2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease
The American College of Cardiology (ACC) and the American Heart Association (AHA) Joint Committee have just published their much anticipated clinical practice guideline on the Diagnosis and Management of Aortic Disease. This guideline covers everything from the basics of aortic anatomy, to in-depth discussions of the evaluation, management, and treatment of acute aortic syndromes. However, at over 400 pages long, we at Guideline Central know that reading through the full text guidelines can be a lengthy process. To make it easier to consume and implement, today’s article will go over the Top 10 Take-Home Messages for the ACC/AHA Diagnosis and Management of Aortic Disease Clinical Practice Guidelines 2022.
#1 – Multidisciplinary Aortic Teams
“Because outcomes for patients with aortic disease are enhanced at programs with higher volumes, experienced practitioners, and extensive management capabilities, Multidisciplinary Aortic Team care is considered in determining the appropriate timing of intervention.”
Comprised of experienced cardiac and vascular surgeons, radiologists and imaging specialists with expertise in aortic disease imaging and interpretation, anesthesiologists experienced in managing acute aortic disease and CSF drainage, and an ICU with staff experienced in the management of acute aortic disease patients, a Multidisciplinary Aortic Team approach allows for a comprehensive, experienced, and collaborative care team to come together and optimize the outcomes for aortic disease patients.
#2 – Shared Decision-Making
“Shared decision-making involving the patient and a multidisciplinary team is highly encouraged to determine the optimal medical, endovascular, and open surgical therapies. In patients with aortic disease who are contemplating pregnancy or who are pregnant, shared decision-making is especially important when considering the cardiovascular risks of pregnancy, the diameter thresholds for prophylactic aortic surgery, and the mode of delivery.”
With all patients, knowing each individual patient’s goals of care is a vital step in providing appropriate interventions and treatment. This is no different for aortic disease patients, where shared decision making is crucial for determining the appropriate time to intervene, what kind of surgical repair should be done, including choosing open versus endovascular approaches, and the type of medical management and surveillance best suited for that patient.
#3 – Aortic Imaging & Evaluation
“Computed tomography, magnetic resonance imaging, and echocardiographic imaging of patients with aortic disease should follow recommended approaches for image acquisition, measurement and reporting of relevant aortic dimensions, and the frequency of surveillance before and after intervention.”
Emphasizing the importance of utilizing the appropriate imaging modalities, imaging techniques, and conventions of measurement when evaluating and monitoring your patients aortic disease, the ACC/AHA discuss in depth the diagnostic performance and indications for the different modalities of aortic imaging, including CT, MRI, TTE, TEE, and ultrasound.
#4 – Lowered Surgical Intervention Threshold
“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 5.0 cm in selected patients, and even lower in specific scenarios among patients with heritable thoracic aortic aneurysms.”
With more recent studies finding that many patients with an aortic dissection had not met the 5.5cm size criteria for prophylactic surgical intervention, the threshold size criteria for patients with familial thoracic aortic aneurysms/dissections and other heritable thoracic aortic diseases has been lowered to 5.0 cm, or lower for some, to help improve outcomes and prevent dissection/disease progression by allowing for earlier intervention with prophylactic surgery.
#5 – Aortic Indexing for Surgical Thresholds
“In patients who are significantly smaller or taller than average, 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.”
Indexing of the aorta is done to both monitor the aortic size and to estimate/assist with risk assessment. In circumstances such as Turner’s Syndrome where the use of absolute aortic diameter measurements alone can underestimate their risk of dissection, this take home message emphasizes the importance of appropriate size indexing when surveilling and assessing for intervention.
#6 – Rapid Aortic Growth Intervention
“Rapid aortic root growth or ascending aortic aneurysm growth, an indication for intervention, is defined as ≥0.5 cm in 1 year or ≥0.3 cm per year in 2 consecutive years for those with sporadic aneurysms and ≥0.3 cm in 1 year for those with heritable thoracic aortic disease or bicuspid aortic valve.”
Rapid aortic growth is associated with an increased risk of rupture, and is an indication for intervention regardless of the absolute aortic diameter.
#7 – Valve-Sparing Aortic Root Replacement Surgery
“In patients undergoing aortic root replacement surgery, valve-sparing aortic root replacement is reasonable if the valve is suitable for repair and when performed by experienced surgeons in a Multidisciplinary Aortic Team.”
Performed as an alternative to the valved-conduit aortic root replacement, shared decision-making should be done to actively involve the patient in the expectations and differences between the valve-sparing and valve replacement procedures.
#8 – Type A Aortic Dissections – Transfers & Repairs
“Patients with acute type A aortic dissection, if clinically stable, should be considered for transfer to a high-volume aortic center to improve survival. The operative repair of type A aortic dissection should entail at least an open distal anastomosis rather than just a simple supracoronary interposition graft.”
With the mortality of Type A dissections being 2-3 times higher when medically managed compared to surgically managed, getting these patients evaluated for surgical intervention urgently is imperative – but getting them to a center that is high-volume and used to these types of cases, with experienced surgeons working within a multidisciplinary aortic team, is even better for improving survival.
#9 – Type B Aortic Dissections – TEVAR
“There is an increasing role for thoracic endovascular aortic repair in the management of uncomplicated type B aortic dissection. Clinical trials of repair of thoracoabdominal aortic aneurysms with endografts are reporting results that suggest endovascular repair is an option for patients with suitable anatomy.”
Though medical management is the initial strategy for uncomplicated Type B dissections, newer studies indicate that the introduction of endovascular techniques has resulted in significantly lower morbidity and mortality rates compared to optimal medical management. For instance, in the INSTEAD-XL trial, patients with uncomplicated type B dissections given prophylactic TEVAR plus medical optimization were associated with improved 5-year aorta specific survival rates, and delayed disease progression.
#10 – Screening of First-Degree Relatives
“In patients with aneurysms of the aortic root or ascending aorta, or those with aortic dissection, screening of first-degree relatives with aortic imaging is recommended.”
This recommendation is essential for detecting unrecognized and asymptomatic thoracic aortic disease, especially considering up to 20% of individuals with thoracic aortic aneurysms or aortic dissections have a family history of thoracic aortic disease, with at least 1 first-degree relative affected. More so, approximately 20% of thoracic aortic aneurysms are related to a genetic or heritable condition, so screening goes beyond just monitoring your aortic disease patient, but also making sure you’re keeping an eye on the first degree relatives.
While the Top 10 Take-Home Messages for the 2022 ACC / AHA Clinical Practice Guidelines for Aortic Disease cover a wide scope of diagnostic and management recommendations, make sure to check out the full text guideline for a comprehensive list of aortic disease recommendations, including information on aortic disease surveillance, screening, medical management, and disease-specific recommendations.
You can find the links to the Diagnosis and Management of Aortic Disease guideline, and thousands more clinical practice guidelines, at GuidelineCentral.com.
Dr. Tabitha Michaud, MD, Clinical Content Coordinator at Guideline Central
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