New aortic disease guideline stresses team approach, family screenings, earlier surgery
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An updated guideline on the diagnosis and management of aortic disease focuses on the importance of a multidisciplinary aortic team, as well as surgical intervention considerations and the importance of genetic and familial screenings.
The guideline, published jointly by the American College of Cardiology and the American Heart Association, brings together guidelines for both the thoracic and abdominal aorta and is targeted to cardiologists involved in the care of people with aortic disease, including general CV care clinicians and emergency medicine clinicians.
“The prior ACC/AHA Guideline, which was focused on thoracic aortic disease, was published in 2010,” Eric M. Isselbacher, MD, MSc, FACC, director of the Healthcare Transformation Lab and co-director of the Thoracic Aortic Center at Massachusetts General Hospital, and chair of the guideline writing committee, told Healio. “During the past 12 years, there have been remarkable advances in both surgical and endovascular techniques to treat patients with aortic disease. In addition, there have been significant advances in our understanding of syndromic and heritable thoracic aortic disease. All of these advances have been summarized and highlighted in the new 2022 Aortic Disease Guideline, making a terrific contemporary resource for clinicians.”
Updated, lower threshold for surgery
The updated guideline includes several new recommendations, including that, at centers with multidisciplinary aortic teams and experienced surgeons, the threshold for surgical intervention for sporadic aortic root and ascending aortic aneurysms has been lowered from 5.5 cm to 5 cm in selected patients, and even lower in specific scenarios among patients with heritable thoracic aortic aneurysms, Isselbacher said. Additionally, aneurysms of the aortic root or ascending aorta, even when not associated with known syndromes, can be familial, so screening of first-degree relatives is recommended to detect unsuspected aortic disease in family members.
“Shared decision-making is highly encouraged to determine the optimal medical, endovascular and open surgical therapies,” Isselbacher told Healio.
The guideline also calls for consistency in imaging, particularly in the way CT or MRI is obtained and reported, in the measurement of aortic size and features, and in how often images are used for monitoring before and after repair surgery or other intervention. The guideline recommends all surveillance imaging for a patient take place using the same modality and in the same lab when possible.
also recommends modifying surgical thresholds in patients who are significantly smaller or taller than average.
Shared decision-making involving a multidisciplinary aortic team is highly encouraged to involve the patient in decision-making, especially when individuals are on the borderline of thresholds for repair or eligible for different types of surgical repair.
Addressing research gaps
Several research gaps in treating aortic disease remain, Isselbacher said.
“The timing of intervention for aortic aneurysms is still based primarily on aneurysm diameter, yet we know many patients dissect at diameters well below our standard thresholds,” Isselbacher told Healio. “It is clear we need to identify other, more individualized predictors of adverse aortic events, which we hope will come from advances in genetics, the discovery of biomarkers, and an increased understanding of the biomechanical properties of the aorta.”
Isselbacher also said more research is needed to better understand how sex, race, ethnicity and patient size impact the natural history and optimal management of aortic disease.
The guideline was published simultaneously in the Journal of the American College of Cardiology and in Circulation and was developed in collaboration with and endorsed by the American Association for Thoracic Surgery, the American College of Radiology, the Society of Cardiovascular Anesthesiologists, the Society for Cardiovascular Angiography and Interventions, the Society of Thoracic Surgeons and the Society for Vascular Surgery. It was endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine.
For more information:
Eric M. Isselbacher, MD, MSc, can be reached at eisselbacher@mgh.harvard.edu.
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