The case against identifying carotid stenosis in asymptomatic patients

Carotid ultrasonography is performed frequently to identify carotid stenosis in patients with no history of carotid-territory cerebrovascular ischemia. The premises of such testing are that the potential benefit of endarterectomy or stenting exceeds the potential harm in patients with asymptomatic stenosis and that discovery of asymptomatic stenosis may trigger beneficial changes in lifestyle or medical management that otherwise would not have occurred. However, given low contemporary rates of stroke in medically managed patients with asymptomatic carotid stenosis, invasive carotid procedures cannot be justified in this population. Moreover, among patients at increased cardiovascular risk, there is no evidence that carotid imaging motivates behavioral change or improves risk stratification beyond consideration of conventional risk factors. In this focused review, we address topics that should help health care professionals advise patients who inquire about carotid screening and patients in whom asymptomatic carotid stenosis has already been identified. We conclude that there is currently no role for carotid imaging in patients without a history of carotid-territory stroke or transient ischemic attack.