Vascular Disease Screening and Intervention in Danish Men
What is the effect of screening and subsequent intervention for abdominal aortic aneurysm (AAA), peripheral artery disease (PAD), and hypertension (HTN)?
Using a randomized trial design, men aged 65-74 years living in Denmark were randomized to screening for AAA, PAD, and HTN or no screening. All participants who were found to have AAA or PAD on screening were invited to undergo confirmation and eventual pharmacologic intervention. Patients with AAA were offered annual screening or surgical repair, based on the aneurysm size. Patients found to have HTN were referred to primary care for management. The primary outcome was all-cause mortality, assessed 5 years after randomization.
Between 2008 and 2011, 50,156 men were randomized to screening or no screening. After a median follow-up of 4.4 years (interquartile range, 3.9-4.8), 2,566 (10.2%) of the screening group and 2,715 (10.8%) of the nonscreening group had died (hazard ratio, 0.93; 95% confidence interval, 0.88-0.98; p = 0.01; number needed to screen, 169 [89-1,811]).
The VIVA trial authors concluded that this population-based randomized trial demonstrated mortality benefit associated with AAA, PAD, and HTN screening for men aged 65-74 years.
While the United States Preventative Service Taskforce (USPSTF) currently recommends AAA screening for men aged 65-74 years who have ever smoked and HTN screening for all adults aged 18 or older, they find insufficient evidence to support PAD screening. This trial provides robust evidence in support of broad cardiovascular disease screening for men aged 65-74. While the absolute mortality risk reduction is small, there was not a significant harm associated with screening and initiation of therapy in this study. Broad public health initiatives will be required to achieve similar screening efforts in the United States, but the potential benefit is quite large. In the interim, primary care and cardiovascular medicine providers should perform routine screening measures for middle-aged men, including a thorough clinical exam (including inspecting feet and palpating pedal pulses).
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