Aortic dissection secondary prevention: Difference between revisions

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{{Template:Aortic dissection}}
{{Template:Aortic dissection}}
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{{CMG}}
==Overview==
Proper treatment and control of hardening of the [[artery|arteries]] ([[atherosclerosis]]) and high [[blood pressure]] may reduce risk of [[aortic]] dissection. It is very important for patients at risk for dissection to tightly control their [[blood pressure]]. Taking safety precautions to prevent injuries can help prevent dissections. Many cases of aortic dissection cannot be prevented. If diagnosed with [[Marfan syndrome|Marfan]] or [[Ehlers-Danlos syndrome]], regular follow-up is advisable.


==2010 ACCF/AHA Guidelines for the Evaluation and Management of Thoracic Aortic Disease: General Medical Treatment and Risk Factor Management - Recommendations for Medical treatment of patients with Thoracic aortic diseases (DO NOT EDIT) <ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780 }} </ref>==
== 2022 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Thoracic Aortic Disease<ref name="pmid36334952">{{cite journal| author=Writing Committee Members. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW | display-authors=etal| title=2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= | issue= | pages= | pmid=36334952 | doi=10.1016/j.jacc.2022.08.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=36334952 }}</ref> ==


=== Recommendations for Physical Activity and Quality of Life ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' For patients with significant aortic dis-ease, education and guidance should be provided about avoiding intense isometric exercises (eg, heavy weightlifting or activities requiring the Valsalva maneuver), burst exertion and activities, and collision sports.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
'''2.''' For patients who have undergone surgery for aortic aneurysm or dissection, postoperative cardiac rehabilitation is  recommended.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''3.''' In patients with thoracic or abdominal aortic aneurysms whose BP is adequately con-trolled, it is reasonable to encourage 30 to 60 minutes of mild-to-moderate intensity aerobic activity at least 3 to 4 days per week''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
'''4.''' For patients with clinically significant aortic disease, it is reasonable to screen for anxiety, depression, and posttraumatic stress disorder and, when indicated, provide resources for support7, 8; it is also reason-able to provide education and resources to minimize patients’ concerns, support optimal decision-making, and enhance quality of life''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}
==2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Thoracic Aortic Disease (DO NOT EDIT)<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>==
===Blood Pressure Control (DO NOT EDIT)<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>===
{|class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Stringent control of hypertension, lipid profile optimization, smoking cessation, and other atherosclerosis risk-reduction measures should be instituted for patients with small aneurysms not requiring surgery, as well as for patients who are not considered surgical or stent graft candidates ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>  
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' [[Antihypertensive]] therapy should be administered to [[Hypertension|hypertensive]] patients with [[thoracic aorta|thoracic aortic]] diseases to achieve a goal of less than 140/90 mm Hg (patients without [[diabetes]]) or less than 130/80 mm Hg (patients with [[diabetes]] or [[chronic renal disease]]) to reduce the risk of [[stroke]], [[myocardial infarction]], [[heart failure]], and [[cardiovascular]] death. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>  
|}
|}


