Abdominal aortic aneurysm risk factors
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Vishnu Vardhan Serla M.B.B.S. [3] Ramyar Ghandriz MD[4]
Overview
The most significant modifiable risk factor for the development of an abdominal aortic aneurysm is smoking which increases the risk of aneurysm development 8 fold. Advanced age and family history are the strongest non-modifiable risk factors for the development of an abdominal aortic aneurysm. Hypercholesterolemia and hypertension are risk factors as well. Both diabetes mellitus and being of African American descent appear to be associated with a lower incidence of abdominal aortic aneurysm. Caucasians report a higher incidence of AAA when compared to the non Caucasians. An increased rate of expansion of abdominal aortic aneurysm is related to systolic hypertension, wide pulse pressure, and ongoing smoking. The risk of abdominal aortic aneurysm rupture is proportional to the size and rate of growth of the aneurysm. Abdominal aortic aneurysms greater than 5 cm diameter or those that grow faster than 1 cm per year have a significantly increased risk of rupture and are indications for elective operative repair. Advanced age, female gender, hypertension, active smoking, outpouchings, and mural thrombus are also risk factors for abdominal aortic aneurysm rupture.
Risk Factors
Risk Factors for Abdominal Aortic Aneurysm Development
- The strongest independent acquired risk factor for AAA is smoking. In a study by Wilmink et. al, it is shown that current smokers are 7.6 times more likely to manifest an abdominal aortic aneurysm than non smokers. Risk of developing abdominal aortic aneurysm increases related to increase in smoking duration, but amount of cigarettes smoked per day did not provide any further information.[1][2]
- Most important non-reversible risk factors are advanced age and family history. There is an increased risk of developing abdominal aortic aneurysm by 2 to 5 folds with family history,compared to normal society[3][4][5].
- The prevalence of abdominal aortic aneurysms among first-degree relatives diagnosed with abdominal aortic aneurysms increases to 15-29%, compared with 2% among relatives of controls.[6]
- Male sex
- Caucasian race
- Genetic factors like genetic polymorphism and presence of HLA-DRB 1 alleles B1*0404 and HLA-DRB1 alleles B1*15[7]
- Hypertension
- Known atherosclerotic disease - coronary artery disease, cerebrovascular disease, peripheral artery disease
- Hypercholesterolemia
- Chronic obstructive pulmonary disease
Cardiovascular risk factors tend to cluster in certain patients:
- Men who smoke and are hypertensive have an incidence of abdominal aortic aneurysm that is 2-5 times than those of the general population.
- Similarly, women over the age of 60 with cardiovascular risk factors are 2-3 times more likely to develop aneurysmal disease.
- Both diabetes mellitus and being of African American descent appear to be associated with a lower incidence of abdominal aortic aneurysm.
Risk Factors for Rapid Abdominal Aortic Aneurysm Expansion
- In small abdominal aortic aneurysm (3-5.4 cm), the expansion rate appears to be proportional to the initial diameter.[8]
- Independent of the initial diameter of the aneurysm, other factors related to rapid expansion of an abdominal aortic aneurysm are:
- Systolic hypertension
- Wide pulse pressure
- Ongoing smoking
Factors not Associated with more Rapid Expansion of Abdominal Aortic Aneurysm
C-reactive protein levels have also been found to be elevated in larger aneurysms, however they do not appear to be linked to rapid expansion.[9]
Risk Factors for Abdominal Aortic Aneurysm Rupture
The risk of rupture is proportional to the size and rate of growth of the aneurysm. Aneurysms greater than 5 cm diameter or those that grow faster than 1 cm per year have a significantly increased risk of rupture and are indications for elective operative repair.[10][11] In the UK small aneurysm trial, important independent variables were identified with abdominal aortic aneurysm rupture:
- Female sex
- Increased diameter of the abdominal aortic aneurysm
- Current smoker
- Mean blood pressure
- Increased age
- Forced expiratory volume in 1 second
- Size at diagnosis is one of the best predictors of rupture.
- The risk increases substantially when the diameter exceeds 6 cm in men and 5 cm in women.
- Small aneurysms can rupture as well, and are threefold more likely to rupture in women.
- Localized outpouchings seems to increase the aneurysm's vulnerability for rupture.
