers of the aortic wall. 65–70% of the patients died of cardiac tamponade, arrhythmia, dissection rupture, etc. At present, echocardiography, computed tomography angiography (CTA), etc. are the main diagnosis tools for aortic dissection. To date, there is no rapid serum molecular marker that can be used for differential diagnosis and risk assessment.

Objectives: To screen serum molecular markers systematically amid aortic dissection and acute coronary syndrome and to preliminarily identify the pathogenesis of acute aortic dissection.

Methods: Related disputes cases of all hospitals were statistically analyzed for the AAD medical disputes ratio, early death ratio and misdiagnosis ratio from the database of Guangdong Province Medical Disputes Coordination Committee from 2013 to 2017. Serum and Aortic tissues samples were respectively quantified by iTRAQ and label-free analysis, further validated by ELISA and protein verified by immunofluorescence and Western blot from AAD and control patients enrolled from the Zhujiang Hospital of Southern Medical University and Guangdong Province people's Hospital from 2016 to 2018.

Results: AAD cases ratio accounted for 15.29% in all 150 cardiovascular disputes, 59.26% in all cardiovascular death less than 24 h, and 88.89% in the patients who remained undiagnosed at the time of death, 84 proteins (66 and 18 upregulated and downregulated, respectively) were identified by iTRAQ and 16 proteins (9 and 7 upregulated and downregulated, respectively) by Label-free. Nine proteins (Lumican, FGL1, PI16, MMP9, FBN1, MMP2, VWF, MMRN1, and PF4) related to the pathogenesis of aortic dissection were identified by David /Ease and String techniques as candidate biomarkers for verification test. Four proteins (Lumican, FGL1, PI16, and MMP9) were found to be statistically different after ELISA verification. The expression of FGL1, PI16, and MMP9 proteins was pathologically significantly increased except for Lumican. Histologically, TGF-β1, α-SMA, and Collagen1 were also significantly higher in the aortic group.

Conclusion: Lumican, FGL1, PI16, and MMP9 may be potential biomarkers in AAD patients, and the Lumican-mediated TGF-β1 pathway is likely to be involved in the pathogenesis of aortic dissection.

Serum Oxylipin Profiles Identify Potential Biomarkers in Patients with Acute Aortic Dissection

Aortic dissection (AD) is a life-threatening cardiovascular disease with a dismal prognosis. Inflammation plays an important role in AD. Oxylipins are bioactive lipids involved in the modulation of inflammation and may be involved in the pathogenesis and progression of AD. This study aims to identify possible metabolites related to AD. A total of 10 type A Aortic dissection (TAAD) patients, 10 type B Aortic dissection (TBAD) patients and 10 healthy controls were included in this study. Over 100 oxylipin species were identified and quantified by liquid chromatography with tandem mass spectrometry (LC-MS/MS) analysis. Our investigation demonstrated substantial alterations in 91 oxylipins between AD and healthy individuals. Patients with TAAD had 89 entries accessible compared to healthy controls. According to orthogonal partial least squares discriminant analysis (OPLS-DA), fitness (R²X = 0.362 and R²Y = 0.807, p = 0.03) and predictability (Q² = 0.517, p = 0.005) are the validation parameters between the two groups. Using multivariate logistic regression, 13-HOTrE and 16(17)-EpDPE were the risk factors in the aortic patients group compared to healthy people (OR = 2.467, 95%CI:1.256–7.245, p = 0.035; OR = 0.015, 95%CI:0.0002–0.3240, p = 0.016, respectively). In KEGG enrichment of differential metabolites, the arachidonic acid metabolism pathway has the most metabolites involved. We established a diagnostic model in distinguishing between AD and healthy people. The AUC was 0.905. Oxylipins were significantly altered in AD patients, suggesting oxylipin profile is expected to exploit a novel, non-invasive, objective diagnosis for AD.

Soluble ST2 Is a Sensitive and Specific Biomarker for Fulminant Myocarditis

Background

The aim of the study was to identify biomarkers that can facilitate early diagnosis and treatment of fulminant myocarditis (FM) in order to reduce mortality.

