What is the management plan for a 60-year-old male with a history of recent pneumonia and coarctation of the aorta, presenting with a significant upper limb and lower limb blood pressure difference of 50 mmHg?

Management of 50 mmHg Upper-to-Lower Limb Blood Pressure Gradient in Coarctation of the Aorta

This patient requires urgent intervention for hemodynamically significant coarctation, as the 50 mmHg gradient far exceeds the 20 mmHg threshold for repair, and transcatheter stenting should be the preferred approach if technically feasible. 1, 2

Immediate Diagnostic Confirmation

Invasive catheterization with manometry is essential to confirm the hemodynamic significance before intervention, as this remains the gold standard—a peak-to-peak gradient >20 mmHg definitively indicates significant coarctation requiring treatment. 1, 2, 3

• The non-invasive 50 mmHg gradient strongly suggests severe obstruction, but invasive confirmation is needed because extensive collateral vessels can affect gradient measurements. 1
• Measure blood pressure in both arms and at least one lower extremity to document the gradient pattern and identify the arm with highest pressure for future monitoring. 1, 4, 3

Pre-Intervention Imaging Requirements

Obtain cardiovascular magnetic resonance (CMR) or cardiac computed tomography (CCT) of the entire thoracic aorta before any intervention to define critical anatomic features. 1, 2

This imaging must assess:

• Exact site, extent, and degree of aortic narrowing to determine technical feasibility of stenting versus surgery. 1, 2
• Transverse arch anatomy and potential hypoplasia, as arch hypoplasia may require surgical rather than endovascular repair. 2, 5
• Pre- and post-stenotic aortic diameters (>50% narrowing relative to diameter at diaphragm level is an additional intervention criterion even with lower gradients). 1, 2
• Presence of aneurysms, pseudoaneurysms, or dissection at previous repair sites or elsewhere in the aorta. 1, 2
• Collateral vessel patterns that may affect gradient interpretation. 1, 2
• Associated bicuspid aortic valve and ascending aortic dilation, present in many coarctation patients. 2

Intervention Strategy

Transcatheter treatment with covered stent placement is the first-choice intervention for this adult patient with significant coarctation. 2

• Stenting is preferred over surgery when technically feasible based on anatomy, as it offers lower morbidity than surgical repair. 2, 6
• Balloon angioplasty alone (without stenting) should be avoided due to higher recurrence rates and increased risk of aneurysm formation. 2
• Surgical repair remains necessary if the anatomy is unsuitable for stenting (e.g., severe transverse arch hypoplasia, unfavorable angulation). 2

Hypertension Management

Initiate antihypertensive therapy immediately according to ESC hypertension guidelines, as this patient has both upper limb hypertension and significant coarctation. 1, 2

• Hypertension commonly persists even after successful coarctation repair and represents a major risk factor for premature coronary artery disease, ventricular dysfunction, and aortic/cerebral aneurysm rupture. 1, 2
• Consider 24-hour ambulatory blood pressure monitoring rather than relying solely on office measurements, as this better detects masked hypertension and abnormal nocturnal patterns common in coarctation patients. 2, 3

Cardiovascular Risk Modification

Implement aggressive lipid management targeting LDL-C <1.4 mmol/L (<55 mg/dL) with ≥50% reduction from baseline, as the inter-arm difference indicates systemic atherosclerotic disease requiring intensified secondary prevention. 1, 4

Special Considerations for Recent Pneumonia

• Ensure the patient is hemodynamically stable and infection is adequately treated before proceeding with elective intervention. [@general medical knowledge@]
• The recent pneumonia does not contraindicate necessary coarctation repair but may influence timing of elective procedures. [@general medical knowledge@]

Lifelong Surveillance Protocol

All coarctation patients require lifelong follow-up regardless of treatment success, with specific monitoring requirements:

• CMR or CCT every 3-5 years (adapted to clinical status and previous findings) to monitor for re-coarctation, aneurysms, pseudoaneurysms, and dissection. 1, 2, 3
• Annual echocardiography to monitor for bicuspid aortic valve dysfunction and ascending aortic dilation. 2
• Regular blood pressure monitoring in both arms and lower extremities, preferably including ambulatory monitoring. 2, 3
• Exercise stress testing may be valuable to detect exercise-induced hypertension or abnormal upper-to-lower limb gradients during exertion, which occur in many patients despite successful repair. 5

Additional Screening Considerations

• Screening for intracranial (berry) aneurysms by magnetic resonance angiography or CT angiography may be reasonable, though routine screening in asymptomatic patients lacks strong evidence and most clinicians do not perform it routinely. 1, 2
• Patients with Dacron patch repairs are at particular risk for repair-site aneurysms and require especially vigilant imaging surveillance. 1

Critical Pitfalls to Avoid

• Do not rely on Doppler echocardiography gradients alone for quantification in native or post-operative coarctation, as they are unreliable—diastolic "run-off" phenomenon is more reliable for detecting significant obstruction. 1
• Do not assume normal blood pressure at rest excludes significant disease—many successfully repaired patients develop exercise-induced hypertension and remain at cardiovascular risk. 5
• Do not delay intervention in this patient with a 50 mmHg gradient, as this represents severe obstruction with high risk of complications including left ventricular hypertrophy, heart failure, and premature death. 1, 2