Key result
Occult shock in normotensive aortic dissection is linked to ~2.4-fold higher in-hospital mortality.
Why the study?
In acute aortic dissection, initial blood pressure alone may miss concealed hypoperfusion, and both the incremental prognostic value of early transthoracic echocardiography alongside computed tomography angiography and the significance of normotensive hyperlactatemia remain uncertain.
Does integrating early transthoracic echocardiography with clinical and computed tomography angiography data in an initial 2-hour multimodal model improve prediction of in-hospital mortality in adults with first-time acute aortic dissection?
Cohort (n=2,584)
Yes
Does integrating early transthoracic echocardiography with clinical and computed tomography angiography data in an initial 2-hour multimodal model improve prediction of in-hospital mortality in adults with first-time acute aortic dissection?
An initial 2-hour multimodal machine learning model incorporating clinical, CTA, and early TTE data accurately predicts in-hospital mortality in acute aortic dissection, highlighting the incremental prognostic value of early TTE and identifying normotensive occult shock as a high-risk phenotype.
Supports early TTE and lactate screening for risk stratification in acute aortic dissection; leaves open whether phenotype-guided escalation improves survival in prospective trials.
Background: Acute aortic dissection (AAD) requires rapid anatomical diagnosis and early risk stratification, yet initial blood pressure alone may miss patients with concealed hypoperfusion. Although computed tomography angiography (CTA) defines dissection anatomy and transthoracic echocardiography (TTE) provides bedside haemodynamic information, the incremental prognostic value of early TTE and the significance of normotensive hyperlactatemia remain uncertain. We aimed to develop and validate an initial 2-hour multimodal model integrating clinical, CTA, and TTE data to predict in-hospital mortality and to describe occult shock in normotensive AAD patients. Methods: This retrospective two-centre cohort study included 2,584 adults with first-time AAD who completed CTA and TTE during the initial 2-hour assessment after emergency department triage. Cohorts were development (n=1,678; 2007–2017), internal temporal validation (n=452; 2018–2021), and external geographic/later-era validation (n=454; 2022–March 2024). Candidate variables were restricted to information available during this initial assessment window. Four supervised algorithms were compared, with ablation analyses assessing modality-specific contribution. Results: XGBoost achieved optimism-corrected development area under the curve (AUC) of 0.86 [95% confidence interval (CI): 0.82–0.88], internal validation 0.83 (0.79–0.87), and external validation 0.78 (0.74–0.82). Adding TTE to Clinical + CTA improved discrimination (Delta AUC +0.04, P=0.002) and integrated discrimination improvement (IDI) (+0.021, P=0.01). Normotensive occult shock occurred in 548/2,082 patients (26.3%) and was associated with mortality 15.9% versus 6.7% in metabolically stable normotension. Conclusions: In high-volume aortic centres where CTA and early TTE are routinely available, this initial 2-hour multimodal model showed temporal validation and moderate external discrimination for in-hospital mortality. TTE added prognostic information, particularly for type A disease, and normotensive hyperlactatemia identified a higher-risk subgroup; however, general use, type B performance, local recalibration, and action thresholds require prospective multicentre validation before clinical implementation.
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Zhou et al. (2026) conducted a cohort in Acute aortic dissection (n=2,584). Occult shock phenotype (normotensive with serum lactate >2.5 mmol/L) and XGBoost multimodal risk model vs. Stable normotensive status (serum lactate <=2.5 mmol/L) and IRAD clinical risk model was evaluated on In-hospital mortality among normotensive patients by occult shock status (serum lactate >2.5 mmol/L vs <=2.5 mmol/L) (RR 2.4, p=<0.001). Occult shock (lactate >2.5 mmol/L) in normotensive acute aortic dissection increased in-hospital mortality vs stable normotension (15.9% vs 6.7%, RR 2.4, p<0.001), while XGBoost achieved an external AUC of 0.78.
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