Management of Acute Aortic Disease With Invasive Arterial BP Monitoring

More than one-third of patients with acute aortic disease experience a change in clinical management following the use of invasive arterial blood pressure monitoring (ABPM), according to the results of a study published in the American Journal of Emergency Medicine.

The researchers theorized that the use of ABPM could change the medical management of BP in patients with acute aortic disease. They conducted a prospective, observational, pilot study of adult patients with acute aortic disease who had been admitted to the Critical Care Resuscitation Unit (CCRU) at the University of Maryland Medical Center between January 1, 2019, and February 28, 2021.

The study included patients with acute aortic disease who had both invasive ABPM and noninvasive cuff BP monitoring (CBPM) measurements available. Based on current guidelines, clinicians’ BP management goals were evaluated in real time both prior to and following arterial catheter placement. The investigators defined change in management as a difference of 10 mm Hg or more between ABPM and CBPM measurements, hypothetically inferring that such a difference would cause a change in management.

The primary study outcome was the prevalence of changes in clinical management, based on the difference in BP readings between invasive ABPM and noninvasive CBPM.  Secondary study outcomes included demographic and clinical predictors at the time of arterial catheter placement that may have been related to changes in management or the magnitude of difference between the 2 BP modalities.

A total of 117 patients with a diagnosis of acute aortic disease who had received arterial catheter placement at the CCRU of University of Maryland Medical Center during the study period were identified electronically. The average participant age was 65±14 years. Among the participants, 34% experienced a change in clinical management and 66% did not have a change in clinical management between the invasive ABPM and noninvasive CBPM measurements.

Results of the study showed no statistically significant difference in demographic characteristics, including age or gender, between patients with a change in medical management and those with no change in management. Among patients with acute aortic disease, 47% presented with type A dissection, 31% with type B dissection, and 19% with aortic aneurysm.

The average systolic BP (SBP) recorded by ABPM in patients with a change in medical management was 139 mm Hg, which differed significantly from patients without a change in medical management, who reported an average SBP of 130 mm Hg (difference between the 2 groups, -9.5; 95% CI, -18.1 to -0.9).

ABPM values were often at least 10 mm Hg higher than CBPM values. Among 34% of
patients with a change in management, 58% experienced ABPM-CBPM differences
of at least 20 mm Hg. Increasing antihypertensive infusion rate was the most common change in clinical management, which was reported 68% of the time. The addition of another antihypertensive agent was reported in 28% of patients with a change in management, followed by decreasing the current infusion rate, which was reported 8% of the time.

Peripheral artery disease was significantly associated with changes in clinical management (odds ratio, 13; 95% CI, 1.12 to 50+; P =.036) in patients with acute aortic diseases. Per ordinal regression, hypertension and serum lactate were associated with differences between ABPM and CBPM.

Some limitations of the study are that the CCRU is a unique clinical setting in which patients have known acute aortic pathology on arrival, which is more often the case in the intensive care unit setting than in the emergency department. Further, because of its limited sample size, the study might not provide an accurate representation of the complications associated with arterial catheter placement.

The investigators wrote, “Clinicians should consider invasive arterial catheters more often in hypertensive patients with acute aortic disease as this may influence the medical management of such patients.”