From Tear to Fear: Posttraumatic Stress Disorder in Patients With Acute Type A Aortic Dissection.

Background Acute type A aortic dissection presents with abrupt onset of pain that requires emergency surgery. However, minimal research exists on posttraumatic stress disorder (PTSD) in survivors. We aimed to quantify the prevalence and describe characteristics of PTSD in patients following dissection. Methods and Results A total of 295 adult survivors of surgical dissection with an email on file were administered a cross-sectional online survey about their dissection experience; 137 returned questionnaires, and 129 (94%) responded to the 4-item Primary Care PTSD portion of the survey that was part of a larger lifestyle survey designed to study survivors of aortic dissection and surgery. In addition to the PTSD screening, it inquired about current sexual activity, exercise habits, and employment within the preceding 30 days. At a median of 6.8 years (quartile 1=2.6, quartile 3=8.9 years) after dissection, 23% of patients (30/129) screened positive for PTSD, with 44% (57/129) stating that within the past month they felt constantly on guard or watchful or were easily startled. Of those who screened positive and matched to their electronic medical record (n=27), only 2 (7.4%) had been tested and clinically diagnosed with PTSD. Patients who screened positive for PTSD were more likely to report limited current sexual activity than those who did not (odds ratio, 5.3; 95% CI, 1.9-15 [P=0.0006]). Conclusions PTSD is an important mental health consideration in aortic dissection survivors. Physicians should screen these patients for PTSD at follow-up visits to identify those who test positive and refer them for further testing and treatment, such as trauma-focused psychotherapy or medication.

Psychological well-being in patients with aneurysms-osteoarthritis syndrome.

Aneurysms-osteoarthritis syndrome (AOS) is characterized by arterial aneurysms and dissection in combination with early-onset osteoarthritis, which can impact quality of life. We describe the subjective quality of life and investigate anxiety and depression in 28 AOS patients aged 15-73 years. Three questionnaires were used: 36-Item Short Form Survey (SF-36), hospital anxiety and depression scale (HADS) and Rotterdam disease specific questionnaire. Results of the SF-36 and HADS were compared to a reference Dutch cohort and the SF-36 questionnaire also to patients with Marfan syndrome. Compared to the general population, AOS patients scored significantly lower on the following SF-36 domains: physical functioning, vitality, social functioning, bodily pain, and general health. Physical functioning was also lower than in Marfan patients. Patients with AOS scored higher on the HADS depression scale, while anxiety did not show a significant difference compared to the general population. No difference in SF-36 and HADS domain scores were found between patient with and without orthopaedic symptoms and patients with or without previous aortic surgery. Additionally, we found that patients' worries for their future and heredity of their disease are important factors for anxiety, which should be addressed in clinical practice.

Surgical repair of aortic aneurysms and reduced incidence of dementia.

BACKGROUND: Dementia and aortic aneurysms share clinical risk factors and molecular signaling pathways. However, the association between dementia and aortic aneurysms has not been examined. The potential effects of open surgical repair (OSR) of aortic aneurysms on future dementia events are unknown. METHODS: We conducted this nationwide population-based, retrospective cohort study using the Taiwanese National Health Insurance Research Database (NHIRD). The cumulative incidence of dementia over a 13-yearfollow-up period was compared among 1)aortic aneurysms and non-aortic aneurysm patients and 2)aortic aneurysm patients who underwent OSR, endovascular aneurysm repair (EVAR) or nonsurgical treatment (NST). RESULTS: This study enrolled 19,921 aortic aneurysms patients and 19,921 matched controls. The aortic aneurysm cohort exhibited a significantly increased incidence of dementia compared with the controls (adjusted hazard ratio (HR)=3.559, p<0.001). Furthermore, 5409 aortic aneurysm patients were treated with surgical intervention, whereas 5409 matched aortic aneurysm patients were not. Aortic aneurysm patients who underwent OSR had a significantly lower incidence of dementia than those who underwent NST (adjusted HR=0.638, 95% confidence interval (CI)=0.411-0.764, p<0.001). Patients who underwent EVAR did not have a lower incidence of dementia than those who underwent NST. CONCLUSION: OSR was associated with a reduced incidence of dementia in patients with aortic aneurysms compared to NST.

