From the Guidelines
The primary medical management for carotid artery stenosis involves aggressive risk factor modification, including optimal medical therapy (OMT), intensive lipid-lowering therapy (ILT), and antiplatelet therapy, as outlined in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. Key recommendations:
- Antiplatelet therapy:
- Aspirin 75-325 mg daily, or
- Clopidogrel 75 mg daily if aspirin intolerant, with dual antiplatelet therapy (DAPT) recommended after carotid stenting for at least 30 days post-procedure 1
- Statin therapy:
- High-intensity statin aiming at >50% LDL-C reduction and LDL-C <1.4 mmol/L (55 mg/dL) 1
- Blood pressure control:
- Proper pharmacological BP control is important in optimizing outcomes, with fluctuations of hypertension and hypotension treated promptly 1
- Lifestyle modifications:
- Regular exercise, Mediterranean-style diet, and moderate alcohol consumption These interventions aim to slow the progression of atherosclerosis and reduce the risk of stroke, with intensive lipid-lowering therapy and antiplatelet therapy playing a crucial role in preventing platelet aggregation and thrombus formation, as well as stabilizing plaques. Regular follow-up with carotid ultrasound (every 6-12 months) is recommended to monitor stenosis progression, with referral for potential revascularization (carotid endarterectomy or stenting) considered if symptoms develop or stenosis progresses significantly. In the peri-operative period, proper pharmacological BP control and antiplatelet therapy are essential in reducing the risk of stroke, TIAs, wound bleeding, and intracranial haemorrhage 1.
From the Research
Medical Management of Carotid Artery Stenosis
The medical management of carotid artery stenosis involves a combination of lifestyle modifications, risk factor reduction, and pharmacological therapy. The goal of medical management is to stabilize or halt the progression of the carotid plaque, reduce the risk of stroke, and improve overall cardiovascular health.
Lifestyle Modifications
- Adoption of a healthy lifestyle, including a Mediterranean diet, exercise, and smoking cessation, has been shown to lead to a reduction in the extent of carotid stenosis 2, 3.
- Lifestyle modification is an essential component of medical management, and patients with carotid artery stenosis should be encouraged to make healthy lifestyle choices.
Risk Factor Reduction
- Control of risk factors such as hypertension, diabetes mellitus, smoking, obesity, and high cholesterol levels is crucial in reducing the risk of plaque formation and progression 2, 4.
- Reduction of risk factors can be achieved through lifestyle modifications, pharmacological therapy, or a combination of both.
Pharmacological Therapy
- Antiplatelet agents, such as aspirin and clopidogrel, are commonly used in the medical management of carotid artery stenosis 4, 5.
- Statins, which are lipid-lowering agents, are also recommended for patients with carotid artery stenosis 4, 3.
- ACE inhibitors may be used in combination with antiplatelet agents and statins as part of a tri-therapy strategy 4.
- Anticoagulants do not play a significant role in the medical management of carotid artery stenosis 2.
Best Medical Therapy
- The best medical therapy for carotid artery stenosis involves a combination of lifestyle modification, risk factor reduction, and pharmacological therapy 3, 6.
- The goal of best medical therapy is to reduce the risk of stroke and improve overall cardiovascular health.
- Best medical therapy should be individualized to each patient's needs and should be based on the latest clinical evidence and guidelines.