What are the next steps in management for a 54-year-old female with a history of Hypertension (HTN), class III obesity, and newly diagnosed Diabetes Mellitus, found to have a dilated ascending aorta measuring 4.4 cm on Computed Tomography (CT) calcium score, and when should a Magnetic Resonance Angiography (MRA) of the chest be considered?

From the Guidelines

The patient should undergo a dedicated CT angiography or MRA of the chest now to better characterize the aortic dilation, as the calcium score CT is not optimized for aortic assessment, and blood pressure control is essential with a target of <130/80 mmHg using medications such as beta-blockers or angiotensin receptor blockers, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

Next Steps in Management

The next steps in management should include referral to a cardiologist or vascular specialist for evaluation and management of the aortic dilation.

• The patient should undergo surveillance imaging with MRA or CT angiography every 6-12 months initially, then annually if stable, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
• For an ascending aorta of this size in a woman, surgical intervention is typically not indicated until the diameter reaches 5.0-5.5 cm, but this depends on growth rate and other risk factors, as discussed in the ACR Appropriateness Criteria for suspected thoracic aortic aneurysm 1.
• The patient should also be counseled to avoid heavy lifting (>50 pounds), extreme physical exertion, and activities that involve Valsalva maneuvers.
• Management of comorbidities, particularly hypertension and diabetes, is crucial as these can accelerate aortic disease progression, and a healthy diet rich in legumes, dietary fibre, nuts, fruits, and vegetables, with a high flavonoid intake (Mediterranean diet), is recommended for CV disease prevention in patients with PAAD, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

Importance of Blood Pressure Control

Blood pressure control is essential to slow aortic expansion, and the patient should be started on medications such as beta-blockers (e.g., metoprolol 25-50 mg twice daily) or angiotensin receptor blockers, with a target blood pressure of <130/80 mmHg, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

• The patient should also be encouraged to make lifestyle modifications, including a healthy diet, regular physical activity, and smoking cessation, to reduce the risk of cardiovascular disease, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
• Lipid-lowering therapy is also recommended, with a target LDL-C level of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C vs. baseline, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

From the Research

Management of Dilated Ascending Aorta

• The patient has a dilated ascending aorta measuring approximately 4.4 cm, which is considered pathologically dilated 2.
• The risk of spontaneous rupture or dissection is closely related to the size of the aorta and the underlying pathology of the aortic wall 2.
• Elective surgery for the dilated ascending aorta may be considered, taking into account the patient's age, the relative size of the aorta, the structure and function of the aortic valve, and the pathology of the aortic wall 2.

Management of Hypertension, Obesity, and Diabetes

• The patient has a history of hypertension, obesity class III, and newly diagnosed diabetes, which increases the risk of macrovascular and microvascular complications 3.
• Body weight reduction, physical exercise, and a combination of antihypertensive and insulin sensitizers agents are strongly recommended to achieve target blood pressure and glucose levels 3.
• ACE inhibitors may be considered as first-line therapy for hypertension, as they have been shown to increase insulin sensitivity and provide cardioprotection in patients with cardiovascular disease 4.
• However, some studies suggest that ARBs may be a better option than ACE inhibitors due to their equal outcome efficacy and fewer adverse events 5.

Imaging Studies

• The patient has already undergone a CT calcium score, which revealed the dilated ascending aorta.
• An MRA of the chest may be considered to further evaluate the aorta and assess for any potential complications, such as dissection or rupture.
• However, the timing of the MRA study is not specified in the provided evidence, and it is unclear when it would be necessary to perform this study.

Treatment Options

• The patient's treatment plan should be individualized, taking into account their specific risk factors and medical history.
• A combination of antihypertensive medications, such as beta-blockers and ACE inhibitors, may be considered to control blood pressure and reduce cardiovascular risk 4.
• Lifestyle modifications, such as weight loss and physical exercise, are also essential for managing hypertension, obesity, and diabetes 3.