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Level IV – Carotid Artery Stenosis Screening

Level IV Services: Preventive services that are not supported by evidence and should not be recommended.

The USPSTF recommendations are fully endorsed by the ICSI Preventive Services work group.
Grade of Recommendation and Level of Certainty as Evaluated by USPSTF
  1. “Against screening for asymptomatic carotid artery stenosis in the general adult population.”
(USPSTF Last Revised 2014)
Grade of Recommendation:
  1. D

Level of Certainty:

  1. Moderate
“Benefits:
There is no direct evidence on the benefits of screening for carotid artery stenosis. Adequate evidence indicates that in selected trial participants with asymptomatic carotid artery stenosis, carotid endarterectomy (CEA) performed by selected surgeons reduces the absolute incidence of all strokes or perioperative death by approximately 3.5% compared with (outdated) medical management. However, this difference is probably smaller with current optimal medical management. The magnitude of these benefits would be smaller in asymptomatic persons in the general population. For the general primary care population, the magnitude of benefit is small to none. 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).
Harms:
Adequate evidence indicates that both the testing strategy for carotid artery stenosis and treatment with CEA can cause harms. Although screening with ultrasonography has little direct harm, all screening strategies, including those with or without confirmatory tests (that is, digital subtraction or magnetic resonance angiography), have imperfect sensitivity and specificity and could lead to unnecessary interventions and result in serious harms. In selected centers similar to those in the trials, CEA is associated with a 30-day stroke or mortality rate of approximately 2.4%; reported rates are as high as approximately 5% in low-volume centers and 6% in certain states. Myocardial infarctions are reported in 0.8 to 2.2% of patients after CEA. The 30-day stroke or mortality rate after carotid angioplasty and stenting (CAAS) is approximately 3.1 to 3.8%. The overall magnitude of harms of screening and subsequent treatment of asymptomatic carotid artery stenosis is small to moderate depending on patient population, surgeon, center volume and geographic location.
Benefits-Harms Assessment:
The USPSTF concludes with moderate certainty that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits.
Electrocardiography measures the electrical activity in the heart and results can be abnormal for many reasons, only some of which are because of CHD. In low-risk patients, these abnormalities are unlikely to result from CHD; in intermediate- and high-risk patients, they are more likely to result from CHD but there is no evidence that targeting these abnormalities instead of or in addition to modifiable risk factors has benefit or biological plausibility.”
Relevant Resources:
http://www.uspreventiveservicestaskforce.org/uspstf/uspsacas.htm
Implementation Tools and Strategies:
Screening for Carotid Artery Stenosis