Reduced Long-Term Risk of Aortic Aneurysm and Aortic Dissection Among Individuals With Type 2 Diabetes Mellitus: A Nationwide Observational Study

Diabetes is not a negative prognostic factor for 30-days mortality after surgery for acute type A aortic dissection

Background

The correlation between diabetes and aortic dissection is not fully understood yet, although in literature many studies have suggested that there may be an association between the two conditions. The purpose of this study is to evaluate whether diabetes represents a short- and long-term risk factor for mortality from type A acute aortic dissection.

Materials and methods

A total of 340 patients with the diagnosis of type A acute aortic dissection underwent aortic surgery between January 2002 and March 2023. The sample was divided into 2 cohorts according to the presence of diabetes (n = 34) or not (n = 306).

Results

The mean age was 66 (±12.4) years and 60.9% were male. The primary endpoint was 30-day mortality. Hospital mortality was 12 (35.3%) for the diabetes group and 70 (22.9%) for nondiabetes group (P = 0.098). Overall survival at 10 years was 48.3% [95% confidence interval (CI): 41.6-54.7%], while the 10-year survival for people with diabetes was 29.5% (95% CI: 13.2-47.9%) and for nondiabetes group 50.6% (95% CI: 43.4-57.3%) (Log-rank, P = 0.024).

Conclusion

Diabetes was not found to be a risk factor associated with 30-day mortality in patients undergoing surgery for type A acute aortic dissection. It was a risk factor for long-term survival, but this may be related to diabetes complications.

Causal relationship between type 2 diabetes mellitus and aortic dissection: insights from two-sample Mendelian randomization and mediation analysis

Objective

Some evidence suggests a reduced prevalence of type 2 diabetes mellitus (T2DM) in patients with aortic dissection (AD), a catastrophic cardiovascular illness, compared to general population. However, the conclusions were inconsistent, and the causal relationship between T2DM and AD remains unclear.

Methods

In this study, we aimed to explore the causal relationship between T2DM and AD using bidirectional Mendelian randomization (MR) analysis. Mediation MR analysis was conducted to explore and quantify the possible mediation effects of 1400 metabolites in T2DM and AD.

Results

The results of 26 datasets showed no causal relationship between T2DM and AD (P>0.05). Only one dataset (ebi-a-GCST90006934) showed that T2DM was a protective factor for AD (I9-AORTDIS) (OR=0.815, 95%CI: 0.692-0.960, P=0.014), and did not show horizontal pleiotropy (P=0.808) and heterogeneity (P=0.525). Vanillic acid glycine plays a mediator in the causal relationship between T2DM and AD. The mediator effect for vanillic acid glycine levels was -0.023 (95%CI: -0.066-0.021).

Conclusion

From the perspective of MR analysis, there might not be a causal relationship between T2DM and AD, and T2DM might not be a protective factor for AD. If a causal relationship does exist between T2DM and AD, with T2DM serving as a protective factor, vanillic acid glycine may act as a mediator and enhance such a protective effect.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The associations among peptic ulcer disease, Helicobacter pylori infection, and abdominal aortic aneurysms: A nationwide population-based cohort study

BACKGROUND

There are overlapping risk factors and underlying molecular mechanisms for both peptic ulcer disease (PUD) and abdominal aortic aneurysm (AAA). Despite improvements in the early diagnosis and treatment of AAA, ruptured AAAs continue to cause a substantial number of deaths. Helicobacter pylori are Gram-negative, microaerophilic bacteria that are now recognized as the main cause of PUD. H. pylori infection (HPI) is associated with an increased risk of certain cardiovascular diseases. HPIs can be treated with at least two different antibiotics to prevent bacteria from developing resistance to one particular antibiotic.

METHODS

We conducted a population-based cohort study using the National Health Insurance Research Database to evaluate whether associations exist among PUD, HPI, and eradication therapy for HPI and AAA. The primary outcome of this study was the cumulative incidence of AAA among patients with or without PUD and HPI during the 14-year follow-up period.

RESULTS

Our analysis included 7003 patients with PUD/HPI, 7003 patients with only PUD, and another 7003 age-, sex-, and comorbidity-matched controls from the database. We found that patients with PUD/HPI had a significantly increased risk of AAA compared to those with PUD alone and matched controls. The patients who had PUD/HPI had a significantly higher cumulative risk of developing AAA than those with PUD and the comparison group (2.67 % vs. 1.41 % vs. 0.73 %, respectively, p < 0.001). Among those patients with PUD/HPI, patients who had eradication therapy had a lower incidence of AAA than those without eradication therapy (2.46 % vs. 3.88 %, p = 0.012).

CONCLUSIONS

We revealed an association among PUD, HPI, and AAA, even after adjusting for age, sex, comorbidities, and annual medical follow-up visits. Notably, we found that HPI eradication therapy reduced the incidence of AAA among patients with PUD.

The effect of exercise training intervention for patients with abdominal aortic aneurysm on cardiovascular and cardiorespiratory variables: an updated meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this meta-analysis was to evaluate the effect of exercise training intervention in patients with abdominal aortic aneurysm (AAA).

METHODS

Eight randomized controlled trials (RCTs) that recruited 588 AAA patients were extracted using 4 databases (PubMed, Embase, Wanfang Data, and Cochrane Library). Physiological and biochemistry parameters that included in this study are high-sensitivity C-reactive protein (hs-CRP), respiratory peak oxygen uptake rate (VO2peak), triglyceride (TG), total cholesterol (TC), anaerobic threshold (AT), the diameter of AAA, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), and matrix metalloproteinase-9 (MMP-9). Standard mean difference (SMD) was used to assess the between group effect.

RESULTS

This meta-analysis was synthesized with findings from RCTs and found that hs-CRP (SMD, - 0.56 mg/dL; 95% CI: - 0.90 to 0.22; P = 0.001), VO2peak (SMD, 0.4 mL/kg/min; 95% CI, 0.21 to 0.60; P < 0.001), TG (SMD, - 0.39 mg/dL; 95% CI: - 0.02 to 0.77; P = 0.04), and AT (SMD, 0.75 mL/kg/min; 95% CI, 0.54 to 0.96; P < 0.001) were significantly improved in the exercise groups, while the size of AAA (SMD, - 0.15; 95% CI: - 0.36 to 0.06; P = 0.15), TC (SMD, 0.16 mg/dL; 95% CI: - 0.10 to 0.42; P = 0.23), HDL/LDL ratio (SMD, - 0.06; 95% CI: - 0.32 to 0.20; P = 0.64), HDL (SMD, - 0.09; 95% CI: - 0.39 to 0.20; P = 0.54), LDL (SMD, 0.08; 95% CI: - 0.21 to 0.38; P = 0.59), and MMP-9 (SMD, - 0.23 mg/dL; 95% CI: - 0.53 to 0.06; P = 0.12) did not differ in the exercise groups compared with the controls.

CONCLUSION

Exercise intervention improved some of the CVD risk factors but not all, hs-CRP, VO2peak and AT were significantly improved after exercise intervention, while, changes of MMP-9, the size of AAA, and the overall lipids profile were not. Exercise intervention provides an additional solution for improving cardiorespiratory capacity and health status among AAA patients, and might lead to a delay of AAA progression.

Risk Factors for and Risk of Peripheral Artery Disease in Swedish Individuals With Type 2 Diabetes: A Nationwide Register-Based Study

OBJECTIVE

To investigate to what extent having control of peripheral artery disease (PAD) risk factors is associated with the risk of incident PAD in individuals with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 148,096 individuals with type 2 diabetes in the Swedish National Diabetes Register between 2005 and 2009 were included and matched with 320,066 control subjects on the basis of age, sex, and county. A few control subjects who developed type 2 diabetes after recruitment, during wash-in (<0.2%), were not censored but instead matched with two new control subjects. Individuals with type 2 diabetes were evaluated according to the number of PAD risk factors beyond recommended guideline levels at baseline, including LDL cholesterol, blood pressure, smoking, glycated hemoglobin, and estimated glomerular filtration rate. Incident PAD events were ascertained from 2006 to 2019.

