From the Guidelines
The best management approach for a 57-year-old male with an acute penetrating atherosclerotic ulcer or saccular aneurysm with mural thrombus who presents with chest pain and shortness of breath (with negative myocardial perfusion) is immediate surgical intervention, typically endovascular repair, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. The patient should be stabilized and transferred to a tertiary care center with cardiothoracic surgical capabilities. Initial management includes:
- Blood pressure control using intravenous beta-blockers such as labetalol (10-20 mg IV bolus, followed by 0.5-2 mg/min infusion) or metoprolol (5 mg IV every 5 minutes for 3 doses) to maintain systolic blood pressure between 100-120 mmHg.
- Pain management with intravenous opioids like morphine (2-4 mg IV every 5-15 minutes as needed) should be provided. Urgent CT angiography of the chest with contrast is essential for definitive diagnosis and surgical planning. Endovascular stent grafting is typically preferred over open surgical repair due to lower morbidity and mortality, especially in this age group, as suggested by the guidelines 1. Post-procedure, the patient will require:
- Lifelong antihypertensive therapy
- Statin medication
- Antiplatelet therapy with aspirin (81 mg daily)
- Regular imaging follow-up at 1,6, and 12 months, then annually. This aggressive approach is necessary because penetrating atherosclerotic ulcers and saccular aneurysms have high rates of progression to aortic rupture or dissection, which carries significant mortality risk. The negative myocardial perfusion study confirms that the symptoms are likely related to the aortic pathology rather than coronary disease. In contrast to older studies such as the one on oral anticoagulation for acute coronary syndromes 1, the current guidelines prioritize endovascular repair for penetrating atherosclerotic ulcers, highlighting the importance of staying updated with the latest evidence-based recommendations.
From the Research
Management Approach
The patient's condition, an acute penetrating atherosclerotic ulcer or a saccular aneurysm of mural thrombus, presenting with chest pain and shortness of breath, and a negative myocardial perfusion study, requires careful consideration of antithrombotic therapy.
- The combination of antiplatelet and anticoagulant therapy may be indicated in this clinical situation, as it can reduce major adverse cardiovascular events, but it also increases the risk of bleeding 2.
- A careful assessment of thrombotic versus bleeding risk is necessary for each patient, taking into account individual patient characteristics and the planned intervention 3.
Antithrombotic Therapy
- Antiplatelet therapy, such as aspirin and a P2Y12 inhibitor, is effective in reducing cardiovascular event rates after acute coronary syndrome, but the optimal duration of therapy is not well established 4.
- The combination of anticoagulant and antiplatelet therapy has been shown to be effective in certain clinical situations, such as patients with prosthetic heart valves, but the benefits and risks must be carefully weighed 5.
- The use of oral anticoagulants, such as warfarin, may be indicated in patients with atrial fibrillation or other conditions that increase the risk of thromboembolism, but the risk of bleeding must be carefully considered 6.
Risk Assessment
- Patients with a high risk of bleeding, such as those with a history of bleeding or those taking oral anticoagulants, may require a shorter duration of antiplatelet therapy or a more cautious approach to antithrombotic therapy 4.
- Patients with a high risk of thrombosis, such as those with atrial fibrillation or prosthetic heart valves, may require more intensive antithrombotic therapy, but the benefits and risks must be carefully weighed 5.