A 60-year-old man is found to have an incidental 3.5-cm abdominal aortic aneurysm on an imaging study. He has no associated symptoms. Past medical history is significant for hypertension, type 2 diabetes, hypercholesterolemia, and hypothyroidism. His medications include aspirin, metformin, glipizide, chlorthalidone, lisinopril, atorvastatin, and levothyroxine. The patient has a 40-pack-year smoking history and continues to smoke 1-2 packs a day. He drinks 3 or 4 glasses of wine daily. His blood pressure is 160/90 mm Hg and pulse is 80/min. Cardiopulmonary examination is within normal limits. Laboratory results are as follows: Which of the following interventions would most decrease the likelihood of expansion of this patient's aortic aneurysm?

Question

A 60-year-old man is found to have an incidental 3.5-cm abdominal aortic aneurysm on an imaging study.  He has no associated symptoms.  Past medical history is significant for hypertension, type 2 diabetes, hypercholesterolemia, and hypothyroidism.  His medications include aspirin, metformin, glipizide, chlorthalidone, lisinopril, atorvastatin, and levothyroxine.  The patient has a 40-pack-year smoking history and continues to smoke 1-2 packs a day.  He drinks 3 or 4 glasses of wine daily.  His blood pressure is 160/90 mm Hg and pulse is 80/min.  Cardiopulmonary examination is within normal limits.  Laboratory results are as follows:  Which of the following interventions would most decrease the likelihood of expansion of this patient's aortic aneurysm?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be04_3616_8f63_8b9c621796d4_MD0005_00 Most patients with abdominal aortic aneurysm (AAA) are initially asymptomatic, and the diagnosis is made during an imaging study for an unrelated cause. Risk factors associated with development of AAA include older age (>60), male, cigarette smoking, family history of AAA, white ethnicity, and atherosclerotic disease. The natural history of AAA is characterized by progressive expansion over time with an increasing risk of rupture. Risk factors associated with aneurysm rupture include large diameter (20% risk in aneurysms >6 cm), rate of expansion (>0.5 cm in 6 months), and current cigarette smoking. Current cigarette smoking is the most important modifiable risk factor and has been associated with the highest rate of aneurysm expansion and rupture. The pathophysiology is likely due to increased inflammation and degeneration of connective tissue in the aortic wall. Therefore, smoking cessation is essential and has the greatest impact on decreasing the likelihood of aneurysm expansion. (Choice A) Diabetes is a strong risk factor for atherosclerosis and cardiovascular disease. However, for unclear reasons, studies have shown a lower risk of AAA development and expansion in patients with diabetes as compared to those without diabetes. (Choice B) Studies have shown a weak association between hypertension, AAA formation, and rate of expansion and rupture. Patients with AAA need adequate blood pressure control for overall cardiovascular risk reduction, but treatment with antihypertensive agents (including beta blockers) has not been clearly shown to reduce the rate of aneurysm expansion. (Choice C) Moderate alcohol intake (1 or 2 drinks/day in men and 1 drink/day in women) is associated with a decreased incidence of coronary heart disease and cardiovascular mortality. However, the effect of alcohol consumption on the risk of AAA expansion is not clear, and alcohol use is not considered a risk factor for AAA expansion or rupture. (Choice D) Hyperlipidemia is an important modifiable risk factor for atherosclerosis, but it has not been found to be associated with AAA growth and expansion. Multiple studies have found no evidence that lipid lowering with statins impacts the rate of AAA expansion. Educational objective: Cigarette smoking is strongly associated with abdominal aortic aneurysm (AAA) formation, expansion, and rupture. It is the most important modifiable risk factor to reduce the likelihood of aneurysm expansion in patients with AAA. References: Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. (http://www.ncbi.nlm.nih.gov/pubmed/15210603) The association between cigarette smoking and abdominal aortic aneurysms. (http://www.ncbi.nlm.nih.gov/pubmed/10587395)

A 60-Year-Old Man Is Found to Have an Incidental 3