Carotid artery atherosclerosis: mechanisms of instability and clinical implications

Luca Saba; Riccardo Cau; Rocco Vergallo; M Eline Kooi; Daniel Staub; Gavino Faa; Terenzio Congiu; George Ntaios; Bruce A Wasserman; John Benson; Valentina Nardi; Rika Kawakami; Giuseppe Lanzino; Renu Virmani; Peter Libby

doi:10.1093/eurheartj/ehae933

Carotid artery atherosclerosis: mechanisms of instability and clinical implications

Eur Heart J. 2025 Jan 10:ehae933. doi: 10.1093/eurheartj/ehae933. Online ahead of print.

Authors

Luca Saba¹, Riccardo Cau¹, Rocco Vergallo², M Eline Kooi³, Daniel Staub⁴, Gavino Faa⁵, Terenzio Congiu⁵, George Ntaios⁶, Bruce A Wasserman⁷, John Benson⁸, Valentina Nardi⁹, Rika Kawakami¹⁰, Giuseppe Lanzino¹¹, Renu Virmani¹², Peter Libby¹³

Affiliations

¹ Department of Radiology, University of Cagliari, Via Università, 40, 09124 Cagliari, Italy.
² Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
³ Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands.
⁴ Vascular Medicine/Angiology, University Hospital Basel and University of Basel, Basel, Switzerland.
⁵ Department of Pathology, University of Cagliari, Cagliari, Italy.
⁶ Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Larissa 41132, Greece.
⁷ The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, 367 East Park building, 600 N Wolfe St, Baltimore, MD 21287, USA.
⁸ Department of Radiology, Mayo Clinic, Rochester, MN, USA.
⁹ Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
¹⁰ Department of Cardiovascular Pathology, CVPath Institute, Inc., Gaithersburg, MD, USA.
¹¹ Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.
¹² Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA.
¹³ Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.

PMID: 39791527
DOI: 10.1093/eurheartj/ehae933

Abstract

Cardiovascular disease remains a prominent cause of disability and premature death worldwide. Within this spectrum, carotid artery atherosclerosis is a complex and multifaceted condition, and a prominent precursor of acute ischaemic stroke and other cardiovascular events. The intricate interplay among inflammation, oxidative stress, endothelial dysfunction, lipid metabolism, and immune responses participates in the development of lesions, leading to luminal stenosis and potential plaque instability. Even non-stenotic plaques can precipitate a sudden cerebrovascular event, regardless of the degree of luminal encroachment. In this context, carotid imaging modalities have proved their efficacy in providing in vivo characterization of plaque features, contributing substantially to patient risk stratification and clinical management. This review emphasizes the importance of identifying high-risk individuals by use of current imaging modalities, biomarkers, and risk stratification tools. Such approaches inform early intervention and the implementation of personalized therapeutic strategies, ultimately enhancing patient outcomes in the realm of cardiovascular disease management.

Keywords: Atherosclerosis; Cardiovascular events; Carotid; Imaging; Stroke.

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