Which drug is the go-to option for HR control in suspected aortic dissection before imaging?

• A. Lisinopril
• B. Esmolol
• C. Hydralazine
• D. Sodium nitroprusside

Answer: (B)

Controlling heart rate quickly is essential in suspected aortic dissection because a high heart rate increases aortic wall stress and the risk of tear propagation while you’re arranging imaging. The best option for this immediate goal is an intravenous beta-blocker with rapid onset and a very short, easily titratable action. Esmolol fits perfectly: it lowers heart rate and reduces myocardial contractility, which decreases dP/dt and the stress on the aortic wall. Because its effects wear off quickly, you can titrate to the desired heart rate and stop or adjust the infusion if blood pressure becomes too low, minimizing risk while you pursue definitive imaging. After heart rate is controlled, blood pressure can be lowered with a vasodilator if needed, but using a vasodilator alone can provoke reflex tachycardia and worsen dissection. Other agents that don’t provide rapid, controllable heart-rate reduction aren’t as suitable for this initial step.