Aortic Pulse Research Articles

Abstract TP216: Subtle Cardiovascular Measures in Young-onset Cryptogenic Ischemic Stroke: A Prospective Case-control Study

Background: Worldwide, ≈1.3 million annual ischemic strokes (IS) occur in young adults (<50 years of age), of which up to 50% remain cryptogenic after a complete diagnostic work-up. In a pilot case-control study, we studied the value of arterial stiffness and related subendocardial viability in the search of underlying pathophysiology in these patients. Methods: We prospectively enrolled 51 patients aged 18-49 with recent imaging-positive cryptogenic IS and 51 age- and sex-matched stroke-free controls (NCT01934725). Measurements were done with an applanation tonometry (SphygmoCor). Augmentation Index (AIx) served as a measure of stiffness in small arteries. Aortic and brachial pulse wave velocities (aPWV; bPWV) reflected stiffness in large and intermediate-sized arteries, respectively. Subendocardial viability ratio (SEVR) was derived from radial artery waveform measures, reflecting myocardial oxygen supply and demand. Related-samples statistics were applied for univariate case-control analyses and linear regression to explore the relationship between parameters with significant association in case-control analysis. Results: AIx, aPWV, bPWV, heart rate, and systolic or diastolic blood pressures did not differ statistically between patients and controls. Mean SEVR was significantly lower in patients compared with controls (148±35 vs. 161±29, P=0.003). In patients, higher heart rate was inversely associated with SEVR (P<0.001). Age, sex, migraine with and without aura, smoking, and systolic and diastolic blood pressure showed no independent association with SEVR. Conclusions: To our knowledge, this is the first report to show an association between SEVR and stroke. Yet unrecognized subtle cardiovascular pathology may play a role in early-onset cryptogenic IS.

Effects of renal denervation on vascular remodelling in patients with heart failure and preserved ejection fraction: A randomised control trial.

ObjectiveTo assess the effect of renal denervation (RDT) on micro- and macro-vascular function in patients with heart failure with preserved ejection fraction (HFpEF).DesignA prospective, randomised, open-controlled trial with blinded end-point analysis.SettingA single-centre London teaching hospital.ParticipantsTwenty-five patients with HFpEF who were recruited into the RDT-PEF trial.Main outcome measuresMacro-vascular: 24-h ambulatory pulse pressure, aorta distensibilty (from cardiac magnetic resonance imaging (CMR), aorta pulse wave velocity (CMR), augmentation index (peripheral tonometry) and renal artery blood flow indices (renal MR). Micro-vascular: endothelial function (peripheral tonometry) and urine microalbuminuria.ResultsAt baseline, 15 patients were normotensive, 9 were hypertensive and 1 was hypotensive. RDT did not lower any of the blood pressure indices. Though there was evidence of abnormal vascular function at rest, RDT did not affect these at 3 or 12 months follow-up.ConclusionsRDT did not improve markers of macro- and micro-vascular function.

Evaluation of Distensibility and Stiffness of Ascending Aortic Aneurysm using Magnetic Resonance Imaging

Magnetic resonance imaging emerging as a new tool for the diagnosis and evaluation of ascending aortic aneurysm. The aim of our study is to evaluate in vivo distensibility and pulse wave velocity of the aortic wall using functional magnetic resonance imaging technique. We enrolled 25 patients undergoing surgery for ascending aortic aneurysm and or aortic valve replacement for a period of 8 months. Preoperatively, all the patients underwent functional MRI study of the aorta. Aortic wall distensibility and pulse wave velocity of ascending aorta was evaluated. Mean age of the patient was 66 years (66.68 ± 5.62 years) with 60% (15) male patients. More than fifty percentages of patients were smoker (52%), hypertensive (64%) and diabetic (56%). We have observed significant decrease of distensibilty in the patients with aortic diameter above 50 mm (p-0.0002). Furthermore, we have found a significant inverse correlation between aortic distensibility and pulse wave velocity (R= -0.650, R2= 0.42, p-0.0004). Similarly, we have found a significant inverse correlation between ascending aortic diameter and distensibility of the aorta (R= -0.785, R2= 0.61, p-0.00001). Statistically significant positive correlation was observed between aortic diameter and pulse wave velocity (R= 0.865, R2= 0.74, p-0.00001). MRI measurement of aortic diameters, distensibility, and flow wave velocity is an easy, reliable and reproducible technique. Distensibility and pulse wave velocity define the elasticity of the aorta. We have observed that elasticity of aortic wall is decreased in ascending aorta aneurysm patients.

