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Richard N. Fogoros, M.D.

Expert Panel Says No to Carotid Artery Screening

By December 21, 2007

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In the December 18 issue of the Annals of Internal Medicine, the US Preventive Services Task Force (USPSTF) released updated guidelines on the advisability of screening for stenosis (blockage) in the carotid arteries (the main arteries, located in the neck, that supply blood to the brain). In patients who have risk factors but no symptoms suggestive of carotid artery disease, the USPSTF concludes that screening for carotid artery stenosis is not recommended.

Screening for carotid artery stenosis has become an issue because prior studies have shown a small reduction in the risk of stroke if asymptomatic, significant carotid artery stenosis is treated surgically. Evidence suggests that relieving carotid artery blockage can reduce the risk of stroke by 5% over 5 years (about 1% per year). While this risk reduction is certainly modest at best, it has enticed many doctors to routinely perform screening with non-invasive ultrasound in individuals who are at risk for this disease.

But the USPSTF has concluded that such non-invasive screening can lead to more harm than good in many patients, and that for the population as a whole, screening should be avoided.

The obvious question is: What harm can non-invasive screening do? As it turns out, quite a bit. A big problem with the ultrasound test is that it produces many false positive exams. That is, it declares blockages to be present when there are none. So, when an ultrasound test is positive, generally an invasive angiographic study is required to confirm the diagnosis - a test that carries its own risk of bleeding, infection, and even stroke. Alternately, the patient may be sent for an MRI study to confirm the diagnosis - but MRI studies of the carotid artery also carry a risk of being falsely positive, in which case surgery would be recommended needlessly. And the surgery itself, in the very best centers, produces a 3% 30-day risk of stroke.

The USPSTF concludes "for individuals with asymptomatic carotid artery stenosis, there is moderate certainty that the benefits of screening do not outweigh the harms."

While I can certainly think of individuals for whom I would ignore this recommendation (the patient, for instance, with a strong family history of stroke and clear evidence of widespread vascular disease, in whom a positive ultrasound screen is much more likely to be a true positive), in general the recommendation is sound. What is needed, obviously, is a non-invasive screening test that is more accurate than the ultrasound. Until then, doctors ought to use available screening methods judiciously.

Comments
January 27, 2009 at 2:09 pm
(1) Juan Delgado says:

There already is an accurate non-invasive exam
using ultrasound.It’s called A HIGHLY SKILLED
SONOGRAPHER.Since the introduction of ultra-
sound as a diagnostic tool,its biggest weaknes
continues to be that it’s operator dependent.
No other imaging modality available today,de-
pends more on the skill of the operator than
the ultrasound exam.If we are willing to accept that even the most skilled tech. can
sometimes miss a finding and that equipment can have certain limitations, than let’s go
with it. If you are not, than we need to start
re-evaluating what ultrasound exams can be used that don’t depend on the skill of the
operator and put the emphasis on CT and MRI.
Thank You. Juan Delgado(RT)RDMS.

March 18, 2013 at 8:25 pm
(2) Dianne S Holt says:

how can I reverse coronary artery disease of 30%. Can a diet help…vegetarian, no dairy , what

February 19, 2014 at 10:19 am
(3) Claire says:

Thanks for this – I find your website article really useful.
My partner was diagnosed with 100% blockage of one carotid artery and 70% blockage on the other via the doppler ultra-sound test – this was revised to 100% and 55% with the MRI scan. We’re in the UK & he was simply told to stop smoking – nothing else – no follow up – no screening – no advice about diet
.
I have done research and it seems Americans are more ‘with it’ We now follow an almost vegan diet (tiny amounts of low fat dairy, no meat) along with exercise – This has reduced his cholesterol from 6.7 to 3.9 – we’ve asked for another doppler so we have information on any progress or stabilising of his condition – but had to push because of the No Symptoms No action attitude – The main symptom that would present would be a STROKE! So Dianne yes diet can make a big difference in reversing heart disease (all artery disease is lumped under heart disease.

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