Evolving Trends in Antihypertensive Therapy for Heritable Thoracic Aortic Disease:A 28-Year Retrospective Analysis

Abstract

Background

Aortic aneurysms, dissections, and ruptures rank as the 19th leading cause of death in the United States, contributing to nearly 50,000 fatalities annually. These conditions often remain silent until catastrophic events occur, underscoring the importance of early detection, including clinical and phenotypic recognition, and proactive management. In contrast to age-related abdominal aortic disease, 20% of thoracic aortic aneurysms are attributed to heritable thoracic aortic disease (HTAD). Typically, HTAD is identified in young patients by surviving an acute aortic event, detecting an incidental imaging finding or phenotypic concern, or investigating familial relationships.

Optimizing medical management of hypertension is essential for mitigating the progression of aortic disease and reducing the risk of dissection and rupture. Beta-blockers (BBs) and angiotensin II receptor blockers (ARBs), specifically Losartan, can decrease hemodynamic stress on the aortic wall, potentially slowing aneurysmal expansion and minimizing life-threatening events.

Aim

This study aims to evaluate a 28-year trend in antihypertensive therapy among HTAD patients undergoing elective aortic repair at a robust aortic center in the Southwest.

Methods

We included 990 HTAD patients ≥18 years (median age, 43 years; quartile 1-quartile 3, 36-49) who underwent elective aortic surgery within a high-volume practice in the Southwest United States (1996-2024). Patients were categorized into one of four groups based on antihypertensive medication regimen at the time of surgery: no medication (NoMeds, n=98), beta-blockers only (BBs only, n=675), angiotensin II receptor blockers only (ARBs only, n=70), or both BBs and ARBs (BBs+ARBs, n=147). Descriptive statistics and group comparisons were performed to retrospectively evaluate trends and outcomes.

Results

Overall, most patients were male (68%, n=668), had hypertension (75%, n=744), and were ≤50 years of age (84%, n=827). Notably, nearly 10% of patients (n=98) were not receiving any antihypertensive medication. Over time, there has been a significant decline in the proportion of patients managed without antihypertensive therapy or with beta blockers (BBs) alone. Specifically, the use of BBs as monotherapy decreased by nearly 24% (p< 0.01) as clinical practice evolved toward greater adoption of angiotensin receptor blockers (ARBs), either alone or in combination with BBs (Figure 1). This shift highlights advancements in evidence-based strategies for optimizing perioperative hypertensive medical management of HTAD patients (Figure 2).

Conclusions

Managing hypertension is essential for reducing the risk of aortic disease progression, dissection, and rupture; beta-blockers (BBs) and angiotensin II receptor blockers (ARBs) are effective treatments. This analysis underscores significant advancements in the medical management of heritable thoracic aortic disease (HTAD), particularly in antihypertensive therapy. The declining reliance on beta-blocker monotherapy and the increased adoption of angiotensin II receptor blockers (ARBs), reflects evolving evidence-based practices aimed at reducing aortic wall stress and improving patient outcomes. These findings highlight not only the critical role of tailored pharmacological strategies in mitigating the progression of aortic disease but also the need for continued efforts to improve practitioner awareness of optimal antihypertensive medication use. Enhancing education and adherence to evolving guidelines can further reduce life-threatening complications and subsequently reduce late aortic events for HTAD patients.