What is the management approach for an older adult patient with a history of hypertension presenting with aortic dissection?

Management of Aortic Dissection in Older Adults with Hypertension

Immediate aggressive blood pressure and heart rate control with intravenous beta-blockers is the cornerstone of acute management, targeting systolic BP 100-120 mmHg and heart rate ≤60 bpm, followed by urgent surgical consultation for Type A dissections or medical management for uncomplicated Type B dissections. 1

Initial Stabilization and Hemodynamic Control

Blood Pressure Management

• Reduce systolic blood pressure to 100-120 mmHg as the primary therapeutic goal 1, 2
• Target heart rate of 60 beats per minute or less to reduce aortic wall stress 1, 3
• Measure blood pressure in both arms (and sometimes both legs) since dissection-related occlusion of branch arteries can cause erroneously low readings in affected limbs 4
• Use the highest measured blood pressure as the true central pressure 4

First-Line Pharmacologic Therapy

• Initiate intravenous beta-blockers as first-line therapy 1
• Labetalol is the preferred agent for combined alpha and beta blockade 5, 6
• For severe hypertension despite adequate beta-blockade, add sodium nitroprusside 1, 7
• Critical caveat: Never administer vasodilators (like nitroprusside) before beta-blockade, as unopposed vasodilation can cause reflex tachycardia and increased aortic wall stress 1

Pain Control

• Provide morphine sulfate for pain relief, which also reduces sympathetic tone 1, 3
• Adequate analgesia is essential as pain itself drives catecholamine release and worsens hypertension 1

Monitoring

• Transfer immediately to intensive care unit 1
• Place arterial line for continuous invasive blood pressure monitoring 5

Type-Specific Management Strategy

Type A Dissection (Ascending Aorta)

• Urgent surgical consultation and evaluation for emergent surgical repair 1
• This is a surgical emergency with mortality increasing 1-2% per hour if untreated 8
• Surgical options include composite graft implantation in the ascending aorta 1
• Left untreated, approximately 75% die within 2 weeks, but successful surgery increases 5-year survival to 75% 8

Type B Dissection (Descending Aorta)

• Initially manage medically unless life-threatening complications develop 1
• Emergency intervention (preferably TEVAR - Thoracic Endovascular Aortic Repair) is recommended for complicated Type B dissection 1
• Complications requiring intervention include: malperfusion syndromes, uncontrolled hypertension despite maximal medical therapy, progression of dissection, or impending rupture 1

Special Considerations in Older Adults

Age-Related Presentation Differences

• Patients over 70 years are significantly less likely to present with typical symptoms (abrupt onset pain) and classic signs (aortic regurgitation murmur, pulse deficits), requiring extra vigilance for diagnosis 4
• Older patients are more likely to have hypertension as a risk factor (present in 65-75% of cases) 5
• Approximately 50% of patients are hypertensive at presentation, with Type B patients more commonly hypertensive (71%) than Type A patients (36%) 4

Hypotension as a Red Flag

• Conversely, nearly 20% present with hypotension or shock, which is associated with worse outcomes 4
• Hypotension indicates: cardiac tamponade, aortic hemorrhage, severe aortic regurgitation, myocardial ischemia/infarction, true lumen compression, or intra-abdominal catastrophe 4
• Patients with hypotension on admission have higher rates of neurologic complications, myocardial/mesenteric/limb ischemia, and death 4

Long-Term Blood Pressure Management

Target Blood Pressure

• Maintain blood pressure below 135/80 mmHg (some guidelines recommend <130/80 mmHg) 4, 3
• Blood pressure variability is an independent risk factor for poor prognosis in aortic dissection 4

Medication Strategy

• Beta-blockers are the preferred long-term therapy 4
• Beta-blockers improve survival in both Type A and Type B dissections 4
• ACE inhibitors did not improve survival in observational studies 4
• Most patients require combination therapy with multiple antihypertensive drugs (median of 4 drugs) 9

Challenges in Blood Pressure Control

• Approximately 40% of patients with chronic aortic dissection have resistant hypertension despite using ≥3 antihypertensive drugs 9
• Younger age and higher body mass index predict poor blood pressure control 9
• Patients with vascular history before dissection, high baseline BP, and greater descending aorta diameter are at risk for uncontrolled BP 10

Critical Diagnostic Pitfalls

Misdiagnosis Risk

• Thrombolytic therapy can be catastrophic if administered to a patient with aortic dissection misdiagnosed as myocardial infarction 1
• ECG should be obtained immediately to exclude STEMI, but a normal ECG should not delay CT angiography if dissection is suspected 5
• Aortic dissection can cause concurrent myocardial infarction or stroke through involvement of coronary or carotid arteries 11

Imaging Requirements

• Every patient with suspected aortic dissection requires urgent definitive imaging 1
• CT angiography of chest, abdomen, and pelvis is the diagnostic test of choice for stable patients 5
• TEE, CT, or MRI are all appropriate; selection depends on patient stability and institutional capabilities 1
• D-dimer below 500 ng/mL makes dissection unlikely, but elevated D-dimer should not be used alone to rule in dissection 1, 3, 5

Prognosis and Follow-Up

• 30-day mortality for all acute aortic dissection ranges from 23-55.8% 5
• Patients require lifelong surveillance with imaging every 2 years for mild-to-moderate dilation, or every 6 months if aortic diameter exceeds 4.5 cm 3
• The majority of late deaths following primary surgery are due to aortic rupture, with reoperation rates of 10% at 5 years and up to 40% at 10 years 4