Assessing a Woman's Risk of AAA
Women's AAA risk should be assessed through identification of specific risk factors—particularly age ≥65 years, smoking history (current or former), and cardiovascular disease—as these factors substantially elevate AAA prevalence from the baseline 0.7% to as high as 6.4% in high-risk subgroups. 1, 2
Risk Stratification Framework
Primary Risk Factors
The most critical risk factors that identify women at elevated AAA risk include:
- Smoking history: Current or former smoking increases AAA risk 3.3-fold (OR = 3.29,95% CI 1.86-5.80), making it the single most important modifiable risk factor in women 2
- Age ≥65 years: Advanced age increases risk 4.6-fold (OR = 4.57,95% CI 1.98-10.54), with prevalence rising from 0.43% at age 65 to 1.15% at age 75 3, 2
- Cardiovascular disease: History of coronary artery disease or other cardiovascular conditions increases risk 3.6-fold (OR = 3.57,95% CI 2.19-5.84) 2
Secondary Risk Factors
Additional factors that contribute to AAA risk assessment include:
- Family history of aortic aneurysm or cardiovascular disease 1
- Hypertension 1
- Hypercholesterolemia 1
- Peripheral artery disease 1
Cumulative Risk Assessment
Women with multiple atherosclerotic risk factors demonstrate substantially elevated AAA prevalence rates reaching 6.4%, compared to 0.7% in the general female population. 2 This multiplicative effect means that a woman aged ≥65 years who smokes and has cardiovascular disease represents a distinctly high-risk profile warranting consideration for screening.
Baseline Prevalence Context
Understanding baseline prevalence is essential for risk assessment:
- General female population aged ≥65 years: 0.43-0.7% prevalence 3, 2
- Women aged 75 years: 1.15% prevalence 3
- High-risk women (age ≥65 + smoking + cardiovascular disease): Up to 6.4% prevalence 2
For comparison, men aged ≥65 years have 3.9-9.1% prevalence, representing a 5-13 fold higher baseline risk than women 1, 2
Clinical Application Algorithm
Step 1: Identify if the woman is aged ≥65 years 1, 2
Step 2: Assess smoking status (current, former, or never smoker) 1, 2
Step 3: Evaluate for cardiovascular disease history 2
Step 4: Document additional risk factors (family history, hypertension, hypercholesterolemia, peripheral artery disease) 1
Step 5: Stratify risk:
- Highest risk: Age ≥65 + smoking history + cardiovascular disease (prevalence up to 6.4%) 2
- Moderate risk: Age ≥65 + smoking history OR cardiovascular disease 2
- Lower risk: Age ≥65 without smoking or cardiovascular disease 3
Important Caveats
Rupture Risk Considerations
Women face a four-fold higher rupture risk compared to men with similar-sized aneurysms, making risk assessment particularly critical for mortality prevention 4, 5 The case fatality rate from rupture remains 75-90%, with over half of deaths occurring before hospital arrival 1
Screening Limitations
Current evidence shows that even in high-risk women (smokers, ex-smokers, or those with coronary disease), AAA prevalence remains relatively low at 0.29%, with current smokers showing the highest prevalence of 0.83% but paradoxically the lowest screening attendance at 75.2% 5 This creates a practical challenge where those at highest risk are least likely to engage with screening.
Sex-Specific Thresholds
Women require intervention at smaller aortic diameters (≥5.0 cm) compared to men (≥5.5 cm) due to their elevated rupture risk 1, 4