Guirguis-Blake JM, Beil TL, Senger CA, et al. Primary Care Screening for Abdominal Aortic Aneurysm: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2019 Dec 10;322(22):2219-2238. doi: 10.1001/jama.2019.17021. (Systematic review)

Importance: Ruptured abdominal aortic aneurysms (AAAs) have mortality estimated at 81%.

Objective: To systematically review the evidence on benefits and harms of AAA screening and small aneurysm treatment to inform the US Preventive Services Task Force.

Data Sources: MEDLINE, PubMed (publisher supplied only), Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through September 2018. Surveillance continued through July 2019.

Study Selection: Trials of AAA screening benefits and harms; trials and cohort studies of small (3.0-5.4 cm) AAA treatment benefits and harms.

Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and extracted data. The Peto method was used to pool odds ratios (ORs) for AAA-related mortality, rupture, and operations; the DerSimonian and Laird random-effects model was used to pool calculated risk ratios for all-cause mortality.

Main Outcomes and Measures: AAA and all-cause mortality; AAA rupture; treatment complications.

Results: Fifty studies (N = 323?279) met inclusion criteria. Meta-analysis of population-based randomized clinical trials (RCTs) estimated that a screening invitation to men 65 years or older was associated with a reduction in AAA-related mortality over 12 to 15 years (OR, 0.65 [95% CI, 0.57-0.74]; 4 RCTs [n = 124?926]), AAA-related ruptures over 12 to 15 years (OR, 0.62 [95% CI, 0.55-0.70]; 4 RCTs [n = 124?929]), and emergency surgical procedures over 4 to 15 years (OR, 0.57 [95% CI, 0.48-0.68]; 5 RCTS [n = 175?085]). In contrast, no significant association with all-cause mortality benefit was seen at 12- to 15-year follow-up (relative risk, 0.99 [95% CI 0.98-1.00]; 4 RCTs [n = 124?929]). One-time screening was associated with significantly more procedures over 4 to 15 years in the invited group compared with the control group (OR, 1.44 [95% CI, 1.34-1.55]; 5 RCTs [n = 175?085]). Four trials (n = 3314) of small aneurysm surgical treatment demonstrated no significant difference in AAA-related mortality or all-cause mortality compared with surveillance over 1.7 to 12 years. These 4 early surgery trials showed a substantial increase in procedures in the early surgery group. For small aneurysm treatment, registry data (3 studies [n = 14?424]) showed that women had higher surgical complications and postoperative mortality compared with men.

Conclusions and Relevance: One-time AAA screening in men 65 years or older was associated with decreased AAA-related mortality and rupture rates but was not associated with all-cause mortality benefit. Higher rates of elective surgery but no long-term differences in quality of life resulted from screening.

Related DynaMed Topics

Discipline Area Score
Family Medicine (FM)/General Practice (GP) 7 / 7
General Internal Medicine-Primary Care(US) 7 / 7
Surgery - Vascular 6 / 7
Geriatrics 6 / 7
Public Health 6 / 7
Internal Medicine 6 / 7
Cardiology 6 / 7
Comments from MORE raters

Cardiology rater

Reassuring that overall results similar to 2014 USPSTF report. I had hoped for stronger updated data on screening women, but screening choices are difficult in low-prevalence diseases. Screening associated with lower AAA mortality in men is a good enough stand-alone endpoint for me. I would not expect reduction in all-cause mortality given competing threats in this population.

Family Medicine (FM)/General Practice (GP) rater

In this article, the USPSTF updated their recommendations of AAA screening in the primary care setting by integrating the latest literature since their 2014 USPSTF review. Despite an additional 113 included articles, there have been no changes in their recommendations, and they continue to recommend one-time ultrasonography screening for AAA in men ages 65-75 who have ever smoked (B recommendation) with selective screening for men ages 65-75 who have never smoked (C recommendation).

General Internal Medicine-Primary Care(US) rater

The conclusion is similar to some other medical interventions: `The surgery was a success but the patient died.`

Internal Medicine rater

This article gives further evidence to the prevailing practice of screening for AAA in high-risk patients.

Internal Medicine rater

No changes in recommendations - supportive of current guidelines.

Public Health rater

This study confirms the evidence favoring the previous guidelines of screening at least once for AAA in a specific subset of population. The pooling of evidence adds to our understanding of previous directions.

Surgery - Vascular rater

This update from the NSPTF has financial implications related to the funding of screening for AAA. Although the prevalence is declining, the data confirm clear statistical evidence of decreased AAA-related mortality and rupture in the screened population. New data also 1) confirm the absence of a decrease in all-cause mortality; 2) the absence of a benefit to intervention for small (<5.5cm) AAA; 3) the failure of pharmacologic interventions with antibiotics, antihypertensives, or mast cell stabilizers; and 4) limited growth 5 years post-screening. One trial provided a comparative prevalence for women vs men: 1.3% vs 7.5%.
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