In reply: I thank Cheng and Richards for highlighting the important role of carotid endarterectomy for high grade symptomatic stenosis in stroke prevention. As this therapy was established in the 1990s,1,2 it was not a focus of the review published in the MJA.3 Nonetheless, carotid endarterectomy is still a central part of the therapeutic armamentarium to reduce the risk of recurrent stroke. The absolute risk reduction in recurrent stroke of about 14% for patients with 70–99% symptomatic stenosis (but not near‐occlusion) observed in the pivotal trials4 may not be as great in contemporary practice with the use of high potency statins and an early combined antiplatelet strategy with aspirin and clopidogrel. This intensive medical therapy is essential in patients with atherosclerotic stroke mechanisms, regardless of whether an endarterectomy is performed, given the risk of recurrent disease and plaque rupture in other regions of the vasculature.
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