Pharmacy & Acute Care University
Pharmacy & Acute Care University
Lesson 1, Topic 1
In Progress

Key Guidelines and Evidence

  1. American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease:
    • Provides comprehensive recommendations for the diagnosis and management of thoracic aortic diseases, including aortic dissection.
  1. Key Recommendations:
    • Intravenous beta blockers (esmolol, labetalol, metoprolol) are recommended as first-line agents to control heart rate and blood pressure.
    • Intravenous vasodilators (nicardipine, clevidipine, nitroprusside) are recommended to rapidly control blood pressure when beta blockers are inadequate or contraindicated.
    • Goal is to reduce heart rate to 60-80 bpm and systolic blood pressure <120 mm Hg.
    • Intravenous opioids are recommended for pain control, as pain can increase heart rate and blood pressure.
    • Oral beta blockers should be continued at hospital discharge to improve long-term outcomes.
  1. Landmark Trials:
    • The INSTEAD-XL Trial
      • The INSTEAD-XL (Endovascular repair of type B aortic dissection—long-term results of the randomized investigation of stent grafts in aortic dissection trial) was a significant study that investigated the long-term outcomes of patients with uncomplicated type B aortic dissection
      • The study was led by Christoph A Nienaber, Heart Center Rostock, University of Rostock, Rostock, Germany1. It involved 140 patients with stable type B aortic dissection who were previously randomised to optimal medical treatment and TEVAR (n=72) vs. optimal medical treatment alone (n=68)
      • Key findings from the INSTEAD-XL trial include:
        • Superiority of TEVAR: The study showed that thoracic endovascular aortic repair (TEVAR) of uncomplicated type B dissections in addition to medical therapy is associated with improved five-year aorta-specific survival and delayed disease progression.
        • Risk Reduction: The risk of all-cause mortality (11.1% vs. 19.3%; p=0.13), aorta-specific mortality (6.9% vs. 19.3%; p=0.04), and progression (27.0% vs. 46.1%; p=0.04) after five years was lower with TEVAR than with optimal medical treatment alone.
        • Landmark Analysis: Landmark analysis suggested a benefit of TEVAR for all end points between two and five years; for example, for all-cause mortality (0% vs. 16.9%; p=0.0003), aorta-specific mortality (0% vs. 16.9%; p=0.0005), and for progression (4.1% vs. 28.1%; p=0.004)1.
        • False Lumen Thrombosis: Both improved survival and less progression of disease at five years after elective TEVAR were associated with stent graft induced false lumen thrombosis in 90.6% of cases (p<0.0001)1.
      • The authors concluded that in survivors of type B aortic dissection, TEVAR in addition to optimal medical treatment is associated with improved five-year aorta-specific survival and delayed disease progression1. Therefore, in stable type B dissection with suitable anatomy, pre-emptive TEVAR should be considered to improve late outcome.
      • Reference
    • Ulici et al 2017
      • The study “Clevidipine versus sodium nitroprusside in acute aortic dissection: A retrospective chart review” by Ulici A, Jancik J, Lam TS, Reidt S, Calcaterra D, Cole JB.
      • Study Design: This was a single-center retrospective chart review that evaluated patients diagnosed with aortic dissection.
      • Aim: The aim of this study was to compare clevidipine versus sodium nitroprusside (SNP) as adjunct agents to esmolol for blood pressure (BP) management in aortic dissection.
      • Methods: The primary outcome measure was time to reach patient-specific systolic blood pressure (SBPPT) goals after initiation of esmolol infusion. The efficacy of clevidipine and SNP was assessed using area under the curve analysis of positive and negative excursions outside of SBPPT goals (AUCSBPe). Cost data was calculated using average wholesale price in U.S. dollars.
      • Results:
        • Median systolic BP immediately prior to initiation of esmolol was similar for both clevidipine and SNP groups.
        • Median time to reach SBPPT goal was similar between clevidipine and SNP.
        • Median AUCSBPe was similar for clevidipine and SNP.
        • Cost was significantly reduced using clevidipine versus SNP.
      • Conclusions: Clevidipine administration during initial medical management of aortic dissection showed similar efficacy compared to SNP when used as adjunct therapy to esmolol. These data suggest clevidipine is a less costly, reasonable alternative to SNP in acute aortic dissection as adjunct therapy to esmolol. Further studies are needed to validate these results.
      • Reference