Screening patients with abdominal aortic aneurysm (AAA) is associated with reduced AAA-related mortality, but population screening is poorly implemented. Opportunistic screening during imaging for other indications might be efficient. Single-center series reported AAA rates of 0.8% to 6.5% in patients undergoing transthoracic echocardiography (TTE), with disparities due to selection bias. In this first multicenter study, we aimed to assess the feasibility and criteria for screening AAA during TTE in real-life practice. During a week of May 2011, 79 centers participated in a nationwide survey. All patients aged ≥65 years requiring TTE for any indication were eligible, except for those with operated abdominal aorta. We defined AAA by an anteroposterior diameter of the infrarenal aorta ≥30 mm. Of 1,382 consecutive patients, abdominal aorta imaging was feasible in 96.7%, with a median delay of 1.7 minutes (>3 minutes in 3.6% of cases). We found AAA in 50 patients (3.7%). Unknown AAA (2.7%) was more frequent in men than women (3.7% vs 1.3%, respectively, p = 0.007) and increased by age at 2.2%, 2.5%, and 5.8% in age bands of 65 to 74, 75 to 84, and 85+ years, respectively. None of the female participants aged <75 years had AAA. Smoking status and family history of AAA were significantly more frequent among patients with AAA. The ascending aorta was larger in those with AAA (36.2 ± 4.7 vs 34.0 ± 5.2 mm, p = 0.006), and bicuspid aortic valve and/or major aortic regurgitation were also more frequent (8% vs 2.6%, p = 0.017). In conclusion, rapid AAA screening during TTE is feasible and should be limited to men ≥65 years and women ≥75 years.
Highlights
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This is the first multicenter study assessing the prevalence of abdominal aortic aneurysm (AAA) in patients undergoing echocardiography and the feasibility of its screening right after cardiac imaging.
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The imaging quality was satisfactory in 96.7%. The abdominal aorta imaging was performed in <3 minutes in 96.4% of cases.
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Among patients ≥65 years undergoing echocardiography, the prevalence of AAA was found to be 3.7%, with higher rates in men (5.4%) than women (1.4%).
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The screening for AAA at the end of echocardiography is highly feasible and should be advocated, especially in men.
Because many patients undergoing transthoracic echocardiography (TTE) present risk factors for abdominal aortic aneurysm (AAA) and the ultrasound probe used for TTE is suitable for abdominal aorta imaging, AAA screening during TTE has been reported in several single-center series, with discrepant results related to different enrollment criteria and lesion definition, as well as patients’ and examiners’ characteristics. To date, no multicenter study assessed the feasibility and interest of a systematic AAA screening during TTE. The aim of this study was to assess the actual rate of AAA among patients undergoing TTE and the feasibility of its screening in a large multicenter study. We hypothesized that screening AAA during TTE is highly feasible.
Methods
The Echocardiographie Trans-Thoracique et Anévrysme de l’Aorte Abdominale (E2T3A) is a prospective, nationwide, multicenter, cross-sectional study in France, promoted by the Working Group of Vascular/Thrombosis and the Council of Echocardiography of the French Society of Cardiology. The study has been approved by the Consultative Committee on Data Management for Biomedical Research (CCTIRS, Ministry of Research, France) and the National Committee of Information and Freedom (CNIL, Paris, France).
During the first trimester of 2011, cardiologists in France performing cardiac ultrasonography have been invited through congresses and e-mails to take part in this study. Those who accepted to participate filled a questionnaire regarding their experience in vascular ultrasonography, as well as the type of medical facility where they work (public hospital, private clinic, or office). Those who had no experience of abdominal aorta imaging received a video clip showing how to use their cardiac ultrasound probe to scan the abdominal aorta and measure the maximal anteroposterior diameter of the infrarenal aorta. They trained themselves before the study period and were assisted by more experienced colleagues during the training period. The study period was set at May 16 to 20, 2011. The investigators were asked to offer AAA screening at the end of TTE to all patients aged ≥65 years during at least half a day. A history of abdominal aortic intervention (either surgery or endovascular) was the only exclusion criterion. Data were collected electronically using an electronic case report form, including demographic data, indications for TTE, cardiovascular risk factors and drugs, family history of AAA, and cardiac and aortic ultrasound measurements. The aorta imaging quality and the time spent specifically to scan and measure the abdominal aorta were recorded. An AAA was defined by an anteroposterior diameter ≥30 mm.