===Recommendations for Blood pressure Control in Thoracic Aortic Disease ===
===Dyslipidemia Treatment (DO NOT EDIT)<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Treatment with a [[statin]] to achieve a target [[LDL]] [[cholesterol]] of less than 70 mg/dL is reasonable for patients with a [[coronary heart disease]] risk equivalent such as non [[coronary]] [[atherosclerotic disease]], [[atherosclerotic]] [[aortic aneurysm]], and coexistent [[coronary heart disease]] at high risk for [[coronary]] [[ischemic]] events.<ref name="pmid17574455">{{cite journal |author=Evans J, Powell JT, Schwalbe E, Loftus IM, Thompson MM |title=Simvastatin attenuates the activity of matrix metalloprotease-9 in aneurysmal aortic tissue |journal=Eur J Vasc Endovasc Surg |volume=34 |issue=3 |pages=302–3 |year=2007 |month=September |pmid=17574455 |doi=10.1016/j.ejvs.2007.04.011 |url=}}</ref><ref name="pmid16849016">{{cite journal |author=Leurs LJ, Visser P, Laheij RJ, Buth J, Harris PL, Blankensteijn JD |title=Statin use is associated with reduced all-cause mortality after endovascular abdominal aortic aneurysm repair |journal=Vascular |volume=14 |issue=1 |pages=1–8 |year=2006 |pmid=16849016 |doi= |url=}}</ref><ref name="pmid16794911">{{cite journal |author=Kurzencwyg D, Filion KB, Pilote L, ''et al.'' |title=Cardiac medical therapy among patients undergoing abdominal aortic aneurysm repair |journal=Ann Vasc Surg |volume=20 |issue=5 |pages=569–76 |year=2006 |month=September |pmid=16794911 |doi=10.1007/s10016-006-9078-z |url=}}</ref><ref name="pmid15717143">{{cite journal |author=Yilmaz MB, Biyikoglu SF, Guray Y, ''et al.'' |title=Level of awareness of on-treatment patients about prescribed statins |journal=Cardiovasc Drugs Ther |volume=18 |issue=5 |pages=399–404 |year=2004 |month=September |pmid=15717143 |doi=10.1007/s10557-005-5065-9 |url=}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}


===Smoking Cessation (DO NOT EDIT)<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>===
{|class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Antihypertensive therapy should be administered to hypertensive patients with thoracic aortic diseases to achieve a goal of less than 140/90 mm Hg (patients without diabetes) or less than 130/80 mm Hg (patients with diabetes or chronic renal disease) to reduce the risk of stroke, myocardial infarction, heart failure, and cardiovascular death. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' [[Smoking cessation]] and avoidance of exposure to environmental [[tobacco]] smoke at work and home are recommended. Follow-up, referral to special programs, and/or [[pharmacotherapy]] (including [[nicotine replacement]], [[buproprion]], or [[varenicline]]) is useful, as is adopting a stepwise strategy aimed at [[smoking cessation]] (the 5 As are Ask, Advise, Assess, Assist, and Arrange). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>  
|-
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' Beta adrenergic–blocking drugs should be administered to all patients with Marfan syndrome and aortic aneurysm to reduce the rate of aortic dilatation unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>  
|}
|}
 
===Employment and Lifestyle in Patients With Thoracic Aortic Disease (DO NOT EDIT)<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>===
{|class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with thoracic aortic aneurysm, it is reasonable to reduce blood pressure with beta blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to the lowest point patients can tolerate without adverse effects. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]])''<nowiki>"</nowiki>
|bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' For patients with a current [[thoracic aortic aneurysm]] or dissection, or previously repaired [[aortic dissection]], employment and lifestyle restrictions are reasonable, including the avoidance of strenuous lifting, pushing, or straining that would require a [[Valsalva maneuver]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' An angiotensin receptor blocker (losartan) is reasonable for patients with Marfan syndrome, to reduce the rate of aortic dilatation unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]])''<nowiki>"</nowiki>  
|}
|}


== References ==
== References ==
{{Reflist|2}}
{{Reflist|2}}
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[[CME Category::Cardiology]]
 
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[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
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Latest revision as of 06:36, 5 December 2022

Aortic dissection Microchapters

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Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Aortic dissection from other Diseases

Epidemiology and Demographics

Risk Factors

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Natural History, Complications and Prognosis

Diagnosis

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Physical Examination

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Electrocardiogram

X-ray

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Treatment

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Management during Pregnancy

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Case #1


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]; Hardik Patel, M.D.

Overview

Proper treatment and control of hardening of the arteries (atherosclerosis) and high blood pressure may reduce risk of aortic dissection. It is very important for patients at risk for dissection to tightly control their blood pressure. Taking safety precautions to prevent injuries can help prevent dissections. Many cases of aortic dissection cannot be prevented. If diagnosed with Marfan or Ehlers-Danlos syndrome, regular follow-up is advisable.

