Screening for Asymptomatic Carotid Artery Stenosis in Adult Patients Unclear Benefit but Downstream Risks

Carotid artery stenosis is a risk factor for stroke, but a relatively small proportion of strokes (approximately 11%) can be attributed to atherosclerosis of the internal carotid arteries. There is no evidence that screening for carotid artery stenosis in the asymptomatic adult population (ie, no history or symptoms of stroke or transient ischemic attack) will reduce the risk of stroke, but there are downstream risks from identifying patients with carotid stenosis. Thus, in a recommendation statement1 and updated evidence report and systematic review,2 the US Preventive Services Task Force (USPSTF) has reaffirmed its 2014 recommendation3 against screening for asymptomatic carotid artery stenosis in the general adult population (D recommendation) based on an assessment of no benefit and possible harm.

Patients identified with carotid artery stenosis are referred to surgeons or other specialists who must make the decision to revascularize based on outdated trial data.4 Carotid revascularization involves the up-front perioperative risks of stroke and death. Stroke risk from carotid artery stenosis has been declining since the original asymptomatic carotid trials were completed.5 The National Institute of Neurological Disease and Stroke funded the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) to determine if revascularization offers any benefit beyond cardiovascular risk factor control.6 CREST-2 was launched in 2014 and is an ongoing trial that involves 2 parallel randomized clinical trials: (1) carotid endarterectomy (CEA) plus intensive medical therapy vs intensive medical therapy alone and, similarly, (2) carotid artery stenting (CAS) plus intensive medical therapy vs intensive medical therapy alone. Results are expected in 2025.

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