Syphilitic Cardiac and Vascular Disease: A Comprehensive Review

Syphilis incidence has been rising worldwide over the last few decades, raising concern for a resurgence of tertiary complications. Syphilitic cardiovascular disease is a rare but serious manifestation of tertiary syphilis, formerly a major cause of aortitis and thoracic aortic aneurysms before the antibiotic era. This review provides an updated overview of syphilitic cardiac and vascular disease for the cardiology specialist. We will discuss the historical and epidemiological context of cardiovascular syphilis, including longitudinal preantibiotic era studies and contemporary case series. We outline the pathophysiology of syphilitic aortitis, highlighting mechanisms whereby Treponema pallidum infection causes obliterative endarteritis of the vasa vasorum, ischemic injury to the aortic wall, and resulting aneurysm formation with aortic valve and coronary ostia involvement. The clinical manifestations are presented, with emphasis on the triad of classic tertiary cardiovascular syphilis, which includes syphilitic thoracic aortic aneurysm, aortic regurgitation, and coronary ostial stenosis. The diagnostic strategies are covered, including modern imaging findings (CT, MRI, echocardiography), serologic test algorithms for syphilis, and histopathologic features. Differential diagnosis is covered in depth, contrasting syphilitic aortitis with other causes of aortitis such as Takayasu arteritis, giant cell arteritis, and other infectious or idiopathic aortitides. Management principles are laid out, with antibiotic therapy and surgery as indicated for late disease. We also cover reported case outcomes and registry reports-including modern surgical series and a recent population-based study implicating syphilis in increased cardiovascular risk-and highlight prognosis with modern therapies. Syphilitic cardiac and vascular disease remains a relevant clinical entity-the "great imitator" of cardiovascular medicine-despite decreased incidence in the antibiotic. Early recognition of this treatable cause of aortitis is critical. Outcomes may be favorable with appropriate antibiotic treatment and early surgical repair of complications, but delayed diagnosis is perilous. Ongoing vigilance, research into optimal management, and public health measures to restrict syphilis are required to further reduce the impact of this disease.