Impact of abdominal aortic aneurysm screening on quality of life

The effect of diabetes on abdominal aortic aneurysm growth - updated systematic review and meta-analysis

Studies have shown that diabetes mellitus is associated with a reduced prevalence and growth of abdominal aortic aneurysms (AAA). Establishing the factors that influence AAA growth will enable us to risk stratify patients and potentially optimise management. We aimed to provide an updated systematic review and meta-analysis that would inform more targeted screening practices based on patient demographics. MEDLINE, EMBASE, and DARE were searched using the Ovid interface and PubMed search engine. Studies were deemed eligible if they compared the growth rate of AAA between diabetic and non-diabetic populations. The mean difference (MD) and 95% confidence internal (CI) was used for data synthesis. Twenty-four studies from 20 articles with a total of 10,121 participants were included in our meta-analysis. An overall negative effect was shown between AAA growth and diabetes, with an annual mean effect of -0.25 mm/year (95% CI -0.35, -0.15; I2 = 73%). Our meta-analysis, which is larger and scientifically more robust compared to previous analyses, has confirmed that diabetes reduces the growth of AAA by approximately 0.25 mm a year compared to non-diabetic populations. This could have significant implications for AAA screening practices.

Improving cardiovascular health in patients with an abdominal aortic aneurysm: development of the cardiovascular risk reduction in patients with aneurysms (CRISP) behaviour change intervention

BACKGROUND

Abdominal aortic aneurysm (AAA) is an important cardiovascular health problem. Ultrasound screening is proven to reduce AAA mortality and programmes have been implemented in some healthcare systems. Those who are identified as having a small AAA in screening enter into a surveillance programme to monitor AAA size. Individuals in AAA surveillance are at elevated risk of cardiovascular events, which is not currently addressed sufficiently. We aimed to develop a simple intervention to reduce cardiovascular risk, which could be embedded in AAA surveillance pathways.

METHODS

Intervention mapping methods were used to co-develop the intervention with individuals with AAA, families/carers, and healthcare staff. We identified "targets for change" by synthesising research evidence and international guidelines and consulting with patients, caregivers and health service providers. We conducted a series of workshops to identify barriers to and facilitators of change and used taxonomies of behaviour change theories and techniques to match intervention strategies to each target. Further stakeholder involvement work helped refine the intervention.

RESULTS

The developed intervention focusses on assessment and individually tailored discussion of risk factors, exchanging information, building motivation and action planning, followed by review of progress and problem-solving. Workbooks covering physical activity, diet, stress management, alcohol, smoking, blood pressure and mental health are provided to support behaviour change. The intervention is facilitated by trained healthcare professionals during the patient's AAA screening appointment for the duration that they are in surveillance.

DISCUSSION

The developed intervention will now be tested to assess whether it can be integrated with the current AAA screening programme. The developed intervention is a novel approach to reducing cardiovascular disease in the AAA population, it is also the first intervention which tries to do this in this population.

TRIAL REGISTRATION

International Clinical Trial Registration: ISRCTN93993995.

Influence of cardiometabolic medications on abdominal aortic aneurysm growth in the UK Aneurysm Growth Study: metformin and angiotensin-converting enzyme inhibitors associated with slower aneurysm growth

BACKGROUND

There is a clinical need for treatments that can slow or prevent the growth of an abdominal aortic aneurysm, not only to reduce the need for surgery, but to provide a means to treat those who cannot undergo surgery.

METHODS

Analysis of the UK Aneurysm Growth Study (UKAGS) prospective cohort was conducted to test for an association between cardiometabolic medications and the growth of an abdominal aortic aneurysm above 30 mm in diameter, using linear mixed-effect models.

RESULTS

A total of 3670 male participants with data available on abdominal aortic aneurysm growth, smoking status, co-morbidities, and medication history were included. The mean age at recruitment was 69.5 years, the median number of surveillance scans was 6, and the mean(s.e.) unadjusted abdominal aortic aneurysm growth rate was 1.75(0.03) mm/year. In a multivariate linear mixed-effect model, smoking (mean(s.e.) +0.305(0.07) mm/year, P = 0.00003) and antiplatelet use (mean(s.e.) +0.235(0.06) mm/year, P = 0.00018) were found to be associated with more rapid abdominal aortic aneurysm growth, whilst metformin was strongly associated with slower abdominal aortic aneurysm growth (mean(s.e.) -0.38(0.1) mm/year, P = 0.00019), as were angiotensin-converting enzyme inhibitors (mean(s.e.) -0.243(0.07) mm/year, P = 0.0004), angiotensin II receptor antagonists (mean(s.e.) -0.253(0.08) mm/year, P = 0.00255), and thiazides/related diuretics (mean(s.e.) -0.307(0.09) mm/year, P = 0.00078).

