A 58-year-old hypertensive man presents with sudden interscapular tearing pain radiating to the abdomen. CT angiography shows an intimal flap beginning just distal to the left subclavian artery and extending to the renal arteries; there is no malperfusion, no rupture, and pain is controlled. Blood pressure is 178/104 mmHg, heart rate 96/min. The best next step is:

• A Immediate surgical repair via left thoracotomy
• B Thrombolysis with alteplase to restore false lumen flow
• C Intravenous esmolol followed by vasodilator to keep heart rate below 60/min and systolic BP around 100 to 120 mmHg, with serial imaging ✓
• D Oral amlodipine monotherapy with discharge once pain settles

Explanation

This is an uncomplicated Stanford type C (DeBakey III) dissection involving the descending aorta distal to the left subclavian artery. Initial management is aggressive medical therapy: an intravenous beta-blocker such as esmolol to reduce dP/dt, then vasodilators if needed, targeting heart rate below 60/min and systolic pressure near 100 to 120 mmHg, with serial imaging. Surgery or TEVAR is reserved for complicated disease: rupture, malperfusion, extension, refractory pain or uncontrolled hypertension. Thrombolysis would be catastrophic.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.