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Episode 21 : Abdominal Aortic Aneurysm Part 2

Release Date: August 28, 2007

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast. This is part two of our series on abdominal aortic aneurysms and in our first segment on this topic, we've been speaking with Dr. Elizabeth Ratchford. She is one of a new breed of physicians trained as internists, not as surgeons, but who are experts in the prevention, diagnosis and treatment of blood vessel diseases. She's Director of Clinical Vascular Medicine at Johns Hopkins. She's also a scientific advisor to the Vascular Disease Foundation. During our first half of this topic, we've been talking about abdominal aortic aneurysms. This is the bulging or weakening of the major blood vessel of the abdomen which can cause life threatening blood loss and other serious circulation complications and first off all, Elizabeth, Dr. Ratchford, thanks for agreeing to fill in with part two of this information that is very, very important to our listeners. Thank you.

Dr. Elizabeth Ratchford: It's my pleasure.

Dr. David Meyerson: During the first part of our discussion, we talked about who is at risk and just in summary, we said that people who were smokers, men who are over the age of sixty-five, men seem to get this disease much more than women, right?

Dr. Elizabeth Ratchford: Yes, that's true.

Dr. David Meyerson: And people with blood vessel disease, you mentioned people who have popliteal artery aneurysms, that's a bulging of an artery in back of your knee. I believe a vice president had something just like that. You said that when people have that, they can also have abdominal aortic aneurysms and people who have blood vessels -- blood vessel problems in other areas can also have these. So, it's important to do screening, but there's one thing that you mentioned to me during our private discussion about how women and men are different. Now we always talk about how men are from Mars and women are from Venus and we know with heart and blood vessel disease, for example for a heart attack, men may have the classic sub sternal crushing and squeezing pain. It can go to the neck and can go to the arm. It can go to the back. It may be associated with shortness of breath and sweating and maybe even dizziness, but women don't -- they may have some or all of those symptoms, but sometimes women don't have anything more than really profound fatigue or maybe shortness of breath or some variation of the symptoms that we mentioned, so we've been teaching doctors for many years now to be more sensitive to how a woman presents with heart disease. There is a distinction between women and men with abdominal aortic aneurysms, isn't there?

Dr. Elizabeth Ratchford: Yes, as I said before they're less likely to get them, but the problem is that when they do get them, they're more likely to rupture at a smaller size and some people think this is because women start out with smaller aortas to begin with, so the cut off should be lower for when you repair them. And the other problem is that when people do --

Dr. David Meyerson: So you're saying that -- and we'll get to this in a moment, but when the doctor measures the size of the abdominal aorta on a two hundred and sixty-pound man, the doctor shouldn't be using the same set of numbers to grade how wide or how important the widening is of the abdominal aorta in the ninety-pound woman.

Dr. Elizabeth Ratchford: Exactly. Right. And it could be at four centimeters, for example, that it might rupture rather than five and a half which is the typical cutoff that we use. The other problem is that --

Dr. David Meyerson: And don't worry audience, we'll get back to that in just a moment.

Dr. Elizabeth Ratchford: We'll get to that, yes. And then if people do decide -- a woman does decide to undergo elective repair of the aneurysm, then studies have shown that they have a higher mortality rate around the time of surgery and the reasons for that are not clear.

Dr. David Meyerson: So again, but the issue then is that prevention and treatment of what you can change before it becomes a big issue, is the big issue for our population today, to try to prevent these things from rupturing, to try to prevent these things from expanding, to get people to get checked and to let them know what it is they're asking about.

Dr. Elizabeth Ratchford: Right. And the other part of that is the cardiovascular risk because that, as we'll talk about, will end up being more important than the rupture risk for most people.

Dr. David Meyerson: And you're saying that if somebody has abdominal aortic aneurysm, it makes them more likely to also have blood vessel -- it's a marker for blood vessel disease in other areas of the body.

Dr. Elizabeth Ratchford: Right.

Dr. David Meyerson: In fact, we do that in our program on peripheral vascular disease when we have peripheral arterial disease. It really tells us, look upstairs. When we have carotid disease, it tells us look downstairs. And again, it's that sixty-year-old house analogy that we always use, if one part of the plumbing, it's the same age plumbing, if the plumbing upstairs is troubled in some way, it wouldn't be surprising if the plumbing downstairs would be troubled. Let's get back to the abdominal aorta. Remember this is the area just above where the aorta splits to feed both legs and it's probably at the level where the kidney arteries come off and below. Am I correct? Somewhere in the abdomen.

Dr. Elizabeth Ratchford: Right.

