Does a patient with a history of aortic dissection require antihypertensive medication to manage hypertension?

From the Guidelines

Patients with a history of aortic dissection require lifelong medication management, with beta-blockers as the cornerstone of treatment, to reduce morbidity and mortality. The goal of medical therapy is to reduce shear stress on the diseased segment of the aorta by reducing blood pressure and cardiac contractility 1. Beta-blockers, such as metoprolol (25-100 mg twice daily) or labetalol (100-300 mg twice daily), are first-line agents, reducing heart rate and blood pressure, and thereby decreasing shear stress on the aortic wall 1. Additional antihypertensive medications like angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) may be added to maintain blood pressure below 130/80 mmHg 1.

Key aspects of management include:

• Blood pressure control with beta-blockers as first-line agents
• Additional antihypertensive medications as needed to maintain blood pressure below 130/80 mmHg
• Lifestyle modifications, including smoking cessation, moderate physical activity, and maintaining well-controlled blood pressure
• Regular follow-up imaging to monitor for progression or complications

The most recent and highest quality study, from 2019, emphasizes the importance of immediately reducing systolic blood pressure and heart rate in patients with acute aortic disease, with beta-blockers as first-line treatment 1. Overall, the management of patients with a history of aortic dissection should prioritize reducing morbidity and mortality through careful medical management and lifestyle modifications.

From the Research

Medication for Patients with Aortic Dissection

• Patients with a history of aortic dissection often require medication to manage their condition and prevent further complications 2, 3, 4, 5.
• Beta-blockers are commonly used as first-line therapy to decrease aortic wall stress and are associated with improved outcomes in patients with aortic dissection 2, 4, 5.
• Other antihypertensive medications, such as calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs), may also be used in combination with beta-blockers to control blood pressure and reduce the risk of adverse outcomes 3, 4.
• The use of ACEIs or ARBs has been associated with benefits in the long-term treatment of aortic dissection, including reduced risk of all-cause mortality and hospital readmission 4.
• Intravenous beta-blocker use has been shown to reduce mortality and stroke risk in patients undergoing surgical repair of type B thoracic aortic dissection 5.
• Patients should continue to take beta-blockers and calcium channel blockers on the day of surgery, but the decision to continue or withhold ACE inhibitors and angiotensin receptor blockers should be made on a case-by-case basis 6.

Types of Medication

• Beta-blockers: metoprolol, atenolol, propranolol 5
• Calcium channel blockers: amlodipine, nifedipine, verapamil 3, 6
• Angiotensin-converting enzyme (ACE) inhibitors: lisinopril, enalapril, captopril 3, 4
• Angiotensin II receptor blockers (ARBs): losartan, valsartan, irbesartan 3, 4

Considerations for Medication Use

• Patients with aortic dissection should be closely monitored for signs of medication side effects and adverse outcomes 2, 3, 4, 5.
• The decision to use medication should be made on a case-by-case basis, taking into account the individual patient's medical history, current condition, and potential risks and benefits of treatment 2, 3, 4, 5, 6.