Is a patient with no visualized pulmonary embolus, moderate atherosclerosis with a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, and dilated upper pole calices of the left kidney, considered an emergency or can they be managed by a Primary Care Physician (PCP)?

From the Guidelines

This patient should be considered an emergency and requires immediate evaluation and management by a specialist, such as a cardiothoracic surgeon or an interventional radiologist, due to the presence of a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta. The patient's condition is a type of acute aortic syndrome (AAS), which includes penetrating atherosclerotic ulcer (PAU) and is associated with a high risk of aortic rupture and mortality 1. According to the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases, PAU is characterized by localized ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media, frequently associated with intramural hematoma (IMH) and diffuse atherosclerosis 1. The guidelines also highlight that symptom onset may indicate PAU expansion, and urgent imaging and therapeutic intervention are needed to prevent aortic rupture 1.

Key Considerations

• The patient's condition requires prompt evaluation and management to prevent aortic rupture and reduce mortality risk 1.
• The presence of a penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta is a high-risk feature that necessitates immediate attention 1.
• The patient's moderate atherosclerosis and dilated upper pole calices of the left kidney are also important considerations, but the primary concern is the management of the PAU to prevent aortic rupture 1.

Management

• The patient should be referred to a specialist, such as a cardiothoracic surgeon or an interventional radiologist, for further evaluation and management 1.
• Imaging studies, such as CT or MRI, should be performed to confirm the diagnosis and assess the extent of the disease 1.
• Medical management, open surgical repair, or endovascular management may be considered, depending on the extent of the disease and the patient's clinical parameters 1.

From the Research

Patient Condition and Emergency Status

The patient's condition is characterized by:

• No visualized pulmonary embolus
• Moderate atherosclerosis with a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta
• Dilated upper pole calices of the left kidney

Management and Treatment

Based on the studies, the patient's condition is considered an emergency, particularly due to the presence of a penetrating ulcer in the atheromatous plaque of the aorta. The studies suggest that:

• Penetrating aortic ulcers have the potential to evolve acutely into aortic rupture, and chronic pictures are possible 2
• Differentiation of PAU from other causes of Acute Aortic Syndrome (AAS) such as intramural haematoma (IMH) and aortic dissection is difficult, and diagnosis is made on computerised tomography (CT) scan, magnetic resonance imaging (MRI), or transoesophageal echocardiography (TOE) 3
• Patients with symptoms of a PAU should be treated immediately if they are fit for surgery, and exceptive observation by imaging modalities is necessary in patients with asymptomatic small (<2 cm) PAU, with or without focal dissection 4
• Surgical replacement of the aorta is recommended for these virulent vascular lesions as long as the patient's comorbidities do not preclude surgical intervention 5

Role of Primary Care Physician (PCP)

Given the emergency nature of the patient's condition, it is unlikely that a Primary Care Physician (PCP) can manage the patient alone. The patient may require immediate referral to a specialist, such as a cardiologist or vascular surgeon, for further evaluation and treatment. The studies suggest that:

• Optimal treatment, either surgical (open or endovascular) or medical, is based on a correct diagnosis, and highlighting the importance of including aortic ulcers in the differential diagnosis of chest pain 2
• Patients with penetrating atheromatous ulcers usually involve the descending thoracic aorta and are very uncommon in ascending aorta, and differentiation of PAU from other causes of AAS is difficult 3