To the Editor.
—The authors of the ACAS1 concluded that patients with asymptomatic carotid artery stenosis of 60% or more and who have an acceptable surgical risk will have a reduced 5-year risk of ipsilateral stroke if carotid endarterectomy is performed vs standard medical management. Standard medical management included risk factor modification and aspirin. It was assumed that surgery could be done with less than a 3% perioperative morbidity and mortality. However, several recent studies demonstrate that in individuals with carotid artery disease and/or coronary artery disease and moderately elevated low-density lipoprotein (LDL) cholesterol levels, aggressive LDL cholesterol lowering (ie, attempting to decrease LDL levels below 2.6 mmol/L [100 mg/dL]) with hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitors can significantly decrease cardiovascular events2-5 and overall mortality.4,5Carotid stenosis frequently indicates widespread vascular disease. Individuals with carotid stenosis commonly have coronary artery disease. It is believed that lowering LDL cholesterol can