Cost-Effectiveness of Risk-Based Screening for Asymptomatic Carotid Artery Stenosis

Background. Extracranial internal carotid artery stenosis (50%–99% arterial narrowing) is an important risk factor for ischemic stroke. Yet, the benefits and harms of targeted screening for asymptomatic carotid artery stenosis (ACAS) have not been assessed in population-based studies. We aimed to estimate the cost-effectiveness of one-time, targeted ACAS screening stratified by atherosclerotic cardiovascular disease (ASCVD) risk using the American Heart Association’s pooled cohort equations. Methods. We developed a lifetime microsimulation model of ACAS and stroke for a hypothetical cohort representative of US adults aged 50 to 80 y without stroke history. Model parameters were derived from multiple cohort studies and the published literature. Outcomes included estimated stroke events prevented, lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) associated with ACAS screening. Costs (2023 USD) and QALYs were discounted at 3% annually. Cost-effectiveness was assessed from the health care sector perspective using a 100, 000/QALY threshold. Results. We found that screening individuals with a 10-y ASCVD risk >30% was the most cost-effective strategy, with an ICER of 89, 000/QALY. This strategy would make approximately 11. 9% of the population eligible for screening, averting an estimated 24, 084 strokes over the cohort’s lifetime. In probabilistic sensitivity analysis, screening those in lower ASCVD risk groups (0%–20%) had only a 0. 6% chance of being cost-effective. If the ongoing CREST-2 trial shows that revascularization reduces stroke risk by less than 30% (relative risk >0. 7), it may shift the balance against any screening. Conclusions. ACAS screening may be cost-effective only for adults at relatively high ASCVD risk. These findings provide a flexible decision-analytic framework that can inform clinical and policy guidance as future trial results refine the role of revascularization and intensive medical therapy. Highlights Targeted screening for asymptomatic carotid artery stenosis may be cost-effective only for adults aged 50 to 80 y at high atherosclerotic cardiovascular disease (ASCVD) risk. Screening individuals with a 10-y ASCVD risk greater than 30% could substantially reduce lifetime stroke burden while remaining within accepted US cost-effectiveness thresholds. Screening lower-risk (0%–20% 10-y ASCVD risk) adults provides minimal health gains at significantly higher costs and should not be recommended. Findings offer a decision-analytic framework to inform future screening guidelines and policy decisions as results from ongoing trials, such as CREST-2, become available.