Decreasing prevalence of abdominal aortic aneurysm and

changes in cardiovascular risk factors

Sven-Erik Persson, PhD,a Kurt Boman, MD, PhD,b Anders Wanhainen, MD, PhD,c Bo Carlberg, MD, PhD,d
and Conny Arnerlv, MD, PhD,a Ume, Skellefte, and Uppsala, Sweden

ABSTRACT
Objective: A signicant reduction in the incidence of cardiovascular disease, including abdominal aortic aneurysm (AAA),
has been observed in the past decades. In this study, a small but geographically well dened and carefully characterized
population, previously screened for AAA and risk factors, was re-examined 11 years later. The aim was to study the
reduction of AAA prevalence and associated factors.
Methods: All men and women aged 65 to 75 years living in the Norsj municipality in northern Sweden in January 2010
were invited to an ultrasound examination of the abdominal aorta, registration of body parameters and cardiovascular
risk factors, and blood sampling. An AAA was dened as an infrarenal aortic diameter $30 mm. Results were compared
with a corresponding investigation conducted in 1999 in the same region.
Results: A total of 602 subjects were invited, of whom 540 (90%) accepted. In 2010, the AAA prevalence was 5.7% (95%
condence interval [CI], 2.8%-8.5%) among men compared with 16.9% (95% CI, 12.3%-21.6%) in 1999 (P < .001). The
corresponding gure for women was 1.1% (95% CI, 0.0%-2.4%) vs 3.5% (95% CI, 1.2%-5.8%; P .080). A low prevalence of
smoking was observed in 2010 as well as in 1999, with only 13% and 10% current smokers, respectively (P .16). Treatment
for hypertension was signicantly more common in 2010 (58% vs 44%; P < .001). Statins increased in the population (34%
in 2010 vs 3% in 1999; P < .001), and the lipid prole in women had improved signicantly between 1999 and 2010.
Conclusions: A highly signicant reduction in AAA prevalence was observed during 11 years in Norsj. Treatment for
hypertension and with statins was more frequent, whereas smoking habits remained low. This indicates that smoking is
not the only driver behind AAA occurrence and that lifestyle changes and treatment of cardiovascular risk factors may
play an equally important role in the observed recent decline in AAA prevalence. (J Vasc Surg 2016;-:1-8.)

In many countries, there has been a noticeable

decrease in abdominal aortic aneurysm (AAA) prevalence and mortality, whereas in others, AAA mortality is
stable or has even increased.1 These different trends
seem to correlate with variations of traditional cardiovascular risk factors.1 The most important documented risk
factors for AAA are high age, male sex, having a rstdegree relative with AAA, and smoking. Hypertension,
hyperlipidemia, and abdominal obesity have also been
associated with AAA.2-6
Mortality from cardiovascular diseases was higher in the
county of Vsterbotten in northern Sweden than in the

From the Department of Surgical and Perioperative Sciences, Surgery,a and

Department of Public Health and Clinical Medicine,d Ume University,
Ume; the Department of Medicine, Skellefte County Hospital, Skellefteb;
and the Department of Surgical Sciences, Uppsala University, Uppsala.c
This study was supported by research funding from Vsterbotten County
Council (VLL) and the Heart Foundation of Northern Sweden.
Author conict of interest: none.
Correspondence: Sven-Erik Persson, PhD, Ume University, Department of
Surgical and Perioperative Sciences, Surgery, 901 85 Ume Sweden (e-mail:
sven-erik.persson@umu.se).
The editors and reviewers of this article have no relevant nancial relationships to
disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conict of interest.
0741-5214
Copyright 2016 by the Society for Vascular Surgery. Published by Elsevier
Inc.
http://dx.doi.org/10.1016/j.jvs.2016.08.091

