Goldstein Drafts Editorial on Carotid Artery Screening for JAMA Internal Medicine

An editorial by University of Kentucky’s Dr. Larry Goldstein concerning the use of screening tests to detect narrowing of the carotid artery was published in the Journal of the American Medical Association (JAMA) Internal Medicine last week.

With more than 35 years of practice, Goldstein is the chair of the Department of Neurology at the UK College of Medicine and co-director of the Kentucky Neuroscience Institute.

Practice guidelines developed by professional societies to screen for narrowings in this major artery supplying blood to the brain are intended to summarize the best available evidence for specific questions to support clinical decisions. However, noted Goldstein, guideline recommendations from different organizations or groups can vary in minor or substantial ways.

"Evidence-based medicine is a linchpin of contemporary clinical practice,” said Goldstein. "However, these disparities among guidelines can lead to considerable uncertainty and variability in clinical practice."

According to Goldstein's editorial, screenings for carotid disease are offered in a variety of settings, yet there is no validated proof showing it is useful for identifying those in the general population who do or do not have a clinically important ACAS. There is a high proportion of carotid imaging studies performed for uncertain indications.

Goldstein wrote that “[S]creening for a disease or condition is rational only if its identification has a meaningful impact on patient management." In the case of narrowing of the carotid artery that is not associated with symptoms, the best approach is currently uncertain. “Specific educational programs, the use of alerts embedded into the electronic health record and audits with feedback, among other interventions, may be helpful in reducing inappropriate testing.”

Knowing the dilemmas that they are now facing, it can be difficult for physicians to understand when it is appropriate to recommend testing. Issues facing clinicians include:
· How can inconsistent guidelines be balanced?
· How are these complicated issues being presented and discussed with patients who look to their clinician for guidance?
· Should a screening test be performed in the face of equivocal, limited, or conflicting data regarding the intervention that would be considered if the condition was detected?
· To what degree should the potential for false-positive or false-negative test results and the attendant need for confirmatory testing be factored into the decision?

According to Goldstein, "despite the available evidence from randomized trials and practice guidelines, decisions regarding whether to proceed with testing are often a matter of informed opinion."

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Media Contact: Laura Dawahare, Laura.Dawahare@uky.edu, (859) 257-5307