In a case of type A aortic dissection, which therapy is most appropriate to initiate immediately?

In a case of type A aortic dissection, initiating therapy with esmolol is the most appropriate choice due to its rapid onset and ability to effectively control both heart rate and blood pressure. Esmolol is a short-acting beta-blocker that is particularly beneficial in this scenario because it helps to decrease the shear stress on the aortic wall by reducing the heart rate and contractility, which can be critical in managing aortic dissection.

By providing an immediate bolus followed by a continuous infusion, esmolol allows for precise titration to achieve optimal hemodynamic control, which is essential in the acute management of such a life-threatening condition. The rapid onset of action also proves advantageous in emergency situations where timely intervention is crucial.

In contrast, other options either do not provide the necessary heart rate control or have slower onset actions that may not be adequate for the immediate needs associated with type A aortic dissection. For instance, enalaprilat, as an ACE inhibitor, is more suited for long-term management of hypertension rather than acute stabilization. Nitroprusside can rapidly lower blood pressure but does not specifically address heart rate and can lead to hypotension if not closely monitored. Hydralazine, while it does lower