Abstract P248: Office and Ambulatory Brachial and Aortic Blood Pressure in Relation to Renal, Cardiac, and Vascular Organ Damage in Hypertension

It has been suggested that aortic BP could be a better predictor of target organ damage (TOD) than peripheral BP. However, studies examining such relationship by using ABPM are scarce. We aimed to examine such relationship in a cohort of hypertensive patients. A total of 208 patients (34% women; mean age: 57±12 years, 90% on antihypertensive treatment) were recruited from 4 hospital clinics in the area of Barcelona, Spain. The presence of TOD was determined if one of the following were present: cardiac, defined as the presence of LVH (LVMI ≥ 115 g/m 2 in men or ≥ 95 g/m 2 in women); renal, defined as the presence of either albuminuria (UAE ≥ 30mg/g) or reduced eGFR (< 60 ml/min/1.73 m 2 , by CKD-EPI formula), or both; vascular: aortic PWV ≥ 10 m/s. Clinic (mean of 4 measurements) and 24-h brachial and aortic BP were determined by the use of the portable automated Mobil-O-Graph device. LVH was present in 37%, albuminuria (17%), reduced eGFR (14%), or both were present in 26%, and elevated aortic PWV in 18%. Overall, 51% of patients presented TOD in at least one organ, whereas 6.3% have all renal, cardiac, and vascular alterations. After adjustments for age, gender, and the use of antihypertensive treatment, odds ratios for clinic, 24-hour, daytime, and nighttime brachial and aortic SBP and pulse pressure (PP) were all significantly associated with the presence of TOD. Higher odds ratios were observed for PP, compared to SBP, and for 24-hour estimates, compared to clinic, daytime or nighttime values. The OR for 5 mmHg increase in brachial and aortic PP were respectively 1.38 (1.16-1.60) and 1.41 (1.14-1.70). PP amplification or augmentation index (clinic or 24-h-derived) were not significantly associated with the presence of TOD, after adjustments. Considering specific organ alterations, aortic SBP and PP estimates were associated with LVH and aortic PWV, but not with albuminuria or reduced eGFR. Both aortic SBP and PP are associated with the presence of TOD in hypertensive patients. The association is stronger for 24-h PP and for LVH and arterial stiffness, whereas renal alterations show a weaker association. The use of ABPM including aortic BP measurement can be of interest in predicting cardiovascular alterations in hypertension.

Abstract 109: Association of Endothelial Dysfunction with Non-invasive Measures of Vascular Stiffness in Young-middle Aged Non-hypertensive Individuals

Arterial stiffness and enhanced wave reflections independently predict cardiovascular risk. Wave reflections augment central (aortic) pulse pressure (PP), an index of arterial stiffness, and systolic pressure. Increased wave reflections and PP have previously been associated with endothelial dysfunction in hypertensive and healthy middle-aged adults. The study objective was to determine whether endothelial dysfunction is associated with PP and other measures of vascular stiffness in young normotensive and prehypertensive subjects. We measured office, central, and 24-hour measurements in 102 (64 female, 38 male) non-hypertensive, non-diabetic participants. Endothelial function was assessed non-invasively using post-ischemic reactive hyperemia with strain-gauge plethysmography. The racially diverse subject pool was comprised of 60% Caucasians, 18% African Americans, and 24% Asians, with mean age 30, mean BMI 25.6, mean office SBP/DBP = 110 ± 13 mm Hg/70 ± 9 mm Hg. Endothelial function was highly associated with office (β= - 4.2 mm Hg, p<0.001) and 24-hour PP (β= - 1.4 mm Hg, p=0.008), along with central measures of wave reflection: ((augmentation pressure (β= - 2.1 mm Hg), augmentation index (β= - 3.7): both p<0.001). Beta values correspond to the change noted for one standard deviation in endothelial function. In conclusion, endothelial dysfunction is significantly and consistently associated with arterial stiffness and increased wave reflections in young non-hypertensive adults. Identification of endothelial dysfunction in otherwise healthy young individuals may provide an opportunity to reduce vascular stiffness and associated cardiovascular risk.