rest of Sweden in the 1970s and in the early 1980s.7 The

highest mortality in the county of Vsterbotten was
found in Norsj municipality. The highest prevalence of
AAA in a general population ever reported was found
in a population-based screening study carried out in
Norsj municipality 1999.8 Risk factors for cardiovascular
diseases were recorded in the screened subjects.
To reduce mortality and morbidity in cardiovascular
disease, health care providers and politicians started
the Vsterbotten Intervention Project (VIP) in 1985 with
a pilot project in Norsj (Fig 1). The aim was to reduce cardiovascular morbidity and mortality by reduction of
smoking, hypertension, and hypercholesterolemia,
mainly by lifestyle changes (healthy food and physical
activity). The strategy used was a combination of a
population-based and an individual high risk-based
program.9 All men and women aged 40, 50, and 60 years
were invited to an individual health screening including
a questionnaire on signicant cardiovascular risk factors.
Body mass index (BMI) and blood pressure were
measured, blood lipids were analyzed, and an oral
glucose tolerance test was performed. A specialist nurse
and, for high-risk patients, a physician offered personal
feedback to every participant of the health survey. In
1991, this program was introduced in all municipalities
in the county of Vsterbotten. The population strategy
included media information, public meetings, school
programs, study groups, health information at work sites,
1

Persson et al

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Fig 1. Map over Sweden: A, Vsterbotten county; B, Norrbotten county; C, Norsj municipality (4304 inhabitants
in 2010).

dental care programs, courses on healthy food, physical

activities, and labeling of healthy food (in general, food
without high fat content) by a logo illustrating a keyhole
on a green background. The effect on cardiovascular risk
factors and the subsequent decline in cardiovascular
morbidity and mortality have been previously published.10-13
Several studies have reported a marked reduction in
AAA prevalence during the last years, mainly attributed
to a signicantly decreased smoking frequency.14-17 No
results of the long-term effects of a broad cardiovascular
intervention program on the prevalence of AAA have
earlier been published.14-20 The aim of this study was to
investigate possible changes in the prevalence of AAA
in Norsj municipality and to relate this to changes in
cardiovascular risk factors 11 years after the index survey
(Fig 1).

METHODS
The population. In 1999, Norsj municipality had 4806
inhabitants. The rst study, performed by Wanhainen
et al in 1999, invited all men and women aged 65 to
75 years in the municipality of Norsj to an AAA ultrasound screening.8 For the second study, performed in
2010, all 602 men and women 65 to 75 years of age in
Norsj were invited to an AAA screening. The study was
performed at the local health care center in Norsj. In
June 2011, all study participants were invited to donate

blood for analyses of high-sensitivity C-reactive protein

level, blood lipid prole, and creatinine concentration.
Ultrasound. The ultrasound examination in 1999 was
performed by one experienced radiologist. The measurement differed from the current one in that the outer-toouter diameter was used. All study persons with an aortic
diameter $28 mm were examined with computed
tomography (CT). The diameter measured by ultrasound
was used in all statistical calculations.
The AAA screening in 2010 was performed by two
experienced sonographers with portable ultrasound
equipment (Logiq e; GE Healthcare, Wauwatosa, Wisc)
equipped with a 4 MHz transducer. The study was performed during three separate weeks, and each patient
was examined once by one sonographer. The screening
procedure was standardized. The infrarenal abdominal
aorta was visualized longitudinally, and the largest anteroposterior (AP) diameter was measured by means of
leading edge to leading edge, which means measuring
the distance between the outermost part of the ventral
wall of the aorta and the innermost part of the dorsal
aortic wall. In all study persons with an AP aortic
diameter $25 mm, measurement of the transverse aortic
diameter was performed. An infrarenal aorta with an AP
or transverse diameter $30 mm was dened as an AAA.
All examinations were stored digitally. In a few cases in
which the aortic diameter could not be measured

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Table I. Comparison of data between the study of Wanhainen in 1999 and the present study in 2010
Men
1999
No. of participants

Women
2010

1999

2010

248

265

256

275

Age, years

70.3 6 2.8

70.3 6 3.1

70.3 6 3.0

71.1 6 3.2

Aortic diameter, mm

26.9 6 7.1

18.7 6 4.9

22.3 6 3.5

15.4 6 3.3

42/248 (16.9%)

15/265 (5.7%)

9/256 (3.5%)

3/275 (1.1%)

Aortic diameter $30 mm

Continuous variables are reported as mean 6 standard deviation.

