Figure 5.

Vulnerable plaques are proinflammatory, profibrotic, prothrombotic, proangiogenic, lipid ladened and recently found to be acidic. The activated endothelium is associated with endothelial dysfunction due to eNOS dysfunction and eNOS uncoupling with resultant overproduction of superoxide [O2']. Diabetes is associated with a dysfunctional endothelium not only at sites of vulnerable plaque but have been shown to be a systemic net producer of [O2']. The inflammatory cells and intimal remodeling are depicted in this image as well as an intraplaque hemorrhage (IPH) from the angiogenic vasavasorum vessels originating from the adventitia of this lipid ladened vulnerable plaque. Redox stress and ROS play a prominent role within the intima. The profibrotic arm of the unstable VP is responsible for the positive outward and negative inward remodeling.