Building The Case For Abdominal Aortic Aneurysm Screening In Women
Elizabeth L. George, MD MS, Michael Paisley, MD, Manuel Garcia-Toca, MD MS, Jordan R. Stern, MD.
Stanford University, Stanford, CA, USA.
OBJECTIVES: Unlike Medicare, the USPSTF AAA screening guidelines do not include a recommendation for screening women. We aimed to strengthen the case for improved AAA screening in women by retroactively evaluating screening eligibility in patients undergoing AAA repair to determine whether traditional criteria identify women at risk.
METHODS: The Vascular Quality Initiative (2003-2020) was queried for patients undergoing AAA repair. Medicare screening eligibility includes both men aged 65-75 with a smoking history and men or women aged 65-75 with a family history of AAA; USPSTF screening eligibility includes only the former. Descriptive statistics and multivariable adjusted logistic regression were performed to assess the relationship of screening eligibility in patients undergoing elective or ruptured (rAAA) repair, and in-hospital mortality following repair.
RESULTS: There were 63,578 AAA repairs (20.6% women), with 5,003 for rAAA (22.3% women). Overall, 20,661 (32.6%) patients were USPSTF screening eligible and 24,386 (38.3%) were Medicare screening eligible. Of rAAA repairs, 1,374 (27.5%) were USPSTF screening-eligible and 1,576 (31.5%) were Medicare screening eligible. Only 1,273 women (9.7%) were Medicare screening eligible, including 5.9% of women who underwent rAAA repair and 10.1% of women undergoing non-ruptured AAA repair. Screening ineligible women had significantly greater in-hospital mortality than screening ineligible men for both rAAA (32.3% vs 26.8%, p=0.002) and elective repair (1.9% vs. 0.7%, p<0.001). In multivariable adjusted logistic regression, compared to screening ineligible men, screening ineligible women were more likely to undergo repair for rAAA (OR 1.15 95% CI 1.05-1.25) and had higher in-hospital mortality following rAAA repair (OR 1.22 95% CI 1.02-1.45). The classic screening criteria of age 65-75, smoking and family history poorly predicted rAAA in women (c-statistic=0.57; Goodness-of-Fit p=0.94). Compared to women who underwent elective repair, women undergoing rAAA repair were significantly less likely to have a smoking history, family history of AAA, hypertension, diabetes, CAD, COPD, or carotid intervention (p<0.001).
CONCLUSIONS: AAA screening in women is indicated: despite accounting for one-fifth of repairs in the dataset, only ~10% of women undergoing non-ruptured AAA repair and ~6% of women undergoing rAAA repair were eligible for AAA screening. Classic risk factors included in current guidelines may not be exhibited by women, particularly those presenting for rAAA repair. More research is needed to generate sex-specific screening guidelines to improve care for women with AAA.
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