Aortic dissection in hypertensive emergencies

An aortic dissection is more likely to propagate if the heart rate and BP are elevated, as this increases the shear stress on the aorta. An aortic dissection is typically very painful, so adequate analgesia is an important component of therapy as it reduces both heart rate and BP by reducing sympathetic drive.

Use an intravenous infusion of a beta blocker to slowly reduce the heart rate to below 60 beats per minute, followed by an intravenous infusion of sodium nitroprusside or glyceryl trinitrate, titrating the dose to achieve a systolic BP of around 100 mmHg. It is important to give a beta blocker before giving a vasodilator, as tachycardia can occur if the vasodilator is given first. Aortic dissection carries an inherent risk of hypotension; esmolol may be the safest choice of beta blocker because of its short duration of action. See Hypertensive emergency for dosage information.