Keywords
Type A aortic dissection - cardiovascular risk management - eHealth Interventions
- lifestyle modifications - postoperative outcomes
Introduction
Acute Type A aortic dissection (ATAAD) is a potentially fatal condition, requiring
prompt surgical intervention.[1] While successful aortic surgery can stabilize patients, many ATAAD survivors experience
considerable challenges in the postoperative period due to a number of cardiovascular
risk factors.[2] These factors, including obesity, hypertension, physical inactivity, and dyslipidemia
can significantly affect long-term results, necessitating comprehensive postoperative
management strategy aimed at improving survival and quality of life.
Current postoperative care tends to prioritize surgical repair and the immediate postsurgery
period, but long-term management of cardiovascular risk factors is often neglected.[3] This gap in care can lead to suboptimal postoperative outcomes, such as recurrent
cardiovascular events and reduced quality of life.[4] To address this, postoperative therapy for ATAAD patients should focus not only
on monitoring the surgical site, but also reducing modifiable risk factors. Incorporating
lifestyle interventions, such as weight management, exercise, and blood pressure control,
a multidisciplinary care plan could help to mitigate the abovementioned risks.
As the prevalence of cardiovascular risk factors remains significant, along with its
association with mortality,[5] the development of a comprehensive, multidisciplinary approach to postoperative
care becomes imperative. Such an approach should integrate lifestyle modifications,
personalized interventions, continuous monitoring, and guidance to address the specific
needs of each patient. Utilizing eHealth technology presents a promising method to
improve patient involvement and compliance with suggested lifestyle modifications.[6]
To understand barriers of postoperative care for ATAAD patients, we carried out a
survey among cardiac and vascular surgeons during the 8th International Meeting on
Aortic Diseases.[7] The survey questioned the health care professionals about the importance of personalized
risk management, lifestyle modifications, and continuous monitoring in the management
of aortopathy. We further collected baseline data from ATAAD patients affiliated with
Stichting Aorta Dissectie Nederland (SADN), a Dutch association for patients who have
survived an aortic dissection. Information on patient demographics, perceived health,
lifestyle factors, and other relevant health indicators were all collected. Such comprehensive
baseline data from the SADN cohort is extremely significant as it allows us to identify
critical targets for intervention and develop tailored strategies to improve patient
outcomes.
In this paper, we describe the combined baseline findings from the SADN population
and the insights from the surgeon survey, which were presented during the 8th Annual
International Meeting on Aortic Diseases (IMAD) and which have been instrumental in
providing a robust foundation for developing the TRAIN (Targeted caRdiovAscular rIsk
reductioN) Health Awareness Clinical Trial. This multicenter prospective randomized
controlled trial will be conducted at the Amsterdam University Medical Center and
Leiden University Medical Center (LUMC). The trial aims to assess the impact of a
customized, multidisciplinary health quality improvement program on cardiovascular
risk factors, cardiovascular events, and health-related quality of life in ATAAD patients.
Materials and Methods
Study Design
This study consists of two primary components: the collection of baseline data from
ATAAD patients affiliated with SADN and a survey conducted among cardiac and vascular
surgeons at the 8th Annual IMAD.[7]
Ethical Considerations
This study was conducted as part of the biobank protocol with reference number: B21.051/MS/ms.
The Medical Ethical Committee of LUMC reviewed and approved the study protocol prior
to the start of the inclusions. Furthermore, all participants were required to provide
informed consent before participating in the study. Ethical principles outlined in
the Declaration of Helsinki and Good Clinical Practice guidelines were upheld during
the entirety of the study, ensuring the confidentiality and anonymity of all collected
data.
Stichting Aorta Dissectie Nederland Baseline Data Collection
Participants
Patients affiliated with SADN who had a history of ATAAD and were willing to participate
were included in the study.
Inclusion criteria included:
Exclusion criteria included:
Survey Instrument
A comprehensive survey was created with the objective of collecting specific data
on the participants' demographics, health status, and additional lifestyle factors.
Questions in the following domains were included in the survey:
-
Demographics: age, gender, education level, and employment status.
-
Health status: medical history, including the prevalence of hypertension, diabetes,
and cholesterol levels.
-
Lifestyle factors: physical activity levels, smoking habits, dietary habits, and alcohol
consumption.
-
Health indicators: sleep quality, mental health status, mobility limitations, and
self-care abilities.
Data Collection Procedure
Participants were contacted through the SADN network and invited to participate in
our study by completing a web-based survey. Paper copies of the survey were distributed
among participants who indicated their preference for this format. All participants
provided informed consent before participating in the survey. To optimize participation,
reminders were given to nonrespondents over the 6-month data-collecting period.
