Evaluation of a standardized protocol for medical management of uncomplicated acute type B aortic dissection

Objectives: The goals of medical management for uncomplicated acute type B aortic dissection (TBAD) are to prevent expansion of the false lumen and malperfusion syndrome. This is accomplished with antihypertensive agents, but medication selection and titration are typically provider-dependent. Given the paucity of data on evidence-based management of this population, we hypothesized that a standardized TBAD medical management protocol would reduce resource utilization and costs, without compromising patient outcomes.

Methods: A multidisciplinary team developed a goal-directed protocol to standardize the medical management of uncomplicated acute TBAD, with an emphasis on early initiation of oral medications, weaning of anti-hypertensive infusions, and frequent assessment for de-escalation of care. Implementation was in April 2018. A retrospective review of patients with acute TBAD presenting to our institution from April 2016 to April 2020 was performed. Patients requiring aortic or peripheral intervention were excluded. Included patients were analyzed based on treatment before or after protocol implementation. Patient demographics, systolic blood pressure, presence of acute kidney injury at presentation, length of stay, cost metrics, and 30-day mortality were compared.

Results: Thirty-nine patients were included, 21 pre- and 18 post-protocol implementation. Baseline demographics, systolic blood pressure, and presence of acute kidney injury at presentation were similar between the groups. Post-protocol patients had shorter total (8.6 vs 5.5 days; P = .02) and intensive care unit (3.2 vs 1.8 days; P = .002) length of stay. The protocol was associated with significantly decreased total hospital ($38,928 vs $28,066; P = .04), total variable ($23,115 vs $15,627; P = .02), and pharmacy ($5094 vs $1181; P < .001) costs, whereas inpatient care costs ($15,152 vs $11,467; P = .09) trended down. Post-protocol patients required fewer oral antihypertensive agents at discharge (3.8 vs 2.7; P = .005). No significant difference in 30-day mortality was observed.

Conclusions: A goal-directed protocol reduces resource utilization and costs without compromising early mortality rates for patients with uncomplicated acute TBAD. Such a strategy may have broader application in medical management of acute aortic syndromes.