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Does intensive medical treatment improve outcomes in aortic dissection?

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5288 (Published 09 September 2014) Cite this as: BMJ 2014;349:g5288
  1. Frank A Lederle, professor of medicine1,
  2. Janet T Powell, professor of vascular biology and medicine2,
  3. Christoph A Nienaber, professor of internal medicine/cardiology3
  1. 1Center for Chronic Disease Outcomes Research, VA Health Care System (111-O), Minneapolis, MN 55417, USA
  2. 2Vascular Surgery Research Group, Imperial College, London W6 8RP, UK
  3. 3Heart Center Rostock, University of Rostock, 18055 Rostock, Germany
  1. Correspondence to: F A Lederle frank.lederle{at}va.gov
  • Accepted 29 July 2014

Each year, aortic dissection affects one in 20 000 people,1 2 resulting in 3000 deaths in the United States. Men are affected twice as often as women, and most people affected are over the age of 65 years.1 2 Two thirds of dissections involve the ascending aorta (type A), and many of these patients die before reaching hospital.1 The survivors, who are usually treated with immediate surgery (open or endovascular) unless contraindicated, have a 30 day mortality of 20-50%.1 2 3 Dissections confined to the descending aorta (type B) are usually managed without repair unless complications develop,2 4 and with this approach they have a 30 day mortality of about 12%.1 3

For nearly half a century, the recommended initial medical management of acute aortic dissection of both types has been “aggressive” lowering of systolic blood pressure to below 100 or 120 mm Hg and heart rate to below 60 beats per minute, with first line use of intravenous β blockers.4 5

These recommendations for aortic dissection are notable in light of the increasing awareness in other areas of medicine of the risks of intensive treatment in general and regarding blood pressure in particular.6 7 After a series of reports of adverse events following rapid blood pressure lowering in hypertensive emergencies,7 the sixth and seventh reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended lowering mean arterial blood pressure by no more than 25% within minutes to one hour, then to 160/100 mm Hg within the next two to six hours, noting that “excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia should be avoided.”8 However, an exception was made for “patients with aortic dissection who should have their [systolic …

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