What is the management plan for a 60-year-old male with a history of recent pneumonia, now resolving, and an incidental finding of coarctation of the aorta?

Management of Incidentally Discovered Coarctation of the Aorta in a 60-Year-Old Male

This patient requires comprehensive diagnostic evaluation with blood pressure measurements in all four extremities, followed by cardiovascular MRI or CT angiography to define the anatomy and severity of coarctation, with intervention indicated if hypertension is present along with a significant gradient or anatomic narrowing, and lifelong surveillance regardless of treatment decisions. 1

Immediate Diagnostic Work-Up

Blood Pressure Assessment

• Measure blood pressure in both arms and at least one lower extremity to detect the characteristic upper-to-lower extremity gradient that defines hemodynamically significant coarctation 1
• A pressure differential >20 mmHg between upper and lower extremities suggests significant coarctation 2
• Consider 24-hour ambulatory blood pressure monitoring, as it better detects hypertension than office measurements alone in coarctation patients 1

Physical Examination Findings to Document

• Assess for diminished or delayed femoral pulses compared to brachial pulses (brachial-femoral pulse delay) 2, 3
• Listen for a midsystolic murmur over the anterior chest and back 1
• Document upper extremity hypertension with lower extremity hypotension or unmeasurable blood pressure in the legs 1

Advanced Imaging (Mandatory)

• Cardiovascular MRI or CT angiography of the entire thoracic aorta is required as a Class I recommendation to define the exact location and severity of coarctation, identify collateral vessels, screen for aneurysms or pseudoaneurysms, and assess for associated bicuspid aortic valve 1, 2
• Transthoracic echocardiography should be performed to assess for associated lesions, particularly bicuspid aortic valve (present in 50-85% of coarctation patients) 1, 2

Criteria for Intervention

Indications for Repair

Intervention is indicated when:

• Hypertension is present with an invasive peak-to-peak gradient >20 mmHg across the coarctation 1
• Hypertension with >50% narrowing relative to the aortic diameter at the diaphragm, even if the invasive gradient is <20 mmHg 1, 3
• Normotensive patients with an invasive peak-to-peak gradient >20 mmHg should also be considered for intervention 1

Treatment Approach

• Covered stent placement is the first-choice treatment for adults with native or recurrent coarctation when technically feasible 1, 2, 3
• Surgical repair with interposition tube graft is preferred if stenting is not suitable 1
• Balloon angioplasty alone may be considered only if stent placement is not feasible and surgical intervention is not an option 1

Medical Management

Hypertension Control

• Treat hypertension according to standard ESC/ACC-AHA hypertension guidelines as a Class I recommendation 1
• Beta-blockers are the most useful first-line agents for coarctation-related hypertension 2, 3
• ACE inhibitors or angiotensin receptor blockers should be used as standard second-line therapy 2, 3

Critical Caveat

• Hypertension remains an important complication even after successful treatment and is more common when initial repair is performed in adulthood (as in this 60-year-old patient) 1, 4, 2
• Many patients require lifelong antihypertensive therapy despite anatomically successful repair 1

Lifelong Surveillance Requirements

Mandatory Follow-Up

• All coarctation patients require lifelong follow-up regardless of whether intervention is performed, as this is a Class I recommendation 1, 4, 2
• Cardiovascular MRI or CT every 3-5 years is required to monitor for re-coarctation, aneurysms, pseudoaneurysms, and dissection, adjusted to clinical status and previous imaging findings 1, 2, 3

Complications to Monitor

• The natural course is driven by hypertension-related complications including heart failure, intracranial hemorrhage, premature coronary/cerebral artery disease, and aortic rupture/dissection 1, 4
• Post-repair complications include re-coarctation (11% require reintervention), aneurysm formation, pseudoaneurysm, and dissection 1
• Patch repairs carry particular risk of para-anastomotic aneurysms 1

Associated Conditions Requiring Surveillance

• Screen for bicuspid aortic valve dysfunction and ascending aortic aneurysms (present in 50-85% of coarctation patients) 1, 2
• Consider screening for intracranial aneurysms by MR angiography or CT angiography, though this is a Class IIb recommendation 1
• Exercise testing to evaluate for exercise-induced hypertension may be reasonable in patients who exercise 1, 4

Algorithmic Approach for This Patient

1. Measure blood pressures in both arms and one leg immediately 1
2. Order cardiovascular MRI or CT angiography to define anatomy 1
3. If hypertension present with gradient >20 mmHg or >50% narrowing: Refer for endovascular stenting 1, 3
4. If no intervention criteria met: Initiate medical management of hypertension and establish lifelong surveillance protocol 1, 2
5. Regardless of intervention decision: Schedule cardiovascular MRI/CT every 3-5 years and maintain lifelong cardiology follow-up 1, 2