CONCLUSION

The strong association of metformin with slower abdominal aortic aneurysm growth highlights the importance of the ongoing clinical trials assessing the effectiveness of metformin with regard to the prevention of abdominal aortic aneurysm growth and/or rupture. The association of angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, and diuretics with slower abdominal aortic aneurysm growth points to the possibility that optimization of cardiovascular risk management as part of abdominal aortic aneurysm surveillance may have the secondary benefit of also reducing abdominal aortic aneurysm growth rates.

Incidental Cardiovascular Abnormalities in the Abdominal Aortic Aneurysm (AAA) Surveillance Population During the AAA Get Fit Trial: A Case Series and Review of the Literature

Background The prevalence of cardiovascular disease and incidence of major adverse cardiovascular events (MACEs) is very high among the abdominal aortic aneurysm (AAA) surveillance population. Formal assessments of and interventions to reduce cardiovascular risk are not a routine part of the surveillance programme at present. However, its potential importance is highlighted by incidental findings during the AAA Get Fit Trial, a randomised controlled trial which included baseline cardiopulmonary exercise testing (CPET). We speculate that CPET can act as an opportunistic screening programme to identify cardiovascular disease in AAA surveillance patients. Methods The AAA Get Fit Trial was a prospective, randomised controlled trial at a tertiary vascular centre, Manchester University NHS Foundation Trust, conducted between November 2017 and August 2019. Patients underwent CPET at baseline, 8, 16, 24 and 36 weeks as well as clinical history and examination and blood tests. We report on incidental cardiovascular abnormalities diagnosed during the trial. Results Of the 59 participants in the trial, four (6.8%) were identified to have abnormal findings suggestive of unstable cardiovascular disease. On subsequent further investigation, two patients were diagnosed and treated for severe coronary artery disease after abnormal ECG findings were noted during CPET. One patient was diagnosed with unstable angina after obtaining a detailed history on baseline assessment which was treated medically before going on to have a successful elective AAA repair. Conclusions There is a high incidence of MACEs among this high-risk population both pre and perioperatively. Identifying and treating cardiovascular disease among the AAA surveillance population must be a focus of the future AAA screening programme.

Serial Quality of Life Assessment around Screening for Familial Intracranial Aneurysms: A Prospective Cohort Study

INTRODUCTION

Screening for intracranial aneurysms (IAs) is cost-effective in first-degree relatives of aneurysmal subarachnoid haemorrhage patients, but its psychosocial impact is largely unknown.

PATIENTS AND METHODS

A consecutive series of persons aged 20-70 years visiting the University Medical Centre Utrecht for first screening for familial IA was approached between 2017 and 2020. E-questionnaires were administered at six time points, consisting of the EQ-5D for health-related quality of life (QoL), HADS for emotional functioning, and USER-P for social participation. QoL outcomes were compared with the general population and between participants with a positive and negative screening for IA. Predictors of QoL outcomes were assessed with linear mixed effects models.

RESULTS

105 participants from 75 families were included; in 10 (10%), an IA was found. During the first year after screening, we found no negative effect on QoL, except for a temporary decrease in QoL 6 months after screening in participants with a positive screen (EQ-5D -11.3 [95% CI: -21.7 to -0.8]). Factors associated with worse QoL were psychiatric disease (EQ-5D -10.3 [95% CI: -15.1 to -5.6]), physical complaints affecting mood (EQ-5D -8.1 [95% CI: -11.7 to -4.4]), and a passive coping style (EQ-5D decrease per point increase on the Utrecht Coping List -1.1 [95% CI: -1.5 to -0.6]).

DISCUSSION AND CONCLUSION

We did not find a lasting negative effect on QoL during the first year after screening for familial IA. Predictors for a worse QoL were psychiatric disease, physical complaints affecting mood, and a passive coping style. This information can be used in counselling about familial IA screening.

