What is the recommended management for a patient with an increased cardiothoracic ratio, prominent and atherosclerotic aortic knob, thoracic osteoarthritis, and degenerative changes throughout the dorsal spine, with no acute pleuropulmonary abnormality?

Management of Increased Cardiothoracic Ratio with Atherosclerotic Aortic Changes and Thoracic Osteoarthritis

Obtain CT angiography of the chest, abdomen, and pelvis with ECG-gating immediately to measure exact aortic diameters and determine if surgical intervention is needed. 1, 2, 3

Immediate Diagnostic Workup

The chest X-ray findings of an increased cardiothoracic ratio and prominent atherosclerotic aortic knob are insufficient for clinical decision-making and cannot accurately measure aortic diameter or detect early complications. 2 You must proceed with definitive imaging:

• CT angiography (CTA) is the primary imaging modality, offering near-universal availability, short examination time, and diagnostic accuracy with sensitivities up to 100% and specificities of 98-99%. 1, 2, 3
• The protocol must include ECG-gating to provide motion-free images of the aortic root and ascending aorta. 1, 2, 3
• Imaging must extend from chest through abdomen to pelvis, as thoracic aortic pathology frequently extends distally. 2, 3
• Use standardized diameter measurements perpendicular to the longitudinal flow axis at defined anatomic locations to avoid tangential measurement errors. 3

Alternative consideration: MRA may be preferred if repeated surveillance imaging will be needed to avoid cumulative radiation exposure, providing equivalent diagnostic accuracy to CTA. 3

Surgical Referral Thresholds

Refer immediately to cardiothoracic surgery if imaging reveals: 1, 2, 3

• Ascending aorta diameter ≥5.0 cm
• Descending thoracic aorta diameter ≥4.0 cm
• Growth rate ≥3 mm per year

These thresholds are absolute and non-negotiable for specialist evaluation.

Medical Management (Initiate Immediately)

Blood Pressure Control

• Start beta-blocker therapy first before any vasodilators to prevent reflex tachycardia that increases aortic wall stress. 1
• Target heart rate ≤60 beats per minute. 1
• Target blood pressure <130/80 mmHg (ideally <135/80 mmHg for aortic disease). 1, 2
• Add ACE inhibitors or ARBs after beta-blocker initiation to achieve target blood pressure at the lowest tolerated level. 1

Lipid Management

• Initiate statin therapy targeting LDL cholesterol <70 mg/dL, particularly given the atherosclerotic changes present. 1, 2
• In patients with peripheral vascular disease manifestations, target LDL-C reduction by ≥50% from baseline with goal <1.4 mmol/L (<55 mg/dL). 4

Risk Factor Modification

• Smoking cessation is mandatory as it significantly accelerates aortic disease progression. 1, 2
• Optimize diabetes control if present. 2

Surveillance Imaging Schedule

The frequency depends on the maximum aortic diameter found on CTA: 1, 3

• 30-39 mm: Every 3 years
• 40-44 mm: Annually
• 45-49 mm: Every 6 months
• ≥50 mm: Consider intervention

If initial imaging shows stable ectasia without aneurysm, follow at 1,3,6, and 12 months post-diagnosis, then annually if stable. 1

Cardiology Referral

Refer to cardiology for cardiovascular risk factor optimization, including aggressive blood pressure control, lipid management, diabetes control, and smoking cessation. 3 The atherosclerotic aortic changes indicate generalized vascular disease, not an isolated finding, and carry significant risk of recurrent stroke and peripheral embolism. 3

Lifestyle Restrictions

• Avoid strenuous lifting, pushing, or straining that would require a Valsalva maneuver. 4
• Regular moderate aerobic exercise is beneficial when heart rate and blood pressure are well controlled with medications. 4
• Avoid occupations involving heavy physical and manual labor with extreme isometric exercise. 4

Management of Thoracic Osteoarthritis

The thoracic spine degenerative changes are incidental findings that do not require specific intervention unless symptomatic. 5, 6 These are managed conservatively with analgesics if pain develops, but are not related to the cardiovascular risk stratification.

Critical Patient Education

Educate the patient that sudden onset of chest, back, or abdominal pain requires immediate emergency department evaluation, as this could indicate aortic dissection requiring emergency surgery. 4, 2 The aortic disease has not been "cured" and represents a lifelong condition requiring ongoing surveillance. 4