MicroRNAs as Harbingers of High-Risk Carotid Artery Atherosclerotic Disease?
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- carotid endarterectomy
- fibrous cap
- plaque rupture
- vascular smooth muscle cells
Atherosclerosis of the extracranial internal carotid artery is a common contributor to stroke. Imaging modalities, such as vascular ultrasound of the neck, can readily identify significant carotid artery stenosis, and guidelines recommend treatment with carotid endarterectomy (CEA) to prevent future stroke in symptomatic patients with signs of cerebral embolism.1 However, therapeutic decision-making for patients with asymptomatic extracranial carotid artery stenosis remains a challenge. Studies performed >20 years ago demonstrated that surgical CEA reduced the rate of stroke in select patients with asymptomatic carotid stenosis compared with medical therapy.2 Since that time, medical treatment of atherosclerotic disease has intensified, including the use of statins, which were not used routinely in these earlier trials. Similarly, improvements in surgical treatment for carotid artery stenosis have reduced postoperative surgical risk, and carotid artery stenting may also offer a noninferior interventional approach in patients. Indeed, it has been argued that the decline in risk with more aggressive medical management coupled with reduced risk with advanced surgical interventions provides again clinical equipoise in patients with asymptomatic carotid artery stenosis, raising the question of whether carotid revascularization is still warranted.1
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Although a variety of risk stratification tools can be used for patients with asymptomatic carotid stenosis, such as unstable plaque characteristics on vascular ultrasound, analysis for silent brain infarcts by imaging, or assessment for intraplaque hemorrhage on magnetic resonance imaging, none have provided compelling insights linking earlier pathophysiological signals in the carotid atherosclerotic plaque that may readily prognosticate cerebral embolic events.1 Identification of circulating biomarkers released from unstable carotid plaques could in theory serve as predictors of cerebral embolic events, thereby, capturing high-risk individuals who could benefit from more intensive therapy, including surgical revascularization. In this context, the study by Eken et al3 provides a strong foundation for …