Relationship Between Hypertension And Prognosis In Chinese Patients With Acute Aortic Dissection

Background:Aortic dissection is a component of acute aortic syndrome,and its incidence has been high and has an obvious upward trend.According to whether the dissection involves the ascending aorta,it can be divided into Stanford type A and Stanford type B.Aortic dissection within 14 days of onset is generally referred to as acute aortic dissection(AAD).Acute aortic dissection is a kind of acute aortic disease with rapid onset,dangerous condition and rapid progression.Open surgical treatment is the preferred method for type A aortic dissection(TAAD),while type B aortic dissection(TBAD)is generally treated by endovascular intervention.Despite improvements in technique and perioperative management,operative mortality remained at around 25% and complication rates were18%.Hypertension is an important risk factor for acute aortic dissection and increases pressure on the aortic wall,which may lead to the development of intimal tears involving the aortic arch and abdominal vessels.Data from the International Registry of Acute Aortic Dissection(IRAD)show that the prevalence of hypertension in patients with aortic dissection is as high as 67.3%-76.6% [2,3].At present,there are few studies in China to evaluate the impact of hypertension on the clinical and prognostic characteristics of acute aortic dissection(AAD),and there is a lack of large-sample studies,which puts forward the hypothesis that hypertension may have a relevant impact on the characteristics and prognosis of AAD patients.In addition,admission blood pressure(BP)at the time of clinical presentation is a readily available variable with strong prognostic value in patients with AAD.Previous case-series-based studies tended to be small in size and limited in the number of AAD cases,thus limiting the ability to investigate the relationship between systolic blood pressure(SBP)and AAD across the entire range of BP values.The effect of blood pressure levels,especially systolic blood pressure levels,on the clinical manifestations of aortic dissection,especially on hospital outcomes,is unclear.Therefore,it is important to assess the relationship between admission blood pressure and AAD hospitalization outcomes.Objective:1.To explore the clinical characteristics and short-term prognosis of AAD patients with hypertension.2.To evaluate the relationship between systolic blood pressure(SBP)on admission and hospitalization outcome,especially all-cause mortality in patients with AAD.Methods:1.All patients with acute type A and type B aortic dissection included in the China Registry of Aortic Dissection(SINO-RAD)from January 1,2012 to May 31,2021 were collected and the clinical characteristics of patients with hypertensive AAD were analyzed.The factors with P<0.1 in univariate analysis were included in multivariate Logistic regression to explore the independent risk factors related to the prognosis of AAD.2.All patients with acute type A and type B aortic dissection enrolled in the China Aortic Dissection Registry(SINO-RAD)from January 1,2012 to May 31,2021 were divided into 4 groups according to quartiles of SBP level at admission for analysis,including general patient data,such as demographic data,medical history,physical examination,imaging examination,treatment mode and results.Multivariate Logistic regression and restricted cubic spline were used to explore the association between admission SBP and in-hospital mortality in patients with AAD.Results:1.A total of 3691 patients with ATAAD were included in this study,with a mean age of(50.2±11.4)years.There were 2413 cases(65.4%)in hypertension group and 1278 cases(34.6%)in non-hypertension group.Patients with hypertension were significantly older and less likely to visit a doctor than those without hypertension(P<0.001).The proportion of smokers and Marfan syndrome was significantly higher in patients with hypertension than those without hypertension(P<0.001).Patients with hypertension were more likely to have stroke(P<0.001),and had significantly higher rates of abdominal vascular involvement,arch vascular involvement,and periaortic hematoma(P<0.001).The incidence of in-hospital stroke,in-hospital coma and acute renal failure was significantly higher in the hypertensive group than in the non-hypertensive group(all P<0.001).Multivariate Logistic regression analysis showed that pericardial effusion,in-hospital stroke,in-hospital coma,in-hospital cardiac tamponade and acute renal failure were independent risk factors for in-hospital death in ATAAD patients with hypertension(all P<0.001).Compared with conservative medical treatment,surgical