Title: Comparison of Heart Rate and Blood Pressure Control Agents in Acute Aortic Dissection
Authors: Brianna Lu, Kathryn Harvell, Ginger Gamble
Background: Anti-impulse therapy is the cornerstone of acute aortic dissection management to prevent rupture or dissection extension and has been shown to decrease long-term aorta-related adverse events. The American Heart Association/American College of Cardiology and European Society of Cardiology recommend a goal heart rate (HR) between 60 and 80 beats per minute and a goal systolic blood pressure (SBP) less than 120 mmHg. Current guidelines recommend beta blockers as initial therapy to achieve goal HR and BP; however, this is muddled by the absence of guideline-directed hierarchies within each drug class and lack of clear criteria for when therapy should be modified.
Methods: This single-center, retrospective, observational analysis identified patients 18 years or older treated for acute aortic dissection at an academic medical center from January 1, 2021 to October 1, 2025 and
received intravenous labetalol, esmolol, nitroprusside, nicardipine, clevidipine, diltiazem, or verapamil. The primary outcome was the percent of patients with treatment failure, defined as switching study drugs, death prior to operative intervention, or not at goal HR (less than or equal to 80 bpm) and SBP (less than 120 mmHg) at 3 hours. Statistical analyses include Fisher’s Exact for categorical variables and Mann Whitney-U for continuous variables.
Results: A total of 56 patients met inclusion criteria, and 38 patients were included in the final analysis. Thirty (88%) patients who received esmolol and 3 (75%) patients who received labetalol failed treatment at 3 hours (p = 0.45). At 6 hours, 27 patients who received esmolol and 3 patients who received labetalol failed treatment (p > 0.99). The median time to switch agents was 4.67 hours versus 3.64 hours in the esmolol and labetalol groups (p = 0.69). There was a difference in median time to first goal HR for esmolol at 0.47 hours compared to 0 hours in the labetalol group (p = 0.02). In contrast, there was no difference in median time to first goal SBP or in the percent of HR or SBP readings at goal at either 6 hours or 24 hours. Four patients (11.7%) died in the esmolol group compared to none in the labetalol group. The median intensive care unit length of stay was 4.05 days and 7.55 days for the esmolol and labetalol groups, respectively. A subgroup analysis comparing patients who received esmolol only (n = 11) versus labetalol found no difference in treatment failure rates at 3 hours (p = 0.47) or 6 hours (p > 0.99).
Conclusion: This study suggests there is no difference in treatment failure rates between esmolol and labetalol used for the management of acute aortic dissection at this institution. Secondary outcomes suggest that there may be benefit in the implementation of protocols to assist with optimizing titration of study drugs to achieve goal HR and SBP in a timelier fashion. Additional studies may be warranted to evaluate other differences in clinical outcomes between esmolol and labetalol.
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