Methodological Considerations in Interpreting Mortality Trends in Aortic Dissection Among Hypertensive Adults.

BackgroundAortic aneurysm and dissection are important causes of death in older people. Ruptured aneurysms show catastrophic fatality rates reaching near 80%. Few population-based mortality studies have been published in the world and none in Brazil. The objective of the present study was to use multiple-cause-of-death methodology in the analysis of mortality trends related to aortic aneurysm and dissection in the state of Sao Paulo, between 1985 and 2009.MethodsWe analyzed mortality data from the Sao Paulo State Data Analysis System, selecting all death certificates on which aortic aneurysm and dissection were listed as a cause-of-death. The variables sex, age, season of the year, and underlying, associated or total mentions of causes of death were studied using standardized mortality rates, proportions and historical trends. Statistical analyses were performed by chi-square goodness-of-fit and H Kruskal-Wallis tests, and variance analysis. The joinpoint regression model was used to evaluate changes in age-standardized rates trends. A p value less than 0.05 was regarded as significant.ResultsOver a 25-year period, there were 42,615 deaths related to aortic aneurysm and dissection, of which 36,088 (84.7%) were identified as underlying cause and 6,527 (15.3%) as an associated cause-of-death. Dissection and ruptured aneurysms were considered as an underlying cause of death in 93% of the deaths. For the entire period, a significant increased trend of age-standardized death rates was observed in men and women, while certain non-significant decreases occurred from 1996/2004 until 2009. Abdominal aortic aneurysms and aortic dissections prevailed among men and aortic dissections and aortic aneurysms of unspecified site among women. In 1985 and 2009 death rates ratios of men to women were respectively 2.86 and 2.19, corresponding to a difference decrease between rates of 23.4%. For aortic dissection, ruptured and non-ruptured aneurysms, the overall mean ages at death were, respectively, 63.2, 68.4 and 71.6 years; while, as the underlying cause, the main associated causes of death were as follows: hemorrhages (in 43.8%/40.5%/13.9%); hypertensive diseases (in 49.2%/22.43%/24.5%) and atherosclerosis (in 14.8%/25.5%/15.3%); and, as associated causes, their principal overall underlying causes of death were diseases of the circulatory (55.7%), and respiratory (13.8%) systems and neoplasms (7.8%). A significant seasonal variation, with highest frequency in winter, occurred in deaths identified as underlying cause for aortic dissection, ruptured and non-ruptured aneurysms.ConclusionsThis study introduces the methodology of multiple-causes-of-death to enhance epidemiologic knowledge of aortic aneurysm and dissection in São Paulo, Brazil. The results presented confer light to the importance of mortality statistics and the need for epidemiologic studies to understand unique trends in our own population.

Little is known about trends in the mortality rate among people with hypertension in the United States. The objective of the present study was to examine the change in the all-cause mortality rate among people with and without hypertension in the United States and whether any such changes differed by sex or race. Data from 10 852 participants aged 25 to 74 years of the National Health and Nutrition Examination Survey (NHANES) I Epidemiological Follow-Up Study (1971 to 1975) and of 12 420 participants of the NHANES III Linked Mortality Study (1988 to 1994) were used. The mean follow-up times were 17.5 and 14.2 years, respectively. In each cohort, the mortality rate was higher among hypertensive adults than nonhypertensive adults, among hypertensive men than hypertensive women, and among hypertensive blacks than hypertensive whites. Among all hypertensive participants, the age-adjusted mortality rate was 18.8 per 1000 person-years for NHANES I and 14.3 for NHANES III (13.3 and 9.1 per 1000 person-years for nonhypertensive participants, respectively). The reduction among hypertensive men (7.7 per 1000 person-years; 95 confidence interval, 5.2 to 10.2) exceeded that among hypertensive women (1.9 per 1000 person-years; 95 confidence interval, [-0.4 to 4.2]) (P<0.001), and the reduction among hypertensive blacks (5.4 per 1000 person-years; 95 confidence interval, [0.6 to 10.1]) exceeded that among hypertensive whites (4.4 per 1000 person-years; 95 confidence interval, [2.2 to 6.5]) (P=0.707). The mortality rate decreased among hypertensive adults, but the mortality gap between adults with and without hypertension remained relatively constant. Efforts are needed to accelerate the decrease in the mortality rate among hypertensive adults.

