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8.2.2 Asymptomatic carotid artery stenosis

8.2.2.1. Medical treatment Optimal medical treatment is based on CVRF correction through lifestyle intervention and pharmacological treatment, with the goal of reducing cerebrovascular and global CV events.19 Concerning hypertension, similar target values as those presented in the general section are recommended for patients with asymptomatic CS.

8.2.2.1.1. Lipid-lowering therapy. See Section 7. 8.2.2.1.2. Antihypertensive therapy. See Section 7. 8.2.2.1.3. Glucose-lowering therapy. See Section 7. 8.2.2.1.4. Antithrombotic therapy. The clinical benefit of antithrombotic treatment in patients with asymptomatic CS remains unproven.664 The only RCT (the Asymptomatic Cervical Bruit Study [ACB]) addressing the issue enrolled only 188 patients per arm, and failed to show superiority of aspirin vs. placebo in reducing TIA, stroke, MI, or death.665 In observational studies, SAPT (mainly low-dose aspirin) was associated with reduced risk of MACE, although data were conflicting for moderate stenosis (i.e. 50%– 75%);664 DAPT, combining aspirin and clopidogrel, has no benefit over SAPT.496,497

The Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial reported a non-significant decrease in MACE in patients with either history of carotid revascularization or asymptomatic patients with >50% CS and CVRFs allocated to dual antithrombotic therapy (aspirin 100 mg o.d. and rivaroxaban 2.5 mg b.i.d.)

NASCET (% stenosis) ECST (% stenosis)

50 75

60 80

70 85

80 91

90 97

A C

B Carotid artery stenosis

equivalents between NASCET and ECST criteria

ECST method

C

NASCET method

x 100% (C-A)

B x 100% (B-A)

Figure 17 North American Symptomatic Carotid Endarterectomy Trial/European Carotid Surgery Trial methods. ECST, European Carotid Surgery Trial; NASCET, North American Symptomatic Carotid Endarterectomy trial.

Table 10 Peak systolic velocity criteria for grading internal carotid artery stenosis

% stenosis Reference 50%–69% (moderate stenosis) ≥70% (severe stenosis) PSV threshold SRUCC662

------------------------- Gornik et al.661 125–230 cm/s

------------------------- ≥180 cm/s or ≥125 cm/s + PSV ICA/CCA ≥2 >230 cm/s

------------------------- Overestimation with SRUCC criteria but no consensus © ESC 2024

CCA, common carotid artery; ICA, internal carotid artery; PSV, peak systolic velocity; SRUCC, Society of Radiologists in Ultrasound.

ESC Guidelines                                                                                                                                                                                          3591

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