ACE-CAA Issue 3 Sample Question

A patient presents to the emergency department with newly diagnosed type A aortic dissection. You prepare to take the patient to the operating room emergently. The patient is hypertensive in the emergency department with a blood pressure of 180/90 mm Hg and a heart rate of 90 beats/min. Which of the following is MOST appropriate to administer before taking the patient to the operating room?

A. β Blocker ✔

B. Corticosteroid X

C. Diuretic X

Read the discussion below.

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Discussion

Aortic dissection results when a tear in the intima of the aortic wall allows blood to flow between the intima and the media of the aortic wall in a false lumen. The aortic dissection may remain localized or extend proximally, distally, or both. Blood flow in the false lumen may obstruct blood flow through arteries branching from the aorta. Aortic dissections that involve the ascending aorta and aortic arch (type A) are considered surgical emergencies. Aortic dissections that only involve the descending aorta (distal to the left subclavian artery) are managed medically (Figure 1).

Figure 1. Stanford classification system of aortic dissections. © 2015 American Society of Anesthesiologists. 

Type A aortic dissections require immediate surgical attention. Until the dissection can be surgically repaired, the immediate goal is to prevent propagation of the dissection. Shear force and high blood pressure increase the risk of dissection propagation. β Blockers can decrease blood pressure, heart rate, and the shear force on the aorta. β Blockers should be titrated to achieve a heart rate around 60 beats/min. If the patient remains hypertensive despite β-blocker therapy, vasodilators should be administered. Corticosteroids and diuretics will not decrease the risk of dissection propagation.

REFERENCES

1. Kaplan JA, Cronin B, Maus T, eds. Kaplan’s Essentials of Cardiac Anesthesia for Cardiac Surgery. 2nd ed. Elsevier; 2018:421-424.
2. Kaplan JA, Augoustides JGT, Manecke GR Jr, Maus T, Reich DL, eds. Kaplan’s Cardiac Anesthesia for Cardiac and Noncardiac Surgery. 7th ed. Elsevier Saunders; 2017:846.
3. Smith HN, Boodhwani M, Ouzounian M. Classification and outcomes of extended arch repair for acute type A aortic dissection: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2017;24(3):450-459. doi:10.1093/icvts/ivw355