Methods and Results

First, the expression profiles of circulating cytokines were determined in the plasma samples from 4 patients with FM and 4 controls using human cytokine arrays. The results showed that 39 cytokines from patients with FM were changed at admission. Among them, 8 cytokines returned to normal levels at discharge, including soluble ST2 (sST2), which showed the most marked dynamic changes from disease onset to resolution. Then, in a cohort of 76 patients with FM, 57 patients with acute hemodynamic dysfunction attributable to other causes, and 56 patients with non‐FM, receiver operating characteristic curve analyses suggested that plasma sST2 level was able to differentiate FM from non‐FM or other FM‐unrelated acute heart failure more robustly N‐terminal pro‐B‐type natriuretic peptide or cardiac troponin I. Moreover, longitudinal analysis of plasma sST2 was performed in 10 patients with FM during hospitalization and 16 patients with FM during follow‐up. Finally, the diagnostic value was validated in an additional 26 patients with acute onset of unstable hemodynamics. The cutoff value of plasma sST2 for optimal diagnosis of FM was established at 58.39 ng/mL, where a sensitivity of 85.7% and specificity of 94.7% were achieved.

Conclusions

Elevated sST2 level was associated with mechanical stress or inflammation. Especially, sST2 might be used as a potential biomarker for the rapid diagnosis of FM, which was characterized by strong mechanical stretch stimulation and severe inflammatory response.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03268642.

Lysophosphatidic Acid May Be a Novel Biomarker for Early Acute Aortic Dissection

Background: Misdiagnosis and delayed diagnosis of acute aortic dissection (AAD) significantly increase mortality. Lysophosphatidic acid (LPA) is a biomarker related to coagulation cascade and cardiovascular-injury. The extent of LPA elevation in AAD and whether it can discriminate sudden-onset of acute chest pain are currently unclear.

Methods: We measured the plasma concentration of LPA in a cohort of 174 patients with suspected AAD chest pain and 30 healthy participants. Measures to discriminate AAD from other acute-onset thoracalgia were compared and calculated.

Results: LPA was significantly higher in AAD than in the AMI, PE, and the healthy (344.69 ± 59.99 vs. 286.79 ± 43.01 vs. 286.61 ± 43.32 vs. 96.08 ± 11.93, P < 0.01) within 48 h of symptom onset. LPA level peaked at 12 h after symptom onset, then gradually decreased from 12 to 48 h in AAD. LPA had an AUC of 0.85 (0.80–0.90), diagnosis threshold of 298.98 mg/dl, a sensitivity of 0.81, specificity of 0.77, and the negative predictive value of 0.85. The ROC curve of LPA is better than D-dimer (P = 0.041, Delong test). The decision curve showed that LPA had excellent standardized net benefits.

Conclusion: LPA showed superior overall diagnostic performance to D-dimer in early AAD diagnosis may be a potential biomarker, but additional studies are needed to determine the rapid and cost-effective diagnostic tests in the emergency department.

Inhibition of Sphingosine-1-Phosphate Receptor 2 Prevents Thoracic Aortic Dissection and Rupture

Background: Numerous pieces of evidence have indicated that thoracic aortic dissection (TAD) is an inflammatory disease. Sphingosine-1-phosphate receptor 2 (S1PR2) signaling is a driver in multiple inflammatory diseases. Here, we examined the S1PR2 expression in TAD lesions and explored the effect of interfering with S1PR2 on TAD formation and progression.

Methods: Aorta specimens and blood samples were collected from patients with TAD and matched controls. The expression of S1PR1, S1PR2, and S1PR3 was examined. The effect of inhibiting S1PR2 on TAD was evaluated in a TAD mouse model induced by β-aminopropionitrile fumarate (BAPN) and AngII. The presence of sphingosine kinase 1 (SPHK1), S1P, and neutrophil extracellular traps (NETs) was investigated. Further, the possible association between S1PR2 signaling and NETs in TAD was analyzed.