Quantitative data are presented as numbers (%) and qualitative data as mean (SD). Differences between groups were tested using chi-square tests for categorical data and Student t tests for quantitative data. Nonparametric tests (Mann-Whitney and Kruskal-Wallis tests) were used when the distributions were skewed. All statistical analyses were performed using Stata/SE, version 10.1 (Stata Statistical Software; StataCorp LP., College Station, Texas).
Results
One-hundred eight cardiologists from 76 centers across the country took part in the study. Overall, 1,407 patients were invited for AAA screening, of whom finally 1,338 were analyzed (58% men, mean age 75.2 ± 6.8 years). Figure 1 displays the patients’ flowchart. The refusal rate was very low (0.2%). The imaging quality as judged by the investigators is displayed in Figure 2 . Overall, the abdominal aorta diameter was measurable in 96.7% of cases. The average time needed to scan and measure the abdominal aorta was 1 minute and 44 seconds (±1 minute 30 seconds). In 96.4% of cases, the imaging lasted <3 minutes. This delay was longer for those without previous experience of vascular imaging ( Figure 3 , p <0.0001).
The abdominal aorta diameter distribution is shown in Figure 4 . The prevalence of AAA was 3.7%, with a mean diameter at 36.2 ± 7.1 mm in subjects with AAA. Among them, the proportion of AAAs within 30 to 34, 35 to 39, 40 to 44, 45 to 49, and ≥50 mm was 54%, 22%, 14%, 2%, and 8%, respectively. The largest aneurysm (61 mm) was found in an 85-year-old man who underwent TTE for dyspnea. Among women, the largest AAA measured 53 mm in a 76-year-old woman who underwent TTE during examination after syncope. Overall, the prevalence of AAA was significantly greater in men compared with women (5.4% vs 1.4%, p <0.0001). Of the 50 patients with AAA, 35 (70%) were unaware of their condition, so that the prevalence of unknown AAA was 2.6%. The prevalence of AAA did not differ according to the type of health care center.
Table 1 lists demographic and clinical parameters of those with and without AAA. Regarding risk factors, only smoking status and family history of AAA were significantly more frequent among patients with AAA. No significant difference was found between the 2 groups regarding co-morbidities and cardiovascular treatments. Table 2 lists the comparison of the 2 groups regarding TTE indications and measurements. Compared with those without AAA, the indications for TTE were less frequently related to heart failure but more frequently related to endocarditis or pulmonary embolism in patients with AAA. These patients had larger left ventricular end-diastolic and end-systolic diameters, with similar ejection fraction and wall thicknesses. Interestingly, among those with AAA, the ascending aorta was larger, with significantly higher rates of aortic valve disease (bicuspid aortic valve and/or 3+ aortic regurgitation: 8.0% vs 2.6% among patients without AAA, p = 0.017). Excluding patients with type-C (« fair ») imaging quality or those screened by inexperienced cardiologists for vascular imaging did not alter significantly the prevalence of AAA (data not shown).
