What is the initial management of aortic dissection?

Initial Management of Aortic Dissection

The initial management of aortic dissection requires immediate anti-impulse therapy targeting systolic blood pressure <120 mmHg and heart rate ≤60 beats per minute, with intravenous beta-blockers as first-line treatment. 1

Immediate Assessment and Stabilization

• Establish intravenous access, obtain blood samples, perform ECG, and initiate continuous heart rate and blood pressure monitoring for all patients with suspected aortic dissection 2
• Provide adequate pain relief with morphine sulfate and transfer to intensive care unit for appropriate monitoring 2
• Invasive monitoring with an arterial line and continuous three-lead ECG recording is recommended for accurate blood pressure management 1

Blood Pressure and Heart Rate Control

• Administer intravenous beta-blockers as first-line therapy, with labetalol being preferred due to its alpha- and beta-blocking properties 1
• If beta-blockers are contraindicated, intravenous non-dihydropyridine calcium channel blockers can be used for heart rate control 1
• If blood pressure target is not reached after initiating beta-blockers, add intravenous vasodilators such as nitrates or dihydropyridine calcium channel blockers (e.g., nicardipine) 1, 2
• In cases of malperfusion, higher blood pressure may be tolerated to optimize perfusion to the threatened region 1

Diagnostic Imaging

• Perform urgent definitive imaging using one of the following modalities: 2
  • Computed tomography (CT) - widely available with high sensitivity and specificity 3
  • Transesophageal echocardiography (TEE) - allows rapid assessment, especially useful for Type A dissections 4
  • Magnetic resonance imaging (MRI) - excellent for detecting small intramural hematomas 2
• Chest X-ray should be performed in stable patients but omitted in unstable patients to avoid treatment delays 2

Type-Specific Management

Type A Dissection (involving ascending aorta)

• Obtain urgent surgical consultation for emergency surgical repair 2
• The aim of surgery is to prevent aortic rupture, pericardial tamponade, and relieve aortic regurgitation 1
• Surgical options include implantation of a composite graft in the ascending aorta with or without reimplantation of coronary arteries 1
• If malperfusion of peripheral branches is present, consider percutaneous revascularization first, with delayed surgical repair until ischemic injury resolves 1

Type B Dissection (distal to left subclavian artery)

• Initially manage medically with anti-impulse therapy and pain control 1, 2
• Emergency intervention (preferably TEVAR - Thoracic Endovascular Aortic Repair) is recommended for complicated Type B dissection presenting with: 1, 5
  • Intractable pain
  • Rapidly expanding aortic diameter
  • Periaortic or mediastinal hematoma (signs of rupture)
  • Malperfusion syndrome
  • Dissection occurring in a previously aneurysmatic aorta

Special Considerations

• In patients with hereditary diseases (Marfan syndrome, Ehlers-Danlos syndrome), lifelong beta-adrenergic blockade is recommended for prevention of dissection 1, 6
• For pregnant patients with aortic dissection, management requires a multidisciplinary team at specialized centers, using drugs with the lowest teratogenic impact 1
• In cases of Type A dissection during pregnancy, if the fetus is viable, caesarean delivery should be performed before aortic repair 1

Follow-up Care

• For patients with aortic dissection who can be managed conservatively and have achieved hemodynamic targets with intravenous anti-impulse therapy, switching to oral beta-blockers is recommended after 24 hours if gastrointestinal transit is preserved 1
• Regular imaging follow-up is essential to monitor for potential complications such as false lumen expansion or aneurysm formation 1, 7