From the Guidelines
The management of carotid stenosis should prioritize a combination of medical therapy, lifestyle modifications, and possibly interventional procedures, with carotid endarterectomy (CEA) recommended for symptomatic stenosis ≥50-99% and carotid artery stenting (CAS) considered for select patients, as supported by the most recent guidelines 1.
Medical Therapy
All patients with carotid stenosis should receive optimal medical therapy, including:
- Antiplatelet agents, 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
- Blood pressure control, with a target <140/90 mmHg
- Diabetes management, if applicable
Lifestyle Modifications
Lifestyle modifications are essential for managing carotid stenosis and include:
- Smoking cessation
- Regular exercise
- A heart-healthy diet
Interventional Procedures
For symptomatic carotid stenosis, CEA is recommended for stenosis ≥50-99% when performed by surgeons with low complication rates (<6%) 1. CAS may be considered as an alternative to CEA in select patients with unfavorable neck anatomy, previous neck radiation, or high surgical risk.
Timing of Intervention
The benefit of intervention is greatest when performed within 2 weeks of symptom onset, as supported by recent guidelines 1.
Monitoring
Regular follow-up with ultrasound surveillance is essential for monitoring disease progression in patients managed medically.
Rationale for Intervention
The rationale for intervention is based on reducing stroke risk by removing or bypassing the atherosclerotic plaque that can either cause hemodynamic compromise or serve as a source of emboli to the brain.
From the Research
Management Approach for Carotid Stenosis
The management of carotid stenosis involves a combination of medical therapy, lifestyle modifications, and revascularization procedures. The goal of management is to reduce the risk of stroke and other cardiovascular events.
Medical Therapy
- Antiplatelet therapy, such as aspirin or clopidogrel, is routinely used to prevent ischemic stroke in patients with carotid stenosis 2, 3, 4.
- Statins are used to lower lipid levels and reduce the progression of carotid artery stenosis 2, 5.
- Antihypertensive agents are used to control blood pressure and reduce the risk of stroke 2, 5.
- Diabetes management is optimized to reduce the risk of cardiovascular events 2.
Lifestyle Modifications
- Smoking cessation is recommended to reduce the risk of cardiovascular events 2, 3.
- Physical activity and a healthy diet are recommended to reduce the risk of cardiovascular events 2, 5.
- Weight management and reduction of alcohol intake are also recommended 2.
Revascularization Procedures
- Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are used to treat symptomatic and asymptomatic carotid stenosis 3, 5.
- The choice of procedure depends on the severity of stenosis, patient anatomy, and medical history 5.
- Revascularization is recommended for symptomatic patients with stenosis >50% and for asymptomatic patients with stenosis >60% 5.