reliably, the aorta was examined by a CT scan. Study

participants with an aortic diameter of $30 mm were
individually re-examined and informed at the Vascular
Policlinic at Ume University Hospital.
Risk factor collection. Height and weight were
measured and BMI was calculated. Sitting systolic and
diastolic blood pressure was measured in both arms
with a mercury sphygmomanometer. All individuals
with elevated blood pressure were advised to contact
their general practitioner for additional measurements
and potential treatment.
The same health questionnaire was used in the two
surveys. Smoking was registered as current smoking,
former smoking, and nonsmoking. Family history of
AAA in rst-degree relatives was registered. Selfreported occurrence of coronary heart disease, transient
ischemic attack/stroke, peripheral arterial occlusive
disease, and earlier cardiovascular surgery was recorded.
Further, the presence of self-reported hypertension,
chronic obstructive pulmonary disease, diabetes mellitus, renal failure, and cancer was registered. The current
medication for each examined individual was obtained.
Blood samples were analyzed for plasma cholesterol,
plasma high-density lipoprotein, plasma triglyceride,
and creatinine concentrations. Plasma low-density lipoprotein concentration was calculated from the Friedewald formula. All analyses were done at the research
unit at Skellefte County Hospital during 1999 and 2011,
respectively. Laboratory methods for analysis of blood
lipids, creatinine, and high-sensitivity C-reactive protein
were unchanged between 1999 and 2011.
The Research Ethics Review Board of northern Sweden
approved the study (Dnr 09-185M and Dnr 2011-170-32M),
and all participants gave written informed consent.
Statistics. The c2 test or Fisher exact test was used to
compare categorical variables. The Shapiro-Wilk
normality test was used to test for normality. Normally
distributed data were compared with independent
samples t-test, and nonparametric data were compared
with Wilcoxon rank sum test. A P < .05 was considered
signicant. R was used for statistical analyses.21

RESULTS
In the 1999 study, 504 (248 men and 256 women) of 555
inhabitants (91%) aged 65 to 75 years participated in the

study. All 504 participants donated blood for further

studies. Ultrasound screening detected aneurysms in 35
men, and by adding seven men who had undergone
aortic aneurysm surgery, 16.9% of the examined men
were diagnosed with an aneurysm. In 10 of the 35 men,
CT examination did not conrm the diameter of
$30 mm. Ultrasound screening detected eight aneurysms in women, and by adding one woman previously
operated on, a prevalence of 3.5% was found. Two of
the ultrasound-detected AAAs were not conrmed by CT.
In 2010, all 602 men and women aged 65 to 75 years
were invited to participate, and 540 of 602 (90%)
accepted (265 men and 275 women). Blood was donated
by 456 persons.
All study participants were northern Europeans (except
one born in Canada).
In the present study, the aortic diameter could be reliably measured by ultrasound in 535 of 540 (99%) individuals, and in 5 individuals, a CT scan was performed that
resulted in discovery of an AAA in 1 woman. In three
cases, the AP diameter was <30 mm but the transverse
diameter was $30 mm, and these were included as
aortic aneurysms. Including all aneurysms detected by
ultrasound and CT and previously operated on AAAs, a
total prevalence of 3.3% (18/540) AAA was found. The
prevalence was 5.7% (15/265) among men and 1.1%
(3/275) among women. An AAA was detected in 12 men
and 3 women at the screening (diameter range,
30-58 mm). Two men with a previously operated on
AAA attending the ultrasound screening and one man
with a normal aortic diameter but with a common iliac
artery aneurysm of 64 mm were included.
Comparing the present study in 2010 with the previous study in 1999. The prevalence of AAA decreased
from 16.9% to 5.7% (P < .001) in men and from 3.5% to
1.1% (P .080) in women between 1999 and 2010
(Table I). The mean and median aortic diameter in
both men and women was signicantly lower in 2010
compared with 1999 (P < .001; Table I).
Distribution of the aortic diameter determined by ultrasound in 1999 and 2010 is presented in Figs 2 and 3,
respectively.
Risk factors for cardiovascular disease and results of
laboratory analyses (including missing data) in the
1999 and 2010 populations are presented in Table II for

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300

250

250

50

50

100

150

Frequency

200

200
150
100

Frequency

2016

300

---

20

40

60

80

Maximun infrarenal aortic diameter (mm)

20

40

60

80

Maximun infrarenal aortic diameter (mm)

Fig 2. Distribution of aortic diameter determined by

ultrasound in 1999 (475 men and women).

