IFT07 - Variability in Impulse Control Management for Type B Aortic Dissection

Objectives: Impulse control – strict blood pressure (BP) and heart rate (HR) control – is an integral part of treating Type B aortic dissections (TBAD), whether as primary management in conjunction with surveillance, or pre-operatively prior to endovascular or surgical intervention. Despite the important role of impulse control, there is significant variability in the literature regarding its mention as well as in specific hemodynamic goals for the treating surgeon or intensivist. We sought to review the available literature to both describe the breadth of these inconsistencies relative to patient-focused data and determine appropriate standardization.

Methods: A systematic review of PubMed-indexed literature was performed including articles with ‘type B aortic dissection’ in the title, and a secondary search including “impulse control” or “blood pressure control” or “medical management” or “conservative management” or “non-operative management.” Exclusion criteria included articles not in English, those with full manuscripts unavailable, and those pertained to trauma, genetic aortopathy, iatrogenic dissection, or the post-intervention dissection. Identified articles were then categorized by type of submission and reviewed for mention of specific BP and/or HR goals.

Results: A total of 1503 articles pertaining to TBAD from 1987 to 2022 were identified, of which 75 (5.0%) were included and mentioned impulse control. Of these 75 articles, 31 (41%) specify a BP and/or HR goal, whereas 44 articles (59%) mention impulse control with any specific parameters. These 31 articles consisted of 13 editorials, 12 retrospective cohort reviews, 5 case reports, and 1 meta-analysis, with 16 (52%) involving patient/cohort data, and 15 (48%) with no specific patient-focused data (Figure 1). In the management of TBAD, the most common goal of systolic BP (SBP) was < 120 or 100-120 mmHg accounting for 61% of those described, followed by SBP 100-120 with liberalization to < 140 mmHg after an acute phase (23%). In addition, it should be noted that the definition of acute phase also varied by publication. Other goals found are described in Table 1.

Conclusions: Despite its critical role in managing TBAD, impulse control is subject to significant variability in specific BP and HR goals in the literature. Through this literature review, we found the most consistent patient-level recommendation was SBP < 120 mmHg (with or without liberalization after an acute period). This BP goal is consistent with the 2022 American College of Cardiology/American Heart Association (ACC/AHA) guideline and should be the standard for clinical use and research reporting until an evidence-based interdisciplinary consensus is made.