Immunology of atherosclerosis as an inflammatory disease: rethinking the dynamic immunoinflammatory activity beneath stability

We critically examine the limitations of the classic dichotomy between stable and unstable plaques, proposing instead a tripartite classification: active, dormant, and inactive plaques, analogous to the states of volcanic activity. Even clinically 'stable' plaques may exhibit silent yet ongoing immunometabolic and thromboinflammatory activity, contributing to residual cardiovascular risk. Advanced imaging, molecular diagnostics, and inflammation-sensitive biomarkers (e.g. high-sensitivity C-reactive protein, IL-6) can help detect subclinical plaque activity. Finally, the concept of 'thromboinflammaging' emphasizes the impact of age-related immune dysregulation on vascular pathology. This evolving paradigm supports immunomodulation as a cornerstone in precision cardiovascular medicine.