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Low prevalence of abdominal aortic aneurysm among 65-year-old Swedish men indicates a change in the epidemiology of the disease
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i D län (CKFD).
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
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2011 (English)In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 124, no 10, 1118-1123 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Screening elderly men with ultrasound is an established method to reduce mortality from ruptured abdominal aortic aneurysm (AAA; Evidence Level 1a). Such programs are being implemented and generally consist of a single scan at 65 years of age. We report the results from screening 65-year-old men for AAA in middle Sweden.

METHODS AND RESULTS:

All 65-year-old men (n=26,256), identified through the National Population Registry, were invited to an ultrasound examination. An AAA was defined as a maximum infrarenal aortic diameter of ≥30 mm. In total, 22 187 (85%) accepted, and 373 AAAs were detected (1.7%; 95% confidence interval, 1.5 to 1.9). With 127 previously known AAAs (repaired/under surveillance) included, the total prevalence of the disease in the population was 2.2% (95% confidence interval, 2.0 to 2.4). Self-reported smoking (odds ratio, 3.4; P<0.001), coronary artery disease (odds ratio, 2.0; P<0.001), and hypertension (odds ratio, 1.6; P=0.001) were independently associated with AAA in a multivariate logistic regression model. Thirteen percent of the entire population reported to be current smokers, one third of the frequency reported in the 1980s. The observed low prevalence of AAA was explained mainly by this change in smoking habits.

CONCLUSIONS:

On the basis of the observed reduced exposure to risk factors, lower-than-expected prevalence of AAA among 65-year-old men, unchanged AAA repair rate, and significantly improved longevity of the elderly population, the current generally agreed-on AAA screening model can be questioned. Important issues to address are the threshold diameter for follow-up, the possible need for rescreening at a higher age, and selective screening among smokers.

Place, publisher, year, edition, pages
2011. Vol. 124, no 10, 1118-1123 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-164849DOI: 10.1161/CIRCULATIONAHA.111.030379ISI: 000294557400015PubMedID: 21844079OAI: oai:DiVA.org:uu-164849DiVA: diva2:470425
Available from: 2011-12-29 Created: 2011-12-29 Last updated: 2017-12-08Bibliographically approved
In thesis
1. Screening for Abdominal Aortic Aneurysm
Open this publication in new window or tab >>Screening for Abdominal Aortic Aneurysm
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Randomised controlled trials have demonstrated that mortality from Abdominal Aortic Aneurysm (AAA) can be cost-effectively reduced by ultrasound-screening of men. Evidence for screening women is insufficient. Reports of falling AAA incidence are emerging.

In an effort to study screening for AAA in a contemporary setting, two cross-sectional multi-centre population-based studies of one-time screening of 65-year-old men, and 70-year-old women in Middle Sweden were undertaken. Cost-efficiency of one-time screening of 65-year-old men was evaluated in a decision-analysis model. Five-year outcomes in men invited to screening at age 65 and age 70, were studied in a longitudinal cohort study.

A lower than expected (1.7%) prevalence of AAA in 65-year-old men was found, as well as a very low (0.4%) prevalence in 70-year-old women. Smoking was the dominating risk factor associated with AAA, but the association was stronger in women. The main cause of reduced contemporary prevalence was falling smoking rates in the population since 30 years.

One-time screening of 65-year-old men was found to be cost-effective and deliver significant clinical impact. The cost per quality adjusted life-year gained, at 13-years follow-up, was €14706, which was below the recommended UK NICE threshold of €25000. 15 lives were saved by inviting 10000 to screening. Prevalence of AAA and the rate of incidental detection of AAAs in the population were important factors affecting cost-efficiency.

New AAAs developed after 5 years in men screened normal at age 65, predominantly in men with sub-aneurysmal aortas (25-29mm) at 65, and smokers. The 5-year rate of AAA repair was high among men with screening detected AAAs, as was non-AAA related mortality. Ruptures were only documented among non-attenders.

Conclusions: A lower than expected prevalence of AAA among 65-year-old men, an unchanged repair rate, and improved longevity of the elderly population was found. Although one-time screening for AAA was still cost-effective within a contemporary context, several issues need to be addressed; the threshold diameter for follow-up, the current rate of opportunistic detection of AAA in the population, re-screening of the entire population at a higher age, and targeted screening of smokers. Screening 70-year-old women who do not smoke is likely to be futile, thus ruling out population screening of women for AAA.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. 82 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 903
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-198677 (URN)978-91-554-8668-6 (ISBN)
Public defence
2013-06-07, Föreläsningssalen, Falu Lasarett, Entré 6:C 01, Söderbaums väg 8, Falun, 13:15 (English)
Available from: 2013-05-17 Created: 2013-04-22 Last updated: 2013-08-30Bibliographically approved

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Svensjö, SverkerBjörck, MartinGürtelschmid, MikaelDjavani-Gidlund, KhaterehWanhainen, Anders

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