Michael L. LeFevre, MD, MSPH; on behalf of the U.S. Preventive Services Task Force *
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Disclosures: Dr. Gillman reports royalties from UpToDate and Cambridge University Press outside the submitted work. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.uspreventiveservices taskforce.org/methods.htm. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1333.
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This article has been corrected. The original version (PDF) is appended to this article as a Supplement.
Update of the 2007 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for carotid artery stenosis.
The USPSTF commissioned a systematic review to synthesize the evidence on the accuracy of screening tests, externally validated risk-stratification tools, the benefits of treatment of asymptomatic carotid artery stenosis with carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAAS), the benefits from medications added to current standard medical therapy, and the harms of screening and treatment with CEA or CAAS.
This recommendation applies to adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms.
The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. (D recommendation)
Screening for asymptomatic carotid artery stenosis: clinical summary of U.S. Preventive Services Task Force recommendation.
Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice
Appendix Table 2. USPSTF Levels of Certainty Regarding Net Benefit
David L. Keller MD
July 7, 2014
Why I will continue to screen carotids
The USPSTF warnings about the possible harms of invasive treatments for asymptomatic carotid stenosis are convincing, especially regarding CEA surgery, but the following arguments favor continued ultrasound screening for asymptomatic carotid atherosclerosis: 1) Specificity can be improved by following up positive ultrasound screens with non-invasive magnetic resonance angiography, or by repeating ultrasound examination with a more skilled technician, both at much less risk of harm than invasive angiography.2) Patients will benefit from introduction or intensification of statin therapy to stabilize or regress their carotid atheromatous lesions, as well as their coexisting undiagnosed asymptomatic coronary atherosclerotic disease. 3) If data from clinical trials is insufficient to support #2, wait a few years. Meanwhile, if any members of the USPSTF believe that statement #2 will not be proven in time, I will wager my house and car and 401K against yours that it will be proven, based on nothing more substantial than my scientific intuition plus every statin trial for heart disease done to date. Any takers?Despite the USPSTF recommendations, it makes sense to continue to treat asymptomatic atherosclerotic carotid stenosis, discovered by screening ultrasound, as a coronary artery disease risk-equivalent for the purpose of assigning a statin dose intensity. These patients should also receive intensive education so that they recognize the symptoms of a TIA or stroke, and also of coronary and peripheral artery disease.
David Louis Keller, MD
July 10, 2015
The CREST-2 investigators recognize that asymptomatic carotid stenosis should be screened for & get intensive medical treatment
The CREST-2 clinical trial will study subjects having asymptomatic carotid stenosis, and will randomize them to receive invasive treatment (such as endarterectomy or stenting), or to receive no invasive treatment. All patients will receive the same background "intensive medical therapy" (1).The USPSTF recommends against screening for asymptomatic carotid stenosis for the purpose of treating it with intensive medical therapy, stating: "There is no evidence that identification of asymptomatic carotid artery stenosis leads to any benefit from adding or increasing medication doses (beyond current standard medical therapy for cardiovascular disease prevention)." (2) Yet, CREST-2 subjects will all be given intensive medical therapy, instead of the standard medical therapy which the USPSTF advises for them.Dr. Chaturvedi, CREST-2 corresponding author, stated their position very clearly in an email to me dated 7/8/2015: "You are correct that intensive medical therapy has never been tested against standard medical therapy. However, we felt that for clinical trial purposes, the "best" form of medical therapy should be tested."So, the CREST-2 subjects will be identified by screening, and will be treated with "intensive" medical therapy, despite the fact that USPSTF still recommends against screening for asymptomatic carotid stenosis, or treating it with anything stronger than "standard preventative" medical therapy. The CREST-2 investigators are ignoring these recommendations, as should all physicians."Atherogenic stenosis in any artery is an indication for intensive medical therapy", is an unproved statement which has become axiomatic. To deny screening for asymptomatic carotid stenosis, and to fail to treat it with intensive therapy when it is discovered, do not make physiological sense. It is time for the USPSTF to get their recommendations into alignment with current best practices, as exemplified by the CREST-2 protocol.References:1: Chaturvedi S, Howard G, Meschia J. Carotid Endarterectomy for Asymptomatic Stenosis.JAMA Intern Med. 2015;175(7):1241-1242. doi:10.1001/jamainternmed.2015.1118.2: United States Preventative Services Task Force web site, accessed 7/7/2015. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/carotid-artery-stenosis-screening
LeFevre ML, on behalf of the U.S. Preventive Services Task Force. Screening for Asymptomatic Carotid Artery Stenosis: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161:356–362. doi: https://doi.org/10.7326/M14-1333
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Published: Ann Intern Med. 2014;161(5):356-362.
Guidelines, High Value Care, Neurology, Prevention/Screening, Stroke.
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