RESULTS

A graded association was observed between the number of PAD risk factors not at target and incident PAD in individuals with type 2 diabetes. The adjusted hazard ratio for PAD was 1.41 (95% CI 1.23-1.63) for those with type 2 diabetes with all PAD risk factors within target compared with control subjects matched for sex, age, and county but not risk factor status, in contrast with 9.28 (95% CI 3.62-23.79) for those with all five PAD risk factors not at target.

CONCLUSIONS

A graded association was observed between increasing number of PAD risk factors not at target and incident PAD in individuals with type 2 diabetes.

A population-based study on hyperinsulinaemia and arterial stiffness in men with and without abdominal aortic aneurysm

Objectives

Patients with type 2 diabetes mellitus (DM) run lower risk for abdominal aortic aneurysm (AAA, aortic diameter ≥ 30 mm) and its complications. We aimed to evaluate associations between disturbances in glucose metabolism and arterial stiffness, AAA, and abdominal aortic diameter in 65-year-old men.

Methods

Forty-eight 65-year-old men with screening-detected AAA and 115 men with normal abdominal aortic diameter underwent examination of glucose metabolism and arterial stiffness.

Results

Men with AAA had higher BMI, waist-hip ratio (WHR), frequency of DM, haemoglobin A1c, smoking exposure, and plasma insulin levels at 0, 60 and 120 min during OGTT compared to those without. The increase in p-insulin (P < 0.001) after OGTT was also higher in men with AAA, adjusted for smoking, WHR, and nadir value of p-insulin. In analyses adjusted for smoking, use of lipid-lowering agents, and WHR, the increase in p-insulin at 2-hours (P = 0.006) after OGTT and p-homocysteine were associated with abdominal aortic diameter. There were no differences between groups in aortic stiffness or skin autofluorescence Advanced Glycation End products.

Conclusion

In this population-based study hyperinsulinaemia as a marker of insulin resistance, but not hyperglycaemia or aortic stiffness, was associated with AAA and abdominal aortic diameter in 65-year-old men.

Proximal aorta dilatation in hypertension

Dilation of the proximal aorta is a common clinical manifestation in hypertensive patients. Although it is straightforward to link hypertension with proximal aortic dilation, previous studies on their interrelation have yielded controversial results. Cross-sectional design, methodology of blood pressure assessment, confounding factors like medications, and inconsistent reference values may lead to the paradoxical conclusions. Recently, advances have been made in the exploration of determinants and clinical value of proximal aortic dilatation. Thus, we reviewed these findings and summarized that aortic dilatation may be the consequence of hemodynamic and nonhemodynamic co-factors' combined action. Moreover, proximal aortic dilatation tends to be a predictor for aortic aneurysm dissection or rupture, hypertensive target organ damage as well as cardiovascular events. The present review contributes to a comprehensive understanding of the pathological process of proximal aortic dilatation in hypertension.

Causal effect of hypertension and blood pressure on aortic diseases: evidence from Mendelian randomization

Hypertension or elevated blood pressure was documented to be an important risk factor for aortic diseases in observational studies, yet the causality remains to be determined. By applying a two-sample Mendelian randomization (MR) approach, we aim to determine whether hypertension or elevated blood pressure (systolic blood pressure [SBP] or diastolic blood pressure [DBP]) is linked causally to aortic aneurysm or aortic dissection. Genetic instruments and summary statistics for hypertension and aortic diseases were obtained from large genome-wide association studies. The traditional inverse variance weighted (IVW) method was used to obtain the causal estimates. Sensitivity analyses including MR-Egger, weighted median and multivariable MR were also performed. Our results suggested that genetic liability to hypertension was associated with aortic dissection (odds ratio [OR]: 1.81; 95% confidence interval [CI]: 1.27-2.58; P = 1.13 × 10-3) and aortic aneurysm (OR: 1.43; 95% CI: 1.22-1.66; P = 7.79 × 10-6). Per standard deviation increase in genetically-determined DBP was significantly associated with increased aortic dissection (OR: 1.14; 95% CI: 1.09-1.19; P = 1.58 × 10-9) and aortic aneurysm (OR: 1.07; 95% CI: 1.05-1.09; P = 8.37 × 10-14). There was a null association between SBP and aortic dissection (OR: 1.01; 95% CI: 0.99-1.94; P = 0.38) or aortic aneurysm (OR: 1.00; 95% CI: 0.99-1.01; P = 0.92). Sensitivity analyses documented similar results. Therefore, hypertension and elevated DBP are causally associated with higher risks of aortic aneurysm and aortic dissection. Preventive interventions for aortic diseases may consider individuals with hypertension, especially those with higher DBP. Meanwhile, further research is required to determine the mechanisms underlying the significantly greater correlation between DBP and aortic diseases than SBP.

Treatment With Small Molecule Inhibitors of Advanced Glycation End-Products Formation and Advanced Glycation End-Products-Mediated Collagen Cross-Linking Promotes Experimental Aortic Aneurysm Progression in Diabetic Mice

Background Although diabetes attenuates abdominal aortic aneurysms (AAAs), the mechanisms by which diabetes suppresses AAAs remain incompletely understood. Accumulation of advanced glycation end- (AGEs) reduces extracellular matrix (ECM) degradation in diabetes. Because ECM degradation is critical for AAA pathogenesis, we investigated whether AGEs mediate experimental AAA suppression in diabetes by blocking AGE formation or disrupting AGE-ECM cross-linking using small molecule inhibitors. Methods and Results Male C57BL/6J mice were treated with streptozotocin and intra-aortic elastase infusion to induce diabetes and experimental AAAs, respectively. Aminoguanidine (AGE formation inhibitor, 200 mg/kg), alagebrium (AGE-ECM cross-linking disrupter, 20 mg/kg), or vehicle was administered daily to mice from the last day following streptozotocin injection. AAAs were assessed via serial aortic diameter measurements, histopathology, and in vitro medial elastolysis assays. Treatment with aminoguanidine, not alagebrium, diminished AGEs in diabetic AAAs. Treatment with both inhibitors enhanced aortic enlargement in diabetic mice as compared with vehicle treatment. Neither enhanced AAA enlargement in nondiabetic mice. AAA enhancement in diabetic mice by aminoguanidine or alagebrium treatment promoted elastin degradation, smooth muscle cell depletion, mural macrophage accumulation, and neoangiogenesis without affecting matrix metalloproteinases, C-C motif chemokine ligand 2, or serum glucose concentration. Additionally, treatment with both inhibitors reversed suppression of diabetic aortic medial elastolysis by porcine pancreatic elastase in vitro. Conclusions Inhibiting AGE formation or AGE-ECM cross-linking enhances experimental AAAs in diabetes. These findings support the hypothesis that AGEs attenuate experimental AAAs in diabetes. These findings underscore the potential translational value of enhanced ECM cross-linking as an inhibitory strategy for early AAA disease.

Risk factors for in-hospital death in 2,179 patients with acute aortic dissection

Background

This study aims to investigate the risk factors for in-hospital death in patients with acute aortic dissection (AAD) and to provide a straightforward prediction model to assist clinicians in determining the outcome of AAD patients.

Methods

Retrospective analysis was carried out on 2,179 patients admitted for AAD from March 5, 1999 to April 20, 2018 in Wuhan Union Hospital, China. The risk factors were investigated with univariate and multivariable logistic regression analysis.

Results

The patients were divided into two groups: Group A, 953patients (43.7%) with type A AAD; Group B, 1,226 patients (56.3%) with type B AAD. The overall in-hospital mortality rate was 20.3% (194/953) and 4% (50/1,226) in Group A and B respectively. The multivariable analysis included the variables that were statistically significant predictors of in-hospital death (P < 0.05). In Group A, hypotension (OR = 2.01, P = 0.001) and liver dysfunction (OR = 12.95, P < 0.001) were independent risk factors. Tachycardia (OR = 6.08, P < 0.001) and liver dysfunction (OR = 6.36, P < 0.05) were independent risk factors for Group B mortality. The risk factors of Group A were assigned a score equal to their coefficients, and the score of -0.5 was the best point of the risk prediction model. Based on this analysis, we derived a predictive model to help clinicians determine the prognosis of type A AAD patients.

