Anticoagulation for Thoracic Aortic Aneurysms
Anticoagulation and dual antiplatelet therapy (DAPT) are not recommended for thoracic aortic aneurysms, as they provide no benefit and significantly increase bleeding risk, particularly in the event of rupture. 1
Primary Recommendation
- Avoid anticoagulation and DAPT in patients with thoracic aortic aneurysms unless there is a separate compelling indication (e.g., atrial fibrillation, mechanical heart valve, recent coronary stent) 1
- The evidence specifically demonstrates that these agents do not prevent aneurysm progression or rupture 1
Single Antiplatelet Therapy (SAPT)
- SAPT (low-dose aspirin) may be considered if the patient has concomitant atherosclerotic disease or aortic arch atheroma with prior embolic events 1
- Low-dose aspirin is not associated with increased rupture risk in abdominal aortic aneurysms, though data specific to thoracic aneurysms is limited 1
- However, aspirin may worsen prognosis if rupture occurs due to increased bleeding 1
Medical Management Focus
The cornerstone of medical management for thoracic aortic aneurysms centers on blood pressure control and cardiovascular risk reduction, not anticoagulation 1:
- Stringent hypertension control to target <140/90 mmHg (or <130/80 mmHg with diabetes/chronic kidney disease) 1
- Beta-blockers are the foundation of medical therapy, particularly for Marfan syndrome and other genetic conditions, to reduce aortic wall stress 1
- Angiotensin receptor blockers (ARBs) or ACE inhibitors are reasonable additions to reduce blood pressure to the lowest tolerable point 1
- Lipid optimization and smoking cessation to reduce overall cardiovascular risk 1
Critical Caveat: Mechanical Valve After Bentall Procedure
- Vitamin K antagonists (VKAs) are required lifelong for all patients who undergo Bentall procedure (composite valve-graft replacement) with a mechanical heart valve prosthesis 1
- This is the only scenario where anticoagulation is indicated specifically related to thoracic aortic aneurysm management, and it addresses the prosthetic valve, not the aneurysm itself 1
Clinical Pitfall to Avoid
Do not initiate anticoagulation or DAPT with the mistaken belief that it will prevent thromboembolic complications from the aneurysm or slow aneurysm growth—there is no evidence supporting this practice and it increases hemorrhagic risk 1. The role of antithrombotic therapy in aortic aneurysms remains uncertain with conflicting observational data 1.