Psychosocial consequences after screening of abdominal aortic aneurysm among 65 year old men

BACKGROUND

In order to reduce the incidence of abdominal aortic aneurysm rupture and mortality, the Swedish Medical Council has introduced a national abdominal aortic aneurysm (AAA) screening program that offers ultrasound examination of 65-year-old men. Screening programmes of AAA may confer both benefits and harms. The study aim was to investigate the psychosocial consequences of AAA screening among men with screening-detected AAA as compared to men identified as AAA-negative at screening, using an AAA-specific questionnaire.

METHODS

This cross-sectional study investigated the psychosocial consequences of AAA screening measured with a condition-specific questionnaire. This study focused on the Experience of the Diagnosis and the Screening Procedure in terms of Anxiety, Sense of Dejection and Existential Values. One hundred and fifty-eight men with AAA (63%) and 275 with normal aorta size (55%) completed the diagnosis-specific questionnaire.

RESULTS

Ninety-six percent of men with screening detected AAA did not regret the screening examination, the corresponding figure for controls being 99.6%. Seventy percent of AAA patients were surprised that something was wrong in their body. Some (85%) of men with AAA were current or previous smokers, about half of them (45%) felt guilty about it and 78% of the current smokers in the AAA group had considered stopping smoking. Both groups considered changing lifestyle, although at a higher rate (32%) among AAA cases than controls (20%), with differences both in intention to change their ways to exercise (p = 0.019) and food intake (p = 0.001). Intergroup differences were identified for the majority of items as captured by the questionnaire where men identified with AAA reported more negative psycho-social consequences for all evaluated items except for the items: Regret of the screening examination (p = 0.069) and feeling terrified (p = 0.10). Fifty-one percent of AAA cases stated that they feared rupture, and 12% were anxious about rupture during sexual activity whereas 57% were worried about rupture during intense physical activity.

CONCLUSION

Men who were diagnosed with AAA reported more psychosocial consequences compared to controls; still only a minority of AAA cases reported psychosocial consequences in greater occurrence. To some degree, men with AAA also feared rupture during various types of activities. There appears to be a need for improved patient information and easy access to caregivers for men with screening-detected AAA, which might help to reduce psychosocial consequences associated with the diagnosis.

Quantifying the burden of survivorship associated with infrarenal abdominal aortic aneurysms

OBJECTIVES

Survivorship encompasses the physical, psychological, social, functional, and economic experience of a living with a chronic condition for both the patient and their caregiver. It is made up of nine distinct domains and remains understudied in nononcological pathologies, including infrarenal abdominal aortic aneurysmal disease (AAA). This review aims to quantify the extent to which existing AAA literature addresses the burden of survivorship.

METHODS

The MEDLINE, EMBASE, and PsychINFO databases were searched from 1989 through September 2022. Randomized controlled trials, observational studies, and case series were included. Eligible studies had to detail outcomes related to survivorship in patients with AAA. Owing to the heterogeneity between studies and outcomes, no meta-analysis was conducted. Study quality was assessed with specific risk of bias tools.

RESULTS

A total of 158 studies were included. Of these, only five (treatment complications, physical functioning, comorbidities, caregivers, and mental health) of the nine domains of survivorship have been studied previously. The available evidence is of variable quality; most studies display a moderate to high risk of bias, are of an observational study design, are based within a limited number of countries, and consist of an insufficient follow-up period. The most frequent complication after EVAR was endoleak. EVAR is associated with poorer long-term outcomes compared with open surgical repair in most studies retrieved. EVAR showed better outcomes in regard to physical functioning in the short term, but this advantage was lost in the long term. The most common comorbidity studied was obesity. No significant differences were found between open surgical repair and EVAR in terms of impact on caregivers. Depression is associated with various comorbidities and increased the risk of a nonhospital discharge.

CONCLUSIONS

This review highlights the absence of robust evidence regarding survivorship in AAA. As a result, contemporary treatment guidelines rely on historic quality-of-life data that are narrow in scope and nonrepresentative of contemporary clinical practice. As such, there is an urgent need to reevaluate the aims and methodology associated with traditional quality-of-life research moving forward.

The impact of population screening for cardiovascular disease on quality of life

Aims

To examine the impact of population screening-generated events on quality of life: invitation, positive test result, initiation of preventive medication, enrolment in follow-up at the surgical department, and preventive surgical repair.

