The importance of initiating "best medical therapy" and intervening as soon as possible in patients with symptomatic carotid artery disease: time for a radical rethink of practice.

Most Health Services are not capable of offering expedited investigation and treatment to the majority of patients presenting with transient ischaemic attack (TIA) or minor stroke. The reasons for this are multifactorial. However, there is now compelling evidence that the risk of stroke after TIA/minor stroke is significantly higher than was previously thought, with one recent study suggesting the stroke risk might be as high as 17% at 72 hours in patients with a clinically significant carotid stenosis. There is also good evidence that TIA services offering 'walk in' access with single visit imaging, combined with antiplatelet, antihypertensive and statin therapy starting during the initial consultation, significantly reduce the early risk of stroke. For many years, stroke has been the 'poor relation' to cancer and heart disease in terms of political and fiscal priorities. Given the plethora of evidence now available to us, it is no longer acceptable to tolerate delays to treatment and, in particular, continued acceptance of the dogma that provided patients undergo carotid revascularisation within 6 months, the patient is receiving optimal care. This philosophy should now be considered obsolete. The only thing that benefits from undue delay to treatment (in order to minimise the procedural risk) is the surgeon/interventionist's ego. It is certainly not the patient.