Performance of carotid ultrasound in evaluating candidates for carotid endarterectomy is optimized by an approach based on clinical outcome rather than accuracy

Background and Purpose The best method of selecting endarterectomy candidates for cerebral angiography is controversial. Carotid duplex ultrasound (CDUS) is widely used, but its performance varies across institutions. The clinical utility of CDUS could be improved with lest criteria based on patient outcome rather than test accuracy. Methods In 155 carotid bifurcations studied by CDUS and cerebral angiography, the degree of angiographic stenosis was measured by a reader, blinded to CDUS, using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method. We calculated accuracy, sensitivity, and specificity for predicting greater than or equal to 70% angiographic carotid stenosis of different peak systolic frequencies (PSF) measured by CDUS and generated a receiver operator characteristic (ROC) curve. We used NASCET outcome data and published data on angiographic complications to define relative ''costs'' of false-positive and false-negative CDUS, and we determined the point on the ROC curve representing the CDUS criterion with the highest clinical utility. We compared projected morbidity and mortality rates for 1000 hypothetical endarterectomy candidates resulting from the use of the most accurate CDUS criterion versus the CDUS criterion with the highest clinical utility by ROC analysis. Results While PSF greater than or equal to 8 kHz had the highest CDUS accuracy (93%), its projected stroke and death rate due to CDUS error was 10.4/1000. On the other hand, PSF greater than or equal to 7 kHz, defined by ROC analysis to have the highest clinical utility, had a lower morbidity and mortality rate of 6.8/1000. Conclusions The use of ROC analysis and available outcome data can improve the performance of CDUS in selecting endarterectomy candidates for cerebral angiography.