ACC and AHA Release Updated Guidance for Diagnosis and Management of Aortic Disease

Eric Isselbacher, MD

The nation’s leading cardiology organizations have released a new set of joint guidelines related to the diagnosis and management of aortic disease.

Published on November 2, the American College of Cardiology (ACC) and the American Heart Association (AHA) released the 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease, which focus on surgical intervention considerations, consistent imaging practices, genetic and familial screenings, and the importance of a multidisciplinary aortic team, were created for concurrent use with the 2020 Guideline for Management of Patients with Valvular Heart Disease and to replace previous guidance published in 2010 and 2015.

“There has been a host of new evidence-based research available for clinicians in the past decade when it comes to aortic disease. It was time to re-evaluate and update the previous, existing guidelines,” said guideline writing committee chair Eric M. Isselbacher, MD, MSc, director of the Healthcare Transformation Lab and codirector of the Thoracic Aortic Center at Massachusetts General Hospital, in a statement from the AHA. “We hope this new guideline can inform clinical practices with up-to-date and synthesized recommendations, targeted toward a full multidisciplinary aortic team working to provide the best possible care for this vulnerable patient population.”

Created in collaboration and endorsed by the American Association for Thoracic Surgery, American College of Radiology, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and Society for Vascular Surgery, the 2022 guidelines diagnosis and management of aortic disease was authored by Isselbacher and a team of 28 colleagues. At 149-pages in length, the multidisciplinary writing committee based the guidelines on data obtained from a comprehensive literature search conducted from January 2021-April 2021 that encompasses studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHLComplete, and other selected databases.

Citing more than 250 references, the document has a target audience of cardiovascular clinicians involved in the care of people with aortic disease, including general cardiovascular care clinicians and emergency medicine clinicians. The document itself begins by highlighting 10 top take-home messages, which is followed by 12 distinct sections dedicated to various topics of interest within the guideline. Topics within these sections include definitions, imaging and measurement recommendations, management of aneurysms, acute aortic syndromes, and more. The American Heart Association highlighted 6 specific areas with new recommendations of note in the aforementioned release.

These recommendations focused on areas related to:

• Family screening - The new guideline recommends family screening, including genetic testing and imaging, of first-degree relatives of individuals diagnosed with aneurysms of the aortic root or ascending thoracic aorta as well as those with aortic dissection.
• Multidisciplinary aortic teams: The new guideline recommends a multidisciplinary aortic team for patients requiring aortic intervention. The guideline recommends these teams may consist of cardiac and vascular surgeons, imaging specialists, anesthesiologists, and an intensive care unit experienced in the management of acute aortic disease.
• Shared decision-making: The multidisciplinary aortic team is highly encouraged to involve the patient in decision-making, especially in individuals on borderline of thresholds for repair or eligible for different types of surgical repair. Shared decision-making should also be used with individuals who are pregnant or may become pregnant to consider the risks of pregnancy in individuals with aortic disease.
• Consistency in imaging - The guideline draws specific attention to the importance of consistency in attainment and reporting ofCT or MRI imaging, in the measurement of aortic size and features, and in how often images are used for monitoring before and after repair surgery or other intervention. Authors suggest all surveillance imaging for a patient should be done using the same modality and in the same lab.
• Patient size adjustments - The guideline recommends modifying surgical thresholds in patients who are significantly smaller or taller than average. Guidance should be adjusted for the patient’s body surface area or height.
• Surgery - At institutions 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 certain individuals. The guideline also updates the definition for rapid aneurysm growth rate to: surgery is recommended for individuals with aneurysms of aortic root and ascending thoracic aorta with a confirmed growth rate of 0.3 cm or more per year across 2 consecutive years or 0.5 cm or more in one year.

The release from AHA points out the new guidelines will be replacing recommendations made within the “2010 ACCF/AHA Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease” and the “2015 Surgery for Aortic Dilation in Patients with Bicuspid Aortic Valves: A Statement of Clarification from the ACC/AHA Task Force on Clinical Practice Guidelines”. The release also notes the new guidance is intended to be used concurrently with the “2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease”.

This document, “2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease,” was simultaneously published in the Journal of the American College of Cardiology and Circulation.