Methods and results

A difference-in-difference design based on data collected alongside two randomized controlled trials where general population men were randomized to screening for cardiovascular disease or to no screening. Repeated measurements of health-related quality of life (HRQoL) were conducted up to 3 years after inclusion using all relevant scales of the EuroQol instrument: the anxiety/depression dimension, the EuroQol 5-dimension profile index (using Danish preference weights), and the visual analogue scale for global health. We compare the mean change scores from before to after events for groups experiencing vs. not experiencing the events. Propensity score matching is additionally used to provide both unmatched and matched results. Invitees reported to be marginally better off than non-invitees on all scales of the EuroQol. For events of receiving the test result, initiating preventive medication, being enrolled in surveillance, and undergoing surgical repair, we observed no impact on overall HRQoL but a minor impact of being enrolled in surveillance on emotional distress, which did not persist after matching.

Conclusion

The often-claimed detrimental consequences of screening to HRQoL could not be generally confirmed. Amongst the screening events assessed, only two possible consequences were revealed: a reassurance effect after a negative screening test and a minor negative impact to emotional distress of being enrolled in surveillance that did not spill over to overall HRQoL.

Prognostic impact of depressive symptoms on all-cause mortality in individuals with abdominal aortic aneurysm and in the general population: a population-based prospective HUNT study in Norway

BACKGROUND

Abdominal aortic aneurysm (AAA) is a potentially life-threatening disease but the high mortality rate is linked to high age and comorbidity pattern. Depression is associated with increased mortality in the general population and individuals with cardiovascular diseases, but this is sparsely studied for AAA. The aim was to examine the prognostic impact of depressive symptoms on all-cause mortality in individuals with AAA and compare with findings in a general population of the same age and risk profile.

METHODS

Population-based prospective study including 36 616 participants (52.1% women) from the Trøndelag Health Study in Norway. A total of 9428 individuals died during a median follow-up of 10 years at ages 60-90 years. Depressive symptoms were defined by a Hospital Anxiety and Depression Scale-Depression score ≥8. Data on AAA diagnoses and death were obtained from medical records and national registers. HRs from Cox proportional hazard regression models are reported.

RESULTS

A total of 4832 (13.2%) individuals reported depressive symptoms, whereas 583 (1.6%) AAAs were identified. The adjusted hazard of death was 2.66 times higher in persons with AAA compared with the general population (95% CI 2.39 to 2.97). Overall, there was no significant adverse effect of depressive symptoms in individuals with AAA (HR 1.15;95% CI 0.88 to 1.51), whereas an increased risk was seen in the general population (HR 1.23;95% CI 1.17 to 1.30).

CONCLUSION

The overall risk of death was considerably higher in individuals with AAA compared with a general population of the same age and risk profile. Depressive symptoms did not significantly influence the risk of death in the AAA group.

AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis

Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.

Costs of abdominal aortic aneurysm care at a regional Veterans Affairs medical center with the implementation of an abdominal aortic aneurysm screening program

BACKGROUND

Abdominal aortic aneurysm (AAA) screening has demonstrated to be cost-effective in reducing AAA-related morbidity and all-cause mortality. However, the downstream care costs of an implemented AAA screening in clinical practice have not been reported. The purpose of this study is to determine direct regional Department of Veterans Affairs (VA) costs in implementing and sustaining an AAA screening program over a 10-year period.

METHODS

A cost data analysis (adjusted to 2021 U.S. dollars) of an AAA screening program was conducted from 2007 to 2016, where 19,649 veteran patients aged 65-75 with a smoking history were screened at a regional VA medical center. A decision support system tracked direct and indirect encounter costs from Medicare billing codes associated with AAA care. Costs from a patient's initial screening, follow-up imaging, to AAA repair or at the end of the analysis period, March 31, 2021, were recorded. Costs for AAA repairs outside the VA system were also tracked.

RESULTS

A total of 1,183 patients screened were identified with an AAA ≥3.0 cm without history of repair. Estimated screening costs were $2.8 million or $280,000 annually ($143/screening) in the care of 19,649 screened patients. There were 221 patients who required repair (143 repairs in VA, 78 repairs outside VA). The average cost of elective endovascular repair was $43,021 and that of open repair was $49,871. The total costs for all elective repairs were $9,692,591. Screening, implementation, maintenance, and surgical repair cost involved in the management of patients with AAA disease was $13.7 million, with $10,686 per life-year lived after repair (5.8 ± 3.5 mean life-years) and $490 per life-year lived after screening (6.9 ± 3.5 mean life-years) for all patients screened. There were 13 deaths of unknown causes and one patient with a ruptured AAA that required emergency repair at a cost of $124,392.