Antihypertensive medication adherence in chronic type B aortic dissection is an important consideration in the management debate.

OBJECTIVE: Early aortic stenting in chronic type B aortic dissection (TBAD) may lead to long-term benefit, although the optimal treatment strategy is hotly debated. A robust comparison to outcomes seen in medically managed patients is challenging as the rate of antihypertensive medication adherence is unknown. The aims of this study were therefore to identify the rate of antihypertensive medication adherence and predictors of adherence in TBAD. METHODS: This was a cross-sectional mixed methods study of patients with TBAD. Medication adherence was assessed by the eight-item Morisky Medication Adherence Scale together with an assessment of demographic, behavioral, and psychological variables and disease-specific knowledge. RESULTS: There were 47 patients (mean age, 59 years; 81% male) who were recruited from a tertiary vascular unit. The mean total number of medications taken was 5.8 (2-14), and the mean number of antihypertensive medications was 1.9 (1-6). Of the 47 patients, 20 (43%) reported high levels of medication adherence, 17 (36%) reported moderate adherence, and 10 (21%) reported low adherence. Previous aortic surgery was associated with higher levels of adherence (ß = 0.332; P = .03), as was taking a greater number of medications (ß = 0.332; P = .026), perceived benefit from treatment (ß = 0.486; P < .001), good memory (ß = 0.579; P < .001), and low fears of side effects (ß = 0.272; P < .014). CONCLUSIONS: Medical management remains the mainstay of treatment in uncomplicated TBAD; however, the majority of patients are poorly adherent to their antihypertensive medications. The merits of thoracic endovascular aortic repair in TBAD are argued, and poor adherence is an important factor in the debate; one cannot robustly compare two strategies when half of a treatment group may not be receiving the stated intervention. To develop an evidence-based treatment strategy for TBAD, we must take into account the direct and indirect effects of medical therapy and thoracic endovascular aortic repair. Further work to improve medication adherence and to understand its impact on disease progression is vital to inform the debate and to deliver the best outcomes for patients.

Health-related quality of life of patients after surgery for acute Type A aortic dissection.

OBJECTIVES: Acute Type A aortic dissection (ATAAD) and the ensuing surgical therapy may be experienced as a traumatic event by patients. This study aimed at analysing the prevalence of post-traumatic stress disorder (PTSD) and the physical and mental well-being of survivors of surgically treated ATAAD. METHODS: A total of 393 survivors were contacted and asked to fill in various health questionnaires. RESULTS: Two hundred and ten (53%) patients returned the questionnaires. The mean follow-up was 51 ± 27.8 months. The results showed that 67.6% had high blood pressure, 12.9% had pre-existing diseases of the aorta and 31.5% or 27% of these groups were at risk for PTSD according to the health questionnaires. Duration of intensive care unit or hospital stay had no effect on the risk for PTSD. According to the questionnaire, Short Form 12, physical and mental well-being was significantly reduced in the patients compared to a large German norm sample, even after adjustment for differences in age between the 2 cohorts. Physical activity prior to the event was associated with improved physical and mental well-being but did not reduce the risk for PTSD. CONCLUSIONS: Emergency surgery for ATAAD is associated with high risk for PTSD, which seems to negatively affect physical and mental well-being. More efforts should be directed at prevention and early diagnosis and therapy of PTSD. This study has evaluated 8-year trends in the presentation, diagnosis and outcomes such as physical and mental measures and prevalence rates of PTSD in patients who have undergone an emergency operation for ATAAD.

Long-Term Outcome and Quality of Life in Aortic Type A Dissection Survivors.