International Meeting on Aortic Diseases Surgeon Survey
Cardiac and vascular surgeons who attended the IMAD and consented to participate in
the survey were included. There were no specific exclusion criteria for surgeons beyond
their attendance at the conference and willingness to participate. When surgeons expressed
their interest, they were given access to the survey through an online survey link.
The survey was designed with the objective of gathering insights from surgeons on
the challenges and best practices in the postoperative management of ATAAD patients.
Questions in the following domains were included in the survey:
-
Experiences: common postoperative complications in post-ATAAD patients.
-
Management strategies: surgeons views on critical factors in postoperative management.
-
Barriers to effective management: challenges faced in implementing effective postoperative
care strategies.
Data Analysis
Descriptive statistics were used to describe the baseline characteristics of the SADN
patients and responses from the surgeons' survey. The SADN survey was used to assess
key variables in postdissection patients. The IMAD survey was used to thematically
analyze recurring themes and insights on postoperative management strategies and challenges
faced by cardiothoracic surgeons throughout the world. All data were analyzed using
SPSS-27 software.
Results
Demographic Characteristics
The baseline survey was conducted among 50 patients with a history of ATAAD. These
patients, whose ages ranged from 35 to 82 years with a mean age of 59 years, predominantly
comprised males (75%) compared with females (25%).
Health and Lifestyle Factors
The responses of our survey revealed that cardiovascular risk factors are quite common
postdissection. First, hypertension was reported by 51.3% of the patients and the
mean blood pressure of the participants was 140/90 mm Hg, which is considered a key
risk factor for adverse cardiovascular outcomes.[8]
[9] Furthermore, 34.2% of respondents had a body mass index of 30 or above, indicating
that they are obese. These results highlight the seriousness of obesity in this patient
group, which is linked to numerous health issues, such as an elevated risk of cardiovascular
disease.[10]
[11] Additionally, diabetes was reported by 12% of patients, adding to this cardiovascular
risk burden. However, the treatment status of patients for these cardiovascular conditions—such
as the use of antihypertensives, cholesterol-lowering medications, or smoking cessation
protocols—was not consistently available in our dataset.
Physical inactivity was another prevalent issue, as 62% of respondents indicated they
were not moderately active for more than 30 minutes a day. Both cardiovascular health
and general well-being are greatly at risk from this sedentary lifestyle.[12]
[13] Sleep quality was another major issue, as 48% of patients reporting sleep disturbances
and the average nightly sleep duration was 6 hours. These problems are well-known
to negatively affect cardiovascular health and general quality of life.[14]
[15]
In addition, 36.7% of patients reported being current or former smokers and 40% of
patients had elevated cholesterol levels, both modifiable risk factors that further
exacerbate their cardiovascular risk profile.[16]
[17] Dietary habits were another area of concern as many patients reported eating fewer
fruits and vegetables than was advised. Addressing this through targeted interventions
that include both pharmacological treatment and lifestyle changes, such as an improved
diet and increased physical activity, is critical for managing cardiovascular risk
and improving overall health outcomes.[17]
[18]
Mental Health and Mobility
Mobility and mental health were also important issues. A notable proportion of patients
reported experiencing anxiety and depression, highlighting the need for postoperative
therapy to incorporate comprehensive mental health support. Additionally, mobility
issues were reported by 25% of the patients, and 15% had difficulties with daily activities
and self-care. These findings suggest that thorough rehabilitation programs are necessary
to promote the patients' functional recovery.
An overview of the risk factors is presented in [Fig. 1].
Fig. 1 Baseline cardiovascular risk factors of ATAAD patients. This figure provides a detailed
overview of the prevalence of various cardiovascular risk factors among ATAAD patients,
including hypertension, obesity, physical inactivity, smoking, hyperlipidemia, diabetes,
and sleep problems. The high prevalence of these modifiable risk factors highlights
the urgent need for comprehensive risk management strategies to improve patient outcomes.
ATAAD, acute Type A aortic dissection.
Insights from the International Meeting on Aortic Diseases Surgeon Survey
In addition to the patient survey, insights from the IMAD were gathered through a
survey of cardiovascular surgeons (N = 48). These surgeons underlined the significance of individualized risk management
programs that are catered to the unique characteristics of each patient. They highlighted
the critical role of lifestyle modifications (>84% considers important), including
dietary changes, increased physical activity, smoking cessation, and stress management,
in the postoperative care of ATAAD patients ([Fig. 2]).
Fig. 2 Importance of lifestyle interventions in the treatment of thoracic aortopathy according
to surgeons. This figure illustrates the distribution of surgeons' opinions on the
importance of various lifestyle interventions, such as dietary changes, physical activity,
and smoking cessation, in managing thoracic aortopathy. The majority of surgeons rated
these interventions as important or very important, underscoring their perceived value
in improving patient outcomes.