Conclusions

This study investigate the independent factors associated with in-hospital death in patients with type A or B aortic dissection, respectively. In addition, we develop the prediction of the prognosis for type A patients and assist clinicians in choosing treatment strategies.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The Presence of Ascending Aortic Dilatation in Patients Undergoing Transcatheter Aortic Valve Replacement Is Negatively Correlated with the Presence of Diabetes Mellitus and Does Not Impair Post-Procedural Outcomes

Both relevant aortic valve stenosis (AS) and aortic valve insufficiency significantly contribute to structural changes in the ascending aorta (AA) and thus to its dilatation. In patients with severe AS undergoing transcatheter aortic valve replacement (TAVR), survival data regarding aortic changes and laboratory biomarker analyses are scarce.

METHODS

A total of 179 patients with severe AS and an available computed tomography were included in this retrospective study. AA was measured, and dilatation was defined as a diameter ≥ 40 mm. Thirty-two patients had dilatation of the AA. A further 32 patients from the present population with a normal AA were matched to the aortic dilatation group with respect to gender, age, body mass index and body surface area, and the resulting study groups were compared with each other. In addition to echocardiographic and clinical characteristics, the expression of cardiovascular biomarkers such as brain natriuretic peptide (BNP), soluble suppression of tumorigenicity-2 (sST2), growth/differentiation of factor-15 (GDF-15), heart-type fatty-acid binding protein (H-FABP), insulin-like growth factor binding protein 2 (IGF-BP2) and soluble urokinase-type plasminogen activator receptor (suPAR) was analyzed. Kaplan-Meier curves for short- and long-term survival were obtained, and Pearson's and Spearman's correlations were calculated to identify the predictors between the diameter of the AA and clinical parameters.

RESULTS

A total of 19% of the total cohort had dilatation of the AA. The study group with an AA diameter ≥ 40 mm showed a significantly low comorbidity with respect to diabetes mellitus in contrast to the comparison cohort with an AA diameter < 40 mm (p = 0.010). This result continued in the correlation analyses performed, as the presence of diabetes mellitus correlated negatively not only with the diameter of the AA (r = -0.404; p = 0.001) but also with the presence of aortic dilatation (r = -0.320; p = 0.010). In addition, the presence of AA dilatation after TAVR was shown to have no differences in terms of patient survival at 1, 3 and 5 years. There were no relevant differences in the cardiovascular biomarkers studied between the patients with dilated and normal AAs.

CONCLUSION

The presence of AA dilatation before successful TAVR was not associated with a survival disadvantage at the respective follow-up intervals of 1, 3 and 5 years. Diabetes mellitus in general seemed to have a protective effect against the development of AA dilatation or aneurysm in patients with severe AS.

Dose-dependent relationship of blood pressure and glycaemic status with risk of aortic dissection and aneurysm

AIMS

Data on the dose-dependent association of blood pressure (BP) and fasting plasma glucose (FPG) level with the risk of aortic dissection (AD) and aortic aneurysm (AA) are limited.

METHODS AND RESULTS

This observational cohort study included 3 358 293 individuals registered in a health checkup and claims database in Japan [median age, 43 (36-51) years; 57.2% men]. Individuals using BP- or glucose-lowering medications or those with a history of cardiovascular disease were excluded. In a mean follow-up period of 1 199 ± 950 days, 1 095 and 2 177 cases of AD and AA, respectively, were recorded. Compared with normal/elevated BP, hazard ratios (HRs) of Stage 1 and Stage 2 hypertension were 1.89 [95% confidence interval (CI): 1.60-2.22] and 5.87 (95% CI: 5.03-6.84) for AD and 1.37 (95% CI: 1.23-1.52) and 2.17 (95% CI: 1.95-2.42) for AA, respectively. Compared with normal FPG level, HRs of prediabetes and diabetes were 0.82 (95% CI: 0.71-0.94) and 0.48 (95% CI: 0.33-0.71) for AD and 0.94 (95% CI: 0.85-1.03) and 0.61 (95% CI: 0.47-0.79) for AA, respectively. The cubic spline demonstrated that the risk of AD and AA increased with increasing BP but decreased with increasing FPG level. Contour plots using generalized additive models showed that higher systolic BP and lower FPG level were associated with an elevated risk of AD and AA.

CONCLUSIONS

Our analysis showed a dose-dependent increase in the risk of AD or AA associated with BP and a similar decrease associated with FPG, and also suggested a potential interaction between hypertension and hyperglycaemia in the development of AD and AA.

Long‐Term Risks of Stroke in Patients With Type A Aortic Dissection: A Nationwide Cohort Study

Background

Patients with type A aortic dissection (TAAD) have a high short‐term risk of stroke. However, whether patients with TAAD have an increased long‐term risk of stroke is still undetermined, and our study aims to address this knowledge gap.

Methods and Results

A nationwide retrospective cohort study was conducted using Taiwan's National Health Insurance Research Database. We included patients with TAAD as well as age‐ and sex‐matched aortic disease–free individuals between 2003 and 2016. Inverse probability of treatment weighting was performed to balance patient characteristics between the groups. The primary outcome was the development of stroke, regardless of subtype; the secondary outcomes were the risk of developing either ischemic or hemorrhagic stroke. The hazard ratios (HRs) of stroke were estimated using the Cox proportional hazards model. After inverse probability of treatment weighting, 3556 and 7023 patients were categorized into the TAAD and aortic disease–free cohorts, respectively. The mean follow‐up period was 5.71 years. The HRs for overall, ischemic, and hemorrhagic strokes in the TAAD cohort were 3.01 (95% CI, 2.40–3.78), 3.18 (95% CI, 2.47–4.10), and 2.32 (95% CI, 1.58–3.41), respectively, compared with the aortic disease–free cohort. Consistent trends of higher stroke risk in patients with TAAD were revealed in the analyses stratified by age; sex; antiplatelet use; and history of hypertension, diabetes, or dyslipidemia.

Conclusions

Our study findings revealed that patients with TAAD had an increased long‐term risk of both ischemic and hemorrhagic strokes. Further studies are warranted to establish optimal strategies for stroke prevention in these patients.

Application of Machine Learning Methods to Analyze Occurrence and Clinical Features of Ascending Aortic Dilatation in Patients with and without Bicuspid Aortic Valve

Aortic aneurysm (AA) rapture is one of the leading causes of death worldwide. Unfortunately, the diagnosis of AA is often verified after the onset of complications, in most cases after aortic rupture. The aim of this study was to evaluate the frequency of ascending aortic aneurysm (AscAA) and aortic dilatation (AD) in patients with cardiovascular diseases undergoing echocardiography, and to identify the main risk factors depending on the morphology of the aortic valve. We processed 84,851 echocardiographic (ECHO) records of 13,050 patients with aortic dilatation (AD) in the Almazov National Medical Research Centre from 2010 to 2018, using machine learning methodologies. Despite a high prevalence of AD, the main reason for the performed ECHO was coronary artery disease (CAD) and hypertension (HP) in 33.5% and 14.2% of the patient groups, respectively. The prevalence of ascending AD (>40 mm) was 15.4% (13,050 patients; 78.3% (10,212 patients) in men and 21.7% (2838 patients) in women). Only 1.6% (n = 212) of the 13,050 patients with AD knew about AD before undergoing ECHO in our center. Among all the patients who underwent ECHO, we identified 1544 (1.8%) with bicuspid aortic valve (BAV) and 635 with BAV had AD (only 4.8% of all AD patients). According to the results of the random forest feature importance analysis, we identified the eight main factors of AD: age, male sex, vmax aortic valve (AV), aortic stenosis (AS), blood pressure, aortic regurgitation (AR), diabetes mellitus, and heart failure (HF). The known factors of AD-like HP, CAD, hyperlipidemia, BAV, and obesity, were also AD risk factors, but were not as important. Our study showed a high frequency of AscAA and dilation. Standard risk factors of AscAA such as HP, hyperlipidemia, or obesity are significantly more common in patients with AD, but the main factors in the formation of AD are age, male sex, vmax AV, blood pressure, AS, AR, HF, and diabetes mellitus. In males with BAV, AD incidence did not differ significantly, but the presence of congenital heart disease was one of the 12 main risk factors for the formation of AD and association with more significant aortic dilatation in AscAA groups.

