What is the treatment for a patient with atherosclerosis of the aorta?

Treatment of Atherosclerosis of the Aorta

The treatment of atherosclerosis of the aorta should include intensive statin therapy to achieve an LDL-C goal of <1.4 mmol/L (55 mg/dL) and >50% reduction from baseline, along with comprehensive cardiovascular risk factor management. 1

Pharmacological Management

Lipid-Lowering Therapy

• Statin therapy: First-line treatment for all patients with atherosclerotic aortic disease

  • High-intensity statins (e.g., atorvastatin 40-80 mg) are recommended for patients <75 years of age 1
  • Moderate-intensity statins may be used if high-intensity statins are not tolerated 1
  • Target LDL-C: <1.4 mmol/L (55 mg/dL) with >50% reduction from baseline 1

• Add-on therapy if LDL-C goals not achieved with maximally tolerated statin:

  • Ezetimibe should be added first 1
  • If targets still not achieved, add PCSK9 inhibitor 1
  • For statin-intolerant patients, consider bempedoic acid alone or in combination with a PCSK9 inhibitor 1

Antihypertensive Therapy

• Target systolic blood pressure: 120-129 mmHg if tolerated 1
• Beta-blockers are recommended as first-line therapy for patients with aortic disease and hypertension 1
• Angiotensin receptor blockers (ARBs) may provide additional benefit beyond blood pressure control 1

Antithrombotic Therapy

• For patients with complex aortic plaques (≥4mm thickness or with mobile/ulcerated components):
  • Consider single antiplatelet therapy after risk/benefit evaluation 2
  • Anticoagulation may be considered for symptomatic cases with floating aortic thrombi or complex mobile plaques 2

Lifestyle Modifications

• Smoking cessation: Mandatory for all patients with aortic atherosclerosis 1

  • Patients who smoke have double the rate of aneurysm expansion 1
  • Provide pharmacotherapy (nicotine replacement, bupropion, varenicline) and behavioral support 1

• Diet: Mediterranean diet rich in legumes, dietary fiber, nuts, fruits, and vegetables 1

• Physical activity: Regular aerobic exercise appropriate to the patient's functional capacity 1

  • Low to moderate intensity if tolerated
  • Structured exercise programs for patients with concomitant PAD

• Weight management: For overweight or obese patients 1

Monitoring and Follow-up

• Regular imaging surveillance with appropriate modalities (CT, MRI, or ultrasound) 1, 2
• Monitor for:
  • Progression of atherosclerosis
  • Development of aneurysmal changes
  • Embolic complications
  • Achievement of lipid targets

Special Considerations

• Diabetes management: For patients with comorbid diabetes 1

  • Tight glycemic control (HbA1c <53 mmol/mol [7%])
  • Prioritize SGLT2 inhibitors and GLP-1 receptor agonists with proven CV benefit

• Complex plaques: Patients with aortic plaques ≥4mm or with mobile/ulcerated components require more aggressive management 2

  • More frequent imaging surveillance
  • Consider antiplatelet therapy

• Location matters: Plaques in the ascending aorta carry higher embolic risk 2

Common Pitfalls to Avoid

• Underestimating risk: Atherosclerosis in the aorta markedly increases risk of MI and stroke, similar to established coronary heart disease 1

• Inadequate lipid management: Many patients require combination therapy to achieve target LDL-C levels 1

• Overlooking concomitant vascular disease: Screen for peripheral arterial disease and carotid stenosis 1

• Fibrates: Not recommended for cholesterol lowering in patients with atherosclerotic disease 1

• Fluoroquinolone antibiotics: Should be avoided due to increased risk of aortic complications 2

By following this comprehensive approach focusing on intensive lipid management, blood pressure control, and lifestyle modifications, the risk of disease progression and cardiovascular events can be significantly reduced in patients with aortic atherosclerosis.