What management approach would you recommend for a patient with atherosclerotic calcifications of the aorta, likely with comorbid hypertension, hyperlipidemia, and diabetes?

Management of Atherosclerotic Aortic Calcifications

Initiate high-intensity statin therapy immediately targeting LDL-C <1.4 mmol/L (55 mg/dL) with >50% reduction from baseline, combined with blood pressure control to 120-129 mmHg, antiplatelet therapy, and mandatory smoking cessation. 1, 2

Lipid Management: The Cornerstone of Therapy

Statins are recommended in all patients with atherosclerotic aortic disease as a Class I, Level A recommendation. 1 The 2024 ESC guidelines for peripheral arterial and aortic diseases establish that patients with atherosclerotic calcifications of the aorta fall into the very high cardiovascular risk category, requiring aggressive lipid lowering. 1

Specific Lipid Targets and Treatment Algorithm:

• Start high-intensity statin therapy immediately (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) with a target LDL-C <1.4 mmol/L (55 mg/dL) AND achieve >50% reduction from baseline. 1, 2

• If target not achieved on maximum tolerated statin, add ezetimibe 10 mg daily. 1

• If target still not achieved on statin plus ezetimibe, add a PCSK9 inhibitor (evolocumab or alirocumab). 1

• For statin-intolerant patients, use ezetimibe plus bempedoic acid, with or without PCSK9 inhibitor. 1

Critical context: While statins will not reverse aortic calcification itself (as demonstrated in SALTIRE, SEAS, and ASTRONOMER trials), they reduce cardiovascular events by approximately 20% and are absolutely indicated for cardiovascular risk reduction. 2 Aortic atherosclerosis represents a coronary artery disease equivalent with >20% 10-year cardiovascular event risk. 2, 3

Blood Pressure Management

Target blood pressure of 120-129 mmHg systolic is recommended in patients with peripheral arterial and aortic disease and hypertension. 1 This represents a Class I, Level A recommendation from the 2024 ESC guidelines. 1

Antihypertensive Selection Strategy:

• Beta-blockers should be first-line therapy as they reduce both blood pressure and left ventricular ejection force, thereby decreasing aortic wall stress. 2, 3

• ACE inhibitors or ARBs are recommended as second-line or combination agents, particularly if heart failure, diabetes, or renal artery stenosis is present. 1, 2

• Start at low doses and titrate gradually upward with appropriate clinical monitoring. 2, 3

Important pitfall to avoid: Do not withhold antihypertensive therapy due to outdated concerns about "fixed cardiac output"—this has been disproven. 2

Antiplatelet Therapy

Antiplatelet therapy with aspirin 75-100 mg daily OR clopidogrel 75 mg daily is recommended in patients with atherosclerotic aortic disease. 1 This is a Class I recommendation for patients with peripheral arterial disease. 1

• Clopidogrel 75 mg daily is recommended as an alternative in patients with aspirin intolerance. 1

• Dual antiplatelet therapy (DAPT) should be considered in patients at very high risk without high bleeding risk: rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily reduces cardiovascular death, MI, and stroke. 1

Diabetes Management (If Present)

Tight glycemic control with HbA1c <53 mmol/mol (7%) is recommended to reduce microvascular complications. 1

Glucose-Lowering Agent Selection:

• SGLT2 inhibitors with proven cardiovascular benefit are recommended in patients with type 2 diabetes and aortic disease to reduce cardiovascular events, independent of baseline HbA1c. 1

• GLP-1 receptor agonists with proven cardiovascular benefit are recommended as an alternative or addition to reduce cardiovascular events. 1

• Prioritize glucose-lowering agents with proven cardiovascular benefits over agents without such evidence. 1

• Avoid hypoglycemia, as this increases cardiovascular risk. 1

Lifestyle Modifications: Non-Negotiable Components

Smoking cessation is a Class I recommendation and must be aggressively pursued using structured counseling programs. 1, 2, 3 This has direct impact on disease progression and mortality. 1

Additional Lifestyle Interventions:

• Mediterranean diet is recommended: high in legumes, dietary fiber, nuts, fruits, vegetables, and flavonoids. 1

• Low- to moderate-intensity aerobic exercise is recommended (or high-intensity if tolerated) to improve cardiovascular outcomes. 1

• Behavioral counseling to promote healthy diet, smoking cessation, and physical activity is recommended to improve the cardiovascular risk profile. 1

• Weight reduction for overweight or obese patients is necessary. 2, 3

Surveillance and Monitoring

Serial imaging with CT or MRI is required to monitor for progression of aortic disease, as most thoracic aortic disease is asymptomatic. 2, 3 The aortic arch and proximal descending aorta are particularly vulnerable sites, concentrating 60% of calcifications. 4

• Measure aortic diameters at prespecified anatomical landmarks using the same imaging modality and measurement method over time. 1

• Assess LDL-C as early as 4 weeks after initiating statin therapy and adjust dosage if necessary. 5

Common Pitfalls to Avoid

• Do not accept inadequate lipid lowering: This patient requires LDL-C <1.4 mmol/L (55 mg/dL), not just "improved" cholesterol. 1, 2

• Do not withhold statins thinking they will "treat the valve calcification": They won't slow calcification progression, but they are absolutely indicated for cardiovascular risk reduction. 2

• Do not neglect smoking cessation counseling: This is a Class I recommendation with direct impact on disease progression. 1, 2, 3

• Do not use fibrates for cholesterol lowering: They are not recommended in this population. 1