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Screening For Abdominal Aortic Aneurysm

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Screening For Abdominal Aortic Aneurysm

Screening For Abdominal Aortic Aneurysm

December 10, 2007

By: Norman Bauman for Veins1

"I'll be all right, won't I, doctor?" said the emergency room patient just before anesthesia. The doctor didn't answer. The chances of surviving a ruptured abdominal aortic aneurysm are like the chances of winning a coin toss. Cigarettes were claiming another victim.

Take Action
Ten Steps to Better Blood Pressure, Adapted from Harvard Medical School
  • Check it. “You can’t do much about your blood pressure unless you know what it is.”
  • Get moving. Even a brisk walk helps because it “improves blood vessel flexibility and heart function.” Also Harvard notes that people can lower their pressure by 10 points through regular exercise.
  • Eat right. Go for food that is not processed: fresh vegetables and fruits, whole grains, beans, nuts, fish, low-fat dairy, poultry. Avoid red meat, sugar, and saturated fat.
  • Control your weight. Harvard observes that even a drop in 10 pounds can make a significant difference in blood pressure.
  • Don’t smoke. Nicotine constricts the small blood vessels and is no one’s friend. Even smoking one cigarette can send the systolic blood pressure up 20 points momentarily.
  • Drink alcohol in moderation. More than one drink daily for women and two for men can contribute to high blood pressure.
  • Shake up your salts. The goal is no more than one teaspoon total per day. Processed foods especially harbor high salt contents and thus the American Medical Association has asked them to cut sodium content in foods by 50 percent by the year 2016.
  • Sleep is good. Harvard recommends six hours at the very least and eight as the more appropriate range for most.
  • Reduce stress. “As surely as mental and emotional stress can raise blood pressure, meditation, deep breathing, and other stress-busting activities can lower it.”
  • Stick with your medications. There’s no substitute for faithfully taking the pills prescribed by one’s physician. While a person will not be able to feel the results of the medication, it is critical in normalizing pressures that are dangerously high.
  • Sometimes, usually in men who smoke, the aorta swells like a balloon, and if it continues to grow and isn't surgically repaired, it bursts and kills him. A simple screening test can tell whether a person has an abdominal aortic aneurysm, and if he does, he can have surgery to repair the aorta.

    Some people think that the more screening tests you get, the better. But this test is a good example of why that's not true.

    At the Veith Symposium in New York, Frank J. Veith, MD, chair of the department of vascular surgery, Cleveland Clinic, explained which people should have screening: men 65 or older, particularly those who have ever smoked or have a family history of aortic aneurysms. But for younger men or for women, aortic aneurysms are so rare that screening has no benefit, and might do harm.

    One hundred lifetime cigarettes

    To test for an abdominal aortic aneurysm, the doctor examines your belly with a simple, painless ultrasonic probe. A normal aorta has a diameter of 19 to 22 millimeters, or about the thickness of your thumb. It grows slightly larger during a lifetime, but a diameter of 30 millimeters is enough to make a doctor worry. A diameter of 40 millimeters is enough to make a doctor worry a lot. A diameter of 55 millimeters is enough to make a doctor recommend surgery, even though the surgery is dangerous itself. Doctors replace the weakened section with a tube made of Dacron. It's major surgery, with a death rate of up to five percent. But at 55 millimeters, the risk of death from rupture is 25 percent a year, so most patients are better off with surgery. Sometimes though, because of age, poor kidney function, or poor respiratory function – due to smoking – surgery is too dangerous.

    The U.S. Preventive Services Task Force (USPSTF), a federal agency that reviews and evaluates the evidence for screening tests, recommends one screening by ultrasound for all men aged 65 to 75 who have ever smoked cigarettes. Medicare pays for that screening – in men who have ever smoked at least 100 cigarettes. If the aorta is normal size, they never have to be screened again. But if it's as large as 30 millimeters, they need to be monitored regularly, so they can have surgery if it reaches 55 millimeters. Other organizations, such as the British health system, follow the USPSTF guidelines.

    Cautious recommendation

    Medical guidelines usually state how confident they are in the scientific basis behind the guidelines. The USPSTF gives letter grades: A is a strong recommendation, because there is good evidence that the test has benefits, and that the benefits outweigh the harm. B is a weaker recommendation, because the evidence is weaker, but the benefits still seem to outweigh the harm. C means that the test has benefits, but the benefits don't clearly outweigh the harm, and the USPSTF makes no recommendation. D means the evidence showed that the test was ineffective or actually did more harm than good, and the USPSTF recommends against it.

    The recommendation for abdominal aortic aneurysm screening, for men 65 to 75 who smoked, was B. But for men who never smoked, their recommendation was C – because the benefit wasn't great enough compared to the harm of surgery itself. For women, their recommendation was D. The prevalence of abdominal aortic aneurysms was very low in women, and the risks of surgery were high, so the harm outweighs the benefits, and the USPSTF recommended against it.

    A different aortic aneurysm

    The Wall Street Journal won a Pulitzer Prize in 2004 for a series of stories on fatal aortic aneurysms in young people and women, who weren't screened early and weren't diagnosed in the emegency room. Kevin Helliker, 43, one of their reporters, found out in a routine examination that he had a 41 millimeter aneurysm above the heart.

    "But those are different kinds of aneurysms," said Dr. Veith. They are thoracic aneuryms, in the chest, which start closer to the heart. They are dissecting aneurysms, caused when the layers of the aorta separate. "And they're due to causes other than the typical degenerative aneurysm that occurs in the abdomen that we're looking for with screening," he said.

    These chest aneurysms can be caused by Marfan's syndrome, other congenital diseases, and high blood pressure. Marfan's is rare, about three people per million. The congenital diseases are even rarer. Ehlers-Danlos syndrome affects only 54 known families. People who have those conditions usually know something is wrong. Relatives have died unexpectedly, sometimes with a diagnosis of aortic aneurysm, sometimes with a mis-diagnosis of "heart disease," sometimes from unexplained causes. One of the strongest risk factors for aneurysm is a family history of aneurysm or sudden death.

    Aneurysms in the chest can't be diagnosed with a simple ultrasound scan. They require a much more expensive CAT scan. They're very rare, so the cost-benefit ratio is much lower.

    So you don't need to screen for thoracic aneurysms in the population at large, says Dr. Veith.

    Dangers of over-screening

    Aside from the cost, over-screening can do actual harm, as the USPSTF noted. "One could pick up an aneurysm," said Dr. Veith, "and if you have an ill-informed or possibly badly-motivated physician, the aneurysm can be treated before it really needs to be treated.

    "I happen to believe that treating small aneurysms is not appropriate," said Dr. Veith. The evidence says that the risk of surgery is greater than the risk of rupture, if the aneurysm is smaller than 55 millimeters in men, or 50 millimeters in women, he said, although there exceptions, such as rapid growth or strong family history.

    But in Germany, the cost-benefit calculation is different. After the age of 50, "we screen every year," said Dr. Gerhard Hoffmann, MD, director of the Department of Vascular Surgery at the University of Cologne Medical School, who was in New York to give a paper at the Veith Symposium. If the aorta is more than 30 millimeters in diameter, "we screen every half year," he said. The diameter of a normal aorta is 17 to 19 millimeters in the female, and 20 to 22 millimeters in the male, he said.

    In Germany, they use ultrasound to screen the liver, gallbladder, and kidneys in a routine visit, explained Dr. Hoffmann. So it's no more effort to screen the aorta while he's at it.

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