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rheumatology&#44; pulmonology&#44; urology and gynecology&#44; not only as a diagnostic tool but also as an assistant in invasive procedures such as thoracentesis&#44; paracentesis and biopsies&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Spanish Society of Internal Medicine created the Clinical Ultrasonography Workgroup in 2011&#44; which since then has organized numerous courses&#44; published manuals&#44; helped increase the widespread use of ultrasonography and even created a website on the subject &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://www.ecografiaclinica.es/">www&#46;ecografiaclinica&#46;es</a>&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The application of clinical ultrasonography in cardiovascular disease is an example of its use&#44; as can be observed in the studies published in this issue of the journal in which AAA screening is performed on patients hospitalized in internal medicine departments&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">AAA &#40;aortic dilation greater than 3<span class="elsevierStyleHsp" style=""></span>cm&#41; is a process with a slow and typically silent progression&#46; The overall mortality rate for spontaneous rupture is very high &#40;80&#8211;90&#37;&#41; because&#44; in addition to the mortality rate prior to admission to the emergency department and the lack of surgical indication due to the patient&#39;s condition&#44; there is the mortality due to the emergency procedure &#40;50&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In contrast&#44; elective repair has a very low mortality rate &#40;&#60;5&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a>&#59; identifying patients with AAA during the silent period can therefore save numerous lives despite its relatively low prevalence&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The 2014 review by Stather et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> of 35 articles published between 1988 and 2012 found a prevalence of AAA of 2&#46;2&#37;&#8211;12&#46;7&#37;&#46; This prevalence depended on sex and age&#44; circumstances that had already been known since 1967 when Fomon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> published a study on 7642 autopsies performed in Miami between 1935 and 1954&#44; which found 77 AAAs &#40;prevalence rate of 1&#37;&#41;&#46; In 1992&#44; Bengtsson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> conducted a study in Sweden of 45&#44;838 autopsies and found a prevalence of AAA of 4&#46;7&#37; in men and 3&#37; in women&#44; with a maximum rate of 5&#46;9&#37; in 80-year-old men and 4&#46;5&#37; in women older than 90 years&#46; The aging of the population is causing an increase in the prevalence of AAA&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In our setting&#44; a recent study by Bravo-Merino<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> conducted with male primary care patients aged 65&#8211;75 years detected a prevalence of 4&#46;6&#37; using ultrasonography&#44; a rate within the 2&#46;6&#8211;4&#46;7&#37; range of other studies in the same setting&#44; a finding mentioned by Belloch Garc&#237;a&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The novel aspect of the study by Belloch Garc&#237;a was the assessment of the prevalence of AAA in a patient group hospitalized in internal medicine departments&#46; The overall prevalence was 2&#46;9&#37;&#44; but since all of the cases &#40;7&#41; occurred in men older than 50 years&#44; the prevalence was 4&#46;6&#37; for men&#46; If almost 75&#37; of the sample is over the age of 65 years&#44; the prevalence in men of this age exceeds 6&#37;&#44; which is higher than the prevalence results in primary care&#46; The study by Cornejo Saucedo<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> found an even higher prevalence &#40;8&#37; in the overall sample and almost 10&#37; in men&#41;&#44; given that these were selected patients with high cardiovascular risk&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This higher prevalence in men hospitalized in internal medicine departments than that found in primary care is due to the type of patient admitted to internal medicine departments&#44; where the rates of arterial hypertension&#44; diabetes&#44; dyslipidemia and tobacco use are higher than in the general population&#46; Thus&#44; in the study by Belloch Garc&#237;a&#44; arterial hypertension was present in 68&#46;9&#37; of the study patients&#44; diabetes was present in 33&#46;6&#37;&#44; dyslipidemia in 39&#37; and tobacco use in 54&#46;8&#37;&#46; These readings increase for the patients with aneurysms&#44; achieving statistically significant differences in the case of tobacco use&#46; There is agreement in the scientific community that age&#44; the male sex and tobacco use are clear risk factors for developing AAA&#46; In contrast&#44; there are disagreements as to whether other factors such as hypertension&#44; diabetes &#40;as can be seen in the study by Cornejo Saucedo<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a>&#41; and dyslipidemia favorably or unfavorably influence the development of aneurysms and their eventual rupture&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The presence of AAAs is associated with other arteriosclerotic vascular diseases &#40;aneurysms in another part of the aorta or femoral artery&#44; ischemic heart disease&#44; peripheral artery disease&#44; etc&#46;&#41;&#46; Hospitalized patients with these antecedents can therefore be candidates for aneurysm screening&#46; In the study by Belloch Garc&#237;a&#44; the presence of AAA was associated with an ankle brachial index &#60;0&#46;9&#46; In the study by Cornejo Saucedo&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> peripheral artery disease had an odds ratio of 3&#46;51&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Reduced tobacco use in the general population explains the reduced prevalence recently observed in some communities&#44; which has resulted in a lack of agreement on implementing populational screening due to its lack of cost-effectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> An alternative could be opportunistic screening&#44; such as that performed in internal medicine hospital wards&#44; where we typically find men older than 65 years with a history of tobacco use&#44; peripheral artery disease or ischemic heart disease&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The main factors that determine an AAA rupture are the size of the aneurysm and its growth rate&#46; The annual rupture rate for AAAs &#60;5<span class="elsevierStyleHsp" style=""></span>cm in diameter is &#60;4&#37;&#59; however&#44; those &#62;5&#46;5<span class="elsevierStyleHsp" style=""></span>cm have a rupture rate of &#62;25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> A size &#62;5&#46;5<span class="elsevierStyleHsp" style=""></span>cm and a growth rate &#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>cm in 6 months are indicators of a maximum risk of aneurysm rupture&#46; According to the guidelines of the Spanish Society of Arteriosclerosis and the Spanish Society of Angiology and Vascular Surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> aneurysms &#8805;50<span class="elsevierStyleHsp" style=""></span>mm in size should be sent for assessment by vascular surgery departments &#40;strong strength of recommendation&#41;&#46; Aneurysms &#8805;80<span class="elsevierStyleHsp" style=""></span>mm in size are of an urgent nature&#59; if they are symptomatic &#40;back or abdominal pain unexplained by other causes&#41; with suspected rupture or evidence of rupture then they are of an emergency nature&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The availability of clinical ultrasonography in the context of internal medicine patients with relatively high likelihood of presenting AAA is an opportunity to save lives&#44; optimize resources and become more efficient&#46;</p></span>"
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DOI: 10.1016/j.rceng.2018.07.003
Clinical ultrasonography and abdominal aortic aneurysms in Internal Medicine
Ecografía clínica y aneurisma de aorta abdominal en Medicina Interna
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J.I. Cuende
Consulta de Riesgo Cardiovascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, Spain
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