Abdominal Aortic Aneurysm (AAA) Screening Guideline

Transcription

1 Abdominal Aortic Aneurysm (AAA) Screening Guideline Prevention 2 Screening Recommendations and Tests 2 Follow-up/Monitoring 2 Evidence Summary and References 3 Guideline Development Process and Team 6 Last guideline approval: February 2012 Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the guidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guideline does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient. Abdominal Aortic Aneurysm (AAA) Screening Guideline 1 Copyright Group Health Cooperative. All rights reserved.

2 Prevention Because a lifetime history of tobacco use is strongly associated with abdominal aortic aneurysm (AAA) and its associated mortality, it is important to avoid tobacco use. Because more than 90% of users start using tobacco before age 21, it also is important to counsel younger patients (ages 11 21) to avoid tobacco experimentation. Tobacco users of all ages should be urged to quit tobacco and be assisted in their quit attempts with counseling and appropriate pharmacotherapy. See the Tobacco Use Guideline for more information. Screening Recommendations and Tests Table 1. Screening recommendations for abdominal aortic aneurysm Eligible population Test Frequency Men aged who have a smoking history of more than 100 cigarettes 1 with no family history (parent or sibling) of AAA Men aged who have a family history (parent or sibling) of AAA Ultrasound of abdominal aorta Ultrasound of abdominal aorta One time One time Women aged who have both a smoking history of more than 100 cigarettes and a family history (parent or sibling) of AAA Women of any age who have neither a smoking history nor a family history (parent or sibling) of AAA Ultrasound of abdominal aorta Screening not recommended Consider one time N/A 1 Screening men aged years who have ever smoked results in a 43% reduction in AAA-specific mortality (absolute risk reduction = 0.12%). There is no evidence that screening for AAA reduces all-cause mortality in this group. Follow-up/Monitoring Table 2. Follow-up recommendations for abdominal aortic aneurysm If aortic diameter is: Less than 3.0 cm Then we recommend follow-up as below: No further testing or screening is recommended cm Re-test with abdominal ultrasound at 3 years after initial screening, then every 3 years until age cm Re-test with abdominal ultrasound at 6 months after initial screening, then annually until age cm or greater Refer patient to Vascular Surgery. Re-test with abdominal ultrasound at 6 months after initial screening, then annually until age 75. Abdominal Aortic Aneurysm (AAA) Screening Guideline 2

3 Evidence Summary and References To develop the AAA Screening Guideline, Group Health has: Adapted recommendations from externally developed evidence-based guidelines and/or recommendations of organizations that establish community standards. Reviewed additional evidence using an evidence-based process, including systematic literature search, critical appraisal, and evidence synthesis. Adapted recommendations U.S. Preventive Services Task Force (USPSTF) Screening for abdominal aortic aneurysm; Recommendation Statement. Ann Intern Med. 2005;142(3): Group Health evidence review Literature search PubMed was searched for studies on AAA screening published after the 2006 update of the Group Health AAA Screening Guideline. The search did not reveal any more recent large, multicenter, populationbased cohort studies or randomized controlled trials (RCTs) that examined the health benefits of screening for AAA. Only long-term follow-ups of the four major screening studies and meta-analyses pooling those study results were identified. Recently published RCTs mainly examined the methods of AAA repair or the effects of lipid-lowering drugs and/or other medications on the prevention of AAA. The literature search also revealed two recently published studies (one in the UK [Conway 2011] and another in Sweden [Svensjö 2011]) that screened 65-year-old men and found a lower than expected prevalence of AAA, compared to that found in the large multicenter studies. Effects of AAA screening on morbidity and mortality were not examined in these studies. The Viborg Vascular (VIVA) screening trial of 65- to 74-year-old men in Denmark is under way; it is studying the effect of screening and modern vascular prophylaxis on all-cause mortality, cardiovascular mortality, and AAA-related mortality and hospitalization. Enrollment started in 2008, and follow-ups will be performed at 3, 5, and 10 years, with study results after 15 years (Grøndal 2010). Long-term benefits of AAA screening The 7- and 10-year follow-ups of the Multicentre Aneurysm Screening Study (MASS) showed that the relative benefit in terms of AAA-related mortality observed at 4 years was maintained during follow-up (hazard ratios 0.53 [95% CI, ] at 7 years and 0.52 [95% CI, ] at 10 years). There was a small but statistically insignificant all-cause mortality benefit for AAA screening at both the 7- and 10-year follow-ups (hazard ratios 0.96 [ ] and 0.97 [ ], respectively) (Kim 2007, Thompson 2009). The 15-year follow-up of the Chichester study showed that some benefit of the single ultrasound scan persisted at 15 years but was statistically insignificant (Ashton 2007). The 15-year follow-up of the Viborg trial (Lindholt 2010) showed a significant 66% risk reduction in AAArelated death (hazard ratio 0.34 [ ]) in the screened group. The risk reduction in all-cause mortality was insignificant (hazard ratio 0.98 [ ]). The Cardiovascular Health Study (CHS) (Freiberg 2008) is a prospective cohort study of men and women 65 years and older, selected from Medicare eligibility lists from 4 communities in the United States. In , 5,888 participants were enrolled. Of those enrolled, 4,781 had an abdominal aortic ultrasound; 47 of those participants had an unreadable ultrasound. From 1992 to 2002, 4,734 participants were followed and contacted annually to obtain health records documenting new diagnoses, hospitalizations, and medical procedures. Ultrasound surveillance of AAAs was not monitored, and incident cases of AAA repair and rupture were identified by reviewing ICD-9-CM codes, as well as by clinical information from hospital records. The primary outcomes of the study were (1) AAA surgical repair, (2) total mortality, and (3) incident cardiovascular disease events, defined as coronary heart disease, congestive heart failure, transient Abdominal Aortic Aneurysm (AAA) Screening Guideline 3

