Lesson 4, Topic 8
Key Guidelines and Evidence
- American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease:
○ Provides comprehensive recommendations for the diagnosis and management of thoracic aortic diseases, including aortic dissection.
○ Key Recommendations
i. Intravenous beta blockers (esmolol, labetalol, metoprolol) are recommended as first-line agents to control heart rate and blood pressure.
ii. Intravenous vasodilators (nicardipine, clevidipine, nitroprusside) are recommended to rapidly control blood pressure when beta blockers are inadequate or contraindicated.
iii. Goal is to reduce heart rate to 60-80 bpm and systolic blood pressure <120 mm Hg.
iv. Intravenous opioids are recommended for pain control, as pain can increase heart rate and blood pressure.
v. Oral beta blockers should be continued at hospital discharge to improve long-term outcomes.
- Landmark Trials:
○ The INSTEAD-XL Trial:
i. Investigated the long-term outcomes of patients with uncomplicated type B aortic dissection treated with medical therapy versus thoracic endovascular repair (TEVAR).
ii. Provided evidence supporting the use of TEVAR in certain patients with uncomplicated type B dissections to reduce disease progression and improve outcomes.
○ Ulici et al 2017
i. A single-center retrospective chart review evaluated patients diagnosed with aortic dissection. The primary outcome measure was time to reach patient specific systolic blood pressure with clevedipine compared to nitroprusside
ii. Clevidipine administration during initial medical management of aortic dissection showed similar efficacy compared to SNP when used as adjunct therapy to esmolol.