Position StatementCanadian Cardiovascular Society Position Statement on the Management of Thoracic Aortic Disease
Section snippets
Size thresholds for elective thoracic aortic intervention
Thoracic aortic aneurysms are largely asymptomatic until a sudden and catastrophic event, including aortic rupture or dissection, occurs, and is rapidly fatal in a large proportion of patients.1, 2 Elective intervention on the thoracic aorta carries a much lower risk of mortality and morbidity, and prophylactic aortic surgery can be life-saving.
The decision to perform aortic intervention is a balance between risks of natural history of the disease vs the risk of the surgical intervention
Antihypertensive therapy
The rationale for antihypertensive therapy is based on mechanistic and animal studies,55, 56 and observational reports linking aortic dissection with hypertension.57, 58 Randomized controlled trials of antihypertensive therapies have not included patients with TAD per se or reported consistently on aortic end points.59, 60 Although summaries of antihypertensive trials support treatment of hypertension when present, they do not offer specific guidance on the management of patients with thoracic
Screening for Family Members of Patients With Genetic Aortopathy
Key features of common genetic aortopathies are described in Table 4.
Knowledge Gaps
Most of the epidemiology and natural history of TAD is based on: (1) surgical series from selected populations; (2) retrospective cohorts of acute aortic syndromes; (3) single-centre studies of patients with inherited or degenerative forms of TAD; and (4) extrapolation from non-TAD patients, leaving important knowledge gaps in this patient population.
Future research should be focused on these key knowledge gaps in the pathophysiology, natural history, and treatment of patients with TAD,
Multidisciplinary Care and Quality Indicators
Comprehensive management of TAD spans multiple disciplines including but not limited to cardiac surgery, vascular surgery, cardiology, genetics, imaging, and adult congenital heart disease. Therefore, care for these patients is best provided in such a multidisciplinary environment and clinics are currently emerging across major cardiac centres in Canada. These might also be an important source of critical natural history data on thoracic aortic pathologies, and facilitate prospective clinical
Acknowledgements
The authors thank the members of the secondary panel for their thorough review of the manuscript draft and insightful comments that helped shape the final document.
Secondary panel: Hal Dietz, MD (McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD), Francois Dagenais, MD (Division of Cardiac Surgery, Laval University, Québec City, Québec, Canada), Christopher Fiendel, MD (Division of Cardiac Surgery, University Health Network, Toronto, Ontario, Canada),
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The disclosure information of the authors and reviewers is available from the CCS on the following websites: www.ccs.ca and/or www.ccsguidelineprograms.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.