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Special Communication | Less Is More

The Case Against Identifying Carotid Stenosis in Asymptomatic Patients

Allan S. Brett, MD1; Joshua D. Levine, MD1
[+] Author Affiliations
1Department of Medicine, University of South Carolina School of Medicine, Columbia
JAMA Intern Med. 2014;174(12):2004-2008. doi:10.1001/jamainternmed.2014.4920.
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Carotid ultrasonography is performed frequently to identify carotid stenosis in patients with no history of carotid-territory cerebrovascular ischemia. The premises of such testing are that the potential benefit of endarterectomy or stenting exceeds the potential harm in patients with asymptomatic stenosis and that discovery of asymptomatic stenosis may trigger beneficial changes in lifestyle or medical management that otherwise would not have occurred. However, given low contemporary rates of stroke in medically managed patients with asymptomatic carotid stenosis, invasive carotid procedures cannot be justified in this population. Moreover, among patients at increased cardiovascular risk, there is no evidence that carotid imaging motivates behavioral change or improves risk stratification beyond consideration of conventional risk factors. In this focused review, we address topics that should help health care professionals advise patients who inquire about carotid screening and patients in whom asymptomatic carotid stenosis has already been identified. We conclude that there is currently no role for carotid imaging in patients without a history of carotid-territory stroke or transient ischemic attack.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Carotid ultrasound for detection of systemic atherosclerosis
Posted on July 7, 2015
David L. Keller
Conflict of Interest: None Declared
Carotid ultrasound, when it identifies carotid stenosis in an otherwise healthy and asymptomatic individual, has diagnosed atherosclerotic arterial disease, a high-risk systemic disorder which can be treated intensively with low-risk medical therapy. Therefore, the USPSTF \"D\" recommendation for carotid screening is not warranted. Physicians should offer carotid screening to appropriate patients.
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