Thoracic Artery Disease Guidelines Published

April 6, 2010—The American College of Cardiology (ACC) and the American Heart Association (AHA) have published new clinical guidelines that offer recommendations for the diagnosis and management of thoracic aortic disease (TAD) and stress the vital importance of early diagnosis and treatment.

The complete practice guidelines were published in the Journal of the American College of Cardiology (2010;55:e27–e129). The complete practice guidelines were also published in the American Heart Association's Circulation (2010;12:e266–e369). An executive summary of the guidelines is available in the journals' April 6 issues and online at the journals' Web sites.

The ACC and AHA were joined in creating the guidelines by various medical societies and disciplines involved in the care of these patients, including the Society of Interventional Radiology and the Society for Angiography and Cardiovascular Interventions.

Risk factors for TAD include poorly controlled high blood pressure, advancing age, male gender, atherosclerosis, inflammatory diseases that damage the blood vessels, and certain genetic conditions that weaken connective tissue, such as Marfan syndrome. In addition, people who have a bicuspid aortic valve may be at increased risk for an aortic aneurysm. Pregnancy, intense weight lifting, and cocaine use increase the risk of aortic dissection.

One of the most important messages in the guidelines is that TAD often runs in families. As a result, family history is a critical tool for uncovering undiagnosed cases of TAD. Patients should tell their physicians not only about close relatives with aortic aneurysm, dissection, or rupture, but also about any family history of unexplained sudden death.

“If thoracic aortic disease can be detected early and managed, it gives us the opportunity to select patients for surgical or endovascular repair when the patient is stable,” commented Loren F. Hiratzka, MD, who chaired the guidelines writing committee. “The results of treatment for stable disease are far better than for acute—and often catastrophic— aortic rupture or dissection.”

Additional highlights from the TAD guidelines include:

• Imaging of the thoracic aorta by computed tomography, magnetic resonance imaging or, in some cases, echocardiography is the best way to detect TAD and determine future risk. A chest x-ray alone is not sufficient.
• Patients with genetic conditions that increase the risk of TAD should have aortic imaging at the time of diagnosis to establish the size of the aorta, with periodic followup imaging thereafter.
• All patients with a bicuspid aortic valve should be evaluated to determine whether the aorta is dilating or widening.
• The symptoms of acute aortic dissection, which can mimic those of a heart attack, often make it difficult to arrive at a prompt diagnosis and may delay life-saving treatment. Physicians should keep aortic dissection in mind when asking questions about medical history, family history, and the type and pattern of pain when examining the patient.
• Aortic dissection involving the ascending aorta is a lifethreatening emergency that should be treated surgically.
• Aortic dissection involving the descending thoracic aorta may often be managed with medications that control blood pressure and heart rate, unless life-threatening complications develop. Additional medical therapy may include statins to lower elevated blood cholesterol levels.
• Minimally invasive endovascular techniques are an option in some patients with aneurysm or dissection of the descending thoracic aorta.
• All immediate relatives of a patient with thoracic aortic aneurysm, dissection, or a bicuspid aortic valve should be evaluated by a cardiovascular physician and undergo aortic imaging to measure the size of the aorta and identify asymptomatic disease. Not all health care insurers pay for aortic imaging in high-risk asymptomatic patients, particularly based on family history, Dr. Hiratzka noted.