The sudden death of United States Senator Lindsey Graham, is drawing new attention to a condition many Americans have never heard of until it becomes fatal: aortic dissection.
Graham, 71, died Saturday night from what his office described as a brief and sudden illness, and the senator's office later said the preliminary cause of death was aortic dissection due to arteriosclerotic cardiovascular disease — a rupture of his aorta brought on by hardened arteries.
His death has prompted renewed public interest in a condition that, according to Dr. James Wudel, kills a large share of the people it strikes before they ever reach a hospital.
Wudel is Director of the Heart, Vascular & Thoracic Institute at Cleveland Clinic Indian River Hospital and holds the Dr. Cary L. Stowe Endowed Chair for Cardiovascular Surgery.
He explained the condition in a recent interview, breaking down what happens inside the body, how doctors catch it, and who's most at risk.
The aorta is the body's largest blood vessel, carrying blood out of the heart and distributing it throughout the body.
"It's distributing or carrying blood, and then it goes into your abdomen, and it is in some ways the highway that carries the blood and then distributes it to the smaller blood vessels," Wudel said.
An aortic dissection occurs when blood forces its way between the layers of the aorta's wall. "In an aortic dissection, the blood gets in between certain layers of the aorta, and it produces a double barrel, if you will, flow in the aorta," Wudel said, "and that causes acute problems, pains, ultimately leading, if not treated, leads to death in many circumstances."
The location of the tear matters enormously. Dissections in the ascending aorta — the section closest to the heart — are considered critical emergencies requiring immediate treatment.
Wudel said the symptoms of an aortic dissection closely mirror those of a heart attack, which can make it harder to diagnose right away.
"The common presentation is just terrible chest pain, terrible back pain, and that typically brings people into the emergency room," he said.
Because heart attacks are far more common than aortic dissections, doctors typically rule one out before finding the other.
Wudel said it's "usually found in the emergency room with a CT scan while a person's undergoing evaluation for typically very severe chest pain or back pain" — often ordered to check for an injury to the chest or a blood clot in the lungs, only for doctors to discover the dissection along the way.
The stakes are high. "Up to 30 to 40 percent of people do not make it to the emergency room," Wudel said. "They pass away instantaneously because it can be so devastating" — a statistic that echoes the swift, sudden nature of Graham's death.
For those who do make it in, treatment depends on where the tear occurred. Patients with a dissection in the ascending aorta, Wudel said, "are recommended to undergo urgent open heart surgery to replace that segment of the aorta and put the layers back together, if you will... so that the flow is restored in a normal pattern and to prevent complications otherwise and bad outcomes."
Wudel said most cases trace back to a familiar set of risk factors. "Being as one gets older, certainly older than 40 and one gets into their 50s, 60s, 70s, things like uncontrolled high blood pressure is a risk factor," he said.
"Ongoing smoking is a risk factor. Poorly controlled atherosclerosis" — the buildup of plaque in the arteries — can affect the aorta as well as the heart, he added, noting that blockages found in the coronary or carotid arteries can be a warning sign.
A smaller number of patients face risk for genetic reasons, including inherited aortic disease or connective tissue disorders.
But Wudel said the larger category is people with "poorly controlled blood pressure" who "continue to smoke" and have atherosclerotic problems elsewhere in the body — risk factors patients and their doctors can act on before a dissection ever occurs.