Patients presenting with an AAD will either be admitted to the ICU or progress immediately from the emergency department to the operating room. Invasive monitoring of blood pressure, large-bore IV access, and aggressive control of blood pressure and heart rate are priorities. Patients can experience pain if uncontrolled blood pressure and heart rate cause an extension of the dissection, and symptoms are often mitigated with hemodynamic management. Opioids should be utilized sparingly and with caution.

Blood pressure reduction is typically accomplished with β-blockers and vasodilators aiming to reduce myocardial contractility and minimize further extension of the dissection. The goal systolic blood pressure and heart rate are 100 to 120 mm Hg and less than 60 beats/min, respectively. If heart rate and blood pressure control remain inadequate after initializing β-blocker and vasodilator therapy, calcium channel blockers provide an adjunct. Hydralazine is typically not used because it can precipitate reflex tachycardia, which can worsen the dissection. Conversely, patients who are hypotensive on presentation should be treated aggressively with vasopressors and fluid resuscitation in an effort to maintain end-organ perfusion until the patient can undergo definitive operative repair.

A Stanford TAAD is typically treated as a surgical emergency because it is a highly lethal condition with a mortality of 1% per hour after onset. After 24 hours, 20% of patients will die without surgical intervention. Surgery for patients presenting with Stanford TAAD who are hemodynamically stable may be delayed for optimal resource availability or transfer to a high-volume center. Conversely, patients with a Stanford TBAD that is not complicated by limb ischemia, malperfusion, or rupture may be managed medically with aggressive blood pressure and heart rate reduction.

References

• Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al; Peer Review Committee Members. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines. Circulation. 2022;146:e334-e482.