The surgeons also emphasized the importance of continuous evaluation of cardiovascular
risk factors in post-AATD patients to enhance patient outcomes. They promoted the
adoption of digital health tools to help with routine follow-ups and early identification
of potential complications. Nonetheless, they expressed their concerns about several
barriers to successful postoperative treatment, such as patients' failure to follow
recommended lifestyle modifications, a lack of resources for ongoing observation,
and a lack of established standards for long-term care ([Fig. 3]). Of all lifestyle interventions, smoking cessation and stress management were identified
as the most challenging to implement ([Fig. 4]). These challenges likely stem from the need for sustained behavioral changes, which
require significant patient engagement and support. These combined findings from the
SADN patient survey and the insights from the IMAD surgeon survey provide a comprehensive
understanding of the current state of postoperative care for ATAAD patients. They
underscore the need for targeted interventions to address the high prevalence of modifiable
cardiovascular risk factors and the barriers to effective management ([Figs. 2]
[3]
[4]).
Fig. 3 Barriers faced by surgeons in implementing lifestyle interventions in patients with
thoracic aortopathy. This figure identifies the main challenges surgeons encounter
when trying to implement lifestyle interventions for their patients. Common barriers
include patient adherence, lack of resources, insufficient evidence, cultural barriers,
and other unspecified issues. Understanding these barriers is crucial for developing
effective strategies to support lifestyle modifications in clinical practice.
Fig. 4 Specific lifestyle interventions that surgeons find most challenging to implement
in patients with thoracic aortopathy. This figure highlights the specific lifestyle
changes that surgeons find difficult to enforce, such as dietary changes, exercise
regimens, stress management, smoking cessation, and alcohol reduction. Smoking cessation
and stress management were identified as particularly challenging, indicating areas
where additional support and resources may be needed.
Discussion
The findings of our study indicate that individuals with ATAAD have substantial cardiovascular
risk factors, necessitating all-encompassing care approaches ([Fig. 1]). The high prevalence of hypertension (51.3%) is particularly notable, as it is
a well-established risk factor for an aortic dissection.[8]
[19] The mean blood pressure of 140/90 mm Hg among respondents indicates suboptimal control
of hypertension, necessitating more aggressive management strategies. Our findings
also revealed that a substantial proportion of patients was obese (34.2%), which is
associated with a variety of adverse cardiovascular outcomes, including increased
blood pressure, dyslipidemia, and insulin resistance.[10]
It is alarming that 62% of respondents reported poor levels of physical exercise because
physical inactivity is a modifiable risk factor for cardiovascular and aortic illnesses.[12]
[20]
[21] In response to these poor levels of physical exercise, regular exercise should be
encouraged to reduce the overall cardiovascular risk in post-AATD patients. Additionally,
as smoking is linked to vascular inflammation, reduced aortic elasticity, and accelerated
atherosclerosis, these patients should receive guidance accordingly to reduce this
strain on their individual risk levels.[22]
[23]
[24]
Elevated cholesterol levels remained common within our study population, consistent
with the literature that identifies hyperlipidemia as a key contributor to atherosclerosis
and the resulting aortic complications.[25]
[26] Twelve percent of respondents reported having diabetes. This introduces additional
complexity, as diabetes is linked to accelerated atherosclerosis and increased vascular
stiffness.[27]
Previous research indicates that suboptimal sleep has also been linked to suboptimal
recovery following surgical intervention.[28] In terms of cardiovascular disease, associations have been identified with underlying
conditions such as sleep apnea.[29]
As our study cohort revealed that sleep disturbances were reported by 48% of patients,
future research into sleep quality in AATD patients and effective treatments could
greatly enhance sleep. Addressing sleep quality could therefore be an integral part
of a holistic approach to cardiovascular risk management, thereby improving overall
recovery. Mobility issues and difficulties with daily activities reported by 25 and
15% of patients, respectively, highlight the impact of aortic disease on quality of
life and functional status, emphasizing the need for comprehensive rehabilitation
programs.
Comparison with Literature
The findings from the SADN survey are consistent with existing literature on cardiovascular
risk factors in aortic dissection patients.[30] Hypertension, as identified in this study, is frequently reported as a predominant
risk factor in similar cohorts.[30] A study by Rueda-Ochoa et al[31] found comparable hypertension rates, underscoring the necessity of effective blood
pressure management in preventing aortic events.[8]
The high prevalence of smoking in our cohort is also supported by previous studies.
Dolmaci et al[32] identified smoking as a crucial risk factor for aortic aneurysms and dissections,
which aligns with our findings. The significant presence of hyperlipidemia among respondents'
parallels studies that link elevated cholesterol levels to increased aortic stiffness
and susceptibility to dissections.[25]
[33]
Insights from Cardiovascular Surgeons
Insights gained from cardiovascular surgeons at the IMAD conference highlight the
importance of developing tailored risk management strategies. The surgeons that participated
in our study underlined the need of incorporating lifestyle modifications into standard
care protocols. This could entail developing personalized guidelines for dietary changes
and increased physical activity. This holistic approach is crucial for addressing
the multifaceted nature of cardiovascular risk factors in thoracic aortopathy patients.
