The cardiovascular risk of patients with carotid artery stenosis

It is commonly accepted that a relationship exists between coronary and carotid arterial disease, given that the prevalence of coronary artery disease (CAD) in patients with carotid stenosis is as high as 77%, depending on the population studied. Elevated cardiovascular (CV) risks are apparent in patients with either asymptomatic or symptomatic carotid stenosis. Patients with asymptomatic carotid stenosis are at about a three-fold higher risk of CV death/myocardial infarction compared with a matched population without carotid stenosis, and this risk may be even higher among patients with symptomatic carotid stenosis. Thus, antiplatelet and lipid-lowering therapies are indicated not only to prevent stroke, but also especially to lower elevated CV risks. Carotid revascularization has become well established in patients with symptomatic carotid stenosis, which is associated with significant absolute risk reductions in terms of recurrent stroke, but remains controversial for patients with significant but asymptomatic carotid stenosis. Carotid revascularization in those with asymptomatic carotid stenosis seems to principally benefit patients with specific clinical/imaging features indicating a high risk of stroke. Screening and treatment of asymptomatic CAD can be beneficial for patients with recently symptomatic carotid stenosis and especially for those for whom surgical or endovascular carotid revascularization is planned. Because evidence of the benefits afforded by prophylactic revascularization of asymptomatic carotid artery stenosis in all CABG candidates (in terms of reducing perioperative stroke) is lacking, it may be reasonable to restrict prophylactic carotid revascularization to patients at the highest risk of postoperative stroke, thus those with severe bilateral lesions or a history of prior stroke/transient ischemic event.