Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).
BACKGROUND
In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection.


RESULTS
Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. "High-risk" patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P=0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P=0.0003). Mortality rates after surgical (20% versus 28%; P=0.74) or endovascular management (3.7% versus 9.1%; P=0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P=0.041).


CONCLUSIONS
Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group.
Trimarchi
Santi
S
Policlinico San Donato IRCCS, Cardiovascular Center E. Malan, University of Milano, via Morandi 30, 20097 San Donato Milanese, Italy. santi.trimarchi@unimi.it
Eagle
Kim A
KA
Nienaber
Christoph A
CA
Pyeritz
Reed E
RE
Jonker
Frederik H W
FH
Suzuki
Toru
T
O'Gara
Patrick T
PT
Hutchinson
Stuart J
SJ
Rampoldi
Vincenzo
V
Grassi
Viviana
V
Bossone
Eduardo
E
Muhs
Bart E
BE
Evangelista
Arturo
A
Tsai
Thomas T
TT
Froehlich
Jim B
JB
Cooper
Jeanna V
JV
Montgomery
Dan
D
Meinhardt
Gabriel
G
Myrmel
Truls
T
Upchurch
Gilbert R
GR
Sundt
Thoralf M
TM
Isselbacher
Eric M
EM
D000208:Acute Disease; D000784:Aortic Dissection / Q000150:complications* / Q000401:mortality / Q000601:surgery; D001014:Aortic Aneurysm / Q000150:complications* / Q000401:mortality / Q000601:surgery; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006973:Hypertension / Q000150:complications*; D038622:Internationality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000150:complications*; D012042:Registries; D014656:Vascular Surgical Procedures