Screening for asymptomatic carotid artery stenosis.

The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment. This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. This document is in the public domain and may be used and reprinted without permission, except for any copyrighted materials noted, for which further reproduction is prohibited without the specific permission of copyright holders. Background: Cerebrovascular disease is the third leading cause of death in the U.S. The proportion of all strokes attributable to previously asymptomatic carotid stenosis is low. In 1996, the United States Preventive Services Task Force concluded that there was insufficient evidence to recommend for or against screening of asymptomatic persons for CAS using physical exam or carotid ultrasound. Purpose: To examine the evidence of benefits and harms of screening asymptomatic patients with duplex ultrasound and treatment with carotid endarterectomy (CEA) for carotid artery stenosis (CAS). Study Selection: English language studies were selected to answer the following: Is there direct evidence that screening with ultrasound for asymptomatic CAS reduces strokes? What is the accuracy of ultrasound to detect CAS? Does intervention with CEA reduce morbidity or mortality? Does screening or CEA result in harm? The following study types were selected: randomized controlled trials (RCT) of screening for CAS; RCTs of CEA versus medical treatment; systematic reviews of screening tests; observational studies of harms from CEA. Data Synthesis: There have been no RCTs of screening for CAS. According to systematic reviews, the sensitivity of ultrasound is approximately 94% and the specificity is approximately 92%. Treatment of CAS in selected patients with selected surgeons could lead to an approximately 5% absolute reduction in strokes over 5 years. Thirty-day stroke and death rates from CEA vary …