Fig 3. Distribution of aortic diameter determined by

ultrasound in 2010 (535 men and women).

men and Table III for women. BMI was slightly lower in
2010 compared with 1999. Current smoking was unchanged, but a higher proportion of women were
former smokers in 2010. The prevalence of diabetes
mellitus did not differ signicantly between the two surveys. Self-reported hypertension was more common in
2010, and medical treatment was given to 59% of all
men and 66% of all women. The prevalence of transient
ischemic attack/stroke among women was higher in
2010 than in 1999. On the other hand, ischemic heart
disease was less frequent among men in the later survey
compared with 1999. A signicantly more favorable
blood lipid prole was seen regarding cholesterol,
high-density lipoprotein, and low-density lipoprotein
concentrations among women but only for highdensity lipoprotein in men. Serum creatinine values
increased in both sexes.
As only 76% of the study participants from 2010
donated blood, a univariate statistical analysis was
performed comparing the group donating blood with
the group that did not regarding age, sex, aortic diameter, BMI, blood pressure, smoking habits, use of statins,
and cardiovascular risk factors. There were no signicant
differences between the groups.

compared with the reported current prevalence in Sweden for both men and women.14,20,22,23
Factors initiating aneurysm formation are unknown
and factors affecting different growth rate in different individuals are poorly understood. Also, the lag time between aneurysm initiation and disease progression is
unknown. So far, no study on medical treatment to
reduce AAA growth has been successful.24 However,
modiable factors such as smoking, hypertension, hypercholesterolemia, and abdominal obesity are associated
with AAA.
In our study, smoking was not less common in the 2010
population compared with the 1999 population, and in
both studies, the smoking frequency was relatively low.
A comparison of pack-years cannot be made because
of lack of reliable data. The importance of smoking for
development of AAA is well documented, and in our
study, 87.5% of participants with an AAA were exposed
to smoking.2,4,5,14,25-27 Nevertheless, reduction of smoking
cannot explain the reduced prevalence of AAA in the
present study.
Several studies have shown an association between
hypertension and the prevalence of AAA.2,5,14,25,26,28 In
the studied population, the awareness of hypertension
as a cardiovascular risk factor has resulted in a high
frequency of diagnosis and antihypertensive treatment.
The effect of statin treatment on aneurysm formation
and growth is unclear, with conicting results in the literature. Several clinical observational studies reported an
association between statin use and reduced AAA progression,29-34 whereas others failed to show an effect.3537
So far, no randomized controlled trial has investigated
the effect of statin on AAA. In 1999, medical treatment for
hypercholesterolemia was uncommon (only 2.8% in the
population), but 34% of the study participants were

DISCUSSION
There was a highly signicant reduction in the prevalence of AAA between 1999 and 2010 for men in Norsj.
The magnitude of this reduction for women was comparable to that for men but did not reach statistical significance, probably because of the low prevalence and
small sample size. Several studies have reported a
decreased prevalence of AAA, but this magnitude of
reduction has never been presented previously.14-20 Still,
the AAA prevalence in Norsj is three to four times higher

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Table II. Comparison of data between the study of Wanhainen in 1999 and the present study in 2010 for men

No. of men
BMI
First-degree relative

1999

2010

248

265

27.4 6 3.7 (3/248)

26.6 6 3.8 (1/265)

8.6 (39/248)

8.5 (29/265)

P value

.0020
1.0

Current smoker

7.8 (6/248)

10.6 (3/265)

.34

Former smoker

36.6 (6/248)

38.5 (4/265)

.70

Hypertension

40.9 (7/248)

55.3 (3/265)

.0016

58.6 (8/265)

Diabetes

Medication for hypertension

14.0 (6/248)

14.4 (2/265)

.98

Ischemic heart disease

33.0 (34/248)

22.6 (8/265)

.015

TIA/stroke

7.2 (40/248)

8.3 (14/265)

PAOD

4.3 (40/248)

Medication with statins

2.8 (in the population)

3.1 (21/265)
33.1 (8/265)

.77
.74
<.001

Plasma cholesterol, mmol/L

5.6 6 1.0 (19/248)

5.5 6 1.2 (48/265)

