Abstract
Thoracic aortic aneurysms rupture and dissection are among the most devastating vascular diseases, being characterized by elevated mortality, despite improvements in diagnostic imaging and surgical techniques.
An increased aortic root diameter (ARD) represents the main risk factor for thoracic aortic dissection and rupture and for aortic valve regurgitation.
Even though arterial hypertension is commonly regarded as a predisposing condition for the development of thoracic aorta aneurysms, the role of blood pressure (BP) as determinant of aortic root enlargement is still controversial. The use of different methods for indexation of ARD may have in part contributed to the heterogeneous findings obtained in the investigations exploring the relationships between ARD and BP. Indeed, the best methods for ARD indexation, as well as the normal values of aortic root size, are still a matter of debate.
Several non-hemodynamic factors influence ARD, including age, gender, and anthropometric variables, such as height, weight and their derivatives body surface area (BSA) and body mass index. Of these factors, anthropometric variables have the greatest impact.
Several studies documented an association between ARD enlargement, assessed by echocardiography, and some indices of hypertensive target organ damage such as left ventricular hypertrophy, diastolic dysfunction, and carotid intima–media thickening. Recently, we found that ARD, expressed either as absolute values or normalized for BSA (ARD/BSA) or height (ARD/H), was significantly greater in hypertensive subjects with chronic kidney disease (CKD) when compared to their counterparts with normal renal function. Moreover, at univariate analyses estimated glomerular filtration rate (eGFR) showed significant inverse correlations with ARD not indexed and with ARD/BSA and ARD/H. Taking into account the effect of age, sex, duration of hypertension and other potentially confounding factors, in multiple regression analyses, only the association of GFR with ARD/H and that between GFR and ARD/BSA remained statistically significant. The receiver-operating characteristic curve analysis revealed that an estimated GFR of about 50 ml/min/1.73 m2 represents the better threshold to distinguish hypertensive patients with dilated aortic root from those with a normal one.
Some population-based studies showed that an enlarged ARD might predict an adverse prognosis, even in absence of aneurysmatic alterations.
In the Cardiovascular Health Study, a dilated aortic root was independently associated with an increased risk for stroke, cardiovascular and total mortality in both sexes and with incident congestive heart failure only in men. The relationship between ARD and heart failure has been observed also in the Framingham Heart Study. More recently, the PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) study demonstrated an independent relationship of ARD/H with incident cardiovascular morbidity and mortality.
Although the relationship between BP and aortic root size is still a matter of debate, increasing evidence seems to support the notion that aortic root dilatation, even in absence of aneurysmatic alterations, may be regarded as an hypertensive organ damage paralleling other preclinical markers whose unfavourable prognostic significance is firmly established. Future studies are needed to assess whether or not antihypertensive therapy is able to reduce aortic root dimension and the increased risk associated with its enlargement.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Agmon Y, Khandheria BK, Meissner I, Schwartz GL, Sicks JD, Fought AJ et al (2003) Is aortic dilatation an atherosclerosis-related process? Clinical, laboratory, and transesophageal echocardiographic correlates of thoracic aortic dimensions in the population with implications for thoracicaortic aneurysm formation. J Am Coll Cardiol 42:1076–1083. doi:10.1016/S0735-1097(03)00922-7
