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A 75-year-old current smoker with hypertension, hyperlipidemia, and a BMI of 31 presents for follow-up of an asymptomatic ascending thoracic aortic aneurysm. He currently takes a beta-blocker and a statin. His blood pressure is 110/68 mm Hg, his heart rate is 60 beats per minute, and his LDL cholesterol level is 68 mg/dL (reference range, <130).

Recent CT of the chest reveals that the aneurysm's diameter has increased from 4.8 cm one year ago to 5.0 cm now.

Echocardiography reveals calcific aortic stenosis, with an aortic valve area of 1.2 cm² and a mean gradient of 27 mm Hg (findings indicative of moderate aortic stenosis). The patient has no history of angina, syncope, near-syncope, or congestive heart failure.

Which one of the following interventions is the most appropriate for this patient? » Aortic aneurysm repair alone » Smoking cessation » Initiation of an angiotensin-converting–enzyme inhibitor » An increase in beta-blocker dosing » Aortic valve replacement and aortic aneurysm repair

From https://knowledgeplus.nejm.org/question-of-week/173/
Your answer is correct.

Aortic aneurysm repair aloneSmoking cessationInitiation of an angiotensin-converting–enzyme inhibitorAn increase in beta-blocker dosingAortic valve replacement and aortic aneurysm repair

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Surgical intervention for ascending thoracic aortic aneurysms is indicated when the aneurysm’s diameter is >5.5 cm or has expanded by >0.5 cm per year. Aneurysms >4.5 cm may be considered for correction in a patient who is undergoing cardiac surgery for another reason. The size of the aneurysm should be monitored yearly, preferably by CT or MRI.

The most effective management strategies for patients with aortic aneurysm who do not require surgery are smoking cessation and blood-pressure control. The rate of expansion of thoracic aortic aneurysms among smokers is twice that in nonsmokers.

If blood pressure is well controlled, initiating an angiotensin-converting–enzyme inhibitor is unnecessary.

If heart rate is well controlled, increasing the beta-blocker dose is unnecessary. In the patient with an aortic aneurysm, the therapeutic goal is to reduce blood pressure with beta-blockers, an angiotensin-converting–enzyme inhibitor, and/or an angiotensin-receptor blocker to the lowest point that the patient can tolerate without adverse effects.

Last reviewed Jul 2019. Last modified Feb 2016.

Citations

Hiratzka LF et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010 Mar 18; 121:e266.   >