Intensive cardiovascular screening has little benefit in older men (DANCAVAS)

Référence

Lindholt JS, Søgaard R, Rasmussen LM, et al. Five-year outcomes of the Danish cardiovascular screening (DANCAVAS) trial. N Engl J Med 2022;387(15):1385-1394.

Sommaire

The US Preventive Service Task Force currently does not recommend routine screening of adults for cardiovascular disease using electrocardiography, stress tests, or gated computed tomography (CT) to determine the coronary calcium (CAC) score. In this Danish study, 46,611 men aged 65 to 74 years were randomly assigned to receive an invitation to screening or usual care. Of the 16,768 invited to screening, 10,471 accepted the invitation (62%). Those who accepted screening were more educated, more likely to be employed, and had a somewhat lower rate of hospitalization for cardiovascular events in the previous 5 years. The screening program included non-contrast electrocardiographically gated CT to measure coronary artery calcium, look for aneurysms, and detect atrial fibrillation; ankle-brachial index measurements for peripheral arterial disease (PAD) and hypertension; and blood tests for diabetes and hyperlipidemia. Any abnormal results resulted in structured recommendations for further evaluation and treatment. The invited and uninvited groups were similar at baseline, with a mean age of 69 years. Patients were followed up for a median of 5.6 years. In the screened group, positive findings included a CAC score greater than 400 AU (33.2%), aortic aneurysm greater than 45 mm (4.5%), iliac aneurysm (2.3%), PAD (11.5%), atrial fibrillation (0.5%), suspected diabetes mellitus (1.8%), and potential hypertension (9.0%). All-cause mortality was slightly lower in participants younger than 70 years (18.7 vs 20.9 deaths per 1000 person-years; hazard ratio [HR] 0.89; 95% CI 0.83 - 0.96; number needed to treat = 91 persons to prevent 1 death over 5 years). There was no benefit for those 70 years or older (30.7 vs 30.3 deaths per 1000 person-years). In the entire population, stroke was less likely (HR 0.93; 0.86 - 0.99) but there were no significant differences in myocardial infarction, aortic dissection, or aortic rupture. The screened group was more likely to be given lipid-lowering drugs and antithrombotics, and they were more likely to have repair of an aortic aneurysm. Bleeding was possibly increased in the screened group (6.8% vs 6.3%; P = .06). The authors estimated that 97.4% of men who received preventive therapy of some kind as a result of screening experienced no mortality benefit.