Screening For Aortic Aneurysm Research Articles

Introducing multi-component cardiovascular health screening into existing Abdominal Aortic Aneurysm (AAA) screening programmes in the UK: a qualitative study of programme staff views

BackgroundCardiovascular disease is a major contributor to poor health in the UK and the leading cause of death in England. Peripheral arterial disease and high blood pressure are conditions that identify individuals at high cardiovascular disease risk, likely to benefit from cardiovascular risk management. Both conditions remain considerably underdiagnosed and untreated. The National Health Service abdominal aortic aneurysm (AAA) screening programmes represent an opportunity to screen for these conditions with potentially minimal additional effort or cost. We explored AAA screening programme staff views on the proposed introduction of such additional screening within AAA screening.MethodsNine focus groups and seven follow-on interviews were undertaken with 38 AAA screening staff. Our study methods were oriented broadly towards a grounded theory methodology, and data were analysed using thematic analysis.ResultsThree themes were identified: (i) ‘Perceptions of patient experience and health-related outcomes’, (ii) ‘Opportunities and challenges for programme staff’, and (iii) ‘Maintaining and improving programme standards’. Staff talked about the high uptake of AAA screening, staff experience and skills in their role, and the programme’s high quality standards as both opportunities and potential challenges linked to the proposed additions to AAA screening. While positive about the potential to improve patients’ health outcomes, participants had questions about the practicalities of incorporating additional procedures within their time- and resource-constrained context, and how this may reconfigure work processes, roles and relationships.ConclusionsThe proposed additions to the programme require taking staff’s views into account. Key areas that need to be addressed relate to ensuring follow-up support for patients, clarity around staff responsibilities, and availability of sufficient resources for the programme.

Cost-effectiveness of a population-based AAA screening program for men over 65 years old in Iran

BackgroundScreening program tend to recognized patients in their early stage and consequently improve health outcomes. Cost-effectiveness of the abdominal aortic aneurysm (AAA) screening program has been scarcely studied in developing countries. We sought to evaluate the cost-effectiveness of a screening program for the abdominal aortic aneurysm (AAA) in men aged over 65 years in Iran.MethodsA Markov cohort model with 11 mutually exclusive health statuses was used to evaluate the cost-effectiveness of a population-based AAA screening program compared with a no-screening strategy. Transitions between the health statuses were simulated by using 3-month cycles. Data for disease transition probabilities and quality of life outcomes were obtained from published literature, and costs were calculated based on the price of medical services in Iran and the examination of the patients’ medical records. The outcomes were life-years gained, the quality-adjusted life-year (QALY), costs, and the incremental cost-effectiveness ratio (ICER). The analysis was conducted for a lifetime horizon from the payer’s perspective. Costs and effects were discounted at an annual rate of 3%. Uncertainty surrounding the model inputs was tested with deterministic and probabilistic sensitivity analyses.ResultsThe mean incremental cost of the AAA screening strategy compared with the no-screening strategy was $140 and the mean incremental QALY gain was 0.025 QALY, resulting in an ICER of $5566 ($14,656 PPP) per QALY gained. At a willingness-to-pay of 1 gross domestic product (GDP) per capita ($5628) per QALY gained, the probability of the cost-effectiveness of AAA screening was about 50%. However, at a willingness-to-pay of twice the GDP per capita per QALY gained, there was about a 95% probability for the AAA screening program to be cost-effective in Iran.ConclusionsThe results of this study showed that at a willingness-to-pay of 1 GDP per capita per QALY gained, a 1-time AAA screening program for men aged over 65 years could not be cost-effective. Nevertheless, at a willingness-to-pay of twice the GDP per capita per QALY gained, the AAA screening program could be cost-effective in Iran. Further, AAA screening in high-risk groups could be cost-effective at a willingness-to-pay of 1 GDP per capita per QALY gained.

