Ask The Doctors: November 2012
Q. I recently found out I have an aortic aneurysm, but my doctor said because it’s located in my abdomen we can monitor it for awhile. I feel like it should be treated now.
The aorta is the largest artery in body. After giving off the tiny but important coronary arteries, the aorta carries blood upwards from the heart. Within a short distance, it makes a U-turn, and from this “aortic arch” provides branches to the right arm, head, and left arm. The aorta then shoots downward along the spine, first in a segment known as the descending thoracic aorta. After leaving the chest by passing through the diaphragm muscle, it becomes the abdominal aorta. This portion supplies blood to the spinal cord, gut, kidneys, and other organs. At about the level of your navel, it splits into the left and right common iliac arteries, which carry blood to the legs.
We hear a great deal on the news about heart attacks and strokes, which are usually due to vascular disease of the coronary arteries and the neck, respectively. However, the same process of atherosclerosis—which involves injury to the blood vessel wall, deposition of cholesterol and subsequent inflammation—is also responsible for most cases of abdominal aortic aneurysm (AAA). Smoking, hypertension, and high cholesterol are major risk factors for AAA, but a portion of the risk can be inherited. Current recommendations for screening suggest that men between the ages of 65 and 75 who have ever smoked, and those over the age of 60 with a 1st-degree relative (father/mother, sister/brother, daughter/son) who had an aneurysm, should undergo one-time screening with an abdominal ultrasound. Women are not included in these recommendations, since their risk appears to be much lower than that of men, but each case must be addressed individually.
If the abdominal aorta is greater than 3 centimeters (cm) in diameter, it is considered an aneurysm, and should be followed by yearly ultrasounds. Traditionally, open AAA repair has not been performed until the aneurysm reaches the diameter of 5.5cm, but surgery may be done sooner if the aneurysm is increasing rapidly in size (1cm or more per year). Also, a newer, minimally-invasive technique known as Endovascular Aneurysm Repair (EVAR) is often performed when the aneurysm exceeds 5cm in diameter, or if an aneurysm between 4-5cm is expanding quickly. However, EVAR is not performed in all hospitals, and may not be appropriate for all types of AAA. For your own safety and reassurance, discuss with your doctor the appropriate type and timing of surgery for you.
Q. My father died of a heart attack when he was 65, but he smoked most of his life. I never smoked, and I do take a statin and baby aspirin daily. How much of your family history risk is affected by the things your parents did? I turn 65 next year, and I’m nervous.
It is true that your father raised his risk of a fatal coronary event by longterm tobacco use. However, the fact that he had a dangerous habit does not completely explain his heart attack and premature death. We have all seen the people who smoked, ate fatty foods, didn’t exercise and were overweight, but still lived to ripe old ages. And on the flip side of the coin, there are the individuals with outstanding, healthy lifestyles who develop coronary artery disease (CAD) anyway. Although these outcomes are frustrating to those who pursue wellness, and seem illogical, the key factor separating them is likely one of genetics. The inheritance of CAD has been studied for many years, and having a 1st-degree relative with a heart attack does suggest an increased risk of heart attack. But by not smoking, maintaining an otherwise healthy lifestyle, and treating your cholesterol, you have already done a great deal to decrease the likelihood that harmful genetic effects will win out in the long run.