Astrand H, Rydén-Ahlgren A, Sundkvist G, Sandgren T, Länne T (2007) Reduced aortic wallstress in diabetes mellitus. Eur J Vasc Endovasc Surg 33: 592–598. doi: http://dx.doi.org/10.1016/j.ejvs.2006.11.011
Baguet JP, Chavanon O, Sessa C, Thony F, Lantelme P, Barone-Rochette G et al (2012) European Society of Hypertension scientific newsletter: hypertension and aortic diseases. J Hypertens 30:440–443. doi:10.1097/HJH.0b013e32834f867a
Bella JN, Wachtell K, Boman K, Palmieri V, Papademetriou V, Gerdts E et al (2002) Relation of left ventricular geometry and function to aortic root dilatation in patients with systemic hypertension and left ventricular hypertrophy (the LIFE study). Am J Cardiol 89:337–341
Biaggi P, Matthews F, Braun J, Rousson V, Kaufmann PA, Jenni R (2009) Gender, age, and body surface area are the major determinants of ascending aorta dimensions in subjects with apparently normal echocardiograms. J Am Soc Echocardiogr 22:720–725. doi:10.1016/j.echo.2009.03.012
Briet M, Bozec E, Laurent S, Fassot C, London GM, Jacquot C, Froissart M, Houillier P, Boutouyrie P (2006) Arterial stiffness and enlargement in mild-to-moderate chronic kidney disease. Kidney Int 69:350–357. doi:10.1038/sj.ki.5000047
Briet M, Boutouyrie P, Laurent S, London GM (2012) Arterial stiffness and pulse pressure in CKD and ESRD. Kidney Int 82:388–400. doi:10.1038/ki.2012.131
Campens L, Demulier L, De Groote K, Vandekerckhove K, De Wolf D, Roman MJ et al (2014) Reference values for echocardiographic assessment of the diameter of the aortic root and ascending aorta spanning all age categories. Am J Cardiol 114:914–920. doi:10.1016/j.amjcard.2014.06.024
Chun KC, Teng KY, Chavez LA, Van Spyk EN, Samadzadeh KM, Carson Teng KY et al (2014) Risk factors associated with the diagnosis of abdominal aortic aneurysm in patients screened at a regional veterans affairs health care system. Ann Vasc Surg 28:87–92. doi:10.1016/j.avsg.2013.06.016
Cipolli JAA, Souza FAS, Ferreira-Sae MCS, Magalhaes JAP, Figueiredo ES, Vidotti VG et al (2009) Sex-specific hemodynamic and nonhemodynamic determinants of aortic root size in hypertensive subjects with left ventricular hypertrophy. Hypertens Res 32:956–961. doi:10.1038/hr.2009.134
Covella M, Milan A, Totaro S, Cuspidi C, Re A, Rabbia F, Veglio F (2014) Echocardiographic aortic root dilatation in hypertensive patients: a systematic review and meta-analysis. J Hypertens 32:1928–1935. doi:10.1097/HJH.0000000000000286
Cuspidi C, Meani S, Fusi V, Valerio C, Sala C, Zanchetti A (2006) Prevalence and correlates of aortic root dilatation in patients with essential hypertension: relationship with cardiac and extra-cardiac organ damage. J Hypertens 24:573–580. doi:10.1097/01.hjh.0000209992.48928.1f
Cuspidi C, Meani S, Valerio C, Esposito A, Sala C, Masaidi M et al (2007) Ambulatory blood pressure, target organ damage and aortic root size in never treated essential hypertensives. J Hum Hypertens 21:531–538. doi:10.1038/sj.jhh.1002200
Cuspidi C, Negri F, Salvetti M, Lonati L, Sala C, Capra A et al (2011) Aortic root dilatation in hypertensive patients: a multicenter survey in echocardiographic practice. Blood Press 20:267–273. doi:10.3109/08037051.2011.565556
Cuspidi C, Facchetti R, Bombelli M, Re A, Cairoa M, Sala C et al (2014) Aortic root diameter and risk of cardiovascular events in a general population: data from the PAMELA study. J Hypertens 32:1879–1887. doi:10.1097/HJH.0000000000000264
Davies RR, Gallo A, Coady MA, Tellides G, Botta DM, Burke B et al (2006) Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg 81:169–177. doi:10.1016/S0003-4975(01)03236-2
