What is the appropriate management for an asymptomatic 47‑year‑old male with incidentally discovered aortic atherosclerosis and no known comorbidities?

Management of Atherosclerotic Aorta in an Asymptomatic 47-Year-Old Male

Aggressive cardiovascular risk factor modification with high-intensity statin therapy targeting LDL-C <55 mg/dL (with ≥50% reduction from baseline), antiplatelet therapy with aspirin 75-162 mg daily, strict blood pressure control to systolic <120 mmHg, and smoking cessation (if applicable) should be initiated immediately, as this represents the cornerstone of management for aortic atherosclerosis to prevent embolic complications and disease progression. 1, 2

Immediate Medical Management

Lipid-Lowering Therapy

• High-intensity statin therapy is mandatory with an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C from baseline 1, 2
• If target LDL-C is not achieved on maximally tolerated statins, add ezetimibe to reach the target values 1
• If the target is still not achieved on statins plus ezetimibe, add a PCSK9 inhibitor 1
• For statin-intolerant patients not achieving LDL-C goals on ezetimibe, add bempedoic acid either alone or combined with a PCSK9 inhibitor 1
• Statins specifically reduce the risk of embolic stroke in patients with severe aortic atherosclerosis 3

Antiplatelet Therapy

• Low-dose aspirin 75-162 mg daily is recommended to reduce cardiovascular event risk and prevent thromboembolic complications from aortic plaque 2, 3
• Aspirin is particularly important given the high risk of stroke and embolic complications from aortic atherosclerosis 3, 4

Blood Pressure Control

• Target systolic blood pressure <120 mmHg indefinitely 2
• This strict control reduces aortic wall stress and progression of atherosclerotic disease 2

Lifestyle Modifications

• Smoking cessation is critical if the patient smokes, as it is a major risk factor for atherosclerosis progression 3
• Glucose control if diabetes is present or develops 3
• Consider web- or app-based secondary prevention risk calculators in shared decision-making to improve patient adherence 1

Risk Stratification and Screening

Assess for Embolic Risk Features

• Aortic atherosclerosis can cause two types of emboli: thromboemboli (causing strokes, TIAs, renal infarcts) and atheroemboli/cholesterol crystal emboli (causing blue toe syndrome, renal insufficiency, gut ischemia) 4
• Patients with severe aortic atherosclerosis are at high risk for stroke and other embolic complications 3

Screen for Comorbid Vascular Disease

• Perform duplex ultrasound screening for femoro-popliteal aneurysm, as this should be considered in patients with aortic disease 1
• Screen for carotid stenosis if the patient has two or more cardiovascular risk factors 1
• Consider screening for abdominal aortic aneurysm with duplex ultrasound 1

Imaging Considerations

• Contrast-enhanced CT is the diagnostic technique of choice if there is concern for penetrating atherosclerotic ulcer or complicated aortic disease, with 96% sensitivity 2
• Transesophageal echocardiography remains the gold standard for visualization of aortic plaques in the thoracic aorta 4

Surveillance Protocol

Follow-Up Imaging

• The frequency of surveillance imaging depends on the severity and location of atherosclerosis 2
• If high-risk features are present (such as ulcerated plaques or mobile thrombi), more intensive surveillance may be warranted 2, 4

Clinical Monitoring

• Regular clinical follow-up to monitor for development of symptoms (chest pain, back pain, abdominal pain, neurological symptoms, limb ischemia) 1
• Monitor for signs of embolic events (new neurological deficits, blue toes, declining renal function) 4
• Assess adherence to medical therapy and achievement of lipid, blood pressure, and glycemic targets 1

Procedural Considerations for the Future

Minimize Iatrogenic Risk

• If this patient requires future invasive vascular procedures or cardiovascular surgery, the risks and benefits must be carefully weighed 3
• For patients requiring coronary artery bypass graft surgery, off-pump CABG is an option to reduce embolic risk 3
• For patients requiring angiography with severe aortic plaque, a brachial approach (rather than femoral) may avoid embolic complications 3
• Prophylactic aortic arch atherectomy should not be routinely performed 3

Common Pitfalls to Avoid

• Do not underestimate embolic risk: Aortic atherosclerosis is a significant source of cerebral and systemic emboli, particularly when plaques are ulcerated or have mobile thrombi 3, 4, 5
• Do not delay statin therapy: Retrospective data strongly support statins for stroke prevention in patients with severe aortic plaque 3
• Do not use fibrates for cholesterol lowering: They are not recommended 1
• Do not ignore cardiovascular risk factor control: Even though there are no proven therapies for aortic embolism per se, general atherosclerosis management strategies are the foundation of care 4

Quality of Life and Long-Term Outcomes

• Aggressive medical management can stabilize or slow progression of aortic atherosclerosis and reduce the risk of life-threatening embolic complications 1, 3
• At age 47, this patient has decades of life ahead, making aggressive primary prevention particularly important to reduce lifetime cardiovascular risk 1
• The goal is to prevent major adverse cardiac events (MACE), major adverse limb events (MALE), stroke, and premature mortality 1