Month: October 2014

Danielle Haines-32

Name: Danielle Haines
Email: elleisrad@gmail.com
Age at time of Dissection: 32
Type of Dissection: Descending
Date of Aortic Dissection: 5 May 2013
Tell Us Your Story:

When I went to my local ER at the end of April, I thought I was having a panic attack. It had happened before, my chest would start to ache and hurt, and I would go in and they would give me a shot to help me relax, then send me home.

This time was different, because when Dr. Turner realized that I have Marfan’s Syndrome, he asked me to get x-rays. When those came back, he was worried, and asked me to get a CT scan. I was worried at that point, because I know doctors don’t just send patients out for extra tests “just because.”

Come to find out, I had two major dissections in my descending aorta–one that was almost the size of a soda can. He immediately told me that I had to have emergency surgery, but there simply wasn’t anyone qualified in my state (Kansas) who could perform the operation. It took them a long time to get things in order, because none of the surgeons locally wanted to take my case, because everybody was certain I was going to die.


Eventually I had a consulting surgeon who signed on, as well as a cardiologist locally, and the next thing I knew my mom and I were on a private jet on our way to Houston.

After taking all the tests to make sure that my body was healthy enough to take the surgery, Dr. Safi (the amazing doctor who performed my surgeries) decided that everything was fine and we were ready to go. Some time after my first surgery, they told me that I had to have a second surgery, because I had so many issues with my descending aorta that they simply couldn’t do it all in one surgery.

I spent 39 days in the hospital. Two people got fired because of the way they treated me, as well as their other patients. It wasn’t until after my second surgery that I realized how close I was to dying. I was only 32! Surgeries like this are supposed to be for older people, not people my age. I still cry about it sometimes.



It’s been five months since my first surgery, and on the 22nd it will be 5 months since my second surgery, and I’m still in major pain on a regular basis. My PCP is at a residency clinic, and every time he has a new student working with him, they always timidly ask me if they can see my scar. Sometimes I feel like a freak. I don’t have anyone to talk to that understands what I’ve gone through, or what I’m still going through. This is the single worst thing I’ve ever gone through in my life, and if I was religious, I’d pray every single day that I never have to go through anything like this ever again.

Mortality associated with aortic dissection improved in recent years

Mortality associated with aortic dissection improved in recent years
Mody PS. Circ Cardiovasc Qual Outcomes. 2014;doi:10.1161/CIRCOUTCOMES.114.001140.
October 21, 2014
Article Source:

From 2000 to 2011, mortality rates improved for patients with aortic dissection while hospitalization rates remained stable during the same period.

Researchers analyzed Medicare data from 2000 to 2011 to determine trends in hospitalization, mortality and interventions for patients with aortic dissection. During that time, they documented 32,057 hospitalizations for aortic dissection among Medicare fee-for-service beneficiaries.

Comorbidities in patients hospitalized for aortic dissection that increased over time included hypertension (2000, 65%; 2011, 71.5%), diabetes (2000, 8.9%; 2011, 13.9%), dementia (2000, 3.8%; 2011, 7.3%), renal failure (2000, 3%; 2011, 9.2%), pneumonia (2000, 8.5%; 2011, 12.6%), respiratory failure (2000, 2.1%; 2011, 5.1%) and depression (2000, 3.3%; 2011, 6.5%).

“Prior literature demonstrates that the profile of patients with chronic [CV] conditions, such as [HF], has become sicker with significant increase in the age and proportion of chronic comorbidities over the last decade,” Purav S. Mody, MD, from the department of internal medicine, University of Texas Southwestern Medical Center, Dallas, and colleagues wrote. “Hence, the aforementioned temporal changes in comorbidities are most likely real vs. more intense coding practice patterns.”

Hospitalization rates stable

The rate of hospitalization for aortic dissection remained stable throughout the study period at 10 per 100,000 person-years. Rates were also stable for all age, race and sex subgroups, and remained highest for older, male and black adults.

In all patients, the observed rate of 30-day mortality decreased from 31.8% in 2000 to 25.4% in 2011 (difference, 6.4%; 95% CI, 6.2-6.5; difference after adjustment for age, sex, race and comorbidities, 6.4%; 95% CI, 5.7-6.9) and the observed rate of 1-year mortality decreased from 42.6% in 2000 to 37.4% in 2011 (difference, 5.2%; 95% CI, 5.1-5.2; adjusted difference, 6.2%; 95% CI, 5.3-6.7), according to the researchers.