Results: In the aortic tissues of patients with TAD and a mouse model, the S1PR2 expression was significantly up-regulated. In the TAD mouse model, JTE013, a specific S1PR2 antagonist, not only blunted the TAD formation and aortic rupture, but also preserved the elastic fiber architecture, reduced the smooth muscle cells apoptosis level, and mitigated the aortic wall inflammation. Augmented tissue protein expression of SPHK1, citrullinated histone H3 (CitH3, a specific marker of NETs), and serum S1P, CitH3 were detected in TAD patients. Surgical repair normalized the serum S1P and CitH3 levels. Immunofluorescence staining revealed that S1PR2 colocalized with NETs. The protein expression levels of SPHK1 and serum S1P levels positively correlated with the protein expression and serum levels of CitH3, separately. Furthermore, JTE013 treatment reduced NETs accumulation.

Conclusion: Inhibiting S1PR2 attenuates TAD formation and prevents aortic rupture. Targeting S1PR2 may provide a promising treatment strategy against TAD.

Why the aortic dissection detection risk score is problematic in emergency departments

Acute aortic syndromes, including aortic dissection (AD), are rare. The AD detection risk score (ADDRS) and associated investigation pathway were developed to reduce missed diagnosis of AD. The methodology for its development was sub-optimal and it has not been robustly validated in the emergency department chest pain population. Recent research suggests that it will drive over-investigation and that the risks of missed diagnosis may not be in balance with the risks of the testing strategy. There are serious doubts about whether the score and investigation pathway are fit for purpose.

Association of IL1R1 Coding Variant With Plasma-Level Soluble ST2 and Risk of Aortic Dissection

Objective: Aortic dissection (AD) is characterized by an acute onset, rapid progress, and high mortality. Levels of soluble ST2 (sST2) on presentation are elevated in patients with acute AD, which can be used to discriminate AD patients from patients with chest pain. sST2 concentrations were found to be highly heritable in the general population. The aim of this study was to investigate the associations of variations in ST2-related gene expression with sST2 concentrations and AD risk. Methods: This case-control study involving a total of 2,277 participants were conducted, including 435 AD patients and age- and sex-matched 435 controls in the discovery stage, and 464 patients and 943 controls in the validation stage. Eight ST2-related genes were selected by systematic review. Tag single-nucleotide polymorphisms (SNPs) were screened out from the Chinese population of the 1,000 Genomes Database. Twenty-one ST2-related SNPs were genotyped, and plasma sST2 concentrations were measured. Results: In the discovery stage, rs13019803 located in IL1R1 was significantly associated with AD after Bonferroni correction (p = 0.0009) and was correlated with circulating sST2 levels in patients with type A AD(AAD) [log-sST2 per C allele increased by 0.180 (95%) CI: 0.002 - 0.357] but not in type B. Combining the two stages together, rs13019803C was associated with plasma sST2 level in AAD patients [log-sST2 increased by 0.141 (95% CI: 0.055-0.227) for per C allele]. Odds ratio of rs13019803 on the risk of AAD is 1.67 (95% CI: 1.33-2.09). Conclusions: The IL1R1 SNP rs13019803C is associated with higher sST2 levels and increased risk of AAD.

The potential value of the neutrophil to lymphocyte ratio for early differential diagnosis and prognosis assessment in patients with aortic dissection

OBJECTIVES

The aim of the study was to assess the diagnostic performance and clinical utility of the neutrophil to lymphocyte ratio (NLR) in patients with suspected aortic dissection (AD) and investigate its role in predicting in-hospital mortality in AD.

METHODS

NLR values were calculated and compared in 467 consecutive patients with initially suspected AD. A receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used to evaluate the discriminative accuracy and predictive capability of the NLR for AD. Clinical utility was determined by decision curve analysis (DCA). The association between NLR and in-hospital mortality was investigated by logistic regression analyses in patients diagnosed with AD.