Devereux RB, de Simone G, Arnett DK, Best LG, Boerwinkle E, Howard BV et al (2012) Normal limits in relation to age, body size and gender of two-dimensional echocardiographic aortic root dimensions in persons >/=15 years of age. Am J Cardiol 110:1189–1194. doi:10.1016/j.amjcard.2012.05.063
Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H et al (2014) 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 J 35:2873–2926. doi:10.1093/eurheartj/ehu281
Farasat SM, Morrell CH, Scuteri A, Ting CT, Yin FCP, Spurgeon HA et al (2008) Do hypertensive individuals have enlarged aortic root diameters? Insights from studying the various subtypes of hypertension. Am J Hypertens 21:558–563. doi:10.1038/ajh.2008.10
Freestone T, Turner RJ, Coady A, Higman DJ, Greenhalgh RM, Powell JT (1995) Inflammation and matrix metalloproteinases in the enlarging abdominal aortic aneurysm. Arterioscler Thromb Vasc Biol 15:1145–1151. doi:10.1161/01.ATV.15.8.1145
Gardin JM, Arnold AM, Polak J, Jackson S, Smith V, Gottdiener J (2006) Usefulness of aortic root dimension in persons > 65 years of age in predicting heart failure, stroke, cardiovascular mortality, all-cause mortality and acute myocardial infarction (from the Cardiovascular Health Study). Am J Cardiol 97:270–275
Geraci G, Mulè G, Geraci C, Mogavero M, D’Ignoto F, Morreale M et al (2015) Association of renal resistive index with aortic pulse wave velocity in hypertensive patients. Eur J Prev Cardiol 22:415–422. doi:10.1177/2047487314524683
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr et al (2010) 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 121:e266–e369. doi:10.1161/CIR.0b013e3181d4739e
Howard DP, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM, for the Oxford Vascular Study (2013) Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation 127: 2031–2037. doi: 10.1161/CIRCULATIONAHA.112.000483
Humphrey JD, Schwartz MA, Tellides G, Milewicz DM (2015) Role of mechanotransduction in vascular biology: focus on thoracic aortic aneurysms and dissections. Circ Res 116:1448–1461. doi:10.1161/CIRCRESAHA.114.304936
Iarussi D, Caruso A, Galderisi M, Covino FE, Dialetto G, Bossone E et al (2001) Association of left ventricular hypertrophy and aortic dilatation in patients with acute thoracic aortic dissection. Angiology 52:447–455
Ingelsson E, Pencina MJ, Levy D, Aragam J, Mitchell GF, Benjamin EJ, Vasan RS (2008) Aortic root diameter and longitudinal blood pressure tracking. Hypertension 52:473–477. doi:10.1161/HYPERTENSIONAHA.108.11415
Iribarren C, Darbinian JA, Go AS, Fireman BH, Lee CD, Grey DP (2007) Traditional and novel risk factors for clinically diagnosed abdominal aortic aneurysm: the Kaiser multiphasic health checkup cohort study. Ann Epidemiol 17:669–678. doi:10.1016/j.annepidem.2007.02.004
Karakaya O, Barutcu I, Esen AM, Dogan S, Saglam M, Karapinar H et al (2006) Relationship between circulating plasma matrix metalloproteinase-9 (gelatinase-B) concentration and aortic root dilatation. Am J Hypertens 19:361–365. doi:10.1016/j.amjhyper.2005.08.013
Kim M, Roman MJ, Cavallini C, Schwartz JE, Pickering TG, Devereux RB (1996) Effect of hypertension on aortic root size and prevalence of aortic regurgitation. Hypertension 28:47–52
Lai CL, Chien KL, Hsu HC, Su TC, Chen MF, Lee YT (2010) Aortic root dimension as an independent predictor for all-cause death in adults <65 years of age (from the Chin-Shan Community Cardiovascular Cohort Study). Echocardiography 27:487–495. doi:10.1111/j.1540-8175.2009.01072.x
Lam S, Verhagen NA, Strutz F, van der Pijl JW, Daha MR, van Kooten C (2003) Glucose-induced fibronectin and collagen type III expression in renal fibroblasts can occur independent of TGF-beta1. Kidney Int 63:878–888. doi:10.1046/j.1523-1755.2003.00824
Lam CS, Xanthakis V, Sullivan LM, Lieb W, Aragam J, Redfield MM et al (2010) Aortic root remodeling over the adult life course: longitudinal data from the Framingham Heart Study. Circulation 122:884–890. doi:10.1161/CIRCULATIONAHA.110.937839
