Tests Not Always Best Way to Fight Stroke, Doctors Say

By Judy Peres, Chicago Tribune

Feb. 17–Dozens of people, some as young as their 30s, had crowded into a Skokie community center, waiting for a team of white-coated technologists to check their arteries for problems.

They were there to find out if they were at risk for a stroke. “We have three kids to raise,” said Roberto Aguado, 39, a sushi chef from Rogers Park who was waiting with his wife, Apolonia, 32. “We have to try to make sure we stay healthy.”

The non-invasive tests, performed with ultrasound machines, have become more popular since the Jan. 4 stroke of Israeli Prime Minister Ariel Sharon, who remains comatose in a Jerusalem hospital. Life Line Screening and Weiss Memorial Hospital, which offer the screening tests, both report a surge in calls.

But many experts say that although the tests sometimes detect treatable disease and can be useful for people with symptoms of clogged arteries, screening the general public is not a good idea.

For most people, the potential costs of such tests exceed the potential benefit, doctors warn. If the tests find something suspicious, they can lead to more invasive and risky procedures–including surgery.

“Screening indiscriminately is very likely to cause more strokes than it prevents, because of the treatment that follows the screening test,” said neurologist Dr. James Brorson of the University of Chicago Hospitals.

Another concern is that clean tests might produce a false sense of security, leading people to ignore known risk factors. “A normal test might tell someone who’s at high risk that he doesn’t need to worry–he can go on smoking,” said Dr. Gilbert Welch of the Department of Veterans Affairs.

Advocates of screening argue that an abnormal test doesn’t have to lead to surgery. “We might advise risk-factor control and repeat the ultrasound in a year,” said Dr. Hisham Bassiouny, a vascular surgeon at Weiss and the University of Chicago Hospitals.

But skeptics argue that controlling risk factors–eating better, taking a daily aspirin or a pill to lower blood pressure–is what at-risk people should be doing anyway.

Life Line, whose vans ferry testing equipment to churches, fieldhouses and similar locations across the country, targets people over 40 by direct mail. It charges $45 to test the carotid arteries leading to the brain to see if they are partially blocked by fatty plaque–a major cause of strokes. For an additional $64 they also will check arteries in the legs and abdomen. Weiss charges $99 for the three-test package.

“I think this is a really great thing,” said Beverly Von Winckler, 70, of Evanston, who calls herself a satisfied Life Line customer. “I probably would have spent a lot more time and money if I had gone to a hospital.”

But Dr. Leonard Berlin, chief of radiology at Rush North Shore Medical Center, says that money would be better spent on preventive medicine.

“They could take a class on healthy eating or giving up smoking, or join a fitness center and work out,” he said.

Many vascular specialists believe almost everyone over 55 or 60 should consider getting screened for artery disease. The American Vascular Association, an advocacy group of the Society of Vascular Surgeons, has a free screening program.

But neurologists and cardiologists tend to be more hesitant to screen people without symptoms.

Ultrasound imaging of the carotid arteries can be valuable for a patient whose doctor suspects something is wrong, Brorson said. The cause for concern could be an abnormal sound when the doctor listens to those arteries with a stethoscope, or a transient ischemic attack, sometimes called a mini-stroke.

In such patients, the risk of having a serious stroke is high enough to justify performing an invasive test or surgery–followup procedures that can have dangerous side effects.

Brorson said at least one person in 200 will have a stroke during a cerebral angiogram, a test often performed to validate an ultrasound finding. And for every 100 patients who undergo surgery to clear the arteries, at least two or three will have a major complication, including a stroke or heart attack.

Studies have shown that surgery to clear a blocked carotid in patients with no symptoms can reduce their risk of stroke from 2 percent to 1 percent a year, Brorson said–at least among men. (The benefit for women is less clear.) But that benefit might be outweighed by the operation’s risks.

Doctors said the best thing healthy people can do to prevent strokes is to eliminate underlying risk factors: reduce high blood pressure and high cholesterol, control high blood sugar, maintain a healthy weight and get plenty of exercise, among other things.

“You can reduce your risk by up to 50 percent by getting your blood pressure under control,” said Dr. Mark Alberts, director of the stroke program at Northwestern Memorial Hospital. “If you stop smoking, you can reduce it by maybe 25 percent.”

Treating risk factors “will give you more bang for your buck,” Alberts said.

Dr. Diana Petitti, vice chair of the U.S. Preventive Services Task Force, says an ultrasound of the abdomen to detect an aortic aneurysm–a bulge in the body’s main artery that could rupture and cause sudden death–illustrates the need for each individual to do his own benefit-risk assessment.

“If I’m 85 years old and have excruciating pain in the abdomen, suggestive of an aortic aneurysm, I’m going to have the test,” Petitti said.

The calculus is simple: For such a patient, the risk of dying of a ruptured aorta is 900 out of 1,000; the risk of dying of surgery to repair the aneurysm is 50 out of 1,000.

But for an 85-year-old with no symptoms, she said, the risk of dying of an aortic aneurysm is only 1 in 1,000. There’s no point in having the test, Petitti said, because even if an aneurysm is detected, that person would not want to risk the operation.

The same is true for nearly everyone under 65, she said, because it’s extremely rare for an aortic aneurysm to rupture before then.

At age 65, Petitti said, the benefit-risk ratio of screening becomes favorable–but only for male smokers. For women, and for men who have never smoked, the risk of repairing an aortic aneurysm is almost always greater than the risk of dying of one.

Petitti’s task force, which issues evidence-based guidelines on behalf of the U.S. government, recommends that male smokers between the ages of 65 and 75–and no one else–have a one-time screening test for an aortic aneurysm.

The task force recommends against screening for peripheral artery disease, another common test, because the harms of routine screening, including false-positive results and unnecessary workups, exceed benefits.

As for ultrasound of the carotid artery, the task force says there is “insufficient evidence to recommend for or against screening asymptomatic persons.”

One thing the experts agreed on: People who decide to get screened for stroke risk should talk to their physicians and bring in their test results.

“If your interest is to understand your risk and act appropriately, you should be hooked up with a doctor,” Welch said. “It’s not in the patient’s interest to go outside to a third party who will take no responsibility.”

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U.S. screening guidelines

The U.S. Preventive Services Task Force issues health recommendations on behalf of the federal government. This is what it says about vascular screening:

Carotid narrowing: Evidence is insufficient to recommend for or against screening people without symptoms.

Aortic aneurysm: A one-time ultrasound test is recommended only for men 65-75 who have ever smoked.

Peripheral artery disease: Screening not recommended.

jperes@tribune.com

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