Abstract 15987: Equitably Identifying Majority and Minority Populations at Risk for Abdominal Aortic Aneurysms

Introduction: Abdominal aortic aneurysm (AAA) screening efforts have had two shortcomings: (1) a high number needed to treat; and (2) persons categorized as black are less frequently identified prior to presenting with a ruptured AAA (rAAA). The goal of this analysis was to identify community-level factors that could be used to identify specific majority and minority populations in Texas that could benefit from directed screening efforts. Methods: The study sample was comprised of all patients who underwent surgical or endovascular treatment for intact AAA (iAAA) and rAAA at all non-federal Texas hospitals from 2006-2014, aggregated by county and by metropolitan statistical area (MSA). These were then combined with demographics and other community-level characteristics in multivariate analyses. Results: In total, 22,455 patients who underwent treatment of iAAA or rAAA were included. 47% of the variance in the rate of AAA or AAA repair among Texas counties was explained by just two variables: proportion elderly (p<0.001) and proportion categorized as white (p<0.001). Within MSAs, the incidence of rAAA was directly and strongly correlated with iAAA incidence (R 2 =0.58, p<0.001). The rAAA:iAAA ratio demonstrated populations in several MSAs that had higher than expected rAAA rates, with the four most extreme high-outliers comprised of black populations (Figure). The incidence rates of AAA ultrasound relative to AAA repair were lower for persons categorized as black than for those categorized as white in 10 MSAs (58%) despite a higher proportion (81 vs 70%, p<0.0001) living within 50 miles of providers of Medicare-reimbursed AAA ultrasound screenings. Conclusion: Readily-accessible, publicly-available data can be used to identify geographic areas and populations that could benefit from more intensive screening efforts. Directing ultrasound screening efforts at persons categorized as black in specific geographic areas may help increase equity in AAA care.

Risk of aortic aneurysm in patients with psoriasis: A systematic review and meta-analysis of cohort studies.

BackgroundThe association between psoriasis and the risk of aortic aneurysm is still unclear.HypothesisPatients with psoriasis have a higher risk of aortic aneurysm than healthy individuals.MethodsPubMed, Embase, and Scopus from inception to 20 July 2019 were searched. We included cohort studies if they reported estimate effects on the risk of aortic aneurysm in patient with psoriasis. We used Newcastle‐Ottawa Scale to evaluate methodology quality of eligible studies. Random‐effect meta‐analyses were used to estimate the overall risk. Subgroup analyses were conducted for analysis of influencing factors.ResultsAfter a view of 2207 citations, we included three large cohort studies enrolling 5 706 525 participants in this systematic review. Psoriasis patients have an increased risk of development of aortic aneurysm (hazard ratio [HR]: 1.30, 95%confidence intervals [CI], 1.10‐1.55, I 2 = 53.1%). The risk is not statistically different between patients with severe psoriasis (HR, 1.51, 95%CI, 1.04‐2.19, I 2 = 40.2%) and patients with mild psoriasis (HR, 1.24, 95%CI, 1.08‐1.42, I 2 = 24.1%). The risk was not statistically increased in female patients (HR, 1.55, 95%CI, 0.65‐3.72), patients ≥50 years old (HR, 4.05, 95%CI, 0.69‐23.75, I 2 = 97.3%), and patients with diabetes (HR, 0.97, 95%CI, 0.83‐1.14).ConclusionsCurrent evidence from observational studies suggests that psoriasis increases the risk of aortic aneurysm, and screening of aortic aneurysm might be considered among psoriasis patients.

Aortic aneurysm screening using duplex ultrasound: Choosing wisely who to examine

The noninvasive vascular laboratory plays a critical role in screening patients at risk for development of abdominal aortic aneurysm (AAA). One-time duplex ultrasound screening reduces aneurysm-related mortality due to rupture and is cost-effective. Population screening based on AAA risk factors is recommended, as it allows for proactive, elective repair of aneurysms at risk for rupture, and surveillance of smaller aneurysms for enlargement. Utilization of societal screening guidelines, such as those published by the Society for Vascular Surgery, can be employed by vascular laboratories to justify individual patient screening, aid primary care physicians to refer patients for testing, and encourage integrated medical health care systems to build prompts in patient electronic health records to ensure compliance with a AAA screening program. Risk factors for developing AAA, that is, age older than 65 years, male sex, family history, and a smoking history of >100 cigarettes, should be used to recommend patient screening, including for women and other elderly (older than 75 years) patients who fall outside of professional societal guidelines.

