GENDER BASED DIFFERENCES IN ABDOMINAL AORTIC ANEURYSM (AAA) RUPTURE - - PowerPoint PPT Presentation

GENDER BASED DIFFERENCES IN ABDOMINAL AORTIC ANEURYSM (AAA) RUPTURE

• Srikrishna Varun Malayala, MBBS

Mentors:

• Khalid J Qazi, MD, MACP
• Paul M Anain, MD
• 1. http:/ / a o rtic ste nts.c o m/ wha t-is-a b do mina l-a o rtic -a ne urysm/ (05/ 23/ 13)

Disclosures None

• 1. http:/ / a o rtic ste nts.c o m/ wha t-is-a b do mina l-a o rtic -a ne urysm/ (05/ 23/ 13)

Cardiovascular diseases

U. U.S. Preventi tive Service ces Task For

• rce

ce-March h 2009 09

Screening modality Grade

Smoking Counseling on cessation A Hypertension Blood pressure monitoring A Dyslipidemia Lipid profile A Diabetes Mellitus Fasting plasma glucose B Obesity Lifestyle modification B Prevention of Cardiovascular diseases Aspirin B

• 1. http:/ / www.uspre ve ntive se rvic e sta skfo rc e .o rg / uspsto pic s.htm
• Cardiovascular disease is the number one cause of death for both men and

women in the United States1.

• Preventive medicine is practiced by screening tests, counseling and preventive

medications owing to the impact of cardiovascular diseases.

Performance Improvement Projects ?? A- Strongly Recommended Benefit>>Risk B-Recommended Benefit>Risk

Introduction

• Dilatation or widening of the abdominal aorta.
• Definition: An abdominal aortic diameter of 3 cm or more, which is

usually more than 2 standard deviations above the mean diameter1.

• 2. Bro wn L

Modifiable

• Smoking
• Hypertension
• Hyperlipidemia
• Atherosclerosis
• Risk factors1:

Non modifiable

• Age
• Male gender
• White race
• Family history
• My out-patient PI project: Screening for AAA in high risk patients.
• AAA rupture is a medical and surgical emergency.
• Mortality could be up to 50%2.

Introduction

• 4. Bre wste r DC, Ge lle r SC, K

a ufma n JA, Ca mb ria RP, Ge rtle r JP, L a Mura g lia GM, e t a l. I nitia l e xp e rie nc e with e nd o va sc ula r a ne urysm re p a ir: c o mp a riso n o f e a rly re sults with o utc o me o f c o nve ntio na l o p e n re p a ir. J Va sc Surg 1998;27:992-1003.

Normal CT scan Abdominal Aortic Aneurysm Abdominal Aortic Aneurysm Rupture

• The strongest risk factor for the rupture of an AAA is maximal aortic

diameter4.

• Risk of rupture4:

i. < 4 cm = 0.5% per year ii. 4.0 – 4.9 cm = 1% per year iii. 5.0 – 5.9 cm = 11% per year iv. 6.0 – 6.9 cm = 26% per year v. 7.0 – 7.9 cm = 40% per year vi. > 8 cm = 50% year year

1 2 3

• Management5:

i. Open repair : conventional method of repair ii. Endovascular repair: faster recovery, reduced length of stay in ICU, reduced hospital stay

Screening guidelines

• USPSTF – Grade B recommendation (benefit>risk)
• Ultrasound has 90% sensitivity and 100% specificity.

• rc e . Ann Inte rn Me d 2005;142:203-11.

• ACT

• “Effective for services furnished on or after January 1, 2007, payment may

be made for a one-time ultrasound screening for AAA for beneficiaries who meet the following criteria2:

• Men aged 65-75 who ever smoked(100 cigarettes in life time)
• Men and women with a family history of AAA
• As a part of “Welcome to Medicare” within the first year of

enrollment

• AAA screening in women: Grade D (not recommended)

SAAAVE Act

Management guidelines

• Indications of elective surgery1:
• Diameter of 5.5 cm for an ‘average’ patient.
• Symptomatic AAA (irrespective of the size)
• Rapid expansion-1 cm in one year (irrespective of the size)
• Decision on repair must be “individualized for each patient”.