.27

Plasma HDL cholesterol, mmol/L

1.2 6 0.3 (19/248)

1.3 6 0.3 (48/265)

.036

Plasma LDL cholesterol, mmol/L

3.4 6 0.8 (19/248)

3.3 6 1.2 (48/265)

.27

1.7 6 1.0 (19/248)

1.9 6 1.3 (48/265)

.063

2.8 6 4.6 (19/248)

3.2 6 5.6 (50/265)

.98

88.0 6 45.9 (19/248)

94.8 6 25.4 (48/265)

Plasma TGs, mmol/L

hs-CRP, mg/L
Plasma creatinine, mmol/L

<.001

BMI, Body mass index; HDL, high-density lipoprotein; hs-CRP, high-sensitivity C-reactive protein; LDL, low-density lipoprotein; PAOD, peripheral arterial
occlusive disease; TGs, triglycerides; TIA, transient ischemic attack.
Categorical variables are presented as percentage. Continuous variables are presented as mean 6 standard deviation. The ratio in parentheses
represents missing data for each variable.

treated with statins in 2010. In the present study, mean

values of blood lipids for men were unchanged
compared with 1999; but among women, a signicant
change toward a more favorable blood lipid prole was
demonstrated. The importance of these small changes
is unclear. A signicant BMI reduction for both men
and women between 1999 and 2010 was also found.
Genetic factors also exist, but we found a relatively low
proportion of family history of AAA compared with a
mean frequency of 13% as reported by Bjrck and
Wanhainen.38 However, missing data for rst-degree
relatives are high in the two studies, and self-reported
family history is uncertain.
Hence, the observed marked reduction in AAA prevalence seen in Norsj is not fully explained by the usual
suspect, that is, changing smoking habits. More likely,
improvement of other modiable cardiovascular risk
factors, such as better blood pressure control, statin
treatment with better lipid levels, and possibly weight
loss, may have an important role. Our data cannot
explain the degree and extent of how the changes of
the different risk factors examined in our study
contribute to the reduction of AAA prevalence.
From the World Health Organization Multinational
Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study performed in the counties
of Vsterbotten and Norrbotten (including the municipality of Norsj), we know that the traditional risk factors
for cardiovascular disease and also cardiovascular

mortality have decreased in this area. Between 1986

and 2009, in the 25- to 64-year-old population, mean
blood pressure decreased 5.1/2.9 mm Hg in women
and 1.7/0.3 mm Hg in men.10 During the same period,
regular smoking decreased from 26.4% to 11.5% in
women and from 22.8% to 10.1% in men.10 Total plasma
cholesterol concentration decreased by 0.89 mmol/L in
women and by 0.87 mmol/L in men.10
It seems possible that the decrease in the prevalence of
AAA could be related to changes in risk factors during
the 1980s and 1990s. If so, it would implicate that the
time lag between risk factor changes and development
of AAA is longer than what is seen for myocardial infarction or stroke.
The VIP includes other activities in the community that
may have positive effects on vascular diseases that are
not mediated through the traditional risk factors. Community activities and individual counseling including
other parts toward a healthy lifestyle, like physical activity
and healthy food choices, have been extensive. An
inverse association between consumption of fruit and
the risk of AAA has been described.39 During the rst
decades of the VIP, coronary heart disease and stroke
were signicantly reduced in Vsterbotten, and simultaneously a highly signicant reduction of AAA prevalence
in Norsj has now been demonstrated.
A possible reason that can contribute to the lower
prevalence detected in 2010 could be that patients
with prior AAA repair or with already known AAA

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Table III. Comparison of data between the study of Wanhainen in 1999 and the present study in 2010 for women

No. of women
BMI
First-degree relative

1999

2010

256

275

28.2 6 5.1 (3/256)

27.4 6 4.9 (1/275)

6.0 (34/256)

7.7 (28/275)

P value

.029
.59

Current smoker

11.4 (10/256)

14.5 (6/275)

.36

Former smoker

13.0 (10/256)

28.4 (13/275)

<.001

Hypertension

46.7 (10/256)

60.8 (2/275)

Medication for hypertension

66.5 (5/275)

.0018
d

Diabetes

12.2 (10/256)

15.7 (1/275)

