The American College of Cardiology and America Heart Association published the 2022 guidelines for the diagnosis and management of aortic disease in the Journal of the American College of Cardiology.
The aorta is unique to other arteries in the body, in which thresholds for defining aneurysms or dilations differ by segment. In general, the recognized diameter thresholds for the aorta are 4.0 to 4.5 cm for patients with a height or body surface area that are within 2 standard deviations of the mean. Diameters that fall outside the threshold may indicate aortic disease.
Acute aortic syndrome (AAS) occurs due to a breach in the integrity of the aortic wall, such as from an aortic dissection, intramural hematoma, or penetrating atherosclerotic ulcer. Aortic dissection is the most common AAS and occurs when an intimal tear allows blood to flow and cause a false lumen, which can lead to aortic aneurysm.
In addition to AAS-associated false lumens, there are many causes of aortic aneurysms, including genetics, congenital conditions, infections, and lifestyle habits. The underlying causes, location of the aneurysm, and patient characteristics will all guide treatment.
Regardless of etiology, the diagnosis and progression of aortic disease should be monitored by imaging techniques (computed tomography, magnetic resonance imaging, echocardiography, ultrasound). Clinicians should keep ionizing radiation doses during imaging to a minimum while maintain imaging quality due to the need for long-term imaging surveillance.
The guideline authors recommended measurements of the root and ascending aortic segments to be taken from inner-edge to inner-edge. Other measurements should be taken in reference to landmarks, perpendicular to the axis of blood flow, such that the same regions are measured during subsequent surveillance. In the case of asymmetric or ovular contours, the longest diameter and its perpendicular diameter should be recorded.
For complete records, the guideline authors provided a list of 9 elements that aortic imaging reports should include.
In addition to imaging surveillance, obtaining a family history, including any unexplained sudden deaths, can be important for establishing a potential role of inherited disease. In some cases, such as aortic dissection, screening of first-degree relatives is advised.
The treatment options for aortic disease include lifestyle modifications, pharmacological treatment, and endovascular and surgical intervention. For patients receiving complex aortic surgical interventions, transfer to a high-volume aortic center should be considered to improve survival. In general, a multidisciplinary aortic team is needed to provide care with optimal outcomes.
For special populations, such as in the setting of pregnancy, a prepregnancy discussion with patients is recommended. Clinicians should discuss potential pregnancy-related complications unique to the setting of aortic disease and in the case of inherited disease, outcomes for their children. During pregnancy, a multidisciplinary team should be consulted to maintain adequate symptom management complemented by aortic diameter and valve function monitoring where appropriate.
The current gaps in knowledge that require additional research include determining more effective imaging, genetic, and clinical biomarkers for aortic diseases as well as more basic research into the biomechanics of the aorta. In general, as with all research, more effort is needed to ensure that study populations are diverse and reflect real-world patient populations.
“More data are needed from basic science studies and RCTs to guide prevention, early diagnosis, and advanced treatment for aortic disease. In the future, precision medicine and patient-centered approaches will enable clinicians to develop care plans to optimize outcomes for each patient,” the study authors wrote. “Future research should include diverse populations and examine race, ethnicity, and sex differences to ensure that all patient groups are represented and that questions pertinent to their aortic health are answered.”
Isselbacher EM, Preventza O, Black JH III, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease. J Am Coll Cardiol. Published online November 2, 2022. doi:10.1016/j.jacc.2022.08.004