Atherosclerosis is a chronic inflammatory disease that serves as both a leading cause and the pathological basis of cardiovascular diseases (1). Approximately 500 million people worldwide currently suffer from cardiovascular diseases, which account for about one-third of total global deaths (2, 3). Despite significant reductions in cardiovascular mortality achieved through existing atherosclerosis treatment strategies (4), the persistently high incidence underscores the necessity for novel preventive and management approaches, marking a critical focus for future research (5). The pathological characteristics of atherosclerosis include vascular endothelial damage, lipid accumulation, and the formation of oxidized low-density lipoprotein (oxLDL) (6). Endothelial cells (ECs), monocytes/macrophages, vascular smooth muscle cells (VSMCs), dendritic cells, B cells, and T cells all participate in the atherosclerotic process (7, 8). Inflammatory responses act as key drivers of atherosclerosis progression, exacerbating the risk of residual cardiovascular complications. Anti-inflammatory strategies targeting atherosclerosis hold significant potential for future therapeutic development (9, 10).

RNA splicing is an essential mechanism for the formation of both coding mRNA and certain non-coding RNAs (11). Splicing events encompass constitutive splicing, alternative splicing, and trans-splicing, with approximately 95% of human genes linked to alternative splicing (12). The accuracy of RNA splicing is critical for maintaining normal gene function and cellular homeostasis (13). Recent research has indicated that splicing events play a broad role in asthma, chronic obstructive pulmonary disease, and chronic inflammatory diseases such as atherosclerosis (14, 15). Specifically, in atherosclerosis, alternative splicing regulates the activation, adhesion, and subsequent differentiation of monocytes into macrophages (16). Additionally, abnormal splicing events are closely associated with the inflammatory responses involving endothelial cells and vascular smooth muscle cells, contributing significantly to the progression of atherosclerosis. Inflammatory responses are interwoven throughout the pathological process of atherosclerosis, emerging evidence underscores the pivotal role of splicing-mediated inflammation in driving disease progression ( Table 1 ) (17, 18). Investigating the molecular mechanisms underlying splicing events in atherosclerosis-related inflammatory responses is highly significant. We systematically analyzed the relationship between splicing events and inflammatory responses in atherosclerosis, aiming to highlight their potential as novel diagnostic biomarkers and therapeutic targets.

Atherosclerosis is a chronic inflammatory cardiovascular disease driven by multiple factors (19). The primary pathological mechanisms include ECs injury, dysregulated lipid metabolism and accumulation, macrophage recruitment, and proliferation and migration of VSMCs ( Figure 1 ) (20). ECs injury and dysfunction are recognized as the initial stages of atherosclerosis (21). Atherosclerosis risk factors, including hypertension, hyperlipidemia, and hyperglycemia, contribute to endothelial damage. Following endothelial dysfunction, LDL infiltrates and accumulates within the vascular intima, where it undergoes oxidation by reactive oxygen species to form pro-inflammatory ox-LDL (22). The interaction between ox-LDL and proteoglycans exacerbates endothelial dysfunction, further promoting monocyte adhesion, accumulation, and differentiation into macrophages (23, 24). Macrophages engulf ox-LDL, resulting in the formation of foam cells. Activated immune inflammatory cells, such as T lymphocytes, neutrophils, and monocytes, persistently infiltrate atherosclerotic plaques. They release pro-inflammatory cytokines, including Tumor necrosis factor-alpha (TNF-α), Interleukin-1β(IL-1β), and Interleukin-6(IL-6) (25). Ultimately, the accumulation of foam cells impairs macrophage efferocytosis and triggers cell death (via apoptosis or necrosis), leading to the formation of a necrotic lipid core (26).

