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cardio.hypertensive-emergency.aortic-dissection.v1PRODUCTION
cardio.hypertensive-emergency.aortic-dissection.v1

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

cardiologyacuteadult
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Care setting:

Encounter flow

10/12 authored

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

Current phase

Frame

Detailed

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.

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Actions
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Advance rule
Set
Advance when

dissection suspected + anti-impulse plan articulated

Patient inputs (11)

Branch malperfusion (limb ischemia, AKI, mesenteric ischemia, stroke) defines complicated Type B → TEVAR per INSTEAD-XL

Bimodal age — Marfan/connective tissue (younger) vs HTN-related (older); informs etiology + surgical risk

Tearing or migrating pain LR+ 10.8 for dissection (Klompas JAMA 2002 PMID 11990624)

>20 mmHg supports dissection diagnosis (ACC/AHA 2022; Klompas JAMA 2002 PMID 11990624)

Renal malperfusion screen + contrast nephropathy + AKI driving drug selection

Coronary involvement (RCA dissection extension → inferior MI); Type A may have ACS overlap

Confirms diagnosis + Stanford classification (A vs B) + branch malperfusion mapping (ACC/AHA 2022 Class I)

Hypertension in 70% of dissection presentations; goal SBP <120 within 20-30 min AFTER HR <60 (ACC/AHA 2022 Class I)

GOAL HR <60 FIRST before vasodilator — critical anti-impulse paradigm (ACC/AHA 2022 Class I)

Mesenteric malperfusion screen — elevated lactate signals branch ischemia

TEE confirms dissection if CTA contraindicated; assesses AI, pericardial effusion, tamponade (ACC/AHA 2022)

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningdissection_extension_on_serial_cta
    New / extended dissection flap on serial CTA OR new branch malperfusion on imaging or exam
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtype_a_dissection_with_tamponade
    Type A (ascending) dissection + pericardial effusion + hemodynamic compromise (Beck triad)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcomplicated_type_b_with_malperfusion
    Stanford B dissection + branch malperfusion (limb ischemia, mesenteric ischemia, AKI, paraplegia, stroke) OR refractory pain OR rapid aneurysm expansion
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_hr_or_bp_despite_max_anti_impulse
    Refractory HR >60 or SBP >120 despite maximum esmolol/labetalol + nicardipine — propagation risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaortic_rupture_or_imminent_collapse
    Free flap on CTA, hemothorax, hemoperitoneum, hemodynamic collapse with HTN history
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Aortic dissection — anti-impulse paradigm: HR <60 FIRST (BB), THEN SBP <120 (vasodilator). Goal achieved within 20-30 min.
axis: aortic_dissection_anti_impulse_first
Selected axis "Aortic dissection — anti-impulse paradigm: HR <60 FIRST (BB), THEN SBP <120 (vasodilator). Goal achieved within 20-30 min." by default fallback (first axis)
  • esmolol
    first line
    beta1_blocker_short_acting
    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
    triggers: aortic_dissection_anti_impulse_FIRST
    ACC/AHA 2022 Class I — anti-impulse FIRST; ultra-short half-life allows fine titration; HR <60 within 5-10 min target
    rxcui 49737
  • labetalol
    first line
    mixed_alpha_beta_blocker
    20 mg IV q10 min (max 300 mg cumulative) OR 0.5-2 mg/min infusion • IV • bolus or infusion
    triggers: aortic_dissection_alt_anti_impulse, esmolol_unavailable
    ACC/AHA 2022 Class I alternative — mixed α/β provides combined HR + SBP control; useful when esmolol not on hand
    rxcui 6185
  • nicardipine
    first line
    DHP_CCB
    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
    triggers: aortic_dissection_after_BB_load
    ACC/AHA 2022 Class I — add ONLY after esmolol/labetalol established HR <60; SBP target 100-120 with HR <60 within 20-30 min
    rxcui 7396
  • nitroprusside
    second line
    arteriolar_vasodilator
    0.25-10 µg/kg/min IV (ONLY after HR <60 with BB) • IV • continuous
    triggers: aortic_dissection_refractory_after_nicardipine_max, normal_egfr
    Alternative vasodilator after BB; AVOID if eGFR <30 (cyanide); ACC/AHA 2022 acceptable adjunct
    rxcui 7476
  • AVOID isolated vasodilator without BB
    contraindication substitute
    do_not_use
    AVOID • N/A • N/A
    triggers: aortic_dissection_diagnosis
    Isolated vasodilator (nitroprusside, hydralazine, nicardipine without BB) increases dP/dt via reflex tachycardia → propagates dissection (ACC/AHA 2022 Class III)
  • AVOID hydralazine
    contraindication substitute
    do_not_use
    AVOID • N/A • N/A
    triggers: aortic_dissection_diagnosis
    Hydralazine causes reflex tachycardia → increases dP/dt → propagation; not recommended in dissection
  • fentanyl
    add on
    opioid_analgesic
    25-100 µg IV q5-10 min titrate • IV • PRN
    triggers: dissection_pain_with_sympathetic_drive
    Pain control reduces sympathetic drive (HR + dP/dt); IV opioid preferred for rapid titration
    rxcui 4337

