U.S. Preventive Services Task Force
Update of the 1996 U.S. Preventive Services Task Force statement about screening for asymptomatic carotid artery stenosis (CAS) in the general population.
The U.S. Preventive Services Task Force examined the evidence on the natural history of CAS; systematic reviews of the accuracy of screening tests; observational studies of the harms of screening and treatment of asymptomatic CAS; and randomized, controlled trials of the benefits of treatment for CAS with carotid endarterectomy.
Do not screen for asymptomatic CAS in the general adult population. (Grade D recommendation)
For a summary of the evidence systematically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go to http://www.preventiveservices.ahrq.gov. USPSTF = U.S. Preventive Services Task Force. *This recommendation applies to adults without neurologic symptoms and without a history of transient ischemic attacks or stroke. If otherwise eligible, an individual who has a carotid-area transient ischemic attack should be evaluated promptly for consideration of carotid endarterectomy.
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Cy-Fair Cardiovascular Associates
January 14, 2008
Carotid Stenosis: A risk Marker or Just an Indication for Intervention
I read with great interest the US Preventive Services Task Force screening for carotid stenosis recommendation statement (1) and the article by Wolff and colleagues (2) advising against the routine screening asymptomatic individuals in the general population. I would concur with the authors if the sole purpose of carotid screening was to define which patients need an intervention. However, in clinical practice this non-invasive testing modality provides much more than that. Carotid ultrasound serves as a surrogate marker of atherosclerosis providing valuable information and modifying the patients overall cardiac risk. Patients found to have carotid stenosis exceeding 50 percent are considered to have a ten year cardiovascular risk exceeding 20 percent (high risk), alerting the clinician to intensify risk factor management and alter the treatment targets (3). The intima media thickness component of this study that is routinely reported by many labs serves not only as a marker of atherosclerosis but also as an indicator of the efficacy of the medical treatment regimen employed (4). Finally, the epidemic of atherosclerosis in the pediatric population (for which no large population studies exist to guide the management) calls for utilization of non- invasive methods such as intima media thickness to monitor response to treatment.
Carotid ultrasound is viewed as having moderate sensitivity and specificity with many false-positive results. This problem should be addressed by standardization of laboratories and mandating accreditation to insure quality. The authors' conclusions did not take into consideration the differences between carotid ultrasound assessment and other imaging modalities. Carotid ultrasound testing offers physiologic information beyond the anatomic data derived from computed tomography and magnetic resonance imaging.
Since the time of the (ACAS) and (ACST), a plethora of developments in our understanding and management of atherosclerosis occurred making it very likely that the implications of these trials might be outdated. Thus, building guidelines based on these trials might not be applicable in this day and age.
We strongly feel that these guidelines should be reevaluated prior as carotid ultrasound assessment even as screening tool offers clinical insights beyond categorizing patients into intervention and non- intervention groups.
1. US Preventive Services Task Force. Screening for carotid stenosis: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2007; 147: 854-859.
2. Wolff T, Guirguis-Blake J, Miller T, et al. Screening for carotid stenosis: An update of the evidence for the US Preventive Services Task Force. Ann Intern Med 2007; 147: 860-870.
3. Grundy SM, Cleeman JI, Bairey Merz CN, et al. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 2004; 110:227-239.
4. Taylor AJ, Sullenberger LE, Lee HJ, Lee JK, Grace KA. Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER) 2: a double-blind, placebo-controlled study of extended-release niacin on atherosclerosis progression in secondary prevention patients treated with statins. Circulation. 2004 Dec 7; 110(23):3512-3517.
Clinic for Internal Medicine III, University of the Saarland, Germany
January 15, 2008
Carotid ultrasound for detection of high risk patients
The authors of the recent comments of the U.S. Preventive Services Task Force provided thoughtful and detailed comments on the use of different screening methods including non-invasive ultrasound techniques in the detection of carotid artery stenosis (1,2). The Task Force members rigorously evaluated the evidence for diagnostic tools in the detection of carotid artery stenosis. They concluded that screening methods in asymptomatic patients to detect stenosis of higher and in particular lower grades might cause harm by overuse of therapeutic interventions.
The distribution of this straightforward and logical analysis could potentially lead to an underuse of non-invasive ultrasound techniques in cardiovascular high risk populations. Plaque formations in the carotid artery or even an increase of intima-media-thickness have been associated to cardiovascular risk in general and in particular with the risk of stroke. The detection of carotid artery changes might influence the intensity of risk factor management as well as the application of anti-platelet agents by physicians. The latter treatments are often initiated depending on the detection of peripheral vascular disease or disease of cerebral arteries (3). Therefore, risk assessment does not only involve the evidence for clinically established cardiovascular disease, but also of subclinical stages of vascular disease (4) and plaque detection in carotid artery might at least in part be representative for other vascular regions and are more easily accessible by non-invasive techniques than the coronary arteries. Therefore, the authors might wish to comment on the potential danger of underuse of non-invasive techniques to detect carotid artery disease, which might worsen the preventive care of patients at high risk in the absence of stroke or heart attack.
Michael BÃ¶hm, MD, PhD Britta Link, MD Ulrich Laufs, MD, PhD
Klinik fÃ¼r Innere Medizin III, Kirrberger Str., 66424 Homburg/Saar, Germany Tel.: +49 6841 16-23372 Fax: +49 6841 16-23369 Email: firstname.lastname@example.org
1. U.S. Preventive Task Force. Screening for carotid artery stenosis: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2007;147:854-9.
2. Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening for carotid artery stenosis: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2007;147:860-70.
3. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: full text. Eur Heart J 2007;9 (Suppl. C):C3-74.
4. Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Constituted by representatives of nine societies and by invited experts). European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Eur Heart J 2007; doi:10.1093/eurheartj/ehm316.
5. Smith SC Jr, Blair SN, Bonow RO, Brass LM, Cerqueira MD, Dracup K, Fuster V, Gotto A, Grundy SM, Miller NH, Jacobs A, Jones D, Krauss RM, Mosca L, Ockene I, Pasternak RC, Pearson T, Pfeffer MA, Starke RD, Taubert KA. AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 2001;104:1577-9.
U.S. Preventive Services Task Force. Screening for Carotid Artery Stenosis: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2007;147:854-859. doi: 10.7326/0003-4819-147-12-200712180-00005
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Published: Ann Intern Med. 2007;147(12):854-859.
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