Disparities in mortality rates from aortic aneurysm and dissection by country-level income status and sex

ObjectiveAortic dissection and aortic aneurysm rupture are aortic emergencies and their clinical outcomes have improved over the past two decades; however, whether this has translated into lower mortality across countries...

Introduction: Aortic dissection and aneurysm rupture are aortic emergencies. Surgical outcomes and interventional procedures have improved over the past two decades; however, whether this has translated into lower mortality across countries remains an open question. Hypothesis: We hypothesized that given improved surgical mortality, there will be improvement in mortality from aortic dissection and rupture in the UK, Japan, USA, and Canada. Methods: We analyzed the WHO mortality database to determine trends in mortality from aortic dissection and rupture in 4 countries from 2000 to 2019. Crude mortality rate and age-standardized mortality rate per 100,000 persons were calculated, and annual percentage change was estimated using joinpoint regression. Results: In 2019, crude and age-standardized mortality rates from aortic dissection were 2.15 and 1.04 in UK, 8.67 and 2.66 in Japan, 1.21 and 0.76 in USA, and 1.30 and 0.67 in Canada, respectively. In 2019, crude and age-standardized mortality rates from aortic rupture were 4.86 and 1.80 in UK, 5.22 and 1.16 in Japan, 1.04 and 0.52 in USA, and 1.99 and 0.81 in Canada, respectively. There was a significantly decreasing trend in age-standardized mortality from aortic aneurysm rupture in all 4 countries over the study period, and a decreasing trend in age-standardized mortality from aortic dissection in the UK over the study period, in USA until 2010, and in Canada until 2012. There was a significantly increasing trend in mortality from aortic dissection in Japan over the study period, in the USA after 2010, and in Canada after 2012. Joinpoint regression identified significant changes in the trends from decreasing to increasing in USA and Canada. In sensitivity analyses stratified by sex, similar trends were observed. Conclusions: Trends in mortality from aortic aneurysm rupture are decreasing, however, mortality from aortic dissection is increasing in Japan, USA, and Canada. Further study to explain these trends is warranted.

In this issue of Circulation , Sidloff and colleagues1 have presented their findings that, among 18 World Health Organization member states over a period of 16 years (1994–2010), there has been a reduction in the age-standardized mortality from both thoracic aortic aneurysm and dissection. If one considers the United States, the United Kingdom, and Sweden, 3 countries that have published extensively on the prevalence and mortality of thoracic aortic disease, the trends are quite favorable: Mortality from thoracic aortic aneurysm has declined by ≈5% to 10% among men and 3% to 6% among women, and mortality from aortic dissection has declined by ≈2% to 3% among men and 1% to 2% among women. However, and not surprisingly, the investigators discovered heterogeneity among mortality trends by country. For example, for men with thoracic aortic aneurysms, although there was a statistically significant reduction in mortality over time in 13 of the 18 countries, in 3 countries, there was instead an increase in mortality. Similarly, for men suffering from aortic dissection, although there was again a statistically significant reduction in mortality over time in 13 of the 18 countries, in 1 country, there was a significant rise in mortality. Japan and Romania were the 2 countries with the most consistent increases in mortality. Article see p 2287 The investigators then considered the impact of changing prevalence of risk factors on the changing mortality from thoracic aortic disease. In all of the countries studied, there was a decline in systolic blood pressure of up to 6% over time, and there was a linear relationship between systolic blood …

Introduction: Hypertension is a major cause of cardiovascular event-related mortality, and its association with aortic aneurysm and dissection is being extensively studied.Aim: To assess mortality trends and demographic disparities in hypertensive diseases with aortic dissection and aneurysm as a contributing cause.Methodology: A retrospective observational study was conducted using the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER) Multiple Cause of Death (MCD) database to assess mortality trends among individuals aged over 25 years in the United States from 1999 to 2020. Hypertension (ICD-10: I10-I15) was considered the underlying cause of death, with aortic dissection and aneurysm (ICD-10: I71.0) recorded as contributing causes. Data were stratified by gender, race, geographic region, and place of death. Age-adjusted mortality rates (AAMR) and annual percentage change (APC) were calculated.Results: A total of 20,782 deaths were recorded, with a crude rate of 4.6 per million. The AAMR initially declined (-2.12% APC from 1999 to 2006) but increased significantly from 2006 to 2009 (+56.82% APC). It then decreased slightly from 2009 to 2020 (-0.42% APC). The highest mortality was observed in males (10,902, 52.5%), White individuals (16,551, 79.6%), metropolitan regions (17,426, 83.9%), and medical facilities (13,328, 64.13%). Temporal trends showed an increasing AAMR in both males (+57.22% APC from 2006 to 2009) and females (+56.32% APC from 2006 to 2009). A similar trend was observed during those years in African American individuals (APC +52.45%) and White individuals (APC +57.22%), indicating evolving disparities.Conclusions: Mortality trends in hypertension with aortic dissection and aneurysm have shifted, with rising disparities in gender, race, geographic areas, and place of death. These findings underscore the need for targeted prevention strategies and improved healthcare access.

