Aortic Dissection Medication

Updated: Jan 08, 2019
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Medication

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.

Esmolol (Brevibloc)

Esmolol is an ultra–short-acting beta1-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.

Labetalol (Trandate)

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

Propranolol (Inderal LA, InnoPran XL, Inderal XL, Hemangeol)

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.

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.

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.

Nifedipine (Procardia, Procardia XL, Adalat CC, Nifediac CC, Afeditab)

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.

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

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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