Summary of the S3 guideline on abdominal aortic aneurysm from an anesthesiological perspective

The current article is a summary of the 2018 revised S3 guideline on screening, diagnosis, therapy, and follow-up of the abdominal aortic aneurysm (AAA) from an anesthesiological point of view. It is the only interdisciplinary guideline that describes in particular the perioperative anesthesiological and intensive care management.

P1822Pocket-size mobile echocardiographic device screening for thoracic aortic aneurysm in asymptomatic hypertensive patients

Abstract Background Patients with hypertension may develop thoracic aortic aneurysm (TAA) that can be asymptomatic but potentially life-threatening. We sought to assess the prevalence of asymptomatic TAA among hypertensive patients and define the effectiveness of a TAA point-of-care screening program using pocket-size mobile echocardiographic (PME) devices. Methods We prospectively performed transthoracic echocardiography for TAA screening using a PME device on 1529 hypertensive patients (age, 62y [30y to 85y], 824 men) who attended our hypertension specialist clinic between June 2016 and July 2018. Measurement of the dimensions of the aortic sinus, sinotubular junction, ascending aorta, aortic arch, and descending thoracic aorta were obtained through multiple standard echo views. Results The prevalence of TAA (defined as maximum aortic diameter of ≥4.5cm and/or >50% diameter of the adjacent aorta) in our study population was 7.3% (111/1529), with distal ascending aorta as the most frequent location (Figure). Multiple logistic regression analysis identified male gender, older age, and presence of heart valve disease as independent factors associated with TAA (all p<0.05). Figure 1 Conclusions Asymptomatic TAA is common among asymptomatic hypertensive patients. Point-of-care use of PME device is effective in detecting TAA in a clinic setting. Such approach may be useful for early detection of TAA among at-risk patients allowing aggressive blood pressure control and early surgical intervention to prevent catastrophic complications such as aortic dissection or rupture. Acknowledgement/Funding Health and Medical Research Fund of the Hong Kong Government

Baseline findings of the population-based, randomized, multifaceted Danish cardiovascular screening trial (DANCAVAS) of men aged 65-74 years.

The challenge of managing age-related diseases is increasing; routine checks by the general practitioner do not reduce cardiovascular mortality. The aim here was to reduce cardiovascular mortality by advanced population-based cardiovascular screening. The present article reports the organization of the study, the acceptability of the screening offer, and the relevance of multifaceted screening for prevention and management of cardiovascular disease. Danish men aged 65-74 years were invited randomly (1 : 2) to a cardiovascular screening examination using low-dose non-contrast CT, ankle and brachial BP measurements, and blood tests. In all, 16 768 of 47 322 men aged 65-74 years were invited and 10 471 attended (uptake 62·4 per cent). Of these, 3481 (33·2 per cent) had a coronary artery calcium score above 400 units. Thoracic aortic aneurysm was diagnosed in the ascending aorta (diameter 45 mm or greater) in 468 men (4·5 per cent), in the arch (at least 40 mm) in 48 (0·5 per cent) and in the descending aorta (35 mm or more) in 233 (2·2 per cent). Abdominal aortic aneurysm (at least 30 mm) and iliac aneurysm (20 mm or greater) were diagnosed in 533 (5·1 per cent) and 239 (2·3 per cent) men respectively. Peripheral artery disease was diagnosed in 1147 men (11·0 per cent), potentially uncontrolled hypertension (at least 160/100 mmHg) in 835 (8·0 per cent), previously unknown atrial fibrillation confirmed by ECG in 50 (0·5 per cent), previously unknown diabetes mellitus in 180 (1·7 per cent) and isolated severe hyperlipidaemia in 48 men (0·5 per cent). In all, 4387 men (41·9 per cent), excluding those with potentially uncontrolled hypertension, were referred for additional cardiovascular prevention. Of these, 3712 (35·5 per cent of all screened men, but 84·6 per cent of those referred) consented and were started on medication. Multifaceted cardiovascular screening is feasible and may optimize cardiovascular disease prevention in men aged 65-74 years. Uptake is lower than in aortic aneurysm screening.

