What are the management and treatment guidelines for aortic dissection with hypertension?

From the Guidelines

Management of aortic dissection with hypertension requires immediate blood pressure control to reduce shear forces on the aortic wall, with a target systolic blood pressure of less than 120 mmHg, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. The initial treatment should focus on rapidly lowering systolic blood pressure while maintaining adequate organ perfusion.

• First-line medications include intravenous beta-blockers such as esmolol, labetalol, or metoprolol, which are preferred as initial therapy because they reduce heart rate and contractility, decreasing aortic wall stress.
• If beta-blockers alone are insufficient, vasodilators like nicardipine, clevidipine, or sodium nitroprusside can be added, but these should never be used without concurrent beta-blockade as they may increase heart rate and worsen shear forces. Key considerations in the management of aortic dissection with hypertension include:
• Prompt treatment with anti-impulse therapy and invasive monitoring of blood pressure in an ICU setting 1.
• Treatment to a target heart rate of 60 to 80 bpm, in addition to blood pressure control 1.
• The use of intravenous beta blockers as initial management, except in patients with contraindications 1.
• The importance of pain control, as pain can worsen hypertension, and the use of opioids for this purpose 1. Once stabilized, patients should transition to oral antihypertensives including beta-blockers, ACE inhibitors, or ARBs to maintain systolic blood pressure below 130 mmHg long-term. Surgical intervention is typically indicated for type A dissections (involving the ascending aorta), while type B dissections (descending aorta only) may be managed medically unless complications develop. Continuous hemodynamic monitoring in an ICU setting is necessary during the acute phase to ensure blood pressure targets are maintained and to monitor for complications. The most recent and highest quality study, the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1, provides the basis for these recommendations, prioritizing morbidity, mortality, and quality of life as the outcome.

From the FDA Drug Label

Sodium nitroprusside is indicated for the immediate reduction of blood pressure of adult and pediatric patients in hypertensive crises. The management and treatment guidelines for aortic dissection with hypertension involve immediate reduction of blood pressure.

• Key treatment goal: Reduce blood pressure promptly to prevent further complications.
• Medication: Sodium nitroprusside (IV) can be used for immediate reduction of blood pressure in hypertensive crises, including those associated with aortic dissection 2.
• Additional consideration: Concomitant longer-acting antihypertensive medication should be administered to minimize the duration of treatment with sodium nitroprusside.

From the Research

Management and Treatment Guidelines for Aortic Dissection with Hypertension

• The primary goal in managing aortic dissection with hypertension is to control blood pressure and reduce myocardial contractility, which can be achieved through pharmacologic management 3.
• Sodium nitroprusside and intravenous propranolol hydrochloride are commonly used in the treatment of acute aortic dissection 3.
• Esmolol, an ultrashort-acting beta-blocker, has been shown to be effective in managing heart rate in patients with acute aortic dissection, with a lenient heart rate goal (≤80 bpm) achieved in most patients within the first 60 minutes of therapy 4.
• The treatment of aortic dissection depends on the severity and location of the dissection, with open surgical repair being the gold standard for dissections located in the proximal part of the aorta and the arch, and endovascular interventions recommended for most distal or type B aortic dissections 5.
• Beta-blockers are commonly used as first-line therapy for chronic type B aortic dissections to decrease aortic wall stress, although there is limited evidence to support their use compared to other antihypertensive medications 6.
• In non-surgical patients with type A aortic dissection, beta-blockers are often used to reduce systolic blood pressure and heart rate, although their effectiveness and potential risks are still being debated 7.

Pharmacologic Management

• Esmolol has been shown to be a safe and effective option for heart rate control in patients with acute aortic dissection, with a low incidence of hypotension 4.
• Sodium nitroprusside and intravenous propranolol hydrochloride are commonly used in combination to control blood pressure and heart rate in patients with acute aortic dissection 3.
• Beta-blockers, such as propranolol and esmolol, are commonly used to reduce myocardial contractility and decrease aortic wall stress in patients with aortic dissection 3, 4.

Surgical and Endovascular Interventions

• Open surgical repair is the gold standard for dissections located in the proximal part of the aorta and the arch 5.
• Endovascular interventions, such as stent-graft placement, are recommended for most distal or type B aortic dissections 5.
• The choice of surgical or endovascular intervention depends on the severity and location of the dissection, as well as the patient's overall health and medical history 5.