What is the best approach to manage atherosclerosis of the aorta in an older adult?

Management of Atherosclerosis of the Aorta in Older Adults

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 systolic, single antiplatelet therapy, and mandatory smoking cessation. 1, 2

Lipid Management: The Foundation of Treatment

Statin therapy is a Class I, Level A recommendation for all patients with atherosclerotic aortic disease. 1, 2

• Start high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) to achieve LDL-C <1.4 mmol/L (55 mg/dL) AND >50% reduction from baseline 1, 2
• If target not achieved on maximum tolerated statin, add ezetimibe 10 mg daily 2
• If target still not achieved on statin plus ezetimibe, add PCSK9 inhibitor (evolocumab or alirocumab) 2
• Statins reduce stroke risk regardless of etiology and prevent disease progression 1

Clinical evidence: Atorvastatin reduces cardiovascular events by 37% in high-risk patients, with stroke reduction of 48% and MI reduction of 42% 3

Blood Pressure Control: Reduce Aortic Wall Stress

Target systolic blood pressure of 120-129 mmHg in patients with aortic atherosclerosis (Class I, Level A recommendation). 1, 2

• Beta-blockers should be first-line therapy as they reduce both blood pressure and left ventricular ejection force, thereby decreasing aortic wall stress 1, 2
• ACE inhibitors or angiotensin receptor blockers are reasonable alternatives to achieve the lowest tolerated blood pressure 1
• Avoid blood pressure >140/90 mmHg, which increases risk of stroke, MI, heart failure, and cardiovascular death 1

Antiplatelet Therapy: Prevent Embolic Events

Single antiplatelet therapy (SAPT) with either aspirin 75-100 mg daily OR clopidogrel 75 mg daily is recommended (Class I recommendation). 1, 2

• For asymptomatic non-severe/non-complex aortic plaques, antiplatelet therapy should be considered after risk/benefit evaluation 1
• For severe/complex plaques or after embolic events, SAPT is mandatory for secondary prevention 1
• Dual antiplatelet therapy (DAPT) is NOT indicated for stable aortic atherosclerosis, as recent studies show increased bleeding risk without added antithrombotic benefit 1
• For symptomatic patients with polyvascular disease and no high bleeding risk, consider rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily 1

Special consideration for floating thrombi or complex mobile plaques: Anticoagulation is favored over antiplatelet therapy, particularly for symptomatic cases, though evidence is limited to case reports and observational studies 1

Smoking Cessation: Non-Negotiable Priority

Smoking cessation is a Class I recommendation and must be aggressively pursued using structured counseling programs. 2, 4

• Continued smoking accelerates aortic disease progression and predicts worse outcomes 4
• Use pharmacotherapy (varenicline, bupropion, or nicotine replacement) combined with behavioral counseling 2
• Smoking has direct impact on disease progression and mortality 2

Diabetes Management (if applicable)

• Achieve HbA1c <53 mmol/mol (7%) to reduce microvascular complications 2
• SGLT2 inhibitors with proven cardiovascular benefit are recommended in patients with type 2 diabetes to reduce cardiovascular events, independent of baseline HbA1c 2
• Diabetic patients with aortic disease face compounded cardiovascular risk requiring aggressive management 4

Surveillance and Monitoring

Serial imaging with CT or MRI is required every 3-5 years to monitor for disease progression, as most thoracic aortic disease is asymptomatic. 1, 2

• Adjust imaging frequency based on clinical status and previous findings 1
• Most patients require lifelong medical treatment including lifestyle modifications 1

Critical Pitfalls to Avoid

• Do not focus solely on aortic symptoms while neglecting systemic cardiovascular risk - the greatest threat is myocardial infarction and stroke, not aortic rupture in atherosclerotic disease 4
• Do not use DAPT routinely - it increases bleeding without additional benefit in stable disease 1
• Do not neglect concomitant coronary disease evaluation - aortic atherosclerosis is a marker for significant coronary artery disease in 76% of cases 5, 6
• Do not underestimate smoking cessation - this single factor accelerates disease progression more than any other modifiable risk factor 4

Lifestyle Modifications Beyond Smoking

• Mediterranean diet high in legumes, dietary fiber, nuts, fruits, vegetables, and flavonoids 2
• Regular physical activity and weight management 1
• Alcohol moderation 1

Prognostic Context

Patients with aortic atherosclerosis face annual mortality rates of 1.2-2.4%, with cardiac death rates of 0.6-1.4% and non-fatal MI rates of 0.6-2.7% 4. Aortic atherosclerosis serves as a sentinel marker for coronary and cerebrovascular disease, requiring comprehensive cardiovascular risk assessment 4, 5.