Lam CSP, Gona P, Larson MG, Aragam J, Lee DS, Mitchell GF et al (2013) Aortic root remodeling and risk of heart failure in the Framingham Heart Study. J Am Coll Cardiol HF 1:79–83. doi:10.1016/j.jchf.2012.10.003
Landenhed M, Engström G, Gottsäter A, Caulfield MP, Hedblad B, Newton-Cheh C et al (2015) Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study. J Am Heart Assoc 4, e001513. doi:10.1161/JAHA.114.001513
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 16:233–271. doi:10.1093/ehjci/jev014
Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, Task Force Members et al (2013) 2013 ESH/ESC Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 31:1281–1357. doi:10.1097/01.hjh.0000431740.32696.cc
Manning WJ, Black JH III. Clinical features and diagnosis of acute aortic dissection. In UpToDate. Retrieved from http://www.uptodate.com/home/index.html. Accessed 29 Mar 2016
Masugata H, Senda S, Murao K, Okuyama H, Inukai M, Hosomi N et al (2011) Aortic root dilatation as a marker of subclinical left ventricular diastolic dysfunction in patients with cardiovascular risk factors. J Int Med Res 39:64–70
Mauer SM (1994) Structural-functional correlations of diabetic nephropathy. Kidney Int 45:612–622. doi:10.1038/ki.1994.80
Milan A, Tosello F, Caserta M, Naso D, Puglisi E, Magnino C et al (2011) Aortic size index enlargement is associated with central hemodynamics in essential hypertension. Hypertens Res 34:126–132. doi:10.1038/hr.2010.185
Milan A, Tosello F, Naso D, Avenatti E, Leone D, Magnino C et al (2013) Ascending aortic dilatation, arterial stiffness and cardiac organ damage in essential hypertension. J Hypertens 31:109–116. doi:10.1097/HJH.0b013e32835aa588
Mitchell GF, Lacourciere Y, Ouellet J-P, Izzo JL Jr, Neutel J, Kerwin LJ et al (2003) Determinants of elevated pulse pressure in middle-aged and older subjects with uncomplicated systolic hypertension: the role of proximal aortic diameter and the aortic pressure-flow relationship. Circulation 108:1592–1598. doi:10.1161/01.CIR.0000093435.04334.1F
Mitchell GF, Conlin PR, Dunlap ME, Lacourciere Y, Arnold JMO, Ogilvie RI et al (2008) Aortic diameter, wall stiffness, and wave reflection in systolic hypertension. Hypertension 51:105–111. doi:10.1161/HYPERTENSIONAHA.107.099721
Mulè G, Cottone S, Cusimano P, Palermo A, Geraci C, Nardi E et al (2010) Unfavourable interaction of microalbuminuria and mildly reduced creatinine clearance on aortic stiffness in essential hypertension. Int J Cardiol 145:372–375. doi:10.1016/j.ijcard.2010.02.047
Mulé G, Nardi E, Morreale M, D’Amico S, Foraci AC, Nardi C et al (2016) Relationship between aortic root size and glomerular filtration rate in hypertensive patients. J Hypertens 34:495–505. doi:10.1097/HJH.0000000000000819
Natoli AK, Medley TL, Ahimastos AA, Drew BG, Thearle DJ, Dilley RJ et al (2005) Sex steroids modulate human aortic smooth muscle cell matrix protein deposition and matrix metalloproteinase expression. Hypertension 46:1129–1134. doi:10.1161/01.HYP.0000187016.06549.96
Nidorf SM, Picard MH, Triulzi MO, Thomas JD, Newee J, King ME et al (1992) New perspectives in the assessment of cardiac chamber dimensions during development and adulthood. J Am Coll Cardiol 19:983–988
O’Rourke MF, Nichols WW (2005) Aortic diameter, aortic stiffness, and wave reflection increase with age and isolated systolic hypertension. Hypertension 45:652–658. doi:10.1161/HYPERTENSIONAHA.107.099721
Palmieri V, Bella JN, Arnett DK, Roman MJ, Oberman A, Kitzman DW et al (2001) Aortic root dilatation at sinuses of valsalva and aortic regurgitation in hypertensive and normotensive subjects: the Hypertension Genetic Epidemiology Network Study. Hypertension 37:1229–1235. doi:10.1161/01.HYP.37.5.1229
