Practice Update - ESC Congress 2017

Screening for Vascular Disease Saves More Lives at Lower Cost than Cancer Screening – VIVA Trial A novel screening program for vascular disease has been shown to save one life for every 169 men assessed. Combined screening for abdominal aortic aneurysm, peripheral artery disease, and hypertension gained more years of life at lower cost than European cancer screening programs. This conclusion, based on results of the prospective, randomized Danish Viborg Vascular (VIVA) trial, was reported at the 2017 European Society of Cardiology (ESC) Congress, from August 26–30.

J es Lindholt, PhD, of Odense University Hospital, Denmark, explained, “National screening programs are implemented for various types of cancer, yet programs for asymptomatic car- diovascular disease have not been researched extensively, irrespective of the fact that such dis- ease causes more deaths.” VIVA evaluated the mortality impact and cost- effectiveness of combined screening for abdominal aortic aneurysm, peripheral artery disease, and hypertension. Dr. Lindholt said, “These diseases are often asymp- tomatic and can be life-threatening. Elective repair of an aneurysm can prevent death due to rupture. Pharmacological therapy for peripheral artery disease, aneurysms, and hypertension holds a much larger potential to reduce risk of death from coronary heart disease, stroke, and heart attack.” Half of 50,156men aged 65 to 74 years were invited to be screened and the other half received usual care (disease is typically detected only when a man reacts to symptoms or is in contact with healthcare providers for other reasons). The primary outcome was all-cause mortality. Men in the screened group underwent a 10-minute procedure in which their aorta was scanned using ultrasonography and their blood pressure was measured and compared in the ankle and arm. More than 20% of those attending screening exhibited positive test results: 3% harbored an abdominal aortic aneurysm, 11% peripheral artery disease, and 11% suspected hypertension. “We were quite surprised that despite modern health- care and diagnostics available virtually everywhere, one out of five men harbored undiagnosed vascu- lar disease,” said Dr. Lindholt. Men who tested positive for abdominal aortic aneu- rysm and/or peripheral artery disease received a confirmatory test and consultation in which

individualized prophylactic activities, including smoking cessation and pharmacological therapy, were recommended. If not already prescribed, low-dose aspirin (75 mg daily) and simvastatin (40 mg daily) were prescribed. Those with an aneurysm >50 mm in diameter were referred to a vascular surgeon to assess the need for elective repair. Men with suspected hyperten- sion were referred to their general practitioner. The two groups were followed using national registries for hospital admissions, surgeries, and overall and cause-specific death. After 5 years, 149 more lives were saved in the screening group (2566 deaths in the screening group vs 2715 in the control group). This tally corresponded to one life saved for every 169 men screened, and a sta- tistically significant, 7% relative risk reduction vs no screening. “A result of this magnitude has not been seen in screening programs of the general population,” said Dr. Lindholt. “The 2.5 times higher incidence of elective aneurysm repairs and doubled rates of initiation of antithrombotic and lipid-lowering therapy in the group invited to screening was the likely reason for the improved survival.” The cost of screening (using 2014 prices) was estimated at an additional €148 per citizen in comparison with usual care. Resulting costs of a life year and quality-adjusted life year gain from screening were estimated at €6872 and €7716, respectively, and corresponding probabilities for the screening to be cost-effective were 97% and 96%, respectively. Coinvestigator Rikke Søgaard, PhD, MPH, MSc, of Aarhus University, Denmark, said, “A cost per life year gained of around €7000 is low by European standards. Vascular screening is sim- ple and inexpensive and the benefit in terms of lives saved is substantial. Vascular screening is

Dr. Jes Lindholt

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