title: Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).
abstract: 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.
authors.affiliation: Policlinico San Donato IRCCS, Cardiovascular Center E. Malan, University of Milano, via Morandi 30, 20097 San Donato Milanese, Italy. santi.trimarchi@unimi.it
authors.forename: Santi
authors.initials: S
authors.lastname: Trimarchi
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
authors.forename: Christoph A
authors.initials: CA
authors.lastname: Nienaber
authors.forename: Reed E
authors.initials: RE
authors.lastname: Pyeritz
authors.forename: Frederik H W
authors.initials: FH
authors.lastname: Jonker
authors.forename: Toru
authors.initials: T
authors.lastname: Suzuki
authors.forename: Patrick T
authors.initials: PT
authors.lastname: O'Gara
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Hutchinson
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Rampoldi
authors.forename: Viviana
authors.initials: V
authors.lastname: Grassi
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bossone
authors.forename: Bart E
authors.initials: BE
authors.lastname: Muhs
authors.forename: Arturo
authors.initials: A
authors.lastname: Evangelista
authors.forename: Thomas T
authors.initials: TT
authors.lastname: Tsai
authors.forename: Jim B
authors.initials: JB
authors.lastname: Froehlich
authors.forename: Jeanna V
authors.initials: JV
authors.lastname: Cooper
authors.forename: Dan
authors.initials: D
authors.lastname: Montgomery
authors.forename: Gabriel
authors.initials: G
authors.lastname: Meinhardt
authors.forename: Truls
authors.initials: T
authors.lastname: Myrmel
authors.forename: Gilbert R
authors.initials: GR
authors.lastname: Upchurch
authors.forename: Thoralf M
authors.initials: TM
authors.lastname: Sundt
authors.forename: Eric M
authors.initials: EM
authors.lastname: Isselbacher
mesh_terms: 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