Carotid plaque instability is not related to quantity but to elemental composition of calcification

Background and aims Recent studies highlighted the role of calcification processes in the clinical progression of chronic cardiovascular diseases. In this study we investigated the relationship between the chemical composition of calcification and atherosclerotic plaque stability in carotid arteries. Methods and results To this end, we characterized the calcification on 229 carotid plaques, by morphology, immunohistochemistry, transmission electron microscopy and energy dispersive X-ray microanalysis. Plaques were classified into two categories: unstable and stable. No significant differences were found in the incidence of the various risk factors between patients with and without carotid calcification, with the exception of diabetes. The energy dispersive X-ray microanalysis allowed us to identify two types of calcium salts in the atheromatous plaques, hydroxyapatite (HA) and calcium oxalate (CO). Our results showed that calcification is a common finding in carotid plaques, being present in 77.3% of cases, and the amount of calcium is not a factor of vulnerability. Noteworthy, we observed an association between HA calcification and unstable plaques. On the contrary, CO calcifications were mainly detected in stable plaques. Conclusions The presence of different types of calcification in atheromatous plaques may open new perspectives in understanding the molecular mechanisms of atheroma formation and plaque instability.