RESULTS

The NLR was significantly elevated in patients with AD, and the optimal cut-off point for the NLR to distinguish AD from other acute chest pain diseases was 5.67 [AUC (95% CI): 0.877 (0.844-0.905)]. We recommended an NLR of 2.43 as the appropriate cut-off point with 96.9% sensitivity and a negative likelihood ratio (LR) of 0.09 to satisfy clinical requirements for diagnosis. DCA showed that the use of NLR had a positive net benefit. The deceased patients with AD had a higher NLR than the discharged patients. Moreover, the NLR was an independent predictor of in-hospital mortality for AD [adjusted odds ratio (OR): 1.084 (1.029-1.142)], and patients with higher NLR values tended to have a higher risk of in-hospital mortality. The optimal cut-off point for the NLR to predict in-hospital mortality was 9.20 [AUC (95% CI): 0.695 (0.619-0.765)].

CONCLUSIONS

As an easily available and inexpensive parameter, the NLR could serve as a valuable clinical biomarker for early differential diagnosis and prognosis assessment of AD.

Altered DNA methylation pattern reveals epigenetic regulation of Hox genes in thoracic aortic dissection and serves as a biomarker in disease diagnosis

BACKGROUND

Thoracic aortic dissection (TAD) is a severe disease with limited understandings in its pathogenesis. Altered DNA methylation has been revealed to be involved in many diseases etiology. Few studies have examined the role of DNA methylation in the development of TAD. This study explored alterations of the DNA methylation landscape in TAD and examined the potential role of cell-free DNA (cfDNA) methylation as a biomarker in TAD diagnosis.

RESULTS

Ascending aortic tissues from TAD patients (Stanford type A; n = 6) and healthy controls (n = 6) were first examined via whole-genome bisulfite sequencing (WGBS). While no obvious global methylation shift was observed, numerous differentially methylated regions (DMRs) were identified, with associated genes enriched in the areas of vasculature and heart development. We further confirmed the methylation and expression changes in homeobox (Hox) clusters with 10 independent samples using bisulfite pyrosequencing and quantitative real-time PCR (qPCR). Among these, HOXA5, HOXB6 and HOXC6 were significantly down-regulated in TAD samples relative to controls. To evaluate cfDNA methylation pattern as a biomarker in TAD diagnosis, cfDNA from TAD patients (Stanford type A; n = 7) and healthy controls (n = 4) were examined by WGBS. A prediction model was built using DMRs identified previously from aortic tissues on methylation data from cfDNA. Both high sensitivity (86%) and specificity (75%) were achieved in patient classification (AUC = 0.96).

CONCLUSIONS

These findings showed an altered epigenetic regulation in TAD patients. This altered epigenetic regulation and subsequent altered expression of genes associated with vasculature and heart development, such as Hox family genes, may contribute to the loss of aortic integrity and TAD pathogenesis. Additionally, the cfDNA methylation in TAD was highly disease specific, which can be used as a non-invasive biomarker for disease prediction.

LncRNA PCNAP1 Promotes Hepatoma Cell Proliferation through Targeting miR-340-5p and is Associated with Patient Survival

Hepatocellular carcinoma (HCC) is one of the most common malignancies and causes poor outcome. Dysregulation of long noncoding RNA (lncRNA) is involved in HCC. Upregulation of the lncRNA PCNAP1 has been reported to promote HBV-infectious HCC growth, but its clinical significance and underlying mechanisms in HCC development remain unclear. Here, we report that PCNAP1 expression is increased in both HBV-infectious and noninfectious HCC tissues compared with matched normal tissues, and its upregulation correlates with poor survival rates of HCC patients. Furthermore, we found that PCNAP1 promotes HCC cell proliferation through acting as a competitive endogenous RNA (ceRNA) to sponge miR-340-5p, which has been reported to directly inhibit ATF7 expression in HCC cells. Moreover, the PCNAP1/miR-340-5p/ATF7 signaling associates with the poor survival rates of HCC patients. Collectively, our findings suggest that the PCNAP1/miR-340-5p/ATF7 signaling may be a potential biomarker for the prognosis of HCC patients and a potential therapeutic target for HCC.

