How does a hypertensive emergency with aortic dissection differ from others?
Such patients typically present with a characteristic history of chest or back pain, often described as “tearing” or “ripping,” with radiation to the arms or upper abdomen. Typically blood pressures are lower in the legs than in the arms, and a murmur of acute aortic regurgitation may be present. A chest x-ray may show nothing, a widened aortic shadow, or a widened mediastinum; in appropriate patients, consideration should be given to initiating therapy before the imaging study (transesophageal echocardiogram, computed tomogram of the chest) is completed.
Therapy for aortic dissection differs in three important ways from other hypertensive emergencies. Therapy should include a beta blocker (unless otherwise contraindicated) to decrease the shear forces driving the dissection. Although not “evidence-based,” the recommended blood pressure target is <120 mm Hg systolic, and it should be achieved within 20 minutes of starting therapy to minimize progression. A cardiothoracic surgeon should be consulted quickly; type A dissections (proximal to the aortic arch) nearly always require emergent surgery, sometimes including valve replacement.
