optimal management of patients with ACS. Both guidelines recognized the uncertainty in the management, as well as the excessive number of unnecessary interventions offered to these patients in the past. 2,3 Both guidelines 2,3 provided a strong recommendation for the implementation of best medical treatment in ACS patients, "regardless of the degree of stenosis or the plan for intervention". 2 The 2011 SVS guidelines clearly reported that the efficacy of a possible carotid intervention in ACS patients depends on minimizing perioperative complication rates, including appropriate risk factor assessment and patient selection, optimal perioperative therapy and performance of a technically excellent operation. 2 The 2018 ESVS guidelines further attempted to identify subgroups of patients at "higher risk for stroke" on best medical treatment who could benefit from an additional prophylactic carotid revascularization procedure. 3 After a critical review of the available literature, they proposed that the presence of one or more clinical and/or imaging features (eg, silent infarction on brain computed tomography/magnetic resonance imaging scans, stenosis progression, large plaque area, large juxta-luminal black area on computerized plaque analysis, plaque echolucency, intraplaque hemorrhage on magnetic resonance imaging, impaired cerebral vascular reserve and spontaneous embolization on transcranial Doppler monitoring) might be useful for selecting "higher-risk for stroke" patients for revascularization. 3 Several risk scores and risk prediction models have been developed in an attempt to identify ACS patient subgroups which may/may not benefit from a prophylactic carotid intervention. [4][5][6] These risk scores/ risk prediction models highlight the fact that the treatment of ACS patients may need to be individualized, preferably in high-volume institutes by high-volume surgeons/practitioners. [4][5][6] The development of more accurate methods able to predict ACS patients at "higher-risk for stroke" (like the authors propose) 7 are welcome. Nevertheless, these methods should first prove to be effective. The upcoming 2021 SVS guidelines for the management of patients with carotid stenosis are expected to help resolve the current controversies regarding the management of patients with ACS.