Richard Holbrooke's Aortic Dissection: Signs of a Tear, and How to Prevent It
The storied diplomat was 69 and had one of the world’s most stressful jobs: two risk factors for aortic dissection, a tear to the body’s largest artery. Casey Schwartz on how to spot signs of a tear to the aorta.
U.S. envoy Richard Holbrooke, who died Monday night, two days after doctors performed surgery to repair a tear in his aorta, was in the highest risk population for aortic dissection—men between the ages of 50 to 70. High blood pressure, which is linked to stress, is also a prominent risk factor. Holbrooke, 69, a storied diplomat and the special envoy to Afghanistan and Pakistan, no doubt had one of the most stressful jobs on the planet, managing America’s strategy in the region and most recently dealing with the WikiLeaks mess, which exposed many of his private diplomatic cables.
On Friday, Holbrooke fell ill during a meeting at the State Department with Secretary of State Hillary Clinton and was rushed to George Washington University Hospital. Doctors there performed a 20-hour surgery in an attempt to repair his aortic dissection. The largest artery, the aorta arches up from the heart, carrying blood throughout the body.
While an aortic dissection is far less common than a heart attack, with roughly 4,000 new cases occurring each year in the United States, doctors do not consider it rare. Many of the symptoms overlap with those of a heart attack; often, it comes on as sudden, sharp pain in the chest or back. But sometimes, the telltale sign that it is aortic dissection and not a heart attack is that one limb will get cold or limp—because the blood flow has been disrupted.
High-profile cases of aortic dissection include Jonathan Larson, the whiz kid composer of the hit musical Rent, who died from a torn aorta in 1996, the night before the show’s off-Broadway debut. In 2003, the actor John Ritter, best known from Three’s Company, died of a tear at the age of 54; his family insisted that he was misdiagnosed when he got to the emergency room and that his doctors, believing he was having a heart attack, lost crucial time treating him.
When treated promptly, surgical outcomes are relatively good, with an 85 percent survival rate. To prevent aortic dissection, taking steps to keep blood pressure in check—healthy diet, exercise, and stress reduction—are strongly urged on patients, particularly those with a family history of heart problems.
The doctor who pioneered the procedure used to repair aortic dissection, Michael DeBakey, wound up requiring the procedure himself. In 2005, DeBakey suffered an aortic dissection and became the world’s oldest survivor, at age 97, of the surgery he had invented.
Sometimes the telltale sign that it is an aortic dissection and not a heart attack is that one limb will get cold or limp—because the blood flow has been disrupted.
Robert Kaiser, an editor at The Washington Post, described his own aortic dissection procedure in a lengthy piece published in The Washington Post magazine in 2004.
The closer the tear occurs to the root of the aorta, where it emerges from the heart, the more dangerous it can be. While not confirmed, doctors suspect that Holbrooke’s dissection was located in a particularly dangerous part of the aorta, where it first ascends upward from the heart.
“I assume it’s the ascending artery because they operated on him,” said Richard Shemin, chief of cardiothoracic surgery at UCLA.
When the aorta tears, blood leaks into the artery’s outer wall and can create a variety of disastrous circumstances—interrupting blood flow through the body, or causing blood to leak into the sac that contains the heart, bearing down on the heart so heavily that it can no longer contract. Most often, it presents as a sudden, searing pain in the chest or back.
It is considered the “great mimicker of heart attacks” because so many of the symptoms are the same, said Gabriele Di Luozzo, a cardiothoracic surgeon at Mount Sinai Hospital.
Di Luozzo said he believes that the incidence of aortic dissection is underreported, as many deaths from aortic dissection are likely to be mislabeled as heart attacks. He stressed the importance of time in responding to aortic dissections—with each hour that passes after the initial appearance of symptoms, mortality rates rise by 1 percent.
According to P.K. Shah, a cardiologist at the Cedars-Sinai Heart Institute in Los Angeles, 50 percent of aortic dissection patients will die within the first 48 hours. Left untreated, the condition, said Shah, is “very lethal.” It is “worse than the worst cancer you can imagine.”
Casey Schwartz is a graduate of Brown University and has a master's degree in psychodynamic neuroscience from University College London. She has previously written for The New York Sun and ABC News. Currently, she's working on a book about the brain world.