A new era in atherothrombosis

Atherothrombosis is a complex vascular disorder in which a thrombus forms on a vascular lesion, typically following the disruption and/or erosion of an atherosclerotic plaque. Atherothrombosis is the main pathological mechanism underlying atherosclerotic cardiovascular diseases (ASCVDs) [i.e., myocardial infarction (MI), ischemic stroke, and peripheral artery disease (PAD)]. In recent years, substantial advances have reshaped our understanding of ASCVD, spanning its pathophysiology, risk stratification, and therapeutic management. Emerging insights into the mechanisms of atherosclerosis progression, including the interplay between cardiovascular risk factors and the vascular wall, endothelial dysfunction, lipid deposition, local niches of innate and adaptive immunity responses and systemic inflammation have refined our understanding of the disease. These advances have, in turn, driven the development of improved pharmacological therapies and a better clinical management of ASCVD. Emerging evidence and novel therapeutic agents have deepened our understanding of the thrombotic complications of atherosclerotic plaques, particularly the mechanisms underlying the transition from subclinical vascular lesions into overt clinical events. Despite remaining the leading cause of death and disability worldwide, ASCVD has evolved in many treated patients from a progressively worsening, rupture-prone condition to a more chronic and controlled disease. The natural history of atherothrombosis, from early lesion development to overt clinical manifestation, has been modified by these improvements in management. Continued progress is expected through the development of novel therapeutic strategies targeting the multiple pathogenic pathways affecting atherothrombosis, as well as through advances in non-invasive imaging and diagnostic tools aimed at earlier detection and personalized intervention. We are entering a new era in the care of patients with atherothrombotic disease.