Prospective studies have found an increased stroke recurrence rate among patients with aortic plaques 4 mm in thickness, particularly with ulceration or mobile or without plaque calcifications.389 There are no strong data from randomized clinical trials or even observational studies that management should be dif- ferent from general secondary prevention recommenda- tions for atherosclerotic stroke. Recommendation-Specific Supportive Text 1. There is evidence that treating patients with ischemic stroke and evidence of atherosclerosis to an LDL tar- get of <70 mg/dL is more effective in stroke preven- tion than less intensive lipid management.210 Detailed guidanceforlipidmanagementbasedonageandvery high-risk status is presented elsewhere in this docu- ment (see Section 4.3, Treatment of Hyperlipidemia for Secondary Prevention of Stroke). Many patients with aortic plaque and ischemic stroke will meet the criteria for very high-risk status because of concomi- tant atherosclerotic conditions and risk factors. In the ARCH study (Aortic Arch Related Cerebral Hazard Trial), the only randomized trial of secondary pre- vention of aortic plaque associated stroke,380 the event rate was only 20% to 30% of the >12% rate expected from observational studies.390 This is likely attributable to the better risk factor management in the trial compared with historical studies. During the trial, mean LDL-C was reduced by 40 mg/dL to 83 to 84 mg/d. It is likely that event rates would be even lower with current, more intensive recommendations for hypertension and cholesterol management. 2. The only randomized trial of this condition, the compared aspirin and clopidogrel with warfarin and was underpowered for the primary end point. Thus, the comparative benefit of these 2 treatments is unknown. However, there were 6 vas- cular deaths (3.4%) in the warfarin arm and none in the dual antiplatelet arm (log-rank test, P=0.013), suggesting no advantage of warfarin over dual anti- platelets. 