What is the recommended treatment for atheroma?

Management of Atheroma

For patients with aortic atheroma, the recommended treatment includes intensive lipid management with statins to achieve LDL-C <1.4 mmol/L (<55 mg/dL), single antiplatelet therapy, and optimal cardiovascular risk factor management, while anticoagulation or dual antiplatelet therapy are not recommended due to increased bleeding risk without proven benefit. 1

Diagnosis and Assessment

• Imaging modalities such as transesophageal echocardiography (TEE), computed tomography angiography (CTA), or cardiovascular magnetic resonance (CMR) are recommended for proper assessment of atheroma location and severity 1
• When atheroma is identified at any location, assessment of the entire aorta is recommended at baseline and during follow-up to identify additional areas of involvement 1
• Atherosclerotic plaques can be graded based on thickness and complexity:
  • Grade 1: Normal (intimal thickness <2 mm)
  • Grade 2: Mild (intimal thickening 2 to <3 mm)
  • Grade 3: Moderate (atheroma ≥3 to <4 mm without mobile/ulcerated components)
  • Grade 4: Severe (atheroma ≥4 mm without mobile/ulcerated components)
  • Grade 5: Complex (atheroma with mobile/ulcerated components) 1

Medical Management

Lipid Management

• Intensive statin therapy at moderate to high intensity is recommended for patients with atheroma to achieve LDL-C target <1.4 mmol/L (<55 mg/dL) 1
• Statins have shown significant regression in aortic and carotid plaques in randomized studies, with benefits related to both LDL lowering and statin dosage 1
• In an observational study of 519 patients with severe aortic plaque on TEE, statin use was associated with a 59% relative risk reduction for ischemic stroke 1
• Statin therapy works through pleiotropic effects including plaque regression, plaque stabilization, decreased inflammation, and inhibitory effects on the coagulation cascade 1, 2

Antiplatelet and Anticoagulation Therapy

• Single antiplatelet therapy (SAPT) with low-dose aspirin (75-162 mg/day) is recommended for patients with atherosclerotic aortic disease, especially if there is evidence of prior embolic events 1
• Anticoagulation or dual antiplatelet therapy (DAPT) are NOT recommended for aortic plaques as they present no benefit and increase bleeding risk 1
• While some observational studies suggest warfarin may reduce stroke rates in patients with aortic arch atheroma, these are not randomized trials and the numbers are relatively small 1
• For patients with mobile aortic atheroma, anticoagulation has shown mixed results with both improvement and worsening reported, making this approach controversial 1, 3

Blood Pressure Management

• Antihypertensive therapy is recommended for patients with aortic disease and hypertension to achieve a systolic blood pressure goal of <130 mmHg and diastolic blood pressure <80 mmHg 1
• Beta blockers should be considered as first-line therapy to reduce aortic wall stress, targeting heart rate at or below 60 beats per minute in acute settings 4
• Lowering blood pressure to target levels has been shown to slow down the progression of atherosclerotic disease and reduces the intima-media thickness of plaques 5

Lifestyle Modifications

• Smoking cessation is strongly recommended for all patients with atherosclerotic disease, as smoking is a risk factor for disease progression and adverse cardiovascular events 1
• Regular moderate physical activity is recommended, but competitive sports and isometric exercises should be avoided in patients with significant aortic disease 4
• Dietary modifications focusing on heart-healthy eating patterns should be implemented 5

Surgical and Interventional Approaches

• Routine revascularization is NOT recommended for asymptomatic atherosclerotic aortic disease 1
• Aortic arch endarterectomy has been attempted but resulted in a relatively high rate (34.9%) of perioperative stroke and mortality 1
• Covered stents may theoretically shield severely diseased aortic segments, but periprocedural embolization remains a significant risk 1
• There is insufficient evidence to recommend prophylactic endarterectomy or aortic arch stenting for stroke prevention 1

Follow-up and Surveillance

• Regular surveillance with duplex ultrasound (DUS) is recommended for monitoring atherosclerotic disease progression 1
• For mild atheromatous changes without aneurysmal dilation, DUS surveillance every 3 years is appropriate 4
• If DUS does not allow adequate measurement, CTA or CMR is recommended 1
• Assessment of neurological symptoms, cardiovascular risk factors, and treatment adherence should be performed at least yearly 1

Common Pitfalls and Caveats

• Do not initiate vasodilator therapy before heart rate control is achieved, as this can cause reflex tachycardia that increases aortic wall stress 4
• Beta blockers should be used cautiously in the setting of acute aortic regurgitation as they may block compensatory tachycardia 4
• The risk of clinical atheroemboli syndrome during warfarin therapy appears to be low (only 1 episode in 134 patients according to the SPAF trial) but remains a theoretical concern 1
• The combination of dietary modification, physical exercise, and use of aspirin, a statin, and an antihypertensive agent can provide a cumulative relative stroke risk reduction of up to 80% 5