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Screening for Carotid Artery Stenosis: US Preventive Services Task Force Recommendation Statement

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besty jacob

on 4 September 2012

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Transcript of Screening for Carotid Artery Stenosis: US Preventive Services Task Force Recommendation Statement

Screening for Carotid Artery Stenosis: US preventive services task force recommendation statement
Besty Jacob OD-4 THE USPTF recommends against screening for asymptomatic cartotid artery stenosis.
These patients have no symptoms of neurological signs/symptoms including TIA/stroke.
They gave a "grade D" recommendation
(Asymptomatic patients) The US Preventive Task Force (USPSTF) makes recommendations for patients without recognized signs/symptoms of conditions If they have had these symptoms in the past...carotid endarectomy is recommended. Detection of severe CAS
Most feasible test is duplex ultrasonography
This produces many false positives
Requiring digital subtraction angiography or carotid endarectomy surgery....
Causing serious side effects
Stroke, death, heart attack
Why not MRI?
not accurate enough High risk individuals with asymptomatic CAS were tested.
By using very experienced surgeons
The 5 year incidence drops by 5% But at what Cost?
Evidence indicates that carotid endareterctomy can cause strokes/deaths
In excellent centers there is an association for 30 day stroke/mortality rate of 3%.
Not good Recommendations of other groups
2006 AHA/ASA did not recommend screening the general population for asymptomatic carotid stenosis.
American Society of Neuroimaging 2007 recommended against screening in unselected populations.
Advised screen patients with 3 or more cardiocvascular risk factors (htn, heart disease, etc..
Society for vasclar surgery made a similar suggestion. So what should be done?
Patients should be screened for HTN, hyperlipidemia, and smoking first then possibly sent for evaluation.
USPSTF also recommends aspirin chemoprevention for patients who are high risk. How accurate testing is....
Based on population studies and accuracy of carotid duplex ultrasonography, the estimated prevalence of CAS is 1%.
More prevalent in older adults,smokers, those with hypertension, and heart disease. How were these recommendations made? Screening studies ACAS (asymptomatic carotid atherosclerosis study) and ACST (asymptomatic carotid surgery trial) compared carotid endartecomy plus medical management to medical management alone.
ACAS says the projected 5 year rate of ipsilateral stroke and perioperative stroke/death was 5.6% vs 11.0%.
With a higher risk for men vs women
Problems with this review
This included very select homogenous patient base with highly selected surgeons.
The medical treatment group was poorly defined and did not include blood pressure/lipid management, which are standards of practice now.
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