From the Guidelines
The management of aortic dissection requires immediate intervention, with emergency surgical repair being the standard treatment for Type A dissections and medical management often being the first approach for Type B dissections, with surgery reserved for complications, as recommended by the most recent guidelines 1. The initial management of aortic dissection should focus on decreasing aortic wall stress by controlling heart rate and blood pressure.
- In the absence of contraindications, intravenous beta blockade should be initiated and titrated to a target heart rate of 60 beats per minute or less, as suggested by the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines 1.
- If systolic blood pressures remain greater than 120 mm Hg after adequate heart rate control has been obtained, then angiotensin-converting enzyme inhibitors and/or other vasodilators should be administered intravenously to further reduce blood pressure that maintains adequate end-organ perfusion, as recommended by the same guidelines 1.
- The ESC Council on Hypertension position document on the management of hypertensive emergencies also suggests that beta-blockers are first-line treatment for acute aortic disease, with esmolol being used together with ultra-short acting vasodilating agents such as nitroprusside or clevidipine, or bolus injections of metoprolol or labetalol being used as alternatives 1.
- For Type A dissections, surgery is the treatment of choice, with the goal of reducing mortality and preventing rupture, as stated in the 2014 ESC guidelines on the diagnosis and treatment of aortic diseases 1.
- Long-term management of aortic dissection includes lifelong blood pressure control, beta-blockers, regular imaging surveillance, and lifestyle modifications, with the aim of reducing the risk of late death and late re-operation, as suggested by the same guidelines 1.
From the Research
Management of Aortic Dissection
The management of aortic dissection involves a combination of medical and surgical interventions. The goal of treatment is to control blood pressure, reduce myocardial contractility, and prevent further complications.
- Medical Management:
- Beta-blockers, such as esmolol, are commonly used to control heart rate and blood pressure 2, 3.
- Sodium nitroprusside may also be used to control blood pressure 3.
- The use of beta-blockers as first-line therapy is recommended for chronic type B aortic dissections, but there is limited evidence to support this practice 4.
- Surgical Management:
- Open surgical repair is the gold standard of treatment for dissections located in the proximal part of the aorta and the arch 5.
- Endovascular interventions are recommended for most distal or type B aortic dissections 5.
- Delayed surgery or nonoperative management may be considered for selected patients with acute type A aortic dissection, but immediate surgical therapy is still recommended for acceptable operative candidates 6.
- Treatment Outcomes:
- The outcomes of treatment for aortic dissection depend on the severity and location of the dissection, as well as the patient's overall health status 5, 6.
- Aggressive medical treatment and delayed surgery may be effective for selected patients with acute type A aortic dissection, with acceptable early and short-term outcomes 6.