Aortic Dissection: The Daily PANCE Blueprint
A 64-year-old man with hypertension has sudden tearing chest-to-back pain, a 20 mm Hg inter-arm blood pressure difference, and a widened mediastinum; CT angiography confirms a Stanford type B dissection. What is the most appropriate initial medical therapy?
A. Intravenous nitroprusside alone
B. Intravenous hydralazine
C. Intravenous heparin infusion
D. Intravenous beta-blocker (esmolol or labetalol)
E. Normal saline bolus
Answer and topic summary
The answer is D. Intravenous beta-blocker (esmolol or labetalol).
The first goal is to reduce shear stress on the aortic wall (dP/dt) by lowering both heart rate and blood pressure – an IV beta-blocker such as esmolol or labetalol is first-line, targeting a heart rate near 60 and a systolic pressure of 100-120 mm Hg. A vasodilator like nitroprusside is added only after beta-blockade (given alone it causes reflex tachycardia that worsens shear); hydralazine has the same problem; anticoagulation is contraindicated; and fluids do not address the problem. Uncomplicated type B is managed medically, while type A goes to surgery.
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