Is a family history of Abdominal Aortic Aneurysm (AAA) a reason for a 76-year-old male with no smoking history to undergo an ultrasound (US) screening?

Screening for Abdominal Aortic Aneurysm in a 76-Year-Old Male with Family History but No Smoking History

Ultrasound screening for AAA is recommended for this 76-year-old male with family history of AAA despite having no smoking history, as family history is an independent risk factor that warrants screening.

Risk Assessment and Recommendations

Primary Recommendation

• Screening is recommended for first-degree relatives (FDRs) of patients with AAA aged ≥50 years, regardless of smoking status, according to the 2024 European Society of Cardiology (ESC) guidelines 1
• This recommendation has been upgraded from a Class IIa (should be considered) in previous guidelines to a Class I (is recommended) in the 2024 guidelines 1

Age Considerations

• While the patient is 76 years old, which is slightly above the typical upper age limit for routine screening (75 years), the ESC guidelines specifically state that screening may be considered in men aged ≥75 years irrespective of smoking history 1
• The presence of family history further strengthens the case for screening in this patient 1

Risk Factor Analysis

• Major risk factors for AAA include:
  • Age ≥65 years (patient is 76) 1
  • Male sex (patient is male) 1
  • Family history of AAA requiring surgical repair (patient has family history) 1
  • Smoking history (patient has no smoking history) 1

Evidence Supporting Screening in This Case

Family History as a Key Risk Factor

• A first-degree family history of AAA requiring surgical repair significantly elevates a man's risk for AAA 1
• The 2024 ESC guidelines specifically recommend screening for FDRs of patients with AAA aged ≥50 years unless an acquired cause can be clearly identified 1

Age and Non-Smoking Status

• While the USPSTF makes no definitive recommendation for or against screening men aged 65-75 who have never smoked (Grade C recommendation) 1, the presence of family history shifts the risk-benefit balance toward screening 1
• The 2024 ESC guidelines specifically state that screening may be considered in men aged ≥75 years irrespective of smoking history 1

Screening Method and Follow-up

Recommended Screening Approach

• Abdominal ultrasonography is the recommended screening modality due to:
  • High sensitivity (95%) and specificity (nearly 100%) when performed with adequate quality assurance 1
  • Safety, non-invasiveness, and relatively lower cost compared to other imaging modalities 2
  • One-time screening is sufficient; there is negligible health benefit in rescreening those with normal aortic diameter on initial screening 1

Management Based on Findings

• If an AAA is detected, management depends on size:
  • Small aneurysms (<5.5 cm) are typically monitored with periodic ultrasound 3
  • Surgical intervention is generally recommended for aneurysms ≥5.5 cm or those growing rapidly 3

Potential Benefits and Harms

Benefits of Screening

• Early detection of AAA can prevent rupture, which has a mortality rate of 65-85% 4
• Elective repair of large AAAs (≥5.5 cm) leads to an estimated 43% reduction in AAA-specific mortality in older men who undergo screening 1

Potential Harms

• Screening and early treatment can lead to:
  • Increased number of surgeries with associated morbidity and mortality (4-5% operative mortality for open surgical repair) 1
  • Short-term psychological harms 1
  • Potential overtreatment of aneurysms that may never rupture 1

Conclusion

For this 76-year-old male with family history of AAA but no smoking history, ultrasound screening is recommended based on the 2024 ESC guidelines, which specifically address this risk profile. The presence of family history is a significant risk factor that warrants screening despite the absence of smoking history.