What is the treatment for atherosclerosis of the artery?

Treatment of Atherosclerosis of the Artery

All patients with atherosclerotic arterial disease require triple medical therapy: intensive statin therapy targeting LDL-C <55 mg/dL (or <70 mg/dL minimum), antiplatelet therapy, and blood pressure control <140/90 mmHg, combined with aggressive lifestyle modification including smoking cessation, regular exercise, and dietary changes. 1

Pharmacologic Management

Lipid-Lowering Therapy (Highest Priority)

• Initiate intensive statin therapy immediately in all patients with atherosclerotic disease, targeting LDL-C <100 mg/dL with at least 30% reduction from baseline 1
• For very high-risk patients (established atherosclerotic disease), target LDL-C <55 mg/dL using high-intensity statins with ezetimibe or PCSK9 inhibitors as adjunctive therapy 1
• If triglycerides ≥200 mg/dL, treat with statins to achieve non-HDL-C <130 mg/dL 1
• If triglycerides >500 mg/dL, add fibrate therapy to prevent acute pancreatitis 1
• For statin-intolerant patients, use bile acid sequestrants and/or niacin as alternatives 1

Antiplatelet Therapy

• Prescribe aspirin 75-325 mg daily for all patients with atherosclerotic disease to prevent MI and other ischemic events 1
• For patients with recent stroke/TIA (within 30 days) and severe stenosis (70-99%), add clopidogrel 75 mg daily to aspirin for up to 90 days 2, 3
• Ticagrelor monotherapy is superior to aspirin monotherapy in patients with ipsilateral atherosclerotic carotid stenosis following acute ischemic stroke or TIA (HR 0.68,95% CI 0.53-0.88) 1
• Consider aspirin 100 mg plus rivaroxaban 2.5 mg twice daily for patients with established atherosclerotic disease, as this combination reduces cardiovascular events compared to aspirin alone 1

Blood Pressure Management

• Target blood pressure <140/90 mmHg in all patients with atherosclerotic disease 1
• Initiate therapy with beta-blockers and/or ACE inhibitors as first-line agents, adding other medications as needed to achieve goal 1
• Counsel all patients on lifestyle modifications: weight control, increased physical activity, alcohol moderation, sodium reduction, and increased consumption of fresh fruits, vegetables, and low-fat dairy products 1

Lifestyle Modifications (Essential Foundation)

Smoking Cessation (Non-Negotiable)

• Ask about tobacco use at every office visit and advise every tobacco user to quit at every visit 1
• Assist patients with counseling and a structured quit plan that includes pharmacotherapy and/or referral to smoking cessation programs 1
• Advise complete avoidance of environmental tobacco smoke at work, home, and public places 1

Dietary Interventions

• Reduce saturated fat intake to <7% of total calories, trans fatty acids to <1%, and cholesterol to <200 mg/day 1
• A high-quality diet (increased vegetables, fruits, soy protein; decreased meat, poultry, eggs) reduces stroke risk by 14% even in patients on optimal medical therapy (HR 0.81,95% CI 0.67-0.98) 1
• Emphasize increased consumption of fresh fruits, vegetables, and low-fat dairy products 1

Physical Activity

• Prescribe at least 30 minutes of moderate physical activity daily, minimum 5 days per week 1
• Daily physical activity and weight management are strongly recommended for all patients 1

Revascularization Considerations

When NOT to Intervene

• Do not perform angioplasty or stenting as initial treatment for carotid or vertebral artery stenosis, even in patients with severe (70-99%) stenosis who were already on antiplatelet therapy when they had their stroke/TIA 2, 3
• Reoperative CEA or CAS should not be performed in asymptomatic patients with <70% carotid stenosis that has remained stable 1

When Revascularization May Be Considered

• For symptomatic patients with carotid stenosis, revascularization decisions should follow established criteria after optimizing medical therapy 1
• Extra-anatomic carotid-subclavian bypass is reasonable for symptomatic subclavian steal syndrome in patients without surgical contraindications 1
• Percutaneous endovascular angioplasty and stenting is reasonable for symptomatic subclavian steal in high surgical risk patients 1

Surveillance and Monitoring

• Establish a lipid profile in all patients; for hospitalized patients, initiate lipid-lowering therapy before discharge 1
• Serial non-invasive imaging (CTA or MRA) is reasonable to assess disease progression and exclude new lesions 1, 2
• For patients who undergo revascularization, perform surveillance imaging at 1 month, 6 months, then annually 2

Critical Pitfalls to Avoid

• Do not treat single risk factors in isolation—atherosclerotic disease requires comprehensive management of all cardiovascular risk factors simultaneously 1
• Do not delay statin initiation—lipid-lowering therapy should begin before hospital discharge in acute presentations 1
• Do not rely on interventional procedures alone—medical therapy is the foundation of treatment and must be optimized regardless of revascularization status 1
• Do not underestimate the importance of lifestyle modification—dietary changes and smoking cessation provide benefits independent of pharmacotherapy 1
• Do not use dual antiplatelet therapy long-term without specific indication—DAPT is typically limited to 1-3 months post-intervention, then transition to single antiplatelet therapy 1