Speech
Ladies and gentlemen, friends and acquaintances of Dr. A Patel, it is an honor to stand here before you in honor of a great man whose absence in our midst cannot go unnoticed and who was a breath of fresh air to everyone who knew him. Dr. A Patel was more than my client, he was one of those people you want to be friends with forever. His demise is a great loss to me and the entire golfing fraternity. Even as we celebrate his life, I believe it is important to use his life and death as a source of enlightenment. As a doctor, he would have loved for the people who know him to understand the illness that eventually led to his demise and to take precautions not to fall victim of the same.
Dr. Patel died of a fatal condition called abdominal aortic aneurysm (AAA). I am sure some of you may have heard about this condition. AAA is a bulge or dilation of the abdominal aorta, the largest blood vessel in the abdomen. Abdominal aortic aneurysms occur when there is a failure of the structural proteins of the aorta. What causes these proteins to fail is not known, but it results in the gradual weakening of the aortic wall.
The weakened wall puts immense pressure on the aorta, causing it to bulge outwards to over twice its size (Ryding, 2019). When left untreated, the aorta continues to bulge and could rupture, causing life-threatening internal bleeding. Aneurysms can occur anywhere in the body; however, the most common sites for aneurysms are in the abdominal aorta and the brain (Ryding, 2019). In most cases, an abdominal aortic aneurysm causes no noticeable symptoms and may, therefore, go undiagnosed for a long time. This poses a significant threat to the affected because large aneurysms are increasingly likely to rupture and have an 80% mortality rate.
AAA is quite common in many Western countries and has a 4-7% prevalence rate amongst males aged above 65 years (Gianfagna et al, 2016). Doctors believe the disease is more common than reported because of the many cases that go undetected and unreported. In the United Kingdom, 1 in 25 men above the age of 65 is affected by AAA. Surprisingly, the rapture rates are quite rare with only 1 in 10,000 cases reported annually (Karthikesalingam et al, 2016). Symptoms of AAA have been reported in 25/100, 000 males at the age of 50. In those over the age of 70, symptoms have been reported in 78/100,000, a clear indication that age is one of the primary predisposing factors for the disease.
In the United States, incidences of AAA range between 2 to 4% in the adult population. Medical evidence has established that brothers of patients with AAA are four to six times more likely to develop the condition with a risk of 20-30%. In simpler terms, mortality rates are higher amongst patients with an AAA family background.
Globally, there has been a decrease in incidences and prevalence of the disease. However, certain parts of Latin America and Asian countries are showing a worrying trend in AAA upsurges. It is equally important to note that some ethnicities are naturally less susceptible to abdominal aorta aneurysms. Individuals of African, Asian, and Hispanic origin are less likely to develop the disease. The reason behind this is yet to be established.
Besides something as innocent as being male, other risk factors are tobacco use, hypertension, chronic obstructive pulmonary disease, hypercholesterolemia, cardiovascular disease (Atherosclerosis), and a family history of AAA.
Of all these risk factors, I find it more important to talk about Atherosclerosis because of its high prevalence and mortality rates today. Atherosclerosis is a medical condition characterized by the buildup of cholesterol, fats, and other substances on the artery walls which can restrict blood flow. It is common among smokers, people with obesity and dyslipidemia (high blood cholesterol). The buildup of fats and other substances causes a plague which may burst to form blood clots. Just like AAA, Atherosclerosis has no symptoms and may only be discovered when an artery narrows and blocks or after a plague bust. Even though Atherosclerosis is considered a heart problem, it can occur in any of the arteries in the body and is one of the leading causes of AAA. Other diseases associated with AAA include HIV, syphilis, dissection, Ehlers-Danlos syndrome, and a condition called cystic medial necrosis.
The enlargement of an aneurysm can be gradual with the stability of the size for some time before rapid enlargement. The rate of enlargement for an AAA will depend on its size. For a small AAA which measures 3-5 cm, the rate of enlargement is 0.2 to 0.3 cm/year. For larger AAA above 5 cm, the enlargement rate is 0.3 to 0.5 cm/year. The pressure that an AAA puts on the aortic wall follows a medical law called the Law of Laplace. This law operates on the theory that wall stress is proportional to the radius of the aneurysm. This explains why larger aneurysm is more likely to rapture and why hypertension increases the risk of rapture. The most common symptom for a raptures AAA is sudden and severe pain in the abdomen or the back that doesn’t go away.
