What is the next step in managing aortic dissection?

From the Guidelines

The next step in managing aortic dissection is to urgently obtain surgical consultation for all patients diagnosed with thoracic aortic dissection, regardless of the anatomic location, as soon as the diagnosis is made or highly suspected. This is based on the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease 1. The initial management of thoracic aortic dissection should be directed at decreasing aortic wall stress by controlling heart rate and blood pressure, with intravenous beta blockade initiated and titrated to a target heart rate of 60 beats per minute or less, in the absence of contraindications 2.

Key Considerations

• Urgent surgical consultation is crucial for all patients diagnosed with thoracic aortic dissection, regardless of the anatomic location 1.
• Acute thoracic aortic dissection involving the ascending aorta should be urgently evaluated for emergent surgical repair due to the high risk of associated life-threatening complications 1.
• Acute thoracic aortic dissection involving the descending aorta should be managed medically unless life-threatening complications develop, such as malperfusion syndrome, progression of dissection, enlarging aneurysm, inability to control blood pressure or symptoms 1.
• Initial hospital management typically includes pain control with IV opioids, blood pressure reduction with beta-blockers, and close monitoring.

Management Strategies

• Beta-blockers, such as labetalol or metoprolol, should be used to control heart rate and blood pressure, with a target systolic blood pressure of less than 120 mmHg 2.
• Vasodilators, such as nicardipine, may be used if needed to further reduce blood pressure 2.
• Long-term management includes lifelong blood pressure control, regular imaging surveillance, and lifestyle modifications, such as smoking cessation and avoiding heavy lifting.

From the Research

Management of Aortic Dissection

The next step in managing aortic dissection involves several key considerations, including:

• Rapid initiation of pharmacologic agents to control hypertension 3
• Strict blood pressure and heart rate control with monitoring for any complications such as malperfusion, rupture, or hemodynamic instability 4
• Potential surgical intervention depending on the type and complexity of the dissection 5, 6
• Transfer to a suitable specialist centre, if possible and required 6

Medical Management

Medical management plays a crucial role in the treatment of aortic dissection, with the goal of preventing exacerbation or rupture of the dissection 5. This includes:

• Use of intravenous esmolol, an ultrashort-acting beta-blocker, to control blood pressure and reduce myocardial contractility 7
• Administration of sodium nitroprusside to control blood pressure 7
• Aggressive medical management to prevent organ ischemia and other catastrophic manifestations of aortic dissection 5

Surgical Intervention

Surgical intervention is often necessary in the management of aortic dissection, particularly in cases involving the ascending aorta 5, 3. The type and timing of surgical intervention depend on the specific characteristics of the dissection, including its location and complexity 6. In some cases, a staged approach may be used, with initial malperfusion repair followed by transfer to a specialized cardiovascular center for further evaluation and treatment 5.