Item ~?Mark <?

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A 48-year-old man comes to the emergency department due to severe chest pain that
started 2 hours ago. He has difficulty localizing the pain, saying that it "hurts all over my
chest." He has had no shortness of breath, lightheadedness, syncope, or palpitations.
The patient has no known medical problems. He is a lifetime nonsmoker and does not
use any illicit drugs. His father died suddenly at age 52 from a presumed heart attack.
His temperature is 36.7 C (98 F), blood pressure is 178/1 02 mm Hg, pulse is 105/min and
regular, and respirations are 16/min. On physical examination, the lungs are clear to
auscultation and heart sounds are normal. ECG shows sinus tachycardia, voltage
criteria for left ventricular hypertrophy, and T wave inversion in leads V5 and V6. ACT
image of his chest is shown below.

In addition to pain control, which of the following is the most appropriate immediate
pharmacotherapy for this patient?

0 A Furosemide
0 B. Hydralazine
0 C. 'Labetalol
0 D. Nitroprusside
0 E. Tissue plasminogen activator
chest." He has had no shortness of breath, lightheadedness, syncope, or palpitations.
The patient has no known medical problems. He is a lifetime nonsmoker and does not
use any illicit drugs. His father died suddenly at age 52 from a presumed heart attack.
His temperature is 36.7 C (98 F), blood pressure is 178/102 mm Hg, pulse is 105/min and
regular, and respirations are 16/min. On physical examination, the lungs are clear to
auscultation and heart sounds are normal. ECG shows sinus tachycardia, voltage
criteria for left ventricular hypertrophy, and T wave inversion in leads V5 and V6. ACT
image of his chest is shown below.

In addition to pain control, which of the following is the most appropriate immediate
pharmacotherapy for this patient?

0 A Furosemide
0 B. Hydralazine
0 C. Labetalol
0 D. Nitroprusside
0 E. Tissue plasminogen activator
0 F. Unfractionated heparin

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Item lliJ?M k <J [> jj ~· l!lj , ~
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A 48-year-old man comes to the emergency department due to severe chest pain that
started 2 hours ago. He has difficulty localizing the pain, saying that it "hurts all over my
chest." He has had no shortness of breath, lightheadedness, syncope, or palpitations.
The patient has no known medical problems. He is a lifetime nonsmoker and does not
use any illicit drugs. His father died suddenly at age 52 from a presumed heart attack.
His temperature is 36.7 C (98 F). blood pressure is 178/102 mm Hg, pulse is 105/min and
regular, and respirations are 16/min. On physical examination, the lungs are clear to
auscultation and heart sounds are normal. ECG shows sinus tachycardia, voltage
criteria for left ventricular hypertrophy, and T wave inversion in leads V5 and V6. ACT
image of his chest is shown below.

In addition to pain control, which of the following is the most appropriate immediate
pharmacotherapy for this patient?

A. Furosemide (2%]
B. Hydralazine [9%]
C. Labetalol (67%]
D. Nitroprusside (14%]
E. Tissue plasminogen activator (4%]
Item lliJ?M k <J [> jj ~· l!lj , ~
0. ld : 3056 ar Previous Next Lob Values Notes Calculator Reverse Color Text Zoom

Ex planat io n: User ld

Management of patients with acute

aortic dissection

• Pain relief with morphine

• Intravenous beta blockers for a target systolic blood
pressure of 100-120 mm Hg
• Transfer to intensive care unit
• Initiate additional vasodilator (eg, sodium nitroprusside)
if systolic blood pressure remains elevated
• Surgery for acute ascending aortic dissections
& complicated descending aortic dissections

<i:>UWOI1d

This patient's clinical presentation and CT scan findings (intimal tears separating the
true and false lumens of the ascending and descending aorta) are consistent with aortic
dissection. Aortic dissection involving the ascending aorta (type A) is considered a
surgical emergency with m ortality rates of 1%-2% per hour following symptom onset,
and rapid diagnosis and treatment are critical.

The goals of initial therapy of aortic dissection include:

• Adequate pain control
• Reduction of syst olic blood pressure (SSP) to a goal of 100-120 mm Hg
• Decrease in left ventricular (LV) contractility to reduce aortic wall stress

Intravenous bet a blockers (eg, labetalol, propranolol, esmolol) are preferred for initial
therapy to reduce heart rate, SSP, and LV contractility. These effects lead to a decrease
in th e rate of rise in SSP (dP/dt) and in aortic wall stress.

(Choice A ) Diuretics are used in patients with pulmonary edema but have no role in th e
management of those with acute aortic dissection.

(Choices B and C) Hydralazine and nitroprusside are vasodilators sometimes used in

hypertensive emergencies. However, they can cause reflex sympathetic stimulation with
consequent rises in heart rate, LV contractility, and aortic wall stress. T hese changes
increase the risk of propagation of an aortic dissection. In patients with aortic dissection,
nitroprusside is used as a second-line agent only if SSP remains above goal despite
 Item lliJ?M k <J [> jj ~· l!lj , ~
0. ld : 3056 ar Previous Next Lob Values Notes Calculator Reverse Color Text Zoom
This patient's clinical presentation and CT scan findings (intimal tears separating the
true and false lumens of the ascending and descending aorta) are consistent with aortic
dissection . Aortic dissection involving the ascending aorta (type A) is considered a
surgical emergency with mortality rates of 1%·2% per hour following symptom onset,
and rapid diagnosis and treatment are critical.

The goals of initial therapy of aortic dissection include:

• Adequate pain control
• Reduction of systolic blood pressure (SSP) to a goal of 100-120 mm Hg
• Decrease in left ventricular (LV) contractility to reduce aortic wall stress

Intravenous beta blockers (eg, labetalol, propranolol, esmolol) are preferred for initial
therapy to reduce heart rate, SSP, and LV contractility. These effects lead to a decrease
in the rate of rise in SSP (dP/dt) and in aortic wall stress.

(Choice A) Diuretics are used in patients with pulmonary edema but have no role in the
management of those with acute aortic dissection.

(Choices B and D) Hydralazine and nitroprusside are vasodilators sometimes used In

hypertensive emergencies. However, they can cause reflex sympathetic stimulation with
consequent rises in heart rate, LV contractility, and aortic wall stress. These changes
increase the risk of propagation of an aortic dissection. In patients with aortic dissection,
nitroprusside is used as a second-line agent only if SSP remains above goal despite
adequate beta blockade.

(Cho ices E and F) Patients with aortic dissection should not receive thrombolytic
therapy with tissue plasminogen activator (appropriate in some with ischemic stroke) or
anticoagulation therapy with intravenous heparin (appropriate in some with acute
coronary syndrome or pulmonary embolism) due to the risks of bleeding and propagation
of the dissection into the pericardia! space (hemopericardium).

Educational objective:
Intravenous beta blockers are the treatment of choice for the initial medical management
of patients with acute aortic dissection as they lower heart rate and blood pressure and
reduce left ventricular contractility.

References:
1. Diagnosis and management of aortic dissection.
2. Acute aortic syndromes.

Time Spent: 8 seconds Copyright© UWorld Last updated: (07/28/2016]

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Media Exhibit

ssection
 Item ~\='Mark <? [> ai ~ ~ , GJIIA)
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Media Exhibit

ssection

DISSECTING AORTIC HEMATOMAS

TYPE A TYPE B

Intimal tear Intimal tear Intimal tear

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