What is the need for further testing in an asymptomatic patient with a bruit (vascular sound) and less than 50% stenosis bilaterally on carotid US (ultrasound) duplex scan?

Management of Asymptomatic Patient with Carotid Bruit and <50% Stenosis

No further testing is needed for an asymptomatic patient with a carotid bruit and less than 50% stenosis bilaterally on carotid ultrasound duplex. 1, 2

Assessment of Current Findings

• Carotid bruits correlate more closely with systemic atherosclerosis than with significant carotid stenosis 1, 3
• For asymptomatic patients with mild carotid stenosis (<50%), surveillance is generally not indicated during the first year after diagnosis 2
• The American Heart Association suggests that once stability has been established over an extended period, longer intervals between scans or termination of surveillance may be appropriate for patients with mild carotid stenosis (<50%) 2

Recommended Follow-up

• Annual duplex ultrasonography is reasonable to assess progression or regression of disease in patients with atherosclerosis who have had stenosis greater than 50% detected previously 1
• Since this patient has <50% stenosis, routine annual surveillance is not indicated at this time 2
• The American College of Cardiology recommends that once stability has been established over an extended period, longer intervals between scans may be appropriate 2, 4

Important Clinical Considerations

• All patients with carotid stenosis should receive optimal medical therapy, including:

  • Antiplatelet therapy (aspirin 81-325 mg daily) 4
  • High-intensity statin therapy 4
  • Blood pressure control with ACE inhibitors preferred 4
  • Smoking cessation 4
  • Diabetes management (if applicable) 4

• The patient should be evaluated for other manifestations of atherosclerotic disease, as patients with carotid bruits are at increased risk of cardiac events 3

When Additional Testing Would Be Warranted

• If the patient develops neurological symptoms corresponding to the territory supplied by the carotid arteries 1
• If future ultrasound surveillance shows progression to stenosis >50% 1, 2
• If the patient develops other evidence of atherosclerotic disease progression 1, 4

Common Pitfalls to Avoid

• Avoid unnecessary testing in asymptomatic patients with mild stenosis, as it does not improve clinical outcomes 1, 3
• Do not order MRI or CT perfusion studies as follow-up tests in the evaluation of asymptomatic carotid bruits with known mild stenosis 3
• Remember that asymptomatic carotid stenosis is more often complicated by a TIA than an unheralded cerebral infarction 5
• Routine serial imaging is not recommended for patients who have no risk factors for development of atherosclerotic carotid disease and no significant disease evident on initial vascular testing 1