1. Da vid C. Bre wste r,a MD, Ja c k L . Cro ne nwe tt, MD,b Jo hn W. Ha lle tt, Jr, MD,c K. Wa yne Jo hnsto n, MD,d Willia m C. Krupski, MD,e a nd Jo n S. Ma tsumura , MD,f Bo sto n, Ma ss; L e b a no n, NH; Ba ng o r, Me ; T

• ro nto , Ca na da ; De nve r, Co lo ; a nd Chic a g o , Ill; Guide lie ns fo r tre a tme nt o f Ab do mina l Ao rtic Ane urysms, Jo urna l o f Va sc ula r Surg e ry, 2007

• Night float-PGY-2: 3 female patients with AAA in the same rotation.
• Aorto-enteric fistula
• 7 cm AAA with elective repair and admitted to ICU
• Multiple aneurysms (aorto-iliacs) with rupture

Case report on aorto-enteric fistula “Time bomb in the belly”

Introduction

Epidemiological differences:

• Prevalence: 7.6% in males vs 1.3% in females1,2
• Rate of rupture for any given size is higher in females3.

1.

2.

3.

4.

• Women with AAA have a stronger familial association than men4.
• Estrogen does have a protective effect on the AAA in women4.

Biological differences:

• At any given age, males have larger abdominal aortic diameters than women1,2.
• 1. L

e de rle F A, Jo hnso n GR, Wilso n SE , Go rdo n IL , Chute E P, L itto o y F N, Krupski WN, Bra ndyk D, Ba ro ne GW, Gra ha m L M, Hye RJ, Re inke DB, Ane urysm De te c tio n a nd Ma na g e me nt Inve stig a to rs. Re la tio nship o f a g e , g e nde r, ra c e , a nd b o dy size to infra re na l a o rtic dia me te r. J Vasc S urg . 1997;26:595– 601.

• 2. Sing h K, Bo na a KH, Ja c o b se n BK, Bjo rk L

, So ldb e rg S. Pre va le nc e o f a nd risk fa c to rs fo r a b do mina l a o rtic a ne urysms in a po pula tio n-b a se d study. Am J E pide mio l. 2001;154:236 –244.

• 3. So ne sso n B, Ha nse n F

, Sta le H, L a nne T . Co mplia nc e a nd dia me te r in the huma n a b do mina l a o rta : the influe nc e o f se x a nd a g e . E ur J Vasc S urg . 1993;7:690 – 697.

• Suitability for EVAR is different: The angulation of iliacs, size of femoral

arteries and tortuosity of aortas are different in females3.

N-67,800 All of them=men

• UK Small Aneurysm trial:

Multicentre, randomised controlled trial conducted across 93 UK hospitals 83% males

• ADAM study (Aneurysm Detection and Management):

73451 veterans aged 50 to 79 99% males

1.

T he Unite d K ing do m Sma ll Ane urysm T ria l Pa rtic ipa nts. L

• ng -te rm o utc o me s o f imme dia te re pa ir c o mpa re d with surve illa nc e o f sma ll a b do mina l a o rtic a ne urysms. N E

ng l J Me d. 2002;346:1445–1452.

2.

L e de rle F , Wiso n S, Jo hnso n G, Re inke D, L ito o y F , Ac he r C, Ba lla rd D, Me ssina L , Go rdo n I, Chute E , K rupski W, Bra dyk D. Imme dia te re pa ir c o mpa re d with surve illa nc e o f sma ll a b do mina l a o rtic a ne urysms. N E ng l J Me d. 2002;346:1437–1444.

• Traditionally, all the cardiovascular diseases were considered as “men’s diseases.”
• Cardiovascular diseases (CVDs) are the number one killer of women1.
• Mortality is more than all forms of cancers combined (breast , cervical and lung

cancer)2.

1. http :/ / www.wo rld -he a rt-fe d e ra tio n.o rg / p re ss/ fa c t-she e ts/ wo me n-a nd -c a rd io va sc ula r-d ise a se / 2. Ame ric a n He a rt Asso c ia tio n. 1997 He a rt a nd Stro ke F a c ts: Sta tistic a l Up d a te . Da lla s, T e x: Ame ric a n He a rt Asso c ia tio n; 1996. 3. Mikha il GW. Co ro na ry he a rt d ise a se in wo me n is und e rd ia g no se d , und e r- tre a te d , a nd und e r-re se a rc he d . BMJ. 2005;331:467–468.

Gender based differences in cardiovascular diseases

• “Women continue to be under-represented in research on heart disease. 3.
• Still women continue to receive similar treatments to men on the basis of trials that include

mainly male participants3.

Goals: 1.Emphasize the importance of screening for AAAs in high risk women. 2.Emphasize the importance of “sex-specific” management guidelines of AAA. Objectives: 1.Compare the outcomes of ruptured Abdominal Aortic Aneurysms between men and women. 2.Compare the characters of ruptured AAAs in men and women.

