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Aortic dissection
KALANI OLMSTED AND DEBORAH B. DIERCKS
n Agents
n Opioids
n Beta-blockers
n Calcium channel blockers
n Vasodilators
n Evidence
According to panels addressing management of aortic dissection (AD), available
levels of evidence rate no higher than “expert opinion.” 1 Hemodynamic
(anti-impulse) therapy remains the foundation of AD care, and successful
control of blood pressure and heart rate improves patient comfort. However,
in most patients with AD, the inability of anti-impulse therapy to control
severe pain mandates an early role for aggressive analgesia. 2
The first step in AD care, anti-impulse therapy, serves as optimal medical
management and also provides some pain relief. Beta-blockers (e.g. metoprolol,
propranolol, esmolol, labetalol) decrease the force of cardiac contraction
and reduce blood pressure; both of these properties make this class
ideal for minimizing AD progression. 1,3,4 In patients with relative betablocker
intolerance, esmolol’s short half-life renders it the best initial
choice. 1
Ongoing pain after beta-blocker administration usually indicates incomplete
blood pressure control. In such cases, pain relief (and optimal medical
management) is facilitated by vasodilation. The traditional choice is sodium
nitroprusside. Fenoldopam (a dopamine-1 agonist that selectively dilates
arterioles and renal vasculature) may also be used. When AD is accompanied
by cardiac ischemia, the calcium channel blocker nicardipine is indicated;
reflex tachycardia renders nitroglycerin (glyceryl trinitrate) potentially dangerous
as a treatment for chest pain when AD is suspected. 1,3–5
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