The necessity of continuous monitoring of cardiovascular risk factors was a key point
highlighted by the surgeons. Risk factors can be identified early and handled timely
by routinely checking in with patients and tracking individual health indicators.
In turn, this will help improve patient outcomes. The integration of eHealth tools,
such as the TRAIN mobile application used in the TRAIN Health Awareness Clinical Trial,
offers a promising solution for continuous patient engagement and monitoring.
Implications for Clinical Practice
The baseline findings from the SADN survey highlight the high prevalence of modifiable
risk factors such as hypertension, obesity, smoking, and physical inactivity. These
findings highlight urgent need for a comprehensive, multidisciplinary approach to
managing cardiovascular risk factors in ATAAD patients. Components of the management
strategy could entail lifestyle modifications, regular monitoring, and patient education.
Our findings informed the development of the TRAIN Health Awareness Clinical Trial,
a proposed multicenter randomized controlled trial aimed at assessing the impact of
a customized, multidisciplinary health quality improvement program on cardiovascular
risk factors, cardiovascular events, and health-related quality of life in ATAAD patients
(protocol presented in [Fig. 5]). Using eHealth interventions can improve patient engagement and adherence to lifestyle
changes by offering personalized feedback and tracking individual progress. This could
ultimately result in more effective management of cardiovascular risk factors.
Fig. 5 Protocol of the Health Awareness Clinical Trial. This figure outlines the structure,
key components, and timeline of the TRAIN Health Awareness Clinical Trial. The trial
includes: (1) patient engagement strategies: utilizing eHealth technologies for real-time
tracking and educational materials. (2) Continuous monitoring: regular follow-ups
and remote monitoring of cardiovascular risk factors. (3) Personalized interventions:
tailored lifestyle modification plans including diet, exercise, and smoking cessation.
(4) Multidisciplinary approach: collaboration among various healthcare professionals
to provide comprehensive care. (5) Health quality improvement program: structured
program aimed at reducing risk factors and enhancing quality of life. The timeline
spans from initial patient enrollment and baseline assessments, through continuous
monitoring and intervention phases, to follow-up evaluations at 6 weeks, 3 months,
and 6 months of postintervention. The goal of the trial is to improve postoperative
outcomes and quality of life for ATAAD patients through a holistic, patient-centered
approach. ATAAD, acute Type A aortic dissection.
Multidisciplinary Aortic Centers
The complexity of managing thoracic aortic illness highlights the necessity for interdisciplinary
aortic centers. Such centers can integrate genetic counseling and testing, particularly
for patients with connective tissue illnesses and those who have a family history
of dissections. Genetic testing can provide crucial insights for patient monitoring
and follow-up, helping tailor individual management plans.
Additionally, lifestyle recommendations ought to be a standard component of patient
care, with an emphasis on tailored therapies that target particular risk factors and
promote overall cardiovascular health. These centers can serve as hubs for comprehensive
care, combining clinical expertise with ongoing research to improve patient outcomes.
Genetic Testing and Lifestyle Recommendations
Another recommendation would be to adopt routine genetic testing for patients with
a family history of dissection and young patients with thoracic aortic disease to
identify those at high risk. By using this method, negative occurrences may be avoided
by early interventions and customized monitoring plans. Additionally, personalized
lifestyle recommendations based on genetic and clinical data can further enhance patient
care.
Future Directions
Future research should focus on longitudinal studies to evaluate the long-term impact
of lifestyle interventions on patient outcomes as proposed in [Fig. 5]. Further, investigating the genetic predispositions and pathophysiological mechanisms
underlying thoracic aortopathy could offer insights into developing targeted therapies
and preventive measures, exploring the role of novel biomarkers in risk stratification
and monitoring could further refine personalized management strategies.
Limitations
It is critical to recognize the limitations of our research. As our study relies on
self-reported data from our participants, some bias and inaccuracies may be introduced.
The survey's cross-sectional design restricts the capacity to draw conclusions about
causality. Furthermore, the study population is limited to patients associated with
the SADN, which may not be representative of the broader ATAAD patient population.
Conclusions
The findings of our study underscore the importance of comprehensive cardiovascular
risk management in post-ATAAD patients. The baseline results show that smoking, obesity,
physical inactivity, and hypertension are important risk factors that require focused
interventions. According to cardiovascular surgeons, individualized risk management
plans that incorporate lifestyle changes and ongoing observation are necessary. The
TRAIN Health Awareness Clinical Trial is an excellent chance to fill in the gaps in
the existing management of ATAAD. Future research should focus on evaluating the long-term
impact of these interventions and refining strategies to integrate them into standard
care.
