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Rapid Responses: Rapid Responses published:
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Judgment Day upon screening for abdominal aortic aneurysm
- Hisato Takagi, Masafumi Matsui, Takuya Umemoto (28 June 2009)
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All-cause mortality ?
- L Sam Lewis (29 June 2009)
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Hisato Takagi, consultant cardiovascular surgeon Shizuoka Medical Centre, Shizuoka 411-8611, Japan, Masafumi Matsui, Takuya Umemoto
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Thompson and colleagues [1] presented new information from the 10- year follow-up in the United Kingdom Multicentre Aneurysm Screening Study (MASS). Meanwhile, a recent meta-analysis, by Lindholt and Normen [2] published in 2008, of randomized controlled trials (not including 10-year results [1] of the MASS) showed that screening for abdominal aortic aneurysm (AAA) reduced both AAA-related and all-cause long-term mortality in men aged ≥ 65 years. Lederle [3] and Koelemay [4], however, revealed citation errors in the meta-analysis [1] and claimed that the reduction in all- cause long-term mortality failed to reach statistical significance. We herein combined 10-year results in the MASS [1], 15-year results in the Chichester study (men) [5], 10-year results in the Viborg Country study [6], and 11-year age-adjusted results (merely all-cause mortality cited in the response to the comment by Lederle [3] upon the meta-analysis by Lindholt and Normen [1]) in Western Australia study [7]. Pooled analysis demonstrated a statistically significant 0.43% absolute risk reduction in AAA-related mortality (fixed-effects risk difference, –0.0043 [–0.43%]; 95% confidence interval, |0.0057 [–0.57%] to –0.0030 [–0.30%]; P < 0.0001; P for heterogeneity = 0.3033) and 0.55% absolute risk reduction in all-cause mortality (fixed-effects risk difference, –0.0055 [–0.55%]; 95% confidence interval, |0.0109 [–1.09%] to –0.0001 [–0.01%]; P = 0.0451; P for heterogeneity = 0.8926) with screening for AAA. Last Judgment suggests that screening for AAA may reduce both AAA- related and all-cause long-term mortality in men aged ≥ 65 years. Mastracci and Cinà hypothesized in their reply to our Letter to the Editor [8] regarding their review article [9] that a reduction in lifestyle-related cardiovascular risk factors, which were addressed when the participants accessed medical care for screening, might decrease all-cause mortality in the screened population. If the hypothesis is valid, nonaneurysm-related deaths are distributed in attenders for screening less than in nonattenders for screening or in uninvited controls. Our previous pooled analysis [10] demonstrated a statistically significant 50% reduction in midterm nonaneurysm-related mortality with attenders for screening (9.73%) relative to nonattenders for screening (17.46%) (odds ratio, 0.50; 95% confidence interval, 0.48 to 0.53). Attenders for screening was associated with a statistically significant 23% reduction in midterm nonaneurysm-related mortality relative to uninvited controls (12.37%) (odds ratio, 0.77; 95% confidence interval, 0.65 to 0.90). Because it is unclear in long-term follow- up whether or not the hypothesis is valid, we would like to know nonaneurysm-related (or AAA-related) mortality separately in attenders and nonattenders for screening in the 10-year follow-up MASS [1]. 1 Thompson SG, Ashton HA, Gao L, Scott RA; Multicentre Aneurysm Screening Study Group. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ 200;338:b2307. (27 June.) 2 Lindholt JS, Norman P. Screening for abdominal aortic aneurysm reduces overall mortality in men. A meta-analysis of the mid- and long-term effects of screening for abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2008;36:167-71. 3 Lederle FA. Comment on "Screening for abdominal aortic aneurysm reduces overall mortality in men". Eur J Vasc Endovasc Surg 2008;36:620- 1; author reply 621-2. 4 Koelemay MJ. Comment on "Screening for abdominal aortic aneurysm and overall mortality in men". Eur J Vasc Endovasc Surg 2009;37:739-40; author reply 740. 5 Ashton HA, Gao L, Kim LG, Druce PS, Thompson SG, Scott RA. Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. Br J Surg 2007;94:696-701. 6 Lindholt JS, Juul S, Fasting H, Henneberg EW. Preliminary ten year results from a randomised single centre mass screening trial for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2006;32:608-14. 7 Norman PE, Jamrozik K, Lawrence-Brown MM, Le MT, Spencer CA, Tuohy RJ, et al. Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm. BMJ 2004;329:1259. Erratum in: BMJ 2005;330:596. 8 Takagi H, Tanabashi T, Kawai N, Umemoto T. Regarding "Screening for abdominal aortic aneurysm reduces both aneurysm-related and all-cause mortality". J Vasc Surg 2007;46:1311-2; author reply 1312. 9 Mastracci TM, Cinà CS; Canadian Society for Vascular Surgery. Screening for abdominal aortic aneurysm in Canada: review and position statement of the Canadian Society for Vascular Surgery. J Vasc Surg 2007;45:1268-1276. 10 Takagi H, Kawai N, Umemoto T. Regarding "Screening for abdominal aortic aneurysm in Canada". J Vasc Surg 2008;47:1376-7. Competing interests: None declared |
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L Sam Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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Despite the phrase '10-year mortality' in the title, and the text stating "We used unadjusted Cox regression to compare deaths related to abdominal aortic aneurysm (censoring other causes of death) and all cause mortality between the two randomised groups", I cannot find any all-cause mortality figures in Thompson et al's paper. I am very keen to know this crucial data. yours L S Lewis Competing interests: None declared |
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