For asymptoamtic AAA, not urgent. For ruptured AAA, type A, intramural hematoma, penetrating ulcer, an acute type B or a symptomatic aneurysm it is urgent and these people should be in an ICU (which opens up your options for management). It depends on the hospital location as to who manages these patients prior to the OR (anesthesia, vascular/CTS or cardiology). It does seem counter-intuitive that people who aren't used to managing hypertension are acutely managing antihypertensives. At my shop, the surgeons found that cardiology was better at acutely managing these patients so so we manage them until the OR is ready. It makes sense as we are also able to evaluate the aortic valve and pericardium by echo acutely prior to the OR.
Management of acute aortic syndromes is the following:
Beta blockers to start. Goal to give as much as you need to bring the HR down to ~60. As above I said we use metoprolol but most would say that esmolol and even labetolol are ok. You push it quick and hard (that's what she said) because with the degree of catecholamine surge, it is exceptionally rare to run into problems. For instance, the other day, in an hour I gave a total of 400mg IV metoprolol in 10-20mg IV pushes (start slow, and then rapidly go up)
Once your HR is at goal, then you use your other agents. We use Clevidipine because NTP is now exceptionally expensive and with nicardipine we were having problems with hypotension from overzealous titration. I would not use hydralazine
