A 65-year-old man is brought to the emergency department with a 2-hour history of sharp, stabbing chest pain under his sternum. The patient was working outside in the yard when the symptoms started. The pain reached its maximum intensity within a few minutes and is now radiating to his upper back and shoulders. His medical history is significant for hypertension for the past 10 years. The patient has smoked 1.5 packs of cigarettes daily for the last 40 years. Blood pressure is 185/104 mm Hg in the right arm and 120/62 mm Hg in the left arm, pulse is 106/min and regular, and respirations are 18/min. Lungs are clear to auscultation bilaterally. Cardiovascular examination reveals a regular heart rhythm with an early diastolic murmur heard at the right sternal border. ECG shows sinus tachycardia and T-wave inversion in leads V5 and V6. Bedside transesophageal echocardiogram in the emergency department confirms ascending aortic dissection with extension into the left subclavian artery. In addition to pain control, what is the best next step in management of this patient?

Question

A 65-year-old man is brought to the emergency department with a 2-hour history of sharp, stabbing chest pain under his sternum.  The patient was working outside in the yard when the symptoms started.  The pain reached its maximum intensity within a few minutes and is now radiating to his upper back and shoulders.  His medical history is significant for hypertension for the past 10 years.  The patient has smoked 1.5 packs of cigarettes daily for the last 40 years.  Blood pressure is 185/104 mm Hg in the right arm and 120/62 mm Hg in the left arm, pulse is 106/min and regular, and respirations are 18/min.  Lungs are clear to auscultation bilaterally.  Cardiovascular examination reveals a regular heart rhythm with an early diastolic murmur heard at the right sternal border.  ECG shows sinus tachycardia and T-wave inversion in leads V5 and V6.  Bedside transesophageal echocardiogram in the emergency department confirms ascending aortic dissection with extension into the left subclavian artery.  In addition to pain control, what is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be05_95a8_8f63_194acc6c542e_MD0005_00 Acute aortic dissection involving the ascending aorta has a mortality rate of 1%-2% per hour after the onset of symptoms. Complications (eg, aortic regurgitation in this patient) may further increase morbidity and mortality, and rapid identification and treatment of aortic dissection is critical. Complications The goals of initial therapy for both ascending and descending aortic dissection include providing adequate pain control, lowering systolic blood pressure to 100-120 mm Hg, and decreasing left ventricular contractility to reduce aortic wall stress. Intravenous beta blockers such as labetalol, propranolol, or esmolol are preferred for slowing the heart rate to <60/min, lowering blood pressure, and reducing left ventricular contractility. Esmolol is preferred in acute settings due to its short half-life (~9 minutes), which allows for rapid titration for optimal heart rate and blood pressure control. In addition to medication therapy, emergency surgical repair is needed for ascending dissection. (Choices A and B) Aspirin is indicated in all patients with acute coronary syndrome (ACS), and a glycoprotein IIb/IIIa receptor inhibitor (eg, eptifibatide, abciximab) is indicated in patients with ACS for whom percutaneous intervention is planned. However, these antiplatelet agents are contraindicated in aortic dissection as they can lead to further bleeding, propagation of the dissection into the pericardial space, and hemopericardium. (Choices D and E) Hydralazine, a primarily arterial vasodilator, and sodium nitroprusside, a mixed arterial and venous vasodilator, can be used for the treatment of hypertensive emergency. However, these drugs can cause reflex sympathetic stimulation with an increase in heart rate, left ventricular contractility, and aortic wall shear stress, potentially leading to further propagation of an aortic dissection. Hydralazine should be avoided in the management of acute aortic dissection. Sodium nitroprusside can be added to a beta blocker in patients with acute aortic dissection and a systolic blood pressure that is persistently >100-120 mm Hg, but monotherapy is contraindicated. Educational objective: Intravenous beta blockers are the preferred initial therapy for lowering heart rate and blood pressure and reducing left ventricular contractility in patients with acute aortic dissection. Sodium nitroprusside should be used only in addition to beta blockers if systolic blood pressure remains >100-120 mm Hg after adequate beta blockade. References: Acute aortic dissection and intramural hematoma: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/27533160)

A 65-Year-Old Man Is Brought to the Emergency Department with a 2-Hour