Aortic dissection is the most devastating complication of thoracic aortic disease. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta. In this review, we describe normal thoracic aortic size; risk factors for dissection, including genetic and inflammatory conditions; the underpinnings of genetic diseases associated with aneurysm and dissection, including Marfan syndrome and the role of transforming growth factor beta signaling; data on the role for medical therapies in aneurysmal disease, including beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors; prophylactic surgery for aneurysm; surgical techniques for the aortic root; and surgical and endovascular management of aneurysm and dissection for different aortic segments.

H eart failure is epidemic in developed countries and is expanding rapidly worldwide. Roughly 5% of patients with heart failure have end-stage disease that is refractory to medical therapy (stage D heart failure). 1 Palliative care consultation relieves symptoms, improves patient satisfaction, and decreases the costs of care for these patients. Despite this, only a small fraction of end-stage heart failure patients receive palliative care consultation. In recognition of this, palliative/hospice care referral was recommended for endstage heart failure (Level of Evidence 1A) in the most recent American College of Cardiology/American Heart Association heart failure guidelines. 2 To identify evidence-based studies of palliative care in heart failure, we searched the Medline database for literature with the medical subject headings "heart failure" and "palliative care," "supportive care," or "symptom management" and found 394 results. We identified 92 systematic reviews, 44 of which were English-language systematic reviews published within the past 5 years.

Background and Purpose-Posttraumatic stress disorder (PTSD) can be triggered by life-threatening medical events such as strokes and transient ischemic attacks (TIAs). Little is known regarding how PTSD triggered by medical events affects patients' adherence to medications. Methods-We surveyed 535 participants, age Ն40 years old, who had at least 1 stroke or TIA in the previous 5 years.PTSD was assessed using the PTSD Checklist-Specific for stroke; a score Ն50 on this scale is highly specific for PTSD diagnosis. Medication adherence was measured using the 8-item Morisky scale. Logistic regression was used to test whether PTSD after stroke/TIA was associated with increased risk of medication nonadherence. Covariates for adjusted analyses included sociodemographics, Charlson comorbidity index, modified Rankin Scale score, years since last stroke/TIA, and depression. Results-Eighteen percent of participants had likely PTSD (PTSD Checklist-Specific for stroke Ն50), and 41% were nonadherent to medications according to the Morisky scale. A greater proportion of participants with likely PTSD were nonadherent to medications than other participants (67% versus 35%, PϽ0.001). In the adjusted model, participants with likely PTSD were nearly 3 times more likely (relative risk, 2.7; 95% CI, 1.7-4.2) to be nonadherent compared with participants without PTSD (PTSD Checklist-Specific for stroke Ͻ25) even after controlling for depression, and there was a graded association between PTSD severity and medication nonadherence.