A 45-year-old man presents to the emergency department with tearing chest pain radiating to the back, BP 200/110 mmHg in the right arm and 165/95 mmHg in the left arm. CT aortogram confirms a Type A aortic dissection. What is the IMMEDIATE pharmacological priority?
- A IV sodium nitroprusside to rapidly lower systolic BP below 100 mmHg
- B IV tissue plasminogen activator (tPA) for suspected coronary dissection
- C IV beta-blocker (esmolol or labetalol) to reduce heart rate and BP before surgery ✓
- D IV heparin anticoagulation to prevent thrombus propagation
Correct answer: C. IV beta-blocker (esmolol or labetalol) to reduce heart rate and BP before surgery
Explanation
In aortic dissection, the immediate pharmacological goal is reduction of dP/dt (rate of pressure rise) by targeting heart rate <60 bpm with IV beta-blockers (esmolol infusion or labetalol) before or alongside BP reduction. Vasodilators like nitroprusside alone reflexively increase HR and dP/dt, worsening dissection — they must only be added after adequate beta-blockade. Type A dissection requires emergency surgical repair; thrombolytics are absolutely contraindicated (risk of haemorrhagic tamponade and catastrophic haemorrhage). Anticoagulation is not indicated.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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