From the Guidelines
The recommended treatment for asymptomatic severe carotid stenosis is medical management as first-line therapy, with carotid revascularization considered in select patients, as supported by the most recent guidelines from 2025 1.
Medical Management
Medical management includes:
- Antiplatelet therapy, such as aspirin 81-325 mg daily or clopidogrel 75 mg daily
- High-intensity statin therapy, such as atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, with a goal of achieving an LDL-C < 55 mg/dL 1
- Blood pressure control, with a target of <140/90 mmHg
- Smoking cessation
- Diabetes management, if applicable
Carotid Revascularization
Carotid endarterectomy (CEA) may be considered for patients with stenosis ≥70%, low surgical risk, and life expectancy >5 years, particularly in men and younger patients, as suggested by guidelines from 2014 1. Carotid artery stenting is an alternative for patients with high surgical risk or unfavorable neck anatomy.
Individualized Decision-Making
The decision between medical management alone versus adding revascularization should be individualized based on patient factors, including age, sex, comorbidities, and degree of stenosis. Medical therapy is preferred for most patients because the annual stroke risk with asymptomatic stenosis is relatively low (approximately 1-2% with modern medical therapy), and surgical intervention carries its own procedural risks of stroke, myocardial infarction, and death. Key points to consider:
- Intensive LDL-C lowering is associated with several beneficial effects in patients with carotid atherosclerotic disease 1
- Combination therapy with clopidogrel and aspirin may be more effective than aspirin alone in reducing asymptomatic embolization, as shown in recent trials 1
From the Research
Treatment Options for Asymptomatic Severe Carotid Stenosis
The recommended treatment for asymptomatic severe carotid stenosis includes:
- Carotid endarterectomy (CEA) 2, 3, 4
- Carotid artery stenting (CAS) 2, 3, 4
- Medical management alone, which has been shown to reduce the risk of stroke in this population to comparable rates seen with CEA 2
- Best medical therapy (BMT), which includes the use of anti-platelet, anti-hypertensive, and statin medications, as well as strict glycaemic control 3, 5
Factors to Consider in Treatment Decision
When deciding on a treatment option, the following factors should be considered:
- Stenosis severity 2, 4
- Plaque morphology and features associated with vulnerable plaque 2
- Patient's life expectancy and risk of perioperative stroke and death 4
- Presence or absence of high-risk criteria for each specified intervention 4
- Patient's surgical risk, with CAS indicated for high-risk patients 3
Antiplatelet Therapy
Antiplatelet therapy is an important aspect of treatment for asymptomatic carotid stenosis, with:
- Aspirin (81-325 mg daily) recommended for prevention of vascular events 5
- Low to medium dose aspirin (81-325 mg daily) superior to higher doses (>650 mg daily) at preventing recurrent vascular events in patients undergoing endarterectomy 5
- Peri-procedural treatment with 81-325 mg of aspirin daily supported by data from endovascular treatment (EVT) trials 5