A 67-year-old man comes to the office for a new patient evaluation after recently relocating to a retirement community. The patient has a history of hypertension treated with losartan. He has a 40-pack-year history but quit smoking 5 years ago. Blood pressure is 130/80 mm Hg and pulse is 80/min. Examination reveals a bruit in the right side of the neck; the remainder of the examination is normal. Carotid duplex ultrasonography reveals 45% stenosis at the right common carotid artery bifurcation. The left common carotid artery has a lesion causing 40% stenosis. Hemoglobin A1c is 5.3% and LDL cholesterol is 120 mg/dL. Which of the following is the best next step in management of this patient's arterial abnormalities?

Question

A 67-year-old man comes to the office for a new patient evaluation after recently relocating to a retirement community.  The patient has a history of hypertension treated with losartan.  He has a 40-pack-year history but quit smoking 5 years ago.  Blood pressure is 130/80 mm Hg and pulse is 80/min.  Examination reveals a bruit in the right side of the neck; the remainder of the examination is normal.  Carotid duplex ultrasonography reveals 45% stenosis at the right common carotid artery bifurcation.  The left common carotid artery has a lesion causing 40% stenosis.  Hemoglobin A1c is 5.3% and LDL cholesterol is 120 mg/dL.  Which of the following is the best next step in management of this patient's arterial abnormalities?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d572_576e_bc81_51ace769bd43_MD0003_00 This patient with multiple atherosclerotic risk factors (eg, hypertension, prior smoking) has bilateral carotid atherosclerotic disease, which was discovered when carotid duplex ultrasonography was performed to evaluate a carotid bruit. Because this patient's carotid disease has not caused transient ischemic attack or stroke symptoms, it is considered asymptomatic; in contrast, disease that has caused focal neurologic symptoms within the previous 6 months would be considered symptomatic. The classification of carotid atherosclerotic disease as asymptomatic or symptomatic, along with its severity, impacts surgical management. For asymptomatic lesions, such as in this patient, the following is recommended: >80% stenosis: Revascularization with carotid endarterectomy (CEA) is generally recommended. 50%-79% stenosis: Revascularization with CEA is generally not recommended but may be considered in select patients with low perioperative risk (eg, <3%). <50% stenosis (such as this patient): Revascularization with CEA has no proven benefit, so it is not recommended; lesions are managed with intensive medical therapy alone (Choices B and E). Intensive medical therapy, which is recommended for all patients with carotid atherosclerotic disease (both asymptomatic and symptomatic), includes an antiplatelet agent (eg, aspirin), a statin, and strict blood pressure control. Patients should also receive counseling about lifestyle changes (eg, exercise, smoking cessation), as well as rigorous management of other comorbidities that increase cardiovascular risk (eg, diabetes, obesity). Finally, patients with stenosis <80% should receive periodic (eg, annual) carotid duplex surveillance to detect any progression. (Choice C) Although CT angiography is sometimes obtained prior to CEA for surgical planning, surgical revascularization is not indicated in this patient with <50% stenosis. CT angiography is not routinely indicated as a follow-up for an abnormal carotid ultrasound, especially when the stenosis is low grade (eg, <50%) and asymptomatic. (Choice D) Periodic (eg, annual) surveillance with carotid duplex ultrasonography is recommended to detect potential progression of stenosis in lesions causing <80% stenosis (as seen in this patient). However, surveillance alone is insufficient; intensive medical therapy (eg, aspirin, statin) should also be initiated. Educational objective: The surgical management of carotid atherosclerotic disease depends on whether it is asymptomatic or symptomatic, as well as the degree of stenosis. Patients with asymptomatic disease and stenosis <50% do not benefit from carotid revascularization. Instead, they are managed with intensive medical therapy (eg, antiplatelet agent, statin) and periodic carotid duplex ultrasonography to assess for progression of lesions. References: Evaluation and management of atherosclerotic carotid stenosis. (http://www.ncbi.nlm.nih.gov/pubmed/28688468) Update on surgical management for asymptomatic carotid stenosis. (http://www.ncbi.nlm.nih.gov/pubmed/20922504) Efficacy of contemporary medical management for asymptomatic carotid artery stenosis. (http://www.ncbi.nlm.nih.gov/pubmed/24160784) A risk prediction model for determining appropriateness of CEA in patients with asymptomatic carotid artery stenosis. (http://www.ncbi.nlm.nih.gov/pubmed/23979268)

A 67-Year-Old Man Comes to the Office for a New