Dr. David Meyerson: And we talked very briefly that these are often picked up incidently. In other words, there's a lot of people having cat scans or X-rays of the abdomen and what, for example, do you say if the doctor says -- if the patient says, "My doctor says there was a lot of calcium in the abdominal aorta on my X-ray of my belly. Does that mean anything?"

Dr. Elizabeth Ratchford: Yes. So there are some aneurysms that are picked up based on X-ray, although it's definitely not the best test if you're trying to find an aneurysm. Sometimes you can see the --

Dr. David Meyerson: But a cat scan's a pretty good test.

Dr. Elizabeth Ratchford: That's true. But starting with the more simple test of the X-ray, now sometimes you can see a rounded rim of calcium on the X- ray and if you see that on an X-ray, you definitely need further evaluation to look specifically for an aneurysm. And --

Dr. David Meyerson: And the least of calcium in a blood vessel, we know that that did not happen yesterday.

Dr. Elizabeth Ratchford: Right.

Dr. David Meyerson: All right. That's a long-standing process, right?

Dr. Elizabeth Ratchford: Right and that whole process is actually -- or making the diagnosis of having this systemic problem of the plumbing in the house, as you mentioned, making that diagnosis of the corrosion of the pipes is probably more important than finding the aneurysm per say, but you definitely need further evaluation if you do see that on an X-ray.

Dr. David Meyerson: Now there is a simpler, a less dangerous, not that cat scans and X-rays are dangerous, but they have a risk involved because of the radiation, but there is a simpler, a painless, probably a less costly method for looking at blood vessels of the abdomen which you're an expert in as well, and that's ultrasound, isn't that right?Dr. Elizabeth Ratchford: Yes.

Dr. David Meyerson: Tell us about that as a screening tool.

Dr. Elizabeth Ratchford: It's by far the best screening tool for looking for an abdominal aortic aneurysm. The sensitivity, just one of the numbers that we quote about how good of a test it is, is about ninety-five percent and the specificity is about ninety- nine percent, so in medicine, you can hardly find a test that is that good.

Dr. David Meyerson: And again, we're talking about a test that's painless, no risk, right?

Dr. Elizabeth Ratchford: Right.

Dr. David Meyerson: And is not uncomfortable in any way, generally, and the cost is modest.

Dr. Elizabeth Ratchford: Right.

Dr. David Meyerson: So it's really an excellent screening test.

Dr. Elizabeth Ratchford: And in fact now, it's covered by Medicare which is a new thing.

Dr. David Meyerson: Tell me about that because Medicare is not, you know, in terms of prevention, we do certain screenings, but we really don't do enough of it in our society and when Medicare decides to pay for screening for abdominal aortic aneurysm, that's going some, isn't it?

Dr. Elizabeth Ratchford: Yes, yes. There's a lot of back and forth in Congress to get that bill passed, but we're very pleased that as of January of this year, 2007, Medicare does cover a one time screening for people, especially men between the ages of sixty-five and seventy-five who have a history of smoking and they define that as more than one hundred cigarettes in a lifetime. And then they'll cover --

Dr. David Meyerson: Well, you don't have to have smoked a lot to have that history then.

Dr. Elizabeth Ratchford: Right. And anybody, men or women, who have a family history or someone in their family who has an aneurysm, but the important thing to realize about the new Medicare guidelines is that this is only covered if the test is ordered when the patient or the person turns sixty-five as part of the welcome to Medicare initial preventive physical exam, so that's people who are newly enrolled in Medicare Part B. It's not that anybody out there who happens to have Medicare can go and have this screening test unfortunately.

Dr. David Meyerson: I see. Okay. And if they -- if a person is newly enrolled and they're going to have the abdominal aortic aneurysm screening, should they also have, what we talked about before, an ankle- brachial index, or do they also have carotid dopplers done as well or is it, would not pay for that?

Dr. Elizabeth Ratchford: It will not pay for that. A lot of people think that it should be done, but it's definitely a controversial topic.

Dr. David Meyerson: I'm looking at your face and believing that what you're telling me nonverbally is that this is a topic for another discussion.

Dr. Elizabeth Ratchford: Yeah.

Dr. David Meyerson: So, let's get back to abdominal aortic aneurysms. Now I'm going to ask that age-old question, is size important?

Dr. Elizabeth Ratchford: Yes. Size is by far the most important thing when it comes to aneurysm. That's the strongest predictor of rupture and the risk of rupture also depends on the rate of expansion.

