Contemporary medical
therapy consists of identification and treatment of all patient-modifiable vascular risk factors. Specific atherosclerotic disease
therapies are designed to reduce the risk of
thrombosis, and the
disease progression in order to reduce the risk of future cardiovascular events. Contemporary medical management emphasizes the need to support the patient in achieving lifestyle modifications and to adjust medication to achieve individualized target values for specific quantifiable risk factors. Antiplatelet
therapy in the form of
aspirin or
clopidogrel is routinely used for the prevention of
ischemic stroke in patients who have had a
transient ischemic attack or
stroke. There is evidence from a recent trial that the use of combination antiplatelet
therapy with
aspirin and
clopidogrel started within 24 hours of minor
stroke or
transient ischemic attack reduces the risk of recurrent
stroke compared to the use of
aspirin alone, and therefore we use
aspirin plus
clopidogrel in recently symptomatic patients with
carotid stenosis pending carotid revascularization. Anticoagulation with heparins or
vitamin K antagonist is not recommended except in patients at risk for cardio-embolic events. Lowering blood pressure to target levels has been shown to slow down the progression of
carotid artery stenosis and reduces the intima-media thickness of the carotid plaque, while lowering
lipid levels with
statins has become an essential
element in the medical
therapy of
carotid artery stenosis. Diabetes management should be optimized. Lifestyle choices, including tobacco smoking, physical inactivity, unhealthy diet,
obesity, and excessive alcohol intake, are all important modifiable vascular risk factors. The combination of
dietary modification, physical exercise, and use of
aspirin, a
statin, and an
antihypertensive agent can be expected to give a cumulative relative
stroke risk reduction of 80%. The evidence suggests that intensive medical
therapy is so effective that carotid revascularization may no longer be necessary in many of the patients in whom carotid surgery or stenting is currently performed. Two large ongoing trials are therefore comparing the risks and benefits of carotid revascularization versus intensive medical
therapy alone.