Carotid Artery Stenosis

470639625Carotid artery stenosis.  Well, if there was ever a bit of medicalese this is it. So let's dissect the term, as Rick and I do on PodMed this week, so we can further dissect new recommendations of the United States Preventive Services Task Force or USPSTF published in Annals of Internal Medicine regarding the condition.

The carotid artery is the major blood vessel carrying blood to your head, including that critical structure: your brain.  You have two of these arteries that pass upward on either side of your neck and then divide into internal and external carotid arteries, where they may dive deep into the brain itself or supply the face, respectively. As you can feel on your own by placing your fingers on the side of your neck and feeling for your pulse, this is a sizable vessel with a big job.  So if/when blockages start to impede the flow of blood through the carotid, so-called 'stenosis' or narrowing, the consequences can be dire. Enter then the strategy of screening for carotid artery stenosis, employed some years ago now by simply listening, with a stethoscope, to blood roiling around in the artery.  This is underpinned by ultrasound examination of the artery, with both of these techniques having the advantage of being quick, inexpensive, noninvasive, and painless.  Sounds great, huh?  But does screening people who don't have symptoms result in less stroke, the aforementioned dire potential consequence of carotid artery stenosis? And once identified, does treating narrowing of the vessel really help reduce the risk of stroke or result in other deleterious consequences of treatment?

As Rick would say, that was the subject of this USPSTF guideline, based on examination of all the evidence relative to screening asymptomatic people, possibly treating them, and their subsequent risk for stroke on the same side of the body in which stenosis was identified? In short, the evidence argues against screening at all, in view of the chance that such screening will result in treatment and its host of potential side effects, none of them good.  To begin with, the use of ultrasound to screen in a population in whom the prevalence of the condition is low results in a very large number of false positive results. A perioperative stroke or death rate of less than 3% was seen in this analysis when carotid enarterectomy to remove plaque inside the artery was employed, but the authors state that observational trial results are much higher.  Finally, in comparison to medical therapy surgery is no longer emerging as the superior choice.  To sum then, in people without symptoms looks like screening for carotid artery stenosis isn't helpful and shouldn't be done.  For those of you considering such an examination as a gift for a loved one, why not choose a golf outing instead?

Other topics this week include infusion pumps for hard to control diabetes in the Lancet, medications for neuropathy in JAMA, and varenicline and a nicotine patch for smoking cessation in JAMA.  Until next week, y'all live well.


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