CONCLUSIONS

Despite known limitations, the implementation of an AAA ultrasound screening program is feasible, cost-effective, and a worthwhile endeavor.

Analysis of High-Risk Factors Associated with the Progression of Subaneurysmal Aorta to Abdominal Aortic Aneurysm in Rural Area in China

Objective

To determine the risk factors associated with the progress of subaneurysmal aorta (SAA) to abdominal aortic aneurysm (AAA) and provide a reference for the prevention of AAA in rural areas.

Methods

A total of 747 SAA patients screened by the Health Management Center of the Second Hospital of Lanzhou University from January 2015 to January 2016 were recruited. The ratio of SAA progressing to AAA was observed through 5 years of follow-up. Logistic stepwise regression analysis was performed to analyze the high-risk factors. The relevant clinical prediction model score table (Nom) was made and the C-index and calibration chart were used to verify the prediction ability of the model.

Results

Of the 747 patients diagnosed with SAA, 260 developed to AAA, with an incidence of 34.8%. Univariate analysis showed that age (62–65 years old), abdominal aorta diameter greater than 2.7 cm, smoking after 30 years old, moderate to severe hypertension, and blood pressure variability were the important high-risk factors of SAA progressing to AAA. Logistic regression analysis showed that these factors were statistically significant. The nomogram of clinical prediction model score showed that when 50–60% of SAA developed to AAA, the score was 189–201 and the C-index was 0.883, verifying the moderate predictive ability of this model.

Conclusion

Age, smoking habit, degree of hypertension, and control situation were high-risk factors associated with the progression of SAA to AAA. The control of the above high-risk factors was imperative for the prevention of AAA in rural areas without sufficient medical resources.

Screening Older Adult Men for Abdominal Aortic Aneurysm: A Scoping Review

Abdominal aortic aneurysm (AAA) is a potentially fatal condition predominantly affecting older adult men (60 years or over). Based on evidence, preventative health-care guidelines recommend screening older males for AAA using ultrasound. In attempts to reduce AAA mortality among men, screening has been utilized for early detection in some Western countries including the UK and Sweden. The current scoping review includes 19 empirical studies focusing on AAA screening in men. The findings from these studies highlight benefits and potential harms of male AAA screening. The benefits of AAA screening for men include decreased incidence of AAA rupture, decreased AAA mortality, increased effectiveness of elective AAA repair surgery, and cost-effectiveness. The potential harms of AAA screening included lack of AAA mortality reduction, negative impacts on quality of life, and inconsistent screening eligibility criteria being applied by primary care practitioners. The current scoping review findings are discussed to suggest changes to AAA screening guidelines and improve policy and practice.

Abdominal aortic aneurysms part one: Epidemiology, presentation and preoperative considerations

An abdominal aortic aneurysm is an irreversible dilatation of the abdominal aorta. The majority of abdominal aortic aneurysms are asymptomatic and identified incidentally while investigating a separate pathology. Others are detected by national screening programmes and some present due to a growth or rupture. Symptomatic or ruptured aneurysms require urgent or emergency repair in patients fit for surgery. Perioperative practitioners should therefore be aware of how patients with abdominal aortic aneurysms present and are investigated, so that they can implement timely management. Guidelines have been recently updated to reflect this. This literature review discusses these recommendations and explores the evidence upon which they are based. The aim of this article is to highlight the important preoperative principles that need to be considered in cases of abdominal aortic aneurysm.

High-frequency murine ultrasound provides enhanced metrics of BAPN-induced AAA growth

