What is the recommended treatment plan for a patient with an increased cardiothoracic ratio, prominent aortic knob, atherosclerotic disease, and degenerative spinal changes?

Management of Increased Cardiothoracic Ratio with Atherosclerotic Aortic Disease and Spinal Degeneration

This patient requires comprehensive cardiovascular risk factor management with aggressive blood pressure control (target <130/80 mmHg using beta-blockers or ACE inhibitors), high-intensity statin therapy (targeting LDL-C <55 mg/dL), and definitive imaging with CT angiography or echocardiography to fully evaluate the extent of aortic disease and guide further management. 1, 2

Immediate Diagnostic Workup

Obtain transthoracic echocardiography (TTE) as the first-line test to evaluate:

• Aortic root and ascending aorta dimensions 2
• Left ventricular structure, mass, and systolic/diastolic function 1
• Presence and severity of any valvular disease 1
• Cardiac chamber sizes to explain the increased cardiothoracic ratio 1

Proceed with ECG-gated CT angiography of the chest for comprehensive evaluation of:

• Atherosclerotic disease throughout the entire thoracic aorta 2
• Precise aortic diameter measurements at multiple levels 1
• Extent of aortic calcification and atheroma burden 1
• Assessment for any aneurysmal dilatation 1

The prominent aortic knob with atherosclerotic changes indicates significant vascular disease that requires quantification, as aortic atherosclerosis is strongly associated with coronary artery disease (75.9% correlation) and increased cardiovascular mortality. 3

Medical Management - Blood Pressure Control

Initiate or optimize antihypertensive therapy with target blood pressure <130/80 mmHg: 1, 2

• Beta-blockers are first-line agents to reduce aortic wall stress and slow potential aneurysm expansion 1
• ACE inhibitors or angiotensin receptor blockers (ARBs) are reasonable alternatives or additions to achieve blood pressure targets 1
• The combination reduces cardiovascular morbidity and mortality, with specific evidence showing ARBs reduce aortic dissection incidence 1

Medical Management - Lipid Control

Start high-intensity statin therapy immediately: 1, 2

• Target LDL-C reduction by ≥50% from baseline 1
• Goal LDL-C <55 mg/dL (<1.4 mmol/L) 1
• Statins may slow progression of aortic valve calcification and atherosclerotic disease when initiated early 1
• This patient qualifies as high-risk per National Cholesterol Education Program criteria given aortic atherosclerosis 1

Medical Management - Additional Risk Reduction

Implement comprehensive atherosclerosis risk reduction: 1

• Smoking cessation is critical - patients who smoke have double the rate of aneurysm expansion 1
• Optimize diabetes control if present (target BP <130/80 mmHg in diabetics) 1
• Consider dual antiplatelet therapy: rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily should be considered in symptomatic polyvascular disease without high bleeding risk 1

Surveillance Strategy

Establish serial imaging protocol based on initial aortic measurements: 1, 2

If aortic diameter <4.5 cm and stable:

• CT or MRI every 3-5 years 1, 2
• Annual TTE to monitor cardiac function and aortic root 1

If aortic diameter ≥4.5 cm or growth ≥3 mm/year:

• CT or MRI every 6-12 months 2
• More frequent monitoring at 1,3,6, and 12 months if concerning features 1

Utilize the same imaging modality at the same institution to allow side-by-side comparison of matching anatomic segments over time. 1

Surgical Thresholds

Refer for surgical evaluation if: 1

• Ascending aorta or aortic sinus diameter reaches ≥5.5 cm 1
• Growth rate exceeds 0.5 cm/year even if diameter <5.5 cm 1
• Development of symptoms suggestive of aneurysm expansion 1
• If concomitant aortic valve surgery needed and ascending aorta >4.5 cm 1

Spinal Degeneration Considerations

The degenerative spinal changes with anterior longitudinal ligament calcification are likely related to the same atherosclerotic process affecting the aorta. 4, 5

• Lumbar artery and aortic atherosclerosis correlate with degenerative disk disease and spinal stenosis even after adjusting for age 4
• The diminished blood flow from atherosclerotic obstruction of lumbar arteries feeding the spine contributes to back problems 5
• Management focuses on the underlying vascular disease rather than isolated spinal treatment 4

Critical Pitfalls to Avoid

• Do not delay imaging - most thoracic aortic disease is asymptomatic and difficult to detect on physical examination alone; maintain low threshold for screening 1
• Do not rely on chest X-ray alone - CT or MRI is required to adequately visualize and measure the aorta 1
• Do not withhold beta-blockers in hypertensive patients with aortic disease due to concerns about diastolic pressure - judicious afterload reduction is beneficial 1
• Do not ignore the increased cardiovascular risk - this patient has higher risk of MI than aortic rupture and requires maximal intensity risk factor modification 1