Thoracic aortic aneurysm medical therapy
|
Thoracic aortic aneurysm Microchapters |
|
Differentiating Thoracic Aortic Aneurysm from other Diseases |
|---|
|
Diagnosis |
|
Treatment |
|
Special Scenarios |
|
Case Studies |
|
Thoracic aortic aneurysm medical therapy On the Web |
|
Directions to Hospitals Treating Thoracic aortic aneurysm medical therapy |
|
Risk calculators and risk factors for Thoracic aortic aneurysm medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]
Overview
Medical Therapy
The goals of medical therapy include:
- Lowering BP to the lowest level tolerated
- Cessation of smoking
- Treat associated coronary and carotid artery disease
- Follow up:
- Using clinical and non-invasive imaging tests
- Initial at 3 months and then 6 monthly or yearly
TAA size is the primary indication for repair. Once a TAA reaches a pre-specified size (>5 cm in the ascending aorta, >6 cm in the descending segment) referral for surgical or endovascular repair sholuld be initiated. Most patients undergo repair once they reach >5.5 for ascending and >6.5 cm for descending TAA, respectively.
In certain populations, such as those with Marfan's syndrome, patients with bicuspid aortic valve (especially when AVR is being considered), personal or family history of prior aortic dissection, or those who have been documented on serial imaging studies to have rapidly expanding aneurysms, clinicians would perform repair sooner (size >4-5 cm for ascending and >5.5-6 cm for descending TAAs).
ACC/ AHA Guidelines - Recommendations for Medical treatment of patients with Thoracic aortic diseases (DO NOT EDIT)
| 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: A) |
ACC/ AHA Guidelines - Recommendations for Blood pressure control in Thoracic aortic disease (DO NOT EDIT)
| 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. (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. (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 or angiotensin receptor blockers to the lowest point patients can tolerate without adverse effects. (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. (Level of Evidence:B) |
ACC/ AHA Guidelines - Recommendations for Dyslipidemia in Thoracic aortic aneurysm (DO NOT EDIT)
| 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 (Level of Evidence:A) |
ACC/ AHA Guidelines - Recommendations for smoking cessation in Thoracic aortic disease (DO NOT EDIT)
| 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) (Level of Evidence: B) |
ACC/ AHA Guidelines - Recommendations for counseling and management of Chronic aortic disease in pregnancy (DO NOT EDIT)
| Class I |
| 1. Women with Marfan syndrome and aortic dilatation, as well as patients without Marfan syndrome who have known aortic disease, should be counseled about the risk of aortic dissection as well as the heritable nature of the disease prior to pregnancy(Level of Evidence: C) |
| 2.For pregnant women with known thoracic aortic dilatation or a familial or genetic predisposition for aortic dissection, strict blood pressure control, specifically to prevent Stage II hypertension, is recommended. (Level of Evidence: C) |
| 3. For all pregnant women with known aortic root or ascending aortic dilatation, monthly or bimonthly echocardiographic measurements of the ascending aortic dimensions are recommended to detect aortic expansion until birth. (Level of Evidence: C) |
| 4.For imaging of pregnant women with aortic arch, descending, or abdominal aortic dilatation, magnetic resonance imaging (without gadolinium) is recommended over computed tomographic imaging to avoid exposing both the mother and fetus to ionizing radiation. Transesophageal echocardiogram is an option for imaging of the thoracic aorta. (Level of Evidence:C) |
| 5.Pregnant women with aortic aneurysms should be delivered where cardiothoracic surgery is available. (Level of Evidence:C) |
| Class IIa |
| 1. Fetal delivery via cesarean section is reasonable for patients with significant aortic enlargement, dissection, or severe aortic valve regurgitation (Level of Evidence:C) |
| Class IIb |
| 1. If progressive aortic dilatation and/or advancing aortic valve regurgitation are documented, prophylactic surgery may be considered (Level of Evidence:A) |