4 ischemic attack or stroke, claudication, and atherosclerotic cardiovascular disease deaths. The results show that of those screened, 416 (8.8%) had an AAA (infrarenal aortic diameter of 3.0 cm or greater, or infrarenal/suprarenal ratio of 1.2 or greater). By 2002, there were 56 surgical repairs (1.3% of those screened). Fifty-five percent of the repairs were made for diameters less than 4.0 cm at baseline (almost 50% for those with diameters less than 3.5 cm). Eight of the repairs were due to rupture (4 patients died during surgery or as a result of postoperative complications). Two of the 48 patients (4%) who underwent elective repairs died of postoperative complications. The authors indicated that aneurysm dilatation of 3 cm or greater on a single screening ultrasound exam identified 68% of all AAA repairs over the next 10 years and 6 of the 10 AAA-related deaths in 4% of the total population; dilatation of 2.5 cm or greater identified 91% of all AAA repairs and 9 of the 10 deaths in 10% of the total population. They concluded that a one-time screening of the abdominal aorta can acceptably identify men and women with a clinically significant AAA. The CHS was a cohort study with limitations. The observed association between AAA detected by ultrasonography, and AAA repair and related mortality could be biased as the reporting of an AAA diameter would in itself result in a treatment intervention (48.2% of repairs were made for baseline infrarenal diameter of less than 3.5 cm). The change in size of AAA diameter over time was not assessed, and gender difference in risk associated with AAA size could not be determined due to size of the population and low prevalence of AAA with greater than 4 cm diameter. References Abramson BL, Huckell V, Anand S, et al. Canadian Cardiovascular Society Consensus Conference: peripheral arterial disease executive summary. Can J Cardiol. 2005;21(12): Aggarwal S, Qamar A, Sharma V, Sharma A. Abdominal aortic aneurysm: a comprehensive review. Exp Clin Cardiol. 2011;16(1): Ashton HA, Gao L, Kim LG, Druce PS, Thompson SG, Scott RA. Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. Br J Surg. 2007;94(6): Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50(4)(suppl):2S-49S. Conway AM, Malkawi AH, Hinchliffe RJ, et al. First-year results of a national abdominal aortic aneurysm screening programme in a single centre. Br J Surg. doi: /bjs Epub 2011 Sep 16. Derubertis BG, Trocciola SM, Ryer EJ, et al. Abdominal aortic aneurysm in women: prevalence, risk factors, and implications for screening. J Vasc Surg. 2007;46(4): Ferket BS, Grootenboer N, Colkesen EB, et al. Systematic review of guidelines on abdominal aortic aneurysm screening. J Vasc Surg Feb 16. (Epub ahead of print). Freiberg MS, Arnold AM, Newman AB, Edwards MS, Kraemer KL, Kuller LH. Abdominal aortic aneurysms, increasing infrarenal aortic diameter, and risk of total mortality and incident cardiovascular disease events: 10-year follow-up data from the Cardiovascular Health Study. Circulation. 2008;117(8): Grøndal N, Søgaard R, Henneberg EW, Lindholt JS. The Viborg Vascular (VIVA) screening trial of year old men in the central region of Denmark: study protocol. Trials. 2010;11:67. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; Trans Atlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006;113(11):e Hupp JA, Martin JD, Hansen LO. Results of a single center vascular screening and education program. J Vasc Surg. 2007;46(2): Abdominal Aortic Aneurysm (AAA) Screening Guideline 4

