1. The Asymptomatic Carotid Bruit: Not Such a Pain in the Neck After All? COPYRIGHT © 2015, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2015 Dear Guys: I have an angry patient and I need your advice. Mrs. J is 70 years old. I see her every few years for follow up of her hypertension. She has no cardiovascular disease and when I last obtained labs, one year ago, her lipid panel was normal. Over the past year, she has developed progressive right hip pain that I attribute to progressive DJD. She saw me today because she needed a physical exam as part of her application to move to a senior residential community. At the visit, she told me that she has seen an orthopedist and that despite analgesics her hip pain is progressing and is limiting her independence. She would like to consider a hip replacement during the next year. I told her that I heard a carotid bruit which I had not heard before. She was angry because I never screened her for carotid disease and told me that her friends had recently gone for carotid artery screening at a mobile van at the senior center. Not only is she angry about the bruit, but she is worried that it will affect her candidacy for hip replacement. Guys- get me out of this one! Dear Guys: I have an angry patient and I need your advice. Mrs. J is 70 years old. I see her every few years for follow up of her hypertension. She has no cardiovascular disease and when I last obtained labs, one year ago, her lipid panel was normal. Over the past year, she has developed progressive right hip pain that I attribute to progressive DJD. She saw me today because she needed a physical exam as part of her application to move to a senior residential community. At the visit, she told me that she has seen an orthopedist and that despite analgesics her hip pain is progressing and is limiting her independence. She would like to consider a hip replacement during the next year. I told her that I heard a carotid bruit which I had not heard before. She was angry because I never screened her for carotid disease and told me that her friends had recently gone for carotid artery screening at a mobile van at the senior center. Not only is she angry about the bruit, but she is worried that it will affect her candidacy for hip replacement. Guys- get me out of this one!

4. Exam BP: 150/80 right and left arm HR: 70 regular Left carotid bruit (new finding compared to exam of one year ago) Lungs: clear Heart: regular rhythm S1, S2 normal, no murmur Abdomen: unremarkable Distal pulses intact, no edema Copyright © 2015

5. Carotid Bruit 1. Do we screen for asymptomatic carotid disease? 2. If we hear a bruit, do we screen the carotid? 3. Will it affect her candidacy for hip surgery? Copyright © 2015

6. Carotid Bruit Screening the asymptomatic patient, without bruit, for carotid disease:  General adult population Carotid stenosis > 75% in 1.2% of the population  With the low prevalence of significant carotid disease in the population the risk of false positive tests are high Example 100,000 adults, prevalence carotid disease 0.5-1% Carotid duplex doppler specificity 92% 940 true positives 7,920 false positives Copyright © 2015

7. Carotid Bruit Screening the asymptomatic patient, without bruit, for carotid disease:  For the general adult population there is no evidence that even if significant asymptomatic carotid disease is found by screening, that a revascularization procedure has significant benefit when compared to medical therapy of cardiovascular disease risk factors.  Must consider the risks of carotid revascularization:  CEA 30 day stroke or death 2.4%, 30 day MI up to 2%  Carotid artery angioplasty and stent 30 day stroke or mortality 3.1-3.8% Copyright © 2015

9. Carotid Bruit USPSTF doesn’t comment on the patient with bruit.  Bruit correlates more with systemic atherosclerosis than with carotid stenosis.  Sensitivity of bruit for significant carotid disease < 50%.  The presence of carotid bruit is not diagnostic of significant carotid disease.  The absence of carotid bruit is not indicative that no carotid disease is present.  Consider bruit a finding of atherosclerosis. Copyright © 2015

10. Carotid Bruit Screening the asymptomatic patient without carotid disease:  General adult population Carotid stenosis > 75% in 1.2% of the population  If you find carotid disease and fix it will you decrease overall risk of stroke? Carotid disease responsible for only 10% of strokes Hypertension and atrial fibrillation responsible for much more Copyright © 2015

11. *Circulation. 2011 Jul 26;124(4):489-532. doi: 10.1161/CIR.0b013e31820d8d78. Epub 2011 Jan 31.

12. Pearls Screening the asymptomatic patient for carotid disease is not indicated. A bruit is a marker of systemic atherosclerosis disease and preventive measures should be undertaken. It is unclear whether a patient should have a carotid ultrasound to evaluate the bruit though it is reasonable. The carotid bruit in the asymptomatic patient has no impact on the outcome after general surgery.

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