What is the best next step for a patient with chest pain radiating to the back, hypertension, and a diagnosis of aortic dissection?

Immediate Management of Confirmed Aortic Dissection

Start intravenous beta-blockers immediately to achieve a target heart rate <60 beats/min, followed by additional antihypertensive agents to reduce systolic blood pressure to 100-120 mmHg, while simultaneously arranging urgent transfer to a cardiac surgery center. 1, 2

First-Line Pharmacologic Intervention: Beta-Blockade

Beta-blockers must be initiated before any other antihypertensive medication to prevent reflex tachycardia that would increase aortic wall shear stress and propagate the dissection. 1, 2, 3

• Intravenous esmolol is the preferred agent due to its ultra-short half-life (allowing rapid titration if complications develop such as hypotension or heart block). 2
• Alternative options include intravenous labetalol, which provides combined alpha- and beta-blockade and can lower blood pressure without reflex tachycardia. 4
• Target heart rate: <60 beats/min before addressing blood pressure control. 1, 2, 3

Secondary Blood Pressure Control

Once adequate beta-blockade is achieved and heart rate is controlled:

• Add intravenous vasodilators if systolic BP remains >120 mmHg despite beta-blockade. 1, 2
• Appropriate vasodilator options include sodium nitroprusside, intravenous nitrates, or calcium channel blockers. 1
• Target systolic blood pressure: 100-120 mmHg (in the absence of neurological complications suggesting malperfusion). 1, 2, 3

Critical Contraindications: What NOT to Do

Withholding antithrombotic therapy is mandatory in confirmed aortic dissection. 1, 3

• Never administer thrombolytics, antiplatelet agents (aspirin, clopidogrel), or anticoagulation (heparin, enoxaparin) as these can cause catastrophic hemorrhage into the dissection or precipitate rupture. 1, 2, 3
• This prohibition applies even if ECG shows ischemic changes, as the ischemia may result from coronary artery involvement by the dissection itself. 2

Pain Management

• Provide adequate analgesia for pain relief during stabilization and transfer. 1, 3
• Pain control is essential both for patient comfort and to reduce sympathetic surge that elevates blood pressure and heart rate. 3

Immediate Transfer Arrangements

Transfer to a center with 24/7 aortic imaging capability and cardiac surgery is mandatory. 1, 3

• Patients with confirmed aortic dissection require facilities equipped for emergency surgical intervention, as Type A dissections (involving the ascending aorta) have mortality approaching 1-2% per hour without surgical repair. 2, 5, 6
• Consider direct admission to radiology for definitive imaging (CT angiography) before proceeding to the operating theater. 1
• If the patient is at a non-surgical center, arrange immediate transfer after initial stabilization rather than delaying for complete imaging workup. 1, 3

Monitoring During Stabilization and Transfer

Continuous intensive monitoring is required: 2

• Continuous ECG and invasive arterial blood pressure monitoring. 2
• Urine output monitoring (to assess renal perfusion). 2
• Serial neurological assessments (to detect stroke or spinal cord ischemia). 2
• Oxygen saturation monitoring. 1

Laboratory Studies

Obtain blood samples for: 2

• Cardiac biomarkers (troponin)
• Complete blood count
• D-dimer
• Lactate dehydrogenase
• Renal function tests (creatinine, BUN)

These help assess for complications such as myocardial ischemia, hemolysis from the dissection, and end-organ malperfusion. 2

Common Pitfalls to Avoid

• Do not allow the patient to ambulate or assume upright position unmonitored, as labetalol and other antihypertensives can cause postural hypotension due to alpha-blockade effects. 4
• Do not start vasodilators before beta-blockade, as unopposed vasodilation causes reflex tachycardia that worsens the dissection. 1, 2, 3
• Do not delay transfer while attempting extensive diagnostic workup at a facility without cardiac surgery capability. 1, 3
• Do not assume the diagnosis is acute coronary syndrome based on chest pain and hypertension alone—aortic dissection mimics ACS but requires opposite management (no anticoagulation/antiplatelets). 2, 3, 5

Definitive Management Expectations

• Type A dissections (involving ascending aorta) require emergency open surgical repair with high mortality if untreated (26-58% surgical mortality, but approaching 75% mortality within 2 weeks without surgery). 5, 6
• Type B dissections (descending aorta only) may be managed with thoracic endovascular aortic repair (TEVAR) or medical management depending on complications. 5