5 Kaiser Permanente Care Management Institute. Abdominal aortic aneurysm (AAA) screening clinical practice guideline. Approved by the National Guideline Directors April Original publication date November Kim LG, P Scott RA, Ashton HA, et al. A sustained mortality benefit from screening for abdominal aortic aneurysm. Ann Intern Med. 2007;146(10): Lee ES, Pickett E, Hedayati N, Dawson DL, Pevec WC. Implementation of an aortic screening program in clinical practice: implications for the Screen for Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act. J Vasc Surg. 2009;49(5): Lindholt JS, Norman P. Screening for abdominal aortic aneurysm reduces overall mortality in men. A meta-analysis of the mid- and long-term effects of screening for abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2008;36(2): Lindholt JS, Sørensen J, Søgaard R, Henneberg EW. Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial. Br J Surg. 2010;97(6): Lim LS, Haq N, Mahmood S, et al.; ACPM Prevention Practice Committee; American College of Preventive Medicine. Atherosclerotic cardiovascular disease screening in adults: American College Of Preventive Medicine position statement on preventive practice. Am J Prev Med. 2011;40(3):381.e1-10. Mastracci TM, Cina CS; Canadian Society for Vascular Surgery. Screening for abdominal aortic aneurysm in Canada: review and position statement of the Canadian Society for Vascular Surgery. J Vasc Surg. 2007;45(6): Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg. 2011;41(suppl 1):S1-S58. Svensjö S, Björck M, Gürtelschmid M, Djavani Gidlund K, Hellberg A, Wanhainen A. Low prevalence of abdominal aortic aneurysm among 65-year-old Swedish men indicates a change in the epidemiology of the disease. Circulation. 2011;124(10): Thompson SG, Ashton HA, Gao L, Scott RA; Multicentre Aneurysm Screening Study Group. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ. 2009;338:b2307. doi: /bmj.b2307. U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm; Recommendation Statement. Ann Intern Med. 2005;142(3): Abdominal Aortic Aneurysm (AAA) Screening Guideline 5

6 Guideline Development Process and Team Development Process To develop the AAA Screening Guideline, Group Health adapted recommendations from externally developed evidence-based guidelines and/or recommendations of organizations that establish community standards. The Group Health guideline team reviewed additional evidence using an evidence-based process, including systematic literature search, critical appraisal, and evidence synthesis. For details, see Evidence Summary and References. This edition of the guideline was approved for publication by the Guideline Oversight Group in February Team The AAA Screening Guideline development team included representatives from the following specialties: endovascular surgery, family medicine, preventive care, radiology.. Clinician lead: John Dunn, MD, MPH, Associate Medical Director, Preventive Care Guideline coordinator: Avra Cohen, MN, Clinical Improvement & Prevention Travis Abbott, MD, Family Medicine Jennifer Macuiba, Clinical Improvement & Prevention Michael Maxin, MD, Radiology Chuck McQuinn, MD, Endovascular Surgery Kathryn Ramos, Health Education Specialist, Clinical Improvement & Prevention Nadia Salama, MD, Epidemiologist, Clinical Improvement & Prevention Ann Stedronsky, Clinical Publications, Clinical Improvement & Prevention Abdominal Aortic Aneurysm (AAA) Screening Guideline 6