Tracy Wolff, MD, MPH; Janelle Guirguis-Blake, MD; Therese Miller, DrPH; Michael Gillespie, MD, MPH; Russell Harris, MD, MPH
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Reprints are available from the USPSTF Web site (www.preventiveservices.ahrq.gov).
Current Author Addresses: Drs. Wolff and Miller: Center for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850.
Dr. Guirguis-Blake: Tacoma Family Medicine Residency, Department of Family Medicine, University of Washington, 521 Martin Luther King Jr. Way, Tacoma, WA 98405.
Dr. Gillespie: School of Medicine, University of North Carolina, CB #7075, 6th Floor, Burnett-Womack Building, 099 Manning Drive, Chapel Hill, NC 27599.
Dr. Harris: School of Medicine, University of North Carolina, CB #7590, Sheps Center, 725 Martin Luther King Jr. Boulevard, Chapel Hill, NC 27599-7590.
Cerebrovascular disease is the third leading cause of death in the United States. The proportion of all strokes attributable to previously asymptomatic carotid artery stenosis (CAS) is low. In 1996, the U.S. Preventive Services Task Force concluded that evidence was insufficient to recommend for or against screening of asymptomatic persons for CAS by using physical examination or carotid ultrasonography.
To examine the evidence of benefits and harms of screening asymptomatic patients with duplex ultrasonography and treatment with carotid endarterectomy for CAS.
MEDLINE and Cochrane Library (search dates January 1994 to April 2007), recent systematic reviews, reference lists of retrieved articles, and suggestions from experts.
English-language randomized, controlled trials (RCTs) of screening for CAS; RCTs of carotid endarterectomy versus medical treatment; systematic reviews of screening tests; and observational studies of harms from carotid endarterectomy were selected to answer the following questions: Is there direct evidence that screening with ultrasonography for asymptomatic CAS reduces strokes? What is the accuracy of ultrasonography to detect CAS? Does intervention with carotid endarterectomy reduce morbidity or mortality? Does screening or carotid endarterectomy result in harm?
All studies were reviewed, abstracted, and rated for quality by using predefined Task Force criteria.
No RCTs of screening for CAS have been done. According to systematic reviews, the sensitivity of ultrasonography is approximately 94% and the specificity is approximately 92%. Treatment of CAS in selected patients by selected surgeons could lead to an approximately 5–percentage point absolute reduction in strokes over 5 years. Thirty-day stroke and death rates from carotid endarterectomy vary from 2.7% to 4.7% in RCTs; higher rates have been reported in observational studies (up to 6.7%).
Evidence is inadequate to stratify people into categories of risk for clinically important CAS. The RCTs of carotid endarterectomy versus medical treatment were conducted in selected populations with selected surgeons.
The actual stroke reduction from screening asymptomatic patients and treatment with carotid endarterectomy is unknown; the benefit is limited by a low overall prevalence of treatable disease in the general asymptomatic population and harms from treatment.
Analytic framework for screening for carotid artery stenosis (CAS).
CEA = carotid endarterectomy; KQ = key question.
Appendix Table 1. Literature Search and Inclusion and Exclusion Criteria*
Appendix Table 2. U.S. Preventive Services Task Force Hierarchy of Research Design and Quality Rating Criteria*
Literature search results for key question 4 on the harms of carotid endarterectomy (CEA).
Table 1. Evidence Table for Randomized, Controlled Trials for Effectiveness of Surgery versus Medical Management for Asymptomatic Carotid Artery Stenosis*
Appendix Table 3. Randomized, Controlled Trials of Effectiveness of Surgery versus Medical Management for Asymptomatic Carotid Artery Stenosis*
Appendix Table 4. Complication Rates of Carotid Endarterectomy*
Table 2. Projected Outcomes of Screening 100 000 Asymptomatic Adults for Carotid Artery Stenosis*
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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;147:860-870. doi: 10.7326/0003-4819-147-12-200712180-00006
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Published: Ann Intern Med. 2007;147(12):860-870.
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