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cardio.aortic-dissection.core.v1PRODUCTION
cardio.aortic-dissection.core.v1

Aortic dissection (Stanford A / B + IMH / PAU)

cardiologyacuteadult
Hard-required inputs
0 / 6
Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Time-critical: type A surgical emergency — 1-2% mortality/h untreated (IRAD Hagan JAMA 2000; ACC/AHA 2022 Isselbacher)

Inputs
1
Actions
0
Advance rule
Set
Advance when

dissection suspected

Patient inputs (10)

Risk of dissection rises with age + HTN (IRAD Hagan JAMA 2000)

Tearing/migrating quality + abrupt onset suggest dissection (IRAD Hagan JAMA 2000; ACC/AHA 2022)

Definitive dx — Stanford A vs B, malperfusion, IMH/PAU (ACC/AHA 2022 Class I; ESC 2024)

Renal malperfusion; contrast planning (ACC/AHA 2022)

Bilateral arm SBP for inter-arm gradient + impulse-therapy target (ACC/AHA 2022 Isselbacher)

Beta-blocker FIRST — target HR <60 before vasodilator (ACC/AHA 2022 Class I; ESC 2024)

Marfan / Loeys-Dietz / vascular EDS lower threshold (ACC/AHA 2022 Isselbacher)

Third-trimester / peripartum dissection management differs (ACC/AHA 2022; ACOG)

Cocaine-precipitated dissection; AVOID beta-blocker monotherapy acute (ACC/AHA 2022)

Elevated d-dimer supports dissection vs alternate dx (ESC 2024; Suzuki Circulation 2009)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningtype_a_dissection
    Stanford Type A on CTA (involving ascending aorta) (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtype_b_complicated
    Type B + malperfusion / rupture / refractory pain or HTN / rapid expansion (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtamponade_with_dissection
    Type A + pericardial effusion + Beck triad (ACC/AHA 2022 Isselbacher)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmalperfusion_pattern
    Coronary, cerebral, mesenteric, renal, or limb malperfusion (ACC/AHA 2022 — malperfusion syndromes; IRAD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpregnancy_with_dissection
    Pregnant patient (esp. third trimester / peripartum) with dissection (ACC/AHA 2022; ACOG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecocaine_associated_dissection
    Recent cocaine + dissection presentation (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Anti-impulse therapy + syndrome-specific repair (ACC/AHA 2022)
axis: aortic_dissection_anti_impulsestep 1 - Step 1 — Anti-impulse: IV β-blocker FIRST to HR <60
Selected step "Step 1 — Anti-impulse: IV β-blocker FIRST to HR <60" — Suspected or confirmed dissection; HR >60; no high-grade block
  • esmolol
    first line
    beta1_blocker_short_acting
    500 µg/kg IV bolus → 50 µg/kg/min, titrate by 50 q5min • IV • continuous
    triggers: HR_above_60
    2022 ACC/AHA — short half-life ideal for titration; lower target HR before vasodilator
    rxcui 49737
  • labetalol
    first line
    mixed_alpha_beta_blocker
    20 mg IV bolus q10min, max 300 mg, then 0.5–2 mg/min infusion • IV • continuous
    triggers: HR_above_60, pregnancy
    Combined α+β blockade — vasodilation without reflex tachy (ACC/AHA 2022)
    rxcui 6185

ed playbook — drug actions (4)

  1. 1. esmolol or labetalol IV (ACC/AHA 2022)
    Esmolol 500 µg/kg bolus + 50 µg/kg/min OR labetalol 20 mg IV q10min (ACC/AHA 2022) • IV • continuous
    trigger: HR >60 + dissection suspected (ACC/AHA 2022)
    Anti-impulse FIRST (ACC/AHA 2022 Class I; ESC 2024)
  2. 2. nicardipine IV
    5 mg/h titrated by 2.5 mg/h q5min • IV • continuous
    trigger: SBP >120 with HR <60 (ACC/AHA 2022)
    Add only after beta-blocker (ACC/AHA 2022 Class I)
  3. 3. morphine IV
    2–4 mg • IV • q5–15 min PRN
    trigger: Severe pain (ACC/AHA 2022)
    Reduces sympathetic surge (ACC/AHA 2022)
  4. 4. avoid in cocaine — alpha-blocker first
    Phentolamine 1–2 mg IV • IV • q5min PRN
    trigger: Cocaine + dissection (ACC/AHA 2022)
    Unopposed alpha effect with BB monotherapy (ACC/AHA 2022)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Tearing / migrating chest or back pain (ACC/AHA 2022 Isselbacher — classic presentation; IRAD Hagan JAMA 2000); Inter-arm SBP gradient ≥20 mmHg (ACC/AHA 2022 Isselbacher; ESC 2024); Syncope with chest/back pain (ACC/AHA 2022 — high-risk feature).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Aortic dissection (Stanford A / B + IMH / PAU)** (cardio.aortic-dissection.core.v1).
Phenotype framing: Stanford A vs B; complicated vs uncomplicated B; IMH / PAU; classify malperfusion territories (ACC/AHA 2022 Isselbacher)
Scope: Time-critical: type A surgical emergency — 1-2% mortality/h untreated (IRAD Hagan JAMA 2000; ACC/AHA 2022 Isselbacher)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Anti-impulse therapy + syndrome-specific repair (ACC/AHA 2022)** — step "Step 1 — Anti-impulse: IV β-blocker FIRST to HR <60".
1. esmolol 500 µg/kg IV bolus → 50 µg/kg/min, titrate by 50 q5min IV continuous (beta1_blocker_short_acting, first line) — 2022 ACC/AHA — short half-life ideal for titration; lower target HR before vasodilator
2. labetalol 20 mg IV bolus q10min, max 300 mg, then 0.5–2 mg/min infusion IV continuous (mixed_alpha_beta_blocker, first line) — Combined α+β blockade — vasodilation without reflex tachy (ACC/AHA 2022)

