Proximal aorta dilatation in hypertension

Chest x-ray aortic size and risk of death and cardiovascular disease in older Chinese: Guangzhou biobank cohort study

BACKGROUND

Chest radiograph can independently predict adverse outcomes in outpatients. We examined the associations of aortic knob width (AKW), ascending aortic length (AAL), and ascending aortic width (AAW) from chest x-ray with death and cardiovascular events in adults aged 50 and above.

METHODS

Participants without cardiovascular disease were included from the Guangzhou Biobank Cohort Study (2003-2008). AKW, AAL, and AAW were indexed by body surface area. Aortic enlargement was defined using sex- and age-specific thresholds, calculated as the average value plus 1.96 multiplied by the standard deviation (SD). The associations of AKW, AAL, and AAW indices with all-cause and cause-specific mortality (cardiovascular and cancer), and incident nonfatal and fatal cardiovascular events, were examined through multivariate Cox regressions. Logistic regressions were performed to determine risk factors for aortic enlargement.

RESULTS

Among 27,047 participants (mean age 62 years ± 7 years SD), there were 6977 deaths and 6478 cardiovascular events over an average follow-up period of 16.3 years. Each SD increase in AKW index was associated with a higher risk of all-cause mortality, cardiovascular mortality, and cardiovascular events, with hazard ratios (95% confidence interval [CI]) of 1.13 (1.11-1.16), 1.20 (1.15-1.25), and 1.11 (1.08-1.14), respectively. Similar findings were observed regarding the AAL and AAW indices. Hypertension was a strong risk factor for enlarged AKW (odds ratio 2.52, 95% CI 2.17-2.93), AAL (1.95, 1.63-2.32), and AAW (1.80, 1.56-2.09), respectively.

CONCLUSIONS

Thoracic aortic parameters measured through an accessible, cheap, and safe chest radiograph were associated with higher risks of death and cardiovascular events. Hypertension should be managed.

Association of pulse pressure and aortic root diameter in elderly Chinese patients with chronic heart failure

Background

High pulse pressure (PP) and aortic root diameter (AoD) are hallmarks of arterial stiffness or vascular aging and they are considered as risk factors for age-related cardiovascular disease, including heart failure (HF). However, the relationship between PP and AoD in patients with heart failure (HF) is uncertain. This study aimed to evaluate the relationship between PP and AoD in the middle-aged and the elderly with HF.

Methods

A total of 1,027 Chinese middle-aged and elderly patients with HF, including HF with reduced ejection fraction (HFrEF), HF with mid-range EF (HFmrEF), and HF with preserved EF (HFpEF) were included in this study. Pearson correlation analysis was used to evaluate the relationship between PP and AoD in the three types of HF. Multiple linear regression analysis was performed to assess the factors that affected AoD. Multivariate logistic regression was performed to determine the association between the PP level quartiles and AoD. The results were validated in an independent dataset included a total of 378 consecutive patients with HFrEF hospitalized at the Pingtan Branch of Fujian Medical University Union Hospital (Fujian, China).

Results

There was a positive correlation between PP and AoD in the middle-aged and the elderly with HFrEF. Multiple linear regression analysis revealed that PP, age, and body mass index (BMI) were independently correlated with AoD in HFrEF patients. In multivariate logistic regression analysis, an increased risk of aortic root dilation was observed in the highest quartile of the PP level compared with the lowest quartile. Age significantly interacted with PP (p = 0.047). A significant association between PP levels and AoD was only observed in patients ≥ 65 years old, but not in patients < 65 years old. In the validation dataset, PP was independently related to AoD in patients with HFrEF (β = 0.205, p = 0.001).

Conclusions

PP level was independently and positively associated with AoD, especially in the elderly with HFrEF, but not in patients with HFmrEF and HFpEF. Arterial stiffening or vascular aging may play a certain role in the elderly HFrEF patients.

Proposal of a Modified Classification of Hypertensive Crises: Urgency, Impending Emergency, and Emergency

Systemic arterial hypertension (HTN) is the main cause of morbidity and mortality, and HTN crises contribute significantly to an unfavourable clinical course. For decades, HTN crises have been dichotomized into hypertensive emergency (HTN-E) and hypertensive urgency (HTN-U). The main difference between the two is the presence of acute hypertension-mediated organ damage (HMOD) - if HMOD is present, HTN crisis is HTN-E; if not, it is HTN-U. Patients with HTN-E are in a life-threatening situation. They are hospitalized and receive antihypertensive drugs intravenously (IV). On the other hand, patients with HTN-U are usually not hospitalized and receive their antihypertensives orally. We suggest a modification of the current risk stratification scheme for patients with HTN crises. The new category would be the intermediate risk group, more precisely the 'impending HTN-E' group, with a higher risk in comparison to HTN-U and a lower risk than HTN-E. 'Impending HMOD' means that HMOD has not occurred (yet), and the prognosis is, therefore, better than in patients with ongoing HMOD. There are three main reasons to classify patients as having impending HTN-E: excessively elevated BP, high-risk comorbidities, and ongoing bleeding/high bleeding risk. Their combinations are probable. This approach may enable us to prevent some HTNEs by avoiding acute HMOD using a timely blood pressure treatment. This treatment should be prompt but controlled.