PP.18.08] INFLUENCE OF FIXED-DOSE COMBINATION PERINDOPRIL/AMLODIPINE ON TARGET ORGAN DAMAGE IN PATIENTS WITH ARTERIAL HYPERTENSION AND ISCHEMIC HEART DISEASE

Objective: To evaluate the antihypertensive effectiveness and changes of target organ damage in patients with arterial hypertension (AH) and ischemic heart disease (IHD) on fixed dose combination (FDC) (perindopril(P)|amlodipin(A)) treatment. Design and method: There were included 27 patients (age > 30 yrs, untreated hypertensives with verified IHD without myocardial infarction history and BP > 160/100 and <200/120 mmHg or who were on monotherapy (except P), but their office BP was >140/90 and <200/120 mmHg,), whom were evaluated office systolic (SBP) and diastolic (DBP) blood pressure (BP), 24-h SBP and 24-h DBP, central SBP (cSBP) and aorta pulse wave velocity (PWV) by Sphygmocor, EchoCG with Tissue Doppler, albuminuria, intima-media thickness (IMT), ankle-brachial index (ABI), biochemical blood analysis. Follow-up period was 12 mths. After wash-out period P|A administered in dose 5|5 mg with up-titration to 10|10 mg every 2 weeks. Indapamide was added as the third drug. Beta-blockers (96.3%) or alpha-blockers were allowed for better BP control and IHD treatment. Primary end-points were BP lowering (office, systolic, central), significant (>SD) dynamic of target organ damage signs, tolerance of FDC. Results: Baseline FDC were administered to 30 pts, but all data were collected at this time only in 27 pts. Office SBP|DBP decreased from 151.2 ± 2.8|92.3 ± 2.7 till 133.3 ± 1.8|77.2 ± 1.4 mmHg(p < 0.001|0.001), 24-hSBP|DBP from 138.2 ± 2.0|85.4 ± 2.7 till 118.8 ± 1.3|73.2 ± 1.2 mmHg(p < 0.001|0.001), cSBP from 139.8 ± 2.1 till 116.3 ± 2.8 mmHg(p < 0.001). Target BP was achieved in all patients. Effective BP control followed by positive target organ changes (tab:^-p < 0.001,^^-p < 0.05). The changes of E|E’ and albuminuria did not correlate with office BP lowering, but with aorta cSBP and PWV decreasing. We did not note any significant changes of biochemical patterns, except LDL-C decreasing, that was due to intensive statin therapy.Conclusions: The treatment based on FDC (P|A) was effective not only in decreasing of office and ambulatory BP, but central SBP too. It led to decreasing of target organ damage. Diastolic left ventricular function and renal damage improving were connected with much decreasing of cSBP and arterial stiffness.

