From the Guidelines
For carotid stenosis of 16-49%, medical management with triple therapy, including anti-thrombotic, anti-hypertensive, and LDL-C–lowering drugs, is the recommended approach to reduce the risk of stroke, MI, and death. This approach is based on the most recent guidelines from the European Society of Cardiology, as outlined in the 2025 study 1. The management plan should include lifestyle modifications such as smoking cessation, regular exercise, weight management, and a heart-healthy diet low in saturated fats.
Medication therapy should include:
- Antiplatelet therapy, typically aspirin 81-325 mg daily or clopidogrel 75 mg daily if aspirin-intolerant
- Intensive statin therapy, with ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor as an alternative or adjunctive therapies, aiming to achieve an LDL-C < 55 mg/dL
- Anti-hypertensive therapy to control blood pressure to below 140/90 mmHg
- Diabetes management to maintain HbA1c below 7%
Follow-up ultrasound monitoring is typically recommended at 12-month intervals to assess for progression, though this may be adjusted based on individual risk factors. The goal of this management approach is to stabilize the plaque, prevent progression, and reduce overall cardiovascular risk, as supported by the recent Acute Stroke or Transient Ischaemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes trial 1. In contrast to older guidelines, such as those from 2014 1, the current recommendation prioritizes medical management over surgical intervention for mild to moderate stenosis, emphasizing the importance of triple therapy in reducing stroke risk.
From the Research
Management of Carotid Stenosis
- For patients with 16-49% carotid stenosis, management is focused on controlling cardiovascular risk factors and preventing the progression of atherosclerosis 2, 3, 4.
- Medical management includes the use of medications such as antiplatelet agents, statins, and ACE inhibitors to control hypertension, hyperlipidemia, and diabetes 2, 3, 4, 5, 6.
- Lifestyle modifications such as stopping smoking and monitoring hypertension, hyperlipidemia, and diabetes are also essential 2, 3.
Antiplatelet Therapy
- Antiplatelet therapy, such as aspirin, may be considered for patients with carotid stenosis to prevent vascular events 2, 5.
- The use of aspirin-clopidogrel combination therapy is not routinely recommended, but may be considered in certain cases 5.
Statin Therapy
- Statins are an essential component of the management of carotid artery disease, as they reduce carotid intima-media thickness progression and stroke risk 4, 6.
- High-dose statin treatment, with or without ezetimibe or PCSK9 inhibitors, is recommended for all patients with carotid stenosis, regardless of their LDL-C levels 6.
Imaging and Monitoring
- Ultrasound is recommended as the first-line examination for evaluating carotid stenosis, with computed tomography angiography (CTA) and/or magnetic resonance angiography used as complementary tests 3.
- Regular monitoring of carotid stenosis and cardiovascular risk factors is essential to prevent the progression of atherosclerosis and reduce the risk of vascular events 2, 3.