BACKGROUND: Aortic dissection is a severe and sophisticated disease that is often linked with a number of possible complications. Our study concerns with long-term outcome and quality of life (QoL) in acute aortic dissection type A (AADA) survivors. METHODS: From January 1999 until December 2006, 120 consecutive patients with AADA received an emergency operation. Of the total number of patients, 84 were males (70.0%) and 36 females (30.0%), mean aged 59.8 ± 12 years with a mean follow-up (FU) of 99.2 ± 6 months. RESULTS: Overall mortality was 39.1% during the observational period with a maximum of 156 months. SF-36 observation showed a significant decay in both Physical Component Summary (PCS) and Mental Component Summary (MCS) in FUII (PCS = 38.4) versus FUI (PCS = 43.4, p = 0.013). CONCLUSION: With ongoing postoperative time, patients did not recover but instead have got worse in terms of QoL. The decrease in MCP and linked subscores is an underestimated factor in QoL and long-term outcome after AADA. This is especially true in younger patients, which are judged to compensate better than older patients.

Aortic Dissection Presenting as "Hysteria".

BACKGROUND: Patients with medical conditions may present with psychiatric symptoms, which may lead to worse physical health care. Here we present the case of a patient with acute aortic dissection masked by psychiatric symptoms after a stressful event. CASE REPORT: A 29-year-old female medical student presented to the Emergency Department (ED) complaining about the feeling of "hysteria" after an argument with her boyfriend earlier the same day. She did not report other symptoms or pain. Careful physical examination, initially impeded by the patient's agitation, revealed pulseless extremities. Blood gas analysis showed metabolic acidosis. Transthoracic echocardiography and computed tomography ultimately led to the correct diagnosis: Stanford Type-A aortic dissection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Medical conditions requiring acute diagnostic work-up and therapy may present with psychiatric symptoms. Increased awareness and the use of standardized operating procedures in the ED may prevent fatal misdiagnoses in these patients.

Survivors of Aortic Dissection: Activity, Mental Health, and Sexual Function.

BACKGROUND: Currently no research exists assessing lifestyle modifications and emotional state of acute aortic dissection (AAD) survivors. We sought to assess activity, mental health, and sexual function in AAD survivors. HYPOTHESIS: Physical and sexual activity will decrease in AAD survivors compared to pre-dissection. Incidence of anxiety and depression will be significant after AAD. METHODS: A cross sectional survey was mailed to 197 subjects from a single academic medical center (part of larger IRAD database). Subjects were ≥18 years of age surviving a type A or B AAD between 1996 and 2011. 82 surveys were returned (overall response rate 42%). RESULTS: Mean age ± SD was 59.5 ± 13.7 years, with 54.9% type A and 43.9% type B patients. Walking remained the most prevalent form of physical activity (49 (60%) pre-dissection and 47 (57%) post-dissection). Physical inactivity increased from 14 (17%) before AAD to 20 (24%) after AAD; sexual activity decreased from 31 (38%) to 9 (11%) mostly due to fear. Most patients (66.7%) were not exerting themselves physically or emotionally at AAD onset. Systolic blood pressure (SBP) at 36 months post-discharge for patients engaging in ≥2 sessions of aerobic activity/week was 126.67 ± 10.30 vs. 141.10 ± 11.87 (p-value 0.012) in those who did not. Self-reported new-onset depression after AAD was 32% and also 32% for new-onset anxiety. CONCLUSIONS: Alterations in lifestyle and emotional state are frequent in AAD survivors. Clinicians should screen for unfounded fears or beliefs after dissection that may reduce function and/or quality of life for AAD survivors.

[Informed consent for aortic pathology].

Obtaining informed consent from patients and their families before surgery, particularly for aortic pathology, is a necessary, and very important, step. This is because, although the risk of death from asymptomatic disease is underestimated in many cases, surgery for aortic pathology is generally associated with higher risks of mortality and morbidity than that in other fields. The importance of informed consent is the same in principle even in emergency cases. The surgeon must faithfully provide accurate medical information to the patient and family members, including a summary of the patient's condition, the purposes and necessity of treatment, alternatives, details of the procedure, risks, and possible postoperative complications. Extra consideration should be given to offering explanations at a level appropriate for the individual patient, according to factors such as age-group, philosophy, and comprehension ability, to ensure that patients fully understand and are in a position to make a decision of their own volition. The process of giving information and obtaining informed consent offers a prime opportunity to build a strong surgeon-patient relationship.

