P1: SBT
0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8
Aortic Dissection 141➣Angiography remains gold standard and allows coronary angiog-
raphy in preparation for surgery
differential diagnosis
■Occasionally misdiagnosed as acute coronary syndrome, generally
with disasterous results
management
What to Do First
■Think of it, work to exclude it
General Measures
■Once diagnosis made, begin immediate medical therapy while fur-
ther assessing classification
➣Stanford type A
Involves ascending aorta
➣Stanford type B
Does not involve ascending aorta
➣DeBakey type I
Involves ascending through descending aorta
➣DeBakey type II
– Involves ascending and arch, not descending aorta
➣DeBakey type III
Involves descending aorta only
■Medical therapy, hemodynamic control is cornerstone for reducing
propagation
➣Control BP
➣Control dP/dt
specific therapy
Indication for surgical therapy: DeBakey type I and II (Stanford type A)
or sometimes propagating type III with end organ effects
Indication for medical therapy: non-surgical candidates and those
awaiting surgery
Treatment Options
■Surgical reconstruction if indicated
■Medical therapy
➣Labetalol is drug of choice with Beta and Alpha blocking proper-
ties dose: Goal HR∼60 and SBP <120
➣Alternatively another IV beta blocker can be used but must be
accompanied by sodium nitroprusside, titrate the combination
to same therapeutic goal (HR∼60 and SBP <120)