Screening Recommendation for Long-Time Smokers
For a chronic smoker, abdominal aortic aneurysm (AAA) ultrasound screening is the appropriate and evidence-based choice if the patient is a man aged 65-75 years, as this is a Grade B recommendation with proven mortality benefit. Coronary artery calcium scoring is not a guideline-recommended screening test for smokers and addresses a different clinical question (cardiovascular risk stratification rather than preventing rupture-related death).
The Clear Evidence for AAA Screening
The decision here is straightforward based on established guidelines:
Men aged 65-75 who have ever smoked should receive one-time ultrasound screening for AAA, which reduces AAA-specific mortality by approximately 50% 1, 2.
This is a Grade B recommendation from the U.S. Preventive Services Task Force, meaning there is high certainty of moderate net benefit 1, 3.
The screening is performed once—rescreening those with normal initial results provides negligible benefit 2.
Why AAA Screening Takes Priority
The rationale for prioritizing AAA screening in smokers is compelling:
AAA rupture carries up to 81% mortality risk, making this a life-threatening condition that is preventable through screening 3.
Smoking is the single strongest modifiable risk factor for AAA development 1, 2, 4.
Ultrasound has 95-100% sensitivity and specificity for detecting AAA, making it an excellent screening tool 2, 4.
The screening must be performed in an accredited facility with credentialed technologists to ensure quality 1, 4.
What Happens After Screening
Management is size-dependent and well-established:
Small AAAs (3.0-3.9 cm): Periodic ultrasound surveillance without immediate intervention 2.
Intermediate AAAs (4.0-5.4 cm): Surveillance preferred over immediate surgery, as randomized trials showed no mortality benefit from immediate repair 2.
Large AAAs (≥5.5 cm in men): Surgical intervention indicated, either open repair or endovascular repair 2.
Important Caveats
Screening rates remain disappointingly low (13-26%) despite clear mortality benefit, so this is an underutilized preventive measure 1.
For men aged 65-75 who have never smoked, screening is only selectively offered (Grade C recommendation), not routinely recommended 1, 4.
Women who have never smoked should not receive routine AAA screening (Grade D recommendation) 1.
Family history matters: First-degree relatives of AAA patients aged ≥50 years warrant screening consideration regardless of other risk factors 2.
Why Not Calcium Scoring?
Coronary artery calcium scoring is not mentioned in any AAA screening guidelines and serves a completely different purpose—it assesses atherosclerotic cardiovascular disease risk, not aneurysm risk. While both conditions share smoking as a risk factor, AAA screening has specific guideline-based recommendations with proven mortality reduction, whereas calcium scoring is used for refining statin therapy decisions in intermediate-risk patients, not as a screening test for smokers per se.