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In Reply: Management of patients with carotid artery disease is complex. There was insufficient space in the Clinical Crossroads article to discuss the timing of surgery in patients with symptomatic severe carotid artery disease or the intricacies of statin dosage.

I concur with Dr Kapoor that stable patients with surgical internal carotid artery lesions should undergo surgery at the earliest possible time. In unstable patients who have active brain ischemia who are on maximal medical treatment, the nonoperative morbidity and mortality rates are quite high, so surgery (despite the high morbidity) is often more effective than watchful waiting. As Dr Mascitelli and colleagues indicate, physicians should carefully weigh the risks vs benefits in deciding on the type and dosage of a statin in older patients with multiple medical conditions.

Financial Disclosures: Dr Caplan reported that he has been an ad hoc consultant or advisory board member for Bayer, Bristol-Myers Squibb–Sanofi . . . [Full Text of this Article]

Louis R. Caplan, MD
lcaplan@bidmc.harvard.edu
Division of Cerebrovascular/Stroke
Beth Israel Deaconess Medical Center
Boston, Massachusetts

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