An abdominal aortic aneurysm (AAA), defined as a pathological expansion of the largest artery in the abdomen, is a common vascular disease that frequently leads to death if rupture occurs. Once diagnosed, clinicians typically evaluate the rupture risk based on maximum diameter of the aneurysm, a limited metric that is not accurate for all patients. In this study, we worked to evaluate additional distinguishing factors between growing and stable murine aneurysms toward the aim of eventually improving clinical rupture risk assessment. With the use of a relatively new mouse model that combines surgical application of topical elastase to cause initial aortic expansion and a lysyl oxidase inhibitor, β-aminopropionitrile (BAPN), in the drinking water, we were able to create large AAAs that expanded over 28 days. We further sought to develop and demonstrate applications of advanced imaging approaches, including four-dimensional ultrasound (4DUS), to evaluate alternative geometric and biomechanical parameters between 1) growing AAAs, 2) stable AAAs, and 3) nonaneurysmal control mice. Our study confirmed the reproducibility of this murine model and found reduced circumferential strain values, greater tortuosity, and increased elastin degradation in mice with aneurysms. We also found that expanding murine AAAs had increased peak wall stress and surface area per length compared with stable aneurysms. The results from this work provide clear growth patterns associated with BAPN-elastase murine aneurysms and demonstrate the capabilities of high-frequency ultrasound. These data could help lay the groundwork for improving insight into clinical prediction of AAA expansion.NEW & NOTEWORTHY This work characterizes a relatively new murine model of abdominal aortic aneurysms (AAAs) by quantifying vascular strain, stress, and geometry. Furthermore, Green-Lagrange strain was calculated with a novel mapping approach using four-dimensional ultrasound. We also compared growing and stable AAAs, finding peak wall stress and surface area per length to be most indicative of growth. In all AAAs, strain and elastin health declined, whereas tortuosity increased.

Symptoms of Depression and Risk of Abdominal Aortic Aneurysm: A HUNT Study

Background

Depression is associated with cardiovascular diseases, but the evidence is scarce regarding depression and risk of abdominal aortic aneurysms (AAA). The aim was to determine whether individuals with depressive symptoms have increased risk of AAA.

Methods and Results

This population‐based prospective study included 59 136 participants (52.4% women) aged 50 to 106 years from the HUNT (Norwegian Nord‐Trøndelag Health Study). Symptoms of depression were assessed using the depression subscale of the Hospital Anxiety and Depression Scale (HADS). During a median follow‐up of 13 years, there were 742 incident cases of AAA (201 women). A total of 6401 individuals (12.3%) reported depressive symptoms (defined as HADS depression scale [HADS‐D]) ≥8) (52.5% women). The annual incidence rate of AAA was 1.0 per 1000 individuals. At all ages, the estimated proportion of individuals diagnosed with AAA was higher among those with depressive symptoms (log‐rank test, P<0.001). People with HADS‐D ≥8 were older than those with HADS‐D<8 (median 57.8 versus 52.3 years, P<0.001) and a statistically significantly higher proportion of them (P<0.001) were smokers, overweight or obese, and reported a history of coronary heart disease, diabetes mellitus, and hypertension. In a Cox proportional hazard regression model adjusted for these factors, individuals with depressive symptoms had a ≈30% higher risk of AAA than those without (hazard ratio, 1.32, 95% CI 1.08–1.61, P=0.007).

Conclusions

This study shows that individuals with depressive symptoms have significantly higher risk of incident AAA, after adjustments for established risk factors.

Plasma Desmosine and Abdominal Aortic Aneurysm Disease

Background

It is recognized that factors beyond aortic size are important in predicting outcome in abdominal aortic aneurysm (AAA) disease. AAA is characterized by the breakdown of elastin within the aortic tunica media, leading to aortic dilatation and rupture. The aim of this study was to investigate the association of plasma desmosine (pDES), an elastin‐specific degradation product, with disease severity and clinical outcome in patients with AAA.

Methods and Results

We measured pDES and serum biomarker concentrations in 507 patients with AAAs (94% men; mean age, 72.4±6.1 years; mean AAA diameter, 48±8 mm) and 162 control subjects (100% men; mean age, 71.5±4.4 years) from 2 observational cohort studies. In the longitudinal cohort study (n=239), we explored the incremental prognostic value of pDES on AAA events. pDES was higher in patients with AAA compared with control subjects (mean±SD: 0.46±0.22 versus 0.33±0.16 ng/mL; P<0.001) and had the strongest correlation with AAA diameter (r=0.39; P<0.0001) of any serum biomarker. After adjustment for baseline AAA diameter, pDES was associated with an AAA event (hazard ratio, 2.03 per SD increase [95% CI, 1.02–4.02]; P=0.044). In addition to AAA diameter, pDES provided incremental improvement in risk stratification (continuous net reclassification improvement, 34.4% [95% CI, −10.8% to 57.5%; P=0.09]; integrated discrimination improvement, 0.04 [95% CI, 0.00–0.15; P=0.050]).

