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QUESTION: Hello. Thank you in advance for making yourself available.  

My 78 year old mother has a large type B aortic dissection with leg claudication. She is on high doses of 2 different blood pressure medications which still does not keep her blood pressure in the range her doctor would like.  We all know that her time is limited. I will also add that she has temporal arteritis and has been treated with Prednisone since May and is currently on 15 mg. My questions are:

1.  If the dissection would rupture, can you give us some idea of what would happen physically?

2.  I am 59 and my sister is 54. Should we be screened?

3.  Is the temporal arteritis a contributing factor to the aortic dissection?

4.  Why are the medications not keeping her blood pressure under control. Why is she resistant to that treatment?  She is on 50 mg. of Toprol and 100 mg. of something that I can't recall the name of.

Thanks Again.

ANSWER: Hi, http://blog.myheart.net

1.  If the dissection would rupture, can you give us some idea of what would happen physically?

Physically there are 2 possibilities that extend on the extent of the rupture. If there is a true rupture, the transition in to shock would be rapid due to the amount of blood lost in such a rapid period, almost immediate and the patient would not survive for long. Its also possible for a less dramatic rupture there would likely be accompanied by low blood pressure, abdominal/chest/ back pain, and transition in to shock that would also likely be fairly rapid.

2.  I am 59 and my sister is 54. Should we be screened?

Its reasonable for you both, as first degree relatives to have a screening ultrasound scan


3.  Is the temporal arteritis a contributing factor to the aortic dissection?

Yes, giant cell arteritis is a well established risk factor for aortic dissection. http://www.ncbi.nlm.nih.gov/pubmed/7872584

4.  Why are the medications not keeping her blood pressure under control. Why is she resistant to that treatment?  She is on 50 mg. of Toprol and 100 mg. of something that I can't recall the name of.

Theres 2 goals in treatment, 1st to reduce shear forces, medications such as beta blockers (toprol) reduce heart rate and force of contraction to try prevent force expanding the dissection and enlarging aneurysm. 2nd Blood pressure control is absolute key, make sure she has regular follow up to get on top of this. toprol is not an ideal blood pressure medication, it should be increased to where it can be max dose allowing for an acceptable heart rate with other suitable medications added and titrated as necessary

Hope that was helpful,


---------- FOLLOW-UP ----------

QUESTION: Hello....a couple more questions, please.

1.  The drs want my mother's systolic bp under 130.  She is now taking 75 mg of Toprol and 100 mg of Losartan.  Her bp is still running 148/90, which is too high for her condition of aortic dissection.  Would it make any difference as to how this medication is dosed throughout the day?  Should it be divided and taken every few hours? Her bp is very high in the morning.  

2.  Since her bp is treatment resistant, could this indicate a renal problem?

3.  Should she see a cardiologist instead of her primary care dr managing her bp?
(The drs who initially treated her bp are 150 miles away to where she was flown when the dissection occurred. She is not in a condition to make that trip. We live in a small town with only a few drs but we have 2 great cardiologists, although they do not deal with dissections.)

Thank you so much for any information or any other advice you may have.

Answer
Hi,

The dosing of medication will take in to account the duration. For example regular toprol is taken twice a day, however there is XL, a long acting preparation that is taken once daily. Either is fine. The medication will be dosed appropriately as per the instructions. There is no preference as to which one taken.

The hypertension in this case isn't technically treatment resistant. The definition of that it is uncontrolled on 3 optimal medications at optimal doses. In this case, further agents can simply be added on as necessary when the maximal tolerate doses of the current drugs have been achieved. There is plenty of room for addition here without concern for rarer causes of hypertension.

The management of a type B dissection is typically medical and cardiologists should be well versed with this. The mainstay of treatment is blood pressure control and treatment of risk factors in addition to surveillance of the dissection which often stabilizes over time.

Hope that was helpful,  

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Mustafa Ahmed MD

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Cardiology, Interventional Cardiology, Cardiac Surgery, Hypertension, Pulmonary Embolism, Structural and Valve Disease

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Board Certification Internal Medicine and Cardiology Interventional and Structural Cardiology

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Multiple Publications In High Quality Peer Reviewed Journals. Internationally Recognized.

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MD from The Royal Victoria University of Manchester, England Medicine, Cardiology, Interventional Cardiology, Research Training - University of Alabama

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