From the Guidelines
The treatment of acute aortic dissection requires immediate medical intervention, with a focus on reducing aortic wall stress through blood pressure control and heart rate management, as outlined in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
Key Principles of Management
- The cornerstone of treatment is initial reduction of the pulse pressure by lowering systolic blood pressure (SBP) below 120 mmHg and heart rhythm ≤60 beats per minute (b.p.m.) to decrease aortic wall stress.
- Intravenous beta blockade, such as labetalol, is generally accepted as the best option for initial treatment, with non-dihydropyridine calcium channel blockers (CCBs) as an alternative if beta blockers are contraindicated 1.
- If the blood pressure target is not reached after initiating beta-blockers, intravenous vasodilators such as nitrates or dihydropyridine CCBs (e.g., nicardipine) can be administered concomitantly with rate-controlling agents to avoid reflex tachycardia.
Medical Management
- Initial medical management should include prompt treatment with anti-impulse therapy and invasive monitoring of blood pressure with an arterial line in an ICU setting, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.
- Patients should be treated to an SBP <120 mm Hg or to the lowest blood pressure that maintains adequate end-organ perfusion, as well as to a target heart rate of 60 to 80 bpm 1.
- Pain control with intravenous opioids is essential for hemodynamic management and patient comfort.
Surgical Intervention
- For type A dissections, emergency surgical repair is the standard treatment to prevent rupture and death.
- For type B dissections, medical management is often the first approach, with surgery reserved for complications such as malperfusion, aneurysmal expansion, or persistent pain despite medical therapy.
- Endovascular repair with stent grafts may be an option for selected patients with type B dissections who develop complications.
Long-term Management
- Long-term management includes lifelong blood pressure control, regular imaging surveillance, and genetic testing for familial aortic syndromes when appropriate.
- The use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) is beneficial in the long-term management of hypertension in patients with aortic dissection, as shown in recent studies 1.
- Statins are used routinely in patients after aortic dissection, although the evidence is not very robust 1.
From the Research
Treatment Overview
- The treatment of acute aortic dissection should begin as soon as the diagnosis is suspected, with aggressive measures to lower systemic blood pressure and its rate of increase 2.
- Patients with type A dissection are typically managed with emergency surgery, while those with type B dissection are treated medically unless complications arise 2, 3.
- Medical therapy for acute aortic dissection involves aggressive blood pressure lowering, usually with intravenous beta-blockade in combination with sodium nitroprusside 2, 4.
Medical Management
- The goal of medical management is to control the heart rate, systolic blood pressure, and pain 4.
- Beta blockers are commonly used to control heart rate and blood pressure, with 90% of patients receiving this treatment 5.
- Statin treatment has been associated with higher long-term survival in medically managed patients 5.
Surgical Intervention
- Patients with type A acute aortic dissection should be referred for emergency aortic surgery 4.
- Patients with type B acute aortic dissection may require surgical or endovascular interventions if complications arise 3, 4.
- Thoracic endovascular aortic repair (TEVAR) can improve clinical outcomes in patients with complicated type B aortic dissection 3.