Medical treatment for carotid stenosis

Reviews of the surgical or interventional management of patients with symptomatic or asymptomatic carotid stenosis are commonplace but consideration of what constitutes best medical treatment in these particular patients has generally been less detailed, and there have been few randomized trials of pharmacological interventions specifically in these patient groups. This paucity of research is due partly to the effectiveness of carotid endarterectomy and stenting in preventing stroke and the tendency for trials of medical treatments in prevention of stroke not to distinguish between patients with different underlying pathologies. Recommendations for particular medical treatments in patients with carotid disease are therefore often made on the basis of extrapolation from trials and observational studies in broader populations of patients with cerebrovascular disease. However, although carotid endarterectomy and stenting can substantially reduce the risk of stroke in patients with symptomatic carotid stenosis, optimal medical treatment is still essential. First, a significant group of patients with symptomatic carotid stenosis (and a larger group with asymptomatic disease) decide against intervention or are not appropriate for various reasons. Second, given the particularly high risk of recurrent stroke in patients with symptomatic carotid stenosis following minor stroke or transient ischemic attack (TIA) (Lovett et al., 2004) and the frequent delays to carotid endarterectomy in such patients (Fairhead et al., 2005), medical treatment plays a very important role in this high-risk window between event and surgery.