.31

Ischemic heart disease

16.4 (30/256)

14.3 (15/275)

.60

2.7 (35/256)

8.4 (11/275)

.014

TIA/stroke
PAOD

3.6 (35/256)

Medication with statins

2.8 (in the population)

1.1 (16/275)
34.5 (5/275)

.14
<.001

Plasma cholesterol, mmol/L

6.2 6 1.1 (30/256)

5.7 6 1.2 (54/275)

<.001

Plasma HDL cholesterol, mmol/L

1.5 6 0.3 (30/256)

1.6 6 0.4 (54/275)

.034

Plasma LDL cholesterol, mmol/L

3.7 6 0.9 (30/256)

3.3 6 1.1 (54/275)

<.001

Plasma TGs, mmol/L

1.8 6 0.9 (30/256)

1.9 6 0.8 (54/275)

.019

hs-CRP, mg/L

3.0 6 4.0 (30/256)

4.0 6 9.3 (55/275)

69.2 6 11.1 (30/256)

77.2 6 17.9 (54/275)

Plasma creatinine, mmol/L

.23
<.001

BMI, Body mass index; HDL, high-density lipoprotein; hs-CRP, high-sensitivity C-reactive protein; LDL, low-density lipoprotein; PAOD, peripheral arterial
occlusive disease; TGs, triglycerides; TIA, transient ischemic attack.
Categorical variables are presented as percentage. Continuous variables are presented as mean 6 standard deviation. The ratio in parentheses
represents missing data for each variable.

declined to participate in the screening. However, since

about 15 years ago, all operations for AAA and most of
the surveillance for known AAA in the county of Vsterbotten are done at the Surgical Department, Ume University Hospital. None of the individuals not participating
in the study has been operated on for AAA or has been
under surveillance for an AAA.
An important methodologic limitation of the current
report is the different methods used to place the calipers
in measuring the AP abdominal aortic diameter with
ultrasound. In the 1999 study by Wanhainen, the aortic
diameter was measured using the outermost ultrasound
reection with the transducer parallel to the longitudinal
axis of the vessel and the outermost CT brightness of the
infrarenal aorta,40 whereas in the present study, the
maximal AP diameter was measured according to
the leading edge to leading edge principle. This can partly
explain the pronounced reduction in mean aortic diameter as well as some of the differences seen in AAA prevalence. However, the aortic wall measures about 2 mm, so
most of the observed differences in prevalence must have
other explanations. In the rst study using strict criteria
that both ultrasound and CT measurement must be
30 mm or more to diagnose an aneurysm, 25 persons
were diagnosed during the screening, and by adding
the 7 men previously operated on, the prevalence among
men was 12.9% (32/248). This is also a high prevalence.
Another weakness of this study is the relatively limited
size of the study population. Although we found a clearly

signicant decrease in the prevalence of AAA in men, the

decrease of similar magnitude in women was not statistically signicant. The accuracy of self-reported risk
factors and cardiovascular disease is subject to bias.
However, screening for risk factors has been ongoing in
this population since 1985.
The strength of the study is the homogeneous population in Norsj. Norsj is located in a sparsely populated,
isolated area. Study participants have all been investigated at the same place during a short time, and the
attendance rate was exceptionally high.

CONCLUSIONS
A highly signicant reduction of AAA prevalence, during
as short a period as 11 years, was demonstrated among
men aged 65 to 75 years in Norsj. Treatment for hypertension and with statins was frequent in 2010, whereas
the frequency of current smoking was unchanged, so
reduction of smoking cannot explain the reduced AAA
prevalence. This indicates that a broad populationbased intervention to improve cardiovascular health,
including lifestyle changes and treatment of cardiovascular risk factors, may also reduce AAA prevalence.

AUTHOR CONTRIBUTIONS
Conception and design: SP, KB, AW, CA
Analysis and interpretation: SP, KB, AW, BC, CA
Data collection: SP, CA
Writing the article: SP, BC, CA

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Critical revision of the article: KB, AW, BC, CA

Final approval of the article: SP, KB, AW, BC, CA
Statistical analysis: SP, CA
Obtained funding: SP, BC
Overall responsibility: CA

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Submitted May 31, 2016; accepted Aug 24, 2016.