What is the emergency management of aortic dissection?

From the Guidelines

Emergency management of aortic dissection requires immediate action to stabilize the patient and prevent fatal complications, with the primary goal of reducing aortic wall stress by controlling heart rate and blood pressure, as recommended by the most recent guidelines 1. The initial management should focus on aggressive blood pressure control with intravenous beta-blockers, such as labetalol, as the first choice due to its alpha- and beta-blocking properties, targeting a systolic blood pressure of 100-120 mmHg and heart rate below 60 beats per minute 1. If beta-blockers alone are insufficient, vasodilators like nitrates or dihydropyridine calcium channel blockers (e.g., nicardipine) can be administered concomitantly with rate-controlling agents to avoid reflex tachycardia 1. Key considerations in management include:

• Early placement of an arterial line to monitor blood pressure invasively
• Admission to an intensive care unit
• Pain control with intravenous opioids
• Immediate imaging with CT angiography, transesophageal echocardiography, or MRI to confirm the diagnosis and classify the dissection
• Type A dissections require emergency surgical repair, while uncomplicated Type B dissections may be managed medically The pathophysiology involves an intimal tear allowing blood to enter the media layer, creating a false lumen that can lead to rupture, tamponade, or malperfusion syndromes if not promptly addressed, highlighting the importance of timely and appropriate management based on the latest guidelines 1.

From the Research

Emergency Management of Aortic Dissection

• The emergency management of aortic dissection involves aggressive blood pressure and heart rate control to minimize further dissection extension and restore perfusion to vital organs 2.
• The management strategies depend on the nature of the dissection, with type A dissections involving the ascending aorta requiring immediate referral to cardiothoracic surgeons for emergency aortic surgery 3.
• Type B aortic dissections, on the other hand, may require surgical or endovascular interventions, and patients should be referred to vascular surgeons if indicated 3.

Medical Management

• Current guidelines recommend β-blockers as first-line therapy for type B aortic dissections, with the goal of controlling heart rate and blood pressure 2, 4.
• The use of oral beta-blockers has been associated with significant protection against in-hospital mortality and stroke following repair of type B thoracic aortic dissection 4.
• Intravenous beta-blockers, such as metoprolol, may also be effective in reducing mortality, with a dose of ≤10 mg associated with significant mortality reduction 4.

Target Blood Pressure Management

• The target blood pressure for patients with acute aortic dissection is typically set at a systolic blood pressure of 100-120 mmHg, with a heart rate of 60-80 beats/min 3, 5.
• The management strategy should be individualized, taking into account the patient's medical history, disease observation, and monitoring methods 5.
• Vasoactive drugs, such as labetalol and esmolol, may be used to control blood pressure, with the choice of agent depending on the patient's specific needs and response to treatment 2, 5.

Diagnosis and Treatment Principles

• The diagnosis of aortic dissection is challenging, and early suspicion, appropriate imaging, and rapid initiation of treatment are crucial 6.
• Critical care clinicians play a key role in the diagnosis, treatment, and post-operative care of patients with aortic dissection, and a thorough understanding of the condition is vital 6.