What is the treatment for aortic dissection?

From the Guidelines

The treatment for aortic dissection should prioritize immediate medical attention, with a focus on controlling blood pressure and heart rate, as well as pain management, to reduce the force of blood against the aortic wall and prevent further complications. The management of aortic dissection depends on the location and severity of the dissection. For type A dissections (involving the ascending aorta), emergency surgery is typically required to repair the damaged section of the aorta, replace it with a synthetic graft, and repair or replace the aortic valve if necessary 1. For type B dissections (affecting only the descending aorta), medical management is often the first approach, focusing on controlling blood pressure with medications like beta-blockers (such as labetalol, metoprolol, or esmolol) and vasodilators (like nitroprusside or nicardipine) 1.

The goal of medical management is to reduce systolic blood pressure to 100-120 mmHg and heart rate below 60 beats per minute to decrease the force of blood against the aortic wall 1. Pain management with opioid analgesics is also essential 1. Patients require close monitoring in an intensive care unit with frequent imaging to assess for progression. Long-term management includes lifelong blood pressure control, typically with beta-blockers and other antihypertensives, regular imaging follow-ups every 6-12 months, and lifestyle modifications.

For type B dissections that become complicated by organ malperfusion, rupture, or continued pain despite medical therapy, endovascular stent grafting or open surgical repair may become necessary 1. The use of beta-blockers as the first-line medical therapy is recommended for patients with acute type B aortic dissection 1. Prompt treatment is crucial as mortality rates increase significantly with delays, particularly for type A dissections where mortality increases by 1-2% per hour without surgical intervention.

Key considerations in the management of aortic dissection include:

• Controlling blood pressure and heart rate to reduce the force of blood against the aortic wall
• Pain management with opioid analgesics
• Close monitoring in an intensive care unit with frequent imaging to assess for progression
• Lifelong blood pressure control with beta-blockers and other antihypertensives
• Regular imaging follow-ups every 6-12 months
• Lifestyle modifications to reduce the risk of further complications.

From the Research

Description of Aortic Dissection

• Aortic dissection is a life-threatening condition where there is a tear in the intimal lining of the aorta, extending 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.
• It is associated with significant mortality and morbidity, with rapid treatment being paramount 2.
• Aortic dissections are classified by location and chronicity, with management strategies depending on the nature of the dissection 2.

Treatment for Aortic Dissection

• The 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.
• The use of sodium nitroprusside and intravenous propranolol hydrochloride is a common treatment approach for acute aortic dissection, with the goal of controlling blood pressure and reducing myocardial contractility 3.
• In some cases, the use of esmolol hydrochloride, an ultrashort-acting beta-blocker, may be beneficial in patients with compromised cardiac function or bronchospastic disease 3.
• Beta-blockers are known to protect a vulnerable aorta from acute dissection and reduce the risk of recurrent dissection, and their discontinuation can lead to acute dissection 4.
• Immediate medical management aims to control heart rate, systolic blood pressure, and pain, with patients with Type A acute aortic dissection requiring emergency aortic surgery and those with Type B acute aortic dissection requiring surgical or endovascular interventions if indicated 5.

Diagnosis and Management

• Diagnosis of aortic dissection is challenging and requires early suspicion, appropriate imaging, and rapid initiation of treatment 2.
• Transesophageal echocardiography (TEE) and computed tomography scans are essential tools in diagnosing aortic dissection, allowing for rapid and safe assessment of the condition 6, 5.
• Effective post-operative care is crucial, with awareness of potential post-operative complications and a multi-disciplinary rehabilitation approach required 2.