**Background:** Type A acute aortic dissection (TAAAD) is a rare but highly lethal cardiovascular emergency, with in-hospital mortality rates ranging from 10% to 49%. Despite improvements in surgical management, few comprehensive studies have examined how outcomes are distributed across racial and ethnic groups. Given known disparities in cardiovascular disease burden, hypertension prevalence, and access to care among Black and Hispanic populations, this study aimed to determine whether racial disparities exist in mortality, cost, and length of stay after surgical repair of TAAAD.
**Methods:** The authors used the National Inpatient Sample (NIS), the largest all-payer inpatient database in the United States, covering approximately 20% of all discharges. Data from the fourth quarter of 2015 through 2018 were analyzed. Patients with TAAAD were identified using ICD-10 codes for thoracic or thoracoabdominal aortic dissection (I71.01, I71.03) combined with surgical procedure codes on the ascending aorta (e.g., 02QX0ZZ, 02RX0JZ). Only nonelective admissions were included. The final cohort comprised 3952 admissions after excluding those with missing race data (n=236). Race/ethnicity was categorized as White, Black/African American, Hispanic, Asian and Pacific Islander (API), and Other. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), total cost (adjusted using cost-to-charge ratios), and postoperative complications (e.g., shock/cardiac failure, pulmonary complications, hemorrhage, stroke). Multivariable logistic regression models were built to assess the independent association of race with mortality, adjusting for demographics, comorbidities (including Elixhauser Comorbidity Index), insurance status, and hospital characteristics. Interaction analyses between race and median household income were also performed.
**Key Results:** Among the 3952 admissions, 63% were White (n=2520), 21% Black/African American (n=848), 8% Hispanic (n=310), 4% API (n=146), and 3% Other (n=128). Black/African American and Hispanic patients presented at a median age of 54 years and 55 years, respectively, compared to 64 years for White and 63 years for API patients (P<.0001). A higher proportion of Black/African American (54%) and Hispanic (32%) admissions lived in ZIP codes with the lowest median household income quartile, whereas 52% of API admissions were in the highest quartile (P<.0001). Hypertension was more prevalent in Black/African American (92%), Hispanic (88%), and API (84%) admissions compared to White admissions (79%) (P<.0001). Unadjusted in-hospital mortality was highest among White admissions (17%) and lowest among Black/African American admissions (11%) (P<.0001). After multivariable adjustment, race was not independently associated with mortality: Black/African American (OR 0.973, 95% CI 0.944-1.003, P=.072), Hispanic (OR 0.972, 95% CI 0.931-1.013, P=.2), API (OR 1.002, 95% CI 0.946-1.062, P=.933). Factors independently associated with higher mortality included increasing age (OR 1.002, 95% CI 1.001-1.003), Elixhauser Comorbidity Index (OR 1.029, 95% CI 1.003-1.056), chronic ischemic heart disease (OR 1.039, 95% CI 1.011-1.068), preoperative shock (OR 1.211, 95% CI 1.179-1.243), and self-pay insurance (OR 1.075, 95% CI 1.021-1.131). Hypertension was associated with lower mortality (OR 0.934, 95% CI 0.907-0.962). No significant interactions between race and income on mortality were found. For secondary outcomes, Hispanic admissions had longer LOS (estimate 1.615 days, 95% CI 0.142-3.088, P=.032) and higher cost (estimate $156,616.55, 95% CI $105,193.82-$208,039.28, P<.0001) compared to White admissions. API admissions also had higher cost (estimate $249,059.36, 95% CI $177,622.48-$320,496.23, P<.0001). Overall complication rates did not differ significantly by race (P=.24).
**Clinical Implications:** This study demonstrates that Black and Hispanic patients present with TAAAD approximately a decade earlier than White and API patients, and are more likely to be from lower-income households and have higher rates of hypertension. These findings suggest that disparities in social determinants of health and cardiovascular risk factor management may predispose minority populations to earlier onset of aortic dissection. Importantly, after adjusting for these factors, race was not independently associated with in-hospital mortality, indicating that surgical care for TAAAD may be delivered equitably in the acute setting. However, the longer LOS and higher costs observed in Hispanic and API admissions warrant further investigation, as they may reflect differences in postoperative care, discharge planning, or resource utilization. The study is limited by the administrative nature of the NIS database, which lacks clinical detail (e.g., severity of hypertension, aneurysm size, presence of complications on admission) and does not allow longitudinal follow-up. Future research should focus on identifying modifiable factors that contribute to earlier presentation in minority populations and on understanding the drivers of increased resource use in Hispanic and API patients.