As 2023 closes, we want to highlight an important paper published in early 2022. This work quantified the increase in risk of having an aortic dissection due to high blood pressure.

Doctors and people with aortic disease have long known that high blood pressure increases the risk of an AD, but to date there has been limited hard data. Current national guidelines variously recommend 130/80 for Thoracic Aortic Aneurysms (ACC/AHA – ref (1) – this also states that 120/80 may be of benefit) and 120/80 in long-term follow-up (ESC – ref (2)).

The new data is specifically oriented to aortic dissection and indicates that the risk of AD increases from as low as 110/75. It shows that existing hypertension guidelines (such as NICE – ref (3)) based on primary prevention of heart attack or stroke using 135/85 to 140/90 (stage 1 hypertension) or 160/100 (stage 2 hypertension) confer a considerably elevated risk of dissection.

Makoto Hibino and team (involving institutions in Toronto, Japan, London, Oslo and Stockholm) performed a very large study on over ½ million individuals from the Japanese Health Check-up Study, another more than 500,000 individuals from the UK Biobank, plus a meta-analysis involving a total of 4.5 million individuals.

The results show that the risk of dissection:

• increases by a factor of around 3 for “hypertensive individuals” in general
• increases by around 30 to 40% for each 20 mm Hg* increase in systolic BP (the upper figure)
• increases by around 65 to 80% for each 10 mm Hg increase in diastolic pressure (the lower figure).

It is now clear that the blood pressure of those with aortic disease must be managed differently from standard guidance based on heart attack or stroke prevention and that the target blood pressure should be in the region  of ‘low normal’.

The Circulation Editorial, commenting on Hibino’s paper states: “…the key message is a wake-up call for the medical community not only to understand the exponential relationship between intravascular tension and the risk of dissection but also to adjust blood pressure probably to the lowest tolerated level.“

For the Circulation Editorial see Taming Hypertension to Prevent Aortic Dissection: Universal Recognition of a “New Normal” Blood Pressure?, Neinaber & Yuan, Circulation. 2022;145:645–647. DOI: 10.1161/CIRCULATIONAHA.121.058133

For the full paper see Blood Pressure, Hypertension, and the Risk of Aortic Dissection Incidence and Mortality, Hibino et al, Circulation. 2022;145:633–644. DOI: 10.1161/CIRCULATIONAHA.121.056546

References.
(1) 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease, JACC 2022, https://doi.org/10.1016/j.jacc.2022.08.004
(2) Acute aortic syndromes: diagnosis and management, an update – European Heart Journal (2018) 39, 739–749. doi:10.1093/eurheartj/ehx319
(3) Hypertension in adults: diagnosis and management NICE guideline NG136, 18th March 2022 https://www.nice.org.uk/guidance/NG136

* mm Hg – the standard ‘millimetres of mercury’ unit used for BP

The CardiacCovid study, run at St Bartholomew’s Hospital, Barts Health NHS Trust, is looking at how patients recover from cardiac surgery carried out during the pandemic. This has included cardiothoracic surgery, with a number of participants having had emergency aortic dissection surgery. As of early March 2022 the 1-year follow-up of all the participants in the study has been completed. The study team are now looking at all of the data.

The results of the study from patients who had surgery in the first wave of the pandemic are being presented at the:

• Society of Cardiothoracic Surgery (SCTS) 2022 conference (Tuesday 10th May), and a scientific paper is in preparation.
• Cardiovascular Care Partnership (CCPUK) patient day at the British Cardiovascular Society (BCS) annual meeting (Tuesday 7th June), also including the great patient and public involvement (PPI) in this study.

The study team also recently published an editorial exploring the lack of women included in cardiovascular trials, which originated from discussions with the study’s Patient & Public Involvement (PPI) partners – https://academic.oup.com/eurjcn/article-abstract/20/7/629/6357313.

We would like to thank all participants for taking part in the study and Aortic Dissection Awareness UK & Ireland for their ongoing support of this work.

Gareth Owens, Chair of Aortic Dissection Awareness UK & Ireland said

“COVID-19 dominated the news in healthcare for much of 2020 and created many challenges in cardiac surgery, for healthcare professionals and their patients. As a full partner in the CardiacCovid research project, the national patient association AD Awareness UK & Ireland are delighted by the quality of the research, the number of patients enrolled in the study and what we are learning from their experience of recovering from cardiac surgery during the COVID pandemic. This will help us improve care for all cardiac surgery patients in future. This study is an example of patient-focused research at its best.”

Read the newsletter by clicking the image.

The Cardiac COVID study run by Barts NHS Health Trust has reached its one year milestone.  Starting in March 2020 just as the first COVID lockdown began, the study is looking at how patients recover from cardiac surgery carried out during the pandemic.  This has included cardiothoracic surgery, with a number of participants having had emergency aortic dissection surgery.

Patients are being studied from one week up to one year after their surgery to find out their quality of life and any other issues around having the surgery during a pandemic.

262 patients have given feedback.  Participants who were there at the outset are now being followed up at their one year point.

Two scientific publications are already in the pipeline, with the first accepted for presentation at the 2021 Society for Cardiothoracic Surgery meeting. See our page on #SCTS2021 for more information.  A later presentation is planned for the EuroHeartCare conference in June.

Gareth Owens, Chair of Aortic Dissection Awareness UK & Ireland said “COVID-19 dominated the news in healthcare for much of 2020 and created many challenges in cardiac surgery, for healthcare professionals and their patients.  The CardiacCOVID study was set up very quickly to understand the impact on patients of having cardiac surgery during the pandemic.

“As a full partner in this research project, AD Awareness UK & Ireland is contributing strongly to the Steering Group and the PPI (Patient & Public Involvement) Group.  I and my team are delighted by the quality of the research, the number of patients enrolled in the study and what we are learning from their experience of cardiac surgery during the COVID pandemic. This will help us improve care for all cardiac surgery patients in future.  This study is an example of patient-focused research at its best.”

Professor Aung Oo, Clinical Lead for Aortovascular Surgery at Barts

Professor Julie Sanders, Chief Investigator for the study