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Screening for Abdominal Aortic Aneurysm: U.S. Preventive Services Task Force Recommendation Statement FREE ONLINE FIRST

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Editor's Note: This online-first version will be replaced with a final version when it is included in the issue. The final version may differ in small ways.

The full report is titled “Screening for Abdominal Aortic Aneurysm: U.S. Preventive Services Task Force Recommendation Statement.” The author is M.L. LeFevre, on behalf of the U.S. Preventive Services Task Force.

This article was published online first at www.annals.org on 24 June 2014.


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Ann Intern Med. Published online 24 June 2014 doi:10.7326/P14-9028
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Who developed these recommendations?

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.

What is the problem and what is known about it so far?

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. Surgery to fix AAAs is a major procedure and 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 for AAA involves performing 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.

How did the USPSTF develop these 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.

What did the authors find?

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.

What does the USPSTF recommend that patients and doctors do?

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.

What are the cautions related to these recommendations?

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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Cost of screening for abdominal aortic aneurysm may be less than expected
Posted on July 11, 2014
Ahmad K Rahal, Ayesha Z Zuberi, Robert G Badgett
KU School of Medicine–Wichita
Conflict of Interest: None Declared
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 Services
Task 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.
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