eMedicine Specialties > Emergency Medicine > Cardiovascular
Dissection, Aortic: Treatment & Medication
Updated: Aug 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Prehospital Care
- Assure adequate breathing, maintain oxygenation, treat shock, and obtain useful historic information.
- Establishing the diagnosis in the field is usually difficult or impossible, but certain salient features of aortic dissection may be observed. It is life threatening if not quickly recognized and treated.
- Radio communication with the receiving hospital permits the medical control physician to direct care and select a capable destination hospital while permitting the ED to mobilize appropriate resources.
- In the rare event that the diagnosis can be made based on prehospital information, the physician directing prehospital care should request transport to a facility capable of operative treatment of an aortic dissection.
Emergency Department Care
- The mortality rate of patients with aortic dissection is 1-2% per hour for the first 24-48 hours. Initial therapy should begin when the diagnosis is suspected. This includes 2 large-bore intravenous lines (IVs), oxygen, respiratory monitoring, and monitoring of cardiac rhythm, blood pressure, and urine output.
- Clinically, the patient must be assessed frequently for hemodynamic compromise, mental status changes, neurologic or peripheral vascular changes, and development or progression of carotid, brachial, and femoral bruits.
- Aggressive management of heart rate and blood pressure should be initiated.
- Beta-blockers should be given initially to reduce the rate of change of blood pressure (dP/dt) and the shear forces on the aortic wall.
- The target heart rate should be 60-80 beats per minute.
- The target systolic blood pressure should be 100-120 mm Hg.
- End organ perfusion should be evaluated. Balancing the risks of dP/dt on the aortic wall versus the benefits of acceptable end organ perfusion may be a difficult clinical decision.
- Urgent surgical intervention is required in type A dissections.
- The area of the aorta with the intimal tear usually is resected and replaced with a Dacron graft.
- The operative mortality rate is usually less than 10%, and serious complications are rare with ascending aortic dissections.
- The development of more impermeable grafts, such as woven Dacron, collagen-impregnated Hemashield (Meadox Medicals, Oakland, NJ), aortic grafts, and gel-coated Carbo-Seal Ascending Aortic Prothesis (Sulzer CarboMedics, Austin, TX) has greatly enhanced the surgical repair of thoracic aortic dissections.
- With the introduction of profound hypothermic circulatory arrest and retrograde cerebral perfusion, the morbidity and mortality rates associated with this highly invasive surgery have decreased.
- Dissections involving the arch are more complicated that those involving only the ascending aorta because the innominate, carotid, and subclavian vessels branch from the arch. Deep hypothermic arrest usually is required. If the arrest time is less than 45 minutes, the incidence of central nervous system complications is less than 10%.
- Aortic stent grafting is a challenging technique. It may prove feasible and has offered good results in a small series of patients. It may be a reasonable alternative in high-risk patients in the near future.
- Retrograde cerebral perfusion may increase the protection of the central nervous system during the arrest period.
- The mortality rate of aortic arch dissections is about 10-15%, with significant neurologic complications occurring in another 10%.
- The mortality rate is influenced by the patient's clinical condition.
- The definitive treatment for type B dissections is less clear.
- Uncomplicated distal dissections may be treated medically to control blood pressure.
- Distal dissections treated medically have the same or a lower mortality rate as those treated surgically.
- Surgery is reserved for distal dissections that are leaking, ruptured, or compromising blood flow to a vital organ.
- Acute distal dissections in patients with Marfan syndrome usually are treated surgically.
- Inability to control hypertension with medication is also an indication for surgery in those with a distal thoracic aortic dissection.
- Patients with a distal dissection are usually hypertensive, emphysematous, or older.
- Long-term medical therapy involves a beta-adrenergic blocker combined with other antihypertensive medications. Avoid antihypertensives (eg, hydralazine, minoxidil) that produce a hyperdynamic response that would increase dP/dt (ie, alter the duration of P or T waves).
- Survivors of surgical therapy also should receive beta-adrenergic blockers.
- A recent series of patients with type B dissections demonstrates that aggressive use of distal perfusion, CSF drainage, and hypothermia with circulatory arrest improves early mortality and long-term survival rates.
