The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population.
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Risk Factor Information
The major risk factors for carotid artery stenosis include older age, male sex, hypertension, smoking, hypercholesterolemia, diabetes mellitus, and heart disease. Despite evidence on important risk factors, there are no externally validated, reliable methods to determine who is at increased risk for carotid artery stenosis or for stroke when carotid artery stenosis is present.
Patient Population Under ConsiderationThis recommendation applies to adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms. It was based on evidence of the benefits and harms of screening using ultrasonography to detect narrowing of the carotid arteries. A previous USPSTF review on the assessment of carotid intima–media thickness in 2009 found insufficient evidence to support its use as a screen for coronary heart disease risk. For this recommendation, the USPSTF did not review new evidence on ultrasonography to characterize carotid plaque structure or intima–media thickness and their association with cardiovascular disease events. However, clinicians considering using ultrasonography to characterize carotid plaque to stratify patient risk for cardiovascular disease should consider the same harms that the USPSTF evaluated for this recommendation (stroke, myocardial infarction, and death from CEA) because surgery may result from this screen.
Assessment of RiskThe major risk factors for carotid artery stenosis include older age, male sex, hypertension, smoking, hypercholesterolemia, diabetes mellitus, and heart disease. Despite evidence on important risk factors, there are no externally validated, reliable methods to determine who is at increased risk for carotid artery stenosis or for stroke when carotid artery stenosis is present.
Screening TestsAlthough screening with ultrasonography has few direct harms, all screening strategies, including those with or without confirmatory tests (that is, digital subtraction or magnetic resonance angiography), have imperfect sensitivity and could lead to unnecessary surgery and result in serious harms, including death, stroke, and myocardial infarction. There is no evidence that screening by auscultation of the neck to detect carotid bruits is accurate or provides benefit.
Useful ResourcesThe USPSTF has made recommendations on many factors related to stroke prevention, including screening for hypertension, screening for dyslipidemia, the use of nontraditional coronary heart disease risk factors, counseling on smoking, and counseling on healthful diet and physical activity. In addition, the USPSTF recommends the use of aspirin for persons at increased risk for cardiovascular disease. These recommendations are available on the USPSTF Web site (www.uspreventiveservicestaskforce.org).
Research Needs and GapsValid and reliable tools are needed to determine which persons are at high risk for carotid artery stenosis or for stroke due to carotid artery stenosis and who might experience harm from treatment with CEA or CAAS. Studies comparing CEA or CAAS with current standard medical therapy are needed. The planned CREST-2 (Carotid Revascularization Endarterectomy versus Stenting Trial 2) may provide important data for future recommendations. CREST-2 will study 2400 patients with greater than 70% stenosis who are randomly assigned to CAAS with intensive medical management versus intensive medical management alone or to CEA with intensive medical management versus intensive medical management alone.
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In 2010, the American Heart Association and the American Stroke Association recommended against screening the general population for asymptomatic carotid artery stenosis. In 2011, the American College of Cardiology Foundation and the American Heart Association, in collaboration with several other organizations, including the American Stroke Association, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Society for Vascular Surgery, and Society for Vascular Medicine, recommended against the use of carotid DUS for routine screening of asymptomatic patients with no clinical manifestations of or risk factors for atherosclerosis. The Society for Vascular Surgery also released a guideline in 2011 stating that routine screening to detect clinically asymptomatic carotid artery stenosis in the general population is not recommended. The American Academy of Family Physicians recommends against screening for asymptomatic carotid artery stenosis in the general adult population.