2022 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Thoracic Aortic Disease[1]

Recommendations for Physical Activity and Quality of Life

Class I
1. For patients with significant aortic dis-ease, education and guidance should be provided about avoiding intense isometric exercises (eg, heavy weightlifting or activities requiring the Valsalva maneuver), burst exertion and activities, and collision sports.(Level of Evidence: C-EO)

2. For patients who have undergone surgery for aortic aneurysm or dissection, postoperative cardiac rehabilitation is  recommended.(Level of Evidence: C-EO)

Class IIa
3. In patients with thoracic or abdominal aortic aneurysms whose BP is adequately con-trolled, it is reasonable to encourage 30 to 60 minutes of mild-to-moderate intensity aerobic activity at least 3 to 4 days per week(Level of Evidence: C-LD)

4. For patients with clinically significant aortic disease, it is reasonable to screen for anxiety, depression, and posttraumatic stress disorder and, when indicated, provide resources for support7, 8; it is also reason-able to provide education and resources to minimize patients’ concerns, support optimal decision-making, and enhance quality of life(Level of Evidence: C-LD)

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Thoracic Aortic Disease (DO NOT EDIT)[2]

Blood Pressure Control (DO NOT EDIT)[2]

Class I
"1. Antihypertensive therapy should be administered to hypertensive patients with thoracic aortic diseases to achieve a goal of less than 140/90 mm Hg (patients without diabetes) or less than 130/80 mm Hg (patients with diabetes or chronic renal disease) to reduce the risk of stroke, myocardial infarction, heart failure, and cardiovascular death. (Level of Evidence: B)"

Dyslipidemia Treatment (DO NOT EDIT)[2]

Class IIa
"1. Treatment with a statin to achieve a target LDL cholesterol of less than 70 mg/dL is reasonable for patients with a coronary heart disease risk equivalent such as non coronary atherosclerotic disease, atherosclerotic aortic aneurysm, and coexistent coronary heart disease at high risk for coronary ischemic events.[3][4][5][6] (Level of Evidence: A)"

Smoking Cessation (DO NOT EDIT)[2]

Class I
"1. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home are recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement, buproprion, or varenicline) is useful, as is adopting a stepwise strategy aimed at smoking cessation (the 5 As are Ask, Advise, Assess, Assist, and Arrange). (Level of Evidence: B)"

Employment and Lifestyle in Patients With Thoracic Aortic Disease (DO NOT EDIT)[2]

Class IIa
"1. For patients with a current thoracic aortic aneurysm or dissection, or previously repaired aortic dissection, employment and lifestyle restrictions are reasonable, including the avoidance of strenuous lifting, pushing, or straining that would require a Valsalva maneuver. (Level of Evidence: C)"

References

  1. ↑ Writing Committee Members. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW; et al. (2022). "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2022.08.004. PMID 36334952 Check |pmid= value (help).
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE; et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780.
  3. ↑ Evans J, Powell JT, Schwalbe E, Loftus IM, Thompson MM (2007). "Simvastatin attenuates the activity of matrix metalloprotease-9 in aneurysmal aortic tissue". Eur J Vasc Endovasc Surg. 34 (3): 302–3. doi:10.1016/j.ejvs.2007.04.011. PMID 17574455. Unknown parameter |month= ignored (help)
  4. ↑ Leurs LJ, Visser P, Laheij RJ, Buth J, Harris PL, Blankensteijn JD (2006). "Statin use is associated with reduced all-cause mortality after endovascular abdominal aortic aneurysm repair". Vascular. 14 (1): 1–8. PMID 16849016.
  5. ↑ Kurzencwyg D, Filion KB, Pilote L; et al. (2006). "Cardiac medical therapy among patients undergoing abdominal aortic aneurysm repair". Ann Vasc Surg. 20 (5): 569–76. doi:10.1007/s10016-006-9078-z. PMID 16794911. Unknown parameter |month= ignored (help)
  6. ↑ Yilmaz MB, Biyikoglu SF, Guray Y; et al. (2004). "Level of awareness of on-treatment patients about prescribed statins". Cardiovasc Drugs Ther. 18 (5): 399–404. doi:10.1007/s10557-005-5065-9. PMID 15717143. Unknown parameter |month= ignored (help)

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