Treatment of Aortic Atherosclerosis

Pharmacological Management

• The American Heart Association recommends intensive statin therapy for patients with aortic atherosclerosis to achieve an LDL-C goal of <70 mg/dL and a >50% reduction from baseline 4, 3
• The European Society of Cardiology indicates that if target LDL-C levels are not achieved with maximally tolerated statins, adding ezetimibe is indicated 3
• For patients who still don't achieve target LDL-C levels on statins and ezetimibe, the European Society of Cardiology recommends PCSK9 inhibitors 3
• Statin therapy should be considered for reduction of growth and rupture of abdominal aortic aneurysms (AAA) and may be considered for thoracic aortic aneurysms (TAA) 2, 3
• Antihypertensive medication is recommended for patients with aortic atherosclerosis and an average SBP ≥130 mm Hg or DBP ≥80 mm Hg 2, 5
• The American College of Cardiology recommends target blood pressure should be <130/80 mmHg to reduce cardiovascular events 1, 5
• Beta-blockers are preferred first-line agents for patients with aortic atherosclerosis, particularly if there is aneurysmal disease 5
• Agents that alter the renin-angiotensin system (ACE inhibitors or ARBs) have shown robust evidence in aortic disease management and can be used in combination with beta-blockers 5
• More intensive SBP control (<120 mmHg) may provide additional benefits in select patients without diabetes who are not undergoing surgical repair 2
• Low-dose aspirin (75-162 mg daily) is reasonable for patients with atherosclerotic aortic aneurysm and concomitant aortic atheroma or penetrating aortic ulceration (PAU) 1, 6
• Aspirin therapy is particularly important in patients with evidence of atherosclerotic disease elsewhere, as aortic atherosclerosis is considered a coronary artery disease equivalent 7, 6

Lifestyle Modifications

• Smoking cessation is strongly recommended for all patients with aortic atherosclerosis 4, 1, 2
• Implementation of the 5 A's strategy (Ask, Advise, Assess, Assist, and Arrange) is recommended 4, 1
• Pharmacotherapy options include nicotine replacement, bupropion, or varenicline 1, 2
• E-cigarettes may be considered as an aid to quitting tobacco smoking, but their long-term effects are unknown and their safety in patients with vascular disease has not been established 1, 3
• Patients with aortic aneurysm who smoke have double the rate of aneurysm expansion 4
• Regular aerobic exercise is recommended for patients with atherosclerotic disease 4, 3
• Weight reduction for overweight or obese patients 4
• Moderation of alcohol consumption 4
• Adoption of a heart-healthy diet with increased consumption of vegetables and fruits, and reduced intake of meat, poultry, and eggs 7

Monitoring and Follow-up

• Regular imaging surveillance is essential for patients with aortic atherosclerosis, especially if there is aneurysmal disease 6
• For patients with concomitant abdominal aortic aneurysm, regular ultrasound surveillance is recommended 2

Special Considerations

• Atherosclerotic aortic disease is often asymptomatic until complications occur, so aggressive risk factor modification is crucial even in asymptomatic patients 8
• Fibrates are not recommended for cholesterol lowering in patients with aortic atherosclerosis 3
• Patients with aortic atherosclerosis should be screened for atherosclerotic disease in other vascular beds, particularly carotid and peripheral arteries 3