The effect of thoracoabdominal aneurysm repair on quality of life.

OBJECTIVE: The objective of this study is to assess the impact of surgery on quality of life (QOL) in patients who underwent thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: This is a prospective single center cohort study using two quality of life questionnaires administered before surgery, at 6 months, and 1 year after surgery. The Illness Intrusiveness Rating Scale (IIRS) is a tool that on a 7-point Likert scale assesses the impact of disease on each of 13 domains of quality of life. The Karnofsky Activity Scale (KAS) uses a single rating to assess the impact on overall quality of life. At each visit, participants completed the IIRS and KAS. Healthy, nonaneurysmal individuals also completed the IIRS to form a control group. RESULTS: From 1998 to 2006, 297 patients underwent thoracoabdominal aneurysm repair at a tertiary care hospital. Quality of life was measured on 80 patients in total. Preoperative data was available in 45 patients (7 completed the IIRS and 3 the KAS only, and 35 both); 6-month postoperative data in 25 (1 completed the KAS only, and 24 both); and 1-year data postoperative in 35 (4 completed the IIRS and 2 the KAS only, and 29 both). Internal consistency was established for IIRS (Cronbach's alpha 0.85) and KAS (0.81). The mean preoperative IIRS score was 32.10 (SD 17.91). After surgery, there was no change at the 6-month and 1-year postoperative intervals: at 6 months, the mean IIRS score was 33.17 (SD 17.66) and at 1 year the mean was 28.09 (SD 13.61). Total IIRS in nonaneurysmal controls was 13.5 (SD 0.7). The mean preoperative Karnofsky Activity Scale score was 80.0 (SD 15.07), which corresponds to an ability to perform normal activity with effort and some signs or symptoms of disease. After surgery, there was no change as patients reported a 6-month mean score of 79.60 (SD 21.89), and a 1-year postoperative mean score of 86.94 (SD 13.94). CONCLUSIONS: Quality of life for patients undergoing TAAA repair who survive to attend follow-up in an ambulatory setting can be measured using reliable and valid instruments. Preoperatively, QOL is poor compared with healthy controls. After surgery, at 6- and 12-month follow-up, QOL seems to return to the preoperative levels. Further research is necessary to address responsiveness and sensitivity of QOL measuring tools.

Quality of life after replacement of the ascending aorta in patients with true aneurysms.

True aneurysms of the ascending aorta often remain undetected, yet their sequelae carry a high rate of mortality and morbidity. The operative risk of nonemergent replacement of the ascending aorta is low. It is important to consider quality of life in determining the most appropriate treatment for patients who have aneurysms but have not yet experienced major complications.From January 1999 to December 2003, 134 consecutive patients underwent replacement of a dilated ascending aorta at our center. Another 124 patients with acute or chronic aortic dissections, aortic rupture, or intramural hematoma were excluded. Standard SF-36 and general health questionnaires were sent to all 124 survivors who could be traced. Follow-up was 98.4% complete. The mean age of the survivors was 61.7 +/- 11 years, and 63.4% were men. Operative procedures consisted of supracoronary replacement of the ascending aorta in 35.9%, the Wheat procedure in 44%, the David procedure in 11.2%, the Bentall-DeBono procedure in 9%, and the Cabrol procedure in 2.2%. Patients were monitored until May 2005.Thirty-day and midterm mortality rates were 3.7% and 3.9%, respectively. Morbidity due to stroke was 6%, to bleeding 6%, and to myocardial infarction 4.4%. Postoperative quality-of-life evaluation revealed many subscales of SF-36 that were below the norm when compared with a standard population in physically dominated categories.Replacement of the dilated ascending aorta carries acceptable risk in regard to operative death and postoperative quality of life, although this last showed some decline in comparison with quality of life in a normal, healthy population.

Role of exertion or emotion as inciting events for acute aortic dissection.