Breakdown by intervention

Mortality rates for patient subgroups by intervention were as follows:

•Patients undergoing surgical repair for type A dissections: 2000 30-day mortality, 30.7%; 2011 30-day mortality, 21.4%; difference, 9.3%; 95% CI, 8.3-10.2; adjusted difference, 7.3%; 95% CI, 5.8-7.8; 2000 1-year mortality, 39.9%; 2011 1-year mortality, 31.6%; difference, 8.3%; 95% CI, 7.5-9.1; adjusted difference, 8.2%; 95% CI, 6.7-9.1.
•Patients undergoing surgical repair for type B dissections: 2000 30-day mortality, 24.9%; 2011 30-day mortality, 21%; difference, 3.9%; 95% CI, 3.5-4.2; adjusted difference, 2.9%; 95% CI, 0.7-4.4; 2000 1-year mortality, 36.4%; 2011 1-year mortality, 32.5%; difference, 3.9%; 95% CI, 3.3-4.3; adjusted difference, 3.9%; 95% CI, 2.5-6.3.
•Patients treated with medical management only: decline from 2000 to 2011 in 30-day mortality, 3.9%; 95% CI, 3.8-4.1; adjusted difference, 4.5%; 95% CI, 3.4-5.2; decline between 2000 and 2011 in 1-year mortality, 2.4%; 95% CI, 2.3-2.7; adjusted difference, 4%; 95% CI, 2.6-4.9.

•Patients undergoing thoracic endovascular aortic repair, which was introduced in 2005: 2005 30-day mortality, 9.5%; 2011 30-day mortality, 13.9%; P=.4; 2005 1-year mortality, 16.7%; 2011 30-day mortality, 25.8%; P=.3; the sample sizes were too small to calculate adjusted mortality rates.
Disclosure: The study was supported by the NHLBI.

Exercise after an Aortic Dissection

Cardiology Patient Page
Activity Recommendations for Postaortic Dissection Patients
Ashish Chaddha, BS; Eva Kline-Rogers, MS, RN, NP; Elise M. Woznicki, BS; Robert Brook, MD; Susan Housholder-Hughes, MSN, RN, ANP-BC; Alan C. Braverman, MD; Linda Pitler, RN, MS, CCRC; Alan T. Hirsch, MD; Kim A. Eagle, MD
+ Author Affiliations

From the Cardiovascular Center, University of Michigan, Ann Arbor, MI (A.C., E.K.-R., E.M.W., R.B., S.H-H., K.A.E); the Cardiovascular Division, Washington University, St. Louis, MO (A.C.B.); the Thoracic Aortic Center, Massachusetts General Hospital, Boston, MA (L.P.); and the Cardiovascular Division, University of Minnesota Physicians Heart Practice, Minneapolis, MN (A.T.H.).
Correspondence to Ashish Chaddha, University of Michigan Cardiovascular Center, 6665 Crabapple Court, Troy, MI 48098. E-mail achaddha@med.umich.edu

Individuals who have survived an aortic dissection are often faced with the question of how life can be maximally and safely lived, with functional independence preserved. Routine exercise is important for both physical and emotional health. During exercise, blood pressure and heart rate increase in part related to the intensity, duration, and specific type of activity performed. The goal of this Cardiology Patient Page is to provide the postaortic dissection patient with an understanding of how blood pressure changes with different activities. We will provide information to patients and families that leads to a greater sense of comfort during physical activity, while possibly decreasing the risk of future aortic complications, thus improving overall quality of life. It is our goal that patients will continue to engage in consistent exercise, given its beneficial effects on mental, physical, and emotional health.

Handgrip Exercise

When a handgrip (Figure) is squeezed maximally for 1 minute, the systolic blood pressure (SBP) increases by approximately 50 mm Hg. The diastolic pressure increases by about 30 mm Hg.1 When a handgrip is squeezed at 30% of maximal effort, the SBP increases by about 20 to 30 mm Hg, and the diastolic pressure increases by about 10 to 20 mm Hg. Although these studies are limited by small sample size, they do suggest that blood pressure may increase more than is appreciated during everyday activities requiring significant effort, such as carrying a heavy bag. The degree of increase in BP depends on how hard the handgrip is squeezed, with the increase being greater for maximal versus submaximal effort. Thus, for aortic dissection survivors, it is prudent to minimize carrying objects that are so heavy as to require a maximal or near maximal effort.

Figure.
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Figure.
Illustration of various exercises. A, Handgrip exercise. B, Bicep curl.

Aerobic Exercise

The increase in BP during aerobic activity depends on the level of exertion. Metabolic equivalents (METs) refer to the intensity of the exercise. A more intense activity has a higher MET value (Table). For individuals with and without high BP, the SBP may increase by 8 to 12 mm Hg per MET of aerobic activity, with only a minimal effect on diastolic pressure. For example, SBP while running at 8 mph (13.5 METs) may increase by 108 to 162 mm Hg over resting levels whereas SBP may only increase by 26 to 40 mm Hg during brisk walking at 3 mph (3 METs). Thus, it is thought that a higher pressure may lead to a higher wall stress on the aorta, increasing the chance of a complication. It may be beneficial to take a cautious approach and limit activities that require extreme or maximal exertion (eg, running, sprinting), as well as activities such as chopping wood, shoveling snow, and mowing the lawn with a nonriding or non–self-propelled mower. The Table lists various activities and their corresponding MET value.

