Aortic Dissection Medication

  • Author: Mary C Mancini, MD, PhD; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: May 16, 2012
 

Medication Summary

Initial therapeutic goals include the elimination of pain and the reduction of systolic blood pressure to 100-120 mm Hg or to the lowest level commensurate with adequate vital organ (ie, cardiac, cerebral, renal) perfusion. Whether systolic hypertension or pain is present, beta-blockers are used to reduce arterial delta pressure/delta time (dP/dt).

To prevent exacerbations of tachycardia and hypertension, treat patients with intravenous morphine sulfate. This reduces the force of cardiac contraction and the rate of rise of the aortic pressure. It then retards the propagation of the dissection and delays rupture.

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Antihypertensives, Other

Class Summary

These agents are used to reduce arterial dP/dt. For acute reduction of arterial pressure, the potent vasodilator sodium nitroprusside is effective. To reduce dP/dt acutely, administer an IV beta-blocker in incremental doses until a heart rate of 60-80 beats/min is attained.

When beta-blockers are contraindicated, such as in second- or third-degree atrioventricular block, consider using calcium channel blockers. Sublingual nifedipine successfully treats refractory hypertension associated with aortic dissection.

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Esmolol (Brevibloc)

 

Esmolol is an ultra–short-acting beta2-blocker. It is particularly useful in patients with labile arterial pressure, especially if surgery is planned, because it can be discontinued abruptly if necessary. This agent is normally used in conjunction with nitroprusside. It may be useful as a means to test beta-blocker safety and tolerance in patients with a history of obstructive pulmonary disease who are at possible risk of bronchospasm from beta-blockade. The elimination half-life of esmolol is 9 minutes.

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Labetalol (Trandate)

 

Labetalol blocks alpha-, beta1-, and beta2-adrenergic receptor sites, decreasing blood pressure.

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Propranolol (Inderal LA, InnoPran XL)

 

Propranolol is a class II antiarrhythmic nonselective beta-adrenergic receptor blocker. It has membrane-stabilizing activity and decreases the automaticity of contractions. Propranolol is not suitable for emergency treatment of hypertension. Do not administer propranolol IV in hypertensive emergencies.

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Metoprolol (Lopressor, Toprol XL)

 

Metoprolol is a selective beta1-adrenergic receptor blocker that decreases the automaticity of contractions. During IV administration, carefully monitor the blood pressure, heart rate, and electrocardiogram (ECG). When considering conversion from IV to oral (PO) dosage forms, use the ratio of 1 mg IV to 2.5 mg PO metoprolol.

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Nitroprusside (Nitropress)

 

Nitroprusside causes peripheral vasodilation by direct action on venous and arteriolar smooth muscle, thus reducing peripheral resistance. It is commonly given intravenously because of its rapid onset and short duration of action. It is easily titratable to reach the desired effect.

Nitroprusside is light sensitive; both bottle and tubing should be wrapped in aluminum foil. Before initiating nitroprusside, administer a beta-blocker to counteract the physiologic response of reflex tachycardia that occurs when nitroprusside is used alone. This physiologic response increases shear forces against the aortic wall, thus increasing dP/dt. The objective is to keep the heart rate at 60-80 bpm.

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Nifedipine (Procardia)

 

Nifedipine is one of the more common channel blockers used for hypertension.

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Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and prevents exacerbations of tachycardia and hypertension.

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Morphine sulfate (Astramorph, Infumorph, MS Contin, Avinza)

 

Morphine is the drug of choice for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Like fentanyl, morphine sulfate is easily titrated to the desired level of pain control. If administered IV, morphine may be dosed in a number of ways; it is commonly titrated until the desired effect is obtained.

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Contributor Information and Disclosures
Author

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership

Additional Contributors

Ali Hmidi, MD Staff Physician, Department of Internal Medicine, Brooklyn Hospital Center, Cornell University

Disclosure: Nothing to disclose.

Sateesh Kesari, MBBS, MD Fellow in Cardiovascular Medicine, New York Presbyterian Hospital/The Brooklyn Hospital Center Program, Weill Cornell Medical College of Cornell University

Sateesh Kesari, MBBS, MD is a member of the following medical societies: American College of Cardiology, American Medical Assocation, American Society of Echocardiography, and American Society of Nuclear Cardiology

Disclosure: Nothing to disclose.

Oladayo Adisa Osinuga Sr, MBBS Attending Physician, Department of Internal Medicine, Atlanta Medical Center

Oladayo Adisa Osinuga Sr, MBBS is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association

Disclosure: Nothing to disclose.

Ramachandra C Reddy, MD Associate Director, Assistant Professor, Department of Surgery, Division of Cardiothoracic Surgery, State University of New York-Downstate Medical Center

Ramachandra C Reddy, MD is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American Medical Association, American Society for Artificial Internal Organs, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Sarath Reddy, MD Associate Director of Cardiac Care Unit, Department of Cardiology, The Brooklyn Hospital Center, Weill Medical College of Cornell University

Sarath Reddy, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Benson B Roe, MD Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center

Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Vincent Lopez Rowe, MD Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Aortic dissection. CT scan showing a flap (right side of image).
Aortic dissection. True lumen versus false lumen in an intimal flap.
Aortic dissection. Left subsegmental atelectasis and left pleural effusion. Flap at lower right of image.
Aortic dissection. Significant left pleural effusion.
Aortic dissection. CT scan showing a flap (center of image).
Aortic dissection. CT scan showing a flap (center of image).
Aortic dissection. CT scan showing a flap.
Aortic dissection. CT scan showing a flap.
Aortic dissection. Mediastinal widening.
Aortic dissection. CT scan showing a flap.
Aortic dissection. CT scan showing a flap.
Aortic dissection. CT scan showing a flap.
Aortic dissection. Thrombus and a patent lumen.
Aortic dissection. Thrombus.
Aortic dissection. True lumen and false lumen separated by an intimal flap.
Aortic dissection. Mediastinal widening.
Aortic dissection. CT scan showing a flap.
Aortic dissection. Intimal flap and left pleural effusion.
Image A represents a Stanford A or a DeBakey type 1 dissection. Image B represents a Stanford A or DeBakey type II dissection. Image C represents a Stanford type B or a DeBakey type III dissection. Image D is classified in a manner similar to A but contains an additional entry tear in the descending thoracic aorta. Note that a primary arch dissection does not fit neatly into either classification.
Aortic dissection.
Chest radiograph of a patient with aortic dissection. Image courtesy of Dr. K. London, University of California at Davis Medical Center.
Chest radiograph of a patient with aortic dissection presenting with hemothorax.
Chest radiograph demonstrating widened mediastinum in a patient with aortic dissection.
Angiogram demonstrating dissection of the aorta in a patient with aortic dissection presenting with hemothorax.
Electrocardiogram of a patient presenting to the ED with chest pain; this patient was diagnosed with aortic dissection.
Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
 
 
 
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