Role of Exertion or Emotion as Inciting Events for Acute Aortic Dissection Ioannis S. Hatzaras, MD, Jesse E. Bible, MD, George J. Koullias, MD, Maryann Tranquilli, RN, Mansher Singh, MD, and John A. Elefteriades, MD* It is well known that hypertension, aortic dilatation, and collagen disorders predispose to acute aortic dissection (AAD). The inciting events that precede the instant of AAD are incompletely understood. One hundred seventy-five consecutive patients having AAD, treated at our institution during a 10-year period, were reviewed; 65 were women and 110 were men (mean age 61 years). The ascending aorta was affected in 110 patients, and the descending in 65. Information was collected using patients’ charts supplemented with direct telephone interviews. Ninety patients were contacted; 65 (24 women, 41 men, mean age 61 years, average aortic size 5.56 cm) could recall specific inciting events for their dissection. In 34 patients, the ascending aorta was involved and in 31 the descending. Eighteen patients (28%) had a positive family history of aortic disease, defined as having >1 first-degree relative with aortic disease (aneurysm or dissection). In 24 of the 90 patients contacted (27%), strenuous activity was identified as a clear precipitating factor before the acute onset of thoracic pain; in 36 of 90 (40%) severe emotional stress preceded the onset of dissection pain. Three dissections were iatrogenic. Two additional patients reported a severe exacerbation of chronic obstructive pulmonary disease before their acute onset of chest pain. In conclusion, severe physical and emotional stress may precipitate AAD, presumably on the basis of a transient, severe hypertensive reaction. © 2007 Elsevier Inc. All rights reserved. (Am J Cardiol 2007;100:1470 –1472) Investigating the inciting events that precipitate the onset of acute aortic dissection (AAD) may shed light into the patho- physiology of this condition, above and beyond known predisposing factors and diurnal and seasonal variations, 1–16 and help develop preventive measures or expand the exist- ing treatment options. We hypothesized that severe emotional stress as well as severe physical straining could be involved in the onset of AAD. We attempted to study a group of patients who had AAD to discover whether physical strain or emotional stress commonly preceded onset of aortic dissection. Methods We retrospectively analyzed data collected from 175 con- secutive AAD patients treated at our institution during a period of 10 years (January 1, 1995 to December 31, 2004). The discharge diagnosis of all patients was AAD, ascending or descending; the diagnosis was based on imaging studies (computerized tomography, magnetic resonance imaging, or echocardiography [transthoracic or transesophageal]) and/or surgical exploration. Information was collected using pa- tient charts and medical records. These records were sup- plemented as needed with direct telephone interviews with the patient, a close family member, or the primary care physician. We attempted to contact all patients; however, a number of patients were lost to follow-up or died during the long follow-up period of this study. A standardized questionnaire was developed, which was approved by the Yale University Human Investigation Committee. We inquired about the patient’s general state of health before the acute event and whether there was a known personal or familial history of aortic disease. We defined positive family history as having 1 first-degree relative with aortic disease. The patient and family members were questioned regarding the patient’s events and activities before the acute onset of chest or back pain. We also recorded the time of pain onset and the calendar date of the visit to the emergency department. We focused on any emotional stressors or any history of physical strain just before the onset of acute chest pain. This information was input into an Excel spreadsheet and statistical analysis done using Prism 3.0 (Prism Inc., Irvine, California). Results Information regarding precipitating events was gathered on 90 patients of the original 175 patients; 85 could not be contacted for detailed information about their original pre- sentation. Thirty-three of the original 175 patients had died on the initial hospital admission, and 5 had died later. Sixty-five patients of the 90 patients with adequate infor- mation (72%) (24 women, 41 men; mean age 60.9 years, range 21 to 83) were able to recall specific inciting events or activities immediately preceding the onset of dissection pain (Figure 1). Twenty-four of these 65 patients had a history of aneurysm in the thoracic aorta. Average aortic size in the recall group was 5.56 cm (SD 2.07). (These are the dimen- Section of Cardiothoracic Surgery, Yale University School of Medi- cine, New Haven, Connecticut. Manuscript received March 22, 2007; revised manuscript received and accepted June 5, 2007. *Corresponding author: Tel: 203-785-2705; fax: 203-785-3346. E-mail address: john.elefteriades@yale.edu (J.A. Elefteriades). 0002-9149/07/$ – see front matter © 2007 Elsevier Inc. All rights reserved. www.AJConline.org doi:10.1016/j.amjcard.2007.06.039