Question

A 65-year-old patient presented with chest pain with ECG changes. However, his transthoracic ECHO was normal and coronary arteries were normal on coronary angiography done through right radial artery. There was suspicion of aortic dissection while carrying out coronary angiography.
How will you manage him?

Hint:

In aortic dissection, blood pressure control and timely surgical intervention (especially for type A dissections) are critical to preventing mortality.

Answer 1

Step 1: Initial management.
The patient with suspected aortic dissection should be treated as a medical emergency. The primary goals are to stabilize the patient, control pain, and prevent the progression of the dissection. The initial management involves:
1. Blood pressure control: The most critical step in management is to control blood pressure and reduce shear stress on the aortic wall. Medications like beta-blockers (e.g., labetalol) are used to control the heart rate and blood pressure. Vasodilators such as nitroprusside may also be used in addition to beta-blockers if necessary.
2. Pain management: Adequate analgesia should be provided to control the chest pain. Opioids may be required in severe cases.
3. Monitoring: Continuous monitoring in an intensive care setting is necessary for hemodynamic stability.

Step 2: Surgical management.
Surgical intervention is required for type A aortic dissections, which involve the ascending aorta. Surgery should be performed as soon as possible, often in an emergency setting. For type B dissections (descending aort, surgery may be considered if there is evidence of rupture, compromised organ perfusion, or failure of medical management. In some cases, endovascular repair may be an option.

Step 3: Long-term management.
Post-operatively, patients should be closely monitored for complications, such as re-dissection, and long-term blood pressure control is crucial. Lifelong surveillance with imaging is often recommended, especially for those with type B dissection.

Step 4: Conclusion.
Management includes controlling blood pressure and heart rate, pain relief, and surgery for type A dissections. For type B, conservative management or endovascular repair may be appropriate. Close follow-up is necessary for long-term monitoring.