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EVIDENCE SUMMARY
Mixed results, quality issues do not support screening asymptomatic patients
A meta-analysis (12 observational studies; n = 1002) compared the diagnostic accuracy of
In a retrospective cohort study (n = 778) from the United States, researchers identified carotid artery calcifications on routine dental radiographs in patients ≥ 55 years old and prospectively performed duplex ultrasound (DUS) to assess for significant carotid stenosis (≥ 50%).2 Twenty-seven patients (3.5%) had carotid artery calcifications on radiographs, and 20 of those patients underwent DUS of bilateral carotid arteries (40 sides). Of 26 sides with calcifications on radiograph, 13 (50%) had stenosis confirmed with DUS. Of the 14 sides without calcification on radiograph, 3 (21%) had stenosis on DUS. The positive predictive value for calcification on PR predicting significant carotid stenosis was between 40% and 80%.
In a cross-sectional study from Sweden, investigators sought surgical candidates for asymptomatic carotid endarterectomy and performed PRs of 1182 patients.3 Calcifications were found in 176 people; 117 of them were eligible for asymptomatic carotid endarterectomy (ages 18-74; no cancer or other serious comorbidity; and no prior stroke or transient ischemic attack) and underwent ultrasound to assess for significant carotid stenosis (≥ 50%). Of the 117 participants who underwent ultrasound, 8 (6.8%; 95% CI, 2.2%-11.5%), all men, were found to have significant carotid stenosis. Compared to a sex- and age-matched reference group (n = 119) with no calcifications on PR, the prevalence of carotid stenosis was significantly higher in men (12.5%; 95% CI, 4.2%-20.8%) and in patients who were current smokers (19%; 95% CI, 0.7%-37.4%), were taking cholesterol medications (13.1%; 95% CI 4.4%-21.8%), and had a cardiovascular event history (15.9%; 95% CI, 7%-27.2%).
Recommendations from others
The US Preventive Services Task Force (USPSTF) and the American Academy of Family Physicians do not mention carotid screening with radiographs but recommend against
Editor’s takeaway
If you see calcification of the carotid artery on an x-ray of an asymptomatic patient, ignore it. The positive and negative predictive values for carotid stenosis are poor, and you should not pursue further testing.
1. Schroder AGD, de Araujo CM, Guariza-Filho O, et al. Diagnostic accuracy of panoramic radiography in the detection of calcified carotid artery atheroma: a meta-analysis. Clin Oral Investig. 2019;23:2021-2040. https://doi.org/10.1007/s00784-019-02880-6
2. Almog DM, Horev T, Illig KA, et al. Correlating carotid artery stenosis detected by panoramic radiography with clinically relevant carotid artery stenosis determined by duplex ultrasound. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:768-773. doi: 10.1067/moe.2002.128965
3. Johansson EP, Ahlqvist J, Garoff M, et al. Ultrasound screening for asymptomatic carotid stenosis in subjects with calcifications in the area of the carotid arteries on panoramic radiographs: a cross-sectional study. BMC Cardiovasc Disord. 2011;11:44. doi: 10.1186/1471-2261-11-44
4. USPSTF. Carotid artery stenosis: screening. Updated February 2, 2021. Accessed September 1, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening
5. American Academy of Family Physicians. Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients. Choosing Wisely website. Published February 21, 2013. Accessed August 29, 2020. www.choosingwisely.org/clinician-lists/american-academy-family-physicians-carotid-artery-stenosis/
EVIDENCE SUMMARY
Mixed results, quality issues do not support screening asymptomatic patients
A meta-analysis (12 observational studies; n = 1002) compared the diagnostic accuracy of
In a retrospective cohort study (n = 778) from the United States, researchers identified carotid artery calcifications on routine dental radiographs in patients ≥ 55 years old and prospectively performed duplex ultrasound (DUS) to assess for significant carotid stenosis (≥ 50%).2 Twenty-seven patients (3.5%) had carotid artery calcifications on radiographs, and 20 of those patients underwent DUS of bilateral carotid arteries (40 sides). Of 26 sides with calcifications on radiograph, 13 (50%) had stenosis confirmed with DUS. Of the 14 sides without calcification on radiograph, 3 (21%) had stenosis on DUS. The positive predictive value for calcification on PR predicting significant carotid stenosis was between 40% and 80%.
In a cross-sectional study from Sweden, investigators sought surgical candidates for asymptomatic carotid endarterectomy and performed PRs of 1182 patients.3 Calcifications were found in 176 people; 117 of them were eligible for asymptomatic carotid endarterectomy (ages 18-74; no cancer or other serious comorbidity; and no prior stroke or transient ischemic attack) and underwent ultrasound to assess for significant carotid stenosis (≥ 50%). Of the 117 participants who underwent ultrasound, 8 (6.8%; 95% CI, 2.2%-11.5%), all men, were found to have significant carotid stenosis. Compared to a sex- and age-matched reference group (n = 119) with no calcifications on PR, the prevalence of carotid stenosis was significantly higher in men (12.5%; 95% CI, 4.2%-20.8%) and in patients who were current smokers (19%; 95% CI, 0.7%-37.4%), were taking cholesterol medications (13.1%; 95% CI 4.4%-21.8%), and had a cardiovascular event history (15.9%; 95% CI, 7%-27.2%).
Recommendations from others
The US Preventive Services Task Force (USPSTF) and the American Academy of Family Physicians do not mention carotid screening with radiographs but recommend against
Editor’s takeaway
If you see calcification of the carotid artery on an x-ray of an asymptomatic patient, ignore it. The positive and negative predictive values for carotid stenosis are poor, and you should not pursue further testing.
