This handout is for aortic dissection in hypertensive crisis (hr + dp/dt first, then sbp). Your care team identified this based on: sudden tearing chest/back pain ± migrating pain (klompas rce jama 2002 lr+ 10.8 pmid 11990624).
Other reasons your team may use this plan: inter-arm sbp gradient >20 mmhg (acc/aha 2022 aortic pmid 36066317); mediastinal widening on cxr (lr+ for dissection ~3) — triggers cta; cta chest/abdomen/pelvis showing intimal flap → confirms diagnosis (acc/aha 2022 class i).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| esmolol | 500 µg/kg IV bolus then 50 µg/kg/min infusion, titrate by 25 µg/kg/min q5 min to HR <60 (max 300 µg/kg/min) | IV | continuous | ACC/AHA 2022 Class I — anti-impulse FIRST; ultra-short half-life allows fine titration; HR <60 within 5-10 min target |
| labetalol | 20 mg IV q10 min (max 300 mg cumulative) OR 0.5-2 mg/min infusion | IV | bolus or infusion | ACC/AHA 2022 Class I alternative — mixed α/β provides combined HR + SBP control; useful when esmolol not on hand |
| nicardipine | 5 mg/h IV (ONLY after HR <60), titrate by 2.5 mg/h q5 min to SBP <120 within 20-30 min | IV | continuous | ACC/AHA 2022 Class I — add ONLY after esmolol/labetalol established HR <60; SBP target 100-120 with HR <60 within 20-30 min |
| nitroprusside | 0.25-10 µg/kg/min IV (ONLY after HR <60 with BB) | IV | continuous | Alternative vasodilator after BB; AVOID if eGFR <30 (cyanide); ACC/AHA 2022 acceptable adjunct |
| AVOID isolated vasodilator without BB | AVOID | N/A | N/A | Isolated vasodilator (nitroprusside, hydralazine, nicardipine without BB) increases dP/dt via reflex tachycardia → propagates dissection (ACC/AHA 2022 Class III) |
| AVOID hydralazine | AVOID | N/A | N/A | Hydralazine causes reflex tachycardia → increases dP/dt → propagation; not recommended in dissection |
| fentanyl | 25-100 µg IV q5-10 min titrate | IV | PRN | Pain control reduces sympathetic drive (HR + dP/dt); IV opioid preferred for rapid titration |
Plan: Aortic dissection — anti-impulse paradigm: HR <60 FIRST (BB), THEN SBP <120 (vasodilator). Goal achieved within 20-30 min.
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: 2022 ACC/AHA Aortic Disease Guideline (Isselbacher PMID 36066317) + 2025 ACC/AHA HTN Guideline (Whelton) + ESC/ESH 2024 HTN (Mancia PMID 38613493)