From the Guidelines
An aortic dissection can be treated with an esmolol drip and a Cardene (nicardipine) drip as part of initial medical management, with the goal of reducing heart rate and blood pressure to decrease aortic wall stress. These medications are used to control blood pressure and heart rate, which are critical in stabilizing patients with aortic dissection. Esmolol, a short-acting beta-blocker, reduces heart rate and the force of cardiac contraction, while Cardene, a calcium channel blocker, primarily reduces blood pressure. According to the 2018 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1, the preferred drugs for treating acute aortic dissection are esmolol and labetalol, with the goal of rapidly lowering systolic blood pressure to ≤120 mm Hg.
Key Considerations
- The typical target is to maintain systolic blood pressure between 100-120 mmHg and heart rate below 60 beats per minute.
- Esmolol is typically started at 50-200 mcg/kg/min and titrated to effect, while Cardene is usually initiated at 5 mg/hr and can be increased by 2.5 mg/hr every 5-15 minutes to a maximum of 15 mg/hr.
- These medications help reduce the shearing forces on the aortic wall, preventing extension of the dissection and allowing time for definitive treatment.
Important Notes
- While these medications are crucial for initial stabilization, most aortic dissections (particularly Type A involving the ascending aorta) ultimately require surgical intervention, as noted in the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease 1.
- Type B dissections (involving only the descending aorta) may sometimes be managed medically with careful blood pressure control.
From the FDA Drug Label
7 DRUG INTERACTIONS
7.1 Antihypertensive Agents Since nicardipine hydrochloride injection may be administered to patients already being treated with other medications, including other antihypertensive agents, careful monitoring of these patients is necessary to detect and to treat promptly any undesired effects from concomitant administration. 7. 2 Beta-Blockers In most patients, nicardipine hydrochloride injection can safely be used concomitantly with beta-blockers.
The treatment of aortic dissection with an esmolol drip (a beta-blocker) and Cardene drip (nicardipine) may be considered, as the label states that nicardipine can be safely used concomitantly with beta-blockers in most patients 2. However, careful monitoring is necessary to detect and treat any undesired effects from concomitant administration.
- Key considerations: careful monitoring of patients, potential for undesired effects
- Main idea: concomitant use of esmolol and nicardipine may be safe in most patients, but requires careful monitoring.
From the Research
Treatment of Aortic Dissection
- Aortic dissection is a serious and life-threatening condition that requires prompt and effective management 3, 4, 5, 6.
- The treatment of aortic dissection involves controlling hypertension and reducing myocardial contractility, with the goal of preventing further dissection and promoting healing 7.
- Medications used to treat aortic dissection include beta-blockers, such as esmolol, and vasodilators, such as sodium nitroprusside 3, 7.
Use of Esmolol and Cardene in Aortic Dissection
- Esmolol, an ultrashort-acting beta-blocker, has been shown to be effective in controlling heart rate in patients with acute aortic dissection 3, 7.
- However, there is limited information on the use of Cardene (nicardipine) in the treatment of aortic dissection.
- The use of esmolol and Cardene in combination may be considered in certain cases, but the evidence is limited and more research is needed to fully understand their effectiveness and safety in this context.
Management of Aortic Dissection
- The management of aortic dissection depends on the location and type of dissection, as well as the patient's overall condition 4, 5, 6.
- Type A dissections, which involve the ascending aorta, typically require immediate surgical intervention, while Type B dissections may be managed medically or with endovascular interventions 5, 6.
- Critical care clinicians play a key role in the diagnosis, treatment, and post-operative care of patients with aortic dissection 5.