What is the treatment for aortic atherosclerosis?

Treatment of Aortic Atherosclerosis

The treatment of aortic atherosclerosis should include aggressive risk factor modification with statin therapy, blood pressure control, smoking cessation, and antiplatelet therapy in patients with concomitant atheroma or penetrating aortic ulceration. 1

Pharmacological Management

Lipid-Lowering Therapy

• Intensive statin therapy is recommended for patients with aortic atherosclerosis to achieve an LDL-C goal of <70 mg/dL and a >50% reduction from baseline 1
• High-intensity statin therapy (e.g., atorvastatin 40-80 mg daily) is preferred as it has been shown to reduce major cardiovascular events by 22% compared to low-intensity therapy 2
• If target LDL-C levels are not achieved with maximally tolerated statins, adding ezetimibe is indicated 1
• For patients who still don't achieve target LDL-C levels on statins and ezetimibe, PCSK9 inhibitors are recommended 1
• Statin therapy should be considered for reduction of growth and rupture of abdominal aortic aneurysms (AAA) and may be considered for thoracic aortic aneurysms (TAA) 1

Blood Pressure Management

• Antihypertensive medication is recommended for patients with aortic atherosclerosis and an average SBP ≥130 mm Hg or DBP ≥80 mm Hg 1, 3
• Target blood pressure should be <130/80 mmHg to reduce cardiovascular events 1, 3
• Beta-blockers are preferred first-line agents for patients with aortic atherosclerosis, particularly if there is aneurysmal disease 3
• Agents that alter the renin-angiotensin system (ACE inhibitors or ARBs) have shown robust evidence in aortic disease management and can be used in combination with beta-blockers 3
• More intensive SBP control (<120 mmHg) may provide additional benefits in select patients without diabetes who are not undergoing surgical repair 1

Antiplatelet Therapy

• Low-dose aspirin (75-162 mg daily) is reasonable for patients with atherosclerotic aortic aneurysm and concomitant aortic atheroma or penetrating aortic ulceration (PAU) 1
• Aspirin therapy is particularly important in patients with evidence of atherosclerotic disease elsewhere, as aortic atherosclerosis is considered a coronary artery disease equivalent 1

Lifestyle Modifications

Smoking Cessation

• Smoking cessation is strongly recommended for all patients with aortic atherosclerosis 1
• Implementation of the 5 A's strategy (Ask, Advise, Assess, Assist, and Arrange) is recommended 1
• Pharmacotherapy options include nicotine replacement, bupropion, or varenicline 1
• E-cigarettes may be considered as an aid to quitting tobacco smoking, but their long-term effects are unknown and their safety in patients with vascular disease has not been established 1
• Patients with aortic aneurysm who smoke have double the rate of aneurysm expansion 1

Other Lifestyle Modifications

• Regular aerobic exercise is recommended for patients with atherosclerotic disease 1
• Weight reduction for overweight or obese patients 1
• Moderation of alcohol consumption 1
• Adoption of a heart-healthy diet with increased consumption of vegetables and fruits, and reduced intake of meat, poultry, and eggs 1

Monitoring and Follow-up

• Regular imaging surveillance is essential for patients with aortic atherosclerosis, especially if there is aneurysmal disease 1
• Transesophageal echocardiography is the modality of choice for diagnosis and monitoring of thoracic aortic atheromas 4
• For patients with concomitant abdominal aortic aneurysm, regular ultrasound surveillance is recommended 1

Special Considerations

• For patients undergoing invasive procedures involving aortic manipulation, careful assessment of aortic atherosclerosis is important to minimize the risk of atheroemboli 5, 4
• In patients with severe aortic arch atherosclerosis requiring angiography, a brachial approach (rather than femoral) may reduce embolic complications 5
• For patients requiring coronary artery bypass surgery with significant aortic atherosclerosis, off-pump techniques should be considered 5

Pitfalls and Caveats

• Atherosclerotic aortic disease is often asymptomatic until complications occur, so aggressive risk factor modification is crucial even in asymptomatic patients 6
• Fibrates are not recommended for cholesterol lowering in patients with aortic atherosclerosis 1
• While antiplatelet therapy is beneficial, the efficacy and safety of anticoagulation for aortic atherosclerosis has not been established in randomized trials 4
• Patients with aortic atherosclerosis should be screened for atherosclerotic disease in other vascular beds, particularly carotid and peripheral arteries 1