Dr. David Meyerson: Before we get there, let me tell you, some people will come to me -- I'm a cardiologist, so we see some of these things as well, but what happens is that I'll get a note from a doctor saying that there is a three-centimeter abdominal aortic aneurysm. Is there -- is three centimeters really considered an abdominal aortic aneurysm or is it just beginning to have that aneurysmal shape? How to begin to define it? We don't want to spend a lot of time on this, but I want to give the listeners an idea of when an aneurysm begins to be an aneurysm and how large it is and how we follow those.

Dr. Elizabeth Ratchford: Well, that's -- it's pretty straight forward. We define things pretty simply in vascular medicine, so an aneurysm of any blood vessel is when it's one and a half times the size of what the normal blood vessel would be. And for the aorta, it's pretty easy because the normal aorta is about two centimeters so when it's one and a half times two, then that makes it three and that's the cutoff.

Dr. David Meyerson: So three and a half begins to be that lower limit of when we start looking at aneurysms and at what level do we think people are at risk for rupture?

Dr. Elizabeth Ratchford: Well, the rupture risk increases exponentially as it gets bigger, so your patient with a three centimeter, not even really an aneurysm yet, just on the cutoff, the risk is minimal and those people, they probably don't need any further follow-up. And just to remind you what, doctors all talk in centimeters, but people usually think in inches --

Dr. David Meyerson: Right.

Dr. Elizabeth Ratchford: -- so two point five centimeters is one inch and five to six centimeters is about the size of a lemon just to give you an idea. But anyway, if it's say between four and five centimeters --

Dr. David Meyerson: Now everybody would agree that if you have a six-centimeter abdominal aortic aneurysm, you are really -- let's start from the top and work our way down -- you're really at risk for something severe happening, are you not?

Dr. Elizabeth Ratchford: Yes.

Dr. David Meyerson: Okay.

Dr. Elizabeth Ratchford: And if it's more than seven centimeters, then the five-year risk of rupture is seventy-five percent which is extremely high.

Dr. David Meyerson: Exactly. So at that point, you really are in -- there's little question that when it gets very large, you really have to do something about it. Now, while you're making up your mind what to do, there are things that we can do to prevent and delay it's progression, but let's talk a little bit about the smaller ones there. Let's say you see somebody who has an abdominal aorta that's four centimeters, which is a little bit large. What do you advise them and what do you do?

Dr. Elizabeth Ratchford: So, those people just need to be followed. There's a couple of randomized trials, really good clinical trials looking at what to do with small aneurysms and basically having surgery on them early is the same as watchful waiting, or just sitting around and waiting for them to get bigger because not everybody's aneurysm will get bigger and if you can just avoid having a somewhat risky surgery in some percentage of those patients, then you're better off.

Dr. David Meyerson: I'm glad -- in fact our listeners will be happy to know that you're not a proponent of early fillet of Uncle Joe, right?

Dr. Elizabeth Ratchford: That's for sure.

Dr. David Meyerson: When surgery's not necessary, you don't want to see it happen.

Dr. Elizabeth Ratchford: Right.

Dr. David Meyerson: Okay. And so, if you have that four-centimeter aneurysm, when would you tell Uncle Joe to come back to be screened again?

Dr. Elizabeth Ratchford: Probably in about a year.

Dr. David Meyerson: Okay.

Dr. Elizabeth Ratchford: The – between three and four centimeters, the earliest would be a year. Some people say two to three years.

Dr. David Meyerson: Now lets go up to four point eight centimeters.

Dr. Elizabeth Ratchford: Okay, so between four and four point five, I'd say every six months --

Dr. David Meyerson: Okay.

Dr. Elizabeth Ratchford: -- and then four point five is the cutoff where I'd say that you need to be referred to a vascular specialist just for further discussion.

Dr. David Meyerson: Okay.

Dr. Elizabeth Ratchford: Not that you need something done, but that -- once it gets to be about four and a half, because of the reliability of ultrasound, you know once it gets to be big enough where you would think about repairing it, then that's where you might want to think about having another test such as a cat scan or an MRI.

Dr. David Meyerson: And those are a little bit more detailed and the measurements are a little finer in those tests, but they also require contrast and radiation and it's a more involved study.

Dr. Elizabeth Ratchford: Right and more expensive and you definitely don't need that at all until it gets to the range where you would consider fixing it.

Dr. David Meyerson: And so, for the person who was in that little gray zone, who we're going to watch every six months to a year. Do we tell them, you must not smoke, do we tell them that we need to be meticulous with your blood pressure control? Are there any studies that suggest that aggressive secondary prevention, once it's aneurysmal, can you retard the rate of growth? Maybe not even let it grow to the point where it ever needs surgery?

