Alan Thicke Died of a Ruptured Aorta

The world was shocked this week when Growing Pains actor Alan Thicke, collapsed on December 13 while playing hockey at the Pickwick Gardens ice rink in Burbank, CA. He died shortly after leaving the ice rink, presumably of a massive heart attack. But the autopsy report, obtained by People magazine, revealed that Thicke had suffered a “ruptured aorta” caused by a “standard type A aortic dissection.”

According to a source that was at the ice rink at the time of Thicke’s collapse:

“Alan had taken a few shifts and seemed to be fine. Then during a shift, he seemed to falter, and skated to the bench. He was sitting on the bench, hunched over, then started experiencing pain. He laid down and started moaning loudly, holding his head. We called 911 and the paramedics came within two to three minutes. He was conscious and had stopped moaning by the time they took him out and to the hospital.”

Thicke had been playing hockey with his 19-year-old son Carter, who took to Twitter late Tuesday to say:  “Today I lost my best friend and my idol, and the world lost one of it’s finest. You are a legend and I love you Pops. Until next time.”

Older son, singer Robin Thicke, told the Los Angeles Times that his father was:  “the greatest man I ever met” and “always a gentleman.” Though he is devastated, he noted, “The good thing was that he was beloved and he had closure. I saw him a few days ago and told him how much I loved and respected him.”

What is aortic dissection and rupture?

The aorta is the main blood vessel that takes blood from the heart to the rest of the body. Like all blood vessels, its walls are made up of three layers:

  • the inner lining (which is in contact with the blood) called the tunica intima (commonly called the intima), which is made up of endothelial cells- thin smooth cell which reduce friction through the blood vessels.
  • the tunica media which is made up of smooth muscles and elastic tissues
  • the tunica adventia, the outer layer of the blood vessel made of a more fibrous material.

Aortic dissection

Blood dissecting from the tunica intima to the tunica media

In aortic dissection, damage to the intima layer allows blood to dissect its way into the media layer. Over time, the wall of the blood vessel balloons out. This weakens the wall of the aorta.  If it reaches a critical point, the wall can rupture, leading to sudden death.

The dissection can occur anywhere along the length of the aortic. Close to the heart it’s called a proximal dissection; lower down in the abdomen is referred to as a distal dissection. Aortic dissection occurs more frequently in men, between the ages of 50-55 for proximal dissection, 60-70 years old for distal dissection.

What causes an aortic dissection?

Factors that can increase the risk of aortic dissection include:

  • high blood pressure
  • an abnormal aortic heart valve (especially one called a bicupsid valve where the valve is made of two instead of the normal three leaflets)
  • family history of aortic dissection
  • certain genetic conditions, such as Marfan’s Disease and Turner’s Syndrome.

How are aortic dissections classified?

stanford-a-type-aortic-dissectionThe main classification system is called The Stanford classification. It is divided into two groups, A and B, depending on whether the ascending aorta is involved.

  • A – involves the ascending aorta and/or aortic arch, and possibly the descending aorta. The tear can originate in the ascending aorta, the aortic arch, or more rarely, in the descending aorta.
  • B – involves the descending aorta or the arch (distal to the left subclavian artery), without the involvement of the ascending aorta.

The Stanford classification is useful as it follows how the two types are treated clinically. Type A ascending aortic dissections generally require primary surgical treatment.  Type B dissections generally are treated medically as initial treatment. Surgery is reserved for any complications.

The reason for surgical repair of type A dissections is that ascending aortic dissections often involve the aortic valve. This can lead to leakiness of the valve. It can also cause damage to the coronary arteries.  To treat a Type A dissection, the area of dissection is removed and replaced with a Dacron graft. Type B dissections are not improved, at least from a mortality point of view, by the operation. That is, unless leaking, rupture, or compromise occurs to other organs, such as the kidneys.

What is the John Ritter Foundation for Aortic Health?

