Aortic dissection risk factors

Aortic dissection Microchapters

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Case #1

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Cafer Zorkun, M.D., Ph.D. [2]; Raviteja Guddeti, M.B.B.S. [3] Sahar Memar Montazerin, M.D.[4]

## Overview

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Common risk factors in the development of aortic dissection include aging, atherosclerosis, diabetes, hypertension and trauma. Less common risk factors include bicuspid aortic valve, cocaine abuse, coarctation of the aorta, cystic medial necrosis, a history of collagen vascular disoders, giant cell arteritis, heart surgery, pseudoxanthoma elasticum, Turner's syndrome, tertiary syphilis and the third trimester of pregnancy.

## Risk Factors

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Common risk factors in the development of aortic dissection include:[1][2][3]

* Aging with the highest incidence in individuals who are 50 to 70 years old
* Atherosclerosis and its associated risk factors like diabetes
* Bicuspid aortic valve especially important in ascending aorta dissection[4]
* The risk of dissection in individuals with bicuspid aortic valve is not associated with the degree of stenosis of the valve.
* Chest trauma including blunt trauma and iatrogenic (for example during cardiac catheterization or due to an intra-aortic balloon pump)
* Coarctation of the aorta[5]

### Less Common Risk Factors

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Less common risk factors in the development of aortic dissection include:[6][7][8][9]

* Cocaine abuse
* Cystic medial necrosis
* Deceleration trauma most commonly causes aortic rupture, not dissection
* Diabetes
* A history of collagen vascular disorders such as:
* Ehlers-Danlos syndrome
* Marfan syndrome
* Familial hypercholesterolemia
* Giant cell arteritis
* Heart surgery particularly aortic valve replacement
* Hypertension most frequently in those with type III dissection
* Male gender
* Preexisting aortic aneurysm
* Preexisting aortic valve disease
* Prior aortic aneurysm repair
* Prior aortic dissection
* Prior aortic dissection repair
* Pseudoxanthoma elasticum
* Tertiary syphilis
* Tetralogy of Fallot
* Third trimester of pregnancy
* Turner's syndrome due to aortic root dilatation in this syndrome
* Vasculitis (inflammation (rarely)

## 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease (DO NOT EDIT)[10]

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### Estimation of Pretest Risk of Thoracic Aortic Dissection (DO NOT EDIT)[10]

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Class I

"1. Providers should routinely evaluate any patient presenting with complaints that may represent acute thoracic aortic dissection to establish a pretest risk of disease that can then be used to guide diagnostic decisions. This process should include specific questions about medical history, family history, and pain features as well as a focused examination to identify findings that are associated with aortic dissection, including:
a. High-risk conditions and historical features[11] (Level of Evidence: B):

* Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, or other connective tissue disease.
* Patients with mutations in genes known to predispose to thoracic aortic aneurysms and dissection, such as FBN1, TGFBR1, TGFBR2, ACTA2, and MYH11.
* Family history of aortic dissection or thoracic aortic aneurysm.
* Known aortic valve disease.
* Recent aortic manipulation (surgical or catheter-based).
* Known thoracic aortic aneurysm.

b. High-risk chest, back, or abdominal pain features[12][11][13][14][15][16][17](Level of Evidence: B):

* Pain that is abrupt or instantaneous in onset.
* Pain that is severe in intensity.
* Pain that has a ripping, tearing, stabbing, or sharp quality.

c. High-risk examination features[12][18][13][17][19][20][21] (Level of Evidence: B):

* Pulse deficit.
* Systolic blood pressure limb differential greater than 20 mm Hg.
* Focal neurologic deficit.
* Murmur of aortic regurgitation (new)."

"2. Patients presenting with sudden onset of severe chest, back, and/or abdominal pain, particularly those less than 40 years of age, should be questioned about a history and examined for physical features of Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, or other connective tissue disorders associated with thoracic aortic disease.[11] (Level of Evidence: B)"
"3. Patients presenting with sudden onset of severe chest, back, and/or abdominal pain should be questioned about a history of aortic pathology in immediate family members as there is a strong familial component to acute thoracic aortic disease.[11] (Level of Evidence: B)"
"4. Patients presenting with sudden onset of severe chest, back, and/or abdominal pain should be questioned about recent aortic manipulation (surgical or catheter-based) or a known history of aortic valvular disease, as these factors predispose to acute aortic dissection. (Level of Evidence: C)"
"5. In patients with suspected or confirmed aortic dissection who have experienced a syncopal episode, a focused examination should be performed to identify associated neurologic injury or the presence of pericardial tamponade. (Level of Evidence: C)"
"6. All patients presenting with acute neurologic complaints should be questioned about the presence of chest, back, and/or abdominal pain and checked for peripheral pulse deficits as patients with dissection related neurologic pathology are less likely to report thoracic pain than the typical aortic dissection patient.[20]

