Tuesday, February 01, 2005

Pop goes the Aorta...
From today's New York Times:Aneurysm Tests Urged in Older Men Who Smoked
In a sharp change from current policy, an influential medical advisory group is recommending that all men ages 65 to 75 who have ever smoked have an ultrasound screening test to see if they are developing a condition that could kill them in minutes by bursting a major artery in the abdomen.

The group, the United States Preventive Services Task Force, is an independent panel of medical experts that advises the federal Agency for Healthcare Research and Quality. Its recommendations help set government policy and are generally followed by primary care doctors.

The task force last looked at the condition, abdominal aortic aneurysms, in 1996 and concluded that there was insufficient evidence that a screening test would save lives. But now, it said, four large clinical trials have provided the evidence it needs, at least for those most at risk.
Recommendations such as this have been going around in the vascular literature for quite awhile. The screening is needed because many patients with aneurysms do not know they have one. During my residency I operated on about 20-30 ruptured aneurysms. How many were aware of the condition? None. Zero. Surprise, surprise.
The condition kills at least 9,000 people a year in the United States. With screening, "the science comes down to saying this is worth doing," said Dr. Ned Calonge, chairman of the task force and chief medical officer of the Colorado Department of Public Health and Environment.....The recommendation affects about 9.8 million Americans, the 70 percent of the nation's 14 million men ages 65 to 75 who are smokers or have ever smoked. The task force defined the group to include any man who had smoked at least 100 cigarettes in his life......The task force estimated that for every 500 men who meet its criteria and are screened, one death would be prevented over five years. In comparison, the only test for colorectal cancer that was evaluated in a randomized controlled trial, the fecal occult blood test, requires that 1,374 people be screened to prevent one death over five years.

While the number affected is large, the criteria are fairly strict:
The task force limited its recommendations to men aged 65 to 75 who have smoked because rupture is rare in people under age 65 and is at least three times as likely in people who have smoked. The condition is about four times as common in men as in women. Anyone with a family member who had an aneurysm is at increased risk. High blood pressure is a more minor contributor to risk and cholesterol does not seem to make much difference, researchers say.
After 75, the life expectancy is considered too short and the operation too risky.
The "operation too risky" argument against screening older people hopefully will diminish in importance as endovascular methods become refined.
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