CORRESPONDENCE: RESEARCH CORRESPONDENCE
Acute Aortic Dissection Presenting With Congestive Heart Failure: Results From the International Registry of Acute Aortic Dissection
James L. Januzzi, MD, FACC*,
Kim A. Eagle, MD, FACC,
Jeanna V. Cooper, MS,
Jianming Fang, MD,
Udo Sechtem, MD,
Truls Myrmel, MD,
Arturo Evangelista, MD,
Jae K. Oh, MD, FACC,
Alfredo Llovet, MD,
Patrick T. O'Gara, MD, FACC,
Christoph A. Nienaber, MD and
Eric M. Isselbacher, MD, FACC
* Massachusetts General Hospital, 55 Fruit Street, YAW-5984, Boston, Massachusetts 02114 (Email: JJanuzzi{at}partners.org).
To the Editor: Congestive heart failure (CHF) has long been recognized as a potential complication of aortic dissection (AoD); however, the understanding of the presentation of AoD with concomitant CHF has remained largely restricted to case reports (1–6). Therefore, we undertook the present analysis to better understand the characteristics and outcomes of patients with acute CHF at the time of AoD, as well as the impact of CHF on the time to AoD recognition and treatment.
The design and initial results from the International Registry of Aortic Dissection (IRAD) have been previously described in detail (7). At the time of our study, 1,069 subjects were eligible for analysis. Of these, 64 subjects (6%) presented with acute CHF at the time of their AoD. The diagnosis of CHF was made based on the impressions of the managing physicians as noted in the IRAD case report form.
The characteristics of CHF patients compared with those without acute CHF at presentation are detailed in Table 1. Patients with CHF at presentation were less likely than those without to have chest pain. Moreover, when pain was present in a patient with CHF, the pain was more often mild and less likely abrupt in onset. Patients with CHF and AoD were less likely to be hypertensive on presentation but more likely to present in shock compared with those without CHF. On examination, the murmur of aortic regurgitation was present more often in patients with CHF. Patients presenting with CHF at the time of dissection were more likely to have Stanford type A AoD than were those without. Additionally, aortic dimensions often were larger among patients with CHF (Table 1).
The median times from symptom onset to presentation, diagnosis, or surgical intervention were all consistently longer among patients with CHF (Fig. 1). In multivariate analyses, CHF was not associated with delays in presentation (odds ratio [OR] 1.27, 95% confidence interval [CI] 0.63 to 2.57, p = 0.50); a trend toward delay in diagnosis was noted among patients with CHF (OR 1.72, 95% CI 0.87 to 3.39, p = 0.11). Importantly, CHF was an independent predictor of a delay in surgical intervention (OR 4.53, 95% CI 1.62 to 12.6, p < 0.004).
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Figure 1 Median times from symptom onset to presentation, diagnosis of aortic dissection, and surgery, expressed as a function of the presence (solid bars) or absence (cross-hatched bars) of congestive heart failure (CHF).
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Mortality rates were similar among type B AoD patients with CHF and without CHF (23% vs. 12%, p = 0.22); the mortality rates were identical (30%) among those who had type A AoD. Overall mortality was 13% for type B AoD and 29.4% for type A dissection.
In this analysis, we have identified key differences between the clinical characteristics and testing results in those with and without CHF at the time of their AoD. Those with CHF tended to present in atypical fashion, and whereas CHF at the time of AoD did not appear to lead to inordinate delays in patient presentation, a potential impact of CHF on time to recognition of AoD was noted, and CHF was an independent predictor of surgical delay. In our data set, it is unclear whether these delays were due to clinician preoccupation with CHF or the more subtle presentation of those with CHF and AoD.
Previous case reports have suggested that CHF in the presence of AoD is due to aortic regurgitation from aortic valve disease, incomplete aortic leaflet closure (due to dilation of the sinotubular junction), or aortic valve disruption (1,2,5). An additional mechanism of CHF at the time of AoD includes high-output heart failure (3,4,6). Although we confirm a high percentage of patients with CHF secondary to proximal aortic involvement, we also demonstrated that as many as 20% of patients with CHF at the time of AoD had a distal dissection; consequently, in this considerable minority, the mechanism of CHF must be something other than direct aortic valve involvement by the dissection itself, such as myocardial ischemia/infarction or hypertension. Delays in AoD diagnosis and treatment are notable in our subjects; this may reflect consideration of diagnoses alternative to AoD, given the atypical presentation in our subjects.
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Footnotes
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Please note: this study was supported by a grant from the Varbedian Fund for Aortic Research.
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References
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