Clinical profiles and outcomes of acute type A aortic dissection and intramural hematoma in the current era: lessons from the first registry of aortic dissection in China
Aortic dissection is a silent killer—untreated, 33% of patients with the most dangerous type (acute type A, or ATAAD) die within 24 hours, and 50% within 48 hours. For Chinese patients, understanding how this disease presents, progresses, and is treated has been limited—until now. A new study using China’s first national registry of aortic dissection (Sino-RAD) offers critical insights into who is at risk, how the disease shows up, and what treatments work best for patients in China.
Led by researchers at Xijing Hospital (Fourth Military Medical University) and colleagues, the study analyzed data from 1,712 patients with ATAAD or acute type A intramural hematoma (ATAIMH)—a related condition where blood collects in the aortic wall—enrolled in Sino-RAD between 2012 and 2016. The goal? To fill gaps in knowledge about China’s unique patient population and improve care for this life-threatening disease.
How the Study Was Done
Researchers included patients with confirmed ATAAD or ATAIMH, excluding those with aortic injury from trauma. They used standard statistical tests to compare groups (e.g., ATAAD vs. ATAIMH) and analyzed data on demographics, medical history, symptoms, diagnostics, treatments, and in-hospital outcomes. All patients provided informed consent, and the study was approved by ethics boards.
Key Findings: Who Is at Risk and How the Disease Presents
The study’s results paint a clear picture of aortic dissection in China:
1. Demographics: Younger, Male-Dominant
- The average age of patients was 48.4 years—much younger than Western cohorts (where aortic dissection typically strikes in the 60s).
- ATAAD patients were even younger (48.9 years) compared to ATAIMH patients (55.6 years).
- Men were far more likely to be affected: 78.3% of ATAAD patients were male, vs. 68.5% of ATAIMH patients.
2. Risk Factors: Hypertension and Genetics
- Hypertension is the top driver: 68.7% of all patients had high blood pressure, and ATAIMH patients had an even higher rate (82.3%) than ATAAD patients (67.6%). Alarmingly, nearly half (44.8%) of hypertensive patients weren’t taking any medication, and 38.9% had poorly controlled blood pressure.
- Marfan syndrome matters: This genetic condition (which weakens the aortic wall) was found in 6% of ATAAD patients—higher than Western registries (4.5%). Notably, no ATAIMH patients had Marfan syndrome, a finding that needs further study.
3. Symptoms: Pain Is the Red Flag
- Severe pain was the most common symptom (92.3% of patients), with back pain (79.3%) more common than chest pain (30.2%)—a shift from Western data, where chest pain is the primary complaint.
- Some patients arrived unconscious and couldn’t report pain, underscoring the need for rapid imaging in high-risk cases.
4. Diagnosis: CT Scans Are King
- Computerized tomography (CT) was the most common initial diagnostic tool (92.8% of cases). It’s fast, accurate, and works even for unstable patients—critical for a disease where every minute counts.
5. Treatment: Surgery for ATAAD, More Options for ATAIMH
- ATAAD: 89.6% of patients had surgery—the gold standard to prevent aortic rupture. The most common procedures were Bentall operation (replacing the aortic root and valve) and ascending aorta replacement.
- ATAIMH: Doctors took a more conservative approach: 39.2% received medical therapy (e.g., blood pressure drugs) and 35.4% had endovascular repair (a minimally invasive stent procedure).
- Overall, 84.7% of patients had surgery, with an in-hospital survival rate of 94.7%—higher than some Western registries, likely because Sino-RAD includes top hospitals with experienced surgical teams.
What This Means for Patients and Doctors
The study’s findings highlight critical opportunities to save lives in China:
1. Time Is Non-Negotiable: Reduce Delay to Care
- The average time from symptom onset to hospital admission was 2 days, and nearly half (44.6%) of patients arrived after 48 hours—when the risk of rupture skyrockets. Improving emergency response (e.g., faster ambulances, better triage) and public awareness (teaching people to seek help for sudden, severe back/chest pain) could cut this delay.
2. Blood Pressure Control Is a Must
- With 245 million hypertensive patients in China, screening and treating high blood pressure is the best way to prevent aortic dissection. For ATAIMH patients—who had even higher rates of hypertension—strict blood pressure management could slow disease progression.
3. Genetic Screening Saves Lives
- Marfan syndrome was found in 6% of ATAAD patients, and aortic dissection strikes 20 years earlier in these patients. Genetic testing and lifelong surveillance (e.g., regular CT scans) are essential to catch problems early.
4. Treatment Guidelines Need Tailoring
- Unlike Western guidelines (which recommend surgery for most ATAIMH), Chinese doctors often use medical or endovascular therapy for ATAIMH. This reflects a belief that ATAIMH is less aggressive—but more research is needed to confirm if this approach is safe long-term.
Limitations to Consider
The study isn’t perfect:
- Selection bias: Sino-RAD includes only top hospitals, so results may not reflect care in rural areas.
- Missing data: Many patients who die before reaching the hospital (and thus aren’t included) could lower the reported survival rate.
- Short follow-up: Long-term outcomes (e.g., 5-year survival) aren’t yet available.
Conclusion: Early Action Saves Lives
For Chinese patients with ATAAD and ATAIMH, the takeaways are clear:
- Early diagnosis: Use CT scans for high-risk patients (e.g., those with hypertension or Marfan syndrome).
- Rapid treatment: Reduce the time from symptom onset to surgery—every hour counts.
- Standardized care: Align treatment protocols across hospitals and train more surgeons in complex aortic procedures.
- Public awareness: Teach people to recognize the signs of aortic dissection (sudden severe back/chest pain) and seek help immediately.
The Sino-RAD registry is a milestone for Chinese cardiovascular care—providing the first large-scale data to tailor treatment to China’s unique patient population. As researchers continue to analyze long-term outcomes, these insights will help turn aortic dissection from a “silent killer” into a manageable condition.
Original study: Duan WX, Wang WG, Xia L, et al. Clinical profiles and outcomes of acute type A aortic dissection and intramural hematoma in the current era: lessons from the first registry of aortic dissection in China. Chinese Medical Journal 2021;134(8):927–934. doi.org/10.1097/CM9.0000000000001459
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