What is the goal blood pressure for a patient with a thoracic aortic aneurysm, particularly those with Marfan syndrome or other connective tissue disorders?

Goal Blood Pressure for Thoracic Aortic Aneurysm

For patients with thoracic aortic aneurysm, the goal blood pressure is systolic <130 mmHg and diastolic <80 mmHg, with consideration for more intensive control to systolic <120 mmHg if tolerated, particularly in patients not undergoing surgical repair. 1

Standard Blood Pressure Targets

The 2022 ACC/AHA guidelines establish clear blood pressure thresholds for all patients with thoracic aortic aneurysm (TAA):

• Primary target: Systolic BP <130 mmHg and diastolic BP <80 mmHg 1
• This target applies regardless of the underlying cause of the aneurysm 1
• Antihypertensive medications are recommended (Class I recommendation) when average systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg 1

Intensive Blood Pressure Control

For selected patients who can tolerate it, a more aggressive systolic BP goal of <120 mmHg may provide additional benefit. 1

• This intensive target is particularly reasonable for patients not undergoing surgical repair 1
• The recommendation is extrapolated from the SPRINT trial, which demonstrated a 25% reduction in cardiovascular events and 27% reduction in all-cause mortality with intensive BP control (SBP <120 mmHg) compared to standard control (SBP <140 mmHg) 1
• Patients without diabetes are the best candidates for this intensive approach 1

Special Considerations for Marfan Syndrome and Genetic Aortopathies

Patients with Marfan syndrome or other connective tissue disorders follow the same blood pressure targets, but with additional considerations:

• The same BP goal of <130/80 mmHg applies 1
• Beta-blockers should be used as first-line therapy in all Marfan syndrome patients with aortic aneurysm to reduce the rate of aortic dilatation (Class I recommendation) 1
• Angiotensin receptor blockers (ARBs) are reasonable as adjunctive therapy to beta-blockers 1

Evolution from Previous Guidelines

The 2010 ACC/AHA guidelines recommended different targets based on comorbidities:

• <140/90 mmHg for patients without diabetes 1
• <130/80 mmHg for patients with diabetes or chronic renal disease 1

However, the 2022 guidelines supersede these recommendations with a uniform target of <130/80 mmHg for all TAA patients, reflecting updated evidence on cardiovascular risk reduction. 1

Pharmacologic Approach to Achieve Targets

Beta-blockers are reasonable as first-line therapy (Class IIa recommendation) to achieve BP goals in TAA patients, regardless of cause and in the absence of contraindications. 1

• ARB therapy is reasonable as an adjunct to beta-blockers to achieve target BP goals (Class IIa recommendation) 1
• The combination of beta-blockers and ARBs addresses both hemodynamic stress reduction and molecular pathways involved in aneurysm progression 1

Critical Clinical Pitfalls

Uncontrolled hypertension dramatically increases the risk of aortic dissection and rupture, making aggressive BP control essential even in asymptomatic patients. 1

• The goal of BP control is not only to reduce cardiovascular events like MI and stroke, but specifically to slow aneurysm growth and prevent aortic dissection 1
• Blood pressure variability is an independent risk factor for adverse outcomes, so consistent control matters, not just adequate average values 2
• Even after surgical repair, lifelong strict BP control remains necessary as patients remain at risk for residual aortic complications 2

Acute Dissection Context

If the question pertains to acute aortic dissection (rather than chronic aneurysm), the target is more aggressive:

• Goal systolic BP <120 mmHg (ideally 100-120 mmHg range) and heart rate ≤60 bpm 3
• Beta-blockers must be administered before any vasodilators to prevent reflex tachycardia, which can propagate dissection 3