Does This Patient Have

Abdominal Aortic Aneurysm?

The Rational Clinical Examination

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Overview
Case Scenario
Context
The Evidence

Populations
Prior Probability
Reference Standard
Test Characteristics

Hands On!
Back to the Case
Scenario
Back to the
Bedside/Exam
Room

The Rational Clinical Examination

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Case Scenario
65-year-old obese man

When abdominal muscles are

adequately relaxed, abdominal
examination reveals 2-cm aortic
pulsation

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Case Scenario: Questions

What do you think is the likelihood
that this patient has an abdominal
aortic aneurysm (AAA)?
At what degree of suspicion would
you order an ultrasound?

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Abdominal Aortic Aneurysm

Significant cause of death in the
United States
Deaths largely preventable given
early detection
1/3 rupture eventually

The Rational Clinical Examination

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When to Consider Surgery

Current data suggest 5.5-cm diameter
is likely the threshold to use for
considering surgery

The Rational Clinical Examination

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Abdominal Aortic Aneurysm

31%-48% of AAAs detected by
physical examination
Risk factors: Male, age, smoking
Risks of examination: None

The Rational Clinical Examination

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Prior Probability
4%-8% older men

<2% older women

Older women who have smoked: 1.5%
Older women who have not smoked: 0.4%

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Risk Factors
Population for Whom AAA Should Be Considered

Age, increasing from 50

History of ever smoking
Male gender
White patients

Family history of AAA

The Rational Clinical Examination

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How to Examine for AAA

Patient supine with knees raised,
abdomen relaxed
Feel deeply for aortic pulsation
(slightly craniad to umbilicus and to
left of midline)

The Rational Clinical Examination

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How to Examine for AAA

Place hands palm-down on abdomen
with index fingers on either side of
pulsation
Measure distance between fingers,
allowing for skin thickness
Normal = less than 2.5 cm

The Rational Clinical Examination

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Reference Standard
Ultrasound

Computed tomography

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Test Characteristics
Sensitivity
SnN()out: Negative tends to rule out

Specificity
SpP(+)in: Positive tends to rule in

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Test Characteristics
Likelihood Ratio (LR)
Determined for a particular test result

Conceptually related to how much more (LR > 1)

or less (LR < 1) likely the disease is, given a
particular test result
LR = 1 will not change your assessment of the
likelihood of disease, given a particular test result

The Rational Clinical Examination

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Using Likelihood Ratios

Values of Likelihood Ratio: How much do they
affect probability of disease?
LR = 1

No effect on likelihood

LR = 3-10
LR = 0.3-0.1

Disease More Likely

Disease Less Likely

LR > 10
LR < 0.10

Disease More Likely

Disease Less Likely

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

LR: Impact on Likelihood of Disease

LR = 0.01

Less
Likely

LR = 0.1

Less
Likely

LR = 0.2
Less

Likely

LR = 5
LR = 0.3

LR = 3

More

Less

More

Likely

Likely

Likely

Increasing impa

LR = 10

More

More

Likely

Likely

ng impact

increasi

ct

LR = 100

LR = 1
No
Impact on
Likelihood of
Disease
The Rational Clinical Examination
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LR: Impact on Likelihood of Disease

LR = 0.01

More
Impact

LR = 0.1

More
Impact

LR = 0.2

LR = 5

More

LR = 0.3

Impact

More

Impact

Increasing

LR = 1
No

LR = 3

More

More

Impact

LR = 10

LR = 100

More

More

Impact

Impact

Impact

ng impact

Impact
impact
increasi

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Test Characteristics
Likelihood Ratios Vary with the Size of the Aneurysm

Ability to detect an
asymptomatic AAA
according to size

LR+
(95% CI)

LR
(95% CI)

Aneurysm > 4.0 cm

16
(8.6-29)

0.51
(0.38-0.67)

Aneurysm > 3.0 cm

12
(7.4-20)

0.72
(0.65-0.81)

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Test Characteristics
Clinical Impression

LR (95% CI)

Examination "definite" for

aneurysm

4.8 (2.7-8.8)