Blood Pressure, Hypertension, and the Risk of Aortic Dissection Incidence and Mortality: Results From the J-SCH Study, the UK Biobank Study, and a Meta-Analysis of Cohort Studies

BACKGROUND

Hypertension or elevated blood pressure (BP) is an important risk factor for aortic dissection (AD); however, few prospective studies on this topic have been published. We investigated the association between hypertension/elevated BP and AD in 2 cohorts and conducted a meta-analysis of published prospective studies, including these 2 studies.

METHODS

We analyzed data from the J-SHC study (Japan-Specific Health Checkups) and UK Biobank, which prospectively followed up 534 378 and 502 424 participants, respectively. Multivariable Cox regression was used to estimate hazard ratios and 95% CIs for the association of hypertension/elevated BP with AD incidence in the UK Biobank and AD mortality in the J-SHC Study. In the meta-analysis, summary relative risks were calculated with random-effects models. A potential nonlinear dose-response relationship between BP and AD was tested with fractional polynomial models, and the best-fitting second-order fractional polynomial regression model was determined.

RESULTS

In the J-SHC study and UK Biobank, there were 84 and 182 ADs during the 4- and 9-year follow-up, and the adjusted hazard ratios of AD were 3.57 (95% CI, 2.17-6.11) and 2.68 (95% CI, 1.78-4.04) in hypertensive individuals, 1.33 (95% CI, 1.05-1.68) and 1.27 (95% CI, 1.11-1.48) per 20-mm Hg increase in systolic BP (SBP), and 1.67 (95% CI, 1.40-2.00) and 1.66 (95% CI, 1.46-1.89) per 10-mm Hg increase in diastolic BP (DBP), respectively. In the meta-analysis, the summary relative risks were 3.07 (95% CI, 2.15-4.38, I2=76.7%, n=7 studies, 2818 ADs, 4 563 501 participants) for hypertension and 1.39 (95% CI, 1.16-1.66, I2=47.7%, n=3) and 1.79 (95% CI: 1.51-2.12, I2 = 57.0%, n=3) per 20-mm Hg increase in SBP and per 10-mm Hg increase in DBP, respectively. The AD risk showed a strong, positive dose-response relationship with SBP and even more so with DBP. The risk of AD in the nonlinear dose-response analysis was significant at SBP >132 mm Hg and DBP >75 mm Hg.

CONCLUSIONS

Hypertension and elevated SBP and DBP are associated with a high risk of AD. The risk of AD was positively dose dependent, even within the normal BP range. These findings provide further evidence for the optimization of BP to prevent AD.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Prospective Comparison of Plasma Biomarker and Traditional Risk Factor Profiles for Incident Isolated Atherosclerotic Disease and Incident Isolated Abdominal Aortic Aneurysm

Background: Traditional risk factors for atherosclerotic disease (AD) are well-known, of which some are relevant also for abdominal aortic aneurysms (AAA). The present study compares the importance of plasma biomarkers and traditional risk factor profiles for incident AD without concomitant AAA (isolated AD) and AAA without concomitant AD (isolated AAA) during long-term follow-up.

Methods: In the Malmö Diet and Cancer Study—cardiovascular cohort, 5,381 participants were free from atrial fibrillation or flutter, AD (coronary artery disease, atherothrombotic ischemic stroke, carotid artery disease, or peripheral artery disease), and AAA underwent blood sampling under standardized fasting conditions between 1991 and 1994. Cox proportional hazards regression analysis was used to calculate hazard ratios (HR) with 95% CIs.

Results: During a median follow-up of 23.1 years, 1,152 participants developed isolated AD, and 44 developed isolated AAA. Adjusted HR for lipoprotein-associated phospholipase A2 (mass) (HR 1.53, 95% CI 1.14–2.04 vs. HR 1.05, 95% CI.99–1.12) was higher for incident isolated AAA compared to incident isolated AD, respectively. Mid-regional pro-adrenomedullin (MR-proADM) was associated with incident isolated AD (HR 1.17, 95% CI 1.1–1.25) and incident isolated AAA (HR 1.47, 95% CI 1.15–1.88). MR-proADM was correlated (r = 0.32; p < 0.001) to body mass index (BMI), and BMI was associated with increased risk of incident isolated AAA (HR 1.43, 95% CI 1.02–2). No participant with diabetes mellitus (DM) at baseline developed isolated AAA (0/44), whereas DM was associated with an increased risk of isolated AD (HR 2.57, 95% CI 2.08–3.18). Adjusted HR for male sex (HR 4.8, 95% CI 2.42–9.48, vs. HR 1.76, 95% CI 1.56–1.98) and current smoking (HR 4.79, 95% CI 2.42–9.47 vs. HR 1.97, 95% CI 1.73–2.23) were higher in the incident isolated AAA group compared to the incident isolated AD group, respectively.

Conclusions: The data supports the view that components of vascular inflammation and cardiovascular stress drives AAA development, whereas glycated cross-links in abdominal aortic wall tissue may have a plausible role in reducing AAA risk in individuals with DM.

Deep learning enables genetic analysis of the human thoracic aorta

Enlargement or aneurysm of the aorta predisposes to dissection, an important cause of sudden death. We trained a deep learning model to evaluate the dimensions of the ascending and descending thoracic aorta in 4.6 million cardiac magnetic resonance images from the UK Biobank. We then conducted genome-wide association studies in 39,688 individuals, identifying 82 loci associated with ascending and 47 with descending thoracic aortic diameter, of which 14 loci overlapped. Transcriptome-wide analyses, rare-variant burden tests and human aortic single nucleus RNA sequencing prioritized genes including SVIL, which was strongly associated with descending aortic diameter. A polygenic score for ascending aortic diameter was associated with thoracic aortic aneurysm in 385,621 UK Biobank participants (hazard ratio = 1.43 per s.d., confidence interval 1.32-1.54, P = 3.3 × 10-20). Our results illustrate the potential for rapidly defining quantitative traits with deep learning, an approach that can be broadly applied to biomedical images.

Exploring the Correlation and Protective Role of Diabetes Mellitus in Aortic Aneurysm Disease

Introduction: Diabetes mellitus is recognised as a significant risk factor for cardiovascular and peripheral vascular disease, as the abnormal metabolic state increases the risk for atherosclerosis, occlusive arterial disease and vascular dysfunction. There have been reports of potential association across the literature that illustrates a link between diabetes mellitus and aortic aneurysm, with the former having a protective role on the development of the latter.

Methods: A thorough literature search was performed through electronic databases, to provide a comprehensive review of the study's reporting on the association of diabetes mellitus and aortic aneurysm, discussing the mechanisms that have been reported; furthemore, we reviewed the reports of the impact of oral hypoglycameic agents on aortic aneurysms.

Results: Various proposed mechanisms are involved in this protective process including endothelial dysfunction, chronic hyperglycemia and insulin resistance. The evidence suggests a negative association between these disease process, with prevelance of diabetes mellitus resulting in lower rates of aortic aneurysm, via its protective mechanistic action. The increase in advanced glycation end products, increased arterial stiffness and vascular remodelling seen in diabetes, was found to have a profound impact on aneurysm development, its slow progression and lower rupture rate in these individuals. This review has also highlighted the role of oral hypoglycaemic agents having a protective effect against AA disease.

Conclusion: A decrease in development, progression and mortality from aortic aneurysms as well as reduced rates of dissection, have been observed in those with diabetes. This review has provided a comprehensive insight on the effect of diabetes and its physiological processes, and elements of its con-committant treatment, having a protective role against these aortic diseases.

Synthesis of multidimensional pathophysiological process leading to type A aortic dissection: a narrative review

Objective

This review aims to synthesize the existing knowledge on the etiological process leading to type A aortic dissection (TAAD) and to clarify the relationship between mechanical, biochemical, and histopathological processes behind the aortic disease.

Background

Extensive research has previously identified several risk factors for TAAD as well as pathological mechanisms leading to TAAD. However, due to the complexity of the pathological process and limited knowledge on the relationships between distinct pathomechanisms leading to TAAD, the ability to identify the patients at high risk for TAAD has been poor.

