What is the recommended management plan for a patient with a history of thoracic aortic ectasia and atherosclerosis of the aorta, with a recent Computed Tomography Angiogram (CTA) showing no thoracic or abdominal aortic aneurysm?

Management of Thoracic Aortic Ectasia with Atherosclerosis and Negative CTA

Initiate aggressive cardiovascular risk reduction immediately with high-intensity statin therapy targeting LDL <70 mg/dL, beta-blocker therapy to reduce aortic wall stress, blood pressure control to <140/90 mm Hg (or <130/80 mm Hg if diabetic), mandatory smoking cessation, and antiplatelet therapy. 1

Blood Pressure Management

Beta-blockers should be first-line antihypertensive therapy as they simultaneously reduce blood pressure and decrease the force of left ventricular ejection, thereby minimizing aortic wall stress. 1 For patients with thoracic aortic disease, it is reasonable to reduce blood pressure with beta-blockers and ACE inhibitors or angiotensin receptor blockers to the lowest tolerable point. 2

Specific Blood Pressure Targets:

• <140/90 mm Hg for patients without diabetes 2
• <130/80 mm Hg for patients with diabetes or chronic renal disease 2

The rationale is that lower blood pressure reduces shear stress on the diseased aortic segment. 2 While the 2010 ACC/AHA guidelines recommend these targets, the 2024 ESC guidelines suggest an even more aggressive systolic blood pressure target toward 120-129 mm Hg if tolerated. 2

Lipid Management

High-intensity statin therapy is mandatory with a target LDL cholesterol <70 mg/dL (1.4 mmol/L) and >50% reduction from baseline. 1, 2 This patient has atherosclerotic thoracic aortic disease, which is considered a coronary artery disease equivalent with >20% risk of cardiovascular events within 10 years. 1

Escalation Strategy if Target Not Met:

• Add ezetimibe to maximally tolerated statin therapy 2
• If still not at goal, add PCSK9 inhibitor 2
• For statin-intolerant patients, use ezetimibe plus bempedoic acid or PCSK9 inhibitor 2

The evidence supporting statins in thoracic aortic disease includes their plaque-stabilizing effects and potential to inhibit aneurysm expansion. 2, 3

Antiplatelet Therapy

Antiplatelet therapy is recommended as part of comprehensive atherosclerotic risk reduction. 1 Patients with thoracic aortic atherosclerosis have an 11.4-fold increased odds ratio for abdominal aortic aneurysms, indicating widespread atherosclerotic disease requiring systemic protection. 1

Smoking Cessation

Smoking cessation is a Class I recommendation and must be aggressively pursued at every visit. 2, 1 Tobacco use is directly associated with thoracic aortic aneurysm growth and increased mortality. 2 This is non-negotiable and should be addressed with behavioral counseling, pharmacotherapy, and referral to cessation programs as needed. 2

Additional Lifestyle Modifications

• Weight reduction if overweight or obese 1
• Moderation of alcohol consumption 1
• Regular aerobic exercise (avoid competitive sports and isometric exercise) 2
• Optimize glycemic control in diabetic patients with SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit 2

Surveillance Imaging Protocol

Serial imaging with CT or MRI is required to monitor for progression of ectasia, as most thoracic aortic disease is asymptomatic and difficult to detect on physical examination. 2, 1

Recommended Surveillance Schedule:

Since the current CTA shows no aneurysm (diameter presumably <4.5 cm), the surveillance interval depends on the exact aortic diameter:

• If aortic diameter <4.5 cm: Annual imaging 2
• Use the same imaging modality at the same institution to allow side-by-side comparison of matching anatomic segments 2
• MRI is preferred for chronic follow-up to avoid repeated radiation exposure, especially in younger patients 2

The 2024 ESC guidelines emphasize measuring aortic diameters at pre-specified anatomical landmarks perpendicular to the longitudinal axis, using the same measurement method over time. 2

Critical Pitfalls to Avoid

• Do not accept LDL >70 mg/dL – this patient requires aggressive lipid lowering as atherosclerotic aortic disease is a high-risk state 1
• Do not neglect smoking cessation counseling at every visit – this has direct impact on disease progression 1, 2
• Do not use axial CT images for diameter measurement – use double-oblique technique perpendicular to the vessel axis 2
• Do not allow blood pressure spikes – counsel patient to avoid competitive sports and extreme exertion 2
• Do not use fibrates for cholesterol lowering – they are not recommended 2

Patient Counseling

Counsel the patient to seek immediate medical care for any unexpected chest discomfort, as patients with aortic ectasia and atherosclerosis remain at risk for acute aortic syndromes. 2 Consider having the patient wear a medical alert bracelet indicating predisposition to aortic emergencies. 2

The patient should understand that while no aneurysm is currently present, the combination of ectasia and atherosclerosis requires lifelong medical management and surveillance to prevent progression to aneurysm formation, dissection, or embolic complications. 3, 4