Management of Arterial Tension in Aortic Syndromes

Acute Aortic Syndromes

The European Society of Cardiology recommends immediate anti-impulse therapy targeting systolic blood pressure <120 mmHg and heart rate ≤60 beats per minute in acute aortic syndromes, with intravenous beta-blockers as first-line agents 1, 2
Target heart rate ≤60 beats per minute to reduce aortic wall stress (anti-impulse therapy) 1, 2
Aggressive targets reduce the risk of aortic rupture, propagation of dissection, and mortality 1, 2
Initiate intravenous beta-blockers (labetalol or esmolol) as first-line agents and titrate to achieve heart rate ≤60 beats per minute before addressing blood pressure 1, 2
If beta-blockers are contraindicated, substitute with non-dihydropyridine calcium channel blockers (diltiazem or verapamil) 1, 2
Administer intravenous opiates titrated to adequate pain control, which is essential to achieve hemodynamic targets and is a Class I recommendation 1, 2
In cases of malperfusion syndromes, maintain higher mean arterial pressure to optimize perfusion to threatened organs 1, 2
Invasive arterial line monitoring is mandatory for continuous blood pressure assessment, and admission to intensive care unit is recommended for all acute aortic syndrome patients 1, 2

The American Heart Association recommends target systolic blood pressure <130 mmHg and diastolic blood pressure <80 mmHg for all patients with aortic aneurysms 3
Consider more intensive control toward systolic 120-129 mmHg if tolerated, particularly in select patients without diabetes who are not undergoing new surgical repair 3
Beta-blockers are recommended as first-line agents for achieving blood pressure targets in thoracic aortic aneurysm patients, regardless of cause and in the absence of contraindications 3
ACE inhibitors or ARBs may be added for combination therapy to achieve blood pressure targets 5
Uncontrolled hypertension is a known risk factor for aortic rupture and dissection, making aggressive blood pressure control essential even in asymptomatic post-operative patients 3
High variability of blood pressure is an independent risk factor for poor prognosis in aortic disease; consistent control should be sought, not just adequate average values 4
Lifelong follow-up with imaging of the entire aorta is required to detect progressive dilation of residual segments 4