What is the management plan for a 72-year-old male (YOM) with bilateral carotid artery atherosclerosis and Plaque-RADS 2, without sonographic evidence of hemodynamically significant stenosis?

From the Guidelines

For a 72-year-old male with bilateral carotid artery atherosclerosis and Plaque-RADS 2 without hemodynamically significant stenosis, the management plan should focus on medical therapy and risk factor modification. I recommend starting the patient on antiplatelet therapy with aspirin 81 mg daily or clopidogrel 75 mg daily if aspirin-intolerant, as suggested by recent guidelines 1. A moderate to high-intensity statin such as atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily should be initiated to target LDL cholesterol below 70 mg/dL, in line with the recommendations for patients with carotid atherosclerotic disease 1. Blood pressure should be controlled to a target of less than 130/80 mmHg using appropriate antihypertensives such as ACE inhibitors or ARBs. Lifestyle modifications are crucial, including:

• Smoking cessation
• Regular physical activity (at least 150 minutes of moderate-intensity exercise weekly)
• Mediterranean or DASH diet
• Diabetes management if applicable Regular follow-up with carotid ultrasound is recommended every 6-12 months to monitor plaque progression, as part of a comprehensive approach to managing carotid artery disease 1. This approach is appropriate because Plaque-RADS 2 indicates non-obstructive atherosclerotic disease with low to intermediate risk, and medical management has been shown to effectively reduce stroke risk in patients without hemodynamically significant stenosis by stabilizing plaques and preventing progression of atherosclerosis 1.

From the Research

Management Plan for Bilateral Carotid Artery Atherosclerosis

The management plan for a 72-year-old male with bilateral carotid artery atherosclerosis and Plaque-RADS 2, without sonographic evidence of hemodynamically significant stenosis, involves the following considerations:

• Medical management is always warranted and applied to any patient with atheromatous lesions, as stated in the study 2.
• Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment, with a tri-therapy strategy of antiplatelet, statins, and ACE inhibitors 2.
• The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar, but the choice of procedure may be influenced by anatomy, prior illness or treatment, or patient risk 2.
• For asymptomatic carotid stenosis, current guidelines put a threshold of 60% for consideration of revascularization, and the addition of CEA to aggressive medical management can reduce the incidence of cerebral infarction in patients with asymptomatic carotid artery stenosis of 60% or greater reduction in diameter 3.
• In cases of bilateral carotid artery stenosis, treatment selection should be based on each individual patient's clinical characteristics, and a proper combination of staged CEA and CAS can achieve good outcomes 4.

Considerations for Bilateral Carotid Artery Stenosis

• The risk of clamping does not appear abnormally high, but the peroperative neurologic risk may be slightly enhanced due to the possibility of accidents in the region contralateral to that of the operated side 5.
• Preventive surgery on narrowed, stenotic, progressive lesions detected by ultrasound imaging can diminish the incidence of onset of neurologic complications 5.
• The incidence of main adverse events for patients with bilateral carotid artery stenosis is similar to that of unilateral patients undergoing CEA and CAS, and restenosis rates are not significantly different 4.

Role of Imaging and Medical Therapy

• Ultrasound is recommended as a first-line examination for evaluating carotid stenosis, with computed tomography angiography (CTA) and/or magnetic resonance angiography as complementary tests 2.
• Aspirin therapy can decrease ischemic symptoms, but may also have a deleterious effect by allowing carotid disease to progress to a dangerous state or by accentuating the process of atherosclerosis 6.
• Medical management, including antiplatelet therapy, statins, and ACE inhibitors, is essential for reducing the risk of cerebral infarction in patients with carotid artery stenosis 2, 3.