A 79-year-old musician with asymptomatic carotid artery disease

Dr DALEY: Mr C, a 79-year-old married professional classical musician with a history of cardiovascular and peripheral vascular disease, was noted to have asymptomatic carotid bruits in March 1995. He is active as a teacher and performer. He is insured by Medicare and carries supplemental Medigap insurance. In 1989, Mr C underwent coronary artery bypass grafting for progressive anginal symptoms. Angina recurred in December 1994, and cardiac catheterization revealed diffuse three-vessel coronary artery disease with patent grafts. In recent months his angina has abated with medical therapy. His risk factors for atherosclerosis include a total cholesterol level of 6.18 mmol/L (239 mg/dL), a family history of coronary artery disease, and a history of smoking cigarettes 20 years ago. Current medications include amlodipine besylate, 5 mg daily; terazosin hydrochloride, 5 mg daily, for mild symptoms of prostatic hypertrophy; and one enteric coated aspirin daily. Hypercholesterolemia is managed by diet, although until