Thoracic aortic aneurysm medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]; Raviteja Guddeti, M.B.B.S. [3] Mohammad Salih, MD.

Overview

Medical therapy for patients with a thoracic aortic aneurysm includes aggressive blood pressure control, smoking cessation, and aggressive lipid management.

Medical Therapy

  • 2 large bore IV needles
  • Adequate airway and breathing
  • Urinary output monitoring

Emergency Care

Medications

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease (DO NOT EDIT)[1]

Medical Treatment of Patients With Thoracic Aortic Diseases (DO NOT EDIT)[1]

Class I
"1. Stringent control of hypertension, lipid profile optimization, smoking cessation, and other atherosclerosis risk-reduction measures should be instituted for patients with small aneurysms not requiring surgery, as well as for patients who are not considered surgical or stent graft candidates. (Level of Evidence: C)"

Blood Pressure Control (DO NOT EDIT)[1]

Class I
"1. Antihypertensive therapy should be administered to hypertensive patients with thoracic aortic diseases to achieve a goal of less than 140/90 mm Hg (patients without diabetes) or less than 130/80 mm Hg (patients with diabetes or chronic renal disease) to reduce the risk of stroke, myocardial infarction, heart failure, and cardiovascular death.[2][3][4][5][6] (Level of Evidence: B)"
"2. Beta adrenergic–blocking drugs should be administered to all patients with Marfan syndrome and aortic aneurysm to reduce the rate of aortic dilatation unless contraindicated.[7] (Level of Evidence: B)"
Class IIa
"1. For patients with thoracic aortic aneurysm, it is reasonable to reduce blood pressure with beta blockers and angiotensin-converting enzyme inhibitors[8] or angiotensin receptor blockers[9][10] to the lowest point patients can tolerate without adverse effects.[11][7][12] (Level of Evidence: B)"
"2.An angiotensin receptor blocker (losartan) is reasonable for patients with Marfan syndrome, to reduce the rate of aortic dilatation unless contraindicated.[10][13] (Level of Evidence: B)"

Dyslipidemia Treatment (DO NOT EDIT)[1]

Class IIa
"1. Treatment with a statin to achieve a target LDL cholesterol of less than 70 mg/dL is reasonable for patients with a coronary heart disease risk equivalent such as noncoronary atherosclerotic disease, atherosclerotic aortic aneurysm, and coexistent coronary heart disease at high risk for coronary ischemic events.[14][15][16][17] (Level of Evidence: A)"

Smoking Cessation (DO NOT EDIT)[1]

Class I
"1. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home are recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement, buproprion, or varenicline) is useful, as is adopting a stepwise strategy aimed at smoking cessation (the 5 As are Ask, Advise, Assess, Assist, and Arrange).[18][19][20] (Level of Evidence: B)"

Takayasu Arteritis and Giant Cell Arteritis (DO NOT EDIT)[1]

Class I
"1. Initial therapy for active Takayasu arteritis and active giant cell arteritis should be corticosteroids at a high dose (prednisone 40 to 60 mg daily at initiation or its equivalent) to reduce the active inflammatory state.[21][22] (Level of Evidence: B)"
"2. The success of treatment of patients with Takayasu arteritis and giant cell arteritis should be periodically evaluated to determine disease activity by repeated physical examination and either an erythrocyte sedimentation rate or C-reactive protein level.[23][24] (Level of Evidence: B)"
"3. Elective revascularization of patients with Takayasu arteritis and giant cell arteritis should be delayed until the acute inflammatory state is treated and quiescent.[25] (Level of Evidence: B)"
Class IIa
"1. It is reasonable to treat patients with Takayasu arteritis receiving corticosteroids with an additional anti-inflammatory agent if there is evidence of progression of vascular disease, recurrence of constitutional symptoms, or re-elevation of inflammatory marker.[21] (Level of Evidence: C)"

Aortic Arch and Thoracic Aortic Atheroma and Atheroembolic Disease (DO NOT EDIT)[1]

