Tracy Wolff, MD, MPH; Janelle Guirguis-Blake, MD; Therese Miller, DrPH; Michael Gillespie, MD, MPH; Russell Harris, MD, MPH
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
Download citation file:
Published: Ann Intern Med. 2007;147(12):860-870.
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 5â€“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.
CEA = carotid endarterectomy; KQ = key question.
Appendix Table 1.
Appendix Table 2.
Appendix Table 3.
Appendix Table 4.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only