treatment,endovascular intervention and hybrid surgical treatment were protective factors for in-hospital death in ATAAD patients(all P<0.001).Hypertension was not an independent risk factor for ATAAD in-hospital mortality(P=0.679).2.A total of 2711 patients with ATBAD were included in this study,with a mean age of(52.9±11.6)years.There were 2118 cases(78.1%)with hypertension and 593 cases(21.9%)without hypertension.The proportion of smoking in hypertension group was significantly higher than that in non-hypertension group(P<0.001).The proportion of Marfan syndrome in non-hypertension group was significantly higher than that in non-hypertension group(P<0.001).The proportion of dissection involving arch vessels was higher in hypertension group(P<0.001).Endovascular intervention was the most common treatment.Multivariate Logistic regression results showed that limb ischemia(P=0.041),in-hospital coma(P=0.007)and in-hospital cardiac tamponade(P<0.001)were independent risk factors for in-hospital death in ATBAD patients.Compared with medical conservative treatment,surgery,endovascular intervention and hybrid surgical treatment were protective factors for in-hospital death in ATAAD patients(P<0.001).Hypertension was not an independent risk factor for ATBAD in-hospital mortality(P=0.621).3.A total of 3691 patients with type A AAD were included.Syncope(P<0.001),aortic regurgitation(P <0.001)and pericardial effusion(P<0.001)were more common in SBP≤120 mm Hg group than in other groups.In SBP >153 mm Hg group,the incidence of aortic arch and abdominal vascular dissection was higher(P<0.001 for both),and the incidence of periaortic hematoma was higher(P<0.001).Surgery was the most common treatment in each group.Multivariate Logistic regression analysis of in-hospital mortality showed that SBP 136-153 mm Hg(OR=1.48;P=0.030)、 SBP >153mm Hg(OR=2.33;P=0.002),pericardial effusion(OR=1.75;P<0.001),in-hospital stroke(OR=2.59;P<0.001),coma in hospital(OR=7.21;P<0.001),cardiac tamponade in hospital(OR=11.50;P<0.001),acute renal failure(OR=3.95;P<0.001)was independently associated with in-hospital mortality,with surgery,endovascular intervention,and hybrid procedures being protective factors for in-hospital mortality compared with conservative medical care(all P<0.001).The restricted cubic spline method suggested a non-linear relationship between admission systolic blood pressure and in-hospital mortality(non-linear test P<0.001),with SBP=120 mm Hg being the node of change in the risk of death.4.A total of 2711 patients with type B AAD were included.Patients with SBP ≤135 mm Hg had more men(P=0.002)and more prior cardiac surgery(P<0.001),while patients with SBP >160 mm Hg had more smokers(P<0.001),shorter hospital visits(P<0.001),and more prior hypertension(P<0.001).Clinically,the incidence of aortic arch and abdominal vessel involvement was higher in SBP ≤135 mm Hg group(both P<0.001),and the incidence of periaortic hematoma was higher in SBP 136-150 mm Hg group(P<0.001).Endovascular intervention is the most common treatment.In-hospital mortality was 6.2% in patients with SBP ≤135 mm Hg,which was comparable to and higher in patients with SBP >160 mm Hg(P=0.042).Multivariate Logistic regression showed that SBP 151-160 mm Hg(OR=2.44;P=0.010)、SBP >160 mm Hg(OR=4.82;P<0.001),coma in hospital(OR=101.35;P=0.004),cardiac tamponade in hospital(OR=71.99;P<0.001)was independently associated with in-hospital mortality.Surgical,endovascular,and hybrid procedures were protective factors for in-hospital mortality compared with conservative medical management(all P<0.001).The restricted cubic spline method suggested a non-linear relationship between admission systolic blood pressure and in-hospital mortality(non-linear test P<0.001),with SBP=135 mm Hg being the node of change in the risk of death.Conclusion:1.Hypertension was not an independent risk factor for in-hospital death in AAD patients.Surgery,endovascular intervention and hybrid surgery were protective factors for in-hospital death in AAD patients.Pericardial effusion,in-hospital stroke,in-hospital coma,in-hospital cardiac tamponade and acute renal failure were independent risk factors for in-hospital death in ATAAD patients;limb ischemia,in-hospital coma,and in-hospital cardiac tamponade were independent risk factors for in-hospital death in ATBAD patients.2.There was a non-linear relationship between SBP at admission and the risk of in-hospital death.SBP at admission for type A dissection was ≤120 mm Hg,and SBP at admission for type B dissection was ≤135 mm Hg.The risk of death decreased with the increase of SBP.When SBP exceeded the node value,the risk of death did not change significantly...