Treatment goals should include secondary prevention measures in accordance with ACC/AHA guidelines [8]. This includes aggressive blood pressure control, dyslipidemia management, smoking cessation, and the addition of an antiplatelet agent [8]. There is not consistent evidence regarding which agent is the best antihypertensive to prevent stroke. ACE inhibitors and diuretics are accepted first line medications. Regardless of the agent chosen, benefit is seen when the patient’s blood pressure is reduced to goal [8]. Strict blood pressure control with a goal blood pressure of less than 130/80 is recommended. Lipid management with a statin is recommended with a goal of LDL less than 100 and most cardiologists recommending a LDL goal of less than 70 both to prevent progression of the plaque and for stabilization [8]. There is some evidence of improved outcomes if the statin is started prior to any planned intervention [9]. Control of diabetes is not known to change outcomes in large vessel disease, but the general consensus is that there should be a goal hemoglobin a1c value of less than 7. Low dose aspirin and/or another antiplatelet medication should be started and continued indefinitely as long as there are no contraindications. The presence of more than one vascular territory affected means that a patient has a higher relative risk of dying from a cardiac cause and should affect a clinicians approach to the patient.

Carotid endartectomy is currently considered the standard of care for prevention of CVA in patients with significant stenoses regardless of symptoms. It has proven usefulness in prevention in combination with medical therapy as compared to medical management alone. Evidence from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) showed sustained benefit in the reduction of stroke or death in symptomatic patients treated with CEA as opposed to medical therapy alone. The benefit was more significant according to the degree of stenosis (70–99 % stenosis – 9 % vs. 26 % (P < 0.001) at 26 months. 50–69 % stenosis – 15.7 % vs. 22.2 % (p = 0.045) at 5 years. <50 % stenosis – No benefit) [10]. The Asymptomatic Carotid artery stenosis (ACAS) demonstrated this benefit in asymptomatic patients with carotid stenosis of 60 % percent or more [11]. However, the data from these trials were derived from mostly male patients with extrapolations of the benefit for women obtained from subgroup analysis. There is evidence that symptomatic women derive less benefit than men from CEA and there is not clear evidence that women with asymptomatic carotid disease even benefit from the procedure [11, 12]. A discussion of CEA in women should include a standard discussion of risks including risk of MI, stroke, or death along with other surgical risks including cranial nerve palsies and wound complications. It should be clear that the quoted benefits of the procedure are based on data mainly from men and that the benefit is known to be lower in women. Surgeons keep track of procedural outcomes and it may be possible to see the outcomes specifically for women to obtain a more accurate assessment of risk according to gender.

Carotid Artery Angioplasty with stent placement is a percutaneous procedure that has evolved into an accepted alternative to CEA in both symptomatic and asymptomatic patients with carotid disease. It has the potential positive attributes of minimal invasiveness, shorter post procedural recovery, and shorter hospital stay. Several randomized studies comparing CEA and CAS have been conducted and summarized in Table 17.2. The largest study using a more contemporary approach and with adequate follow up is the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) trial. It compared the outcomes of carotid-artery stenting with those of carotid endarterectomy among patients with symptomatic or asymptomatic extracranial carotid stenosis. The primary end point of the study, myocardial infarction, stroke or death was similar and no statistically significant difference between the two alternative revascularization modalities [13]. Although, there was no statistically significant difference in outcomes between men and women, there was a trend towards worse outcomes for women. CEA seemed to be better for older patients (defined as above75). CAS is preferred in certain groups that are known to have worse surgical outcomes including those with previous neck surgery or radiation, prior CEA, and younger patients. CAS does carry a higher risk of minor stroke than CEA. However, CEA carries a higher risk of myocardial infarction [13].

Abdominal aortic aneurysms (AAAs) account for 15,000 deaths yearly and are the 10th leading cause of death in the United States [19]. They are more common in men, but are associated with rupture more frequently in women [20]. In fact, although the ratio of the prevalence of AAA is 9:1 with more men being affected, women account for 40 % of all deaths from AAA. The risk factors for AAA are age, hypertension, dyslipidemia, and smoking (Table 17.3). Unlike other atherosclerotic disease, diabetes seems to have a protective role [20]. There is also a genetic component with those with a first degree relative with an AAA have a high prevalence of disease [21].

The medical management of AAA includes aggressive management of risk factors including dyslipidemia and hypertension. The preferred class of medications for treating hypertension in patients with AAA is B-blockers. By reducing pulse pressure, they can decrease the progression of AAA and decrease the risk of rupture [25].

Table 17.4 shows the annual risk of rupture according to aneurysm size [26]. Guidelines recommend intervention when an AAA is 5.5 cm in size or if a patient is symptomatic [27]. However, these guidelines were developed based on data from men. Based on data demonstrating a high risk of rupture in women at lower diameters, certain societies have recommended that surgery or endovascular repair should be offered to women at diameters of 5 cm or with symptoms [28]. Although AAAs are less prevalent among women, they are more prone to rupture and tend to rupture at smaller aortic diameters compared with men. Even though elective repair of asymptomatic AAAs is recommended when the diameter reaches 5.5 cm, many experts lower the threshold to 4.5 to 5.0 cm, especially among patients of a smaller body size, women, or those with a family history of rupture [29, 30].