Coarctation of the aorta (CoA) is a congenital narrowing typically detected in childhood; survival into adulthood without repair is uncommon. Aortic dissection (AD) is an exceedingly rare complication in this specific context, particularly involving the descending aorta. We describe a case of a 46-year-old Caribbean-Black male with a medical history of chronic hypertension (HTN) who presented with unstable angina and hypertensive crisis. Emergent computed tomography angiography revealed critical proximal descending CoA with poststenotic dilatation and an acute Stanford type B AD. He was initially stabilized on guideline-directed medical therapy, and while definitive surgical repair was recommended, the patient declined. This exceedingly rare case of type B AD complicating unrepaired CoA underscores the importance of recognizing congenital aortic disease as a cause of refractory HTN in adults. Additionally, it highlights the need for continued vigilance for long-term complications in adults with congenital heart disease.

Aortic aneurysm (AA) and aortic dissection (AD) are life-threatening cardiovascular diseases. AA includes thoracic (TAA) and abdominal (AAA) subtypes, while AD involves primary intimal tear. In the U.S., mortality trends, and demographic disparities remain unclear. This retrospective population-based study analyzed US AA/AD burden and disparities to guide targeted prevention and management. We extracted AA/AD mortality data (1999–2023; urban-rural 1999–2020) for adults aged ≥ 25 in the continental U.S. from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research, stratified by sex, age, race/ethnicity and region. We calculated crude and age-adjusted rates (CMR/AAMR), and estimated annual and average annual percentage change (APC/AAPC) via joinpoint regression. Two-tailed t-tests were used (p < 0.05). Between 1999 and 2023, there were 289,971 AA/AD-related deaths in the U.S., with AAMR declining (AAPC = -3.73%, 95% CI: -4.33 to -3.14; p < 0.001). Males and non-Hispanic Black adults had higher AAMR and slower declines. Crude mortality rose with age, while the 35–44 age group showed a small increase (AAPC = 1.04%, 95% CI: 0.63 to 1.46; p < 0.001). The Midwest exhibited a higher disease burden, and between 1999 and 2020, nonmetropolitan areas consistently showed greater disease burden compared with metropolitan regions. From 1999 to 2023, U.S. mortality from aortic aneurysm and dissection declined overall, but burdens remained disproportionately high in non-Hispanic Black individuals, those aged 85+, and the Midwest. 1999–2020 data show greater burden in nonmetropolitan areas, highlighting persistent disparities in resources and risk management.

Background: Aortic aneurysm and dissection (AAD) are highly fatal in older adults. While AAD mortality has declined since 1999, reductions have been uneven across U.S. regions, sexes, and racial/ethnic groups, likely due to healthcare variability. Methods: We used CDC WONDER data (1999–2020) to identify AAD deaths among adults aged 65–75. We focused on this group because AAD incidence peaks here, Medicare coverage ensures near-complete reporting, and guideline-based screening is recommended—maximizing data quality and translational value. After excluding 577 unreliable records, 55,531 deaths remained. Crude mortality rates per 100,000 were calculated by sex and race/ethnicity (White, Black, Asian or Pacific Islander [API], American Indian or Alaska Native [AIAN]) using census denominators. State trends were assessed versus vascular surgeon density, Medicaid expansion, rural hospital closures, smoking, and hypertension. Results: From 1999 to 2020, there were 36,791 AAD deaths among males and 18,740 among females. Male mortality declined from 32.7 to 9.0 (–72.4%); female from 12.7 to 4.5 (–64.5%). Males showed higher rates and volatility, with spikes in 2000, 2015, and 2017. Average annual decline was larger for males (–1.1) than females (–0.39), peaking in 2008. Black females had slightly greater mean declines (–0.40) than White females (–0.39); White males declined more than Black males (–1.1 vs. –0.6). API adults improved steadily (females: 10.6 to 3.7; males: 14.5 to 5.3). AIAN data were too sparse for reliable conclusions. High-mortality states included West Virginia (14.8), Wyoming (14.7), Arkansas (14.5), and Indiana (14.4), clustered in Appalachia and rural Midwest/South. Low-mortality states—California (5.6), Massachusetts (6.0), and New York (6.2)—had stronger healthcare systems. High-burden states had under 0.8 vascular surgeons per 100,000 vs. ≥1.5 in low-burden states. Uninsured rates exceeded 12% vs. under 6%. Medicaid expansion was delayed. Since 2005, 193 rural hospitals have closed. Smoking rates were 21% vs. 10%; uncontrolled hypertension 30% vs. 18%. Conclusions: From 1999 to 2020, AAD mortality declined substantially but unevenly across sex, race, and geography. Disparities reflect access, coverage, and prevention gaps. Addressing these requires specialty expansion, rural hospital support, earlier Medicaid uptake, and community prevention. Keywords: Aortic aneurysm; Aortic dissection; Mortality trends; Racial disparities; Geographic variation

