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Dear Doctor: Blockages in the carotid arteries are a common cause of stroke.

DEAR DR. ROACH: I am a 79-year-old woman who was scheduled to have a carotid endarterectomy. The artery was blocked and the procedure failed. The surgeon did not recommend further carotid surgery.

I take warfarin and diltiazem for paroxysmal atrial fibrillation (AFib); losartan and hydrochlorothiazide for controlled hypertension; and atorvastatin for high cholesterol. I do cardio three hours a week, walk frequently, and have an active social life. I recently lost 10 pounds and started a plant-based diet.

Will a plant-based diet remove plaque from my arteries? Can some of the plaque break off and cause a stroke when the arteries become loose? What do you think about not pursuing carotid surgery? –PF

ANSWER: Blockages in the carotid arteries are a common cause of stroke, and partial occlusions of these arteries are often treated with surgery. The indications are precise and depend on the degree of occlusion and the presence of symptoms. Surgery is not indicated for 100% occlusion, so I certainly do not recommend pursuing surgery any further.

Intensive medical treatment is key, and blockages can ease over time with proper treatment. You have described many of the crucial elements of treatment. The most important are:

— Blood pressure control: People at high risk, such as those with blockages, benefit from strict control, below 120 on less than 80 mm Hg.

— Statin medications: High-dose atorvastatin (and possibly additional medications) is used to bring the LDL level below 70 mg/dL, possibly below 50 or even 40 mg/dL .

— Diet: A plant-based diet has been shown to help reduce risk. Several types of diets have been found to be helpful, but all include small amounts of meat, processed foods, and sugar, while emphasizing vegetables, legumes, fruits, whole grains, nuts, and fatty fish. You need to find a diet that works for you.

— Exercise: Cardio exercise and strength training exercises each have unique benefits when it comes to reducing heart risk.

— Stopping smoking is obligatory.

— Weight reduction provides a small benefit for most, combined with diet and exercise.

— Diabetes control is appropriate, if applicable.

— Anticoagulant or antiplatelet medications: Aspirin is recommended for most, but people with atrial fibrillation, like you, need an individualized approach.

All of these together can significantly reduce the risk of stroke and heart attack. These treatments do not increase the risk of embolism (plaque detachment causing a stroke).

DEAR DR. GARDON: I started taking lisinopril at night based on an article I read. However, I check my blood pressure twice a day and it is always higher in the morning. I’m wondering if I should take lisinopril when my blood pressure is at its lowest. I also notice that my blood pressure is lower after a workout.

I would like to know if this is unusual, what causes it and when should I take lisinopril. — EU

ANSWER: The normal pattern of blood pressure shows that it rises sharply upon waking and falls before and during sleep. What you see is normal physiology. Lisinopril lasts a long time in the body, so this is probably not an effect of lisinopril.

A study done a few years ago seemed to show a significant benefit to taking blood pressure medications in the evening compared to the morning, but other studies have not shown this benefit.

You can take lisinopril at any time convenient for you, preferably at the same time each day.

Dr. Roach regrets not being able to respond to individual letters, but he will incorporate them into the column as much as possible. Readers can email questions to ToYourGoodHealth@med.cornell.edu or mail to 628 Virginia Dr., Orlando, FL 32803.

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