Age-related association of aortic arch pulse wave velocity assessed by MRI with incident cardiovascular events: the multi-ethnic study of atherosclerosis (MESA)

Age-related association of aortic arch pulse wave velocity assessed by MRI with incident cardiovascular events: the multi-ethnic study of atherosclerosis (MESA)

Ascending aortic wall shear stress and distensibility are different in patients with corrected atrioventricular septal defect compared to healthy controls: a comprehensive CMR and 4D flow MRI evaluation

Background In patients with an atrioventricular septal defect (AVSD), the left ventricular outflow tract (LVOT) and the ascending aorta (AAo) are located more anteriorly due to the position of the common AV valve. This may alter proximal aortic flow, and we hypothesize that this can result in impaired LV systolic function and AAo wall degeneration. We aimed to quantify differences in AAo wall shear stress (WSS), distensibility (Dist), aortic arch pulse wave velocity (PWV) and LV ejection fraction (EF) in these patients versus healthy controls using cardiovascular magnetic resonance (CMR) and four dimensional (4D) flow MRI.

Elevated Aortic Augmentation Index in Children Following Fontan Palliation: Evidence of Stiffer Arteries?

Children born with a functional single ventricle who undergo Fontan palliation are prone to early pump failure. Whether they develop early arterial stiffness with resultant increase in afterload is not well known. We hypothesized that the aortic stiffness is higher in pediatric Fontan patients when compared to healthy controls. A prospective study was conducted at the Children's Hospital of Michigan. Twenty-two Fontan patients (aged 6-21 years) were compared with 22 healthy controls (aged 9-17 years) selected from children referred to our clinic who had normal cardiac anatomy and function on the echocardiogram. Aortic stiffness was assessed noninvasively by measuring the aortic augmentation index (AAI) using applanation tonometry (Sphygmocor, Atcor, IL). AAI was calculated as AP/PP where augmentation pressure (AP) is the increase in aortic systolic blood pressure (BP) and pulse pressure (PP) is the difference between aortic systolic and diastolic BP. Ten patients (45 %) had hypoplastic left ventricle, and 11 (50 %) had undergone aortic arch surgery. The median AAI was significantly higher in Fontan patients when compared to controls (12.5, IQR 4.8, 17.3 vs 0, IQR -6.3, 5.8; p = 0.0003). History of aortic arch surgery and single ventricle morphology did not have a significant impact on AAI. Pediatric patients who undergo Fontan palliation have significantly higher AAI, a marker of aortic stiffness and increased afterload, compared to healthy controls. Larger longitudinal studies are warranted to elucidate the possible contribution of elevated AAI on pump failure in these patients.

Abstract P182: Aortic Arch Pulse Wave Velocity Assessed by MRI as a Predictor of All-Cause Mortality and Incident Cardiovascular Events: The Multi-Ethnic Study of Atherosclerosis (MESA)

Background: The carotid-femoral pulse wave velocity (PWV) assessed by tonometry is predictive of future cardiovascular disease (CVD) events. However, the predictive value of aortic arch PWV assessed by MRI for mortality and CVD events has not been established in the general population. The aim of this study was to evaluate the association of arch PWV with all-cause mortality and incident CVD events over 10 years in the Multi-Ethnic Study of Atherosclerosis (MESA). Method: Aortic arch PWV was measured using phase contrast (PC) cine MRI at the level of the pulmonary artery bifurcation for transit time and black blood sagittal image for transit length at baseline in 3537 MESA participants free of overt CVD. Cox regression was used to evaluate the risk of death and incident CVD in relation to arch PWV adjusted for age, gender, race, and CV risk factors. Results: At baseline, participants were aged 62 ± 10 years; 53% women; 36% White, 15% Chinese, 29% African American, 20% Hispanic; 45% hypertension. The mean value of arch PWV was 9.0 ± 6.3 m/s. There were 418 deaths and 236 CVD events over 10-year follow-up. There was significant interaction between arch PWV and mean age for both outcomes, so we stratified by age; below 60 years (n=1503) and above 60 years (n=2034). Increased PWV had a trend with increased risk of all-cause mortality with a hazard ratio for the 4th vs 1st quartile of PWV of 2.1 (95%CI: 1.0-4.6, p=0.05) independent of risk factors in age below 60 years group. There was no significant association of PWV with incident CVD in age below 60 years after adjustment for risk factors. In age above 60 years group, increased PWV was not associated with either all-cause mortality or incident CVD events in univariate or multivariate analysis (Table). Conclusion: Arch PWV assessed by MRI is not a significant predictor of all-cause mortality and incident CVD events among individuals without overt CVD.

