This scientific presentation covered in this article was part of the STS 2023 session “Perspectives from Asia: Aortic Disease, Coronary Disease, and Mechanical Circulatory Support,” and is available in Annual Meeting Online. Access or purchase it here.
For Asian patients with aortic disease, determining whether to take a surgical or conservative approach to treatment may depend on much more than size.
“Given my particular interest in aortic surgery and participation in the recently released American College of Cardiology/American Heart Association guidelines, I was asked to try to answer this question,” said Edward P. Chen, MD, from Duke University School of Medicine in Durham, North Carolina. “As I dug deeper, I found that the answer is considerably more complicated than a simple yes or no.”
In terms of comparative studies, data that can help to quantify aortic disease risk can vary significantly in populations identified as “Asian,” Dr. Chen said. Even as body habitus fluctuates from region to region, the risk of adverse events may be based not only on the diameter of the aorta, but also aortic diameter indexed to both body surface area and height.
“As it turns out, despite what I heard occasionally when I was growing up, Asians do not all look the same.”
Environmental and cultural factors throw another wrench: A patient who is a Japanese national, for example, might have a markedly different lifestyle than an ethnically Japanese patient living in the West.
“When I was a medical student, for instance, I learned there was a high incidence of gastric cancer in Japan," Dr. Chen said. "But Japanese people living in the US have more colorectal cancer, which could potentially be explained by differences in both diet and environmental conditions.”
The incidence of comorbid conditions—as well as access to health care—ranges widely in patient cohorts across the globe. When Dr. Chen began researching his presentation, he reached out to Dr. Kay-Hyun Park of Seoul, Korea, president of the Asian Society for Cardiovascular and Thoracic Surgery, for an additional perspective.
Dr. Park’s blunt reply: “I (and probably any Asian surgeon) cannot represent the entire ‘Asia’ and deliver the ‘Asian perspective,’ because I have no means to grasp what they are doing in the other Asian countries.”
Dr. Park added, “Even in my own neighborhood in Korea, their aggressiveness is quite varied.” He went on to say that, in areas where patients might have more limited access to state-of-the-art surgical care, a surgeon might err more aggressively on the side of surgery—not knowing when they might get to see that patient again.
Acknowledging the limitations and complexity at work, Dr. Chen and his coauthors aimed to design the latest guidelines to assist the clinician in making the best decisions for each patient on a case-by-case basis.
The presentation was part of a session hosted jointly by STS and the Asian Society for Cardiovascular and Thoracic Surgery, “Perspectives from Asia: Aortic Disease, Coronary Disease, and Mechanical Circulatory Support,” moderated by S. Christopher Malaisrie, MD, and Wilson Y. Szeto, MD.
“Shared decision making is going to be the key here,” Dr. Chen said. “Yes, we don't actually have all the answers. But what we should do is take the data we have and try to individualize it to every patient we take care of, and not have a uniform umbrella policy. Particularly here in the United States, with the potpourri of diverse ethnic groups we take care of, it’s important to use the guidelines along with the data we have, the patient’s known measurable anatomic factors as well as lifestyle considerations, and one’s own experience and clinical judgment to make the best decision possible for the patient.”