- It has been suggested that the aneurysm growth and rupture correlate with the growth of the aneurysm's mural thrombus: the part of the aneurysm wall that is covered with thrombus has been shown to be thinner and showed focal anoxia, inflammation, apoptosis of the smooth muscle cells, and a more degraded extracellular matrix than wall segments not covered by the thrombus.
Management of Patients With Peripheral Artery Disease
Atherosclerotic Risk Factors
- (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[12]
| Class I |
| "1.In patients with AAAs, blood pressure and fasting serum lipid values should be monitored and controlled as recommended for patients with atherosclerotic disease. (Level of Evidence: C)" |
| "2.Patients with aneurysms or a family history of aneurysms should be advised to stop smoking and be offered smoking cessation interventions, including behavior modification, nicotine replacement, or bupropion(Level of Evidence: B) " |
References
- ↑ Wilmink TB, Quick CR, Day NE (1999). "The association between cigarette smoking and abdominal aortic aneurysms". Journal of Vascular Surgery. 30 (6): 1099–105. PMID 10587395. Unknown parameter
|month=ignored (help) - ↑ Kent, KC.; Zwolak, RM.; Egorova, NN.; Riles, TS.; Manganaro, A.; Moskowitz, AJ.; Gelijns, AC.; Greco, G. (2010). "Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals". J Vasc Surg. 52 (3): 539–48. doi:10.1016/j.jvs.2010.05.090. PMID 20630687. Unknown parameter
|month=ignored (help) - ↑ Larsson, E.; Granath, F.; Swedenborg, J.; Hultgren, R. (2009). "A population-based case-control study of the familial risk of abdominal aortic aneurysm". J Vasc Surg. 49 (1): 47–50, discussion 51. doi:10.1016/j.jvs.2008.08.012. PMID 19028058. Unknown parameter
|month=ignored (help) - ↑ Salo, JA.; Soisalon-Soininen, S.; Bondestam, S.; Mattila, PS. (1999). "Familial occurrence of abdominal aortic aneurysm". Ann Intern Med. 130 (8): 637–42. PMID 10215559. Unknown parameter
|month=ignored (help) - ↑ Lederle, FA.; Johnson, GR.; Wilson, SE.; Chute, EP.; Hye, RJ.; Makaroun, MS.; Barone, GW.; Bandyk, D.; Moneta, GL. (2000). "The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators". Arch Intern Med. 160 (10): 1425–30. PMID 10826454. Unknown parameter
|month=ignored (help) - ↑ Aggarwal S, Qamar A, Sharma V, Sharma A (2011). "Abdominal aortic aneurysm: A comprehensive review". Exp Clin Cardiol. 16 (1): 11–5. PMC 3076160. PMID 21523201.
- ↑ Rasmussen, Todd E; Hallett, John W.; Mathieu Metzger, Renate L.; Richardson, Darcy M.; Harmsen, William S.; Goronzy, Jorg J.; Weyand, Cornelia M. (1997). "Genetic risk factors in inflammatory abdominal aortic aneurysms: Polymorphic residue 70 in the HLA-DR B1 gene as a key genetic element". Journal of Vascular Surgery. 25 (2): 356–364. doi:10.1016/S0741-5214(97)70358-6. ISSN 0741-5214.
- ↑ Devaraj, S; Dodds, SR (2008). "Ultrasound Surveillance of Ectatic Abdominal Aortas". The Annals of The Royal College of Surgeons of England. 90 (6): 477–482. doi:10.1308/003588408X301064. ISSN 0035-8843.
- ↑ Norman, Paul; Spencer, Carole A.; Lawrence-Brown, Michael M.; Jamrozik, Konrad (2004). "C-Reactive Protein Levels and the Expansion of Screen-Detected Abdominal Aortic Aneurysms in Men". Circulation. 110 (7): 862–866. doi:10.1161/01.CIR.0000138746.14425.00. ISSN 0009-7322.
- ↑ Dahnert W. Radiology Review Manual, 5th edition. Lippincott, Williams and Wilkins 2003
- ↑ Rakita D, Newatia A, Hines JJ, Siegel DN, Friedman B (2007). "Spectrum of CT findings in rupture and impending rupture of abdominal aortic aneurysms". Radiographics. 27 (2): 497–507. doi:10.1148/rg.272065026. PMID 17374865.
- ↑ Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 61 (14): 1555–70. doi:10.1016/j.jacc.2013.01.004. PMC 4492473. PMID 23473760.