Palpable or auscultable carotid murmur

Specialty: Cardiovascular.

• breast on the neck
• carotid thriller
• palpable carotid thrill

Why it occurs

• Stenosis of the internal carotid artery due to atherosclerotic plaque
• Transmission of a systolic murmur of severe aortic stenosis
• Carotid-cavernous or cervical arteriovenous fistula
• Takayasu arteritis or carotid involvement of giant cell arteritis
• Fibromuscular dysplasia of the carotid arteries
• Severe hyperdynamic states (severe anemia, thyrotoxicosis)

Initial workup

Carotid and vertebral duplex Doppler ultrasound to measure flow velocities (peak systolic and end-diastolic velocities) and quantify the percentage of carotid stenosis according to the criteria of the Society of Ultrasound Radiologists; Angiotomography of supra-aortic arteries to specify the anatomy of the bifurcation and the degree of calcification or ulceration of the plaque; Magnetic resonance imaging of the brain and neck vessels (MR Angio) if concomitant silent cerebral ischemia is suspected.

Standard management

• Acetylsalicylic acid — antiplatelet agent indicated for secondary prevention of cerebral ischemic events in patients with significant symptomatic or asymptomatic carotid stenosis; 100 mg once a day orally
• Clopidogrel — 75 mg once daily orally as alternative or combination therapy according to clinical guidelines and bleeding risk
• Atorvastatin — high-potency statin to reduce carotid plaque volume and stabilize the endothelium; 40 to 80 mg per day orally, with LDL goal <55 mg/dL
• Ramipril (ACEI indicated for strict control of blood pressure, a critical factor in the progression of carotid disease; 5 to 10 mg once daily orally).