What is the management approach for a patient with suspected aortic dissection, particularly those with a history of hypertension, atherosclerosis, or connective tissue disorders?

Management of Aortic Dissection

Immediately initiate aggressive blood pressure and heart rate control targeting heart rate <60 beats per minute and systolic blood pressure 100-120 mmHg, obtain CT angiography for diagnosis, and pursue emergency surgical repair for Type A dissection or medical management for uncomplicated Type B dissection. 1, 2

Immediate Hemodynamic Control: First Priority

Beta-blockers must be administered first, before any vasodilators, to reduce aortic wall shear stress. 3, 2

• Intravenous esmolol is the preferred agent due to its ultra-short half-life allowing rapid titration if complications develop 3
• Target heart rate <60 beats per minute before addressing blood pressure 1, 3
• The leading cause of death is progressive dissection resulting in rupture, driven by pulsatile blood flow—reducing the kinetic energy of blood flow through heart rate control is critical 4, 1

After adequate beta-blockade, target systolic blood pressure 100-120 mmHg. 1, 3, 2

• If blood pressure remains >120 mmHg despite beta-blockade, add intravenous vasodilators such as sodium nitroprusside or nicardipine 3, 2
• Never use vasodilators without prior beta-blockade—this can cause reflex tachycardia and worsen dissection 3, 2
• Nicardipine can be initiated at 5 mg/hr and titrated by 2.5 mg/hr every 15 minutes up to 15 mg/hr for gradual blood pressure reduction, or titrated every 5 minutes for more rapid control 5

Critical pitfall: Aggressive blood pressure reduction can cause adverse events in patients with severe aortic insufficiency or pericardial tamponade—careful evaluation is essential before initiating therapy 1

Diagnostic Imaging Strategy

CT angiography is the primary diagnostic test to exclude thoracic aortic dissection. 4, 1, 2

• CTA has sensitivity of 93% (95% CI 90-95%) and specificity near 100% 4, 1
• CTA is preferred over transesophageal echocardiography (TEE) due to rapid availability in most emergency departments and ability to detect alternative diagnoses in 13% of cases 4
• TEE has sensitivity of 88% (95% CI 82-92%) but is less readily available 4, 1

For profoundly unstable patients, perform bedside transthoracic echocardiography to identify cardiac tamponade or other immediate life-threatening complications. 2

• If TTE is suggestive of aortic dissection, surgical consultation or transfer to higher level of care should be considered immediately 4

Definitive Management Based on Stanford Classification

Type A dissection (involving ascending aorta and/or arch) requires emergency surgical repair. 4, 1, 3, 2

• Surgical management has been shown to reduce mortality rates in Type A dissections, with mortality approaching 1-2% per hour without intervention 4, 3
• Surgical options include resection of all aneurysmal aorta and proximal extent of dissection, aortic valve resuspension, and aortic root replacement 2
• In-hospital mortality with surgical therapy is 27-29% compared to 53% with medical therapy alone for Type A dissection 4

Type B dissection (involving descending aorta distal to left subclavian artery) is managed medically unless complicated. 4, 1, 2

• Uncomplicated Type B dissections should receive aggressive blood pressure and heart rate control with medical therapy 2, 6, 7
• In-hospital mortality with medical therapy for Type B dissection is 9% 4
• Complicated Type B dissections (rupture, malperfusion, progression) require thoracic endovascular aortic repair (TEVAR), which has resulted in fourfold increase in early survival 6, 7

High-Risk Clinical Features Requiring Immediate Action

Maintain high clinical suspicion in patients with predisposing conditions: 1, 8

• Marfan syndrome or other connective tissue disorders (Ehlers-Danlos, Loeys-Dietz syndrome)
• Family history of aortic disease
• Known aortic valve disease (especially bicuspid aortic valve)
• Long-term history of arterial hypertension
• Advanced age and male gender

High-risk pain features: 1

• Abrupt onset of severe chest pain
• Migrating pain quality
• Tearing or ripping character

High-risk examination findings: 1

• Pulse deficit or blood pressure differential >20 mmHg between extremities
• New murmur of aortic insufficiency
• Focal neurologic deficits

Critical Contraindications

Thrombolytics, antiplatelet agents, and anticoagulation are absolute contraindications in suspected aortic dissection, as they can cause hemorrhage into the dissection. 3

• This is particularly critical when ECG changes suggest myocardial ischemia—do not administer thrombolytics even if ST-elevation is present 3

Monitoring and Supportive Care

Transfer patient to intensive care unit immediately with: 3, 2

• Invasive arterial blood pressure monitoring via arterial line 2
• Continuous heart rate and rhythm monitoring 3
• Adequate pain control with morphine sulfate to reduce sympathetic stimulation 2
• Monitoring of urine output and neurological status 3

Special Population Considerations

Patients with hereditary connective tissue disorders require lifelong beta-blocker therapy and periodic routine imaging of the aorta. 4, 2

• Prophylactic replacement of the aortic root should be performed before diameter exceeds 5.0 cm in patients with family history of dissection, or 5.5 cm in others 4

Women with aortic dissection present at older age, are less likely to present within first 6 hours, and have higher in-hospital mortality compared to men. 1

Elderly patients are less likely to present with typical symptoms and may have higher risk of postoperative complications. 1

Long-Term Management

After 24 hours of hemodynamic stability, transition from intravenous to oral beta-blockers. 2

• Target long-term blood pressure <135/80 mmHg 2
• Regular imaging follow-up is necessary to monitor for complications such as false lumen expansion or aneurysm formation 2, 7
• All patients require strict antihypertensive management combined with imaging surveillance and careful periodic clinical follow-up regardless of initial treatment 7