Methods

PubMed (National Library of Medicine) database was searched for suitable literature. The most relevant articles focusing on anatomy, histopathology, physiology, and mechanics of ascending aorta and aortic diseases were reviewed.

Conclusions

Pathophysiology of the TAAD is related to biochemical and histological as well as mechanical and hemodynamic alterations leading to a degeneration of the aortic wall via inflammatory response. The degradative mechanisms of aortic wall structures and the mechanical forces, to which the wall is predisposed, are interrelated and influence one another. The relativity between the factors influencing aortic wall strength and healing capacity, and factors influencing mechanical stress on the aortic wall suggest that the risk of TAAD is not a linear but rather a dynamic phenomenon. Accounting for the dynamical property of the aortic disease in assessing the need for preventive surgical aortic reconstruction may provide a wider perspective in identifying patients at risk of TAAD and in planning preventive medical therapies.

Preoperative Predictors of Adverse Clinical Outcome in Emergent Repair of Acute Type A Aortic Dissection in 15 Year Follow Up

Background: Acute type A aortic dissection (AAAD) has high mortality. Improvements in surgical technique have lowered mortality but postoperative functional status and decreased quality of life due to debilitating deficits remain of concern. Our study aims to identify preoperative conditions predictive of undesirable outcome to help guide perioperative management. Methods: We performed retrospective analysis of 394 cases of AAAD who underwent repair in our institution between 2001 and 2018. A combined endpoint of parameters was defined as (1) 30-day versus hospital mortality, (2) new neurological deficit, (3) new acute renal insufficiency requiring postoperative renal replacement, and (4) prolonged mechanical ventilation with need for tracheostomy. Results: Total survival/ follow-up time averaged 3.2 years with follow-up completeness of 94%. Endpoint was reached by 52.8%. Those had higher EuroSCORE II (7.5 versus 5.5), higher incidence of coronary artery disease (CAD) (9.2% versus 3.2%), neurological deficit (ND) upon presentation (26.4% versus 11.8%), cardiopulmonary resuscitation (CPR) (14.4% versus 1.6%) and intubation (RF) before surgery (16.9% versus 4.8%). 7-day mortality was 21.6% versus 0%. Hospital mortality 30.8% versus 0%. Conclusions: This 15-year follow up shows, that unfavorable postoperative clinical outcome is related to ND, CAD, CPR and RF on arrival.

Development and Validation of a Predictive Model to Identify Patients With an Ascending Thoracic Aortic Aneurysm

Background

Screening protocols do not exist for ascending thoracic aortic aneurysms (ATAAs). A risk prediction algorithm may aid targeted screening of patients with an undiagnosed ATAA to prevent aortic dissection. We aimed to develop and validate a risk model to identify those at increased risk of having an ATAA, based on readily available clinical information.

Methods and Results

This is a cross‐sectional study of computed tomography scans involving the chest at a tertiary care center on unique patients aged 50 to 85 years between 2013 and 2016. These criteria yielded 21 325 computed tomography scans. The double‐oblique technique was used to measure the ascending thoracic aorta, and an ATAA was defined as >40 mm in diameter. A logistic regression model was fitted for the risk of ATAA, with readily available demographics and comorbidity variables. Model performance was characterized by discrimination and calibration metrics via split‐sample testing. Among the 21 325 patients, there were 560 (2.6%) patients with an ATAA. The multivariable model demonstrated that older age, higher body surface area, history of arrhythmia, aortic valve disease, hypertension, and family history of aortic aneurysm were associated with increased risk of an ATAA, whereas female sex and diabetes were associated with a lower risk of an ATAA. The C statistic of the model was 0.723±0.016. The regression coefficients were transformed to scores that allow for point‐of‐care calculation of patients' risk.

Conclusions

We developed and internally validated a model to predict patients' risk of having an ATAA based on demographic and clinical characteristics. This algorithm may guide the targeted screening of an undiagnosed ATAA.

Elevated Glucagon-like Peptide-1 and a Th2 Shift May Support Reduced Prevalence of Thoracic Aortic Aneurysm in Patients with Diabetes

Glucagon-like peptide-1 (GLP-1) regulates processes involved in the pathophysiology of thoracic aortic aneurysms (TAAs), including inflammation, while protecting against aortic aneurysms in animal models. Type 2 diabetes (T2D) involves altered GLP-1 signaling due to pathology and/or therapy and is associated with reduced prevalence of TAAs. We aimed to assess whether T2D alters the inflammatory profile/proteolytic activity, possible correlations to elevated fasting GLP-1 (F-GLP-1), and its relevance for TAA. F-GLP-1, pro-inflammatory T helper 1 (Th1) cytokines, Th2 cytokines, C-reactive protein, and matrix metalloproteinase-2 activity (MMP-2) were analyzed in surgical patients with aortic valve pathology with/without T2D and without T2D but with TAA. Patients with T2D displayed an increase in the relative systemic expression of interleukin 6 and tumor necrosis factor α and a clear trend towards reduced levels of interferon γ (IFNγ). In addition, a positive association between GLP-1 and the plasma interleukin 4 (IL-4)/IFNγ ratio was detected. TAA was associated with significantly lower plasma levels of the Th2 cytokines IL-4 and interleukin 5. Plasma MMP-2 activity did not differ between groups. We conclude that T2D involved a Th2 shift, which associates with elevated F-GLP-1 and may-considering Th1 bias in TAA-contribute to reduced prevalence of TAA in T2D.

A Systematic Review and Meta-analysis of the Incidence of Acute Aortic Dissections in Population-Based Studies

OBJECTIVE

To perform a systematic-review and meta-analysis of all population-based studies reporting on incidence of acute aortic dissections.

METHODS

We searched MEDLINE, EMBASE, CENTRAL and Open Grey databases from inception to August 2020 for population-based studies reporting on the incidence of AAD. A systematic review was conducted following the PRISMA guidelines using a registered protocol (CRD42020204007). Data was pooled using a random-effects model of proportions using Freeman-Tukey double arcsine transformation. The main outcome was the incidence of AAD. Secondary outcomes were incidence type A aortic dissections (TAAD) and type B aortic dissections (TBAD); incidence of aortic dissection repair and medical management and incidence of in-hospital mortality. In addition, we estimated the proportion of aortic dissection repair and mortality (in hospital, overall and specific mortality according to sub-type) among patients with AAD.

RESULTS

Thirty-three studies were included. The pooled incidence of AADs was 4.8 per 100 000 individuals/year (95%CI: 3.6; 6.1). Incidence of TAAD was 3.0 per 100 000/year (95%CI: 1.8; 4.4) and incidence of TBAD was 1.6 per 100 000/year (95%CI: 1.1; 2.2). The incidence of AAD needing repair was 1.4 per 100 000/year (95%CI: 1.0; 2.0) [1.4 (95%CI: 1.2; 1.7) for TAAD and 0.4 (95%CI: 0.2; 0.7) for TBAD]. Incidence of medically managed AAD was 3.4 per 100 000/year (95%CI: 2.4; 4.5). Incidence of in-hospital death due to AAD was 1.3 per 100 000 individuals/year (95%CI: 0.9; 1.9); 1.0 (95%CI: 0.6; 1.4; I²97%) for TAAD and 0.3 for TBAD (95%CI: 0.2; 0.4; I²96%).

CONCLUSION

A global estimate regarding the incidence rate of acute aortic dissections was achieved. Incidence of acute aortic dissection varied significantly between study designs and geographical regions. More accurate information on acute aortic dissection epidemiology is crucial for public-health decisions, clinical understanding, and healthcare management.

Current pharmacological management of aortic aneurysm

ABSTRACT

Aortic aneurysm (AA) remains one of the primary causes of death worldwide. Of the major treatments, prophylactic operative repair is used for AA to avoid potential aortic dissection (AD) or rupture. To halt the development of AA and alleviate its progression into AD, pharmacological treatment has been investigated for years. Currently, β-adrenergic blocking agents, losartan, irbesartan, angiotensin-converting-enzyme inhibitors, statins, antiplatelet agents, doxycycline, and metformin have been investigated as potential candidates for preventing AA progression. However, the paradox between preclinical successes and clinical failures still exists, with no medical therapy currently available for ideally negating the disease progression. This review describes the current drugs used for pharmacological management of AA and their individual potential mechanisms. Preclinical models for drug screening and evaluation are also discussed to gain a better understanding of the underlying pathophysiology and ultimately find new therapeutic targets for AA.

Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review

Background and Aims:

There are increasing reports on case series on spontaneous isolated mesenteric artery dissection, that is, dissections of the superior mesenteric artery and celiac artery, mainly due to improved diagnostic capacity of high-resolution computed tomography angiography performed around the clock. A few case–control studies are now available, while randomized controlled trials are awaited.

Material and Methods:

The present systematic review based on 97 original studies offers a comprehensive overview on risk factors, management, conservative therapy, morphological modeling of dissection, and prognosis.

Results and Conclusions:

Male gender, hypertension, and smoking are risk factors for isolated mesenteric artery dissection, while the frequency of diabetes mellitus is reported to be low. Large aortomesenteric angle has also been considered to be a factor for superior mesenteric artery dissection. The overwhelming majority of patients can be conservatively treated without the need of endovascular or open operations. Conservative therapy consists of blood pressure lowering therapy, analgesics, and initial bowel rest, whereas there is no support for antithrombotic agents. Complete remodeling of the dissection after conservative therapy was found in 43% at mid-term follow-up. One absolute indication for surgery and endovascular stenting of the superior mesenteric artery is development of peritonitis due to bowel infarction, which occurs in 2.1% of superior mesenteric artery dissections and none in celiac artery dissections. The most documented end-organ infarction in celiac artery dissections is splenic infarctions, which occurs in 11.2%, and is a condition that should be treated conservatively. The frequency of ruptured pseudoaneurysm in the superior mesenteric artery and celiac artery dissection is very rare, 0.4%, and none of these patients were in shock at presentation. Endovascular therapy with covered stents should be considered in these patients.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Effect of Glycation on Interlamellar Bonding of Arterial Elastin

BACKGROUND

Interlamellar bonding in the arterial wall is often compromised by cardiovascular diseases. However, several recent nationwide and hospital-based studies have uniformly reported reduced risk of thoracic aortic dissection in patients with diabetes. As one of the primary structural constituents in the arterial wall, elastin plays an important role in providing its interlamellar structural integrity.

OBJECTIVE

The purpose of this study is to examine the effects of glycation on the interlamellar bonding properties of arterial elastin.

METHODS

Purified elastin network was isolated from porcine descending thoracic aorta and incubated in 2 M glucose solution for 7, 14 or 21 days at 37 °C. Peeling and direct tension tests were performed to provide complimentary information on understanding the interlamellar layer separation properties of elastin network with glycation effect. Peeling tests were simulated using a cohesive zone model (CZM). Multiphoton imaging was used to visualize the interlamellar elastin fibers in samples subjected to peeling and direct tension.

RESULTS

Peeling and direct tension tests show that interlamellar energy release rate and strength both increases with the duration of glucose treatment. The traction at damage initiation estimated for the CZM agrees well with the interlamellar strength measurements from direct tension tests. Glycation was also found to increase the interlamellar failure strain of arterial elastin. Multiphoton imaging confirmed the contribution of radially running elastin fibers to resisting dissection.

CONCLUSIONS

Nonenzymatic glycation reduces the propensity of arterial elastin to dissection. This study also suggests that the CZM effectively describes the interlamellar bonding properties of arterial elastin.

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

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

Review of Studies Reporting the Incidence of Acute Type B Aortic Dissection

Aortic dissection (AD) causes more deaths each year in the United Kingdom than road traffic collisions. Yet the incidence of AD is not known. The management of acute type B AD (TBAD) is changing, with the greater use of thoracic aortic stent grafts (TEVAR) in treatment and fewer open surgical procedures performed. The study’s aim is to review the worldwide, English language published, literature on acute TBAD incidence and treatment, to report on its strengths and limitations, and better understand changes in incidence over time and between countries. Thirty-one studies were identified that focus on the epidemiology and treatment of TBAD. Eight of these studies report the incidence of acute TBAD as between of 0.5–6.3 per 100,000 person years. Hospital admissions for aortic dissection are reported to be increasing in six studies and stable in one study. The proportion of patients with TBAD operated on varies between studies (range 13% to 76%). Studies identify patient age (median 51–77 years), gender (range 48%–81% male) and prevalence of cardio-vascular risk factors, specifically hypertension, in the populations studied as independent factors influencing aortic dissection incidence. Treatment of acute TBAD remains largely conservative with analgesia, hypertension control and serial cross-sectional imaging (range 24%–87% TBAD medically treated). The use of TEVAR to treat acute AD is increasing worldwide (range 13%–76% TBAD treated with TEVAR). The incidence of TBAD is under-reported due to out of hospital deaths, variable clinical presentation (miss-diagnosis) and coding errors. Importantly for research, the single International Classification of Diseases (ICD) code for aortic dissection, I17.0, does not distinguish between acute, chronic, type A or type B dissection types. Similarly, the OPCS Classification of Interventions and Procedures version 4 (OPCS-4) codes for TEVAR, L27.4 and L28.4, do not distinguish between acute and chronic AD presentation, unlike the codes for open thoracic aortic replacement. Standardised reporting of aortic dissection type, and the urgency of both the initial presentation (acute or chronic) and treatment (emergency, urgent or planned) in future studies would allow more meaningful comparisons between populations.

Acute type A aortic dissection in-hours versus out-of-hours: A systematic review and meta-analysis

OBJECTIVE

We sought to compare clinical outcomes in patients with acute type A aortic dissection that undergone surgical repair during in-hours (IH) versus out-of-hours (OOH).

METHODS

An electronic literature search was done till March 2020 to include studies with comparative cohorts of IH versus OOH. Primary outcomes were 30-day mortality, stroke, and reoperation for bleeding; secondary outcomes were acute kidney injury, total hospital stay, and intensive care unit stay.

RESULTS

Six articles with a total of 3744 patients met the inclusion criteria. Mean age was similar, 60 ± 12 versus 60 ± 13 in IH versus OOH (p = .25). Aortic root and total arch replacement were similar in both cohorts, 22% in IH versus 25% in OOH (risk ratio [RR], 1.10; 95% confidence interval [CI: 0.78, 1.55]; p = .58) and 29% in IH versus 32% in OOH (RR, 0.96; 95% CI [0.89, 1.04], p = .37) respectively. Reoperation for bleeding and stroke rate were similar, with 18% in IH versus 23% in OOH (RR, 0.89; 95% CI [0.73, 1.08]; p = .24), and 12% in IH versus 13% in OOH (RR, 0.83; 95% CI [0.66, 1.03]; p = .09) respectively. Thirty-day mortality was significantly lower in IH (RR, 0.81; 95% CI [0.72, 0.90]; p = .0001).

CONCLUSION

There was higher 30-day mortality rate during OOH surgery, yet this difference diminished following sensitivity analysis. There were no significant differences in major postoperative outcomes. Therefore, operating on such cases should be decided on clinical priority without delay.

Comparisons of Risk Factors for Abdominal Aortic Aneurysm and Coronary Heart Disease: A Prospective Cohort Study

Even though abdominal aortic aneurysm (AAA) and coronary heart disease (CHD) are both related to atherosclerosis, there could be important differences in risk factors. Based on Malmö Diet and Cancer Cohort, the incidence of AAA and CHD was followed prospectively. Cox regression was used to calculate the association of each factor with AAA and CHD and hazards ratio were compared using a modified Lunn-McNeil method; 447 participants developed AAA and 3129 developed CHD. After multivariate adjustments, smoking, antihypertensive medications, lipid-lowing medications, systolic and diastolic blood pressures, apolipoprotein (Apo) A1 (inversely), ApoB, ApoB/ApoA1 ratio, total leukocyte count, neutrophil count, and neutrophil to lymphocyte ratio were associated with the risks of both AAA and CHD. When comparing risk factor profiles for the 2 diseases, smoking, diastolic blood pressure, ApoA1, and ApoB/ApoA1 ratio had stronger associations with risk of AAA than with risk of CHD, while diabetes and unmarried status showed increased risk of CHD, but not of AAA (all P values for equal association <.01). The results from this big population study confirm that the risk factor profiles for AAA and CHD show not only many similarities but also several important differences.

