Aortic dissection medical therapy

Aortic dissection Microchapters
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Case #1

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Medical Therapy

The prime consideration in the medical management of aortic dissection is strict blood pressure control. The target blood pressure should be a mean arterial pressure (MAP) of 60 to 75 mmHg. Another factor is to reduce the shear-force dP/dt (force of ejection of blood from the left ventricle).

To reduce the shear stress, a vasodilators such as sodium nitroprusside should be used with a beta blocker, such as esmolol, propranolol, or labetalol. The alpha-blocking properties of labetalol make it especially attractive in this situation.

Calcium channel blockers can be used in the treatment of aortic dissection, particularly if there is a contraindication to the use of beta blockers. The calcium channel blockers typically used are verapamil and diltiazem, because of their combined vasodilator and negative inotropic effects.

If the individual has refractory hypertension (persistent hypertension on the maximum doses of three different classes of antihypertensive agents), involvement of the renal arteries in the aortic dissection plane should be considered.

ACC/ AHA Guidelines - Recommendations for Initial management of Aortic dissection (DO NOT EDIT)

Class I

1.Initial management of thoracic aortic dissection should be directed at decreasing aortic wall stress by controlling heart rate and blood pressure as follows:

a. In the absence of contraindications, intravenous beta blockade should be initiated and titrated to a target heart rate of 60 beats per minute or less. (Level of Evidence: C)

b. In patients with clear contraindications to beta blockade, nondihydropyridine calcium channel–blocking agents should be utilized as an alternative for rate control.(Level of Evidence: C)

c. If systolic blood pressures remain greater than 120 mm Hg after adequate heart rate control has been obtained, then angiotensin-converting enzyme inhibitors and/or other vasodilators should be administered intravenously to further reduce blood pressure that maintains adequate end-organ perfusion. (Level of Evidence:C)

d. Beta blockers should be used cautiously in the setting of acute aortic regurgitation because they will block the compensatory tachycardia (Level of Evidence:C)

Class III (No Benefit)

1.Vasodilator therapy should not be initiated prior to rate control so as to avoid associated reflex tachycardia that may increase aortic wall stress, leading to propagation or expansion of a thoracic aortic dissection (Level of Evidence: C)

ACC/ AHA Guidelines - Recommendations for definitive management of Aortic dissection (DO NOT EDIT)

Class I

1. Urgent surgical consultation should be obtained for all patients diagnosed with thoracic aortic dissection regardless of the anatomic location (ascending versus descending) as soon as the diagnosis is made or highly suspected (Level of Evidence: C)

2. Acute thoracic aortic dissection involving the ascending aorta should be urgently evaluated for emergent surgical repair because of the high risk of associated life-threatening complications such as rupture. (Level of Evidence: B)

3. Acute thoracic aortic dissection involving the descending aorta should be managed medically unless life-threatening complications develop (e.g., malperfusion syndrome, progression of dissection, enlarging aneurysm, inability to control blood pressure or symptoms) (Level of Evidence: B)