What is the recommended blood pressure management for patients with aortic aneurysms?

Blood Pressure Control in Aortic Aneurysm

For patients with aortic aneurysms, antihypertensive therapy is recommended to achieve a systolic blood pressure (SBP) target of <130 mmHg and diastolic blood pressure (DBP) <80 mmHg, with consideration for more intensive lowering toward 120-129 mmHg if tolerated, to reduce cardiovascular events, aneurysm growth, and risk of rupture or dissection. 1

Blood Pressure Targets

Abdominal Aortic Aneurysm (AAA)

• Primary target: SBP <130 mmHg and DBP <80 mmHg is recommended for all patients with AAA and hypertension (SBP ≥130 mmHg or DBP ≥80 mmHg) to reduce cardiovascular events including myocardial infarction, stroke, and to prevent aneurysm rupture 1

• Intensive target: An SBP target toward 120-129 mmHg, if tolerated, is recommended based on the most recent 2024 ESC guidelines for patients with peripheral arterial and aortic diseases 1

• More aggressive lowering: Select patients without diabetes who are not undergoing surgical repair may benefit from intensive SBP control to <120 mmHg, based on SPRINT trial data showing 25% reduction in cardiovascular events and 27% reduction in all-cause mortality 1

Thoracic Aortic Aneurysm (TAA)

• Standard target: SBP ≤130 mmHg and DBP ≤80 mmHg is recommended for patients with TAA to slow aneurysm growth, prevent dissection, and reduce cardiovascular events 1

• Historical targets: Older 2010 guidelines recommended <140/90 mmHg for patients without diabetes or <130/80 mmHg for those with diabetes or chronic renal disease, but these have been superseded by more aggressive targets 1

• Lowest tolerable pressure: For TAA patients, it is reasonable to reduce blood pressure to the lowest tolerable point using beta blockers and ACE inhibitors or ARBs 1

Preferred Antihypertensive Agents

Beta Blockers

• First-line therapy: Beta blockers are reasonable as first-line agents for achieving target BP goals in TAA patients regardless of cause, in the absence of contraindications 1

• Marfan syndrome: Beta blockers are specifically recommended for all patients with Marfan syndrome and aortic aneurysm to reduce the rate of aortic dilatation, based on randomized trial data showing attenuated expansion over 10-year follow-up 1

• Mechanism: Beta blockade reduces shear stress on the aortic wall and has demonstrated inhibition of aneurysm expansion, particularly in genetic aortopathies 1

ACE Inhibitors and ARBs

• Adjunctive therapy: ARB therapy is reasonable as an adjunct to beta blocker therapy to achieve target BP goals in TAA patients, regardless of etiology 1

• Marfan syndrome: Losartan (an ARB) is reasonable for patients with Marfan syndrome to reduce the rate of aortic dilatation, based on animal models and preliminary pediatric studies showing slowed progression of aortic root dilatation 1

• General PAD: ACE inhibitors or ARBs may be considered in all patients with peripheral arterial disease (which includes aortic aneurysms), regardless of BP levels, in the absence of contraindications 1

• Valsartan data: The Jikei Heart Study demonstrated that valsartan significantly reduced the incidence of aortic dissection in addition to other cardiovascular events 1

Important Caveat on Agent Selection

• No proven growth inhibition: Despite the robust evidence for beta blockers and renin-angiotensin system agents in AAA, no specific antihypertensive agent has been proven in prospective clinical trials to inhibit AAA growth in humans 1

• Meta-analysis findings: A 2021 meta-analysis of 2,045 participants found that blood pressure-lowering medications did not significantly reduce AAA growth (2.0±2.4 vs 2.3±2.7 mm/year) or AAA-related events 2

• Primary benefit: The main benefit of antihypertensive therapy is reduction of cardiovascular events (MI, stroke) and prevention of rupture through BP control, rather than direct effects on aneurysm growth 1

Special Considerations

Aortic Dissection

• Strict control: Blood pressure should not exceed 130 mmHg systolic in patients with aortic dissection; this applies to both children and adults 1

• Target range: A level below 135/80 mmHg is advised for patients with aortic dissection, with beta-blocking agents preferred and combination therapy usually needed 1

Ruptured AAA

• Permissive hypotension: In patients with ruptured AAA, maintaining SBP between 60-90 mmHg (permissive hypotension) is suggested to maintain mentation while minimizing bleeding prior to definitive repair 1

• Avoid aggressive resuscitation: Rapid fluid replacement causing normotension may disrupt clot formation and exacerbate bleeding through the "lethal triad" of hypothermia, acidemia, and coagulopathy 1, 3, 4

• Local anesthesia preferred: For endovascular repair of ruptured AAA, local anesthesia is associated with lower mortality compared to general anesthesia, which can cause circulatory collapse 1

Clinical Pitfalls to Avoid

• Don't delay treatment: Uncontrolled hypertension is a known risk factor for aortic rupture and dissection; aggressive BP control is essential even in asymptomatic patients 1

• Don't use single-agent therapy: Combination therapy is usually required to achieve target BP goals; beta blockers should be combined with ACE inhibitors or ARBs for optimal control 1

• Don't ignore smaller aneurysms: Rupture can occur at diameters <10 cm; in fact, 88% of ruptured thoracic aneurysms in one series were ≤10 cm, contradicting the notion that only large aneurysms rupture 5

• Don't overlook cardiovascular risk reduction: Stringent control of hypertension should be combined with lipid optimization, smoking cessation, and other atherosclerosis risk-reduction measures 1