Lindsay Graham death and ‘one of the biggest unanswered questions’

Sen. Lindsey Graham’s death Saturday at age 71 following an aortic dissection has focused attention on the life-threatening condition. Details about his diagnosis and treatment are not available while a final death certificate is pending, but experts agree on both how serious it is and how suddenly it erupts after a long prelude.

One cardiothoracic surgeon had questions about the South Carolina senator’s care. 

“Somebody of his stature and age surely has had access to very high-level medical care. At some point he’s had an echocardiogram of the chest to look at the heart and some imaging study of the chest. If he hadn’t had any of those studies, I’d wonder why,” Mark Peterson, the system director of aortic surgery at NYU Langone Health, told STAT in an interview. “And if he did, did he have signs of a dilated or aneurysmal aorta that was either being monitored or was missed?”

Patients who come to his aorta clinic often say they’d had an echocardiogram a few years ago that showed a dilated aorta — a predictor of dissection — or the bulging vessel wall of an aneurysm, but nobody took it seriously or told them about it.

“I’d be very curious to know if he’s had some advanced imaging study of the chest and if so, what it showed and if it showed any signs of enlargement or dilatation or aneurysm, what was the recommendation based on his medical team?” Peterson said about Graham. “It’s all speculation now.”

Aortic dissection is abrupt, but it doesn’t come out of nowhere. When the body’s most important blood vessel tears from the inside, it’s a medical emergency that can be years in the making. More common as people reach their 50s and 60s, it’s rare after age 80. It occurs twice as often in men than women. 

What doctors don’t know is whose aorta might be most likely to fail — and why.

“This is one of the biggest unanswered questions in the field,” Joanna Chikwe, chair of cardiac surgery in the Smidt Heart Institute at Cedars-Sinai, told STAT in an email interview. “Improving risk prediction — by combining genetics, clinical factors, imaging, biomechanics, and potentially AI — is likely to be one of the major advances in preventing aortic dissection over the next decade.”

People diagnosed with atherosclerosis are vulnerable to sudden damage from high blood pressure hammering their arteries while fats, cholesterol, and calcium harden and narrow those vessels. Their weakened arteries widen, a warning sign that they might shear under pressure. Aortic diameter is an important predictor, Chikwe said, but it’s an imperfect surrogate for the underlying strength of the aortic wall.

Still, when imaging scans show an aorta is getting wider, patients are cautioned to limit any tension — like lifting weights — that could undermine the integrity of these important blood vessel walls that shred from the inside out. 

Cardiologist Eric Topol, who is also director of the Scripps Research Translational Institute, will never forget a patient who died outside his gym right after a workout. The man was considered at risk for an aortic dissection, based on imaging studies, and was warned against lifting weights.

Long before the aorta ruptures, there are tools to treat the underlying atherosclerosis, including statins to lower cholesterol and blood pressure pills to bring down hypertension, but surveillance and surgery remain the options to avoid aortic dissection. 

Echocardiograms and CT scans offer a picture of blood vessel health, with guidelines based on vessel width dictating when surveillance should begin. Surgery can correct the problem, but it’s a major, high-risk operation to replace the weakened aorta with a graft. Another option is a minimally invasive repair that threads a stent into the artery to close the torn vessel lining. 

The challenge is determining who might benefit.

That’s where AI might help, Topol said, something scientists are exploring. 

“We are terribly weak at predicting who is going to progress from a widened aorta into a dissection, unfortunately. Where AI could make a huge contribution is to help pinpoint the people at risk because we waste a lot of imaging, putting people through all these MRIs and CTs and echoes on a frequent basis and only a very small proportion of those actually go ahead and have a dissection,” he told STAT. “Our ability to discriminate is very weak. And we need help.” 

Right now clinical decisions lean heavily on aortic diameter, Chikwe said, but many dissections happen below surgical thresholds of about 4.5 to 5 centimeters. The goal would be more personalized risk prediction rather than relying on diameter alone. She called it an active area of research but not yet part of routine clinical practice.

“AI may help identify more subtle markers of risk by analyzing CT, MRI, or echocardiographic images, including aortic shape, wall characteristics, tissue properties, growth patterns, and biomechanical stress that are difficult for the human eye to quantify,” she said. “AI can be used to identify people at high risk of aortic disease from other routine imaging.” 

Family history in heart disease is a well-known risk factor, but aortic dissection may not always be declared as the cause of death. Aortic dissections are estimated to occur in 20,000 people in the United States every year, half of which are fatal. The incidence may well be higher, experts believe, because so many people don’t have autopsies after sudden death. The more common heart attack may be blamed when the cause in some cases was actually aortic dissection. 

Graham’s father died of a heart attack at age 60.

Chikwe called family history one of the most important clues to increased risk. About 1 in 5 patients with aortic aneurysm or dissection have a first-degree relative with similar disease, who may have died suddenly. 

“Early identification can be lifesaving because many affected individuals have no symptoms before a catastrophic event,” she said.

Unexplained sudden death, thoracic aneurysm, or dissection in a family member should prompt discussion of genetic testing and imaging of first-degree relatives, the experts said.

Genetic syndromes are more rare. Connective tissue disorders such as Marfan syndrome and Loeys-Dietz syndrome make people vulnerable, while Turner syndrome and other genetic disorders affecting the aorta and aortic valve, place people at high risk of developing an enlarged aorta. That can lead to abnormalities in the heart and blood vessels that later result in a tear or dissection in the aorta.

All told, aortic dissections and the related aneurysms — when a weakened part of the aorta bulges — accounted for 3.5 out of 100,000 deaths in 2023, ranking it 10th highest on the list of cardiovascular death causes in the U.S. and globally, Gregory Roth, professor of professor of cardiology at the University of Washington and co-author of a study tracking coronary artery disease mortality, told STAT. The leading risk for aortic disease is by far tobacco smoking, followed by high blood pressure and high BMI. 

The relatively rare condition doesn’t warrant routine surveillance screening, Peterson of NYU Langone said. That makes family history all the more crucial, he said, comparing aortic dissection to a “silent ticking time bomb” in those at risk.

Once the aorta ruptures, it’s a surgical emergency, Peterson said, so much so that if it happened in the emergency department, there wouldn’t be enough time to get the patient to the operating room. “Unless you have a surgical team scrubbed and ready to go, and you can immediately open the chest and put somebody on bypass, even then it may not be fast enough.” 

Graham’s death has given heart doctors an opportunity to get the word out on how to tell if an aortic dissection or some other serious heart problem is happening. When in doubt, call 911. 

“Treat it as a medical emergency,” Chikwe wrote. Longer term, she said, “aortic dissection is time-critical, and early diagnosis and treatment substantially improve survival.”