1. In a new statement, the U.S. Preventive Services Task Force recommended against screening for carotid artery stenosis in adult patients without a history of transient ischemic attack (TIA), stroke, or other neurological signs or symptoms (Class D recommendation).
Evidence Rating Level: 1 (Excellent)
Study Rundown: Carotid artery stenosis (CAS) is often identified as the etiology in ischemic stroke. Given that stroke is a leading cause of disability and mortality in North America, there is great interest in the role of screening for CAS in asymptomatic individuals. The USPSTF has released a new statement based on a systematic review of CAS screening in the general population. The statement recognized that ultrasonography was the most practical screening test with high sensitivity and specificity, although it is associated with a high rate of false positive results in a general asymptomatic population. There was no direct evidence pertaining to the benefits of CAS screening. However, the review identified evidence that showed that carotid endarterectomy (CEA) reduced stroke or perioperative death by 3.5% compared to medical management. However, the medical management in these trials were outdated, and likely the magnitude of these benefits would be minimal with current medical management in asymptomatic patients in the general population. Regarding the harms, the USPSTF identified that although there was no direct harm in ultrasound screening, interventions such as unnecessary CEA or stenting as a result of false positive results could result in significant harms to patients. These harms include further stroke, myocardial infarction, and death. Although this new statement provides guidance for clinicians, there is clearly the need for further direct evidence regarding the benefits and harms of CAS screening, particularly for those patients who are high risk.
Click to read the study, published today in the Annals of Internal Medicine
Click to read the recommendations, published today in the Annals of Internal Medicine
Relevant Reading: Sensitivity and specificity of color duplex ultrasound measurement in the estimation of internal carotid artery stenosis: A systematic review and meta-analysis
In-Depth [systematic review]: The systematic review identified no studies pertaining to the direct benefits of screening for asymptomatic CAS. Three randomized controlled trials (RCTs) looked at the benefit of treating asymptomatic CAS with CEA. Pooled estimates found that CEA in these asymptomatic patients was associated with 3.5% fewer death, perioperative stroke or subsequent stroke. Furthermore, no studies directly examined the harms of screening. Pooled analysis of data from 6 trials showed that CEA was associated with 1.9% increased risk of death or stroke within 30 days of CEA compared to medical therapy. Other important harms studied were myocardial infarction and perioperative complications including cranial nerve injury, lung embolism, pneumonia or local hematoma. Overall, the USPSTF determined that the magnitude of benefit is small-to-none, while the magnitude of harm is small-to-moderate. Thus, the USPSTF concluded with moderate certainty that the harms of screening for CAS in asymptomatic general population outweigh the benefits.
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