“If you ask the wrong question, you are certain to get the wrong answer.” In medicine, it’s a little scary to think that professionals may be asking the wrong question, but in some instances, that may be the case. Recent news articles question the value, even the “ethics” of heart screenings, specifically the carotid ultrasound. Since we perform diagnostic screening in our practice, I thought I would take this opportunity to clarify the difference between what the critics describe, why they don’t think they are useful, and what a truly valuable assessment might look like.
There has been some publicity related to concerns expressed about a scanning program that is mass marketed to the public without physician orders. If you are over 50, you have probably been invited to be scanned by mass mailing, print and TV advertising. As a physician, I have long had concerns about the generalized use of this screening program.
In addition, the US Preventive Services Task Force recently issued guidance that recommends against the routine screening of asymptomatic individuals for vascular disease using carotid ultrasound. The concern stems from risk, including stroke, involved in what may be unnecessary procedures resulting from irregular findings in patients who are not yet experiencing any issues.
Medical professionals who review scan results should ask themselves: “Does this patient have enough disease to “do something” about it?” Current protocol suggests that “doing something” will likely be some type of intervention: a stent or surgery. Both of these approaches can improve flow of blood through the pipe by lessening a blockage. But both can also increase the risk of stroke in the short term while the evidence that it decreases heart attacks or stroke is variable. For patients who have not had a heart attack, stroke or transient ischemic attack, these procedures may do more harm than good.
The screenings in question focus on the lumen, and they look for obstructions within the “pipe” that might hinder blood flow. The formation of plaque however doesn’t start inside the arteries; plaque begins to form in the wall of the arteries. By waiting for the plaque to be present inside the lumen of the artery, we are putting off diagnosis and potential treatment as the disease progresses.
So what if we actually measure atherosclerotic disease volume and consequences, including formation of plaque where it actually forms: IN THE WALL! What if we could use the same tools researchers use to measure the effect of treatment on atherosclerosis to decide how much, if any, treatment is right for you? And what if this testing is accurate, noninvasive, quick and affordable?
If we use a better version of ultrasound to look for disease earlier in order to INDIVIDUALIZE and PERSONALIZE each patient’s treatment plan, the concerns raised by these publications are about as relevant as a forecast of the weather in Hawaii is to the plans for outdoor activities in Springfield. We may have an accurate forecast of weather, but it is of no use to us unless we are in Hawaii.
The earlier atherosclerotic disease is detected, the more non-invasive options there are for treatment of individuals who are not experiencing any symptoms. Changes in lifestyle, including diet and exercise, are proven to reverse some of the early development of disease and, with guidance from a physician and continued monitoring, can be used without risk of the side effects of more invasive procedures. Commonly used medications can further improve the disease and its contributing conditions.
The bottom line is that individuals should beware of generalized recommendations and how they affect you as an individual. And beware of anyone who treats you based on recommendations for the “average” patient. Every individual is unique and everyone should have personalized care.