Medical Management of Aortic Emergencies in Critical Care Transport

Aortic emergencies (e.g., dissection or aneurysm; AE) are life-threatening events commonly encountered in critical care transport. Guidelines recommend beta-blockers to control heart rate (HR), with calcium channel blockers added for systolic blood pressure (SBP) control or as an alternative. There is little human data to support either strategy or to document adverse events. We aimed to determine the frequency with which medications commonly used to treat AE reach guideline-recommended hemodynamic targets and characterize adverse events during critical care transport (CCT).

We performed an observational study design and retrospective cohort analysis of patients ≥18 years old with an AE undergoing CCT between 2003-2024. We included patients who received esmolol, nicardipine, labetalol, or combinations. We evaluated the primary outcome of target HR (60-80 bpm) or SBP (90-120 mmHg) with multivariable logistic regression controlling for age, sex, weight, year, and prior vasoactive medications. Secondary outcomes included hypotension (SBP <90 mmHg), bradycardia (HR <50 bpm), tachycardia (HR >100 bpm), and vasopressor support or cardiac arrest.

We included 1,530 AE encounters, of which 792 (51.8%) received nicardipine, 236 (15.4%) esmolol, 194 (12.7%) labetalol, 163 (10.7%) esmolol and nicardipine, and 145 (9.5%) labetalol and nicardipine. Compared to esmolol alone, all other treatment strategies had a similar likelihood of achieving target HR or SBP goals. Patients receiving labetalol alone had the lowest incidence of hypotension (2.1% [0.1-4.1%]) and combined esmolol/nicardipine had the lowest incidence of tachycardia (11.0% [6.2-15.9%]). Esmolol compared to nicardipine alone had similar rates of tachycardia (19.1% [14.1-24.1%] versus 25.3% [22.2-28.3%], respectively), while esmolol had the highest incidence of hypotension (9.3% [5.6-13.0%]).

We observed a similar odds of achieving HR and SBP targets regardless of medication used in a large sample of patients with aortic emergencies. While a combination of beta and calcium channel blockers may be optimal medical therapy, treatment with esmolol, labetalol, or nicardipine as single agents may be reasonable to achieve HR and SBP goals.