The passing of Sen. Lindsey Graham on Saturday at 71 due to an aortic dissection has drawn attention to this severe medical condition. While specifics of his diagnosis and treatment remain undisclosed pending a final death certificate, experts concur on the conditionâs critical nature and its rapid onset after a prolonged development period.
Questions have arisen regarding the medical care received by the South Carolina senator.
Mark Peterson, the system director of aortic surgery at NYU Langone Health, expressed his curiosity about Graham’s medical evaluations. “Someone of his status and age surely had access to top-tier medical care. It would be expected that he had undergone an echocardiogram and possibly a chest imaging study. If not, I would question why,” Peterson told STAT in an interview. “If he did, were there indications of a dilated or aneurysmal aorta that were either monitored or overlooked?”
Peterson noted that patients at his aorta clinic often report having had an echocardiogram years prior, revealing a dilated aortaâa precursor to dissectionâor an aneurysm’s bulging vessel wall, yet no one took these findings seriously or informed them.
“I’m very curious to know if he had advanced chest imaging, and if so, what it revealed. Was there enlargement, dilation, or an aneurysm, and what were the medical team’s recommendations?” Peterson speculated about Graham’s case. “It’s all speculation now.”
Aortic dissection occurs suddenly, though it builds over time. This medical emergency involves the inner tearing of the bodyâs main blood vessel, and while more common in individuals in their 50s and 60s, it is rare past 80. It affects men twice as frequently as women.
One of the unresolved issues for doctors is determining who is most at risk for an aortic failure and why.
Joanna Chikwe, chair of cardiac surgery at the Smidt Heart Institute at Cedars-Sinai, remarked on the challenge in an email interview with STAT. “This is one of the biggest unanswered questions in the field,” she said. “Enhancing risk prediction by integrating genetics, clinical factors, imaging, biomechanics, and potentially AI could be a significant advancement in preventing aortic dissection over the next decade.”
Individuals diagnosed with atherosclerosis are susceptible to damage from high blood pressure, which can weaken arteries as fats, cholesterol, and calcium cause them to harden and narrow. The widening of these weakened arteries signals the risk of rupture. Chikwe noted that while aortic diameter is a key predictor, it is not a perfect measure of the aortic wallâs strength.
When scans show widening of the aorta, patients are advised to avoid activities like weightlifting that could jeopardize these blood vessels’ integrity from the inside.
Cardiologist Eric Topol, director of the Scripps Research Translational Institute, recalled a patient who died after a gym workout despite being warned against lifting weights due to dissection risk identified through imaging.
Preventative tools for atherosclerosis include statins to lower cholesterol and medications for hypertension, but regular monitoring and surgery are the main preventive measures for aortic dissection.
Echocardiograms and CT scans provide insights into blood vessel health, with guidelines based on vessel width dictating surveillance timing. While surgery can address the issue, it involves a high-risk procedure to replace the aorta with a graft. Alternatively, a minimally invasive stent repair may be used to seal the torn lining.
Determining who should undergo these procedures remains a challenge.
Topol noted the potential of AI in this regard, stating scientists are exploring its applications. “We are not very good at predicting who will progress from a widened aorta to a dissection. AI could help identify at-risk individuals more accurately, reducing unnecessary imaging,” he told STAT.
Currently, clinical decisions heavily depend on aortic diameter, Chikwe explained, but many dissections occur below the surgical threshold of 4.5 to 5 centimeters. The aim is to develop more personalized risk predictions rather than relying solely on diameter. This is an active research area, though not yet standard practice.
âAI may help identify more subtle risk markers by analyzing CT, MRI, or echocardiographic images, including aortic shape, wall characteristics, tissue properties, growth patterns, and biomechanical stress, which are hard for the human eye to quantify,â Chikwe said. âAI can be used to identify people at high risk of aortic disease from other routine imaging.â
Family history of heart disease is a recognized risk factor, but aortic dissection might not always be listed as the cause of death. Annually, aortic dissections are estimated to occur in 20,000 people in the U.S., with half being fatal. The actual incidence might be higher as autopsies are not always conducted following sudden deaths, and heart attacks are sometimes incorrectly attributed as the cause instead of aortic dissection.
Grahamâs father died of a heart attack at 60.
Chikwe emphasized the significance of family history in assessing risk. Approximately 20% of patients with aortic aneurysm or dissection have a first-degree relative with a similar condition, potentially leading to sudden death.
âEarly identification can save lives because many individuals show no symptoms before a catastrophic event,â she stated.
Sudden unexplained deaths, thoracic aneurysm, or dissection in a family member should prompt consideration of genetic testing and first-degree relatives’ imaging, according to experts.
Genetic syndromes are rarer, but connective tissue disorders like Marfan syndrome and Loeys-Dietz syndrome increase vulnerability, while Turner syndrome and other genetic disorders affect the aorta and valve, raising risks of enlargement, heart, and blood vessel abnormalities, potentially leading to aortic tears or dissections.
In 2023, aortic dissections and related aneurysms accounted for 3.5 out of 100,000 deaths, ranking 10th among cardiovascular death causes globally. Gregory Roth, a cardiology professor at the University of Washington and co-author of a coronary artery disease mortality study, noted that tobacco smoking is the leading aortic disease risk, followed by high blood pressure and high BMI.
Given the condition’s rarity, routine surveillance screening is not warranted, according to Peterson of NYU Langone, who stressed the importance of family history, likening aortic dissection to a “silent ticking time bomb” for at-risk individuals.
Once the aorta ruptures, it becomes a surgical emergency, Peterson explained, noting that even if it occurs in the emergency department, there might not be sufficient time to reach the operating room. “Unless a surgical team is scrubbed and ready, and the chest can be immediately opened to put someone on bypass, it still might not be fast enough.”
Grahamâs death has provided heart specialists a platform to educate the public about recognizing an aortic dissection or similar heart issue. In uncertain situations, calling 911 is advised.
“Treat it as a medical emergency,” Chikwe wrote. Long-term, she added, “aortic dissection is time-critical, and early diagnosis and treatment substantially improve survival.”
