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USPSTF recommends against screening for carotid artery stenosis in asymptomatic adults
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The United States Preventive Services Task Force has issued a recommendation statement against screening for carotid artery stenosis in adults without a history of stroke, transient ischemic attack and other neurologic signs or symptoms.
The task force found that, “with moderate certainty,” available evidence indicates that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits.
The new recommendation reaffirms a 2007 statement from the USPSTF, and is consistent with recommendations from the American Heart Association/American Stroke Association, American College of Cardiology Foundation and other organizations, statement chair Michael L. LeFevre, MD, MSPH, and colleagues wrote.
According to the report, the prevalence of carotid artery stenosis in the United States is 0.5% to 1%, and there are no reliable tools to distinguish between carotid artery stenosis that is clinically important and that which is not, as well as between those who will experience harm after treatment with carotid endarterectomy (CEA) or carotid angioplasty and stenting and those who will not.
Risks outweigh benefits
“The USPSTF found no evidence that screening for carotid artery stenosis leads to additional treatment and benefit beyond standard preventative treatments based on traditional [CV] risk factors,” the task force wrote. “Adequate evidence indicates that both the testing strategy for carotid artery stenosis and treatment with CEA or [carotid angioplasty and stenting] can cause serious harms.”
Existing screening methods “have imperfect sensitivity and could lead to unnecessary surgery and result in serious harms, including death, stroke and [MI],” according to the statement.
More research is needed on which people are at high risk for carotid artery stenosis or stroke caused by it, as well as who might be harmed by CEA or carotid angioplasty and stenting. There is also a need for more studies to compare CEA or carotid angioplasty and stenting vs. standard medical therapy, and the planned CREST-2 study could provide data to influence future recommendations, the task force wrote.
Tests unlikely to help
Larry B. Goldstein
In a related editorial, Larry B. Goldstein, MD, from the Duke Stroke Center and Durham Veterans Affairs Medical Center, wrote that potential consumers of screening services for carotid artery stenosis “should be aware that the test is unlikely to prevent them from having a stroke or to lead to improvements in their health.”
Goldstein, a member of the Cardiology Today Editorial Board, also noted that the population-attributable risk for stroke in those with asymptomatic carotid artery stenosis is just 0.9% and its prevalence would need to be 14 times greater for it to reach a population-attributable risk for stroke similar to that of hyperlipidemia. “As the [USPSTF] mentioned, there is no validated risk-stratification tool that can reliably identify a subpopulation of persons with a prevalence of asymptomatic [carotid artery stenosis] approaching” the level of hyperlipidemia, Goldstein wrote.
For more information:
Goldstein LB. Ann Intern Med. 2014;doi:10.7326/M14-1332.
LeFevre ML. Ann Intern Med. 2014;doi:10.7326/M14-1333.
Disclosure: The task force members and Goldstein report no relevant financial disclosures.
Perspective
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Gina Lundberg, MD, FACC
In general, I agree with the recommendation. I do not agree with screening of completely asymptomatic and low-risk patients, and I do not agree with indiscriminate screening just for the sake of screening. But I think the recommendation is more narrow than I am comfortable with. The USPSTF is saying you should not perform carotid ultrasound screening unless the patient has already had a stroke — which obviously indicates they have had disease — or TIA, which we treat as an equivalent to a stroke, or other neurologic signs. I think that they should include in that recommendation that people with known CVD or high-risk indicators for CVD should be screened. For instance, when we know that a patient has CAD, there’s about a 25% chance they could have aortic disease, peripheral artery disease or carotid disease. When we hear a carotid bruit, we generally order a carotid ultrasound to quantitate any narrowing there. Sometimes we hear a bruit because a patient has turbulent flow, and there is still plenty of blood flow, but sometimes we hear it because the carotid artery has narrowed.
If you don’t look for the disease, you’re not going to find the disease. By the time you have a neurologic symptom, that’s pretty significant narrowing, so that doesn’t work well for trying to prevent strokes and MIs. You have to be looking a little more aggressively than that. So I’m in the middle on this: I don’t agree with waiting until there is a neurologic symptom, but I agree with not doing it in young, healthy, asymptomatic patients.
I think the carotid ultrasound can be useful in detecting potential signs of stroke. I don’t want the message to get out that we should not do any screening ever. I think the message needs to be that we should do appropriate screening in the right individuals.
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