Acute Type A Aortic Dissection 中老年的临床特点

JournaloftheAmericanCollegeofCardiologyVol.40,No.4,2002©2002bytheAmericanCollegeofCardiologyFoundationISSN0735-1097/02/$22.00PublishedbyElsevierScienceInc.PIIS0735-1097(02)02005-3AorticDissectionAcuteTypeAAorticDissectionintheElderly:ClinicalCharacteristics,Management,andOutcomesintheCurrentEraRajendraH.Mehta,MD,FACC,MS,*PatrickT.O’Gara,MD,FACC,†EduardoBossone,MD,‡ChristophA.Nienaber,MD,FACC,§TrulsMyrmel,MD,࿣JeannaV.Cooper,MS,*DeanE.Smith,PHD,*WilliamF.Armstrong,MD,FACC,*EricM.Isselbacher,MD,FACC,¶LindaA.Pape,MD,FACC,#KimA.Eagle,MD,FACC,*DanGilon,MD,FACC,**onbehalfoftheInternationalRegistryofAcuteAorticDissection(IRAD)InvestigatorsAnnArbor,Michigan;BostonandWorcester,Massachusetts;SanDonato,Italy;Rostock,Germany;Tromsø,Norway;andJerusalem,IsraelOBJECTIVESWesoughttoevaluatetheclinicalcharacteristics,management,andoutcomesofelderlypatientswithacutetypeAaorticdissection.BACKGROUNDFewdataexistontheclinicalmanifestationsandoutcomesofacutetypeAaorticdissectioninanelderlypatientcohort.METHODSWecategorized550patientswithtypeAaorticdissectionenrolledintheInternationalRegistryofAcuteAorticDissectionintotwoagestrata(Ͻ70andՆ70years)andcomparedtheirclinicalfeatures,management,andin-hospitalevents.RESULTSThirty-twopercentofpatientswithtypeAdissectionwereagedՆ70years.Marfansyndromewasexclusivelyassociatedwithdissectionintheyoung,whereashypertension,atherosclerosisandiatrogenicdissectionpredominatedinolderpatients.Typicalsymptoms(abruptonsetofchestorbackpain)andsigns(aorticregurgitationmurmurorpulsedeficits)ofdissectionwerelesscommonamongtheelderly.Fewerelderlypatientsweremanagedsurgicallythanyoungerpatients(64%vs.86%,pϽ0.0001).Hypotensionoccurredmorefrequently(46%vs.32%,pϭ0.002)andfocalneurologicdeficitslessfrequently(18%vs.26%,pϭ0.04)amongtheelderly.In-hospitalmortalitywashigheramongolderpatients(43%vs.28%,pϭ0.0006).LogisticregressionanalysisidentifiedageՆ70yearsasanindependentpredictorofhospitaldeathforacutetypeAaorticdissection(oddsratio1.7,95%confidenceinterval1.1–2.8;pϭ0.03).CONCLUSIONSOurstudyshowssignificantdifferencesbetweenolder(ageՆ70years)andyounger(ageϽ70years)patientswithacutetypeAaorticdissectionintheirclinicalcharacteristics,manage-ment,andhospitaloutcomes.Futureresearchshouldevaluatestrategiestoimproveoutcomesinthishigh-riskelderlycohort.(JAmCollCardiol2002;40:685–92)©2002bytheAmericanCollegeofCardiologyFoundationCardiovasculardiseasesarethemostcommoncauseofdifferencesintheclinicalpresentation,management,andmorbidityandmortalityamongtherapidlyincreasingpop-hospitaloutcomesbetweenpatientswithacutetypeAaorticulationofelderlypatients(1,2).AlthoughmanystudiesdissectionwhowereϽ70yearsofageandthoseՆ70years.haveevaluatedelderlypatientswithcoronary(3–5)andWeanticipatedthatthisanalysiswouldprovidefurthervalvularheartdisease(6,7),therearenostudiestodatethatinsightsintothedistinguishingfeaturesofaorticdissectionhaveaddressedtheclinicalcharacteristics,management,andamongelderlypatients.outcomesinalargecohortofelderlypatientswithacutetypeAaorticdissection.TheInternationalRegistryofAorticDissection(IRAD)providesauniqueopportunitytoMETHODSexaminearelativelylargenumberofpatientswithaorticPatientselection.Weanalyzedallpatientswithacutetypedissection(8).WeutilizedtheregistrytoevaluatetheAaorticdissectionenrolledinIRADfromJanuary1,1996,toDecember31,1999.TheinstitutionandstructureofFromthe*UniversityofMichigan,AnnArbor,Michigan;†BrighamandWomen’sIRADhavebeendescribedpreviously(8).PatientswereHospital,Boston,Massachusetts;‡IstitutoPoliclinicoSanDonato,SanDonato,identifiedprospectivelyatpresentationorretrospectivelybyItaly;§UniversityofRostock,Rostock,Germany;࿣TromsøUniversityHospital,Tromsø,Norway;¶MassachusettsGeneralHospital,Boston,Massachusetts;#Uni-searchinghospitaldischargediagnosisrecordsandsurgicalversityofMassachusettsHospital,Worcester,Massachusetts;and**HadassahUni-andechocardiographicdatabases.DiagnosiswasbasedonversityHospital,Jerusalem,Israel.PresentedinpartattheAmericanCollegeofhistory,imagingstudy,visualizationatsurgery,orpostmor-CardiologymeetinginOrlando,Florida.ManuscriptreceivedAugust21,2001;revisedmanuscriptreceivedApril25,2002,temexamination.AcutetypeAdissectionwasdefinedasacceptedMay16,2002.anydissectionthatinvolvedtheascendingaortawithpre-686Mehtaetal.JACCVol.40,No.4,2002AcuteAorticDissectionintheElderlyAugust21,2002:685–92variablesmarginallysuggestiveofunadjustedassociationtoAbbreviationsandAcronymsin-hospitaldeath(pϽ0.20).VariableswerereviewedforIRADϭInternationalRegistryofAcuteAorticclinicalsignificancebeforetesting.DiagnosticroutinesDissection(Hosmer-Lemeshowtestforlackoffit,changeindevianceandlikelihoodratiotest)wereusedforthefinalmodelselection(9).SASVersion8.2(SASInstitute,Cary,Northsentationwithin14daysofsymptomonset(8).PatientsCarolina)wasutilizedforallanalyses.werestratifiedbyageϽ70yearsandՆ70years.Datacollection.Datawerecollectedonastandardques-tionnairedevelopedbytheIRADinvestigators.Datacol-Resultslectedincludedpatientdemographics,history,clinicalpre-sentation,physicalfindings,imagingstudyresults,medicalDemographicsandetiologyofaorticdissection(Table1).andsurgicalmanagement,in-hospitalclinicalevents,lengthPatients70yearsofageandoldermadeup31.6%(174/550)ofstay,andhospitalmortality.CompleteddataentryformsofallacutetypeAaorticdissections.ThenumberofwereforwardedtotheIRADcoordinatingcenteratthepatientsindifferentagegroupsoftheelderlywere:70to74UniversityofMichigan.Datawerescannedelectronicallyyearsϭ69,75to79yearsϭ70,80to84yearsϭ23,andintoanaccessdatabase.