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This article was published online first at www.annals.org on 24 June 2014.
The full report is titled “Screening for Abdominal Aortic Aneurysm: U.S. Preventive Services Task Force Recommendation Statement.” It is in the 19 August 2014 issue of Annals of Internal Medicine (volume 161, pages 280-289). The author is M.L. LeFevre, on behalf of the U.S. Preventive Services Task Force.
Screening for Abdominal Aortic Aneurysm: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161:I-26. doi: 10.7326/P14-9028
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Published: Ann Intern Med. 2014;161(4):I-26.
The U.S. Preventive Services Task Force (USPSTF) developed these recommendations. The USPSTF is a group of health experts that reviews published research and makes recommendations about preventive health care.
The aorta is a large blood vessel that passes through the chest and abdomen. Abdominal aortic aneurysms (AAAs) are bulges in weakened sections of the aorta. They are most common in men older than 65 years, people with high blood pressure, and smokers. Large aneurysms can burst or rupture, which often causes death.
The general recommendation is for patients with AAAs larger than 5.5 cm to have surgery to fix the aorta. However, this is a major procedure that can have serious complications, including death. Most patients have no symptoms from AAAs until rupture nears.
Ultrasound is the best test to look for AAA. Screening involves an ultrasound in people at risk for this condition who have normal findings on physical examination and no symptoms. The goal of screening is to find AAAs and, if they are large enough, fix them before rupture.
The USPSTF last looked at screening for AAA in 2005 and wanted to update those recommendations.
The USPSTF reviewed published research from January 2004 to September 2013 to identify the benefits and harms of screening for AAA with an ultrasound.
Available studies showed that inviting men aged 65 years or older for 1-time screening decreased AAA rupture and death from AAA rupture but did not improve overall survival up to 15 years after screening. Screening was also associated with more overall and elective surgeries but fewer emergency surgeries. Only 1 high-quality study involved women; this study suggested that screening may not reduce AAA-related deaths or improve overall survival, but further research is needed to be certain about this finding.
Men aged 65 to 75 years who have ever smoked should get 1-time screening for AAA with an ultrasound. “Ever smoked” is defined as having smoked at least 100 cigarettes during a lifetime.
Clinicians should selectively offer an ultrasound to men aged 65 to 75 years who have never smoked but need to discuss the small risk for AAA in such men, the harms associated with screening, patient family history, other risk factors, and patient preferences.
The USPSTF did not find enough information to be able to make a recommendation about screening for AAA in women aged 65 to 75 years who have ever smoked. Women who have never smoked should not be screened for AAA.
These recommendations apply to people without symptoms. Ultrasound to look for AAA is indicated in any patient with abnormal findings on medical examination or symptoms that might be due to AAA. Recommendations may change as new studies or safer procedures for AAA repair become available.
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Ahmad K Rahal, Ayesha Z Zuberi, Robert G Badgett
KU School of Medicine–Wichita
July 11, 2014
Cost of screening for abdominal aortic aneurysm may be less than expected
The updated United States Preventive Services Task Force (USPSTF) guidelines recommend screening men aged 65 to 75 who have ever smoked for abdominal aortic aneurysm (AAA) (1). In designing the screening process in our internal medicine clinic, we speculated whether Atul Gawande’s observation of the frequency of tomography in a community would warrant querying regional health care providers for existing abdominal imaging prior to undergoing screening (2). This could reduce the cost of mass screening.To assess the prevalence of existing imaging which would qualify as screening, we executed a review of our clinic’s electronic health records (EHR) of patients who met the USPSTF criteria for AAA screening: males aged 65 to 75 ever-smokers. In addition, we reviewed EHR of the same patients at our two major regional hospitals to identify incidental imaging, specifically computed tomography (CT) and magnetic resonance imaging (MRI) with specific mention of the aorta, as well as the standard screening ultrasound. We randomly selected 83 patients for review at our resident clinic. Only one patient had properly documented screening in the clinic’s EHR. Hospital records indicated an additional 43% of patients had incidental imaging, but 20% of these radiology reports did not comment on the aorta.We found a high rate of existing abdominal imaging after review of regional hospital records. While these numbers could be inflated due to fragmented health care in Wichita, the results are high enough to suggest clinics should consider searching for pre-existing diagnostic imaging. These results suggest that better documentation of the aorta in older adults by radiologists and better exchange of patient information between providers would improve cost as well as quality of care.References:1. LeFevre ML. Screening for Abdominal Aortic Aneurysm: U.S. Preventive ServicesTask Force Recommendation Statement. Ann Intern Med. 2014 [Epub ahead of print] PMID: 24957320.2. Gawande, A. How do we heal medicine? 2012. Accessed at TED at https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine on 07/11/2014.
Emergency Medicine, Prevention/Screening.
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