Pape LA, Tsai TT, Isselbacher EM, Oh JK, O’gara PT, Evangelista A et al (2007) Aortic diameter > or = 5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD). Circulation 116:1120–1127
Portik-Dobos V, Anstadt MP, Hutchinson J, Bannan M, Ergul A (2002) Evidence for a matrix metalloproteinase induction/activation system in arterial vasculature and decreased synthesis and activity in diabetes. Diabetes 51:3063–3068. doi:10.2337/diabetes.51.10.3063
Prakash SK, Pedroza C, Khalie YA, Milewicz DM (2012) Diabetes and reduced risk for thoracic aortic aneurysms and dissections: a nationwide case–control study. J Am Heart Assoc 1:jah3-e00032310.1161/JAHA.111.000323
Rayner BL, Goodman H, Opie LH (2004) The chest radiograph. A useful investigation in the evaluation of hypertensive patients. Am J Hypertens 17:507–510. doi:10.1016/j.amjhyper.2004.02.012
Reed CM, Richey PA, Pulliam DA, Somes GW, Alpert BS (1993) Aortic dimensions in tall men and women. Am J Cardiol 71:608–610
Roman MJ, Devereux RB, Niles NW, Hochreiter C, Kligfield P, Sato N et al (1987) Aortic root dilatation as a cause of isolated, severe aortic regurgitation. Ann Intern Med 106:800–807
Roman MJ, Devereux RB, Kramer-Fox R, O’Loughlin J (1989) Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol 64:507–512
Savage DD, Drayer JI, Henry WL, Mathews EC Jr, Ware JH, Gardin JM et al (1979) Echocardiographic assessment of cardiac anatomy and function in hypertensive subjects. Circulation 59:623–632. doi:10.1161/01.CIR.59.4.623
Sawabe M, Hamamatsu A, Chida K, Mieno MN, Ozawa T (2011) Age is a major pathobiological determinant of aortic dilatation: a large autopsy study of community deaths. J Atheroscler Thromb 18:157–165
Shantikumar S, Ajjan R, Porter KE, Scott DJA (2010) Diabetes and the abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 39:200–207. doi:10.1016/j.ejvs.2009.10.014
Singh R, Song RH, Alavi N, Pegoraro AA, Singh AK, Leehey DJ (2001) High glucose decreases matrix metalloproteinase-2 activity in rat mesangial cells via transforming growth factor-beta1. Exp Nephrol 9:249–257, 52619
Teixido-Tura G, Almeida AL, Choi EY, Gjesdal O, Jacobs DR Jr, Dietz HC et al (2015) Determinants of aortic root dilatation and reference values among young adults over a 20-year period: coronary artery risk development in young adults study. Hypertension 66:23–29. doi:10.1161/HYPERTENSIONAHA.115.05156
Tell GS, Rutan GH, Kronmal RA, Bild DE, Polak JF, Wong ND et al (1994) Correlates of blood pressure in community-dwelling older adults. The Cardiovascular Health Study. Cardiovascular health study (CHS) Collaborative Research Group. Hypertension 23:59–67
Vasan RS, Larson MG, Levy D (1995) Determinants of echocardiographic aortic root size. The Framingham heart study. Circulation 91:734–740. doi:10.1161/01.CIR.91.3.734
Virmani R, Avolio AP, Mergner WJ, Robinowitz M, Herderick EE, Cornhill JF et al (1991) Effect of aging on aortic morphology in populations with high and low prevalence of hypertension and atherosclerosis. Comparison between occidental and Chinese communities. Am J Pathol 139:1119–1129
Vriz O, Driussi C, Bettio M, Ferrara F, D’Andrea A, Bossone E (2013) Aortic root dimensions and stiffness in healthy subjects. Am J Cardiol 112:1224–1229. doi:10.1016/j.amjcard.2013.05.068
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2016 Springer International Publishing AG
About this chapter
Cite this chapter
Mulè, G. et al. (2016). The Relationship Between Aortic Root Size and Hypertension: An Unsolved Conundrum. In: Islam, M.S. (eds) Hypertension: from basic research to clinical practice. Advances in Experimental Medicine and Biology(), vol 956. Springer, Cham. https://doi.org/10.1007/5584_2016_86
Download citation
DOI: https://doi.org/10.1007/5584_2016_86
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-44250-1
Online ISBN: 978-3-319-44251-8
eBook Packages: MedicineMedicine (R0)