The newest clinical guideline from the ACC and the American Heart Association aims to guide clinicians in the diagnosis and management of patients with aortic disease. Specifically, the 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease, published Nov. 2 in JACC, provides recommendations regarding diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance across multiple clinical presentation subsets, ranging from asymptomatic patients to those with acute aortic syndromes.

Among the highlights, the guideline encourages the use of centers with Multidisciplinary Aortic Teams in determining the appropriate timing of intervention. There is also added emphasis on the role of shared decision-making, especially in the management of patients with aortic disease both before and during pregnancy due to the "cardiovascular risks of pregnancy, the diameter thresholds for prophylactic aortic surgery, and the mode of delivery."

In terms of computed tomography, magnetic resonance imaging and echocardiographic imaging of patients with aortic disease, the guideline authors suggest clinicians follow recommended approaches for image acquisition, measurement and reporting of relevant aortic dimensions, and the frequency of surveillance before and after intervention.

Surgical, Endovascular Intervention

At centers with Multidisciplinary Aortic Teams and experienced surgeons, the guideline lowers the threshold for surgical intervention for sporadic aortic root and ascending aortic aneurysms from 5.5 cm to 5.0 cm in selected patients (Central Illustration). This threshold is even lower in specific scenarios among patients with heritable thoracic aortic aneurysms.

Additionally, in patients who are significantly smaller or taller than average, the guideline recommends that surgical thresholds "may incorporate indexing of the aortic root or ascending aortic diameter to either patient body surface area or height, or aortic cross-sectional area to patient height."

The guideline also defines rapid aortic root growth or ascending aortic aneurysm growth and provides guidance on when to use genetic screening and when valve-sparing aortic root replacement is reasonable. It also discusses the increasing role for thoracic endovascular aortic repair in the management of uncomplicated type B aortic dissection.

The Future: More Data, Precision Medicine

"Most of the current recommendations for patients with aortic disease are based on expert opinion and data from observational studies, large registries, and prospective studies, but few are from randomized clinical trials (RCTs)," according to the Writing Group, chaired by Eric M. Isselbacher, MD, MSc, FACC, and Vice Chairs Ourania Preventza, MD, MBA, and James Hamilton Black III, MD, DFSVS. "More data are needed from basic science studies and RCTs to guide prevention, early diagnosis, and advanced treatment for aortic disease."

They add that "in the future, precision medicine and patient-centered approaches will enable clinicians to develop care plans to optimize outcomes for each patient." They also stress the importance of including diverse populations and examining race, ethnicity and sex differences in future research "to ensure that all patient groups are represented and that questions pertinent to their aortic health are answered.

Promoting Patient-Centered Care

CardioSmart's new infographic on aortic disease explains the conditions that affect the aorta. Use this infographic with your patients to help them understand common conditions such as aortic aneurysm, aortic valve disease, aortic occlusive disease and aortitis. The infographic also explains how the aorta works and risk factors for aortic disease. Click here to download the free infographic. For more on this topic, visit CardioSmart.org/AorticAneurysm.

Don't miss the infographic on high-risk heart problems for pregnancy to facilitate shared decision-making. Click here to download it for free.