From the Guidelines
The management plan for this 75-year-old female with moderate atherosclerotic changes without hemodynamically significant stenosis should focus on risk factor modification and preventive therapy, prioritizing lifestyle modifications, statin therapy, and blood pressure control to reduce morbidity, mortality, and improve quality of life.
Key Recommendations
- Lifestyle modifications: smoking cessation if applicable, regular physical activity (30 minutes of moderate exercise most days), and a Mediterranean or DASH diet low in saturated fats and sodium 1.
- Statin therapy: a moderate-intensity statin such as atorvastatin 20mg daily or rosuvastatin 10mg daily to stabilize plaques and prevent progression, with an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C vs. baseline 1.
- Blood pressure control: target of <140/90 mmHg using appropriate antihypertensives if needed, with an SBP target towards 120–129 mmHg, if tolerated 1.
- Regular monitoring: lipid panels every 6-12 months and follow-up CT angiography in 1-2 years to assess disease progression 1.
- Diabetes management: target HbA1c <7% if she has diabetes 1. This comprehensive approach addresses the underlying atherosclerotic process through multiple mechanisms - antiplatelet therapy prevents thrombotic complications, statins stabilize plaques and reduce inflammation, while lifestyle modifications and risk factor control prevent further endothelial damage and disease progression in her peripheral arterial system.
Rationale
The 2024 ESC guidelines for the management of peripheral arterial and aortic diseases recommend a comprehensive approach that addresses the entirety of arterial circulation, including lifestyle modifications, statin therapy, and blood pressure control 1. The guidelines also emphasize the importance of regular monitoring and diabetes management to reduce the risk of cardiovascular events.
Additional Considerations
- Antiplatelet therapy: may be considered in addition to statin therapy and lifestyle modifications to prevent thrombotic complications, although the decision to initiate antiplatelet therapy should be individualized based on the patient's risk factors and medical history 1.
- Patient education: promoting patient and caregivers’ education and empowerment through tailored guidance on lifestyle adjustments and the importance of regular physical activity is crucial to improve the cardiovascular risk profile 1.
From the FDA Drug Label
In this multicenter, placebo-controlled, double-blind clinical trial, subjects were randomly allocated to either atorvastatin calcium 10 mg daily (1,429) or placebo (1,411) in a 1:1 ratio and were followed for a median duration of 3. 9 years. The primary endpoint was the occurrence of any of the major cardiovascular events: myocardial infarction, acute CHD death, unstable angina, coronary revascularization, or stroke. Atorvastatin calcium significantly reduced the rate of major cardiovascular events (primary endpoint events) (83 events in the atorvastatin calcium group vs. 127 events in the placebo group) with a relative risk reduction of 37%, HR 0. 63,95% CI (0.48,0.83) (p=0.001)
The management plan for a 75-year-old female with moderate atherosclerotic changes in the abdominal aorta, iliac arteries, and left arteries bilaterally, without hemodynamically significant stenosis, as shown on computed tomography (CT) angiography of the lower limbs, may include statin therapy to reduce the risk of major cardiovascular events, such as myocardial infarction and stroke, as evidenced by the study results showing a 37% relative risk reduction with atorvastatin calcium 10 mg/day 2. Key considerations for the management plan include:
- The patient's age and sex do not affect the efficacy of atorvastatin calcium in reducing major cardiovascular events
- The patient's baseline lipid levels are not provided, but atorvastatin calcium has been shown to be effective in reducing LDL-C and TG, and increasing HDL-C, in patients with hyperlipidemia
- The patient's moderate atherosclerotic changes and lack of hemodynamically significant stenosis suggest a need for ongoing monitoring and management to prevent progression of atherosclerosis and reduce the risk of cardiovascular events.
From the Research
Management Plan
The management plan for a 75-year-old female with moderate atherosclerotic changes in the abdominal aorta, iliac arteries, and left arteries bilaterally, without hemodynamically significant stenosis, as shown on computed tomography (CT) angiography of the lower limbs, involves:
- Lifestyle modifications, including smoking cessation and supervised exercise therapy, as recommended by 3
- Secondary prevention medications, such as antiplatelet therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins, as suggested by 3
- Risk assessment and management of atherosclerotic cardiovascular disease (ASCVD) using global risk scores and consideration of "risk enhancing" factors, as outlined in 4
Treatment Considerations
- Aspirin therapy may be considered for primary prevention of ASCVD, particularly in individuals with elevated lipoprotein(a), as discussed in 5
- However, the use of aspirin for primary prevention is still a topic of debate, and the benefits must be weighed against the potential risks of bleeding, as noted in 6
- Surgical revascularization may be considered for patients with lifestyle-limiting claudication who have an inadequate response to lifestyle modifications and secondary prevention medications, as recommended by 3
Risk Reduction Strategies
- Reducing low-density lipoprotein cholesterol (LDL-C) levels is crucial for preventing ASCVD, and treatment should aim for far lower goals in cholesterol management, as emphasized in 7
- Early and intensive risk assessment and management are essential for preventing ASCVD and its complications, as highlighted in 7