What is the management of aortic dissection?

From the Guidelines

Management of aortic dissection should prioritize immediate reduction of pulse pressure by lowering systolic blood pressure below 120 mmHg and heart rate to 60 beats per minute or less, using intravenous beta blockade as the first line of treatment, as recommended by the 2024 ESC guidelines 1. The goal of this approach is to decrease aortic wall stress and prevent further extension of the dissection, which can lead to rupture or malperfusion.

• Key considerations in the management of aortic dissection include:
  • Initial treatment should be centralized in experienced centers and managed by aorta teams
  • Intravenous beta blockade, such as labetalol, is the preferred initial treatment for reducing heart rate and blood pressure
  • If beta blockers are contraindicated, intravenous non-dihydropyridine calcium channel blockers (CCBs) can be used as an alternative for heart rate control, as suggested by both the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines 1 and the 2024 ESC guidelines 1
  • Vasodilators, such as nitrates or dihydropyridine CCBs (e.g., nicardipine), can be added to beta blockers if the blood pressure target is not reached, but should not be used before beta blockade to avoid reflex tachycardia
• It is essential to monitor blood pressure invasively using an arterial line and to admit patients to an intensive care unit for close monitoring and management, as the in-hospital mortality rate for aortic dissection can be high, reaching 60% in some cases, and is correlated with the type and location of the dissection, patient comorbidities, and treatment outcomes, as noted in the 2024 ESC guidelines 1.

From the Research

Management of Aortic Dissection

The management of aortic dissection involves immediate medical attention and a combination of pharmacologic and surgical interventions.

• The initial management includes controlling the heart rate and systolic blood pressure, as well as pain management 2.
• Imaging studies such as chest computed tomography scan and transthoracic echocardiography (TTE) are essential to confirm the diagnosis 2.
• Patients with Type A acute aortic dissection require emergency aortic surgery, while those with Type B acute aortic dissection may be treated medically or with surgical/endovascular interventions if indicated 2.

Pharmacologic Management

Pharmacologic management of aortic dissection focuses on controlling blood pressure and reducing myocardial contractility.

• The use of beta-blockers, such as esmolol, in combination with sodium nitroprusside, has been reported to be effective in managing acute aortic dissection 3.
• Beta-blockers are recommended as first-line therapy for chronic type B aortic dissections to decrease aortic wall stress, although there is limited evidence to support this recommendation 4.
• Other antihypertensive medications, such as calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers, may also be used in the medical therapy of type B aortic dissection 4.

Surgical Interventions

Surgical interventions play a crucial role in the management of aortic dissection.

• Emergency aortic surgery is indicated for patients with Type A acute aortic dissection 2, 5.
• Patients with Type B acute aortic dissection may require surgical or endovascular interventions if complications arise 2, 5.
• Catheter-based techniques, including fenestration, stenting, and endoluminal graft insertion, may be used in selected patients with acute dissection 5.

Post-Operative Care

Effective post-operative care is essential in the management of aortic dissection.

• Critical care clinicians play a key role in the diagnosis, treatment, and post-operative care of patients with aortic dissection 6.
• A multi-disciplinary rehabilitation approach is required to ensure optimal outcomes for patients with aortic dissection 6.