AHA guidelines discourage widespread carotid screening
MedWire News: Screening for carotid stenosis in asymptomatic people should only be considered in those with at least two stroke risk factors, according to American Heart Association (AHA)-led guidelines on management of patients with carotid artery disease.
"The guidelines will provide new information and evidence to help clinicians select treatment approaches with their patients," said committee co-chair Thomas Brott (Mayo Clinic, Jacksonville, Florida, USA).
The guidelines, which are published in several journals including Stroke, recommend duplex ultrasonography as the initial diagnostic test for patients with known or suspected carotid disease. Testing is advised in patients with carotid bruit and to monitor progression or regression in patients with known disease.
Ultrasonography "may be considered" in patients with symptomatic peripheral artery disease and in those with at least two major risk factors for atherosclerosis, but is concluded to be of no benefit in other patients.
If ultrasonography is not available, or does not yield diagnostically helpful results, the guidelines suggest that magnetic resonance or computed tomography angiography be used instead.
The advice covers modification of risk factors in patients with carotid or vertebral atherosclerosis, particularly treatment of hypertension (except in the hyperacute stroke phase) and hyperlipidemia, and cessation of smoking. The guideline authors consider control of diabetes to be "useful," while noting that the benefits of tight glycemic control in stroke prevention are not established. Antiplatelet therapy, primarily with aspirin, is also recommended.
In terms of intervention, the strongest recommendations are for endarterectomy in symptomatic patients with more than 70% stenosis on noninvasive imaging or 50% on catheter angiography. Carotid artery stenting is cited as an alternative to surgery for such patients.
Prophylactic endarterectomy is considered "reasonable" for asymptomatic patients with more than 70% stenosis.
"The guidelines support carotid surgery as a tried-and-true treatment for most patients," said Brott. "However, for patients who have a strong preference for less invasive treatments, carotid stenting offers a safe alternative."
He added: "Because of the anatomy of their arteries or other individual considerations, some patients may be more appropriate for surgery and others for stenting."
The guidelines also offer advice on managing patients during surgery or stenting and later if they experience restenosis, and on treating patients with atherosclerosis of the vertebral subclavian, or brachiocephalic arteries.
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By Eleanor McDermid