Rationale for screening selected patients for asymptomatic carotid artery stenosis

Abstract

Stroke is a leading cause of death and disability worldwide. Approximately 15% of all first-ever strokes occur due to atheroembolism from a previously undetected/untreated asymptomatic carotid stenosis (ACS). Despite that, international guidelines do not recommend screening for ACS. The rationale for not recommending screening include: (a) the harm associated with screening, (b) the questionable clinical benefit associated with surgery, (c) the lack of proven reduction in the risk of stroke, (d) the large number of false positive/false negative tests, and (e) the cost-effectiveness of such screening programs. A critical analysis of each of these arguments is presented. Patients with ACS have a very high risk of all-cause and cardiac mortality. Detection of ACS should not be viewed as an indication for surgery, but rather as an opportunity to implement best medical treatment (BMT) and lifestyle changes to prevent not only strokes, but also cardiac events. The implementation of screening programs for abdominal aortic aneurysms (AAAs) has led to a considerable reduction in the number of ruptured AAAs and AAA-related deaths. Similarly, screening high-risk individuals for ACS would enable timely identification of patients with ACS and implementation of BMT and lifestyle measures to prevent future strokes and cardiac events.

Keywords:

• Asymptomatic carotid stenosis
• screening
• carotid endarterectomy
• best medical treatment

Transparency

Declaration of funding

There are no funders to disclose for this study.

Declaration of financial/other relationships

HHE is the Principal Investigator for the ROADSTER 2 Registry and the ENROUTE DW-MRI study at the Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. DPM has given talks and attended conferences sponsored by Amgen, Novo Nordisk and Libytec. JDS is a consultant to Amgen and Orphan Technologies and an officer of Vascularis Inc.; he has received lecture fees from Pfizer and Bristol Myers Squibb. FJV and KIP have no conflicts of interest. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgements

None reported.