An AAA rapture may cause a dissection in some individuals. A dissection is a tearing of the inner layers of the aorta causing the middle and the inner layers to separate. Aortic dissections are the leading cause of death amongst AAA patients, killing at least 15,000 every year in the U.S. alone. Fatal raptures occur in 1-3% of men aged 65 and above and have a 70-95% mortality rate.
Even though AAA is particularly harsh on the elderly, early screening and detection offer hope to those who are at risk. Many countries, the United States included, have launched screening services to assess males over the age of 65 for the condition. Diagnosis can be done through non-invasive tests like imaging studies, including ultrasonography, CT scan, and MRI. MR angiography reveals the defined size and structure of an aneurysm and aids in planning surgery.
Notably, the safest way to recovery is through preventative and emergency surgeries. Preventative surgery is done after a risk assessment has determined the high possibility of rapture and is based on other factors like age, general health of the patient, and the rate of growth of the aneurysm (Ryding, 2019). An emergency surgery occurs after a rapture and is similar to the preventative one. However, time is of the essence to prevent bleeding that could cause death.
The United States Preventative Services Task Force (USPSTF) continues to create awareness of the condition and the importance of early screening. The organization emphasizes screening for target subgroups at a higher risk of AAA only. Screening all men above the age of 65 has been found to be of little significant value if any (U.S Preventive Services Workforce, 2019). USPSTF recommends screening with ultrasonography for men who are smokers, have a history of smoking and medical history of hypertension, diabetes, and other inflammatory conditions. Early screening is cost-effective at a prevalence of about 1% (Gianfagna et al, 2016). We should feel blessed to live in a country where the disease is understood and screening services are available.
I have talked about men so much that it might seem to some of you that the disease has a soft spot for women. Well, that is not quite the case.
The female gender is less threatened by this condition, and have a prevalence rate that is six times lower than the males. Affected women tend to be much older than men however, the outcomes of the disease are the same across both genders (Machado et al, 2016). The USPSTF recommends routine screening with ultrasonography in women between 65 and 75 years who have a history of smoking or a family history of AAA. On the contrary, the organization warns against routine screening in women who have never smoked and have no family history of the disease. Smokers generally have a higher rate of AAA than non-smokers, and are 8 times more likely to develop AAA than nonsmokers (Aune et al, 2018). Smoking is more detrimental as a risk factor in women than in men and the risk reduces gradually when one stops smoking.
Sir Francis Bacon, an ancient English philosopher is known for these three powerful words “Knowledge is power”. Awareness about this silent yet deadly condition will help both you and I identify the warning signs and risk factors and take the necessary precautions.
As I conclude, I would like to again express my deepest condolences to the family and friends of Dr. Patel. Until his demise, Dr. Patel’s service to humanity in the medical field was heroic to say the least. He was a joy to be around and a light to the world. He was and will remain one of the most selfless, generous, and caring people I have ever known. Even as we all remember him in different ways, may all the good things that he represented remain alive through us. Thank you.
References
Aune, D., Schlesinger, S., Norat, T., & Riboli, E. (2018). Tobacco smoking and the risk of abdominal aortic aneurysm: a systematic review and meta-analysis of prospective studies. Scientific reports, 8(1), 1-9.
Gianfagna, F., Veronesi, G., Bertù, L., Tozzi, M., Tarallo, A., Ferrario, M. M., & RoCAV Project Investigators. (2016). Prevalence of abdominal aortic aneurysms and its relation with cardiovascular risk stratification: protocol of the Risk of Cardiovascular diseases and abdominal aortic Aneurysm in Varese (RoCAV) population based study. BMC cardiovascular disorders, 16(1), 243.
Karthikesalingam, A., Vidal-Diez, A., Holt, P. J., Loftus, I. M., Schermerhorn, M. L., Soden, P. A., & Thompson, M. M. (2016). Thresholds for abdominal aortic aneurysm repair in England and the United States. New England Journal of Medicine, 375(21), 2051-2059.
Machado, R., Teixeira, G., Oliveira, P., Loureiro, L., Pereira, C., & Almeida, R. (2016). Endovascular abdominal aneurysm repair in women: what are the differences between the genders?. Brazilian journal of cardiovascular surgery, 31(3), 232-238.
Ryding, S. ( 2019, June 20). Abdominal Aortic Aneurysm (AAA): Causes, Symptoms, & Management. News Medical Life Sciences. Retrieved from https://www.news-medical.net/health/Abdominal-Aortic-Aneurysm-(AAA)-Causes-Symptoms-Management.aspx
U.S Preventive Services Workforce. (2019, Dec 10). Final Recommendation Statement
Abdominal Aortic Aneurysm: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/abdominal-aortic-aneurysm-screening