CMR-assessed aortic arch stiffness is associated with brain tissue integrity assessed by diffusion tensor imaging in patients with hypertension

Background Increased aortic stiffness may lead to insufficient flow wave dampening and subsequent transmission of excessive pulsatile energy towards end-organs such as the brain. It has been shown that CMR-assessed aortic stiffness may augment cerebral small vessel disease in patients with hypertension, as assessed by conventional structural magnetic resonance imaging (MRI). However, in addition to these overt brain abnormalities, currently it is unknown whether aortic stiffening relates to subtle changes in brain tissue integrity, which may be a precursor to overt brain abnormalities. Diffusion tensor imaging (DTI) in the brain has been used to evaluate such subtle changes in tissue integrity. The aim of this study was to assess the association between aortic arch pulse wave velocity (PWV) as a marker of arterial stiffness and brain changes assessed by conventional structural MRI as well as DTI in patients with hypertension.

Reproducibility of functional aortic analysis using MRI: the multi-ethnic study of atherosclerosis

Methods Twenty-five participants underwent aortic MRI twice over 13 ± 7 days. All aortic variables (ascending aortic area, descending aortic area, ascending and descending aortic strain [maximum area minus minimum area divided by minimum area], aortic arch transit time and pulse wave velocity [PWV]) from baseline and repeat MR were analyzed using a semi-automated method by the ARTFUN software. Phase contrast (PC) cine at the level of the pulmonary artery bifurcation was used for assessment of aortic area, aortic strain, and PWV. Steady State Free Precession (SSFP) sagittal images were used to measure aortic arch transit distance. To assess the inter-study reproducibility of aortic variables, we calculated intraclass correlation coefficient (ICC) for individual aortic measurements. Intraand inter-observer variability was also assessed using the baseline MR data.

MRI assessment of aortic flow and pulse wave velocity in response to exercise

Background The effect of exercise on cardiac function is important in the diagnosis of cardiovascular disease [1], yet is clinically not available with MRI. Instead, pharmacological agents are used, which have several disadvantages [2]. Recent work has addressed this shortcoming with an MR compatible ergometer next to the magnet [3], albeit with an unavoidable time delay between exercising and actual scanning, which can reduce the measured effect. In this pilot study, we investigated flow and area changes in the aorta with customized exercise equipment that functions in the bore.

Routine cine-CMR segmentation via a novel automated algorithm (LV-METRIC) for assessment of aortic physiology: a clinical validation study

Methods Cine-CMR (SSFP) was performed on 1.5 Tesla (GE) scanners; pulse sequence parameters were equivalent to those for routine CMR (typical TR 3.4 msec, TE 1.14 msec, flip angle 60, temporal resolution 30 msec). Images were acquired in conventional cardiac (2, 3, 4 chamber) long axis or axial imaging planes. Aortic area was uniformly measured in a non-aneurysmal location within the mid-descending thoracic aorta: Cine-CMR was quantified via a novel “partial voxel” segmentation algorithm (LV-METRIC) that accounts for relative proportion of blood within each individual imaging voxel. Maximum (systolic) and minimum (diastolic) aortic areas and brachial pulse pressure were used to calculate distensibility, a measure of arterial compliance, of the mid-descending thoracic aorta.

