A 63 year-old female presents to the Emergency Department with sudden onset chest pain that is tearing to the back. Blood pressure is 200/110 and the patient looks very uncomfortable. You order a CTA of the Chest, Abdomen and Pelvis and diagnose Aortic Dissection. What is the medication of choice in the initial management of aortic dissection in this patient?

A. Nitroprusside

B. Nicardipine

C. Esmolol

D. NItroglycerin

E. Diltiazem 

Answer is C: Esmolol

-The goals of management of aortic dissection are early diagnosis, pain control, prevention of extension of the dissection by reduction of shearing force via heart rate control and early cardiothoracic consultation

-A beta-blocker is ideal to reduction of heart rate and therefore shearing force of intimal flap because there is no vasodilation induced reflex tachycardia 

-Esmolol is often the first line agent because it is short acting and easily titratable to a heart of 60 bpm or lowest tolerated heart rate. 

-Reduction of Systolic blood pressure to a goal of 120 or lowest tolerable by the patient via a vasodilatory agent like nitroprusside, nitroglycerin or nicardipine also helps reduce shearing force. 

-If the patient is hypotensive in the setting of aortic dissection, consider cardiac tamponade or acute aortic regurgitation as the source of their obstructive or cardiogenic shock.