Ͼ85yearsϭ12.Menconstituted48.3%oftheelderly,butStatisticalanalysis.Summarystatisticsofthetwoage73.6%oftheyoungercohort.Transferfromoutsidehospi-groupswerepresentedasfrequenciesandpercentages,meantalstoIRADsitesaccountedforasimilarproportionofϮSDorasmedianandinterquartilerange.Inallcases,patientsinbothgroups.Theproportionofpatientsagedmissingdatawerenotdefaultedtonegativeanddenomina-Ն70yearswassignificantlygreateramongthosetreatedattorsreflectcasesreported.UnivariateassociationsamongtheU.S.sites.theagegroupsfornominalvariableswerecomparedusingAcuteaorticdissectionasaresultofMarfansyndromethePearsonchi-squaretestortwo-sidedFisherexacttest;wasseenonlyintheyoungerpatientcohort.Incontrast,thetwo-tailedStudentttestwasusedforcontinuoushypertension,atherosclerosis,iatrogenicdissection(partic-variables.Iterativelogisticregressionmodelingwasper-ularlyfollowingcardiacsurgery),anddissectioninanformedtoderiveindependentpredictorsofhospitalmor-existingaorticaneurysmweremorecommonintheelderly.talityandtoderiveadjustedestimatesfortheoddsratiosofComorbiditiessuchashistoryofdiabetesandpriorcardiacin-hospitalmortalityfortheyoungerversustheoldersurgerywerealsomorefrequentinpatientsՆ70yearspatientsusinglikelihoodratiotests.Initialmodelingused(Table1).Table1.DemographicsandPatientHistoryforAllPatientsWithTypeAAorticDissectionVariableOverallPatients<70yearsPatients>70yearspValueN(%)550376(68.4)174(31.6)DemographicsAge-mean(ϮSD),yrs61.8(14.2)54.9(11.4)76.8(4.6)NAGender-male(%)360(65.6)276(73.6)84(48.3)Ͻ0.0001TransferredtoIRADsites(%)372(67.8)260(69.3)112(64.4)0.25SeenatIRADsitesinU.S.(%)217(39.5)124(33.0)93(53.5)Ͻ0.0001Timefromsymptomstopresentation(h)2.9(16.1)2.8(12.4)3.1(22.1)0.89EtiologyandhistoryMarfansyndrome(%)31(5.8)31(8.5)0(0.0)NAPregnancy(%)1(0.2)1(0.3)0(0.0)NACocaineabuse(%)1(0.2)1(0.3)0(0.0)NAHypertension(%)368(69.2)244(66.7)124(74.7)0.06Atherosclerosis(%)145(27.1)73(19.7)72(43.4)Ͻ0.0001Biscuspidaorticvalve(%)(reportedin263patients)15(5.7)7(4.1)8(8.9)0.11Iatrogenicdissection(%)33(6.8)15(4.2)18(11.3)0.003Cardiaccatheterization/PTCA(%)11(2.1)8(2.3)3(1.9)0.78Cardiacsurgery(%)23(4.5)9(2.5)14(8.8)0.002Prioraorticdissection(%)18(3.4)16(4.4)2(1.2)0.06Prioraorticaneurysm(%)66(12.4)38(10.3)28(17.0)0.03Diabetes(%)25(4.7)9(2.5)16(9.8)0.0002Priorcardiacsurgery(%)*80(15.3)47(13.1)33(20.1)0.04Aorticvalvereplacement(%)23(4.5)18(5.1)5(3.1)0.33Aorticaneurysm/dissectionrepair(%)33(6.4)18(5.1)16(9.3)0.07Othercardiacsurgeries(CABG,MVR)(%)38(7.3)21(5.9)17(10.6)0.05*Surgeriesnotmutuallyexclusive.CABGϭcoronaryarterybypassgraftsurgery;IRADϭInternationalregistryofAcuteAorticDissection;MVRϭmitralvalvereplacementorrepair;PTCAϭpercutaneoustransluminalcoronaryangioplasty.JACCVol.40,No.4,2002Mehtaetal.687August21,2002:685–92AcuteAorticDissectionintheElderlyTable2.ClinicalPresentations,Signs,andDiagnosticImagingResultsofAllPatientsWithTypeAAorticDissectionVariableOverallPatients<70yearsPatients>70yearspValueClinicalpresentationsandsignsChestpain(%)418(78.7)293(80.3)125(75.3)0.19Abruptonsetofpain(%)439(84.7)315(88.5)124(76.5)0.0005Migratingpain(%)70(13.7)51(14.5)19(12.0)0.43Allneurologicdeficits(%)94(17.1)70(18.6)24(13.8)0.16Coma/alteredconsciousness(%)78(14.9)54(15.2)24(14.4)0.80Syncope(%)96(18.4)71(19.7)25(15.4)0.25Congestiveheartfailure(%)31(6.0)22(6.2)9(5.6)0.77Meansystolicbloodpressure(SD),mmHg127(39.9)129(39.5)123(40.4)0.08Meandiastolicbloodpressure(SD),mmHg72(25.0)73(23.5)70(28.0)0.16Murmurofaorticregurgitation(%)203(41.7)162(47.1)41(28.7)0.0002Hypotension/shock/tamponade(%)154(28.8)99(27.0)61(32.7)0.17Anypulsedeficit(%)154(30.1)114(33.0)40(24.2)0.04DiagnosticimagingresultsChestX-ray(%)476(86.5)330(87.8)146(83.9)0.22Normal(%)64(13.4)46(13.9)18(12.3)0.63Widenedmediastinum(%)296(62.3)206(62.4)90(62.1)0.94Abnormalaorticcontour(%)213(45.1)148(45.0)65(45.5)0.92Pleuraleffusion(%)88(18.7)51(15.6)37(26.1)0.008Electrocardiogram(%)517(94.0)354(94.2)163(93.7)0.83Normal(%)155(30.0)114(32.2)41(25.2)0.10NewQ-waveST-elevationsand/orischemia(%)33(6.6)18(5.2)15(9.7)0.06AnyimagingwithTEE,CT,MRI,oraortogram(%)541(98.4)372(98.9)169(97.1)0.15Transesophagealechocardiography(%)429(78.0)296(78.7)133(76.4)0.55Computerizedtomography(%)370(67.3)249(66.2)121(69.5)0.44Magneticresonanceimaging(%)32(5.8)21(5.6)11(6.3)0.73Aortogram(%)112(20.4)78(20.7)34(19.5)0.74Coronaryangiography(%)24(5.5)12(3.7)12(10.7)0.005FindingsondiagnosticimagingArchinvolvement(%)122(27.3)92(29.8)30(21.7)0.98Intramuralhematoma(%)26(5.3)11(3.2)15(9.7)0.003Periaortichematoma(%)124(25.6)84(25.3)40(26.3)0.81Falselumenthrombosis(%)35(8.9)14(5.0)21(18.3)Ͻ0.0001Aorticregurgitation(%)297(58.9)211(60.5)86(55.5)0.29Coronaryarteryinvolvement(%)61(14.6)42(15.1)19(13.8)0.73Pericardialeffusion(%)231(45.2)156(44.1)75(47.8)0.44Widestdiameterofascendingaorta(meanϮSD,cm)5.4(2.8)5.4(3.1)5.3(1.5)0.63Widestdiameterofaorticarch(meanϮSD,cm)4.1(2.8)4.1(3.3)4.1(0.9)0.97CTϭcomputerizedtomography;TEEϭtransesophagealechocardiography;MRIϭmagneticresonanceimaging.Clinicalpresentationsanddiagnosticimagingfindingstomography,transesophagealechocardiography,magnetic(Table2).ElderlypatientswithacutetypeAaorticresonanceimaging,oraortography).Frequenciesofuseofdissectionwerelesslikelytopresentwithabruptonsetoftheseimagingmodalitieswerenotdifferentbetweenthetwochestorbackpain(76.5%vs.88.5%,pϭ0.0005).Meangroupsofpatients,withtheexceptionofcoronaryangiog-systolicbloodpressureatthetimeofpresentationtendedtoraphy,whichwasperformedmorefrequentlyintheelderlybelowerintheolderpatients.Similarly,themurmurofgroup(Table2).Similarly,thepreferredmodalityfortheaorticregurgitation(28.7%vs.47.1%,pϭ0.0002)andinitialdiagnosisintheyoungeraswellastheolderpatientspulsedeficits(24.2%vs.33.0%,pϭ0.04)werenotedinwascomputerizedtomography.FindingsonanyimagingproportionatelyfewerelderlypatientswithacutetypeAmodalities(includingthewidestdiameterofascendingaortaaorticdissection.Ontheotherhand,theincidencesoforarch)didnotdifferbetweenthetwogroupsofpatients.congestiveheartfailure,hypotension/shock/tamponade,orHowever,intramuralhematoma(9.7%vs.3.2,pϭ0.003)anyneurologicdeficitorcomaatpresentationdidnotdifferandfalselumenthrombosis(18.3%vs.5.0%,pϽ0.0001)betweenthetwogroupsofpatients.weremorefrequentamongtheolderpatientscomparedPleuraleffusionsonachestX-rayweremorecommoninwiththeyoungergroup.olderpatients(26.1%vs.15.6%,pϭ0.008).Electrocardio-In-hospitaltreatmentandoutcomes(Tables3and4).graphicevidenceofnewQwavesorST-segmentdeviationsRelativelyfewerelderlypatientsweremanagedsurgicallytendedtobemoreintheolderpatients(9.7%vs.5.2%,pϭ(64.4%vs.86.4%,pϽ0.001).Thereasonsformedical0.06).VirtuallyallpatientswithtypeAaorticdissectionmanagementintheyoungercohortwerenotrecordedinunderwentsomeformofimagingstudy(computerized26%ofpatients,andintheremainingwerecitedas688Mehtaetal.JACCVol.40,No.4,2002AcuteAorticDissectionintheElderlyAugust21,2002:685–92Table3.In-HospitalTreatmentsandSurgicalDataofAllPatientsWithTypeADissectionPatientsPatientsVariableOverall<70years>70yearspValueDefinitivemanagementSurgery(%)437(79.5)325(86.4)112(64.4)Ͻ0.0001*Medicaltreatment(%)113(20.5)51(13.6)62(35.6)OperativevariableSurgerybeyond24hofpresentation(%)90(20.9)70(21.9)20(18.2)0.41Rootreplacement(%)115(31.8)92(34.0)23(25.3)0.12Ascendingaorticreplacement(%)384(91.4)289(92.6)95(88.0)0.14Openprocedure(%)383(92.1)287(92.3)96(91.4)0.78Completearchreplacement(%)51(12.6)45(15.0)6(5.8)0.02Hypothermiccirculatoryarrest(%)316(87.5)271(88.0)94(86.2)0.64Retrogradecerebralperfusion(%)227(55.6)173(57.1)54(51.3)0.31Aorticcross-clamptime(min,mean[SD])69.7(68.8)68.9(90.1)70.0(60.0)0.92Initialmedicaltreatment(excludinghypotensivepatients,Nϭ429)Beta-blockers(%)231(56.3)170(59.2)61(49.6)0.07Nitroprusside(%)136(34.4)97(34.9)39(33.3)0.77Calciumchannelantagonist(%)64(16.4)50(18.1)14(12.3)0.16Othervasodilators(%)151(38.4)110(39.7)41(35.3)0.42*Chi-squaretestformanagementtype.comorbidconditions(54%),patientrefusal(10%),and60.0%amongolderandyoungerpatients,respectively).intramuralhematoma(10%).Similarly,15%oftheolderHowever,amongpatientsmanagedwithsurgery,mortalitycohortdidnothavethereasonformedicalmanagementwashigheramongtheelderly(37.5%vs.23.0,pϭ0.003)listed.Intheremainingolderpatients,comorbidconditions(Table4,Fig.1).Totalhospitalmortalitywashighamong(56%),age(15%),patientrefusal(11%),andintramuralpatientsyoungerthan35yearsofage(33.3%),lowestforhematoma(4%)werealludedtoasthereasonformedicalpatients35yearsto44yearsofage(21.1%)andthereaftertherapy.Mostoperativevariablesdidnotdifferbetweentheincreasedgraduallywithage,withhighestmortalityob-twogroups,withtheexceptionofalowerincidenceofservedamongpatientsage85andolder(58.3%).In-hospitalcompletearchreplacementintheoldercohort.Therewasamortalityratesamongtheelderlypatientsmanagedsurgi-trendtowardslessfrequentuseofbeta-blockersamongthecallywere:70to74yearsϭ31.6%,75to79yearsϭ42.5%,elderly(49.6%vs.59.2%,pϭ0.07)withoutcontraindica-80to84yearsϭ45.5%,