Abstract 166: The Brain and Aortic Aneurysm Screening (BAAS) Study - Screening for Occult Intracranial Aneurysms in Those With Abdominal Aortic Aneurysms

Introduction: Abdominal aortic aneurysm (AAA) rupture has a mortality rate of 64% and intracranial aneurysm (IA) rupture has a mortality rate of 50%. Despite the high mortality rates, early detection and treatment of these vascular lesions prior to rupture can prevent devastating clinical outcomes, underscoring the need to identify high-risk populations for screening. Current evidence demonstrates shared genetic and environmental risk factors for both AAA and IA. Methods: The BAAS study sought to establish the co-prevalence of AAA and IA. In one arm of BAAS, we recruited patients presenting with AAA and screened them for IA. All participants underwent a detailed interview to collect demographic, radiographic, and clinical data and also had genetic counseling. Results: Of the 126 individuals with an AAA enrolled, 65% (82/126) completed the MRA. Difficulty with logistics of obtaining the research MRA with long distance travel to clinic was the principal reason for failure to obtain MRA. We identified 20.7% (17/82) with one or more IA, including 21 aneurysms found during systematic screening. IA ranged in size from 1.5-14 mm (height) x 1.4-7 mm (width) and varied in location. 9.5% (2/21) had a maximum diameter of 7 mm or more. One participant with a positive MRA underwent early coil embolization with the remainder undergoing continued clinical surveillance. Of the 15 individuals completing the genetic counseling screening, two underwent recommended clinical genetic testing, revealing one negative screen and one variant of unknown significance in the MYH11 gene. Conclusion: Consistent with our prior cost effectiveness models, these prospective data support the clinical utility of routine screening for IA in patients presenting with AAA.

Annals for Educators - 21 February 2017

Annals for Educators - 21 February 2017

The decreasing incidence of ruptured abdominal aortic aneurysm in Wales.

AimsPrior to the introduction of the NHS Abdominal Aortic Aneurysm (AAA) Screening Programme some authors have reported a decline in incidence of clinically-relevant AAAs. The aim of this study was to identify the changing pattern of, and mortality from, ruptured AAA (rAAA) in patients reaching hospital alive in Wales.MethodsData was obtained from the Public Health Wales Observatory retrieved Patient Episode Database submitted by all seven Welsh Health Boards of patients admitted alive with a rAAA over a five year period from 2007 - 2012. This data was compared to an historic publication of similar data (Basnyat et al.) for Wales in 1997.ResultsFor 1996-1997 233 patients (158 males) presented to Welsh hospitals with a rAAA, in comparison to 115 (78 male) in 2012-13. Furthermore in 1996-1997 133 patients underwent emergency surgery with 48 (36%) surviving compared to 66 (51%) operated and 21 (19%) surviving in 2012-13. ConclusionsOver a 16 year period prior to the introduction of a national screening program the number of patients presenting with a rAAA has more than halved in Wales. Unfortunately, outcomes for patients undergoing emergency repair of a rAAA remains poor.

Aortic aneurysm screening.

Still needs refining

How can an AAA screening program be implemented in Germany?

Background Screening programs are currently of crucial importance in health politics. Large international studies of abdominal aortic aneurysm (AAA) screening programs have shown a significant decrease in aneurysm-related mortality. In view of these findings, AAA screening programs have been implemented in a number of countries using various healthcare infrastructures.

