Biomarkers of Plaque Instability and Rupture in Acute Coronary Syndromes: From hs-CRP to Myeloperoxidase

Plaque instability and rupture are central to the pathogenesis of acute coronary syndromes (ACS). This review examines biomarkers reflecting distinct pathophysiological processes in plaque destabilization, including systemic inflammation, represented by high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6); oxidative stress, indicated by myeloperoxidase and oxidized low-density lipoprotein (oxLDL); plaque vulnerability markers such as matrix metalloproteinase-9 (MMP-9) and pregnancy-associated plasma protein A (PAPP-A); and thrombotic activity, reflected by tissue factor pathway inhibitor (TFPI) and D-dimer. We evaluate their diagnostic and prognostic performance, highlighting clinical applications for early risk stratification, identification of high-risk lesions, guidance of targeted therapies, and monitoring of treatment response. Challenges in biomarker validation, assay standardization, and integration into clinical pathways are critically discussed, with emphasis on their potential role in personalized management of ACS.