outpatient playbook — drug actions (1)

  1. 1. continue lifelong BB ± ARB
    rxcui 7512
    Metoprolol XL + losartan at max-tolerated • PO • daily
    trigger: Post-dissection lifelong
    ACC/AHA 2022 Class I

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sudden tearing chest/back pain ± migrating pain (Klompas RCE JAMA 2002 LR+ 10.8 PMID 11990624); Inter-arm SBP gradient >20 mmHg (ACC/AHA 2022 Aortic PMID 36066317); Mediastinal widening on CXR (LR+ for dissection ~3) — triggers CTA.

Objective

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

Assessment

**Aortic dissection in hypertensive crisis (HR + dP/dt FIRST, then SBP)** (cardio.hypertensive-emergency.aortic-dissection.v1).
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Aortic dissection — anti-impulse paradigm: HR <60 FIRST (BB), THEN SBP <120 (vasodilator). Goal achieved within 20-30 min.**.
1. 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 (beta1_blocker_short_acting, first line) — ACC/AHA 2022 Class I — anti-impulse FIRST; ultra-short half-life allows fine titration; HR <60 within 5-10 min target
2. labetalol 20 mg IV q10 min (max 300 mg cumulative) OR 0.5-2 mg/min infusion IV bolus or infusion (mixed_alpha_beta_blocker, first line) — ACC/AHA 2022 Class I alternative — mixed α/β provides combined HR + SBP control; useful when esmolol not on hand
3. 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 (DHP_CCB, first line) — ACC/AHA 2022 Class I — add ONLY after esmolol/labetalol established HR <60; SBP target 100-120 with HR <60 within 20-30 min
4. nitroprusside 0.25-10 µg/kg/min IV (ONLY after HR <60 with BB) IV continuous (arteriolar_vasodilator, second line) — Alternative vasodilator after BB; AVOID if eGFR <30 (cyanide); ACC/AHA 2022 acceptable adjunct
5. AVOID isolated vasodilator without BB AVOID N/A N/A (do_not_use, contraindication substitute) — Isolated vasodilator (nitroprusside, hydralazine, nicardipine without BB) increases dP/dt via reflex tachycardia → propagates dissection (ACC/AHA 2022 Class III)
6. AVOID hydralazine AVOID N/A N/A (do_not_use, contraindication substitute) — Hydralazine causes reflex tachycardia → increases dP/dt → propagation; not recommended in dissection
7. fentanyl 25-100 µg IV q5-10 min titrate IV PRN (opioid_analgesic, add on) — Pain control reduces sympathetic drive (HR + dP/dt); IV opioid preferred for rapid titration