СENTRAL AORTIC PRESSURE AND AUGMENTATION INDEX IN YOUNG ADULTS WITH REGARD TO CARDIOVASCULAR RISK FACTORS

O bjective. To estimate central aortic blood pressure (BP) and index of augmentation in young people, taking into account the presence of risk factors (RF), during preventive medical examination. Desig n an d methods. Altogether 78 students of 3–4 years, aged 19–23 years old have been surveyed within the framework of the regular medical examinations, at the Center of Students’ Health, Stavropol State Medical University, as a part of the project “University is the territory of health”. Besides RF assessment, central aortic pressure was evaluated by oscillometric method (BPLab, “Peter Telegin”,Novosibirsk,Russia; Vasotens Office). In addition to common peripheral BP parameters, this technology provides measurements of systolic BP aortic (SYSао), diastolic BP aortic (DIAао), pulse BP aortic (PPао), average BP aortic (ABPао), left ventricular ejection duration (ED), augmentation index in aorta (AIxао), pulse pressure amplification (PPA) and subendocardial viability ratio (SEVR). Surveyed students were distributed into two groups: first group — without RF (control group), and second group — with RF (main group). For automatic tubulation of all parameters we used the operational system BPStat ® version 05.00.04 (“Petr Telegin”). For statistical data processing program “Statistica8” was used. R esults. At young age RF are associated with the increase of both peripheral and aortic BP, especially systolic and pulse ВР, as well as augmentation index of central ВР. In students RF are associated with the increase of aortic BP (isolated central or masked hypertension/prehypertensionwith the simultaneous increase of both peripheral and aortic BP). The frequency of isolated increase of peripheral BP among students with RF is similar to that in students without RF. C onclusions. Thus, planimetric analysis of central pulse wave in young people allows to define various mechanisms leading to the early BP increase. These data enable differentiated premorbid diagnostics of hemodynamic status in young adults with cardiovascular RF. This approach will contribute to the more individualized preventive measures in young population.

GW25-e1717 The value of aorta pulse pressure/pulse pressure index in predicting the coronary heart disease in female patients

GW25-e1717 The value of aorta pulse pressure/pulse pressure index in predicting the coronary heart disease in female patients

EDITORIAL-Blood Pressure as a Risk Factor of Global Disease Burden and its Association with Lifetime Risks of Different Manifestations of Cardiovascular Disease

The evaluation of lifetime cardiovascular disease (CVD) risk and the life-years lost due to CVD in specific age groups in a population of 1.25 million people showed that not all elements of hypertension are causally associated with all manifestations of CVD. High systolic blood pressure (BP) was strongly related to intracerebral haemorrhage, subarachnoid haemorrhage, stable angina, myocardial infarction, and peripheral arterial disease (PAD). On the other hand, high diastolic BP had a stronger relationship with abdominal aortic aneurysm and pulse pressure had a stronger association with PAD and an inverse association with abdominal aortic aneurysm. Unstable angina was related to loss of life in younger ages, whereas heart failure and stable angina pectoris were related to years of life lost in the elderly. Thus, specific elements of BP were linked to specific manifestations of CVD and causes of death by CVD. Another recent study analysed the independent effects of 67 all-disease risk factors in 21 regions worldwide in 2010 and compared them with those of 1990. Hypertension immerged as the first cause of all-cause disease burden (7%), while in 1990 it was not included in the first 3 causes. A shift from communicable diseases of the children to the non-communicable diseases of the adults was also recorded in this 20-year period. A plethora of data suggests the hypertension is the number one killer both in Western World and Worldwide. The adoption of lifetime CVD risk estimates combined with efforts for increased awareness, education, and BP control will probably improve outcomes and substantially reduce CVD mortality.

First in vivo application and evaluation of a novel method for non-invasive estimation of cardiac output

