Aortopathy

February 10, 2020


Having been away the past few weeks for CaRMS, I was excited to come back to medicine. I started my first day of my CEEP selective in the cardiology clinic. It was nice being able to review some common cardiology topics, such as post-MI management (i.e. dual-antiplatelet therapy, ACE inhibitor, beta-blocker, and high-dose statin) and its intricacies. Some of the more interesting cases that I saw that day were related to aortopathies. I had several patients with cardiovascular co-morbidities who presented with an incidental finding

After reviewing these cases with my team and additional readings, the following is my takeaways for thoracic aortic aneurysms.

Presentation: usually asymptomatic but can result in aortic rupture, dissection, and death.

Etiology:

• Degenerative
• Usually older patients with atherosclerotic risk factors (e.g. smoking, hypertension)
• Genetics: e.g. Marfan, Ehlers-Danlos, Loeys-Dietz syndrome, bicuspid aortic valve
• Consider if family history, physical exam findings in keeping with genetic syndrome, younger patients (no specific cut-off but ~<50 years old).
• Inflammatory: giant cell arteritis, Takayasu arteritis, Behcet's disease, ankylosing spondylitis

Management (in general):

• Consider genetics referral 
• Monitor every 6 months until stable then annually with imaging (echo, CT/MR angiography)
• Consider elective surgical management if symptomatic (e.g. malperfusion, compression), ascending aorta diameter >55 mm or annual expansion >5 mm (see guidelines for specifics)
• Evaluate for other aneurysms
• Preventative
• Blood pressure control 
• Beta-blocker preferred over ACEi/ARBs 
• Target 140/90 or if diabetic, 130/80 
• CV risk reduction - smoking cessation, lifestyle modification
• Avoid strenuous and isometric exercises
• Avoid fluoroquinolones - increase risk of aortic dissection/rupture
• Counsel patient on symptoms to watch out for, including sudden chest pain, and need for seeking immediate medical attention.

-JT-

Reference(s):
Boodhwani, M., Andelfinger, G., Leipsic, J., Lindsay, T., McMurtry, M. S., Therrien, J., & Siu, S. C. (2014). Canadian Cardiovascular Society position statement on the management of thoracic aortic disease. Canadian Journal of Cardiology, 30(6), 577-589.