Letter to the Editor Looking beyond luminal stenosis in carotid artery disease P. Narayan ⁎ Department of Cardiac Surgery, NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India article info Article history: Received 10 February 2018 Received in revised form 16 February 2018 Accepted 22 February 2018 Letter to the editor I read with interest the comments of Paraskevas and Naylor on the influence of asymptomatic carotid artery stenosis on peri-operative stroke following coronary artery bypass grafting (CABG). The authors have significant expertise in this field and I am in agreement with the views expressed which are in keeping with the findings of our study. There is now enough evidence to establish that majority of the strokes following CABG is embolic in nature and that carotid stenosis is a risk factor but not necessarily the cause of neurological events in majority of the cases. However, utility of carotid screening lies in iden- tifying patients who maybe at higher risk of neurological morbidity as in bilateral disease or severe stenosis. Currently it may be prudent to focus our attention beyond luminal stenosis and concentrate on the qualitative assessments of plaques. With advancements in vascular imaging it is possible to identify intraplaque hemorrhage, ulceration, neovascularity, fibrous cap thick- ness, and presence of a lipid-rich necrotic core [1]. Plaque inflammation can also be used to distinguish potentially symptomatic from asymp- tomatic plaques [2]. In fact there is growing evidence that statins by their pleiotropic anti-inflammatory action can contribute to carotid plaque stabilization [3]. Routine ultrasound can identify the hypoechoic and homogenous plaques more likely to produce symptoms compared to hyperechoic and heterogenous plaques [4]. Echolucent plaques have been shown to carry a higher relative risk of neurological events irrespective of the degree of luminal stenosis [5]. Future screening and research should be directed towards these aspects of carotid disease. Disclosure statement None. References [1] W. Brinjikji, J. Huston 3rd, A.A. Rabinstein, G.M. Kim, A. Lerman, G. Lanzino, Contem- porary carotid imaging: from degree of stenosis to plaque vulnerability, J. Neurosurg. 124 (1) (2016) 27–42. [2] J.M. Chan, C. Monaco, M. Wylezinska-Arridge, J.L. Tremoleda, R.G. Gibbs, Imaging of the vulnerable carotid plaque: biological targeting of inflammation in atherosclerosis using iron oxide particles and MRI, Eur. J. Vasc. Endovasc. Surg. 47 (5) (2014) 462–469. [3] N. Artom, F. Montecucco, F. Dallegri, A. Pende, Carotid atherosclerotic plaque stenosis: the stabilizing role of statins, Eur. J. Clin. Investig. 44 (11) (2014) 1122–1134. [4] T.J. Tegos, P. Stavropoulos, M.M. Sabetai, P. Khodabakhsh, A. Sassano, A.N. Nicolaides, Determinants of carotid plaque instability: echoicity versus heterogeneity, Eur. J. Vasc. Endovasc. Surg. 22 (1) (2001) 22–30. [5] A. Gupta, K. Kesavabhotla, H. Baradaran, H. Kamel, A. Pandya, A.E. Giambrone, et al., Plaque echolucency and stroke risk in asymptomatic carotid stenosis: a systematic review and meta-analysis, Stroke 46 (1) (2015) 91–97. International Journal of Cardiology 260 (2018) 52 DOI of original article: https://doi.org/10.1016/j.ijcard.2018.02.001. ⁎ Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata 700099, India. E-mail address: pradeep.narayan.dr@narayanahealth.org. https://doi.org/10.1016/j.ijcard.2018.02.090 0167-5273/© 2018 Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard