What is the management of hypertension in a patient with a 6cm abdominal aortic aneurysm (AAA)?

From the Guidelines

For a patient with a 6 cm abdominal aortic aneurysm (AAA), blood pressure management is crucial to reduce the risk of aneurysm expansion and rupture, and a target blood pressure of 120-129 mmHg is recommended, if tolerated, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

Blood Pressure Management

To achieve this target blood pressure, first-line medication therapy should include a beta-blocker, as these agents reduce shear stress on the aortic wall by decreasing heart rate and contractility.

• Beta-blockers such as metoprolol (25-100 mg twice daily) or atenolol (25-100 mg once daily) can be used.
• If additional medication is needed, an ACE inhibitor like lisinopril (10-40 mg daily) or an ARB such as losartan (25-100 mg daily) can be added, as recommended for patients with PAAD and hypertension 1.

Lifestyle Modifications

Lifestyle modifications are also important, including:

• Sodium restriction (<2.3g/day)
• Regular aerobic exercise (avoiding heavy lifting >10 kg)
• Smoking cessation, as cessation and abstinence from smoking of any kind is recommended to reduce the risk of AD, MI, death, and limb ischaemia in patients with PAAD 1
• Limiting alcohol consumption These interventions help reduce hemodynamic stress on the aneurysm wall, potentially slowing expansion rates and decreasing rupture risk while the patient awaits definitive surgical management.

Additional Recommendations

• Lipid-lowering therapy is recommended for patients with atherosclerotic PAAD, with an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C vs. baseline 1.
• Statins are recommended in all patients with PAD, and if the target LDL-C level is not achieved, a combination of statins and ezetimibe is indicated to achieve the given target values 1.

From the FDA Drug Label

Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits

The management of blood pressure in a patient with an Abdominal Aortic Aneurysm (AAA) of 6cm should focus on comprehensive cardiovascular risk management.

• Blood pressure control is crucial to reduce the risk of cardiovascular events, such as strokes and myocardial infarctions.
• Lisinopril can be used to lower blood pressure in adult patients, as part of a comprehensive management plan that may include lifestyle modifications (e.g., exercise, limited sodium intake) and other treatments (e.g., lipid control, diabetes management) 2.
• The goal is to achieve optimal blood pressure control to reduce the risk of cardiovascular morbidity and mortality.

From the Research

BP Management for AAA 6cm

• The management of blood pressure (BP) in patients with abdominal aortic aneurysms (AAA) is crucial to prevent further growth and rupture of the aneurysm.
• According to a study published in 2023 3, amlodipine (AML) may prevent AAA growth in patients with chronic kidney disease (CKD) or lower systolic blood pressure (SBP), associated with a decline in plasma renin activity (PRA) and circulating high-sensitivity C-reactive protein (hs-CRP).
• Another study published in 2021 4 found that beta-blockers do not significantly influence aortic aneurysm growth, with a standard mean difference of -0.44 (95% CI [-0.44,0.00]).
• A study published in 2002 5 found that calcium-channel blockers were independently associated with AAA, with an odds ratio of 2.6 (95% CI 1.5-4.2), while angiotensin-converting enzyme (ACE) inhibitors were associated with decreased stiffness and greater collagen turnover.
• A systematic review and meta-analysis published in 2019 6 found that hypertension increases the risk of developing AAA by 66%, with a 14% and 28% increase in the risk of AAA for every 20 mmHg and 10 mmHg increase in systolic blood pressure (SBP) and diastolic blood pressure (DBP), respectively.

Treatment Options

• Amlodipine (AML) may be a suitable treatment option for patients with AAA, particularly those with CKD or lower SBP 3.
• Beta-blockers may not be effective in reducing AAA growth 4.
• Calcium-channel blockers may be associated with an increased risk of AAA 5.
• ACE inhibitors may be associated with decreased stiffness and greater collagen turnover 5.

Blood Pressure Control

• Controlling blood pressure is crucial to prevent further growth and rupture of AAA 6.
• A target blood pressure control level should be set to minimize the effects of blood pressure control on AAA growth 3.
• The relationship between blood pressure and AAA growth is complex, and further studies are needed to clarify the underlying mechanism 6.