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Winning The Battle But Losing The War: Increased Population-based Mortality From Aortic Dissection –

We read with great interest ‘Temporal Trends in Mortality of Aortic Dissection and Rupture in the UK, Japan, the USA, and Canada’. In their study, Hibino and colleagues1 performed a retrospective database analysis examining trends in mortality from aortic dissection and rupture across four countries over a 19-year time-period. The main outcome was age-standardised mortality rates and annual percentage change of mortality over the study period, with a comparison between trends in aortic dissection versus aortic rupture. Their hypothesis was that given improved surgical mortality and the uptick of endovascular management, a broad improvement in age-standardised mortality from both aortic dissection and rupture would be seen across all four countries. Indeed, mortality from aortic rupture tended to decrease in all countries, however, mortality from aortic dissection unexpectedly tended to increase across both decades in Japan and, in the second decade of the study period, also in the USA and Canada.

The improvement in mortality from aortic rupture, seen across all four countries, is both expected and satisfying. The past two decades have seen significant changes in the management of acute aortic disease. As imaging studies and screening programmes become more refined, transfer processes to designated tertiary centres with aortic specialisation and endovascular experience become more routine, and our pharmacological management of hypertension improves, the increased ability to efficiently care for those with treatable aortic emergencies naturally results in decreased mortality overall for both surgically and non-surgically treated patients. What deserves further attention is the increase in mortality from aortic dissection. While this difference was noticed by Hibino et al across the entire study period in Japan, a trend was also seen in both the USA and Canada in more recent years. Therefore, while the specific difference across countries and the increased mortality in Japan is important, what is more …