From the Guidelines
Further evaluation and management are warranted when arteriosclerosis of the carotids is incidentally found on CT, even if the patient is already on a statin, to reduce the risk of stroke and improve outcomes, as recommended by the most recent guidelines 1.
Key Recommendations
- Schedule a carotid ultrasound to assess the degree of stenosis and determine if additional intervention is needed.
- Continue statin therapy and consider optimizing other cardiovascular risk factors, such as:
- Ensuring blood pressure is controlled (target <130/80 mmHg) 1.
- Recommending smoking cessation if applicable.
- Encouraging regular physical activity.
- Promoting a heart-healthy diet.
- Consider antiplatelet therapy with aspirin 81mg daily if not contraindicated.
- For patients with significant stenosis (>50%), referral to a vascular specialist may be necessary to evaluate for potential surgical intervention, as part of a multi-disciplinary approach to carotid stenosis management 1.
Rationale
The presence of carotid arteriosclerosis indicates systemic atherosclerotic disease and increased stroke risk. While statins help reduce plaque progression and stabilize existing plaques, comprehensive management addressing all modifiable risk factors provides the best protection against future cerebrovascular events, as supported by recent clinical consensus statements 1 and guidelines 1.
From the Research
Management of Carotid Artery Disease
If arteriosclerosis is noted in the carotids incidentally on CT and the patient is already taking statin, the following points should be considered:
- The patient is already on statin therapy, which is an essential component in the management of carotid artery disease, as it reduces carotid intima-media thickness progression and stroke risk 2.
- Antiplatelet therapy should be considered, as it is beneficial in preventing stroke or the progression of stenosis in symptomatic patients, and may be beneficial in asymptomatic patients 3, 4.
- Intensive medical management, including lifestyle modification and pharmacological therapy, is recommended for all patients with asymptomatic carotid stenosis, regardless of the decision to refer for revascularization 5.
- The management of carotid stenosis is impacted by whether there are associated symptoms, along with the degree of stenosis, and understanding the pathogenesis of carotid atherosclerosis is important in management 6.
Considerations for Asymptomatic Carotid Stenosis
- Asymptomatic carotid stenosis is a risk factor for ipsilateral ischemic cerebrovascular events and cognitive impairment, and optimal medical management is likely to reduce events outside the carotid arteries 5.
- The use of antiplatelet therapy, such as aspirin, may be beneficial in preventing vascular events in asymptomatic patients, but the evidence is not as robust as in symptomatic patients 3, 4.
- Lifestyle modifications, such as a Mediterranean diet, exercise, and smoking cessation, are recommended as part of intensive medical management 5.
Considerations for Symptomatic Carotid Stenosis
- Symptomatic carotid stenosis is generally managed with intervention, either by carotid endarterectomy or carotid stenting, and antiplatelet therapy is recommended for secondary prevention of recurrent stroke 4, 6.
- Perioperative antithrombotic therapy, including aspirin and clopidogrel, is recommended for patients undergoing carotid endarterectomy or stenting 4.