From the Guidelines
Aortic dissection is a life-threatening emergency that requires immediate medical attention, with treatment depending on the location and severity of the dissection, and the most recent guidelines from 2021 1 emphasize the importance of prompt diagnosis and management. The treatment approach for aortic dissection varies based on the location of the dissection, with type A dissections (involving the ascending aorta) typically requiring emergency surgery to repair the damaged section and prevent rupture, as highlighted in the 2014 ESC guidelines 1.
- Key considerations in the management of aortic dissection include:
- Aggressive blood pressure reduction using intravenous medications like labetalol, esmolol, or nitroprusside to achieve a systolic blood pressure of 100-120mmHg, as recommended in the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines 1.
- Pain control with opioids like morphine, as emphasized in the 2001 European Heart Journal article 1.
- Long-term management includes oral antihypertensives (beta-blockers, ACE inhibitors), regular imaging follow-up with CT or MRI every 6-12 months, and lifestyle modifications.
- The importance of prompt recognition of symptoms like sudden, severe chest or back pain described as tearing or ripping cannot be overstated, as mortality increases by about 1% per hour without treatment in the first 48 hours, as noted in the 2021 Journal of the American College of Radiology article 1. The most critical aspect of managing aortic dissection is to prioritize the patient's morbidity, mortality, and quality of life, and to make decisions based on the most recent and highest-quality evidence, such as the 2021 guidelines from the Journal of the American College of Radiology 1.
From the Research
Definition and Classification of Aortic Dissection
- Aortic dissection is a serious condition characterized by a tear in the intimal lining of the aorta that extends into the media of the wall, leading to the formation of a false passage bordered by the inner and outer layers of the media 2.
- Aortic dissections are classified by location and chronicity, with management strategies depending on the nature of the dissection 2.
- The Stanford method splits aortic dissections into type A and B, with type A dissections involving the ascending aorta 2, 3.
- De Bakey classifies dissections into I, II or III depending on their origin and involvement and degree of extension 2.
Diagnosis and Treatment of Aortic Dissection
- The diagnosis of aortic dissection is challenging, with most deaths caused by aortic dissection diagnosed at post-mortem 2.
- Early suspicion, appropriate imaging, and rapid initiation of treatment are key to diagnosis and management 2, 4.
- Treatment focuses on initial resuscitation, transfer to a suitable specialist centre, strict blood pressure and heart rate control, and potentially surgical intervention depending on the type and complexity of the dissection 2, 5.
- Esmolol has been evaluated for heart rate control in patients with acute aortic dissection, with a lenient heart rate goal achieved in most patients 3.
- Continuous infusion labetalol and esmolol combination therapies have been compared for type B aortic dissections, with no significant difference in hemodynamic safety 6.
Management and Complications of Aortic Dissection
- Effective post-operative care is extremely important, with awareness of potential post-operative complications and a multi-disciplinary rehabilitation approach required 2.
- Hypertension during pregnancy, combined with unsuccessful attempts at delivery, may be a significant risk factor for aortic dissection 4.
- Endovascular aortic repair, such as placement of an aortic stent graft, may be used to manage type B aortic dissections 4.
- Nursing management includes blood pressure monitoring, serial physical assessment, and postoperative care, as appropriate 5.