Surgical or critically ill patients often require continuous assessment of cardiac output (CO) for diagnostic purposes or for guiding therapeutic interventions. A new method of non-invasive CO estimation has been recently developed, which is based on pressure wave analysis. However, its validity has been examined only in silico. Aim of this study was to evaluate in vivo the reproducibility and accuracy of the “systolic volume balance” method (SVB). Twenty two subjects underwent 2-D transthoracic echocardiography for CO measurement (reference value of CO). The application of SVB method required aortic pressure wave analysis and estimation of total arterial compliance. Aortic pulses were derived by mathematical transformation of radial pressure waves recorded by applanation tonometry. Total compliance was estimated by the “pulse pressure” method. The agreement, association, variability, bias and precision between Doppler and SVB measures of CO were evaluated by intraclass correlation coefficient (ICC), mean difference, SD of differences, percentage error (PR) and Bland–Altman analysis. SVB yielded very reproducible CO estimates (ICC=0.84, mean difference 0.27±0.73L/min, PR=16.7%). SVB-derived CO was comparable with Doppler measurements, indicating a good agreement and accuracy (ICC=0.74, mean difference=−0.22±0.364L/min, PR≈15). The basic mathematical and physical principles of the SVB method provide highly reproducible and accurate estimates of CO compared with echocardiography.

Pulse Pressure and Type A Acute Aortic Dissection In-Hospital Outcomes (from the International Registry of Acute Aortic Dissection)

Little is known about the relation between type A acute aortic dissection (TAAAD) and pulse pressure (PP), defined as the difference between systolic and diastolic blood pressure. In this study, we explored the association between PP and presentation, complications, and outcomes of patients with TAAAD. PP at hospital presentation was used to divide 1,960 patients with noniatrogenic TAAAD into quartiles: narrowed (≤39 mm Hg, n=430), normal (40 to 56 mm Hg, n=554), mildly elevated (57 to 75 mm Hg, n=490), and markedly elevated (≥76 mm Hg, n=486). Variables relating to index presentation and in-hospital outcomes were analyzed. Patients with TAAAD in the narrowed PP quartiles were frequently older and Caucasian, whereas patients with markedly elevated PPs tended to be male and have a history of hypertension. Patients who demonstrated abdominal vessel involvement more commonly demonstrated elevated PPs, whereas patients with narrowed PPs were more likely to have periaortic hematoma and/or pericardial effusion. Narrowed PPs were also correlated with greater incidences of hypotension, cardiac tamponade, and mortality. Patients with TAAAD who were managed with endovascular and hybrid procedures and those with renal failure tended to have markedly elevated PPs. No difference in aortic regurgitation at presentation was noted among groups. In conclusion, patients with TAAAD in the third PP quartile had better in-hospital outcomes than patients in the lowest quartile. Patients with narrowed PPs experienced more cardiac complications, particularly cardiac tamponade, whereas those with markedly elevated PPs were more likely to have abdominal aortic involvement. Presenting PP offers a clue to different manifestations of acute aortic dissection that may facilitate initial triage and care.

Refractory Hypertension Leads to both Type A and B Aortic Dissections in a Single Patient

more prevalent in the population of patients with Type B dissections at 76.7% vs. those with Type A dissections at 69.3% there was no significant difference between the high proportion in these two groups (p=0.08) [8]. This contribution to aortic dissection is also remarkable in that the most affected demographic for either aortic dissection type is typically male (65.3%) and Caucasian (82.8%) with a mean age of 63.1 ± 14 years, with the rest of the patient population comprised of only1.7% African American and 13.5% Asian patients [8]. In each circumstance, the most common presenting symptom was found to be abrupt onset of sharp pain of the utmost severity either in the anterior chest in Type A dissections (p<0.001) or back in Type B dissections (p<0.001), which this patient also experienced. Patients were also found to present with systolic hypertension on physical exam most commonly (49%) with significantly more during a Type B vs [8]. Type A aortic dissection (70.1% vs. 35.7% respectively, p<0.001), with Type A dissections presenting significantly more with new-onset murmur of aortic insufficiency (44%, p<0.001), pulse deficit (18.7%, p=0.006), and congestive heart failure (8.8%, p=0.02) [8]. The most common imaging modality used to detect aortic dissection was computed tomography (61.1%) [8], which was used in the diagnosis of this patient (Figure 1). Only 3.9% of patients with a Type A aortic dissection had experienced a previous unspecified type dissection versus 10.6% of patients with a Type B aortic dissection (p<0.005), making this