• Sample: All the AAA ruptures in Sisters and Mercy Hospitals admitted from

January 1 2007 to September 2012 (6 years).

• Type of study: Retrospective review of paper charts and Electronic Medical

Records.

• A total of 39 parameters were compared between males and females.
• SPSS v.19 was used for statistical analysis.
• Binary logistic regression, ANOVA (analysis of variance) and ANCOVA (analysis of

co-variance) were used for comparing the means.

• Survival plots were created by Kaplan-Meier analysis.

Methods

• Total no. of cases reviewed= 1538 (100%)

Results

Exclusion criteria

• Elective repairs
• Endovascular leak
• Endovascular revision
• Total no. of cases excluded = 1417 (92%)
• Total no. of cases included= 117 (8%)

Results

Incidence of AAAs

N (% )

Ma le s 79 (67.6%) F e ma le s 38 (32.4%) T

• ta l

117

67.6 32.4 Males Females

N (% )

Ma le s 1085 (70.6%) F e ma le s 453 (29.4%) T

• ta l

1538

70.6 29.4 Males Females

Incidence of AAA ruptures

Demographics

Male s F e male s T

• tal

p- value

Site

0.17

SOCH

52(65.8%) 20(52.6%) 72

SBMH

27(34.2%) 18(47.4%) 45

Ra c e

N/ A

Ca uc a sia n

79 (100%) 38(100%) 117

Othe rs

BMI

(n=77)

0.02

No rma l

15(25.8%) 11(58.0%) 26

Ove rwe ig ht

24(41.3%) 6(31.5%) 30

Ob e se

19(32.9%) 2(10.5%) 21

Smo king

0.06

Ye s

66(83.5%) 26(68.4%) 92

No

13(16.5%) 12(31.6%) 25

Co-morbidities and medications

Ma le s F e ma le s T

• ta l

p-va lue Hype rte nsio n 0.64 Ye s 66(83.5%) 33(86.8%) 99 No 13(16.5%) 5(13.2%) 18 Ma jo r c o -mo rb iditie s 0.64 Ye s 38 (48.1%) 20(52.6%) 58 No 41(52.9%) 18(47.4%) 59 Sta tin 0.74 Ye s 40(50.6%) 18(47.4%) 68 No 39(49.4%) 20(52.6%) 59 Be ta -Blo c ke r 0.48 Ye s 24(30.4%) 14(36.8%) 38 No 55(69.6%) 24(63.2%) 79 Aspirin 0.10 Ye s 40(50.6%) 18(47.4%) 58 No 39(49.4%) 20(52.6%) 59 Clo pido g re l 0.47 Ye s 7(8.9%) 5(13.1%) 12 No 72 33(86.8%) 105

Age at rupture

p=0.005

N Me a n (ye a r s) S.D. (ye a r s) Ra ng e (ye a r s)

Ma le s 79 75.75 10.0 50-97 F e ma le s 38 82.39 8.6 59-103 Ove ra ll 117 77.91 10.1 50-103

• Gender was an independent predictor of age of rupture after controlling the effects
• f hypertension, co-morbidities, smoking, use of statins and previous history of

aneurysms.

Characters of AAAs at presentation

Male s F e male s T

• tal

p- value

L

• c a tio n

0.28

I nfra -re na l

75 (94.9%) 34 (89.5%) 109

Supra -re na l

1 (2.6%) 1

Bo th

4 (5.1%) 3 (7.9%) 7

I lia c a rte rie s

0.42

L e ft

6 (7.6%) 1(2.6%) 7

Rig ht

9(11.4%) 4(10.5%) 13

Bo th

12(15.2%) 3(7.9%) 15

No ne

52 (65.8%) 30(78.9%) 82 (Pa ra me te rs fro m the CT sc a n a b do me n a t a dmissio n)

Characters of AAAs at presentation

Size at rupture

Me a n size (c m) S.D. (c m) Ra ng e (c m) Ma le s 8.23 1.84 4-12

F e ma le s

7.46 2.09 3-14.7

p=0.04

Effect of gender on Hospital course

Yes No Males 74 (93.7%) 5 (6.3%) Females 24 (63.2%) 14 (36.8%)

Incidence of surgery

P=0.03

Males Females Total p-value EVAR 57 (72.2%) 16 (42.1%) 73 <0.01 Open 17 (21.5%) 8 (21.1%) 25 None 5 (6.3%) 14 (36.8%) 19

