What is the workup for a 79-year-old patient with incidentally found atherosclerotic calcific plaque in the right carotid artery on a neck X-ray?

From the Guidelines

For a 79-year-old patient with incidentally found atherosclerotic calcific plaque in the right carotid artery on a neck X-ray, the recommended workup should include carotid duplex ultrasonography as the initial imaging study to assess the degree of stenosis and characterize the plaque, as suggested by the most recent guidelines 1. This non-invasive test provides information about blood flow velocity and the extent of narrowing. If significant stenosis (typically >50%) is identified, further evaluation with CT angiography or MR angiography may be warranted to better visualize the vasculature. A comprehensive cardiovascular risk assessment should be performed, including:

• Blood pressure measurement
• Lipid panel (total cholesterol, LDL, HDL, triglycerides)
• Fasting blood glucose or HbA1c
• Assessment of other risk factors such as smoking status and family history Neurological examination should be conducted to assess for any subtle deficits that might suggest previous cerebrovascular events. Based on findings, management typically includes:
• Antiplatelet therapy (aspirin 81-325 mg daily or clopidogrel 75 mg daily)
• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily)
• Blood pressure control (target <140/90 mmHg) For significant stenosis (>70%) in symptomatic patients or very high-grade stenosis in asymptomatic patients, referral to vascular surgery for possible carotid endarterectomy or stenting may be appropriate, as per the guidelines 1. This comprehensive approach is essential because carotid atherosclerosis reflects systemic atherosclerotic disease and indicates increased risk for stroke and other cardiovascular events, as highlighted in previous studies 1.

From the Research

Workup for Atherosclerotic Calcific Plaque in the Right Carotid Artery

The workup for a 79-year-old patient with incidentally found atherosclerotic calcific plaque in the right carotid artery on a neck X-ray involves several steps:

• Evaluation of the patient's medical history and risk factors for stroke and cardiovascular disease 2, 3
• Non-invasive imaging of the carotid plaque to identify high-risk features, such as plaque necrosis, hemorrhage, fibrous cap thinning, and the presence of foam cells 2
• Calculation of the carotid artery calcification score using computed tomography angiography (CTA) to assess the extent of calcification 3
• Consideration of other diagnostic imaging modalities, such as magnetic resonance angiography (MRA), duplex ultrasound (DUS), positron emission tomography, and computed tomography (PET-CT) imaging with (18) F-Sodium Fluoride, and Optical Coherence Tomography (OCT) 3

Treatment Options

The treatment options for atherosclerotic calcific plaque in the right carotid artery include:

• Best medical therapy, which is recommended for all patients with carotid artery calcification 3
• Carotid endarterectomy (CEA), which is recommended for patients with ≥60-99% asymptomatic carotid stenosis and ≥70-99% symptomatic stenosis 4
• Carotid artery stenting (CAS), which may be considered for patients <70 years old with symptomatic ≥50-99% carotid stenosis 4
• Antiplatelet therapy, which is recommended for patients with a history of ischemic stroke and/or significant carotid artery stenosis 2

Plaque Vulnerability

The vulnerability of the carotid plaque is closely related to its calcification characteristics, with multiple calcification and mixed type calcification being associated with a higher risk of plaque rupture 5

• The presence and extent of carotid plaque are also associated with long-term coronary heart disease risk and incident coronary artery calcium 6