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cardio.hypertensive-emergency.aortic-dissection.v1

Aortic dissection in hypertensive crisis (HR + dP/dt FIRST, then SBP)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.hypertensive-emergency.core.v1 — narrowed to aortic dissection in HTN crisis. Inherits HTN-emergency framework from parent; specializes for anti-impulse paradigm (HR <60 FIRST with esmolol/labetalol, THEN SBP <120 with nicardipine — ACC/AHA 2022 Class I). AVOID isolated vasodilator + hydralazine (reflex tachy → propagation). Stanford A → emergent OR (24-h mortality ~50% per IRAD); uncomplicated B → ICU medical; complicated B → TEVAR per INSTEAD-XL. Lifelong BB + ARB; lifetime CTA surveillance per ACC/AHA 2022. Manifest pointer reuses cardio.hypertensive-emergency.core.v1 manifest. Design-brief pointer reuses parent (dissection-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as part of HTN emergency Phase E variant batch.

Entry points (4)

  • symptom
    Sudden tearing chest/back pain ± migrating pain (Klompas RCE JAMA 2002 LR+ 10.8 PMID 11990624)
    tearing_chest_or_back_pain
  • vital_abnormality
    Inter-arm SBP gradient >20 mmHg (ACC/AHA 2022 Aortic PMID 36066317)
    inter_arm_bp_gradient_gt_20mmhg
  • imaging
    Mediastinal widening on CXR (LR+ for dissection ~3) — triggers CTA
    mediastinal_widening_on_cxr
  • imaging
    CTA chest/abdomen/pelvis showing intimal flap → confirms diagnosis (ACC/AHA 2022 Class I)
    cta_chest_with_flap

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Bimodal age — Marfan/connective tissue (younger) vs HTN-related (older); informs etiology + surgical risk
  • sbprequired
    vital • used at TREATMENT
    Hypertension in 70% of dissection presentations; goal SBP <120 within 20-30 min AFTER HR <60 (ACC/AHA 2022 Class I)
  • hrrequired
    vital • used at TREATMENT
    GOAL HR <60 FIRST before vasodilator — critical anti-impulse paradigm (ACC/AHA 2022 Class I)
  • inter_arm_sbp_differencerequired
    vital • used at INITIAL_WORKUP
    >20 mmHg supports dissection diagnosis (ACC/AHA 2022; Klompas JAMA 2002 PMID 11990624)
  • pain_quality_tearingrequired
    symptom • used at ENTRY
    Tearing or migrating pain LR+ 10.8 for dissection (Klompas JAMA 2002 PMID 11990624)
  • limb_or_organ_malperfusion_signsrequired
    symptom • used at BRANCHING_WORKUP
    Branch malperfusion (limb ischemia, AKI, mesenteric ischemia, stroke) defines complicated Type B → TEVAR per INSTEAD-XL
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal malperfusion screen + contrast nephropathy + AKI driving drug selection
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Coronary involvement (RCA dissection extension → inferior MI); Type A may have ACS overlap
  • lactate
    lab • used at BRANCHING_WORKUP
    Mesenteric malperfusion screen — elevated lactate signals branch ischemia
  • cta_chest_abdomen_pelvisrequired
    imaging • used at INITIAL_WORKUP
    Confirms diagnosis + Stanford classification (A vs B) + branch malperfusion mapping (ACC/AHA 2022 Class I)
  • tte_or_tee
    imaging • used at INITIAL_WORKUP
    TEE confirms dissection if CTA contraindicated; assesses AI, pericardial effusion, tamponade (ACC/AHA 2022)

12-phase flow (10)

  1. 1FRAME
    Aortic dissection in HTN crisis — anti-impulse paradigm: HR <60 + dP/dt reduction FIRST (esmolol/labetalol), THEN SBP <120 with vasodilator. Stanford A (ascending) → emergent surgery; Stanford B uncomplicated → medical; complicated B (malperfusion, refractory pain, propagation) → TEVAR per INSTEAD-XL. Inherits parent HTN-emergency framework.
    inputs: sbp, hr, pain_quality_tearing
    advance: dissection suspected + anti-impulse plan articulated
  2. 2ENTRY
    Recognize tearing pain + inter-arm gradient + HTN; STAT CTA chest/abdomen/pelvis; activate CT surgery + vascular surgery teams
    inputs: age, sbp, hr, pain_quality_tearing
    advance: dissection workup launched + surgery teams notified
  3. 3CONTEXT
    Marfan/connective tissue history, family hx of dissection/aneurysm, prior aortic surgery, cocaine use, chronic HTN duration
    inputs: age
    advance: context complete
  4. 4RED_FLAGS
    Tamponade (Type A complication — pericardial effusion on TEE → emergent surgery); rupture (free flap, pleural effusion, hemodynamic collapse); branch malperfusion (limb pulse loss, mesenteric ischemia signs, stroke, AKI); AI (new diastolic murmur Type A)
    inputs: sbp, limb_or_organ_malperfusion_signs
    actions: htn_emergency
    advance: red flags screened + emergent surgical evaluation triggered
  5. 5INITIAL_WORKUP
    BMP, troponin, CBC, coags, type & cross 6 units, CTA chest/abdomen/pelvis (preferred — confirms diagnosis + classification + branch involvement); TEE alternative if contrast contraindicated; ECG (rule out STEMI overlap with RCA-extended Type A)
    inputs: creatinine, troponin, cta_chest_abdomen_pelvis, inter_arm_sbp_difference
    actions: panel.cardiac, panel.renal
    advance: CTA confirms dissection + Stanford classification documented
  6. 6BRANCHING_WORKUP
    Stanford A → STAT cardiothoracic surgery (open repair); uncomplicated Stanford B → ICU medical management; complicated Stanford B (malperfusion / refractory pain / propagation / aneurysm expansion) → STAT vascular surgery for TEVAR per INSTEAD-XL; serial CTA q6-24h to detect extension
    inputs: cta_chest_abdomen_pelvis, limb_or_organ_malperfusion_signs, lactate
    actions: aortic_dissection
    advance: surgical strategy decided
  7. 7TREATMENT
    Anti-impulse FIRST: esmolol IV bolus 500 µg/kg + 50-300 µg/kg/min infusion titrate to HR <60 within 5-10 min OR labetalol 20 mg IV q10 min (mixed α/β provides combined HR + SBP control). AFTER HR <60: add nicardipine 5 mg/h IV titrate to SBP <120 within 20-30 min. AVOID isolated vasodilator (nitroprusside) without prior BB — increases dP/dt → propagation. Pain control with IV opioids (fentanyl).
    inputs: sbp, hr, creatinine
    advance: HR <60 + SBP <120 achieved + pain controlled
  8. 8DISPOSITION
    Stanford A → emergent OR; Stanford B uncomplicated → ICU medical management with arterial line + serial CTA; complicated B → vascular IR/OR for TEVAR
    advance: OR booking or ICU bed assigned
  9. 9MONITORING
    Arterial line + q5-15 min BP + HR; serial CTA q6-24 h to detect extension; daily exam for new murmur, pulse change, neuro deficit; serial Cr + lactate for branch malperfusion
    inputs: sbp, hr, creatinine
    actions: panel.renal
    advance: BP/HR at target × 24-48 h + no extension on imaging
  10. 10FOLLOWUP
    Lifetime aortic surveillance (CTA at 1, 3, 6, 12 mo then yearly); strict BP control to <120/80 outpatient (per ACC/AHA 2022); BB lifelong; genetic testing if Marfan/Loeys-Dietz/EDS suspected; cardiac surgery follow-up if Type A repair
    advance: outpatient surveillance + BB regimen documented