Setting playbook (outpatient) — Lifetime aortic surveillance with annual CTA, lifelong BB, strict BP <120/80, family screening if connective tissue disease, recurrence symptom education
8. continue lifelong BB ± ARB Metoprolol XL + losartan at max-tolerated PO daily — Post-dissection lifelong (ACC/AHA 2022 Class I)

Non-pharmacologic actions:
- Lifelong activity restriction
- Annual CTA
- Family screening

AVOID / contraindication checks:
- NEVER_isolated_vasodilator_in_dissection_dpdt_propagation_risk (ACC/AHA 2022 Class III)
- Hydralazine_reflex_tachy_avoid (ACC/AHA 2022)
- Nitroprusside_cyanide_avoid_if_egfr_lt_30 (ACC/AHA 2022)
- Hr_lt_60_FIRST_before_vasodilator (ACC/AHA 2022 Class I)
- Sbp_lt_120_within_20_30_min_after_HR_target (ACC/AHA 2022 Class I)

Monitoring

Regimen monitoring:
- arterial line q5min BP HR (ACC/AHA 2022)
- serial CTA q6-24h for extension (ACC/AHA 2022)
- daily exam for new murmur pulse change neuro deficit (ACC/AHA 2022)
- serial Cr q4-6h for renal malperfusion (ACC/AHA 2022)
- serial lactate for mesenteric malperfusion (ACC/AHA 2022)
- serial neuro exam for carotid or spinal branch involvement (ACC/AHA 2022)

Setting (outpatient) monitoring:
- Annual CTA
- Quarterly BP review

Follow-up plan: 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
- Close-out criterion: outpatient surveillance + BB regimen documented

Monitoring phase: 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

Disposition

Current setting: outpatient — Lifetime aortic surveillance with annual CTA, lifelong BB, strict BP <120/80, family screening if connective tissue disease, recurrence symptom education

Disposition criteria:
- Long-term continuation; cross-link to cardio.aortic-dissection.core.v1 + cardio.htn.core.v1

Escalation triggers (move to higher acuity):
- Recurrent pain → STAT CTA + ED
- New aneurysm on CTA → vascular intervention

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] New / extended dissection flap on serial CTA OR new branch malperfusion on imaging or exam
- [LIFE_THREATENING] Type A (ascending) dissection + pericardial effusion + hemodynamic compromise (Beck triad)
- [LIFE_THREATENING] Stanford B dissection + branch malperfusion (limb ischemia, mesenteric ischemia, AKI, paraplegia, stroke) OR refractory pain OR rapid aneurysm expansion

Citations

- 2022 ACC/AHA Aortic Disease Guideline (Isselbacher PMID 36066317) + 2025 ACC/AHA HTN Guideline (Whelton) + ESC/ESH 2024 HTN (Mancia PMID 38613493) [PMID:36066317](https://pubmed.ncbi.nlm.nih.gov/36066317/)
- Cited evidence (PMID 17307915) [PMID:17307915](https://pubmed.ncbi.nlm.nih.gov/17307915/)
- Cited evidence (PMID 25840177) [PMID:25840177](https://pubmed.ncbi.nlm.nih.gov/25840177/)
- Cited evidence (PMID 38316810) [PMID:38316810](https://pubmed.ncbi.nlm.nih.gov/38316810/)
- Cited evidence (PMID 38613493) [PMID:38613493](https://pubmed.ncbi.nlm.nih.gov/38613493/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2022 ACC/AHA Aortic Disease Guideline (Isselbacher PMID 36066317) + 2025 ACC/AHA HTN Guideline (Whelton) + ESC/ESH 2024 HTN (Mancia PMID 38613493) — PMID:36066317
  • Cited evidence (PMID 17307915) — PMID:17307915
  • Cited evidence (PMID 25840177) — PMID:25840177
  • Cited evidence (PMID 38316810) — PMID:38316810
  • Cited evidence (PMID 38613493) — PMID:38613493