What is the recommended blood pressure range for patients with an aortic aneurysm?

Recommended Blood Pressure Range for Patients with Aortic Aneurysm

For patients with aortic aneurysm, a systolic blood pressure target of 120-129 mmHg and diastolic blood pressure target of <80 mmHg is recommended to reduce the risk of aneurysm growth, rupture, and cardiovascular events. 1

Blood Pressure Targets by Aneurysm Location

Thoracic Aortic Aneurysm (TAA)

• Primary target: SBP 120-129 mmHg, DBP <80 mmHg 1
• More intensive SBP goal of <120 mmHg may provide additional benefit in select patients if tolerated 1
• First-line therapy: Beta-blockers (reasonable for all TAA patients regardless of cause) 1
• Second-line/adjunct therapy: ARBs (angiotensin receptor blockers) 1

Abdominal Aortic Aneurysm (AAA)

• Primary target: SBP <130 mmHg, DBP <80 mmHg 1
• More intensive SBP goal of <120 mmHg may provide additional benefit in select patients without diabetes who are not undergoing surgical repair 1
• First-line therapy: Beta-blockers and agents that alter the renin-angiotensin system 1

Rationale for Strict BP Control

1. Reduced aneurysm expansion: Uncontrolled hypertension is a known risk factor for aortic rupture and dissection 1

2. Decreased wall stress: Lower blood pressure reduces mechanical stress on the weakened aortic wall 1

3. Cardiovascular protection: Evidence supports aggressive BP lowering to reduce vascular-related adverse events and all-cause mortality 1

4. Mortality reduction: The SPRINT trial showed that intensive BP control to SBP <120 mmHg reduced cardiovascular events by 25% and all-cause mortality by 27% compared to a target of <140 mmHg 1

Medication Selection Algorithm

1. First-line therapy:

   • Beta-blockers (preferred for all aortic aneurysms) 1
   • Mechanism: Reduce heart rate, contractility, and blood pressure, decreasing shear stress on aortic wall

2. Second-line/adjunct therapy:

   • ARBs (particularly losartan) 1
   • ACE inhibitors 1
   • Mechanism: Both reduce BP and may have beneficial effects on aortic wall remodeling

3. Additional agents (if needed to reach target BP):

   • Calcium channel blockers
   • Diuretics
   • Other antihypertensives as needed to achieve target

Special Considerations

• Acute aortic dissection: In patients with Type B aortic dissection, 24-hour BP monitoring shows that a target of <130/80 mmHg is associated with better outcomes 2

• Ruptured AAA: For patients with ruptured AAA, permissive hypotension with SBP 60-90 mmHg (sufficient to maintain mentation) may be used temporarily until surgical repair 1

• Surveillance: Regular monitoring of blood pressure is essential - office measurements may underestimate true BP, so consider 24-hour ambulatory monitoring in patients with difficult-to-control hypertension 2

Pitfalls to Avoid

1. Inadequate monitoring: 34% of patients with Type B aortic dissection show uncontrolled BP at follow-up despite prescribed medications 2

2. Overlooking diastolic pressure: Research suggests DBP may have a stronger association with AAA risk than SBP, with a steeper risk increase from 80 mmHg and above 3

3. Excessive BP lowering in elderly: Avoid orthostatic hypotension by careful titration of medications in elderly patients

4. Neglecting other risk factors: Smoking cessation, lipid management, and other atherosclerosis risk-reduction measures should accompany BP control 1, 4

The 2024 ESC guidelines represent the most current evidence-based recommendations, emphasizing the importance of maintaining SBP in the 120-129 mmHg range while ensuring adequate perfusion and minimizing aortic wall stress to improve outcomes in patients with aortic aneurysms 1.