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#75 Screening for Abdominal Aortic Aneurysm: None, Some or All?


CLINICAL QUESTION
QUESTION CLINIQUE
Does screening asymptomatic patients in primary care for abdominal aortic aneurysm (AAA) alter mortality?


BOTTOM LINE
RÉSULTAT FINAL
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
DONNÉES PROBANTES
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. 
Women: 
  • 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. 
Systematic reviews4,5 of 4 RCTs (MASS was ~50% of patients): 
  • No difference in all-cause mortality (men or women) 
  • AAA-related mortality decreased only in men. 
Context:  
  • 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. 
  • Abdominal palpation (accuracy):9 
    • 50% sensitivity for AAA 4-4.9 cm. 
updated aug 5 2016 by ricky


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Author(s)
Auteur(s)
  • Ian C Taylor MD
  • Michael R Kolber MD CCFP MSc
  • Robert G Turnbull MD FRCSC

1. The Multicentre Aneurysm Screening Study Group. Lancet 2002;360:1531-9.

2. Thompson SG, Ashton HA, Gao L, et al. BMJ 2009;338:b2307.

3. Scott RAP, Bridgewater SG, Ashton HA. Br J Surg 2002;89:283-5.

4. Cosford PA, Leng GC, Thomas J. Cochrane Database Syst Rev 2011;2:CD002945.

5. Guirguis-Blake JM, Beil TL, Senger CA, Whitlock EP. Ann Intern Med 2014;160:321-9.

6. J Vasc Surg 2010;52:539-48.

7. Mastracci TM, Cina CS. J Vasc Surg 2007;45:1268-76.

8. US Preventive Services Task Force. Ann Intern Med 2014;161:281-90.

9. Lederle FA, Simel DL. JAMA 1999;281:77-82.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.

Most recent review: 05/08/2016

By: Ricky Turgeon BSc(Pharm) ACPR PharmD

Comments:

Evidence Updated: None; updated context; Bottom Line: No change.

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