Setting playbook (ed) — Recognise dissection, stabilise BP/HR, classify type via CTA, activate appropriate surgical / endovascular team within minutes (ACC/AHA 2022)
3. esmolol or labetalol IV (ACC/AHA 2022) Esmolol 500 µg/kg bolus + 50 µg/kg/min OR labetalol 20 mg IV q10min (ACC/AHA 2022) IV continuous — HR >60 + dissection suspected (ACC/AHA 2022) (Anti-impulse FIRST (ACC/AHA 2022 Class I; ESC 2024))
4. nicardipine IV 5 mg/h titrated by 2.5 mg/h q5min IV continuous — SBP >120 with HR <60 (ACC/AHA 2022) (Add only after beta-blocker (ACC/AHA 2022 Class I))
5. morphine IV 2–4 mg IV q5–15 min PRN — Severe pain (ACC/AHA 2022) (Reduces sympathetic surge (ACC/AHA 2022))
6. avoid in cocaine — alpha-blocker first Phentolamine 1–2 mg IV IV q5min PRN — Cocaine + dissection (ACC/AHA 2022) (Unopposed alpha effect with BB monotherapy (ACC/AHA 2022))

Non-pharmacologic actions:
- STAT cardiothoracic surgery activation if Type A (ACC/AHA 2022 Class I)
- STAT vascular / IR if Type B complicated (INSTEAD Nienaber NEJM 2013; ESC 2024)
- Permissive hypotension only if hemorrhagic shock from rupture (ACC/AHA 2022)
- IV access x 2 large-bore + arterial line (ACC/AHA 2022)
- NPO (ACC/AHA 2022)
- Continuous monitoring (ACC/AHA 2022; ESC 2024)

AVOID / contraindication checks:
- Vasodilator_BEFORE_beta_blocker_AVOID_reflex_tachy (ACC/AHA 2022 Class III Harm)
- Cocaine_dissection_AVOID_BB_monotherapy_use_combined_alpha_beta (ACC/AHA 2022)
- Nitroprusside_cyanide_risk (ACC/AHA 2022)
- High_grade_AV_block_avoid_BB (ACC/AHA 2022)

Monitoring

Regimen monitoring:
- arterial line q5min BP (ACC/AHA 2022; ESC 2024)
- continuous ECG (ACC/AHA 2022)
- neurologic exam q1h (ACC/AHA 2022 — malperfusion surveillance)
- pulse check all 4 extremities q1h (ACC/AHA 2022)
- urine output hourly (ACC/AHA 2022)
- serial creatinine for renal malperfusion (ACC/AHA 2022)
- serial troponin for coronary malperfusion (ACC/AHA 2022)

Setting (ed) monitoring:
- Continuous ECG, art-line BP q5 min target (ACC/AHA 2022)
- Hourly neuro + perfusion + UOP (ACC/AHA 2022)
- Lactate q1-2 h (ACC/AHA 2022 — malperfusion marker)

Monitoring phase: Arterial line, q5min BP, neurologic + perfusion checks q1h (ACC/AHA 2022; ESC 2024)

Disposition

Current setting: ed — Recognise dissection, stabilise BP/HR, classify type via CTA, activate appropriate surgical / endovascular team within minutes (ACC/AHA 2022)

Disposition criteria:
- OR for Type A (ACC/AHA 2022)
- IR/Vascular for complicated B (ACC/AHA 2022)
- ICU for uncomplicated B (ACC/AHA 2022)

Escalation triggers (move to higher acuity):
- Type A → emergent surgery (ACC/AHA 2022 Class I)
- Type B complicated (malperfusion, rupture, refractory pain/HTN, rapid expansion) → TEVAR (INSTEAD Nienaber NEJM 2013; ESC 2024)
- Hemodynamic instability + tamponade → urgent pericardiocentesis only as last bridge to OR (ACC/AHA 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Stanford Type A on CTA (involving ascending aorta) (ACC/AHA 2022)
- [LIFE_THREATENING] Type B + malperfusion / rupture / refractory pain or HTN / rapid expansion (ACC/AHA 2022)
- [LIFE_THREATENING] Type A + pericardial effusion + Beck triad (ACC/AHA 2022 Isselbacher)

Citations

- 2022 ACC/AHA Guideline for Diagnosis and Management of Aortic Disease (Isselbacher) + IRAD registry + INSTEAD-XL + ADSORB type-B dissection evidence [PMID:36322642](https://pubmed.ncbi.nlm.nih.gov/36322642/)
- Cited evidence (PMID 10685714) [PMID:10685714](https://pubmed.ncbi.nlm.nih.gov/10685714/)
- Cited evidence (PMID 23922146) [PMID:23922146](https://pubmed.ncbi.nlm.nih.gov/23922146/)
- Cited evidence (PMID 24962744) [PMID:24962744](https://pubmed.ncbi.nlm.nih.gov/24962744/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2022 ACC/AHA Guideline for Diagnosis and Management of Aortic Disease (Isselbacher) + IRAD registry + INSTEAD-XL + ADSORB type-B dissection evidence — PMID:36322642
  • Cited evidence (PMID 10685714) — PMID:10685714
  • Cited evidence (PMID 23922146) — PMID:23922146
  • Cited evidence (PMID 24962744) — PMID:24962744