Dr. Elizabeth Ratchford: Well, smoking cessation is very, very important because continued smoking has been shown to increase the rate of expansion by twenty percent, so --

Dr. David Meyerson: And you know what I tell patients, cutting down isn't good enough. I tell them, if they say, "Doc, I'm cutting down." I tell them it's like saying, "I only drive a hundred and thirty miles per hour three days a week." So you're going to run off the road on a Monday, a Tuesday, or a Saturday, but cutting down is not enough. There is no human being that is designed to accept and use cigarette smoke. This is the only product we sell, I think in the United States or in the world where when used as directed, it will harm you, it will kill you. This is my moment for my commercial. If you are a smoker, I really, I desperately want you to look at yourself in the mirror and use whatever epithet that moves you, but look at yourself and say to yourself, "Who am I kidding?" This is one thing, if you want to give yourself a gift – if you are putting money away for retirement, if you are planning to be present at your child's wedding, if you are planning to be present at your grandchild's graduation from high school, you must not smoke. This is a bullet that you are aiming right at yourself. How are we doing? You would agree with everything I said?

Dr. Elizabeth Ratchford: Absolutely. Smoking cessation is one of my favorite topics, in fact.

Dr. David Meyerson: There we go, there we go. So again, so if -- you would recommend that those people be very careful to stop smoking, we want to be really meticulous with their blood pressure control because that would be -- anything that stresses, but then, so we talked about the actual size, so size does matter. But let's talk about the rate of growth because that's also something that worries you too. If it gets big in a hurry, that's a red flag, isn't it?

Dr. Elizabeth Ratchford: Yes. Normally aneurysms expand about point three to point four centimeters in a year or about ten percent, but once it gets to be bigger, then bigger aneurysms expand faster, so the other cutoff for when you decide that it might need to be fixed is if it grows by half a centimeter in six months. So that yeah, that definitely is an important feature, if it's expanding. And sometimes you can have symptoms of this expansion which can be a -- heralds, you know, the rupture, they say. So, you could experience some pain when it's growing quickly.

Dr. David Meyerson: So we talked about the risk of abdominal aortic aneurysms more to rupture than for blood clots to shower down and hurt the legs and we talked about the dissection being a slightly different event than an aneurysm. Are there -- and when the aneurysm begins to leak, all right, that's a real dangerous herald for bad things to come. You really have to be in a doctor's hands virtually immediately, isn't that right?

Dr. Elizabeth Ratchford: More of an emergency room than a doctor, but yes. Or emergency room doctor, I suppose.

Dr. David Meyerson: And so, where I wanted to go with this is, how does a person who's being followed for an abdominal aortic aneurysm know that their discomfort is relating to the aneurysm or whether it's related to some other abdominal issue that might be much more benign or low back issue that's much more benign? It's a tough one for a patient, isn't it?

Dr. Elizabeth Ratchford: Yes, and a tough one for a doctor too because, you know, everybody wants to be on alert for these things, but you don't want to constantly be ordering tests on, and sending people to the emergency room for no reason. Traditionally, they say that the pain that comes from an aneurysm is very steady and a gnawing-type of pain that lasts hours to days and it's not positional the way low back pain typically is, although it can be sometimes relieved by bending your knees.

Dr. David Meyerson: Where would the pain be located mostly?

Dr. Elizabeth Ratchford: Sometimes it can radiate to the groin, but in the lower abdomen, although the aneurysm itself is just about the bellybutton as we called it in the last program. So it can be any sort of abdominal pain and then back pain as well. And it can radiate to funny places, you know, to the legs or to the groin, but the pain is not subtle, especially if it's leaking. I mean, it usually new pain that's severe and constant which is --

Dr. David Meyerson: And you said severe, constant gnawing and not able to be relieved by position.

Dr. Elizabeth Ratchford: Right.

Dr. David Meyerson: These are very common and a doctor really has to keep a high index of suspicion on who is at risk and to get an emergent study. In that situation in the emergency room, they would do a cat scan immediately, wouldn't they?

Dr. Elizabeth Ratchford: Yes.

Dr. David Meyerson: And so just – our purpose today is not to discuss surgery, rather we'd like to prevent our patients from every getting that far, so are there medicines that you use in your practice that you think might be of some value?

