Clinical Profiles And Risk Factors For In-hospital Deaths In Patients With Acute Aortic Dissection

Objective:To explore the epidemiology, clinical characteristics, diagnosis, treatment and prognosis of acute aortic dissection. To analysis the different of StanfordA and StanfordB acute aortic dissection. To determine the risk factors for in-hospital deaths in patients with acute aortic dissection and establish a simple prediction model to identify patients at increased risk of in-hospital death.Methods:Clinical data of 360 patients with acute AD in the First Affiliated Hospital An Hui Medical University from January 2007 to August 2013 were analyzed retrospectively. To record all of the patient’s age, gender, time of hospitaled, medical history (high blood pressure, Marfan’s syndrome), symptoms (acute chest pain, back pain, abdominal pain, dizziness, fatigue, syncope, hemiplegia, etc.), signs (systolic blood pressure, diastolic blood pressure, heart rate), examinations(blood lipid, blood routine, renal function,, D-dimer, c-reactive protein, ECG,X-ray, UCG,CT and MRI) Stanford classification, complications (pericardium or pleural effusion, syncope, tissue ischemia, renal insufficiency), treatment and prognosis.To discuss the clinical characteristics of all the patients and to explore the clinical epidemiology features and change trend by two groups which divided according to the admission time. To contrast the differents of characteristics, atypical pain, signs, laboratory examinations,imaging datas, complications, misdiagnosis, treatment and prognosis for Stanford A and B. Risk factors were used in statistical analysis for prediction of hospital mortality by dividing two groups of death and survival. Risk factors for hospital death were investigated with univariate and multiple logistic regression analysis.Results:1 Three hundred sixty patients with acute AD were enrolled in this study, the mean age was 54.31±14.24 years, the male/female ratio was 3:1. Number of type A was 121 and of type B was 239,the ratio was 1:2.162 cases have the history of high blood pressure and 8 cases have the history of Marfan’s syndrome.316 cases(87%) have the complain of pain at different positions, among them 227 cases (63%) with the chest and back pain and 73 cases (20%) with abdominal pain. The mean heart rate was 83.9 ±14.2bpm, systolic blood pressure was 144.4± 30.9 mmHg and diastolic pressure was 84.1±18.8 mmHg. The mean values of TC, TG, LDL, HDL, serum potassium, calcium, magnesium APTT, PT and 1NR were in the normal range. The mean values of white blood cell, neutrophil percentage, c-reactive protein, D-dimer were higher than the normal people.261 patients (72.5%)have the abnormal ECG with the nonspecific changes. The accuracy of diagnosis was 75% by UCG, but was 100% by CT or MRI.47 cases have the complication of pericardial or pleural effusion,32 cases have syncope or no-consciousness,24 cases have the tissue ischemia and 72 cases have the renal insufficiency. The total misdiagnosis rate was 6.1%.186 cases with drug treatment and 174 cases with surgical treatment. The rate of in-hospital mortality was 21.4%(77 cases).2 Acute aortic dissection more occured in winter and with 60-69 years old. The number of cases increased year by year and especially rapidly for the typeB.There were no statistical difference in mean age, sex, history of high blood pressure and marfan’s syndrome in the two groups divided by the admission time. Surgical and interventional treatment have increased in recent years but the hospital mortality was no statistical difference between the two groups (p= 0.619).3 The mean age,percent of sex and hypertension history were not different between two types. Stanford A has the higher percent of Marfan’s syndrome than type B aortic dissection. The percent of pain in typeB group was higher than that of typeA,especially with the waist and abdomen pain. Stanford A has the incidence of atypical symptoms than type B.There were no difference between the two types with the average heart rate. The level of mean systolic pressure and diastolic blood pressure with Type A group was lower than that of type B group, but there were no statistical difference between the two groups, StanfordA has the higher proportion of low blood pressure (SBP≤110 mmHg) than type B (p<0.001), but has the lower proportion of higher blood pressure (SBP≥180 mmHg) (p=0.006). There were no statistical differences with the mean TC, TG, LDL, HDL,serum potassium, calcium, magnesium, white blood cell, neutrophil percentage, CRP, APTT, PT and INR between the two groups. Mean blood platelet count and D-dimer have the statistically differences between the two groups. There was no significant statistical differences with the abnormal ECG for the two groups. The accuracy of diagnosis was 85.7% by UCG for typeA but 66.1% for typeB, it was statistically significant difference, The accuracy of diagnosis by CTA and MRI were higher but no difference between the two groups. The percent of complications with type A were significantly higher than typeB. The misdiagnosis rate was 8.3% and 5.0% in type A group and type B group. The misdiagnosis rate was no statistical difference between the two types. In type A group, the mortality was 59% and 27.2% in medical treatment group and surgery treatment group. In type B group, the mortality was 17.5% and 1.2% in medical treatment group and surgery group.the prognosis of typeB was better than the type A ignore the way of treatment.4 Univariate analysis revealed 10 risk factors(systolic pressure, diastolic pressure, white blood cell, neutrophil percentage, APTT, D dimer, platelet count, syncope or loss of consciousness, acute renal insufficiency and ischemic complications)to be statistically significant predictors of hospital death(p<0.05).Multiple logistic regression analysis identified that typeA (OR,10.53; 95%CI,2.89 to 23.25;p=0.001), hypotention (OR,5.72; 95%CI,1.07 to 20.51;p=0.04), syncope (OR,8.24; 95%CI, 1.25to33.85; p=0.03), ischemic complications (OR,4.67;95%CI,1.02to14.63;p=0.05), renal dysfunction(OR,31.32;95%CI,15.62to123.4;p<0.001),neutrophil percentage≥ 80%(OR,5.67;95%CI 1.47tol4.86;p=0.01)were significant predictors of in-hospital death.With the simple prediction model, total score of 4 offered the best point value with the highest sensitivity and specificity.Conelusion:1 Acute aortic dissection increase year by year and especially rapidly for the typeB. Acute AD happen more frequently in winter and with 60-69 years old people. Male occure more frequently than female and typeB occure more than the type A. The percents of patients with hypertension is high, A lot of patients usually present with chest,back or waist pain, some of people have no typical symptoms. The levels of white blood cell count, neutrophil percentage, D-dimer and c-reactive protein much higher than that of normal people.ECG is more frequently nonspecific changes. The rate of diagnosis correctly with CTA and MRI are high as 100%. There are untypical symptom and misdiagnosis for acute AD. Drug therapy is a foundation and the surgical treatment increase year by year. The overall mortality is high, but has a drawdown in recent years.2 There are no different between typeA and typeB in age,gender and medical history. Pain is much more common in typeB than type A, especially with the waist and abdomen pain. Type A has the incidence of atypical symptoms than type B. TypeA have the higher proportion of low blood pressure than type B, but have the lower proportion of higher blood pressure. Mean blood platelet is higher in type B than type A, but D-dimer is lower in type B than type A. The percent of complications with type A are significantly higher than typeB. The misdiagnosis rate is no difference between the two types but the accuracy of diagnosis is highter by UCG for typeA. Method of treatment is no different between the two types. The prognosis of typeB is better than the type A ignore the way of treatment and surgery was better than the medical ignore the type.3 TypeA, hypotention, neutrophil percentage^80%, syncope, ischemic complications and acute renal dysfunction are the independent risk factors for in-hospital mortality in patients with acute AD. Surgery can improve the prognosis of acute AD. The risk prediction means could be used to identify the prognosis and to quickly determine the therapeutic technique for patients with acute AD.