From the Guidelines
Calcium Channel Blockers (CCBs) should not be used as first-line therapy in aortic dissection because they can potentially worsen the condition by causing reflex tachycardia and increased contractility. In aortic dissection, the primary goal is to reduce blood pressure and decrease the force of cardiac contraction (dP/dt), which reduces shear stress on the aortic wall.
Preferred Treatment
Beta-blockers like labetalol are preferred first-line agents because they reduce both heart rate and blood pressure, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
Alternative Treatment
If contraindicated, i.v. non-dihydropyridine CCBs could be used for heart rate control, but with caution.
Additional Considerations
If the BP target is not reached after initiating beta-blockers, i.v. vasodilators such as nitrates or dihydropyridine CCBs can be administered concomitantly with rate-controlling agents first to avoid reflex tachycardia, as recommended by the 2024 ESC guidelines 1.
Key Points
- The primary goal in aortic dissection is to reduce blood pressure and decrease the force of cardiac contraction (dP/dt) to reduce shear stress on the aortic wall.
- Beta-blockers are the preferred first-line agents.
- CCBs, particularly dihydropyridines, can cause reflex sympathetic activation, increasing heart rate and contractility, which may extend the dissection.
- Non-dihydropyridine CCBs might be considered only in patients with absolute contraindications to beta-blockers, but with caution and preferably in combination with other agents that reduce contractility.
From the Research
Reasons for Not Using Calcium Channel Blockers (CCBs) in Aortic Dissection
- CCBs can potentially increase the shear stress on the aortic wall, which may worsen the dissection 2, 3
- The use of CCBs in aortic dissection is not well-studied, and there is limited evidence to support their effectiveness in this condition 2, 4
- Beta-blockers are generally preferred over CCBs in the management of aortic dissection, as they can reduce the force of cardiac contraction and lower blood pressure, which can help to reduce the risk of further dissection 4, 5
- CCBs may not provide the same level of protection against aortic dissection as beta-blockers, and their use may be associated with a higher risk of adverse outcomes 3, 6
Alternative Treatments for Aortic Dissection
- Beta-blockers, such as esmolol, are commonly used to control heart rate and blood pressure in patients with aortic dissection 4, 6
- Sodium nitroprusside may also be used to control blood pressure in patients with aortic dissection, although its use requires careful monitoring to avoid hypotension 4
- Surgical repair is often necessary to treat aortic dissection, especially in patients with type A dissection 5