#75 Screening for Abdominal Aortic Aneurysm: None, Some or All?
CLINICAL QUESTION
Does screening asymptomatic patients in primary care for abdominal aortic aneurysm (AAA) alter mortality?
BOTTOM LINE
Recommended ultrasound screening of men aged 65-74 for AAA can prevent 1 AAA-related death in 238 screened after 10 years, but does not change all-cause mortality. Population-based screening is not indicated for women.
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EVIDENCE
Men:
- MASS study:1 High-quality randomized controlled trial (RCT) of 67,800 asymptomatic primary care British men aged 65-74 years randomized to invitation to 1-time screening with abdominal ultrasound versus no invitation
- Prevalence of AAA (>3 cm)=4.9%
- After 10 years of follow-up:2
- AAA-related mortality: 4.6/1000 deaths with screening versus 8.7/1000 without
- Number needed to screen (NNS)=238 to prevent 1 AAA-related death at 10 years.
- AAA-related mortality: 4.6/1000 deaths with screening versus 8.7/1000 without
- One RCT subgroup3 of 9342 asymptomatic primary care British women aged 65-80 years randomized to invitation to screening with ultrasound versus no invitation
- Prevalence of AAA = 1.3%
- After 30 months of follow-up:
- No difference in AAA rupture or deaths, or all-cause mortality.
- No difference in all-cause mortality (men or women)
- AAA-related mortality decreased only in men.
- AAA risk factors, odds ratios:6
- Major: Male=5.7, smoking=3 per 10 pack-years, family history of AAA=3.8, age=2.8 per 5-year increase over 55,
- Minor: Concurrent atherosclerotic disease~1.5, dyslipidemia=1.3, hypertension=1.25, BMI >25=1.2.
- Annual risk of rupture according to maximum diameter of aneurysm:7
- <4 cm = 0.5%, 4-4.9 cm = 1%, 5-5.9 = 11%, 6-6.9 cm = 26%
- Guideline recommendations:
- Canada:7
- Men: Screening ultrasound if 65-75 years (if reasonable surgical candidate)
- Women: No routine screening
- Individualized screening if >65 years and multiple risk factors
- United States:8
- Men: 1-time screening ultrasound for current or previous smokers 65-75 years old
- Consider selectively screening non-smoking males 65-75 years with other risk factors
- Women: No routine screening.
- Men: 1-time screening ultrasound for current or previous smokers 65-75 years old
- Canada:7
- Abdominal palpation (accuracy):9
- 50% sensitivity for AAA 4-4.9 cm.
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abdominal examination not a bad screen then ?