How should I assess the risk of stroke in patients with asymptomatic carotid artery stenosis?

To assess the risk of stroke in patients with asymptomatic carotid artery stenosis, current NICE guidelines do not recommend routine carotid imaging or intervention unless the patient has symptoms suggestive of transient ischaemic attack (TIA) or stroke. For asymptomatic patients, formal cardiovascular risk assessment using tools such as QRISK3 is advised to estimate their 10-year cardiovascular disease risk, which includes stroke risk. This assessment helps guide primary prevention strategies including lifestyle modification and medical management of risk factors such as hypertension, cholesterol, and diabetes. Carotid imaging and consideration for carotid endarterectomy are reserved for patients with symptomatic carotid stenosis (TIA or stroke) and significant stenosis (50%–99% NASCET criteria or 70%–99% ECST criteria) ¹,².

Therefore, in asymptomatic carotid artery stenosis, focus on comprehensive cardiovascular risk assessment and management rather than direct stroke risk stratification based on stenosis alone ².