Esmolol 100 to 500 mcg/kg IV bolus then 25 to 100 mcg/kg/min
Labetalol 0.2 to 1 mg/kg IV per dose
Blood pressure targets
Age-adjusted percentiles
Anti-impulse principle preserved
Imaging approach
MRI to limit cumulative radiation
CT angiography when unstable
Background
Epidemiology
Disease burden
Demographics
Mean age about 63 years
Male predominance
Progression risk
25 to 40% of uncomplicated cases progress to complicated disease
Aneurysmal degeneration exceeds 70% at 3 to 5 years
Mortality
Uncomplicated in-hospital mortality 1 to 10%
Complicated early mortality about 16%
Follow-up adherence burden
Loss to follow-up
About 50% lost by 28 months
Surveillance adherence critical
Late complications
38% of medically managed patients develop complications requiring intervention
Late aortic events
Pathophysiology
Mechanism of dissection
Intimal tear
Distal to left subclavian artery
Blood enters media
True and false lumen formation
Intimal flap
False lumen propagation
Wall stress drivers
Hypertension
dP/dt and heart rate
Complication pathways
Malperfusion
Static or dynamic branch obstruction
End-organ ischemia
Rupture
Adventitial breach
Hemothorax
Aneurysmal degeneration
False lumen expansion
Late aortic events
Therapeutic Considerations
Medical management rationale
Anti-impulse therapy
Reduces aortic wall shear stress
Beta-blocker before vasodilator
Blood pressure and heart rate targets
Limit false lumen propagation
Prevent reflex tachycardia
Intervention strategy
TEVAR for complicated disease
Covers entry tear
Promotes false lumen thrombosis
Open repair selectively
Unsuitable anatomy
Connective tissue disease
Surveillance and lifestyle
Imaging at 1, 6, and 12 months then annually
CTA or MRI
Class I recommendation
Lifestyle modification
Avoid heavy static exercise and Valsalva
Mild to moderate dynamic exercise allowed
Patient Discharge Instructions
copy discharge instructions
Aortic dissection home care
Take all blood pressure medications exactly as prescribed
Keep blood pressure at or below 120/80 if monitoring at home
Do not stop beta-blocker suddenly
Stop smoking and avoid cocaine or stimulants
Activity guidance
Avoid heavy lifting and straining
Avoid collision and contact sports
Light to moderate walking is encouraged
No Valsalva or breath-holding during exertion
Warning signs to return to ER
New or worsening chest, back, or abdominal pain
Leg pain, weakness, or color change
Decreased urine output
Fainting or near-fainting
Any new numbness, weakness, or trouble speaking
Follow-up
Repeat CT or MRI at 1 month, 6 months, and 12 months
Vascular or cardiothoracic surgery clinic appointment
Primary care for blood pressure monitoring
References
Guidelines and key sources
Society guidelines
2022 ACC/AHA guideline for diagnosis and management of aortic disease
STS/AATS clinical practice guidelines on type B aortic dissection
EACTS/STS guidelines for acute and chronic aortic syndromes
Landmark evidence and reviews
INSTEAD-XL trial on TEVAR plus medical therapy
NEJM 2025 review on management of acute type B aortic dissection
JACC review on optimal treatment of uncomplicated type B dissection
Decision tools and coding
Aortic Dissection Detection Risk Score with D-dimer meta-analysis
ICD-10 I71.01 dissection of thoracic aorta
2021 AHA/ACC chest pain evaluation guideline
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.