From the Guidelines
The most appropriate initial intravenous treatment for a patient with ascending aortic dissection is a beta-blocker, specifically esmolol or labetalol, to rapidly reduce heart rate and blood pressure. The goal is to reduce the heart rate to 60 beats per minute or less and systolic blood pressure to 120 mmHg or less, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. Key considerations in managing ascending aortic dissection include:
- Reducing aortic wall stress by controlling heart rate and blood pressure
- Using beta-blockers as the first line of treatment, with esmolol or labetalol being suitable options
- Adding vasodilators such as nicardipine or sodium nitroprusside if necessary to achieve target blood pressure, but only after heart rate control has been established
- Monitoring blood pressure invasively and admitting the patient to an intensive care unit for close monitoring and management.
In this case, the patient's initial presentation with a heart rate of 118/min and systolic blood pressure of 210/120 mmHg in the right arm and 180/100 mmHg in the left arm indicates the need for immediate reduction of heart rate and blood pressure to prevent further dissection and potential rupture. The use of esmolol, as recommended by the 2019 ESC council on hypertension position document on the management of hypertensive emergencies 1 and 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, is a suitable option for initial treatment. Esmolol should be started with a loading dose of 500 mcg/kg over 1 minute, followed by 50-200 mcg/kg/min, with the goal of reducing heart rate to 60 beats per minute or less. Once heart rate is controlled, a vasodilator such as nicardipine can be added to further reduce blood pressure if necessary. Target systolic blood pressure should be 100-120 mmHg or the lowest level that maintains adequate organ perfusion, as recommended by the 2024 ESC guidelines 1.
From the Research
Initial Intravenous Treatment for Ascending Aortic Dissection
The most appropriate initial intravenous treatment for a patient with ascending aortic dissection should aim at controlling blood pressure and reducing myocardial contractility. Considering the patient's presentation and medical history, the following options are available:
- Esmolol: A beta-blocker that can help control heart rate and reduce myocardial contractility, which is beneficial in managing acute aortic dissection 2, 3.
- Hydralazine: A vasodilator that can help lower blood pressure, but it may not be the best initial choice as it can cause reflex tachycardia, which may worsen the condition.
- Nicardipine: A calcium channel blocker that can help lower blood pressure, but its use in acute aortic dissection is not as well-established as esmolol or sodium nitroprusside.
- Nitroprusside: A vasodilator that can help lower blood pressure, but it should be used with caution as it can cause reflex tachycardia and may not be suitable for all patients 2, 4.
Key Considerations
When choosing the initial intravenous treatment, the following factors should be considered:
- The patient's blood pressure and heart rate
- The presence of any concomitant medical conditions, such as heart failure or bronchospastic disease
- The potential for reflex tachycardia or other adverse effects
Recommended Treatment
Based on the available evidence, esmolol is a suitable initial intravenous treatment for ascending aortic dissection, as it can help control heart rate and reduce myocardial contractility 2, 3. Additionally, clevidipine may be considered as an adjunct therapy to esmolol, as it has been shown to be effective in managing blood pressure in acute aortic dissection and is less costly than sodium nitroprusside 4.