What is the management for incidental imaging findings of atherosclerotic changes on the aorta, specifically regarding the initiation of a statin (HMG-CoA reductase inhibitor)?

From the Guidelines

Incidental atherosclerotic changes in the aorta on imaging should prompt consideration of statin therapy as part of a comprehensive cardiovascular risk management approach, with a recommendation to start a moderate-intensity statin such as atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily, as supported by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. For most patients with this finding, statin therapy is reasonable, especially if other cardiovascular risk factors are present. Before initiating therapy, obtain a baseline lipid panel and liver function tests. Lifestyle modifications are equally important, including a heart-healthy diet, regular physical activity, smoking cessation, and blood pressure control. The rationale for statin therapy is that aortic atherosclerosis, even when found incidentally, indicates systemic atherosclerotic disease and increased cardiovascular risk, as noted in the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. Statins work by reducing LDL cholesterol and have pleiotropic effects that stabilize plaques and reduce inflammation. Follow-up should include lipid panel testing 4-12 weeks after starting therapy, with a goal of at least 30-50% LDL reduction, and an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) as recommended by the 2024 ESC guidelines 1. Annual monitoring of lipids and liver function is recommended thereafter, along with assessment of muscle symptoms at each visit. It is also important to consider the patient's overall cardiovascular risk profile and to individualize treatment based on their specific needs and circumstances, as emphasized in the 2021 guide for primary care physicians on coronary artery calcium scoring 1.

Some key points to consider in the management of patients with atherosclerotic changes in the aorta include:

• The importance of a comprehensive approach that addresses the entirety of arterial circulation, as recommended by the 2024 ESC guidelines 1
• The need for thorough clinical, vascular, and CVRF laboratory evaluation, as recommended by the 2024 ESC guidelines 1
• The role of statin therapy in reducing cardiovascular risk, as supported by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1 and the 2024 ESC guidelines 1
• The importance of lifestyle modifications, including a heart-healthy diet, regular physical activity, smoking cessation, and blood pressure control, as recommended by the 2024 ESC guidelines 1

From the FDA Drug Label

Rosuvastatin tablets are an HMG Co-A reductase inhibitor (statin) indicated: To reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, nonfatal stroke, or an arterial revascularization procedure) in adults without established coronary heart disease who are at increased risk of CV disease based on age, high-sensitivity C-reactive protein (hsCRP) ≥2 mg/L, and at least one additional CV risk factor. reduce LDL-C and slow the progression of atherosclerosis in adults.

The patient should be started on a statin, such as rosuvastatin, to reduce the risk of major adverse cardiovascular events and slow the progression of atherosclerosis 2.

• The presence of atherosclerotic changes noted on incidental imaging findings suggests an increased risk of CV disease.
• Starting a statin is indicated to reduce LDL-C and slow the progression of atherosclerosis in adults.

From the Research

Atherosclerotic Changes on Aorta Incidental Imaging Finding

• Atherosclerotic lesions in the abdominal aorta or its major branches are often incidentally detected on abdominal CT, and are associated with significant coronary heart disease in asymptomatic adults 3
• The presence of aortic atherosclerosis is a marker for significant coronary artery disease, with a sensitivity and specificity of 75.9% and 67.7%, respectively 4
• Statin therapy, such as rosuvastatin, can improve peripheral atherosclerosis and reverse atherosclerotic plaques, and has been shown to delay the progression of carotid atherosclerosis in patients with subclinical carotid atherosclerosis 5, 6

Management of Atherosclerotic Changes

• The use of statins, such as rosuvastatin, can be effective in managing atherosclerotic changes, with studies showing significant regression of atherosclerosis in patients with established coronary heart disease 6
• Early detection and treatment of aortic atherosclerosis may contribute to diagnostic and therapeutic interventions and improve prognosis, especially in young patients with hypertension 7
• The decision to start statin therapy should be based on individual patient risk factors and clinical guidelines, taking into account the presence of atherosclerotic changes and other cardiovascular risk factors 5, 3, 4, 6