- Endovascular stenting remains an option for treatment of some type B dissections. Some studies recommend that patients with complicated acute type B dissections undergo endovascular stenting with the goal to cover the primary intimal tear.7
- Definitive treatment involves segmental resection of the dissection with interposition of a synthetic graft.
- When thoracic dissections are associated with aortic valvular disease, replace the defective valve.
- With combined reconstruction–valve replacement, the operative mortality rate is approximately 5% with a late mortality rate of less than 10%.
- Operative repair of the transverse aortic arch is technically difficult, with an operative mortality rate of 10% despite induction of hypothermic cardiocirculatory arrest.
- Repair of the descending aorta is associated with a higher incidence of paraplegia than repair of other types of dissections because of interruption of segmental blood supply to the spinal cord.
- The operative mortality rate is approximately 5%.
The American College of Radiology has established ACR Appropriateness Criteria for diagnosis and treatment of suspected aortic dissection.8
Consultations
- Once a thoracic dissection is suspected, consult a thoracic surgeon.
- Because many patients with this disorder have concomitant medical illness, consult the patient's primary care provider to expedite preoperative preparation.
- Early consultation is encouraged when ordering further imaging studies if the patient requires rapid operative intervention.
- Consult a radiologist prior to obtaining aortography.
Medication
Initial therapeutic goals include elimination of pain and 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 dP/dt.
To prevent exacerbations of tachycardia and hypertension, treat patients with IV morphine sulfate. This reduces the force of cardiac contraction and the rate of rise of the aortic pressure (dP/dt). It then retards the propagation of the dissection and delays rupture.
Antihypertensives
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.
Esmolol (Brevibloc)
Ultra–short-acting beta2-blocker, particularly useful in patients with labile arterial pressure, especially if surgery is planned, because it can be discontinued abruptly if necessary. Normally used in conjunction with nitroprusside. May be useful as a means to test beta-blocker safety and tolerance in patients with history of obstructive pulmonary disease who are at uncertain risk of bronchospasm from beta-blockade. Elimination half-life is 9 min.
Adult
250-500 mcg/kg/min IV for 1 min as loading dose, followed by a 4-min maintenance infusion of 50 mcg/kg/min; repeat loading dose and follow with maintenance infusion using increments of 50 mcg/kg/min for 4 min; if therapeutic effects not observed in 5 min, repeat sequence up to 4 times prn
As desired BP is approached, omit loading infusion and reduce incremental dose of maintenance infusion from 50 mcg/kg/min to 25 mcg/kg/min or lower; may increase interval between titration steps to 5-10 min if desired
Pediatric
Not established
Aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease bioavailability and plasma levels, possibly resulting in decreased pharmacologic effect; sparfloxacin, astemizole (recalled from US market), calcium channel blockers, quinidine, flecainide, and contraceptives may increase cardiotoxicity; digoxin, flecainide, acetaminophen, clonidine, epinephrine, nifedipine, prazosin, haloperidol, phenothiazines, and catecholamine-depleting agents may increase toxicity
Documented hypersensitivity; uncompensated CHF; bradycardia; cardiogenic shock; AV conduction abnormalities
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockers may mask signs and symptoms of acute hypoglycemia and clinical signs of hyperthyroidism; symptoms of hyperthyroidism, including thyroid storm, may worsen when medication is withdrawn abruptly; withdraw drug slowly and monitor patient closely
Labetalol (Normodyne, Trandate)
Blocks alpha-, beta1-, and beta2-adrenergic receptor sites, decreasing BP.
Adult
Initial dose: 20 mg (0.25 mg/kg for 80-kg patient) IV over 2 min; follow with 20-80 mg q10-15min until BP controlled
Maintenance dose: 2 mg/min continuous IV infusion; titrate up to 5-20 mg/min; not to exceed a total dose of 300 mg
Pediatric
Not established
Decreases effects of diuretics and increases toxicity of methotrexate, lithium, and salicylates; may diminish reflex tachycardia associated with nitroglycerin use without interfering with hypotensive effects; cimetidine may increase blood levels; glutethimide may decrease effects by inducing microsomal enzymes
Documented hypersensitivity; cardiogenic shock; AV block; uncompensated CHF; pulmonary edema; bradycardia; reactive airway disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in impaired hepatic function; discontinue therapy with signs of liver dysfunction; in elderly patients, lower response rate and higher incidence of toxicity may be observed
Propranolol (Inderal, Betachron E-R)
Class II antiarrhythmic nonselective beta-adrenergic receptor blocker. Has membrane-stabilizing activity and decreases automaticity of contractions. Not suitable for emergency treatment of hypertension. Do not administer IV in hypertensive emergencies.