EVIDENCE SUMMARY
Mixed results, quality issues do not support screening asymptomatic patients
A meta-analysis (12 observational studies; n = 1002) compared the diagnostic accuracy of
In a retrospective cohort study (n = 778) from the United States, researchers identified carotid artery calcifications on routine dental radiographs in patients ≥ 55 years old and prospectively performed duplex ultrasound (DUS) to assess for significant carotid stenosis (≥ 50%).2 Twenty-seven patients (3.5%) had carotid artery calcifications on radiographs, and 20 of those patients underwent DUS of bilateral carotid arteries (40 sides). Of 26 sides with calcifications on radiograph, 13 (50%) had stenosis confirmed with DUS. Of the 14 sides without calcification on radiograph, 3 (21%) had stenosis on DUS. The positive predictive value for calcification on PR predicting significant carotid stenosis was between 40% and 80%.
In a cross-sectional study from Sweden, investigators sought surgical candidates for asymptomatic carotid endarterectomy and performed PRs of 1182 patients.3 Calcifications were found in 176 people; 117 of them were eligible for asymptomatic carotid endarterectomy (ages 18-74; no cancer or other serious comorbidity; and no prior stroke or transient ischemic attack) and underwent ultrasound to assess for significant carotid stenosis (≥ 50%). Of the 117 participants who underwent ultrasound, 8 (6.8%; 95% CI, 2.2%-11.5%), all men, were found to have significant carotid stenosis. Compared to a sex- and age-matched reference group (n = 119) with no calcifications on PR, the prevalence of carotid stenosis was significantly higher in men (12.5%; 95% CI, 4.2%-20.8%) and in patients who were current smokers (19%; 95% CI, 0.7%-37.4%), were taking cholesterol medications (13.1%; 95% CI 4.4%-21.8%), and had a cardiovascular event history (15.9%; 95% CI, 7%-27.2%).
Recommendations from others
The US Preventive Services Task Force (USPSTF) and the American Academy of Family Physicians do not mention carotid screening with radiographs but recommend against
Editor’s takeaway
If you see calcification of the carotid artery on an x-ray of an asymptomatic patient, ignore it. The positive and negative predictive values for carotid stenosis are poor, and you should not pursue further testing.
1. Schroder AGD, de Araujo CM, Guariza-Filho O, et al. Diagnostic accuracy of panoramic radiography in the detection of calcified carotid artery atheroma: a meta-analysis. Clin Oral Investig. 2019;23:2021-2040. https://doi.org/10.1007/s00784-019-02880-6
2. Almog DM, Horev T, Illig KA, et al. Correlating carotid artery stenosis detected by panoramic radiography with clinically relevant carotid artery stenosis determined by duplex ultrasound. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:768-773. doi: 10.1067/moe.2002.128965
3. Johansson EP, Ahlqvist J, Garoff M, et al. Ultrasound screening for asymptomatic carotid stenosis in subjects with calcifications in the area of the carotid arteries on panoramic radiographs: a cross-sectional study. BMC Cardiovasc Disord. 2011;11:44. doi: 10.1186/1471-2261-11-44
4. USPSTF. Carotid artery stenosis: screening. Updated February 2, 2021. Accessed September 1, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening
5. American Academy of Family Physicians. Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients. Choosing Wisely website. Published February 21, 2013. Accessed August 29, 2020. www.choosingwisely.org/clinician-lists/american-academy-family-physicians-carotid-artery-stenosis/
1. Schroder AGD, de Araujo CM, Guariza-Filho O, et al. Diagnostic accuracy of panoramic radiography in the detection of calcified carotid artery atheroma: a meta-analysis. Clin Oral Investig. 2019;23:2021-2040. https://doi.org/10.1007/s00784-019-02880-6
2. Almog DM, Horev T, Illig KA, et al. Correlating carotid artery stenosis detected by panoramic radiography with clinically relevant carotid artery stenosis determined by duplex ultrasound. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:768-773. doi: 10.1067/moe.2002.128965
3. Johansson EP, Ahlqvist J, Garoff M, et al. Ultrasound screening for asymptomatic carotid stenosis in subjects with calcifications in the area of the carotid arteries on panoramic radiographs: a cross-sectional study. BMC Cardiovasc Disord. 2011;11:44. doi: 10.1186/1471-2261-11-44
4. USPSTF. Carotid artery stenosis: screening. Updated February 2, 2021. Accessed September 1, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening
5. American Academy of Family Physicians. Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients. Choosing Wisely website. Published February 21, 2013. Accessed August 29, 2020. www.choosingwisely.org/clinician-lists/american-academy-family-physicians-carotid-artery-stenosis/
EVIDENCE-BASED ANSWER:
Not very well. In asymptomatic patients, carotid artery calcification seen on radiograph has a positive predictive value of 70% and a negative predictive value of 75% for carotid artery stenosis (strength of recommendation [SOR]: B, systematic review of observational studies with heterogeneous results and a retrospective cohort study). Carotid calcifications on radiographs may be more predictive of carotid stenosis in people with atherosclerotic risk factors (SOR: C, cross-sectional study). Harms outweigh benefits in screening for carotid artery stenosis in asymptomatic adults (SOR: B, multiple cohort studies); therefore, incidental radiographic carotid artery calcifications in asymptomatic patients should not prompt further testing.
