On 2015 Jul 08, David Keller commented:

The CREST-2 investigators recognize that asymptomatic carotid stenosis should be screened for & get intensive medical treatment

The CREST-2 clinical trial will study subjects having asymptomatic carotid stenosis, and will randomize them to receive invasive treatment (such as endarterectomy or stenting), or to receive no invasive treatment. All patients will receive the same background "intensive medical therapy" (1).

The USPSTF recommends against screening for asymptomatic carotid stenosis for the purpose of treating it with intensive medical therapy, stating: "There is no evidence that identification of asymptomatic carotid artery stenosis leads to any benefit from adding or increasing medication doses (beyond current standard medical therapy for cardiovascular disease prevention)." (2) Yet, CREST-2 subjects will all be given intensive medical therapy, instead of the standard medical therapy which the USPSTF advises for them.

Dr. Chaturvedi, CREST-2 corresponding author, stated their position very clearly in an email to me dated 7/8/2015: "You are correct that intensive medical therapy has never been tested against standard medical therapy. However, we felt that for clinical trial purposes, the "best" form of medical therapy should be tested."

So, the CREST-2 subjects will be identified by screening, and will be treated with "intensive" medical therapy, despite the fact that USPSTF still recommends against screening for asymptomatic carotid stenosis, or treating it with anything stronger than "standard preventative" medical therapy. The CREST-2 investigators are ignoring these recommendations, as should all physicians.

"Significant but asymptomatic atherosclerotic stenosis in any artery is an indication for intensive medical therapy", is a statement which has not been proved directly, but which has accumulated enough circumstantial evidence from the statin trials to have achieved the status of a clinical axiom. For example, the CREST-2 investigators were not willing to expose any of their patients with asymptomatic carotid stenosis to the risk of standard preventative medical therapy, despite the current dictum of the USPSTF (which is a mandate in many health systems). To deny screening for asymptomatic carotid stenosis, and to fail to treat it with intensive therapy when it is discovered, are not sensible or even ethical, given only minor extrapolation on the evidence we do have.

It is time for the USPSTF to bring their recommendations into alignment with current best practices, as exemplified by the CREST-2 protocol.

References:

1: Chaturvedi S, Howard G, Meschia J. Carotid Endarterectomy for Asymptomatic Stenosis.JAMA Intern Med. 2015;175(7):1241-1242. doi:10.1001/jamainternmed.2015.1118.

2: United States Preventative Services Task Force web site, accessed 7/7/2015. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/carotid-artery-stenosis-screening

On 2015 Jul 08, David Keller commented:

The CREST-2 investigators recognize that asymptomatic carotid stenosis should be screened for & get intensive medical treatment

The CREST-2 clinical trial will study subjects having asymptomatic carotid stenosis, and will randomize them to receive invasive treatment (such as endarterectomy or stenting), or to receive no invasive treatment. All patients will receive the same background "intensive medical therapy" (1).

The USPSTF recommends against screening for asymptomatic carotid stenosis for the purpose of treating it with intensive medical therapy, stating: "There is no evidence that identification of asymptomatic carotid artery stenosis leads to any benefit from adding or increasing medication doses (beyond current standard medical therapy for cardiovascular disease prevention)." (2) Yet, CREST-2 subjects will all be given intensive medical therapy, instead of the standard medical therapy which the USPSTF advises for them.

Dr. Chaturvedi, CREST-2 corresponding author, stated their position very clearly in an email to me dated 7/8/2015: "You are correct that intensive medical therapy has never been tested against standard medical therapy. However, we felt that for clinical trial purposes, the "best" form of medical therapy should be tested."

So, the CREST-2 subjects will be identified by screening, and will be treated with "intensive" medical therapy, despite the fact that USPSTF still recommends against screening for asymptomatic carotid stenosis, or treating it with anything stronger than "standard preventative" medical therapy. The CREST-2 investigators are ignoring these recommendations, as should all physicians.

"Significant but asymptomatic atherosclerotic stenosis in any artery is an indication for intensive medical therapy", is a statement which has not been proved directly, but which has accumulated enough circumstantial evidence from the statin trials to have achieved the status of a clinical axiom. For example, the CREST-2 investigators were not willing to expose any of their patients with asymptomatic carotid stenosis to the risk of standard preventative medical therapy, despite the current dictum of the USPSTF (which is a mandate in many health systems). To deny screening for asymptomatic carotid stenosis, and to fail to treat it with intensive therapy when it is discovered, are not sensible or even ethical, given only minor extrapolation on the evidence we do have.

It is time for the USPSTF to bring their recommendations into alignment with current best practices, as exemplified by the CREST-2 protocol.

References:

1: Chaturvedi S, Howard G, Meschia J. Carotid Endarterectomy for Asymptomatic Stenosis.JAMA Intern Med. 2015;175(7):1241-1242. doi:10.1001/jamainternmed.2015.1118.

2: United States Preventative Services Task Force web site, accessed 7/7/2015. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/carotid-artery-stenosis-screening