## References

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1. ↑ Larson, Eric W.; Edwards, William D. (1984). "Risk factors for aortic dissection: A necropsy study of 161 cases". The American Journal of Cardiology. 53 (6): 849–855. doi:10.1016/0002-9149(84)90418-1. ISSN 0002-9149.
2. ↑ Januzzi, James L; Isselbacher, Eric M; Fattori, Rossella; Cooper, Jeanna V; Smith, Dean E; Fang, Jianming; Eagle, Kim A; Mehta, Rajendra H; Nienaber, Christoph A; Pape, Linda A (2004). "Characterizing the young patient with aortic dissection: results from the international registry of aortic dissection (IRAD)". Journal of the American College of Cardiology. 43 (4): 665–669. doi:10.1016/j.jacc.2003.08.054. ISSN 0735-1097.
3. ↑ "Correspondence". The Annals of Thoracic Surgery. 67 (2): 593. 1999. doi:10.1016/S0003-4975(99)00037-5. ISSN 0003-4975.
4. ↑ Losenno, Katie L.; Goodman, Robert L.; Chu, Michael W. A. (2012). "Bicuspid Aortic Valve Disease and Ascending Aortic Aneurysms: Gaps in Knowledge". Cardiology Research and Practice. 2012: 1–16. doi:10.1155/2012/145202. ISSN 2090-8016.
5. ↑ Senaha S, Uezu T, Shimoji M, Akasaki M (March 2015). "[Stanford type B aortic dissection associated with coarctation of the aorta]". Kyobu Geka (in Japanese). 68 (3): 184–7. PMID 25743550.CS1 maint: Unrecognized language (link)
6. ↑ Dioguardi GS, Pimenta J, Knoplich J, Ghorayeb N, Ramos LR, Giannini SD (June 1994). "[Risk factors for cardiovascular diseases in physicians. Preliminary data from the VIDAM Project of the Paulista Medical Association]". Arq. Bras. Cardiol. (in Portuguese). 62 (6): 383–8. PMID 7826227.CS1 maint: Unrecognized language (link)
7. ↑ Caglayan, Ahmet Okay; Dundar, Munis (2009). "Inherited diseases and syndromes leading to aortic aneurysms and dissections". European Journal of Cardio-Thoracic Surgery. 35 (6): 931–940. doi:10.1016/j.ejcts.2009.01.006. ISSN 1010-7940.
8. ↑ "Acute aortic dissection: pathogenesis, risk factors and diagnosis". Swiss Medical Weekly. 147 (3334). 2017. doi:10.4414/smw.2017.14489. ISSN 1424-7860.
9. ↑ Increased maternal cardiovascular mortality associated with pregnancy in women with Turner syndrome.
10. ↑ 10.0 10.1 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE; et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
11. ↑ 11.0 11.1 11.2 11.3 Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, Lenferink S, Deutsch HJ, Diedrichs H, Marcos y Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, Deeb GM, Eagle KA (February 2000). "The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease". JAMA. 283 (7): 897–903. doi:10.1001/jama.283.7.897. PMID 10685714.
12. ↑ 12.0 12.1 Coady MA, Davies RR, Roberts M, Goldstein LJ, Rogalski MJ, Rizzo JA, Hammond GL, Kopf GS, Elefteriades JA (April 1999). "Familial patterns of thoracic aortic aneurysms". Arch Surg. 134 (4): 361–7. doi:10.1001/archsurg.134.4.361. PMID 10199307.
13. ↑ 13.0 13.1 von Kodolitsch Y, Schwartz AG, Nienaber CA (October 2000). "Clinical prediction of acute aortic dissection". Arch. Intern. Med. 160 (19): 2977–82. doi:10.1001/archinte.160.19.2977. PMID 11041906.
14. ↑ Mészáros I, Mórocz J, Szlávi J, Schmidt J, Tornóci L, Nagy L, Szép L (May 2000). "Epidemiology and clinicopathology of aortic dissection". Chest. 117 (5): 1271–8. doi:10.1378/chest.117.5.1271. PMID 10807810.
15. ↑ Spittell PC, Spittell JA, Joyce JW, Tajik AJ, Edwards WD, Schaff HV, Stanson AW (July 1993). "Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990)". Mayo Clin. Proc. 68 (7): 642–51. doi:10.1016/s0025-6196(12)60599-0. PMID 8350637.
16. ↑ Mehta RH, O'Gara PT, Bossone E, Nienaber CA, Myrmel T, Cooper JV, Smith DE, Armstrong WF, Isselbacher EM, Pape LA, Eagle KA, Gilon D (August 2002). "Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era". J. Am. Coll. Cardiol. 40 (4): 685–92. doi:10.1016/s0735-1097(02)02005-3. PMID 12204498.
17. ↑ 17.0 17.1 Klompas M (May 2002). "Does this patient have an acute thoracic aortic dissection?". JAMA. 287 (17): 2262–72. doi:10.1001/jama.287.17.2262. PMID 11980527.
18. ↑ Januzzi JL, Isselbacher EM, Fattori R, Cooper JV, Smith DE, Fang J, Eagle KA, Mehta RH, Nienaber CA, Pape LA (February 2004). "Characterizing the young patient with aortic dissection: results from the International Registry of Aortic Dissection (IRAD)". J. Am. Coll. Cardiol. 43 (4): 665–9. doi:10.1016/j.jacc.2003.08.054. PMID 14975480.
19. ↑ Armstrong WF, Bach DS, Carey LM, Froehlich J, Lowell M, Kazerooni EA (December 1998). "Clinical and echocardiographic findings in patients with suspected acute aortic dissection". Am. Heart J. 136 (6): 1051–60. doi:10.1016/s0002-8703(98)70162-0. PMID 9842019.
20. ↑ 20.0 20.1 Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ (February 2007). "Neurological symptoms in type A aortic dissections". Stroke. 38 (2): 292–7. doi:10.1161/01.STR.0000254594.33408.b1. PMID 17194878.
21. ↑ Roberts WC, Ko JM, Moore TR, Jones WH (August 2006). "Causes of pure aortic regurgitation in patients having isolated aortic valve replacement at a single US tertiary hospital (1993 to 2005)". Circulation. 114 (5): 422–9. doi:10.1161/CIRCULATIONAHA.106.622761. PMID 16864725.

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