Type of surgery performed

Use of ventilator+ Pressor Support+ LOS ICU (days) Post-op complications*

Males 59.5 % 54.1 % 4.1 48.6% Females 75 % 70.8 % 5.5 58.3%

*Ma jo r c o -mo rb iditie s wa s a sig nific a nt pre dic to r o f

po st-o pe ra tive c o mplic a tio ns, VDRF a nd use o f va so pre sso rs (p<0.001, lo g istic re g re ssio n)

Indicators of post-operative morbidity

+Ag e wa s a sig nific a nt pre dic to r o f VDRF

a nd use o f va so pre sso rs (p<0.001, lo g istic re g re ssio n)

N=98, Men=74 and Women=24

Overall Mortality

Alive Dead Total Males 54 (68.4%) 25 (31.6%) 79 Females 12 (31.6%) 26 (68.4%) 38 Overall 66 (56.4%) 51 (43.6%) 117

• P=0.001
• Adjusted for hypertension, smoking,

statins, major co-morbidities (logistic regression)

Post-operative mortality

• P=0.05
• Adjusted for hypertension,

smoking, statins, major co-morbidities (logistic regression)

Alive Dead Total Males 53 (71.6%) 21 (21.4%) 74 Females 12 (50.0%) 12 (50.0%) 24 Overall 65 (66.3%) 33 (33.7%) 98

EVAR OPEN Males 17.5 % 64.7% Females 43.8% 63% P-value 0.02 N/A

Mortality based on type of surgery

• Adjusted for hypertension, smoking,

statins, major co-morbidities (logistic regression)

Mean size (cm) S.D. (cm) Range (cm) Males 4.0 3.3 4-10 Females 5.0 2.6 3-9.3

Elective surgery could have been performed !!

Size at previous diagnosis

Long term survival

Kaplan-Meier survival curve analysis

Males=11.0 months Females=9.3 months P= 0.41

• unadjusted data.
• very small sample.
• Patients discharged alive were followed for a period of -2 years.
• Date of death was procured from ssdmf.com (SSN database)

It is about….…. Will the screening be cost effective?

1.http:/ / www.123rf.c o m/ pho to _18118258_e ld e rly-wo ma n-suffe ring -with-a -b e lly-pa in-in-the -living -ro o m.html-05/ 232013

1

Summary of financials from previous 3 years (SOCH & SBMH)

• Average re-imbursement for surgical repair after a AAA rupture was 8500$

more for male patients over female patients.

• Average re-imbursement for AAA rupture admissions was 7500$ more for

male patients over female patients.

• Average re-imbursement for an ultrasound for AAA screening=97.77$1

http:/ / www.g e he a lthc a re .c o m/ use n/ c o mmunity/ re imb urse me nt/ do c s/ Va sc ula r_Surg e ry_re imb urse me ntv2.pdf

Will the screening be cost effective?

Conclusions: “Lower AAA prevalence is balanced by a higher rupture rate, mortality and morbidity. So screening is indeed cost-effective.”

Limitations

• Study could not comment on the current guidelines of elective surgery

at 5.5 cm

• Single center study
• Missing co-variates: smoking quantity, COPD (use of steroids), family

history, age at menopause, occupation

• Small AAAs (Prospective trial)
• Total no. of visits (Catholic Health System) = >1500

Future studies….

Conclusions

• The overall incidence of AAA rupture was higher in males

(68%) than in females (32%).

• There was a significant effect of gender on the age of death

from AAA rupture after controlling the effect of hypertension, co-morbidities, smoking, use of statins and previous history of aneurysms; F (1,110)=8, p=0.005.

• There was a significant difference in the size of AAA rupture

between females (mean=7.4 cm, SD=2.0) and males (mean=8.2 cm, SD=1.8); t (115)=2.0, p = 0.04.

• The probability to undergo surgery for ruptured AAA was

significantly lower for women as compared to men, even after adjusting for age at admission and major co-morbidities (p=0.03).

Conclusions

• There was a significant effect of gender on the overall mortality

(p=0.001) and post-operative mortality after EVAR (p=0.02) from AAA rupture after controlling the effect of hypertension, co-morbidities, smoking, use of statins and previous history of aneurysm.

• Length of ICU stay, incidence of post-operative complications,

use of pressors and use of ventilator was more in females.

• Using a similar threshold of size (5.5 cm) for elective surgery for

both males and females might not be appropriate.

• AAA screening might be warranted for high risk females owing

to their higher morbidity and mortality.

• CHS IRB members
• Andrew Bishop (Data analyst)-- Financial analysis
• Kamal Tourbaf, MD
• Henri Woodman, MD
• Paul M Anain, MD
• Khalid J Qazi, MD, MACP

Acknowledgements

THANK YOU