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Abdominal Aortic Aneurysm: Frank Lederle, MD, discusses the clinical examination for abdominal aortic aneurysm.
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Abdominal Aortic Aneurysm: Frank Lederle, MD, discusses the clinical examination for abdominal aortic aneurysm.
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives section. Today, I have the pleasure of speaking with Dr. Frank Lederle about abdominal aortic aneurysm, a condition that causes more than 10,000 deaths each year in the United States. Dr. Lederle, why don't you introduce yourself to our listeners? >> Hi, I'm Frank Lederle. I am a General Internist at the Minneapolis VA where I spend most of my time doing research on abdominal aortic aneurysm. >> Dr. Lederle, what do we know about the prevalence of abdominal aortic aneurysm?
And, are there important demographic characteristics? >> Well, the prevalence depends on a number of factors including age, gender, smoking history, race, and family history of abdominal aneurysm, and on the definition of abdominal aneurysm that you're using. Using the most common definition, which is 3.0 cm in width of the aorta, for men over 65 with a history of smoking, which is the high-risk group, prevalence is 5 to 7% rising with age. Men who have never smoked and women, even if they have smoked, have prevalence of less than 2% at any time.
Factors like black race and, interestingly, diabetes are associated with lower prevalence. >> How accurate is abdominal palpation for detecting abdominal aortic aneurysm? >> Well, the accuracy of palpation varies with both the size of the aneurysm and the size of the patient. And while overall sensitivity is low, less than 50%, it rises to over 90% for aneurysms larger than 5.0 cm in a patient with a waist that is less than about 40 inches. Even in obese patients, the sensitivity is reasonably high at about 80% if the aorta can be palpated.
Of course, ultrasound has a sensitivity of nearly 100% and is a preferable test. And routine abdominal examination, not directed at detecting the width of the aorta, has a very low sensitivity. >> Which history and physical examination findings are helpful when detecting abdominal aortic aneurysm? And, which findings are not helpful in this regard? >> Well, as William Osler pointed out more than a century ago, the only finding that has shown any value in detecting abdominal aortic aneurysm is the width of the pulsating aorta, specifically bruits, pulse deficits, prominence of the abdominal pulse, or whether it's palpable, all of these have not been predictive at all when studied.
>> What are the reference standard tests for abdominal aortic aneurysm? >> Well, ultrasound is best for diagnosis and has many advantages, near-perfect accuracy, it's non-invasive, there's no radiation, no contrast, it's relatively inexpensive. Its disadvantages are that it has low ability to detect rupture and insufficient detail for preoperative evaluation. So, when these are the issues, CT scan is preferable. >> Is there anything else JAMAevidence users should know about abdominal aortic aneurysm? >> Well, the U.S. Preventive Services Task Force now recommends one-time ultrasound screening for men 65 to 75 years old who have ever smoked and Medicare covers this, though at present only for those recently turning 65.
Also, several large trials have shown that repair of aneurysm smaller than 5 and 1/2 centimeters does not reduce mortality. Nevertheless, repairs of smaller aneurysms are common suggesting a failure of counseling, which should begin with the primary care provider. So, we should screen the appropriate patients but we should also counsel patients not to have their aneurysms repaired when they're small and probably wait to refer patients until the aneurysms are close to the size at which repair is recommended. But for patients with aneurysms that are as yet too small to be referred for repair, appropriate management is periodic imaging surveillance usually with ultrasound and this can be done at six-month intervals for aneurysms of 4 to 5 and 1/2 centimeters and for small aneurysms, one to two years is often enough.
>> Thank you, Dr. Lederle, for this overview of abdominal aortic aneurysm. For more information, JAMAevidence subscribers can consult Dr. Lederle's article, Does This Patient Have Abdominal Aortic Aneurysm, which was originally published with an update in the Rational Clinical Examination. This has been Joan Stephenson of JAMA interviewing Dr. Frank Lederle about abdominal aortic aneurysm for JAMAevidence.
