Exercise and Thoracic Aortic Aneurysms: A Paradigm Shift Toward Informed, Personalized Activity Guidelines

Exercise is widely recognized for its cardiovascular benefits; however, its safety and role in patients with thoracic aortic aneurysms (TAAs) remains complex due to its distinctive biomechanical vulnerabilities. Fundamentally different from abdominal aortic aneurysms, TAAs develop from distinct pathophysiological processes that affect their hemodynamic responses to stressors and influence their risk of adverse aortic events. Exercise induces acute hemodynamic changes, including increased stroke volume, systolic and pulse pressures, and transient aortic stiffening. These changes impose mechanical stress on the aortic wall, potentially accelerating aneurysm progression or triggering adverse aortic events. Although moderate aerobic exercise generally appears safe with potential cardiovascular benefits, evidence supporting safe practices in TAAs is limited. Current guidelines frequently extrapolate from abdominal aortic aneurysm data, which overlook the specificities of the thoracic aorta. This review underscores the urgent need for comprehensive research, using advanced imaging, biomarker profiling, and real-time hemodynamic monitoring to understand how different exercise modalities and intensities affect TAAs. Well-designed prospective studies are crucial to improve risk stratification, optimize antihypertensive strategies, develop personalized exercise prescriptions, and provide evidence-informed guidance to patients. Perioperative strategies like prehabilitation and structured postoperative rehabilitation show promise but lack rigorous evaluation. Ultimately, this work advocates a paradigm shift from conservative inactivity toward informed, individualized physical activity regimens tailored to each patient's risk profile. This approach aims to maximize cardiovascular benefits while minimizing adverse aortic events, thereby improving overall health and quality of life in patients with TAAs.