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Randomisierte Studien mit EBM-Level 1 beweisen es

Ein Screeningprogramm für abdominelle Aortenaneurysmen ist sinnvoll!

Randomised studies with EBM level 1 prove it

A screening programme for abdominal aortic aneurysms makes sense

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Zusammenfassung

Die Ergebnisse randomisierter kontrollierter Studien zum Screening älterer Männer hinsichtlich abdominaler Aortenaneurysmen (AAA) sind veröffentlicht worden. Daher wurde eine systematische Überprüfung und Metaanalyse durchgeführt, um die gepoolten Effekte einschätzen zu können. Hierzu erfolgte eine Medline-Recherche (PubMed) mit den Schlüsselwörtern „screening“ und „Aortenaneurysma“ hinsichtlich randomisierter kontrollierter Studien in englischer Sprache. Es wurden 4 Studien identifiziert: die „Chichester Study“ (UK/England), die „Multicentre Aneurysm Screening Study“ (MASS; UK, England), die „Western Australian Aneurysm Screening Study“ (AUS) und die Viborg-Studie (Dänemark). Die mittelfristigen (3,5–5,0 Jahre) und langfristigen (7–15 Jahre) Effekte als Odds-Ratio (OR) mit 95%-Konfidenzintervall (-KI) wurden berechnet. Die mittelfristige Analyse ergab, dass durch das Screening die Wahrscheinlichkeit einer AAA-Ruptur um 47% signifikant sank, die AAA-bedingte Letalität (nach Ausschluss der Männer >80 Jahren) um 49% zurückging und auch die Gesamtletalität reduziert werden konnte (OR=0,93; 95%-KI=0,90–0,96). Die Zahl der geplanten Operationen stieg um das 3fache (p<0,05) und die Wahrscheinlichkeit von Notoperationen reduzierte sich um 45% (p<0,05). Die langfristigen gepoolten Ergebnisse zeigten eine signifikante Reduktion der Wahrscheinlichkeit sowohl der AAA-Ruptur als auch der AAA-bedingten Letalität um jeweils 47% sowie einen signifikante Rückgang der Gesamtletalität (OR=1,77; 95%-KI=0,92–0,97). Insgesamt wurden bei den einbestellten Männern nach 7–15 Jahren 1,7-mal mehr Operationen durchgeführt als bei den Kontrollpersonen (OR=1,77; 95%-KI=1,57–1,99). Das AAA-Screening senkt die Wahrscheinlichkeit von Rupturen und AAA-bedingten Todesfällen jeweils um etwa 50% und die Gesamtmortalität um etwa 6–7%, wobei Unterschiede bestehen, die das lokale Kosten-Nutzen-Verhältnis des Screenings beeinflussen können.

Abstract

Results have been published of randomised controlled studies on the screening of elderly men for abdominal aortic aneurysms (AAA). A systematic review and meta-analysis was therefore carried out in order to be able to assess the pooled effects. A Medline search (PubMed) for randomised controlled studies was carried out using the key words “screening” and “aortic aneurysms” in English. The medium-term (3.5-5 years) and long-term (7-15 years) effects were calculated as the odds ratio with a 95% confidence interval. Four studies were identified, the “Chichester Study” (UK/England), the “Multicentre Aneurysm Screening Study” (MASS) (UK/England), the “Western Australian Aneurysm Screening Study” (AUS) and the “Viborg Study” (Denmark). The analysis showed that the probability of an AAA rupture fell significantly by 47% as a result of screening, AAA-related mortality (after men over the age of 80 years were excluded) decreased by 49% and overall mortality was also reduced (OR 0.93; 95% CI: 0.90-0.96). The number of planned operations increased 3-fold (p<0.05) and the probability of emergency operations decreased by 45% (p<0.05). The long-term pooled results showed a significant reduction of 47% in the probability of both AAA rupture and AAA-related mortality and a significant decrease in overall mortality (OR 1.77; 95% CI: 0.92-0.97). Overall, 1.7 times more operations were carried out on the men invited for screening than on the controls (OR 1.77; 95% CI: 1.57; 1.99). AAA screening reduces the probability of rupture and AAA-related mortality by about 50% each and overall mortality by about 6-7%, although there are differences which might have an impact on local cost-benefit ratio of the screening.

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Authors and Affiliations

  1. Klinik für Gefäßchirurgie, Vaskuläre und Endovaskuläre Chirurgie, Chirurgische Universitätsklinik, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    D. Böckler

  2. Abteilung für Gefäßchirurgie, Universitätsklinikum, Erlangen, Deutschland

    W. Lang

  3. Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg, Universitätsklinikum, Hamburg-Eppendorf, Deutschland

    E.S. Debus

  4. Klinik für Vaskuläre und Endovaskuläre Chirurgie, DRK Klinikum Berlin-Mitte, Berlin, Deutschland

    I. Flessenkämper

  5. Klinik für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Phlebologie, Weisseritztal-Kliniken, Freital, Deutschland

    H.J. Florek

  6. Medizinsiches Versorgungszentrum Gefäßmedizin, Nürnberg, Deutschland

    T. Noppeney

  7. Klinik für Gefäß- und Endovascularchirurgie, Universitätsklinikum, Frankfurt a.M., Deutschland

    T. Schmitz-Rixen

  8. Abteilung für Gefäßchirurgie, Klinikum, Garmisch-Partenkirchen, Deutschland

    S. Nöldecke

  9. Klinik für Gefäßchirurgie, Katharinenkrankenhaus, Klinikum, Stuttgart, Deutschland

    T. Hupp

  10. Klinik für Gefäßchirurgie, Klinikum rechts der Isar, Technische Universität, München, Deutschland

    H.-H. Eckstein

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  1. D. Böckler
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  2. W. Lang
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  10. H.-H. Eckstein
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Correspondence to D. Böckler.

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Böckler, D., Lang, W., Debus, E. et al. Randomisierte Studien mit EBM-Level 1 beweisen es. Gefässchirurgie 14, 350–361 (2009). https://doi.org/10.1007/s00772-009-0696-y

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