Management of Carotid Stenosis Medical Management

A 67-year-old man with a history of hypertension and hyperlipidemia is seen for a routine examination. His medications include hydrochlorothiazide (25 mg daily), simvastatin (20 mg daily), and aspirin (81 mg daily). He drinks alcohol rarely and does not smoke. His body-mass index (the weight in kilograms divided by the square of the height in meters) is 27, consistent with overweight. His blood pressure is 140/85 mm Hg, and his heart rate is 72 beats per minute and regular. His cardiac examination is normal. Auscultation of the neck shows normal carotid upstrokes but reveals a middle-pitched bruit only in systole at the angle of the right jaw. A detailed neurologic examination is normal. On questioning, the patient does not report any history of transient neurologic deficits — specifically, no unilateral weakness or sensory symptoms, visual disturbances, or speech or language difficulty. Noninvasive testing of the carotid arteries reveals a stenosis of 70 to 80% of the proximal right carotid artery with an irregular plaque and peak velocity of 339 cm per second. There is 20% stenosis in the left proximal carotid artery. Which one of the following initial treatment options, any of which could be considered correct, would you find most appropriate for this patient? Base your choice on the published literature, your past experience, recent guidelines, and other sources of information, as appropriate.