Unraveling the arterial threat: a 25-year U.S. mortality analysis of aortic dissection among patients with atherosclerosis

Background Aortic dissection (AD) is a life-threatening vascular emergency characterized by high case fatality. Atherosclerosis, a chronic inflammatory arterial disease, contributes to vascular stiffness, medial degeneration, and hypertension which are pathophysiologic processes that increase susceptibility to AD. As the U.S. population ages and cardiometabolic risk factors remain prevalent, understanding the burden of AD mortality in individuals with coexisting atherosclerosis is critical. Purpose To evaluate national trends in AD–related mortality among U.S. adults with atherosclerosis from 1999 to 2023 and to assess demographic and geographic disparities in age-adjusted mortality rates. Methods Mortality data from 1999 to 2023 were extracted from the CDC WONDER database using ICD-10 codes for AD and atherosclerosis. Adults with both conditions listed as underlying or contributing causes of death were included. Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated using the 2000 U.S. standard population. Joinpoint regression was applied to assess temporal trends, estimating Annual Percent Change (APC) and Average Annual Percent Change (AAPC), with statistical significance defined as p < 0.05. Analyses were stratified by sex, age, race/ethnicity, census region, urban–rural status, and state. Results A total of 30,779 deaths were attributed to AD among individuals with atherosclerosis between 1999 and 2023, with 48.2% occurring in inpatient settings. The overall AAMR declined by approximately 70%, from 0.80 in 1999 to 0.24 in 2023 (AAPC: –5.7%, 95% CI –6.6 to –4.7, p < 0.001). Mortality rates in men were approximately double those in women (0.86 vs. 0.41), with men demonstrating a slightly steeper decline (–5.9% vs. –4.7%). Adults aged ≥65 years had nearly 46-fold higher AAMRs compared to those aged 25–64 years (2.8 vs. 0.06), although the younger group exhibited a marginally faster decline (–5.8% vs. –5.6%). Non-Hispanic Whites had the highest overall AAMR (0.63), while Hispanics experienced the steepest reduction (–6.9%, 95% CI –8.5 to –5.3, p < 0.001). Regionally, the West had the highest AAMR (0.77), whereas the Midwest showed the sharpest decline (–6.5%, 95% CI –7.7 to –5.7). Rural areas exhibited higher mortality than urban areas (0.76 vs. 0.61) and also a more pronounced decline (–6.7% vs. –6.5%). Conclusion Although AD mortality among individuals with atherosclerosis has declined substantially over the past 25 years, significant demographic and geographic disparities persist, particularly among older adults, men, and rural populations. These improvements likely reflect enhanced cardiovascular risk factor control, earlier detection, and advances in surgical and perioperative management. Continued focus on atherosclerosis prevention, hypertension control, and equitable access to specialized vascular care remains essential to further reduce AD-related mortality.