Table 5. Elements of “Treating arteries instead of treating risk factors”.
| Measure | Intervention |
|---|---|
| Lifestyle modification | |
| All | Show patients images of their plaque, compare the patient's plaque burden with that of healthy persons of the same age and sex, describe the risks associated with that degree of plaque burden and progression and the possibility of plaque regression |
| Smoking cessation | Counselling, liberal nicotine replacement, varenicline or bupropion (depending on history of depression) |
| Mediterranean Diet | Counselling, provision of a booklet summarizing advice and providing recipes and links to internet sites; repeated at follow-up visits as necessary |
| Obesity | Counselling on caloric restriction, referral to dietician, bariatric surgery in refractory patients with severe obesity and diabetes or insulin resistance |
| Exercise | Recommendations for moderate exercise at least 30 minutes a day, with advice tailored to the patient’s disabilities if any |
| Blood pressure | Advice on how to reduce salt intake, limit alcohol intake, avoid licorice, decongestants |
| Medical therapy | |
| Blood pressure control | Physiologically individualized therapy for resistant hypertension based on renin/aldosterone profile (30); switch NSAIDs to sulindac (25) |
| Lipid lowering | Statins increasing according to plaque progression to the highest dose tolerated (with use of CoQ1O to minimize myopathic symptoms); addition of ezetimibe, and as needed for low HDL/high triglycerides, addition of fibrates; PCSK9-based treatments if feasible |
| Antiplatelet agents | Low-dose aspirin, with addition of clopidogrel in patients with severe stenosis or other indicators of high risk |
| Anticoagulation | In patients with atrial fibrillation or other cardiac sources of stroke |
| Insulin resistance, prediabetes | Pioglitazone (79); reinforcement of lifestyle issues |
| Diabetes | Reinforcement of lifestyle changes; referral to diabetes clinic |
Reproduced by permission of the American Heart Association (with updating of references) from the supplement to: Yang C, Bogiatzi C, Spence JD. Risk of Stroke at the Time of Carotid Occlusion. JAMA Neurol 2015;72:1261-7.