From the Guidelines
The next steps in management for this 67-year-old male with a dilated thoracic ascending aorta measuring 4.3 cm at its maximum dimension should include continued surveillance imaging and medical management. I recommend scheduling another CTA or MRA of the chest in 6 months to monitor for any progression in aortic dilation, as the current diameter is 4.3 cm, which is close to the threshold for more frequent monitoring 1. The patient should be started on blood pressure control with a beta-blocker such as metoprolol 25-50 mg twice daily or losartan 50 mg daily if not contraindicated, targeting a systolic blood pressure below 130 mmHg. Lifestyle modifications are essential, including:
- Smoking cessation if applicable
- Moderate aerobic exercise while avoiding heavy lifting or straining
- Maintaining a heart-healthy diet The patient should be referred to a cardiothoracic surgeon for consultation since his aortic dilation is approaching the threshold for surgical intervention (typically 5.0-5.5 cm for the ascending aorta) 1. Surgical repair would be indicated if the aorta shows rapid expansion (>0.5 cm/year) or reaches 5.0-5.5 cm. This management approach is based on the understanding that thoracic aortic aneurysms carry a risk of dissection or rupture that increases with size, and early intervention with medical therapy and timely surgical referral can prevent these potentially fatal complications 1.
From the Research
Next Steps in Management
The patient has a dilated thoracic ascending aorta with a maximal dimension of 4.3 cm. The following are potential next steps in management:
- Medical therapy to reduce aortic wall stress, such as beta-blockers 2, 3
- Statin treatment to improve long-term survival 3
- Routine surveillance imaging to monitor the size of the aorta
- Consideration of surgical repair if the risk of dissection exceeds the risk of repair 4
- Potential use of angiotensin receptor blockers (ARBs) to slow the progression of aortic dilatation, particularly in patients with Marfan syndrome 5
Key Considerations
- The patient's age and comorbidities, such as polymyalgia rheumatica (PMR), skin cancer, thoracic aortic aneurysm (TAA), osteoarthritis (OA), lymphocytic colitis, erosive gastropathy, and kidney cyst, should be taken into account when determining the best course of management
- The patient's history of skin cancer and lymphocytic colitis may impact the choice of medical therapy
- The use of beta-blockers and statins may be beneficial in reducing the risk of aortic dissection and improving long-term survival 2, 3
Potential Therapies
- Beta-blockers: to reduce aortic wall stress and slow the progression of aortic dilatation 2, 3
- Statins: to improve long-term survival and reduce the risk of aortic dissection 3
- Angiotensin receptor blockers (ARBs): to slow the progression of aortic dilatation, particularly in patients with Marfan syndrome 5
- Other antihypertensive medications, such as calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, or angiotensin II receptor blockers (ARBs), may also be considered 2