| Variable | Abdominal Aortic Aneurysm | ||
|---|---|---|---|
| No | Yes | p | |
| Age (years) | 75.2 ± 6.8 | 76.1 ± 7.8 | 0.45 |
| Male gender | 737 (57.2%) | 42 (84.0%) | 0.0001 |
| Smoker | 422 (34.1%) | 24 (50.0%) | 0.023 |
| Hypertension ∗ | 876 (68.9%) | 33 (66.0%) | 0.662 |
| Hypercholesterolemia ∗ | 677 (54.7%) | 30 (60%) | 0.22 |
| Diabetes mellitus ∗ | 298 (24.0%) | 11 (22.0%) | 0.804 |
| Body mass index (kg/m 2 ) | 26.6 ± 4.8 | 27.0 ± 4.3 | 0.27 |
| Family history of AAA | 12 (1.0%) | 2 (4.0%) | 0.037 |
| Coronary artery disease ∗ | 347 (27.6%) | 17 (34%) | 0.319 |
| Heart failure ∗ | 234 (18.4%) | 8 (16.0%) | 0.662 |
| Peripheral artery disease ∗ | 118 (9.4%) | 2 (4%) | 0.208 |
| Cerebrovascular disease ∗ | 183 (14.4%) | 6 (12%) | 0.58 |
| Chronic obstructive pulmonary disease ∗ | 122 (9.6%) | 5 (10%) | 0.891 |
| Chronic kidney disease ∗ | 121 (9.8%) | 7 (14%) | 0.28 |
| Cancer (5 yrs) ∗ | 92 (7.4%) | 2 (4.0%) | 0.411 |
| Antiplatelet drugs | 581 (47.1%) | 25 (50%) | 0.413 |
| Statins | 652 (53.1%) | 24 (48%) | 0.902 |
| RAS blockers | 730 (59.8%) | 34 (68%) | 0.086 |
| Beta-blockers | 543 (44.4%) | 18 (36%) | 0.408 |
| Variable | Abdominal Aortic Aneurysm | ||
|---|---|---|---|
| No | Yes | p | |
| Indications for TTE | |||
| Heart failure | 151 (11.7%) | 1 (2.0%) | 0.033 |
| Hypertension | 310 (24.1%) | 14 (28.0%) | 0.52 |
| Dyspnea | 249 (19.4%) | 6 (12.0%) | 0.194 |
| Arrhythmia | 127 (9.9%) | 6 (12.0%) | 0.62 |
| Coronary artery disease | 246 (19.1%) | 10 (20.0%) | 0.878 |
| Pre-operative work up | 61 (4.7%) | 0 (0%) | 0.115 |
| Chemotherapy | 40 (3.1%) | 0 (0%) | 0.205 |
| Pericarditis/myocarditis | 10 (0.8%) | 0 (0%) | 0.531 |
| Pulmonary embolism | 11 (0.9%) | 2 (4.0%) | 0.026 |
| Stroke/peripheral embolism | 42 (3.3%) | 1 (2.0%) | 0.619 |
| Endocarditis | 16 (1.24%) | 3 (6.0%) | 0.005 |
| Prosthetic valve | 97 (7.5%) | 3 (6.0%) | 0.684 |
| Hypertrophic cardiomyopathy | 24 (1.9%) | 1 (2.0%) | 0.945 |
| Findings | |||
| LV end-diastolic diameter (mm) | 50.1 (7.7) | 52.6 (6.6) | 0.0096 |
| LV end-systolic diameter (mm) | 32.2 (8.4) | 35.6 (8.2) | 0.0039 |
| Septal thickness (mm) | 10.9 (3.6) | 11.0 (2.1) | 0.376 |
| Posterior wall thickness (mm) | 10.3 (4.0) | 11.5 (10.5) | 0.99 |
| LV ejection fraction | 0.61 (0.12) | 0.61 (0.13) | 0.728 |
| Abdominal aorta antpost diam (mm) | 19.5 (3.6) | 36.2 (7.1) | 0.0001 |
| Ascending aorta diameter (mm) | 34.0 (5.2) | 36.1 (4.4) | 0.0015 |
| Aortic regurgitation 2+ | 192 (15.4%) | 12 (24%) | 0.061 |
| Bicuspid aortic valve | 10 (0.8%) | 1 (2.0%) | 0.383 |
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