[show abstract][hide abstract] ABSTRACT: A best-evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether screening asymptomatic individuals for an abdominal aortic aneurysm (AAA) is feasible and improves disease-free survival. Seven studies presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and limitations of the studies are tabulated. In total, four randomized population-based studies have evaluated ultrasound screening for AAA: two British studies, Multicentre Aneurysm Screening Study (MASS) and the Chichester trial, and one each in Viborg County, Denmark and Western Australia. Participants were randomized to receive an invitation to screen or not. The MASS trial randomized 67 770 men, followed participants over 10 years and concluded that screening would almost half AAA-related deaths in men aged 65-74 years. The smaller Chichester trial included only 6040 men but demonstrated a 42% reduction in AAA-related mortality at 5 years, with ongoing benefit at 15 years (11% reduction). The Viborg County trial recruited 12 639 men aged 64-73 years, showed a 66% reduction in AAA-related mortality over 14 years. Finally, the Western Australia trial evaluated 41 000 men but included an older population of 65-83 years old. No benefit was seen in this age group but subgroup analysis of men aged 65-74 showed a significant mortality benefit. Only a small or insignificant benefit in all-cause mortality was seen in any of these studies. A recent meta-analysis of these trials has shown a significant benefit in AAA-related mortality in the long term and concluded that AAA screening is superior to other established screening programmes. The cost-effectiveness of screening was assessed in the MASS and Viborg County trials and was found to be substantially below the cost threshold set by the National Institute of Clinical Excellence for acceptance of interventions. Quality of life was assessed in the MASS and in a case-control study and showed no adverse effects that outweigh the benefits. We concluded that ultrasound screening for AAAs has met all the criteria to become a screening programme and would substantially reduce disease-related death with no adverse effect on quality of life.
Interactive cardiovascular and thoracic surgery 01/2012; 14(4):399-405.
[show abstract][hide abstract] ABSTRACT: A best evidence topic was written according to a structured protocol. The question addressed was 'Is it safe to perform coronary angiography (CA) in acute endocarditis?' Three hundred and ninety-seven papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, key results and limitations of these papers are tabulated. One of the papers is a case report, which reported a fatal vegetation embolism from an infected aortic valve into the left main coronary artery 14 h after angiography. The remaining five papers are cohort studies. Four of these studies were performed between 1970 and 1980 before the era of echocardiography and were aimed at quantifying the severity of valvular regurgitation. No embolic complications or dislodgement of vegetations occurred in any of the five studies (186 patients). Guidelines published by the European Society of Cardiology (ESC) in 2009 recommended CA in the context of infective endocarditis (IE) for men >40 years old, postmenopausal women, and patients with at least one cardiovascular risk factor or a history of coronary artery disease. Exceptions include patients with large aortic vegetations which may be dislodged during catheterisation, and when emergency surgery is necessary - 1) native aortic or mitral IE with severe acute regurgitation or valve obstruction, or prosthetic valve IE with severe prosthetic dysfunction (dehiscence or obstruction) causing refractory pulmonary oedema or cardiogenic shock; 2) native aortic, mitral, or prosthetic valve IE with fistula into a cardiac chamber or pericardium causing refractory pulmonary oedema or shock. This is reiterated by the guidelines on the management of valvular heart disease published by the ESC in 2007. From the findings of the six papers, it can be concluded that coronary angiography can be performed safely in IE and should be performed if deemed necessary, unless the patients are haemodynamically unstable requiring emergency surgery, or have large vegetations of the aortic valve. This is consistent with the ESC guidelines.
Interactive cardiovascular and thoracic surgery 05/2011; 13(2):158-67.