Hypertension in thoracic aortic aneurysm and dissection: considerations in the choice of antihypertensive agents for the long-term management

Background Thoracic aortic aneurysm (TAA) is a life-threatening condition that often remains asymptomatic until a catastrophic aortic dissection (TAD) occurs. Hypertension is a major risk factor, yet current guidelines provide limited direction on the most effective antihypertensive strategy. Prior concerns regarding calcium channel blockers (CCBs) and aortic pathology have further complicated treatment decisions. To address this critical gap, we conducted the first head-to-head comparison of different antihypertensive classes in managing both TAA and TAD. Methods A comprehensive systematic review was performed, screening over 6,000 studies from MEDLINE and EMBASE up to August 2024. A total of 27 studies met inclusion criteria and were analyzed. Results Hypertension significantly increases the risk of both TAA (HR 1.77, 95% CI: 1.47–2.13, p<0.01) and TAD (HR 2.51, 95% CI: 1.75–3.60). Among antihypertensive agents, CCBs demonstrated the greatest reduction in adverse outcomes (HR 0.46, 95% CI: 0.32–0.67, p<0.01), followed by beta-blockers (HR 0.61, 95% CI: 0.45–0.84, p=0.002) and ARBS/ACE inhibitors(HR 0.75, 95% CI: 0.66–0.85, p<0.0001). Notably, beta-blockers provided significant protection in Type B dissection but did not show a marked reduction in adverse events for Type A dissection whereas ACE inhibitors/ARBs did show significant protection for type A dissection. Conclusion Our findings highlight the outsized role of hypertension in driving aortic disease, with an even stronger link to dissection than aneurysm formation. CCBs emerge as the most effective therapy, particularly for Type B dissection, followed by beta-blockers and ARBS/ACE inhibitors. These insights provide critical evidence to optimize antihypertensive management in high-risk patients, potentially influencing future clinical guidelines.