Promising Novel Biomarkers in Cardiovascular Diseases

Cardiovascular diseases remain the most common causes of death globally, according to the World Health Organization. In recent years, a great number of biomarkers have been investigated, whereas only some have gained value in the diagnosis, prognosis, and risk stratification of different cardiovascular illnesses. As numerous studies have investigated the diagnostic yield of novel biomarkers in various disease entities every year, this review aims to provide an overview of the current status of four promising representatives. In particular, this manuscript refers to soluble suppression of tumorigenicity 2 (sST2), heart-type fatty acid binding protein (H-FABP), growth differentiation factor (GDF-15) and soluble urokinase-type plasminogen activator receptor (suPAR). These markers are of special interest as they are thought to provide an accurate estimate of cardiovascular risk in certain patient populations, especially those with pre-existing diseases, such as obesity or diabetes mellitus. We sought to give an overview of their function, individual diagnostic and predictive value and determination in the laboratory. A review of the literature regarding the aforementioned cardiovascular biomarkers yielded manifold results with respect to their individual diagnostic and prognostic value. Yet, the clinical relevance of these findings remains unclear, warranting further studies to identify their optimal use in clinical routine.

Prognostic Value of Circulating sST2 for the Prediction of Mortality in Patients With Cardiac Light-Chain Amyloidosis

Aims: Systemic light-chain (AL) amyloidosis is a multisystemic disorder leading to multiple organ dysfunction and mortality that is often caused by cardiac involvement. Soluble suppression of tumorigenicity 2 (sST2) is a novel biomarker identified for risk stratification of heart disease. The aim of this study was to investigate the value of circulating sST2 levels in prognosis and mortality risk assessments for the AL amyloidosis population.

Methods and Results: A total of 56 patients diagnosed with AL amyloidosis were enrolled in Peking Union Medical College Hospital (PUMCH) from January 2015 to May 2018. The relationships between the clinical parameters and overall survival (OS) and risk factors for disease progression were assessed. Additionally, receiver operating characteristic (ROC) curves, Kaplan–Meier analysis, and Cox hazard models were performed to explore the predictive value of sST2 in mortality rates. We found that the median OS of all patients was 7.3 [interquartile range (IQR) 4.4, 15.9] months. The median baseline sST2 level was 12.2 (IQR 5.1, 31.1) ng/ml, and the sST2 high group had more severe patients with a higher Mayo stage. In the ROC analysis, the area under the curve (AUC) was 0.728 [95% confidence interval (CI) 0.603–0.853] for sST2 to predict the outcomes of AL amyloidosis patients, and the optimal cutoff value was 12.34 ng/ml (sensitivity 80.2%, specificity 61.1%). Moreover, in multivariate Cox proportional hazards regression analysis, sST2 acted as an independent predictor of poor functional outcome in patients with AL amyloidosis.

Conclusion: In AL amyloidosis patients, sST2 was a strong and independent prognostic biomarker for all-cause mortality, providing complementary prognostic information of a novel scoring system for risk stratification.

Mechanistic Biomarkers Informative of Both Cancer and Cardiovascular Disease: JACC State-of-the-Art Review

Cardiovascular disease (CVD) and cancer are leading causes of morbidity and mortality worldwide. Although conventionally managed as separate disease processes, recent research has lent insight into compelling commonalities between CVD and cancer, including shared mechanisms for disease development and progression. In this review, the authors discuss several pathophysiological processes common to both CVD and cancer, such as inflammation, resistance to cell death, cellular proliferation, neurohormonal stress, angiogenesis, and genomic instability, in an effort to understand common mechanisms of both disease states. In particular, the authors highlight key circulating and genomic biomarkers associated with each of these processes, as well as their associations with risk and prognosis in both cancer and CVD. The purpose of this state-of-the-art review is to further our understanding of the potential mechanisms underlying cancer and CVD by contextualizing pathways and biomarkers common to both diseases.

Diagnosis and management of acute aortic syndromes in the emergency department

Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.