John Ritter Foundation for Aortic Health was founded in October 2003, just weeks after Three’s Company actor John Ritter’s sudden death due to an acute aortic dissection. Formed by his widow, Amy Yasbeck, and their family for the purpose of receiving donations in honor of John’s life, the foundation is focused on thoracic aortic disease education, support, and research.Their mission is to promote knowledge of aortic aneurysm and dissection through research and education.

Working with the TAD (Thoracic Aortic Disease) Coalition, the Ritter Foundation is working to increase public awareness of new Treatment Guidelines for Thoracic Aortic Disease released in March of 2010 from the American Heart Association (AHA) and the American College of Cardiology (ACC) as well as other interested groups. Part of this campaign includes what are now called the Ritter Rules, life-saving reminders to recognize, treat and prevent thoracic aortic dissection

What are the Ritter Rules?

(Reproduced here with permission from the TAD Coalition)

URGENCY: Thoracic aortic dissection is a medical emergency. The death rate increases 1% every hour thediagnosis and surgical repair are delayed.

PAIN: Severe pain is the #1 symptom. Seek immediate emergency medical care for a sudden onset of severe pain in the chest, stomach, back or neck. The pain is likely to be sharp, tearing, ripping, moving or so unlike any pain you have ever had that you feel something is very wrong.

MISDIAGNOSIS: Aortic dissection can mimic heart attack. Heart attacks are far more common than aortic dissection. But if a heart attack or other important diagnosis is not clearly and quickly established, then aortic dissection should be quickly considered and ruled out, particularly if a patient has a family history or features of a genetic syndrome that predisposes the patient to an aortic aneurysm or dissection.

IMAGING: Get the right scan to rule out aortic dissection. Only three types of imaging studies can identify aortic aneurysms and dissections: CT, MRI and transesophageal echocardiogram. A chest X-ray or EKG cannot rule out aortic dissection.

RISK FACTOR: Aortic dissections are often preceded by an enlargement of the first part of the aorta where it comes out of the heart, called an aortic aneurysm. If you have an aneurysm, you are at increased risk for an aortic dissection.

RISK FACTOR: A personal or family history of thoracic disease puts you at risk. If you or a family member is living with an aneurysm or if you have a family member who has had an aortic dissection, you are at an increased risk for thoracic aortic dissection. You and your other family members should be evaluated to determine if a predisposition for aortic aneurysm and dissection is running in the family.

RISK FACTOR: Certain genetic syndromes put you at risk. These genetic syndromes greatly increase your risk for thoracic aortic disease and a potentially fatal aortic dissection: Marfan syndrome, Loeys-Dietz syndrome, Turner syndrome and vascular Ehlers-Danlos syndrome.

RISK FACTOR: Bicuspid aortic valve disease puts you at risk. If you have a bicuspid aortic valve (two leaflets instead of the typical three), or have had a bicuspid aortic valve replaced, you need to be monitored for thoracic aortic disease.

TRIGGERS: Lifestyle and trauma can trigger aortic dissection. It is possible to trigger an aortic dissection through injury to the chest, extreme straining associated with body building, illicit drug abuse, poorly controlled high blood pressure or by discontinuing necessary blood pressure medications. Rarely, pregnancy can trigger an aortic dissection. However, women with aortic aneurysms and connective tissue disorders who are pregnant are at higher risk of aortic dissection during late pregnancy and delivery and should be carefully monitored by a cardiovascular specialist.

PREVENTION: Medical management is essential to preventing aortic dissection. If you have thoracic aortic disease, medical management that includes optimal blood pressure control, aortic imaging and genetic counseling is strongly recommended. Talk with your physician.

Michele R. Berman, M.D. was Clinical Director of The Pediatric Center, a private practice on Capitol Hill in Washington, D.C. from 1988-2000, and was named Outstanding Washington Physician by Washingtonian Magazine in 1999. She was a medical internet pioneer having established one of the first medical practice websites in 1997. Dr. Berman also authored a monthly column for Washington Parent Magazine.

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