Optimal Medical Therapy

**Antiplatelet therapy:** For carotid endarterectomy (CEA), single antiplatelet therapy (aspirin 75–325 mg daily) should be administered preoperatively and continued indefinitely. For carotid artery stenting (CAS) and transcarotid artery revascularization (TCAR), dual antiplatelet therapy (aspirin(DAPT) with aspirin plus clopidogrel)clopidogrel is recommended for at least 1 month (often extended to 3 months), followed by single antiplatelet therapy [@esvs2023]. Given the variability in clopidogrel metabolism, CYP2C19 genotype-guided therapy may be considered to identify poor metabolizers who may require alternative antiplatelet strategies [@lee2022]. In patients with high-risk transient ischemic attack (TIA) or minor stroke, short-term dual antiplatelet therapyDAPT reduces early stroke recurrence (CHANCE, POINT trials) [@johnston2018, @wang2013].

**Lipid management:** High-intensity statin therapy is indicated for all patients with atherosclerotic carotid disease. The SPARCL trial demonstrated that intensive statin therapy reduces stroke recurrence [@amarenco2006]. Consider adding ezetimibe or PCSK9proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors if LDLlow-density lipoprotein (LDL) cholesterol remains above target [@esvs2023].

**Blood pressure control:** Target blood pressure <130/80 mmHg in most patients with prior stroke or TIA if tolerated [@aha2021].

**Diabetes management:** Individualized glycemic control (often HbA1chemoglobin A1c (HbA1c) <7%) with comprehensive cardiovascular risk reduction [@aha2021].

**Lifestyle modifications:** Smoking cessation, weight management, Mediterranean-style diet, and regular physical activity are essential components of secondary prevention [@aha2021]. Despite the proven benefits of optimal medical therapy (OMT), adherence remains suboptimal in many patients undergoing carotid interventions; however, consistent OMT is associated with significantly smaller areas of cerebral infarction in the event of a subsequent stroke [@teter2024].