Conclusions

pDES concentrations predict disease severity and clinical outcomes in patients with AAA.

Clinical Trial Registration

http://www.isrctn.com. Unique identifier: ISRCTN76413758.

Impact on Quality of Life of Men with Screening-Detected Abdominal Aortic Aneurysms Attending Regular Follow ups: A Narrative Literature Review

OBJECTIVE

This study aimed to review, summarise, and assess the available evidence regarding the impact on the quality of life (QoL) of men undergoing screening for abdominal aortic aneurysm (AAA) and attending regular follow ups.

METHODS

PubMed, MEDLINE, CINAHL, and PsycINFO were used for searching. The search was performed from April to July 2016, with an update in February-March 2018. The quality of the studies was appraised with respective checklists from the Critical Appraisal Skills Programme. A narrative synthesis of the included studies was performed. The analysis included studies evaluating QoL in relation to one or more of the following concepts: physical function, psychological impact and social life in men undergoing AAA screening, but excluded studies evaluating QoL in AAA patients diagnosed outside a screening program.

RESULTS

The initial results from the search were 128 articles. Duplicates were removed, titles and abstracts were screened, and 22 full text articles were collected. Based on the inclusion criteria, 11 quantitative studies were included. Inferior quality of life among men with detected AAA was identified compared to those without the diagnosis and the general population in the included studies. The self-perceived health decreased over time for the participants with AAA. Assessments after surgery showed that the participants returned to similar health as before the screening. A wide variety of factors regarding the methodologies, designs, measurements, sample sizes, and the time for the assessment were noted in the included studies.

CONCLUSION

Quality of life is an important outcome for AAA screening and studies have been conducted in an attempt to address the imbalance between benefits and harm. However, it is still difficult to draw clear conclusions, possibly due to the heterogeneity of the original studies. Nevertheless, it is important to identify men with an AAA who develop conditions influencing their health and QoL in order to understand their care needs to further support them and improve their situation.

Quality of life and patient-reported outcomes

The lay view

Abdominal aortic aneurysms

An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.

Swedish men and smoking: Views on screening-detected abdominal aortic aneurysm

Abdominal aortic aneurysms (AAA), most common among elderly male smokers, often show no symptoms before rupture. To facilitate better care and counselling targeted to smoking cessation for these patients, more knowledge is required about their views. Therefore, the aim of the present study was to describe the views on AAA and smoking among male smokers with screening-detected AAA. A qualitative approach with individual interviews with 16 men with screening-detected AAA was applied. Three had quit smoking by the time of the interviews. Thematic analysis was performed, and four themes emerged: (i) accepting the course of life; (ii) the elusive AAA: a disturbing experiencing or merely a minor inconvenience?; (iii) being in safe hands; and (iv) smoking as an unexpected topic of discussion. Most of the participants felt they were in "safe hands", although thoughts about death were also evoked. However, the information about smoking cessation was unexpected, and the relationship between AAA and smoking unclear. Presenting the connection between AAA and smoking in a clear manner and motivating smoking cessation in an individually-targeted way are important.

Chinese Herbal Medicine as a Potential Treatment of Abdominal Aortic Aneurysm

Abdominal aortic aneurysm (AAA) is an irreversible condition where the abdominal aorta is dilated leading to potentially fatal consequence of aortic rupture. Multiple mechanisms are involved in the development and progression of AAA, including chronic inflammation, oxidative stress, vascular smooth muscle (VSMC) apoptosis, immune cell infiltration and extracellular matrix (ECM) degradation. Currently surgical therapies, including minimally invasive endovascular aneurysm repair (EVAR), are the only viable interventions for AAAs. However, these treatments are not appropriate for the majority of AAAs, which measure <50 mm. Substantial effort has been invested to identify and develop pharmaceutical treatments such as statins and doxycycline for this potentially lethal condition but these interventions failed to offer a cure or to retard the progression of AAA. Chinese herbal medicine (CHM) has been used for the management of cardiovascular diseases for thousands of years in China and other Asian countries. The unique multi-component and multi-target property of CHMs makes it a potentially ideal therapy for multifactorial diseases such as AAA. In this review, we review the current scientific evidence to support the use of CHMs for the treatment of AAA. Mechanisms of action underlying the effects of CHMs on AAA are also discussed.