It is well known that hypertension, aortic dilatation, and collagen disorders predispose to acute aortic dissection (AAD). The inciting events that precede the instant of AAD are incompletely understood. One hundred seventy-five consecutive patients having AAD, treated at our institution during a 10-year period, were reviewed; 65 were women and 110 were men (mean age 61 years). The ascending aorta was affected in 110 patients, and the descending in 65. Information was collected using patients' charts supplemented with direct telephone interviews. Ninety patients were contacted; 65 (24 women, 41 men, mean age 61 years, average aortic size 5.56 cm) could recall specific inciting events for their dissection. In 34 patients, the ascending aorta was involved and in 31 the descending. Eighteen patients (28%) had a positive family history of aortic disease, defined as having > or =1 first-degree relative with aortic disease (aneurysm or dissection). In 24 of the 90 patients contacted (27%), strenuous activity was identified as a clear precipitating factor before the acute onset of thoracic pain; in 36 of 90 (40%) severe emotional stress preceded the onset of dissection pain. Three dissections were iatrogenic. Two additional patients reported a severe exacerbation of chronic obstructive pulmonary disease before their acute onset of chest pain. In conclusion, severe physical and emotional stress may precipitate AAD, presumably on the basis of a transient, severe hypertensive reaction.

Quality of life in patients with chronic type B aortic dissection.

OBJECTIVE: To study functioning and well-being among patients with conservatively treated acute type B aortic dissection. DESIGN: Cross-sectional survey. METHODS: Patients referred with acute type B dissection between January 1990 and November 2000 were prospectively followed after conservative initial management. In October 2002, we sent the SWED-QUAL questionnaire to all patients who were alive and had not undergone surgery of the dissected aorta. Fifty-three of 55 patients responded, 39 males and 14 females. Patient scores for the 12 aspects of health-related quality of life included in the SWED-QUAL were compared to a normative Swedish population, controlled for age and gender differences. RESULTS: There were only minor differences in functioning and well-being between patients and the normative population. Patients reported similar emotional well-being, cognitive functioning, quality of sleep, overall general health and quality of social relations as their normative counterparts. However, patients' perception of their current health, prior health, perceived resistance to illness and health concern was worse than in the normative population. Female patients also reported worse physical functioning and a lower satisfaction with their physical functioning than male patients or female counterparts in the normative population. We did not find any significant association between length of follow-up and quality of life scores. CONCLUSIONS: In terms of functioning and well-being, patients with uncomplicated acute type B aortic dissection, who are initially managed conservatively, differ little from a normative Swedish population. Our study supports conservative management of this group of patients.

Validation of the Cardiac Depression Scale in a cardiac rehabilitation population.

OBJECTIVE: The current study was undertaken to provide further evidence supporting the reliability and validity of the Cardiac Depression Scale (CDS) in a population of cardiovascular patients. METHODS: The CDS was administered to 627 consecutive ambulatory adult cardiac patients attending an outpatient Cardiac Rehabilitation program, and a subgroup also completed the Geriatric Depression Scale--Short Form (GDS-SF). RESULTS: Factor analysis revealed six subscales accounting for 62% of scale variance. The CDS demonstrated high internal consistency (Cronbach's alpha=.92) and correlation coefficient with the GDS-SF of .77. Receiver operating characteristic curves suggested a CDS cutoff score of 100 to detect more severe depression, and 90 to detect mild to moderate depression. CONCLUSION: These findings encourage the continued use and evaluation of the CDS for measuring symptoms of depressive affect in cardiac patients.

[Type A acute aortic dissection presenting as mental status confusion: is it an atypically really uncommon presentation?]. / Dissezione aortica acuta tipo A esordita con stato confusionale: una presentazione atipica davvero infrequente?

The most common initial symptom of acute aortic dissection is chest or abdominal pain. Nevertheless, in a minority of cases, it may have an atypical presentation, making the diagnosis clinically challenging. This article reports on a case of acute type A aortic dissection presenting as mental status confusion. The diagnostic suspicion for a cerebrovascular accident may have catastrophic consequences in a clinical condition, which is associated with a high mortality during the first 48 hours after the onset of symptoms if untreated. The right diagnosis was made by combining a careful physical examination, echocardiography, and computed tomography. The available literature about neurologic manifestations, their pathophysiology and prevalence as the initial symptom of acute type A aortic dissection is reviewed.