(151) SCAPE or Aortic Dissection: A Beta Blockade Dilemma

Introduction: Recent literature has described a subset of acute heart failure patients presenting with dramatic onset, life-threatening flash pulmonary edema in the setting of increased sympathetic activity as the central pathophysiology, known as Sympathetic Crashing Acute Pulmonary Edema (SCAPE). We present a patient with an acute type B aortic dissection, who developed SCAPE after initiation of the standard medical therapy for blood pressure and impulse control.

Description: A 45-year old male with no significant past medical history presented in hypertensive emergency with imaging findings of an acute type B aortic dissection, extending from the left subclavian artery to the left common femoral artery with left renal artery originating from the false lumen. Aortic dissection was managed acutely with pressure and impulse control therapy with multi-agent antihypertensive therapy, included β-blockade.

The patient developed flash pulmonary edema, refractory to noninvasive ventilation, requiring mechanical ventilation.  He subsequently developed oliguria and required renal replacement therapy. After initial acute phase optimization, the patient underwent an endovascular intervention of his aortic dissection, left carotid to subclavian artery bypass, coil embolization of the left subclavian artery origin, and left vertebral artery transposition.

Discussion: The pathophysiology of SCAPE involves increasing sympathetic outflow, which in turn amplifies afterload, aggravating heart failure and driving fluid shifts into the lung. Impulse control with β-blockade is critical for acute type B aortic dissection, but could potentially exacerbate SCAPE. The patient developed SCAPE, secondary to a sympathetic response driven by renal hypoperfusion that lead to his swift decline in his pulmonary status and presented a management dilemma in the setting of aortic dissection. SCAPE develops very rapidly and when identified early, can resolve very quickly if treated aggressively.