### Case A 68-year-old right-hand-dominant man was brought to the hospital because of a speech disturbance and right arm and leg weakness. He awoke with these deficits and was last known to be symptom-free when retiring to bed the previous evening 8 hours earlier. His past medical history was notable for coronary heart disease, the patient having underwent coronary artery bypass surgery 7 years previously for unstable angina, but he had no known history of myocardial infarction. He also had hypertension and hyperlipidemia, and smoked 1 pack of cigarettes daily for more than 40 years. He had no history of calf claudication. His hypertension was being treated with a diuretic and β-adrenergic receptor blocker. He was also prescribed 325 mg of aspirin daily and an HMG CoA-reductase inhibitor (statin); however, his wife remarked that he often forgot to take his medications. His last total cholesterol was 240 mg/dL, with LDL cholesterol of 130 mg/dL. He had a strong family history of coronary heart disease after the age of 50. He had no known drug allergies. #### Physical Examination The patient’s blood pressure was 195/100 mm Hg in both arms, with a regular pulse of 90 bpm. His weight was 225 lb (body mass index: 31.4 kg/m2). His lungs were clear to auscultation. Cardiac examination showed a laterally displaced point of maximum impulse with an S4 gallop and a soft nonradiating systolic murmur at the base. His abdomen was obese without organomegaly and no abdominal bruits were detected. He had no rashes and no joint deformities. The left superficial temporal artery pulse was stronger than the right. There were soft bilateral anterior cervical bruits, left louder than right, but no supraclavicular bruits. There were bilateral femoral bruits. Radial pulses were 2+ and symmetric. Dorsalis pedis and posterior tibial pulses were 1+. …

GW28-e0055 The Management Manner and Reasons Analysis for Stress-induced Hypertension in Adults with Aortic Dissection (Stanford type A) after Bentall or Improved-Cabrol of Cardiac Surgery

Guidelines for the diagnosis and treatment of hypertension were published by the American Heart Association (AHA) in 2017. The prevalence of hypertension in adults with congenital heart disease (ACHD) under these guidelines has yet to be characterized. We sought to assess the prevalence, impact, and provider response to hypertension under current guidelines. Data were obtained retrospectively from records of routine clinic visits over a 10year period. Potential hypertension-related adverse outcomes including stroke, myocardial infarction, surgical intervention for aortic aneurysm, aortic dissection, atrial fibrillation or flutter, cardiac transplantation and death were recorded. The 1070 patients who met inclusion criteria had a mean age of 30.8 ± 10.0years. The prevalence of hypertension under the 2017 guidelines was 46.6%. Multivariate modeling identified cyanosis, male gender, older age, and overweight/obesity as independent risk factors for hypertension. Guideline-directed management of hypertension in ACHD patients occurred more frequently in ACHD and adult cardiology clinics than in pediatric cardiology clinics (44.1% and 45.1% vs. 24.0%, p < 0.01, respectively). Adverse outcomes were reported in 217 (20%) patients, the most prevalent of which was atrial fibrillation or flutter (11%). Multivariable modelling for any adverse outcome identified older age, hypertension, cyanosis, greater complexity ACHD, and obesity as risk factors. Modifiable risk factors for atherosclerotic cardiovascular disease are common and often under addressed in the ACHD population.

Impact of centralized care on aortic dissection outcomes in the United States.

TRENDS IN INCIDENCE AND MORTALITY IN ED VISITS FOR AORTIC DISSECTION