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Thanks to all who have commented on this.  I agree that we have to constantly question the indications for doing these tests, carotid duplex in particular.  However, my original question was about your interpretation standards.  Nearly all of the responses have been about the issue of misuse of the test or the information provided by the test.  I don’t think we should alter our interpretation as a strategy to impact on how we predict the ordering practitioner will respond to the report.  I believe our job is to tell them what we think about the study and if they want advice on how to take care of the patient that’s another question.
Once again thanks to all.
Joe

From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Bill Schroedter
Sent: Monday, October 26, 2015 9:20 AM
To: [log in to unmask]
Subject: Re: carotid plaque standards

Great article Crash. Thanks very much for sharing.
The IMT measurements were semi adopted for a general cardiovascular risk assessment as the article states and not specifically for risk of carotid bifurcation disease. If I remember correctly, not too many years after IMT came into vogue, brachial artery reactivity which was shown to be a better marker for cardiovascular risk. But that was rather cumbersome. Now it seems the risk assessment if done by coronary calcium scoring.  Interestingly, there is a general recommendation that not all people should have the screening ….
“The American Heart Association and the American College of Cardiology don't recommend routine use of heart scans on people who don't have symptoms of heart disease and who don't smoke or have cardiac risk factors, such as elevated cholesterol or high blood pressure.”   i.e.: those individuals who are high risk for cardiovascular disease. ?????So if you are high risk, you can have this test to assess whether you are at risk??????  Radiation exposure notwithstanding.  So your income observation may be correct.
Don’t get me wrong, when a patient has carotid bifurcation disease, I do believe it is prudent to follow on some sort of accepted schedule that we can debate, especially given that most symptoms likely occur with unpredictable, abrupt, and / or quantum changes in the plaque.  With regards to screening exams for CV risk, it’s akin to the US screening exams to some degree.  Yes, they occasionally find disease but generally there is no evidence that they save lives or are of significant benefit.  As to patient anxiety, I believe most people who go to screenings would be better served to spend that $100 on an office visit with a physician.

Bill

William B Schroedter, BS, RVT, RPhS, FSVU
Quality Vascular Imaging, Inc
Venice, Florida
(941) 408-8855
www.qualityvascular.com<http://www.qualityvascular.com/>
www.compressionsocks.pro<http://www.compressionsocks.pro/>
www.virtualveincenter.com<http://www.virtualveincenter.com>


From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Crash Bandicoot
Sent: Sunday, October 25, 2015 7:41 PM
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: Re: carotid plaque standards

Sorry I havent had time to read most of the replies. Personally I think by and large that these measures are used to generate income, and satisfy some patient's expectation that if you have enough tests and exercise your orthorexia often enough you will live forever. I dont routinely do them in the practice where I work which is neither a specialist vascular or echo site. This is something I came across recently as I got sick of being asked by upwardly mobile students about it. Its old, but hey, so am I!

http://www.karger.com/Article/Fulltext/97034

On Mon, Oct 26, 2015 at 9:35 AM, Mina Tohid <[log in to unmask]<mailto:[log in to unmask]>> wrote:
I agree with Christina. At least couple of times I had patients that prior Carotid Duplex showed calcified establish plaques but to my surprise new small vulnerable plaque was on top of old one which had to be treated invasively . Ultrasound has no radiation. So I think NICE is a good practice.

> On Oct 22, 2015, at 8:02 AM, Christina Lewis <[log in to unmask]<mailto:[log in to unmask]>> wrote:
>
> I would argue that an annual check-up can relieve a patient's anxiety, because now they are being periodically evaluated, which is better for many patients than the great "not knowing."  And for those that do worry about it, I've found it very helpful to reframe it for them in that way.
>
> To address the original query, we don't measure IMT.  So we wouldn't consider a minimally thickened wall to be a <50% stenosis.  I do agree that there are a lot of <50% stenoses that don't need to be followed every year, but I also recognize that there are limitations to plaque evaluation by ultrasound.  I certainly wouldn't want to be the one that wrote a preliminary report that missed an ulcerated plaque hidden by plaque shadowing and have that person put into five-year recalls and show up two years later with a stroke.  We look at these so often, that we think we KNOW what kind of plaque we are looking at, but the data doesn't seem to support that.  For that reason, I'm pretty comfortable with performing annual check-ups on carotid patients.  There are a lot of other things that can really get me going, but this isn't one of them.
>
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