Adult
40-80 mg PO bid initially; increase to usual range of 160-320 mg/d prn; up to 640 mg/d may be required
Pediatric
0.5 mg/kg/d PO divided bid/qid; increase gradually q3-7d; usual dosage range is 2-4 mg/kg/d divided bid; not to exceed 16 mg/kg/d
Aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity; may increase toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines
Documented hypersensitivity; uncompensated CHF; bradycardia; cardiogenic shock; AV conduction abnormalities
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; withdraw drug slowly and monitor closely
Metoprolol (Lopressor)
Selective beta1-adrenergic receptor blocker that decreases automaticity of contractions. During IV administration, carefully monitor BP, heart rate, and ECG. When considering conversion from IV to PO dosage forms, use ratio of 2.5 mg PO to 1 mg IV metoprolol.
Adult
100 mg/d PO qd or divided bid/tid initially; increase at 1-wk intervals prn; not to exceed 450 mg/d prn
Pediatric
Not established
Aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease bioavailability and plasma levels, possibly resulting in decreased pharmacologic effects; sparfloxacin, phenothiazines, astemizole (recalled from US market), calcium channel blockers, quinidine, flecainide, and contraceptives may increase toxicity; may increase toxicity of digoxin, flecainide, clonidine, epinephrine, nifedipine, prazosin, verapamil, and lidocaine
Documented hypersensitivity; uncompensated CHF; cardiogenic shock; bradycardia; AV conduction abnormalities
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Beta-adrenergic blockade may reduce signs and symptoms of acute hypoglycemia and may decrease clinical signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; monitor patient closely and withdraw drug slowly; during IV administration, carefully monitor BP, heart rate, and ECG
Nitroprusside (Nitropress)
Causes peripheral vasodilation by direct action on venous and arteriolar smooth muscle, thus reducing peripheral resistance. Commonly used IV because of rapid onset and short duration of action. Easily titratable to reach desired effect. Light sensitive; both bottle and tubing should be wrapped in aluminum foil. Prior to initiating nitroprusside, administer beta-blocker to counteract physiologic response of reflex tachycardia that occurs when nitroprusside used alone. This physiologic response increases shear forces against aortic wall, thus increasing dP/dt. Objective is to keep heart rate at 60-80 bpm.
Adult
0.5-3 mcg/kg/min IV; rates >4 mcg/kg/min may lead to cyanide toxicity
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; subaortic stenosis; idiopathic hypertrophic subaortic stenosis; atrial fibrillation or flutter
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in increased intracranial pressure, hepatic failure, severe renal impairment, and hypothyroidism; in renal or hepatic insufficiency, levels may increase and can cause cyanide toxicity; sodium nitroprusside has ability to lower BP and thus should be used only in patients with mean arterial pressures >70 mm Hg
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and prevent exacerbations of tachycardia and hypertension.
Morphine sulfate (Astramorph, Infumorph)
DOC for narcotic analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Similar to fentanyl, morphine sulfate easily titrated to desired level of pain control. If administered IV, may be dosed in a number of ways; commonly titrated until desired effect obtained.
Adult
Initial dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg q4h IV/IM/SC
Pediatric
0.1-0.2 mg/kg IV/IM/SC q2-4h prn
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
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| Differential Diagnoses & Workup: Dissection, Aortic |
 Treatment & Medication: Dissection, Aortic |
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Further Reading
Keywords
aortic dissection, thoracic aortic dissection, dissection of the thoracic aorta, aortic aneurysm, aortic tear, tear in the aortic wall, Stanford classification, DeBakey classification, cystic medial necrosis, atherosclerosis, Marfan syndrome, Ehlers-Danlos syndrome, adult polycystic kidney disease, Turner syndrome, Noonan syndrome, osteogenesis imperfecta, bicuspid aortic valve, coarctation of the aorta, connective-tissue disorders, homocystinuria, familial hypercholesterolemia, syphilis, crackcocaine use, cardiac catheterization, myocardial infarction, syncope, cerebrovascular accident
