1. It’s not just blood pressure…it’s poor impulse control! dP/dt – Change in pressure per Unit of time

2. Anti-impulse therapy Negative inotropy (and thus rate of rise of blood pressure, as well as mean and peak systolic pressure) Negative chronotropy (fewer peak systolic pressures for the vulnerable vessel to experience) Alpha blockade (prevent compensatory vasoconstriction) Goal blood pressure: as low as possible without inducing organ failure….Systolic BP of 100, or MAP of 60-70. No great evidence; this would be a tough population to ethically randomize.

3. Pharmacologic options: with invasive monitoring Esmolol: Beta blocker, bolus and infusion options – 1 mg/kg (usually about 80 mg) bolus – 150-300 mcg/kg/min Labetalol: alpha-antagonistic properties – 20 mg IV bolus (may require up to 80 mg over 10 min) – 0.5-6 mg/min infusion Propranolol: 1-10 mg bolus, followed by 3 mg/hr

4. Others Nitroprusside: beware cyanide toxicity (at about 500 mcg/kg). Do not use without beta-blockade (reflex tachycardia) – 0.5 mcg/kg/min, titrate in 0.5 increments to max 10 mcg/kg/min ACE inhibitors may be used, but given the high risk of renal failure, and unreliable gut function depending upon the course of the dissection, they would not be plan A. For patients who cannot tolerate beta blockers, non-DHP calcium channel blockers (verapamil or diltiazem) are viable options.

5. 4. Quit eating fast food and check into rehab. Again.

6. Classification systems for Thoracic Aortic Dissections Time course: Acute vs. Chronic Anatomical: Ascending, descending or both Stanford: – Type A: Involving the ascending aorta (with or without descending aortic involvement) – Type B: Involving only the descending aorta De Bakey: – I: Ascending and Descending aorta – II: Ascending Aorta only – III: Descending Aorta only