I woke up this morning early before the kids to enjoy a cup of coffee in the cold morning here. While scanning the news, I saw a mention of “aortic aneurysm”, headlined on the CNN website – an unusual topic.
There is big news coverage of an exciting World Cup in Qatar (Morocco in its unlikely run for the title and Messi in the finals, his last chance for World Cup win).
One of the lead American reporters there, Grant Wahl, had unexpectedly died on Dec 10, 2022. A young man, apparently healthy, whose wife is a leading public health physician. It was a shocking tragedy amidst the festivities.
Many people, of course, wondered what happened. Today, it appears the autopsy report says he had an aortic aneurysm (sounds like it was in his chest).
What is an aorta? What is an aneurysm?
The aorta is the largest primary blood vessel carrying blood out of the heart and into the rest of the body. It travels, with all the blood of each heart beat, from the heart, upwards towards the neck briefly, then twisting downwards to the midline chest and towards the lower abdomen. Along the way, it splits off smaller blood vessels to supply the rest of the body.
The aorta is a high pressure vessel – so, like a rubber hose, it expands and contracts with the pressure. With age and some medical conditions, there’s an increasing risk that a part of the rubber hose becomes defective and causes an out-pouching.
That out-pouching is an aneurysm. An aneurysm can happen anywhere along the aorta – from the heart down to the abdomen. If it is in the chest, we call it a Thoracic Aortic Aneurysm. If in the abdomen, Abdominal Aortic Aneurysm.
Both can be very dangerous. Both can be fixed – if you can find it in time.
As a family medicine physician, I see patients for general wellness exams and for all sorts of complaints. The concern for aneurysms are often in my thoughts – why?
The literature describes an aneurysm as silent – meaning no significant symptoms – until it becomes large and suddenly rupture. Symptoms, if there are any, is not exact or precise – they describe chest or abdomen pressure, “tearing pain”, etc. The window for a diagnosis (the time between presenting symptoms and catastrophic rupture) is small. Even if the doctor found the aneurysm, there is still the time it takes to set up surgery & repair!
I remember a study estimating that 50% of patients with a ruptured aneurysm do not make it to the hospital. Of the 50% that make it to the hospital, half that group will not survive.
That is all to say, an aneurysm can grow to a dangerous size and rupture (kill) suddenly. Much better to find it ahead of time.
Who is at risk? The data below is for abdominal aortic aneurysm, but likely similar for thoracic aneurysm also.
- For men 55-64 yo, AAA <4.0cm prevalence is ~1%. Then increase by 2-4% each 10 years after. For men >60 yo, AAA is about 3-5% prevalence, some studies show as high as 9%.
- How about women? Less common than men. >60 yo women ~0.37-1.53%.
- Age 60-70 yo ~0.43%. Age 70-80 ~1.15%. Age >80 yo ~1.67%.
- Smoking – the more cigarettes the higher the risk. If a person smokes 1/2 pack a day for 10 years – the risk is increased by 260%. If 1 pack a day or more for 10 years – the risk is increased by 1210%!
- If there is family history of abdominal aortic aneurysms – the risk is 200-400% greater.
Then the question is – among day to day clinics patients, who should we consider checking for an aneurysm? This is the “too-long didn’t read” section.
- Family history of aneurysms. Aneurysms run in the family – due to genetically-programmed abnormal connective proteins forming the basis of tissue in the body. Some family genetics have a more “loose” connective tissue – leading to risk of aneurysms, joint dislocations, tendon ruptures, etc. If the family has a “connective tissue disorder” (Marfans, Ehlers-Danlos, etc.) or has a history of aneurysms (brain aneurysm, thoracic or abdomen aneurysm – especially at young age) – I would consider doing screening tests *see options below.
- High risk persons – especially, older men who are smokers and has high blood pressure. I care for many East Asian patients, many of whom use tobacco – the tobacco (nicotine) damages blood vessels over time, weakening it. High blood pressure also increases the chance of out-pouching – think of blowing a balloon. Age also weakens the blood vessels, but we don’t have a medicine for that yet.
- The USPSTF (see link below) recommends a screening ultrasound for ABDOMEN aortic aneurysm for MEN between 65-75, who has EVER smoked. In the US, this should be 100% covered by health insurance.
- The USPSTF do not recommend screening test for women, even if they are smokers. However, I’ve spoken with vascular specialists who disagree.
Ok, what tests are available?
- For abdomen aortic aneurysm – we use an abdominal ultrasound. In my area, it costs about $150 (2022) if no insurance. It is fast, basically no-risk, and there is no radiation.
- For chest (thoracic) aortic aneurysm – it would be between an echocardiogram or CT-scan (with contrast). The vascular specialists and surgeons prefer CT-scan, but that is high cost and has lots of radiation.
What if an aneurysm is found?
- Monitor the aneurysm. The bigger the aneurysm, the faster it grows and higher chance of sudden rupture. Depending on the size, it can be monitored with repeat imaging or if reaches certain criteria, will be referred to see the vascular surgeon for repair
- Control the risk factors! (Talk to your doctor about specifics.)
- Keep blood pressure under control.
- Stop smoking.
- Avoid exercises that increases chest & abdomen pressure (such as weight-lifting).
- Some medications – statins and baby aspirin – can reduce risk of progression & rupture.
- Generally for my patients, I avoid fluoroquinolone antibiotics (Levaquin, levofloxacin, ciprofloxacin, moxifloxacin). This class of antibiotics may increase risk of rupture.
The main thing is I would remind every male smoker or former smoker that is 65 years or older, to ask their doctor about getting screening ultrasound. A simple, fast and affordable test that can save your life.
Reference:
Interstitium 