What are the current guidelines for the management of symptomatic carotid artery stenosis in primary care?

In primary care, the management of symptomatic carotid artery stenosis begins with rapid recognition of symptoms suggestive of transient ischaemic attack (TIA) or stroke, using validated tools such as the FAST test, and immediate exclusion of hypoglycaemia as a cause of neurological symptoms ¹. Upon suspicion of symptomatic carotid stenosis, urgent referral to specialist services for assessment and investigation within 24 hours is essential to confirm diagnosis and determine the degree of stenosis ¹. Aspirin 300 mg daily should be started immediately unless contraindicated, as part of initial secondary prevention ¹.

Following specialist assessment, management depends on the severity of stenosis and symptomatology. For patients with symptomatic carotid artery stenosis of 50% or greater, carotid endarterectomy (CEA) is generally recommended to reduce stroke risk, ideally performed within two weeks of symptom onset to maximize benefit (Musialek et al., 2025; Henning and Hoh, 2025). Carotid artery stenting (CAS) may be considered in selected patients at high surgical risk or with anatomical considerations, but CEA remains the first-line intervention ¹; (Musialek et al., 2025). Medical management includes antiplatelet therapy (aspirin), statin therapy to achieve lipid targets, and rigorous control of cardiovascular risk factors such as hypertension, diabetes, and smoking cessation ¹; (Ismail et al., 2023).

In primary care, ongoing management focuses on optimisation of secondary prevention measures including lifestyle modification, blood pressure control, lipid management, and adherence to antiplatelet therapy ¹; (Ismail et al., 2023). Patients should be counselled on diet, physical activity, and smoking cessation in line with cardiovascular disease prevention guidelines ². Regular follow-up to monitor symptoms and risk factor control is important, with prompt re-referral if neurological symptoms recur or worsen ¹.

In summary, primary care's role in symptomatic carotid artery stenosis involves rapid recognition, immediate initiation of aspirin, urgent referral for specialist evaluation, and comprehensive secondary prevention including lifestyle and pharmacological interventions while awaiting or following specialist treatment ¹; (Musialek et al., 2025; Henning and Hoh, 2025; Ismail et al., 2023).