Abstract W MP33: Brain and Aortic Aneurysm Screening - Cost-Effectiveness of Screening for Intracranial Aneurysms

Introduction: Intracranial aneurysm (IA) and abdominal aortic aneurysm (AAA) rupture carry high mortality (40% and 75% respectively) and substantial morbidity in survivors. Recent research suggests that IA and AAA share genetic risk in addition to environmental factors. Retrospective data from our institution identified a population harboring both IA and AAA and showed a high rupture rate for IA (44.2%). We previously demonstrated that screening for AAA in patients with IA is cost-effective based on estimated and published data. We hypothesize that screening for IA in patients with AAA is also cost-effective. Method: We developed a decision-making model using TreeAge Pro 2013 software assuming a hypothetical population with known AAA and truncated screening versus no screening for IA using magnetic resonance angiography. Based on IA size and location, patients were either treated endovascularly or placed on surveillance. Proportions, risks, utilities, and costs for each decision arm were derived from literature. Results: At a given rupture rate, incremental effectiveness varied linearly with coprevalence of AAA and IA. For an assumed rupture rate of 5%/year, screening was effective for coprevalence >6.8% (top graph) and was cost-effective for coprevalence >7.7%. The incremental cost-effectiveness ratio (ICER) favored screening (ICER=$54,193/QALY) at a 7.8% coprevalence and dropped to $27,841.50/QALY at 8.8% coprevalence. Our model was sensitive to IA rupture rate as well as coprevalence (bottom graph). Conclusion: Our model suggests the cost-effectiveness of screening for IA in patients with AAA, below the accepted societal threshold of an ICER $60,000/QALY at a coprevalence ≥7.8% and IA rupture rate ≥5%. These are plausible assumptions for this genetically high-risk population. Further prospective study is warranted to establish coprevalence of AAA and IA, rupture rates, and determine the benefit of dedicated screening.

Aortic aneurysm screening in a high-risk population: a non-contrast computed tomography study in korean males with hypertension.

Background and ObjectivesScreening strategies for aortic aneurysm (AA) according to risk factors and ethnicity are controversial. This study explored the prevalence of AA and determined whether screening is necessary in a population of multiple risk factors.Subjects and MethodsFrom June, 2012 to April, 2013, 542 consecutive elderly (≥65 years) male hypertensive patients without a history of AA were prospectively enrolled. After excluding 15 patients (2.8%) with aortic valve surgery, 30 patients (5.5%) with suboptimal computed tomography (CT) images, the remaining 496 patients (age 73±5 years) comprised the study population. Maximal diameters of the thoracic and abdominal aorta were measured using non-contrast CT.ResultsThe prevalence of thoracic AA (TAA, diameter ≥40 mm) and abdominal AA (AAA, diameter ≥30 mm) was 36.5% (181/496) and 6.0% (30/496), respectively. In the multivariate logistic regression analysis, determinants for TAA were age {odds ratio (OR) 1.059, 95% confidence interval (CI) 1.018-1.101, p=0.005}, dyslipidemia (OR 0.621, 95% CI 0.418-0.923, p=0.018), body surface area (OR 11.92, 95% CI 2.787-50.97, p=0.001), diastolic blood pressure (OR 1.029, 95% CI 1.009-1.049, p=0.004) and AAA (OR 3.070, 95% CI 1.398-6.754, p=0.005). In contrast, AAA was independently associated with dysplipidemia (OR 2.792, 95% CI 1.091-7.143, p=0.032), current/past smokerfs (OR 4.074, 95% CI 1.160-14.31, p=0.028), and TAA (OR 3.367, 95% CI 1.550-7.313, p=0.002).ConclusionThe prevalence of AA was significant and TAA was more prevalent than AAA in elderly Korean males with hypertension. Future research should establish distinct screening strategies for TAA and AAA according to risk factors and ethnicity.

