Treatment-acute aortic syndromes

(Circ 2010;121:1544; EHJ 2018;39:739; JACC 2019;74:1494 & 2020;76:1703)

• ↓ dP/dt targeting HR <60 & central BP <120 (or lowest that preserves perfusion; r/o pseudohypotension, eg, arm BP ↓ due to subclavian dissection; use highest BP reading)
• First IV βB (eg, esmolol, labetalol) to blunt reflex ↑ HR & inotropy in response to vasodilators; verapamil/diltiazem if βB contraindic; then ↓ SBP w/ IV vasodilators (eg, nitroprusside)
• If HoTN: urgent surgical consult, IVF to achieve euvolemia, pressors to keep MAP 60-65 mmHg; r/o complication (eg, tamponade, contained rupture, severe AI)
• Proximal: surgery considered in all acute and in chronic if c/b progression, AI or aneurysm
• Distal: med Rx unless complication (see below) or favorable TEVAR anatomy w/ high-risk imaging features (JACC 2019;74:1494); pre-emptive TEVAR may ↓ late complic. & mortality