Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Rupture of abdominal aortic aneurysm and HRT in the WHI study
- Ellen C G Grant (17 October 2008)
-
Screening for abdominal aortic aneurysms in women may save lives
- ayesha k chaudhary (21 October 2008)
|
|
|||
|
Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames. KT2 7JU
Send response to journal:
|
Aortic rupture and repair were strongly related to smoking in the latest Women’s Health Institute (WHI) study report.1 The negative association found with HRT is spurious and does not mean that HRT attenuates the risk of abdominal aortic aneurysm. The average age of cases was 67.2 years which was nearly twice (77% per 10 years) the age for cases compared with controls and older women are less likely to have taken or be still taking HRT. Also HRT use was stopped prematurely in the WHI study because of increases in HRT-induced vascular diseases and exogenous hormones have long been known to increase the risk of rupture of cerebral arterial aneurysms. Women randomised to take HRT had significantly more abdominal aortic aneurysm events than controls in the Estrogen Alone trial (14 v 6 cases, hazard ratio 2.40 and a number similar to controls in the Estrogen plus Progesterone trial (7 v 6, hazard ratio 1.1). The authors write that further studies might clarify the sources of their discrepancies such as duration of treatment. However, the total duration and doses of progesterones and oestrogens taken for all purposes, including contraception or fertility treatment, is not available in the WHI study. In contrast most women know how long and how much they have smoked. Women with aortic rupture and repair had smoked for 44.0 pack-years compared with 21.0 pack-years or twice as much or twice as long as non- event smoking controls. (Pack-years are defined as - 1.5 pack/day for 40 yrs = 60 pack-years.) As there is a synergistic adverse effect on vascular diseases with both smoking and the use of progesterones and oestrogens, a true comparison of the risks should include durations of use of either separately and both together. For example, the average duration of oral contraceptive use before attending a hospital migraine clinic was 4 years for non-smokers and 3 years for smokers. The average duration of smoking was 25 years for women who were not taking hormones.2 These facts suggest that hormone use causes vascular disease in a much shorter time than smoking alone. Aortic aneurysms have long been associated with pregnancy3, with diethylstilboestrol exposure in turkeys4, and also with progestogen use in hamsters5. 1 Lederle FA, Larson JC, Margolis KL, Allison MA, et al. Abdominal aortic aneurysm events in the women’s health initiative: cohort study. BMJ 2008;337;a1724. 2 Grant ECG, Clifford-Rose F. Smoking and migraine. In Smoking and Arterial Disease. Ed Roger M Greenhalgh, Pitman Medical. London 1981 pp 29 -34. 3 Anderson EG. Massive aortic dissection (dissecting aneurysm) associated with pregnancy and hypertension. Am J Obstet Gynecol. 1949;57:793-6. 4 Beall CW, Simpson CF, Pritchard WR, Harms RH. Aortic rupture in turkeys induced by diethylstilbestrol. Proc Soc Exp Biol Med. 1963;113:442 -3. 5 Cobb LM, Bloom HJ, Roe FJ, MacKenzie HM. Rupture of the aorta in the hamster by anti-ovulatory progestogens. Nature 1971;229 :50-1. Competing interests: None declared |
|||
|
|
|||
|
ayesha k chaudhary, FY2 Obs & Gyane Wishaw general hospital
Send response to journal:
|
Abdominal aortic aneurism screening is aimed at early detection of: 1. The presence of an aneurysm 2. Rapidly deteriorating (widening) aneurysm 3. Detecting early complications. 4. Intervene (planning of elective repair) before it ruptures The following persons should be get a one-time abdominal aortic aneurism screening • Any male aged 60 – 75 who have ever smoked more than 100 cigarettes in his lifetime • Any male above 60 years of age with a family history of abdominal aortic aneurysm • Any female above 65 years of age who have ever smoked up to 100 cigarettes in her whole life time • Any female aged above 65 with family history of AAA Numbers of studies at audit and research level have been carried out in the past few years to do cost-effectiveness analysis of targeted screening for abdominal aortic aneurysm (AAA). Summary of results are as follows Four studies involving 127,891 men and 9,342 women were included in this review. Only one study included women. Results for men and women were analysed separately. Three to five years after screening there was no significant difference in all-cause mortality between screened and unscreened groups for men or women. There was a significant decrease in mortality from AAA in men. In this analysis mortality includes death from rupture and from emergency or elective surgery for aneurysm repair. There was also a decreased incidence of ruptured aneurysm in men but not in women There was a significant increase in surgery for AAA in men. This was not reported in women. There was no data on life expectancy, complications of surgery or subjective quality of life. Another study carried out in United States in 2007 which included 17,540 patients from 100 hospitals and clinics spread across the United States. Overall, the cohort included 10,012 women over the age of 65 (average age 69.6 years) and 7,528 men over the age of 60 (average age 70). Patients were questioned as to their demographics, history of smoking and medical histories. They also underwent conventional AAA ultrasound screening. Overall, AAA showed up in 291 (3.9 per cent) of the men and 74 (0.7 per cent) of the women -- similar to the usual rate. But certain subgroups of women fared much worse. For example, women over age 65 were more than four times as likely to have this type of aneurysm than women younger than 65, and that risk grew by ten per cent with every added year of age. Women with a history of smoking, or a history of heart disease (i.e., a prior heart attack or coronary bypass) faced triple the risk of AAA, the researchers found. Any combination of the above risk factors boosted a woman's odds of AAA by up to six-fold, the team found. The bottom line, in terms of the cost-effectiveness of screening older women, is that these tests are probably not useful for the general population, but are certainly warranted for women over 65 with risk factors such as smoking and a history of heart disease. Reference: Screening for abdominal aortic aneurysm (Review) Cosford PA, Leng GC NewYork-Presbyterian Hospital Competing interests: None declared |
|||