PE, tamponade and aortic emergencies

Acute aortic dissection: BP and HR targets

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Recognise acute aortic syndrome, start impulse control (HR < 60, SBP < 120) with beta-blocker first, and route type A to surgery.

Definition
Acute aortic syndrome = dissection, intramural haematoma, penetrating ulcer. Stanford type A involves the ascending aorta (surgical emergency, mortality rises ~1-2% per hour untreated); type B does not (medical therapy unless complicated).

At the bedside

Timed steps
  1. 1

    Suspect

    0 min

    Abrupt severe tearing chest/back pain, pulse or BP differential > 20 mmHg between arms, new aortic regurgitation murmur, neurological deficit, syncope, mesenteric/limb ischaemia. Risk: hypertension, Marfan/connective tissue disease, bicuspid valve, cocaine, pregnancy, recent aortic instrumentation.

  2. 2

    Risk-stratify and image

    < 30 min

    ADD-RS (high-risk condition, pain features, exam features; 0-3). ADD-RS ≤ 1 with D-dimer < 500 ng/mL makes dissection unlikely. CT angiography aorta is the test of choice; bedside TTE (flap, AR, effusion) if unstable.

  3. 3

    Analgesia

    IV opioid (morphine or fentanyl) titrated: pain drives sympathetic surge.

  4. 4

    Beta-blocker first

    Within 20 min

    Target HR < 60/min and SBP < 120 mmHg (as low as tolerated with preserved perfusion and urine output). Esmolol or labetalol IV. If beta-blocker contraindicated: diltiazem/verapamil for rate.

  5. 5

    Then vasodilator if SBP still high

    Add GTN, nicardipine or nitroprusside only after HR control to avoid reflex tachycardia.

  6. 6

    Type A: emergency surgery

    Immediate cardiothoracic surgery referral; avoid anticoagulants/antiplatelets (rule out dissection before treating 'ACS'). Pericardiocentesis is avoided for tamponade.

  7. 7

    Type B

    Uncomplicated: ICU, impulse control, analgesia, serial imaging. Complicated (malperfusion, rupture, refractory pain/hypertension, rapid expansion): TEVAR.

First-line impulse control

Esmolol

IV
Dose
500 mcg/kg over 1 min, then 50-300 mcg/kg/min
Target
HR < 60/min
Worked example
70 kg: 35 mg bolus; infusion 50 mcg/kg/min = 3.5 mg/min = 21 mL/h of 10 mg/mL
Open infusion calculator

Alternative beta + alpha blocker

Labetalol

IV
Dose
20 mg over 2 min then 20-80 mg every 10 min (max 300 mg) or 0.5-2 mg/min infusion
Preparation
200 mg in 200 mL = 1 mg/mL; 30-120 mL/h
Open infusion calculator

Add-on vasodilator after beta-blockade

Glyceryl trinitrate (nitroglycerin)

IV
Dose
5-10 mcg/min, up-titrate every 3-5 min
Preparation
50 mg in 50 mL = 1,000 mcg/mL (0.3 mL/h = 5 mcg/min)
Target
SBP < 120 mmHg
Open infusion calculator

Analgesia

Morphine / fentanyl

IV
Dose
Morphine 2-4 mg every 5-10 min titrated, or fentanyl 25-50 mcg

Aortic Dissection Detection Risk Score (1 point per category present)

CategoryFeatures
High-risk conditionsMarfan or connective tissue disease, family history of aortic disease, known aortic valve disease, recent aortic manipulation, known thoracic aortic aneurysm
High-risk pain featuresAbrupt onset, severe intensity, ripping or tearing
High-risk exam featuresPulse deficit, SBP differential, focal neuro deficit + pain, new AR murmur + pain, hypotension or shock
Red flag · call your senior now
Chest pain + neurological deficit or pulse deficit: think dissection before thrombolysis or heparin.
Red flag
Hypotension in dissection suggests tamponade, rupture, severe AR or myocardial ischaemia: emergency surgery.
Pitfall
Starting a vasodilator before the beta-blocker: reflex tachycardia increases aortic wall stress (dP/dt).
Pitfall
Giving antiplatelets/heparin/thrombolysis for presumed STEMI when dissection involves the coronary ostia (usually RCA - inferior STEMI).
Pearl
Measure BP in both arms and use the higher arm reading to titrate therapy.
Pearl
A normal chest X-ray does not exclude dissection; CTA is required if suspicion remains.

Calculators for this topic

Infusion rate from mcg/kg/min

Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).

Infusion rate from a fixed hourly or per-minute dose

Pump rate for non-weight-based infusions such as vasopressin (U/min), labetalol (mg/min) or amiodarone (mg/h).

Mean arterial pressure

(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).

References

  1. 1

    Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation 2022;146:e334-482.

  2. 2

    Mazzolai L, Teixido-Tura G, Lanzi S, et al. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024;45:3538-700.

  3. 3

    Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation. Circulation 2011;123:2213-8.

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