What is the next step for a 76-year-old male with a history of transient monocular blindness (amaurosis fugax), who has mild stenosis (<50%) of the right internal carotid artery and near occlusion of the left internal carotid artery?

From the Guidelines

The next step for this 76-year-old male with amaurosis fugax and severe left internal carotid artery stenosis (near occlusion) is urgent referral for carotid endarterectomy or carotid artery stenting, as revascularization significantly reduces stroke risk in symptomatic patients with high-grade stenosis, as indicated by the most recent guidelines 1. While awaiting intervention, the patient should be started immediately on dual antiplatelet therapy with aspirin 81mg daily and clopidogrel 75mg daily, along with high-intensity statin therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) to reduce the risk of further ischemic events, as recommended by previous guidelines 1. The near occlusion of the left carotid artery combined with the patient's history of amaurosis fugax (temporary monocular vision loss) indicates a high risk for stroke, and thus, prompt intervention is necessary to prevent a potentially devastating outcome. The right carotid artery with mild stenosis (<50%) can be managed medically without intervention, as the risk of stroke is lower in this case, and medical therapy is the preferred approach for stenosis of this degree, as stated in the guidelines 1. Key considerations in the management of this patient include:

• Optimization of blood pressure to target levels below 140/90 mmHg
• Management of other modifiable risk factors such as smoking cessation and diabetes management
• The choice between endarterectomy and stenting should be determined by the vascular surgeon based on the patient's anatomy, surgical risk factors, and comorbidities, taking into account the latest clinical consensus statement on stroke risk management in carotid atherosclerotic disease 1. It is essential to involve a multi-disciplinary team, including neurologists, vascular surgeons, and other specialists, to ensure the best possible outcome for the patient, as emphasized in the guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps for 76-Year-Old Male with Carotid Artery Stenosis

• The patient has a history of amaurosis and carotid artery ultrasound results showing mild stenosis (<50%) in the right internal carotid artery and near occlusion in the left internal carotid artery.
• According to 2, optimal management of carotid artery stenosis requires the use of medications or lifestyle modifications to control the processes associated with atheroma and reduce the risk of embolic events.
• The patient's symptomatic status (history of amaurosis) may indicate a need for more aggressive management, as suggested by 3, which states that carotid intervention for symptomatic high-grade carotid stenosis is best managed with intervention either by carotid endarterectomy or carotid stenting.
• Antiplatelet therapy, such as aspirin, may be considered as part of the management plan, as suggested by 2 and 4, which recommend antiplatelet therapy for secondary stroke prevention in patients with noncardioembolic ischemic stroke.
• However, the effectiveness of aspirin in preventing the progression of carotid atherosclerosis or reducing vascular events and all-cause death in asymptomatic patients is unclear, as noted in 5.
• The patient's individual characteristics, such as the degree of stenosis and symptomatic status, should be taken into account when determining the best course of treatment, as suggested by 6 and 4.

Considerations for Asymptomatic vs. Symptomatic Carotid Stenosis

• Asymptomatic carotid stenosis is a subject of controversy in terms of optimal management, as noted in 3.
• Symptomatic carotid stenosis, on the other hand, is generally managed with more aggressive interventions, such as carotid endarterectomy or carotid stenting, as suggested by 3 and 6.

Role of Antiplatelet Therapy

• Antiplatelet therapy, such as aspirin, may be beneficial for secondary stroke prevention in patients with symptomatic carotid stenosis, as recommended by 2 and 4.
• However, the use of antiplatelet therapy in asymptomatic patients is less clear, as noted in 5.
• The choice of antiplatelet agent and duration of therapy should be individualized based on the patient's characteristics and risk factors, as suggested by 4.