Screening for Aortic Aneurysm After Treatment of Coarctation

Isolated coarctation of the aorta (CoA) occurs in 6-8% of patients with congenital heart disease. After successful relief of obstruction, patients remain at risk for aortic aneurysm formation at the site of the repair. We sought to determine the diagnostic utility of echocardiography compared with advanced arch imaging (AAI) in diagnosing aortic aneurysms in pediatric patients after CoA repair. The Congenital Heart Databases from 1996 and 2009 were reviewed. All patients treated for CoA who had AAI defined by cardiac magnetic resonance imaging (MRI), computed tomography (CT), or catheterization were identified. Data collected included the following: type, timing, and number of interventions, presence and time to aneurysm diagnosis, and mortality. Patients were subdivided into surgical and catheterization groups for analysis. Seven hundred and fifty-nine patients underwent treatment for CoA during the study period. Three hundred and ninety-nine patients had at least one AAI. Aneurysms were diagnosed by AAI in 28 of 399 patients at a mean of 10±8.4years after treatment. Echocardiography reports were available for 380 of 399 patients with AAI. The sensitivity of echocardiography for detecting aneurysms was 24%. The prevalence of aneurysms was significantly greater in the catheterization group (p<0.05) compared with the surgery group. Aneurysm was also diagnosed earlier in the catheterization group compared with the surgery group (p=0.02). Multivariate analysis showed a significantly increased risk of aneurysm diagnosis in patients in the catheterization subgroup and in patients requiring more than three procedures. Aortic aneurysms continue to be an important complication after CoA repair. Although serial echocardiograms are the test of choice for following-up most congenital cardiac lesions in pediatrics, our data show that echocardiography is inadequate for the detection of aneurysms after CoA repair. Because the time to aneurysm diagnosis was shorter and the risk greater in the catheterization group (particularly for patients requiring more than one procedure), surveillance with cardiac MRI or CT should begin earlier in these patients.

FRI0361 Aortic aneurysm related to gca – an overestimated risk?

BackgroundGiant cell arteritis (GCA) is an autoimmune disorder affecting medium- and large sized arteries. The most common symptoms are related to ischemic cranial involvement. Nevertheless, asymptomatic aortic involvement may cause...

Large-vessel involvement in giant cell arteritis: a population-based cohort study of the incidence-trends and prognosis

ObjectivesTo evaluate incidence-trends and timing of large-vessel (LV) manifestations in patients with giant cell arteritis (GCA), and to examine the influence of LV manifestations on survival.MethodsA population-based incident cohort of...

Fishing for BASS: Surveying Primary Physicians in the Barriers to Aortic Screening Study

Introduction In response to published guidelines for abdominal aortic aneurysm (AAA) screening, primary care physicians were surveyed to determine attitudes and identify barriers to screening. Methods Six hundred standardized, structured surveys were distributed to all primary care practitioners in a defined geographic area. Participation was voluntary, and results were anonymous. Results A total of 10.7% of surveys were returned. All questions were answered by &gt;93% of respondents. A total of 71.9% of respondents were general practitioners; 94.4% worked in a community setting. 60.9% saw &gt;11 male patients per week who were older than 65 years of age. Responses indicated support for identifying asymptomatic AAAs; only 4.7% thought their patients were too sick to undergo repair, 0% felt their patients would be unwilling to undergo repair, and 0% felt the risk of rupture was too small to justify repair. Access to vascular surgical services was available to more than 75% in the hospital closest to them, and to 100% in the city in which they practice. A total of 42.2% were aware of recommendations regarding AAA screening, and 65.6% of physicians routinely screened eligible patients for AAAs. Screening for other diseases was more frequent. Respondents routinely screened their patients for breast cancer (79.1%), prostate cancer (80.5%), colon cancer (80.9%), and hypertension (83.7%); 42.9% routinely screened for peripheral artery disease. Conclusion Screening for AAAs lags significantly behind other major screening programs. Although primary practitioners are routinely exposed to the target population, a minority of patients are screened. Neither access to a vascular surgeon nor knowledge about the importance of AAAs appears to be limiting factors. Despite recent publicity, almost 60% of primary care physicians remain unaware of screening guidelines for AAAs. Of those who were aware of guidelines, only one third follow them. Further research and education is required to increase the efficacy of screening.

Screening and Management of Abdominal Aortic Aneurysm

Guidelines from the U.S. Preventive Services Task Force recommend that men aged 65 to 74 who have ever smoked be screened with abdominal