A new approach of statin therapy in carotid atherosclerosis: Targeting indices of plaque vulnerability on the top of lipid-lowering. A narrative review

Novel imaging techniques and biomarkers have emerged as surrogate markers of carotid plaque vulnerability. In parallel, statins' administration in patients with established carotid atherosclerosis not requiring revascularization have reduced the consequent cerebrovascular events. This is not only attributed to the lipid-lowering properties of statins, but to their pleiotropic actions as well. The aim of the present literature review was to summarize the stabilizing effects of statins on carotid plaques based on imaging modalities and biomarkers proposing an alternative approach of their implementation. Moreover, we assessed the perioperative use of statins in patients undergoing carotid revascularization and the impact of aggressive vs. conventional statin therapy. Recent studies using: 1) ultrasound indices of plaque echogenicity, 2) fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scan for plaque inflammation assessment or 3) magnetic resonance imaging (MRI) scan quantifying intraplaque hemorrhage, and lipid rich necrotic core (LRNC) have shown quite promising results for the objective evaluation of carotid plaque vulnerability. Based on those imaging modalities a growing number of studies have demonstrated a very modest carotid plaque regression of statins, while their stabilizing impact is disproportionally higher. Other studies assaying several biomarkers (e.g. inflammation, etc.) have confirmed a statin-induced carotid plaque stabilization. All the aforementioned benefits followed a dose-dependent pattern of statins, on the top of the low-density lipoprotein cholesterol (LDL-C) target in current guidelines. In case of symptomatic patients with carotid atherosclerosis suitable for revascularization, robust evidence implicates a significant statin-related reduction of perioperative cardiovascular risk only in patients undergoing endarterectomy.