Class IIa
"1. Treatment with a statin is a reasonable option for patients with aortic arch atheroma to reduce the risk of stroke.[26] (Level of Evidence: C)"
Class IIb
"1. Oral anticoagulation therapy with warfarin (INR 2.0 to 3.0) or antiplatelet therapy may be considered in stroke patients with aortic arch atheroma 4.0 mm or greater to prevent recurrent stroke. (Level of Evidence: C)"

Quality Assessment and Improvement for Thoracic Aortic Disease (DO NOT EDIT)[1]

Class I
"1. Hospitals that provide regional care for patients with acute sequelae of thoracic aortic disease (eg, procedures for thoracic aortic dissection and rupture) should participate in standardized quality assessment and improvement activities, including thoracic aortic disease registries. Such activities should include periodic measurement and regional/national interfacility comparisons of thoracic aortic disease-related procedural volumes, complications and risk-adjusted mortality rates. (Level of Evidence: C)"
2. Hospitals that provide regional care for patients with acute sequelae of thoracic aortic disease (eg, procedures for thoracic aortic dissection and rupture) should facilitate and coordinate standardized quality assessment and improvement activities with transferring facilities and emergency medical services teams. Such activities might include:

a. cooperative joint facility meetings to discuss opportunities for quality improvement and

b. interfacility and emergency medical services team comparisons of pretransfer care based on available outcome data and future performance measures developed in accordance with this guideline. (Level of Evidence: C)"

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE; et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780.
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  11. Genoni M, Paul M, Jenni R, Graves K, Seifert B, Turina M (2001). "Chronic beta-blocker therapy improves outcome and reduces treatment costs in chronic type B aortic dissection". Eur J Cardiothorac Surg. 19 (5): 606–10. PMID 11343940. Unknown parameter |month= ignored (help)
  12. Ladouceur M, Fermanian C, Lupoglazoff JM; et al. (2007). "Effect of beta-blockade on ascending aortic dilatation in children with the Marfan syndrome". Am. J. Cardiol. 99 (3): 406–9. doi:10.1016/j.amjcard.2006.08.048. PMID 17261408. Unknown parameter |month= ignored (help)
  13. Lacro RV, Dietz HC, Wruck LM; et al. (2007). "Rationale and design of a randomized clinical trial of beta-blocker therapy (atenolol) versus angiotensin II receptor blocker therapy (losartan) in individuals with Marfan syndrome". Am. Heart J. 154 (4): 624–31. doi:10.1016/j.ahj.2007.06.024. PMC 3042860. PMID 17892982. Unknown parameter |month= ignored (help)
  14. Evans J, Powell JT, Schwalbe E, Loftus IM, Thompson MM (2007). "Simvastatin attenuates the activity of matrix metalloprotease-9 in aneurysmal aortic tissue". Eur J Vasc Endovasc Surg. 34 (3): 302–3. doi:10.1016/j.ejvs.2007.04.011. PMID 17574455. Unknown parameter |month= ignored (help)
  15. Leurs LJ, Visser P, Laheij RJ, Buth J, Harris PL, Blankensteijn JD (2006). "Statin use is associated with reduced all-cause mortality after endovascular abdominal aortic aneurysm repair". Vascular. 14 (1): 1–8. PMID 16849016.
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  17. Yilmaz MB, Biyikoglu SF, Guray Y; et al. (2004). "Level of awareness of on-treatment patients about prescribed statins". Cardiovasc Drugs Ther. 18 (5): 399–404. doi:10.1007/s10557-005-5065-9. PMID 15717143. Unknown parameter |month= ignored (help)
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  22. Mazlumzadeh M, Hunder GG, Easley KA; et al. (2006). "Treatment of giant cell arteritis using induction therapy with high-dose glucocorticoids: a double-blind, placebo-controlled, randomized prospective clinical trial". Arthritis Rheum. 54 (10): 3310–8. doi:10.1002/art.22163. PMID 17009270. Unknown parameter |month= ignored (help)
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  24. Kyle V, Cawston TE, Hazleman BL (1989). "Erythrocyte sedimentation rate and C reactive protein in the assessment of polymyalgia rheumatica/giant cell arteritis on presentation and during follow up". Ann. Rheum. Dis. 48 (8): 667–71. PMC 1003844. PMID 2782977. Unknown parameter |month= ignored (help)
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