MET Values For Various Exercise and Daily Activities2

Weightlifting

BP increased to about 230/165 mm Hg (from 130/80 mm Hg) when a biceps curl was performed with heavy weights for the maximum amount of repetitions possible (meaning failure was reached as even 1 more repetition could not be performed without rest), with heavy referring to a weight that is 90% of the 1-repetition maximum (a weight with which only 1 repetition can be performed). Using lighter weights (40% of the 1-repetition maximum) led to an even greater increase in BP if the maximum number of repetitions possible was performed.3 Thus, when weightlifting, it seems that the greatest increase in blood pressure occurs when performing repetitions to the point that even 1 more cannot be performed, regardless of how light or heavy the weight is. Given this, it is important for the postaortic dissection patient to use a low amount of weight and to stop several repetitions before failure. These data may also suggest using caution and minimizing lifting heavy objects, with heavy being defined as objects that require a lot of effort and straining (such as a Valsalva maneuver) to lift.

Daily Exercise Suggestions

Regular aerobic exercise may lower resting BP by a greater amount compared with weight lifting (3–8 mm Hg versus 2–3 mm Hg).4 Lowering resting BP may reduce the chance of future aortic complications. High intensity exercise may not be necessary to receive these benefits.4 The general health recommendation is to engage in aerobic activity at an intensity of 3 to 5 METs (moderate exertion), for at least 30 minutes on most days of the week, for a total of 150 minutes/week or more. Thus, walking, slow jogging, and recreational cycling at a casual pace may be sufficient if the goal is a reduction in resting blood pressure and improved cardiovascular health, while possibly minimizing the risk of aortic complications. We also recommend weightlifting using a very low amount of weights, given its positive effect on strength and bone mineral density, but encourage patients to avoid straining and to stop well before fatigue.

Sexual Activity

Sexual activity has only a moderate effect on BP and HR among healthy individuals. The greatest increase in blood pressure during sexual activity occurs at orgasm, with an increase in SBP of 40 mm Hg. The BP normalizes within 2 minutes. A common sense approach to sexual activity, avoiding straining or maximal exertion, may be safe for the postdissection patient.

Conclusion

Routine physical exercise performed at a safe level is important for all individuals, including the patient after aortic dissection. It is prudent for postaortic dissection patients to minimize carrying objects that are so heavy that one has to strain or squeeze. It may also be important to avoid maximal exertion during aerobic activity (eg, running, sprinting). We recommend aerobic exercise at mild to moderate exertion (3–5 METs), for at least 30 minutes on most days of the week, for a total of 150 minutes/week, if the goal is a reduction in resting blood pressure and improved cardiovascular health, while possibly minimizing the risk of aortic dissection. If weightlifting is performed, we recommend using small amounts of weight and stopping several repetitions before failure, which will avoid straining. We suggest a common sense approach to sexual activity by avoiding straining, intense physical activity, or performance leading to shortness of breath. Because the response of BP and HR to exercise may vary widely among different individuals, one may consider low-level exercise testing or monitoring BP and HR during activity to ensure safety. Lastly, we encourage patients to discuss their activity concerns with the clinicians monitoring their cardiovascular health.

Amy Gonzales-90

Name: Amy Gonzales
Email: gonzo7578@yahoo.com
Age at time of Dissection: 90
Type of Dissection: Ascending
Date of Aortic Dissection: 1 October 2014
Tell Us Your Story:

This is my story, but I am not the one with an aortic dissection. I am looking for answers because my grandmother has one. She is 90 years old and has lived a good life. She has a DNR, and is sure that is what she wants. I live 6 hours away, and I just feel helpless. My mom, aunt, and uncle are with her, but I am not getting much information.

I do not know exactly where her dissection is or what type, but I do know they said the scar tissue from a bypass surgery was holding things together at the moment. They are sounding as though she is not going to make it through, but she has made it to almost 48 hours.

Can you give me any insight to what to expect? They are telling me it could be fast or slow, but not really defining what that means. She is heavily medicated, but conscious and aware. I am just trying to grasp best and worse case scenarios.



My grandfather is 92 and still alive. I am just so sad for everyone, and it seems as though she is in a lot of pain. Any insight would be appreciated.
Thank you!

Update:
Thank you so much for your prompt response, but I got the answers tonight. My grandmother passed. I am relieved she is not suffering but very concerned what this will do to my grandfather. He is 92 and they have been married for 68 years. He is already having circulation problems and he is diabetic. So we are moving on to best ways to care for him. I am grateful it went relatively quickly for her, and hope she is in a better place.
Sincerely,
Amy Gonzales

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