Dr. Elizabeth Ratchford: Well, I think the most important thing to realize, like with peripheral arterial disease, the risk is not so much the rupture, but it's the cardiovascular risk that's associated with it. So even though aneurysms aren't per say, caused by atherosclerosis, necessarily, or at least not all of them, they're so closely associated with them that it's considered a coronary heart disease equivalent by the guidelines that we use for treating cholesterol, for example. So people who have aneurysms, whether they're three centimeters or three point five or six centimeters, need to be treated just like, as if they have the blockages in the heart arteries.

Dr. David Meyerson: It's our sixty-year-old house, there's disease in one part of the plumbing, look for it in others.

Dr. Elizabeth Ratchford: Right. So the standard of care there would be number one, having something to thin the blood such as aspirin. Aspirin would be the first line treatment and if that's not tolerated, then clopitogrel or plavix would be second line.

Dr. David Meyerson: And for somebody who's at risk for bleeding though, if we say that an aneurysm is beginning to leak, then wouldn't that seem to be a contradiction or is it that early on, you're better off because clots are less likely to form in that area and you did say something earlier about that when clot forms in the area of an aneurysm, it actually contributes to the weakening of the wall. Is that right?

Dr. Elizabeth Ratchford: Yes. Although this aspirin is to prevent heart attacks and stroke, it really has nothing to do with the aneurysm and, in fact, people with aneurysms are much more likely to die from a heart attack or a stroke than they are to die from something related to the aneurysm, so this treatment, just like with the blockages in the leg arteries, the treatment is really aimed at decreasing the risk of heart attack and stroke, not for anything related to the aneurysm itself. And my feeling is, I mean, of course it's risky if you're worried about bleeding with the aneurysm, but bleeding is bleeding and if your aorta ruptures, then you know, that's it.

Dr. David Meyerson: Yes, that's all she wrote as the saying goes. Now there are -- in another episode, we'll talk about there are a couple of different ways to repair these, one of which is an open surgical repair, but something that's coming into a lot of favor more recently is what they call endo vascular repair and that's through an artery in the leg, you can actually deliver a graph that will exclude the aneurysm from the circulation. But I just mention that for our public to know that we'll talk about that in the future, but let me ask you one more thing. So, medicine such as the excellent blood pressure control medicines that we have such as ace inhibitors. Wouldn't you believe, if somebody's blood pressure was a hundred and eighty over a hundred and they had an abdominal aorta aneurysm and they were looking the other way and not treating their blood pressure, that that would predispose to enlargement and rupture earlier and if you control that blood pressure adequately with good medicines, can we delay that enlargement that we talked about?

Dr. Elizabeth Ratchford: It's controversial as to whether they're proven, but definitely recommended.

Dr. David Meyerson: But you would do it?

Dr. Elizabeth Ratchford: Yes. Beta blockers would be the drug of choice for people with aneurysms to -- although some of the studies have said yes and some have said no, but the consensus and expert opinion would be that anybody with an aneurysm should be on a beta blocker and then ace inhibitors, as you mention, have been shown to delay the corrosion in other parts of the body, so those would also be important to have onboard.

Dr. David Meyerson: And our group of medicines called statins, would you – the athroschloratic process plays some role, but not every role in the formation of these. Would that be of value here?

Dr. Elizabeth Ratchford: Yes. In fact, there are some new studies that have shown that statins decrease the rate of expansion as well, so whether that's from their anti-inflammatory properties or something else, we're not sure, but statins are -- every patient with an abdominal aortic aneurysm should be on a statin.

Dr. David Meyerson: I think we've had some really wonderful, wonderful information here. Are there any final words, any watch words that you'd like to leave our public before? Do you think we've kind of said most of all?

Dr. Elizabeth Ratchford: I think we've covered it all, as long as people are aware and they ask their doctor about aneurysms and whether they are at risk and whether they should be screened and making sure that they're on all the right medicines. Those are the key things to remember.

Dr. David Meyerson: And one of the other things is that as a marker for other diseases that when you see an abdominal aortic aneurysm, look elsewhere, look elsewhere. Our sixty-year-old house, when you see disease upstairs, look downstairs. When you see disease downstairs, look upstairs. My special guest has been Dr. Elizabeth Ratchford. She's one of a new breed of physicians trained as internists, not as surgeons who are experts in the prevention, diagnosis and treatment of blood vessel diseases. We certainly hope that this information has been an enormous value to you. I hope you've enjoyed our presentation format for the Vascular Disease Foundation, and from my partner in this PodCast, my partner in crime as it were, Dr. Kerry Stewart who actually invented these PodCasts. It's his idea that brought them to the public and I publicly thank him again. I'm Dr. David Meyerson, have a great day.

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