The aim of this research is to determine the optimum blood pressure (BP) control goal for hypertensive type B aortic dissection (TBAD) patients undergoing surgery.
Methods
Between January 2019 and April 2021, 259 hypertensive TBAD patients undergoing surgery were included in the research. 98 patients received intensive BP control with a target of systolic BP (SBP) < 120 mmHg, and 161 received standard BP control targeting SBP between 120 and 140 mmHg. Clinical data from two groups were compared.
Results
Patients who received intensive BP control experienced a significantly higher incidence of acute kidney injury (AKI) postoperatively (21/98, 21.4% vs 14/161, 8.7%, p = 0.004). The intensive group took more anti-hypertensive drugs per day compared with the standard group (1.9 vs 1.5, p < 0.001). Triple-drug combination treatment was more frequent in the intensive group (38.8% vs 14.3%, p < 0.001), as were angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB; 67.3% vs 44.7%, p 0.001), and thiazide-like diuretic (44.9% vs 18.0%, p < 0.001).
Conclusions
Intensive BP control treatment increases the incidence of AKI and raises the utilization of the anti-hypertensive drug, but did not reduce the operative mortality and late mortality in TBAD patients undergoing surgical repair.
NienaberCACloughRESakalihasanN, et al.Aortic dissection. Nat Reviews Dis Primers2016; 2: 16053.
2.
YehTYChenCYHuangJW, et al.Epidemiology and medication utilization pattern of aortic dissection in Taiwan: a population-based study. Medicine2015; 94: e1522.
3.
ErbelRAboyansVBoileauC, et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European society of cardiology (ESC). Eur Heart Journal2014; 35: 2873–2926.
4.
WrightJTJr.WilliamsonJDWheltonPK, et al.A randomized trial of intensive versus standard blood-pressure control. New Engl Journal Medicine2015; 373: 2103–2116.
5.
UngerTBorghiCCharcharF, et al.2020 International society of hypertension global hypertension practice guidelines. Hypertension2020; 75: 1334–1357.
6.
MilewskiRKSzetoWYPochettinoA, et al.Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J Thoracic Cardiovascular Surgery2010; 140: 590–597.
7.
ZhuJMQiRDChenL, et al.Stented elephant trunk procedure with left subclavian artery transposition for acute type B dissection with distal arch involvement. J Thoracic Cardiovascular Surgery2015; 150: 1160–1165.
8.
SunLQiRZhuJ, et al.Total arch replacement combined with stented elephant trunk implantation: a new "standard" therapy for type a dissection involving repair of the aortic arch?Circulation2011; 123: 971–978.
9.
XuSDHuangFJYangJF, et al.Early and midterm results of thoracic endovascular aortic repair of chronic type B aortic dissection. J Thoracic Cardiovascular Surgery2010; 139: 1548–1553.
10.
CzernyMSchoenhoffFEtzC, et al.The impact of pre-operative malperfusion on outcome in acute type a aortic dissection: results from the GERAADA registry. J Am Coll Cardiol2015; 65: 2628–2635.
11.
MehtaRLKellumJAShahSV, et al.Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care (London, England)2007; 11: R31.
12.
LandenhedMEngströmGGottsäterA, et al.Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study. J Am Heart Assoc2015; 4: e001513.
13.
FreibergMSArnoldAMNewmanAB, et al.Abdominal aortic aneurysms, increasing infrarenal aortic diameter, and risk of total mortality and incident cardiovascular disease events: 10-year follow-up data from the cardiovascular health study. Circulation2008; 117: 1010–1017.
14.
LewisCEFineLJBeddhuS, et al.Final report of a trial of intensive versus standard blood-pressure control. New Engl Journal Medicine2021; 384: 1921–1930.
15.
BeddhuSRoccoMVTotoR, et al.Effects of intensive systolic blood pressure control on kidney and cardiovascular outcomes in persons without kidney disease: a secondary analysis of a randomized trial. Ann Internal Medicine2017; 167: 375–383.
16.
HoltkampFAde ZeeuwDThomasMC, et al.An acute fall in estimated glomerular filtration rate during treatment with losartan predicts a slower decrease in long-term renal function. Kidney International2011; 80: 282–287.
17.
CushmanWCEvansGWByingtonRP, et al.Effects of intensive blood-pressure control in type 2 diabetes mellitus. New Engl Journal Medicine2010; 362: 1575–1585.
18.
PeraltaCAMcClureLAScherzerR, et al.Effect of Intensive versus usual blood pressure control on kidney function among individuals with prior lacunar stroke: a post hoc analysis of the secondary prevention of small subcortical strokes (SPS3) randomized trial. Circulation2016; 133: 584–591.
19.
HaynesRBSackettDLGibsonES, et al.Improvement of medication compliance in uncontrolled hypertension. Lancet (London, England)1976; 1: 1265–1268.
20.
RuddPByynyRLZacharyV, et al.The natural history of medication compliance in a drug trial: limitations of pill counts. Clin Pharmacology Therapeutics1989; 46: 169–176.
21.
BradyARThompsonSGFowkesFG, et al.Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. Circulation2004; 110: 16–21.
22.
GroeninkMden HartogAWFrankenR, et al.Losartan reduces aortic dilatation rate in adults with Marfan syndrome: a randomized controlled trial. Eur Heart Journal2013; 34: 3491–3500.
23.
ChiuHHWuMHWangJK, et al.Losartan added to β-blockade therapy for aortic root dilation in Marfan syndrome: a randomized, open-label pilot study. Mayo Clinic Proceedings2013; 88: 271–276.
24.
ShoresJBergerKRMurphyEA, et al.Progression of aortic dilatation and the benefit of long-term beta-adrenergic blockade in Marfan's syndrome. New Engl Journal Medicine1994; 330: 1335–1341.
25.
MilleronOArnoultFDelormeG, et al.Pathogenic FBN1 genetic variation and aortic dissection in patients with marfan syndrome. J Am Coll Cardiol2020; 75: 843–853.
26.
HowardDPBanerjeeAFairheadJF, et al.Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford vascular study. Circulation2013; 127: 2031–2037.
