Stroke prevention in asymptomatic carotid artery disease: revascularization of carotid stenosis is not the solution

Asymptomatic carotid stenosis (ACS) exceeding 50% is present in about 2% of 60-year-old patients and an even higher fraction of older individuals. The major independent risk factors include advancing age, male sex, tobacco smoking, and a history of vascular disease. The best available evidence does not support either population screening for ACS or routine carotid revascularization when ACS is discovered. There is an urgent need to identify patients with ACS and a sufficiently high risk of ipsilateral stroke (despite contemporary medical management) to warrant invasive treatment. The mainstays of medical management are antiplatelet therapy (usually low-dose aspirin), high-dose statins, blood pressure control, and smoking cessation. Patients with ACS should be periodically educated about symptoms of transient ischemic attack and stroke that require emergent medical attention. Current guidelines vary widely in recommendations regarding revascularization (ie, endarterectomy or carotid stenting). The benefits of revascularization strategies remain uncertain for patients with ACS who receive contemporary medical management.