Carotid artery stenosis (CAS) is defined as an atherosclerotic occlusive disease of the common carotid bifurcation and/or the proximal internal carotid artery that is associated with significant cerebrovascular and cardiovascular (CV) complications. Epidemiologic projections indicate a CAS prevalence of 1.5% in the population between the ages of 30-79, affecting up to 58 million people worldwide.[1] CAS is more common in older age groups, affecting approximately 7.5% of men and 5% of women above the age of 80.[2] In fact, there has been a reported 59% increase in the prevalence of CAS between 2000-2020, likely due to the aging population, sedentary lifestyles, and an increase in high-fat diets.[1,3] Individuals with CAS are at increased risk for stroke and transient ischemic attack (TIA)[4] as well as cognitive impairment.[5] Further, due to the systemic nature of atherosclerosis, CAS patients are at increased risk for disease in other vascular beds, with up to 50-75% of patients with CAS exhibiting concomitant coronary artery disease (CAD).[6] Conversely, up to 25% of patients with peripheral artery disease (PAD) exhibit >50% CAS by imaging.[7] Indeed, some studies have shown that the risk of myocardial infarction (MI) and nonstroke death is higher than that of ipsilateral stroke in patients with CAS.[8,9] The Reduction of Atherothrombosis for Continued Health (REACH) international registry revealed that patients with asymptomatic CAS were at significantly higher risk of CV death (2.29% vs. 1.52%, P = 0.002) compared to patients without CAS and also exhibited a higher level of the composite end-point of CV death/MI/stroke (6.03% vs. 4.29%, P < 0.0001).[10]

The Framingham Study reported that the four most common risk factors associated with CAS include age, cigarette smoking, elevated systolic blood pressure, and elevated total cholesterol.[11] Additional CAS risk factors include diabetes, chronic kidney disease, and elevated C-reactive protein.[6] The goals of medical therapy in CAS are to reduce the risk of both ipsilateral cerebrovascular events and global CV events, including MI and CV death. Lifestyle modification and intensive risk factor control with pharmacologic therapy are foundational to the medical treatment of CAS.

The objective of this review is to present a comprehensive overview of lifestyle interventions and contemporary medical therapies used in the management of CAS for reducing both stroke and cardiovascular risk.