Examination suggestive
of aneurysm

1.4 (0.92-2.1)

Examination "normal"

0.43 (0.35-0.54)

The Rational Clinical Examination

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AAA Exam in Obese Patients

Obesity affects clinical examination
for AAA.
In an obese patient, if you feel a wide
aorta, you can be confident in the
findings.
However, if you fail to appreciate a
wide aorta you can not be confident
that you have ruled out a clinically
important widening.
The Rational Clinical Examination
Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Other Interesting Findings

AAA examination does not perform
well if abdominal muscles are not
relaxed
The interobserver variability for
detecting aneurysms is moderate
( = 0.53)

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Evidence from Guidelines

The US Preventive Services Task
Force (USPSTF) now recommends
1-time screening for AAA by
ultrasonography in men aged 65-75
who have ever smoked.

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Hands On!

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Nomogram for Interpreting LR

Plot patients
pretest probability
on left
Draw straight line
through LR for
given test result
Line points to
posttest probability

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Return to Case Scenario

65-year-old obese man

When abdominal muscles adequately

relaxed, abdominal examination
reveals 2-cm aortic pulsation

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Case Scenario: Questions

What do you think is the likelihood
that this obese patient has an AAA?

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Test Characteristics
Likelihood Ratios Vary with the Size of the Aneurysm

Ability to detect an
asymptomatic AAA
according to size

LR+
(95% CI)

LR
(95% CI)

Aneurysm > 4.0 cm

16
(8.6-29)

0.51
(0.38-0.67)

Aneurysm > 3.0 cm

12
(7.4-20)

0.72
(0.65-0.81)

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

LR: No AAA > 4 cm Detected

LR = 0.51
4%-8% Pretest
probability of any
AAA present

~2%-4%
Posttest
probability

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

LR: No AAA > 3 cm Detected

LR = 0.72
4%-8% Pretest
probability of any
AAA present

~3%-6%
Posttest
probability

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

LR: AAA > 4 cm Detected

LR+ = 16

4%-8% Pretest
probability of any
AAA present

~40%-58%
Posttest
probability

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

LR: AAA > 3 cm Detected

LR+ = 12
4%-8% Pretest
probability of any
AAA present

~33%-51%
Posttest
probability

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

The Bottom Line

Clinicians can detect asymptomatic
AAAs
Examination performs just as well in
obese patients when AAA is found
Examination is not as efficient at
ruling out an aneurysm in obese
patients or if the patient does not relax
the abdominal muscles
The Rational Clinical Examination
Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

This Education Guide slide set

has been created as a part of
The Rational Clinical Examination series
Catherine P. Kaminetzky, MD, MPH
Durham Veterans Affairs Medical Center and
Duke University Medical Center

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Abdominal Aortic Aneurysm

Lederle FA, Simel DL. Does this patient have abdominal aortic
aneurysm? In Simel DL, Rennie D, Keitz SA, eds. The Rational Clinical
Examination: Evidence-Based Clinical Diagnosis. NY: McGraw-Hill;
2008:17-24. http://www.jamaevidence.com/content/3474662.

Lederle FA, Etchells E. Update: abdominal aortic aneurysm. In Simel

DL, Rennie D, Keitz SA, eds. The Rational Clinical Examination:
Evidence-Based Clinical Diagnosis. NY: McGraw-Hill; 2008:25-28.
http://www.jamaevidence.com/content/3474722.
Lederle FA, Etchells E. Abdominal aortic aneurysmmake the
diagnosis. In Simel DL, Rennie D, Keitz SA, eds. The Rational Clinical
Examination: Evidence-Based Clinical Diagnosis. NY: McGraw-Hill;
2008:27. http://www.jamaevidence.com/content/3474650.
Lederle FA. Evidence to support the update: abdominal aortic
aneurysm. In Simel DL, Rennie D, Keitz SA, eds. The Rational Clinical
Examination: Evidence-Based Clinical Diagnosis. NY: McGraw-Hill;
2008. http://www.jamaevidence.com/content/3474752.

The Rational Clinical Examination

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

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The Rational Clinical Examination

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