andՆ85yearsϭ50%.Mortalitytionstosuchtreatment.amongthemedicallymanagedcohortoftheelderlypatientsTheelderlyweremorelikelytosustainhypotensionwas:70to74yearsϭ50%,75to79yearsϭ53.3%,80to(45.7%vs.32.2%,pϭ0.002)buthadalowerincidenceof84yearsϭ45.5%,andՆ85yearsϭ62.5%.Multivariableneurologicdeficitduringhospitalization(17.8%vs.26.0%,logisticregressionanalysis(9)identifiedageՆ70yearsasanpϭ0.04,Table4).PostoperativecomplicationswereindependentpredictorofdeathforacutetypeAaorticsimilarinthetwogroups(datanotshown).In-hospitaldissection(oddsratio1.7,95%confidenceinterval1.1tomortalitywas50%higherintheelderlycohort(42.8%vs.2.8;pϭ0.03).Thecauseofdeathwasnotspecifiedorwas28%,pϭ0.0006).Themortalitywassimilarlyhighforunknownin28.6%and40.3%oftheyoungerandolderpatientsmanagedmedicallyinbothgroups(52.5%andpatients,respectively.Intheremainingpatients,rupture,neu-Table4.In-HospitalComplications(IncludingPostoperative)andMortalityofAllPatientsWithTypeADissectionPatientsPatientsVariableOverall<70years>70yearspValueIn-hospitalcomplicationsAllneurologicdeficits(%)128(23.4)97(26.0)31(17.8)0.04Coma/alteredconsciousness(%)98(18.5)66(18.2)32(19.2)0.80Myocardialischemia/infarction(%)75(14.5)48(13.3)27(17.1)0.26Mesentericischemia/infarction(%)28(5.4)19(5.3)9(5.7)0.85Acuterenalfailure(%)104(20.2)78(21.9)26(16.6)0.17Hypotension(%)200(36.4)121(32.2)79(45.7)0.002Cardiactamponade(%)98(17.9)65(17.3)33(19.1)0.61Limbischemia(%)61(11.9)45(12.6)16(10.3)0.47Mortality(%)178(32.7)104(28.0)74(42.8)0.0006Mortalityforpatienttreatedsurgically(%)116(26.7)74(23.0)42(37.5)0.003Mortalityforpatienttreatedmedically(%)62(55.9)30(60.0)32(52.5)0.43JACCVol.40,No.4,2002Mehtaetal.689August21,2002:685–92AcuteAorticDissectionintheElderlyFigure1.Kaplan-MeiersurvivalcurvesforpatientswithtypeAaorticdissectionageՆ70yearsversusthoseϽ70yearstreatedmedicallyorsurgically.Thelogrankpϭ0.003forpatientsϽ70yearsversusthoseՆ70yearstreatedwithsurgery.Thelog-rankpϭ0.10forpatientsϽ70yearsversusthoseՆ70yearstreatedmedically.rologicdeficit,visceralischemia/renalfailure,andcardiactam-treatedatU.S.sitesthanatnon-U.S.sites.Thisdifferenceponadeaccountedforthecauseofdeathin30.6%,16.3%,couldmerelybeareflectionoflongerlifeexpectancyinthe13.3%,and11.2%ofpatientsϽ70yearsand37.3%,10.5%,U.S.population,agreateravailabilityofnewertechnology9.0%,and3.0%ofpatientsՆ70years,respectively.(computerizedtomography,magneticresonanceimaging,transesophagealechocardiography,andaortography)amongDISCUSSIONU.S.hospitals,amoreaggressiveapproachtakentotheIRAD:anopportunitytostudytheelderlywithacutehealthcareoftheelderlyatU.S.sites,ortodifferencesinaorticdissection.Thecurrentstudyrepresentsthelargest,patientandphysicianattitudesinthesegeographicareas.mostcomprehensiveinvestigationofthedifferencesinTheetiologyoftypeAaorticdissectionvariedbetweendemographics,clinicalcharacteristics,treatments,andout-theyoungandoldercohorts.Marfansyndrome-relatedtypecomesofalargeunselectedgroupofelderlypatientswithAdissectionswereseenexclusivelyinyoungerpatients,acutetypeAaorticdissection.Wefoundthattheelderlywhereashypertension,atherosclerosis,prioraorticaneu-differfromyoungerpatientsinseveralimportantrespects.rysms,andiatrogenicdissectionswereseenmorefrequentlyAlthoughsomeoftheobserveddifferenceswereexpectedonintheelderly(Table1).Theseobservationsmayhavethebasisofpreviouslyreportedseries,otherswerenotdifferentimplicationsregardingdiseasepreventionintheanticipated.Severalofthesedifferenceshaveimportanttwocohorts.Forexample,geneticcounseling,screeningofdiagnosticandtherapeuticimplications.familymembers,avoidanceofpregnancyandbeta-blockersDifferencesindemographics,etiology,clinicalpresenta-forpatientswithMarfansyndromewouldbemoreappro-tion,andimagingfindingsbetweenpatients<70yearspriateintheyoungergroup.Ontheotherhand,aggressiveandthose>70years.PatientsageՆ70wereasignificantmanagementofhypertensionandspecialeffortstoavoidproportion(31.6%)ofpatientspresentingwithacutetypeAiatrogenicdissection(carefulcannulationoftheaortaduringaorticdissection.Aslifeexpectancyincreases,thisnumberiscardiothoracicsurgeryandmoregentlemaneuveringofboundtoincreasefurther.Thus,itisimportanttobecardiaccatheters)wouldrepresentpotentiallyeffectivepre-familiarwiththeclinicalcharacteristics,management,andventionstrategiesintheelderly.Althoughcocaineabuseoutcomesofthiscohortofelderlypatients.Themaleandpregnancyarelistedascausesofaorticdissection,thesepreponderanceseeninyoungerpatientswiththisdiseaseconditionswereassociatedwithtypeAdissectioninonlyentitytendstodisappearintheelderly,likelyaresultoftheonepatienteachinIRAD(bothintheyoungercohort),relativelylongerlifeexpectancyofwomen(10).Agedoessuggestingthattheseentitiesarerarecausesofdissection.notseemtoplayadecisiveroleinthetransferofpatientsClassicsymptomsandsignsofaorticdissectionalsodifferwithacuteaorticdissectiontotertiaryreferralcenters.betweenpatientsϽ70yearsandՆ70years.AlthoughmostRelativelymoreelderlypatientswithaorticdissectionwereclinicianshavebeentaughttoassociatetheabruptonsetof690Mehtaetal.JACCVol.40,No.4,2002AcuteAorticDissectionintheElderlyAugust21,2002:685–92atearingorrippingchestorbackpainwithacuteaorticfailure,andcardiactamponade)wassimilarinthetwodissection(11),ourstudysuggeststhatthesesymptomsgroups.Onlyhypotensionoccurredmorefrequentlyandoccurlessfrequentlyintheelderly.Thepresenceofpulseneurologicdeficitslessfrequentlyintheelderlygroup.Thedeficitsoramurmurofaorticregurgitationinpatientsgreaterincidenceofruptureamongtheelderlymayexplainpresentingwithchestorbackpainoftenmakesaphysicianthehigherincidenceofhypotension.Onthecontrary,thesuspectaorticdissection,butthesesignsareseenlessoftenlesscommonoccurrenceofneurologicdeficitsmaybeaintheelderly.Indistinction,symptomsandsignsofreflectionofalowerincidenceofmajorbranchvesselcong