Diabetes Mellitus and Noncardiac Atherosclerotic Vascular Disease-Pathogenesis and Pharmacological Treatment Options

Diabetes mellitus (DM) is also a cause of cardiovascular (CV) disease (CVD). Addressing the atherosclerotic CVD (ASCVD) burden in DM should reduce premature death and improve quality of life. Diabetes mellitus-associated ASCVD can lead to complications in all vascular beds (carotids as well as coronary, lower extremity, and renal arteries). This narrative review considers the diagnosis and pharmacological treatment of noncardiac atherosclerotic vascular disease (mainly in patients with DM). Based on current knowledge and the fact that modern DM treatment guidelines are based on CV outcome trials, it should be noted that patients with noncardiac CVD may not have the same benefits from certain drugs compared with patients who predominantly have cardiac complications. This leads to the conclusion that in the future, consideration should be given to conducting well-designed trials that will answer which pharmacological treatment modalities will be of greatest benefit to patients with noncardiac ASCVD.

Metformin Prescription Associated with Reduced Abdominal Aortic Aneurysm Growth Rate and Reduced Chemokine Expression in a Swedish Cohort

BACKGROUND

Recent reports suggest that the negative association between diabetes mellitus and abdominal aortic aneurysm (AAA) may be driven by metformin, the world's most common antidiabetic drug rather than diabetes per se. We sought to investigate the association among AAA growth rate, chemokine profile, and metformin prescription in a contemporary Swedish cohort.

METHODS

Patients under surveillance for small AAA were identified at 4 Swedish vascular centers with active AAA screening programs. Annual AAA growth rate, medical history, and prescribed medications were recorded for linear regression analysis. In a subset of patients with AAA and control subjects without AAA or diabetes, plasma samples were available and analyzed for 40 inflammatory chemokines.

RESULTS

A total of 526 patients were included for AAA growth analysis: 428 without type 2 diabetes mellitus (T2DM), 65 with T2DM and metformin prescription, and 33 with T2DM but without metformin prescription. Patients were included from 2005 to 2017 with mean follow-up of 3.2 (1.7) years and median annual AAA growth rate 1.6 mm, range -4.8 to 15.4 mm. Mean (standard deviation) annual AAA growth rates were 2.3 (2.2) mm in non-T2DM patients versus 1.1 (1.1) mm in patients with T2DM with metformin prescription and 1.6 (1.4) mm among those with T2DM without metformin prescription. With non-T2DM patients as reference in an unadjusted and 2 adjusted models, metformin prescription was significantly associated with reduced AAA growth rate (P < 0.001, P = 0.005, and P = 0.024, respectively), but not T2DM without metformin prescription (P = 0.137, P = 0.331, and P = 0.479, respectively). Among 240 patients with AAA (152 without T2DM, 51 with T2DM and metformin, and 37 with T2DM without metformin) and 59 without AAA or T2DM, metformin prescription was associated with reduced expression of chemokines representing all classes of leukocytes.

CONCLUSIONS

Metformin prescription is associated with reduced AAA growth rate, possibly mediated by broad anti-inflammatory effects. A randomized controlled trial is needed to determine what role metformin may play in AAA disease, particularly in the absence of T2DM.

Molecular basis of the therapeutic properties of hemorphins

Hemorphins are endogenous peptides, 4-10 amino acids long, belonging to the family of atypical opioid peptides released during the sequential cleavage of hemoglobin protein. Hemorphins have been shown to exhibit diverse therapeutic effects in both human and animal models. However, the precise cellular and molecular mechanisms involved in such effects remain elusive. In this review, we summarize and propose potential mechanisms based on studies that investigated the biological activity of hemorphins of different lengths on multiple therapeutic targets. Special emphasis is given to molecular events related to renin-angiotensin system (RAS), opioid receptors and insulin-regulated aminopeptidase receptor (IRAP). This review provides a comprehensive coverage of the molecular mechanisms that underpin the therapeutic potential of hemorphins. Furthermore, it highlights the role of various hemorphin residues in pathological conditions, which could be explored further for therapeutic purposes.

Pathogenic mechanisms and the potential of drug therapies for aortic aneurysm

Aortic aneurysm is a permanent focal dilation of the aorta. It is usually an asymptomatic disease but can lead to sudden death due to aortic rupture. Aortic aneurysm-related mortalities are estimated at ∼200,000 deaths per year worldwide. Because no pharmacological treatment has been found to be effective so far, surgical repair remains the only treatment for aortic aneurysm. Aortic aneurysm results from changes in the aortic wall structure due to loss of smooth muscle cells and degradation of the extracellular matrix and can form in different regions of the aorta. Research over the past decade has identified novel contributors to aneurysm formation and progression. The present review provides an overview of cellular and noncellular factors as well as enzymes that process extracellular matrix and regulate cellular functions (e.g., matrix metalloproteinases, granzymes, and cathepsins) in the context of aneurysm pathogenesis. An update of clinical trials focusing on therapeutic strategies to slow abdominal aortic aneurysm growth and efforts underway to develop effective pharmacological treatments is also provided.

Prevalence of abdominal aortic aneurysm and associated lower extremity artery aneurysm in men hospitalized for suspected or known cardiopulmonary disease

BACKGROUND

AAA is a disease affecting predominantly male patients ≥65 years and its dreaded complications such as rupture led to population-based screening programs as preventive measure. Nonetheless, the supposed prevalence may have been overestimated, so that targeted screening of high risk populations may be more effective. This study was performed to evaluate the prevalence of abdominal aortic aneurysm (AAA) of an inpatient high-risk cohort and to estimate the co-prevalence of lower extremity arterial aneurysms.

METHODS

Participants: 566 male inpatients, ≥ 65 years of age, hospitalized for suspected or known cardiopulmonary disease. Primary and secondary outcome measures: Maximal infrarenal aortic diameters using abdominal ultrasound (leading edge to leading edge method). Upon detection of an AAA (diameter ≥ 30 mm), the lower extremity arteries were examined with regard to associated aneurysms.

RESULTS

In 40 of 566 patients (7.1%) AAAs were detectable. Fourteen patients (2.5%) had a first diagnosis of AAA, none of which was large (> 55 mm), the remaining 26 patients were either already diagnosed (14 patients, 2.5%) or previously repaired (12 patients, 2.1%). The three most common main diagnoses at discharge were acute coronary syndrome (43.3%), congestive heart failure (32.2%), and chronic obstructive pulmonary disease (12%). The cohort showed a distinct cardiovascular risk profile comprising arterial hypertension (82.9%), diabetes mellitus (44.4%), and a history of smoking (57.6%). In multivariate analysis, three-vessel coronary artery disease (Odds ratio (OR): 4.5, 95% confidence interval (CI): 2.3-8.9, p <  0.0001) and history of smoking (OR: 3.7, CI: 1.6-8.6, p <  0.01) were positively associated with AAA, while diabetes mellitus (OR: 0.5, CI: 0.2-0.9, p = 0.0295) showed a negative association with AAA. Among the subjects with AAA, we found two large iliac and two large popliteal aneurysms.

CONCLUSION

Ultrasound screening in male inpatients, hospitalized for suspected or known cardiopulmonary disease, revealed a high AAA prevalence in comparison to the present epidemiological screening programs. There was a moderate proportion of newly-screen detected AAA and additional screening of the lower extremity arteries yielded some associated aneurysms with indication for possible intervention.

ABO blood group does not impact incidence or outcomes of surgery for acute type A aortic dissection

Objectives. To evaluate the distribution and impact of ABO blood groups on postoperative outcomes in patients undergoing surgery for acute type A aortic dissection (ATAAD). Design. A total of 1144 surgical ATAAD patients from eight Nordic centres constituting the Nordic consortium for acute type A aortic dissection (NORCAAD) were analysed. Blood group O patients were compared to non-O subjects. The relative frequency of blood groups was assessed with t-distribution, modified for weighted proportions. Multivariable logistic regression was performed to identify independent predictors of 30-day mortality. Cox regression analyses were performed for assessing independent predictors of late mortality. Results. There was no significant difference in the proportions of blood group O between the study populations in the NORCAAD registry and the background population (40.6 (95% CI 37.7-43.4)% vs 39.0 (95% CI 39.0-39.0)%). ABO blood group was not associated with any significant change in risk of 30-day or late mortality, with the exception of blood group A being an independent predictor of late mortality. Prevalence of postoperative complications was similar between the ABO blood groups. Conclusions. In this large cohort of Nordic ATAAD patients, there were no associations between ABO blood group and surgical incidence or outcomes, including postoperative complications and survival.

Diabetes and aortic aneurysm: current state of the art

Aortic aneurysm is a life-threatening disease due to the risk of aortic rupture. The only curative treatment available relies on surgical approaches; drug-based therapies are lacking, highlighting an unmet need for clinical practice. Abdominal aortic aneurysm (AAA) is frequently associated with atherosclerosis and cardiovascular risk factors including male sex, age, smoking, hypertension, and dyslipidaemia. Thoracic aortic aneurysm (TAA) is more often linked to genetic disorders of the extracellular matrix and the contractile apparatus but also share similar cardiovascular risk factors. Intriguingly, a large body of evidence points to an inverse association between diabetes and both AAA and TAA. A better understanding of the mechanisms underlying the negative association between diabetes and aortic aneurysm could help the development of innovative diagnostic and therapeutic approaches to tackle the disease. Here, we summarize current knowledge on the relationship between glycaemic parameters, diabetes, and the development of aortic aneurysm. Cellular and molecular pathways that underlie the protective effect of diabetes itself and its treatment are reviewed and discussed, along with their potential implications for clinical translation.

Survival, cardiovascular morbidity, and reinterventions after elective endovascular aortic aneurysm repair in patients with and without diabetes: A nationwide propensity-adjusted analysis

Epidemiological data indicate decreased risk for development and growth of abdominal aortic aneurysm (AAA) among patients with diabetes mellitus (DM). On the other hand, DM adds to increased cardiovascular (CV) morbidity and mortality. In a nationwide observational cohort study of patients registered in the Swedish Vascular Register and the Swedish National Diabetes Register, we evaluated potential effects of DM on total mortality, CV morbidity, and the need for reintervention after elective endovascular aneurysm repair (EVAR) for AAA. We compared 748 patients with and 2630 without DM with propensity score-adjusted analysis, during a median 4.22 years of follow-up for patients with DM, and 4.05 years for those without. In adjusted analysis, diabetic patients showed higher rates of acute myocardial infarction (AMI) during follow-up (relative risk (RR) 1.44, 95% CI 1.06-1.95; p = 0.02), but lower need for reintervention (RR 0.12, CI 0.02-0.91; p = 0.04). There were no differences in total (RR 0.88, CI 0.74-1.05; p = 0.15) or CV (RR 1.58, CI 0.87-2.86; p = 0.13) mortality, or stroke (RR 0.95, CI 0.68-1.32; p = 0.75) during follow-up. In conclusion, patients with DM had higher rates of AMI and lower need for reintervention after elective EVAR than those without DM, whereas neither total nor CV mortality differed between groups. The putative protective effects of DM towards further AAA enlargement and late sac rupture may help explain the lower need for reintervention and absence of excess mortality.

Healthy diet and fiber intake are associated with decreased risk of incident symptomatic peripheral artery disease – A prospective cohort study

Peripheral artery disease (PAD) is caused by atherosclerosis and associated with an increased risk of leg amputation, cardiovascular disease, and death. A healthy diet has been shown to reduce the risk of cardiovascular events, but relationships between diet, fiber intake, and incidence of PAD are virtually unknown. The aim was to investigate the long-term impact of diet on the development of PAD among 26,010 middle-aged individuals in the prospective Malmö Diet and Cancer study (MDCS). Data on dietary intake were collected through a 7-day food diary combined with a food questionnaire and a 1-hour interview. Adherence to a recommended intake of six dietary components – saturated fat, polyunsaturated fat, fish and shellfish, fiber, fruit and vegetables, and sucrose – was scored (sum 0–6 points) to assess a diet quality index, adjusting for potential confounders. Cox regression analysis was used to estimate associations between diet variables and PAD incidence expressed in hazard ratios (HR) with 95% CI. During a median follow-up of 21.7 years, 1122 participants developed PAD. Diet score was associated with a reduced risk of PAD in multivariable analysis ( p = 0.03). When mutually adjusting for all dietary variables, only adherence to recommended levels of fiber intake was associated with a reduced risk of incident PAD (HR 0.84; 95% CI 0.72–0.99). In this prospective, population-based study including 26,010 participants with over 20 years of follow-up, a healthy diet, especially a high intake of fiber, was associated with a reduced risk of PAD. Primary prevention programs directed against PAD should therefore include a fiber recommendation.

Intake of fibre and plant foods and the risk of abdominal aortic aneurysm in a large prospective cohort study in Sweden

Purpose

The purpose of this study was to investigate fibre, and plant foods, and its association with AAA risk.

Methods

In this prospective cohort study, Malmö Diet and Cancer Study, baseline data collection was carried out 1991–1996. The study participants’ (n = 26,133) dietary habits were extensively recorded at baseline. The specific diagnosis of AAA in the in-hospital registry was found valid in 95%. The association between plant foods, such as cereals and types of vegetables, and AAA was assessed by using Cox regression analysis expressed as hazard ratios (HR) with 95% confidence intervals (CI).

Results

A high intake of fibre was independently associated with AAA risk (HR per quintile 0.87, 95% CI 0.79–0.97). High intake of vegetables (HR 0.91, 95% CI 0.84–0.98), specifically leaf vegetables (HR 0.87, 95% CI 0.81–0.94), and fruits and berries (HR 0.89, 95% CI 0.82–0.96), citrus (HR 0.91, 95% CI 0.85–0.98) and non-citrus fruits (HR 0.87, 95% CI 0.81–0.95) were independently associated with a decreased AAA risk.

Conclusions

A high intake of fruits and berries and vegetables, in particular leaf vegetables, are associated with a decreased risk of developing AAA.

Electronic supplementary material

The online version of this article (10.1007/s00394-019-02054-w) contains supplementary material, which is available to authorized users.

Type 2 diabetes mellitus reduces clinical complications and mortality in Stanford type B aortic dissection after thoracic endovascular aortic repair: A 3-year follow-up study

BACKGROUND

Previous studies have demonstrated that type 2 diabetes mellitus (T2DM) is negatively correlated with the occurrence of aortic dissection (AD). This study aimed to investigate the effects of T2DM on the prognosis of Stanford type B AD (STBAD) patients after thoracic endovascular aortic repair (TEVAR).

METHODS

STBAD patients (n = 141) who underwent TEVAR received an oral glucose tolerance test (OGTT) and were divided into a normal glucose (NG, n = 55) group, an abnormal glucose tolerance (AGT, n = 48) group and a T2DM (n = 38) group according to the results of the OGTT. Data on mortality, clinical complications, left ventricular (LV) remodeling and aortic remodeling were collected during the 3-year follow-up.

RESULTS

Lower mortality and fewer clinical complications after TEVAR were found in the T2DM group than in the NG group. Multivariate linear regression analysis showed that 2-hour postprandial glucose (Glu-2h) was negatively correlated with mortality and the occurrence of clinical complications in STBAD patients after TEVAR. In addition, better LV remodeling, larger true lumen areas and smaller false lumen areas in both the proximal aortas and abdominal aortas were observed in the T2DM group than in the NG group. Furthermore, no significant differences in mortality or clinical complications after TEVAR were found between the NG group and the AGT group or between the T2DM group and the AGT group.

CONCLUSION

During the 3-year follow-up period, mortality and clinical complications in STBAD patients after TEVAR were significantly reduced in the T2DM group. For STBAD patients who undergo TEVAR, properly relaxing of blood glucose control requirements may be beneficial for their prognosis.