Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Attention all echo techs! 104 seconds to scan the aorta and save a lifeNov 6, 2012 17:27 EST
My office cardiac echo tech has saved many lives over the past 20 years. I'm not just referring to her savvy for stress testing and the imaging of valvular heart disease. I'm talking about her long-term habit of screening the abdominal aorta in almost 100% of the patients who lie down on her table. I can't tell you how many times she's made my partner and me look really great by knocking on the exam-room door with the image of an abdominal aortic aneurysm (AAA) the size of a baby's head. Dr Victor Aboyans (Dupuytren University Hospital, Limoges, France) gets my vote today for the most practical, potentially cost-effective, and most painless mode of life-saving technique presented at the American Heart Association 2012 Scientific Sessions .
Dr Aboyans started his talk with an overview. Over 9000 US patients die of abdominal aortic aneurysm annually. It is a disease that doesn't play fair ball, as 77% of those who experience rupture never knew they had it. From the perspective of healthcare providers, an abdominal aortic aneurysm death is an indictment of our failure to detect a most treatable malady. With the advent of endovascular graft therapy, we no longer have to fear that the treatment is worse than the cure. Data from a Glasgow, Scotland study revealed that of patients with ruptured AAA, 76% had been in a hospital in the four-year period preceding the event, and 55% had visited their physician in the year prior. Of patients who rupture, 70% will die prior to making it to the operating room and 12 % will die of postoperative complications, leaving a dismal 18% survival rate overall. The incidence of AAAs has declined since the late 1970s, a statistic that most attribute to a decline in cigarette smoking.
The E2T3A study presented today is a foray into opportunistic screening. Based on the knowledge that incidental screening finds only 1% of AAAs and population screening yields a detection rate of 5%, the investigators sought to prove that patients who present for a transthoracic echocardiogram for any indication might benefit from a simple swipe of the echo probe downward toward the abdominal aorta—a 104-sec maneuver with a huge payoff in life-years saved if aneurysmal dilatation is detected. The opportunity to change a patient's longevity is as dramatic as saving someone from stepping off the sidewalk in front of a city bus: cheap, quick, effective, painless—even adrenalin and endorphin producing.
In the study, 1382 patients aged 65 or older were examined, with a yield of nearly 10% detection rates in patients aged 85 or older. The detection rate in males was 5.4% and females 1.4%. The age group of 65-to-74 years yielded a detection rate of 4.9%. Male gender, smoking, and family history of aneurysm were significant risk factors. The disappointing but previously noted suggestion that prescription drugs do not affect the development of aneurysm was also noted in this study. There were no significant differences among the type of pharmaceuticals utilized. Those with aneurysm had a higher left ventricular end-diastolic dimension, a larger ascending aortic diameter, and higher rates of aortic insufficiency at 24%. Many were referred to vascular surgeons for monitoring and therapy. The number needed to scan for men was only 21 patients and for women a moderately higher 35.
For the average echo tech who rolls folks in and out of a busy noninvasive lab daily, that's scores of lives saved in the span of each career. Finding an expanding aneurysm is the ultimate opportunity to "do unto others as you'd do unto yourself," so do it, no excuses. Furthermore, I recommend that every single noninvasive lab in the country, whether office based or hospital based, should immediately adopt abdominal screening into their daily cardiac scanning protocol.
Some of my most grateful patients are those who came to the office for hypertension therapy, dyslipidemia, or for stress testing and went home with the powerful knowledge that a demon was growing inside them. If they didn't require immediate lifesaving intervention, our finding set them on a course of follow-up and monitoring that led to a lifesaving procedure years later. Because of the diligence of my echo tech, we've found so many previously undetected aneurysms that I've forgotten on many occasions that we were the ones who found it. A testimony to that fact is a gentleman who is now 85 years of age who came to discuss his fitness for endovascular graft therapy recently. "How long have you known about that aneurysm?" I asked him. He smiled and said, "Check your chart again, Melissa. Aren't you the one who found it a few years ago?"
I flipped through the chart, located the echo performed in 2006 and the order for referral, then smiled and replied, " Yes, sir. I certainly am."