BARCELONA – Non-invasive population-wide screening for high blood pressure, abdominal aortic aneurysm and peripheral artery disease appears to be life-saving, feasible and cost-effective, according to researchers who performed the Danish Viborg Vascular (VIVA) study that included 50,000 men.
When compared with the men who were not screened, there was a 7% reduction in mortality – or it required 169 screenings to save one life (P=0.01), said Jes Lindholt, MD, professor of vascular surgery,at Odense University Hospital, Denmark.
“Screening for cardiovascular disease hasn’t caught much attention,” Lindholt said at a press conference at the annual congress of the European Society of Cardiology. “We sought to test whether triple vascular screening for abdominal aortic aneurysm, peripheral artery disease and hypertension could reduce overall mortality in 64-75 year old men.”
He said that only men were considered for the trial because the diseases were predominantly found in the male population.
The screening and usual care groups were followed using national registries for hospital admissions, surgeries, and overall and cause-specific death. After 5 years, 149 more lives were saved in the screening group. There were 2,566 deaths in the screening group versus 2,715 in the control group.
“A result of this magnitude has never been seen before in general population screening programs,” said Lindholt. “We believe that it is primarily explained by the 2.5 times higher incidence of elective aneurysm repairs and the doubled initiation rates of anti-thrombotic and lipid-lowering therapy in the group invited to screening.”
He noted, “These diseases are often asymptomatic and can be life threatening. Of course, elective repair of an aneurysm can prevent dying of rupture. However, pharmacological therapy for peripheral artery disease, aneurysms or hypertension holds a much larger potential to reduce the risk of dying from coronary heart disease, stroke, and heart attack.”
The study was published online in The Lancet at the same time it was presented at the conference.
The prospective study randomized 50,156 men ages 65 to 74 years, all of whom lived in the central region of Denmark. Half were invited to screening and the other half to usual care where disease is typically detected only if a man reacts to symptoms or is in contact with healthcare for other reasons. The primary outcome was all-cause mortality.
Men in the screening group underwent a 10-minute procedure in which their aorta was scanned using ultrasonography and their blood pressure was measured and compared for the ankle and the arm. Two specially trained nurses undertook the procedure.
More than 20% of those attending screening had positive test results: 3% had an abdominal aortic aneurysm (AAA or triple A), 11% had peripheral artery disease, and 11% had suspected hypertension that was untreated. “We were quite surprised that despite modern healthcare with diagnostic technology being available essentially everywhere, one out of five men had undiagnosed vascular disease,” said Lindholt.
Men who tested positive for abdominal aortic aneurysm and/or peripheral artery disease had a confirmatory test and consultation where individualized prophylactic activities, including smoking cessation and pharmacological therapy, were recommended. If not already prescribed, low dose aspirin (75 mg/day) and simvastatin (40 mg/day) were prescribed. Those with an aneurysm larger than 50 mm in diameter were referred to a vascular surgeon to assess the need for elective repair. Men with suspected hypertension were referred to their general practitioner.
The cost of screening (using 2014 prices) was estimated at an additional $175 per citizen in comparison with usual care from a healthcare sector perspective.
In commenting on the study, George Vetrovec, MD, professor emeritus of cardiology at Virginia Commonwealth University, Richmond, told MedPage Today, “The VIVA trial really shows what you can do with a rather simple, large data study. They screened 50,000 patients in central Denmark. Of the invited patients to be screened, only 75% showed up. This starts to talk about perhaps some of the difficulties in clinical medicine.
“If a triple A was found, then they were referred for follow-up – to medical treatment if the aneurysm was less than 5 centimeters and to surgical treatment if it was greater in size. When peripheral artery disease was found, the patients were started on statins or aspirin or both. And the hypertension patients were referred a specialist physician,” Vetrovec explained.
“It turns out that they were very successful and over 5 years they were able to reduce mortality over the screened group by 7% which was statistically significant. They had excellent follow-up,” he said.
‘What was disappointing, was that the number of patients started with statins or aspirin was about a third of the patients who had the disease and the percentage of hypertension patients treated was small,” Vetrovec said. “So the potential could have been greater.
“They did look at quality of life and there was a little anxiety for people who occasionally got a false diagnosis for peripheral artery disease but overall, the quality of life was positive, and the cost savings by doing this screening was well within the $50,000 per quality year life saved. You only had to screen 169 people to save a life. So overall a very positive study,” he said.
Lindholt and Vetrovec disclosed no relevant relationships with industry.
F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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