During the progression of atherosclerosis, endothelial cell injury and dysfunction, leukocyte recruitment, and foam cell formation activate inflammatory signaling pathways and release inflammatory factors, thereby promoting the formation and development of atherosclerotic plaques and increasing plaque instability (27). Endothelial dysfunction and inflammatory responses are tightly interconnected in atherosclerosis, where injured endothelial cells promote tissue repair by expressing inflammatory factors such as monocyte chemoattractant protein-1 (MCP-1), Interleukin-8(IL-8), selectins, chemokines, and adhesion molecules such as Vascular Cell Adhesion Molecule 1 (VCAM-1) and Intercellular Adhesion Molecule 1 (ICAM-1). Meanwhile, macrophages, VSMCs, and lymphocytes participate in the inflammatory response associated with atherosclerosis (28, 29). Foam cells predominantly originate from the differentiation of M2 macrophages (8), and VSMCs can transdifferentiate into macrophage-like cells (30), exacerbating endothelial injury. In addition, lymphocytes, encompassing both B cells and T cells, play intricate roles in the pathogenesis of atherosclerosis (31). Subsets of B cells exhibit dual functions, being both protective and pathogenic during the progression of atherosclerotic disease (27). Meanwhile, autoreactive effector T cells are capable of recognizing self-antigens such as oxLDL (30), thereby triggering inflammatory responses. Overall, chronic inflammation and immune dysregulation significantly influence the progression of atherosclerosis. Elucidating the underlying pathological mechanisms will deepen our understanding of this disease and foster the development of novel therapeutic strategies.

Splicing events are critical post-transcriptional processes essential for the formation of mature mRNA, encompassing constitutive splicing, alternative splicing, and trans-splicing (11). The process of removing introns from pre-mRNA and retaining exons, thereby connecting them to form mature mRNA, is known as constitutive splicing and is regulated by spliceosomes (32). Constitutive splicing is essential for sustaining fundamental cellular functions. Alternative splicing regulates the selective removal of introns from mRNA precursors while retaining specific exons (33), serving as a crucial factor in gene expression and protein functional diversity in multicellular eukaryotes (34, 35). Additionally, alternative splicing can interact with non-coding RNAs, including long non-coding RNAs (lncRNAs), circular RNAs (circRNAs), and microRNAs (miRNAs). While non-coding RNAs do not directly encode proteins, they influence gene transcription by regulating splicing events (36, 37). Recent research has shown that various splicing events and non-coding RNAs can mediate inflammatory responses in atherosclerosis by regulating RNA splicing (38–40). Considering the significant role of splicing events in the inflammatory response in atherosclerosis, we further investigated the interplay between splicing events, non-coding RNAs, and inflammation in this condition.

The risk for patients with atherosclerosis remains high, even with standardized treatment strategies, due to the crucial role of splicing events in the inflammatory response mechanisms of atherosclerosis, investigating splicing-related molecules as potential biomarkers for the diagnosis and therapeutic targets for atherosclerosis holds great promise (90). Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is closely related to atherosclerosis and is present in immune cells such as ECs, macrophages, and lymphocytes (91, 92). LOX-1 can activate inflammatory signaling pathways and molecules related to inflammation, including NF-κB and NLRP3 (93). Furthermore, it can upregulate cell adhesion molecules and MCP-1 via activation of the MAPK pathway, thereby facilitating the adhesion and infiltration of monocytes. Studies have shown that overexpression of the LOX-1 splicing variant Lectin-like Oxidized Low-Density Lipoprotein Receptor-1 Inhibitor (LOXIN) reduces ox-LDL-induced apoptosis, providing a protective effect (94, 95). In a 20-year prospective study, circulating LOX-1 was linked to the inflammatory marker High-sensitivity C-reactive protein (Hs-CRP), which elevated the risk of myocardial infarction, and this association remained significant even after adjusting for related risk factors (96). Numerous studies have identified LOX-1 as having distinct diagnostic and prognostic value in atherosclerosis (97–99).

Salusin-α and Salusin-β are bioactive peptides derived from the C-terminal alternative splicing of the torsin family member 2A (TOR2A) protein, exhibiting opposing roles in atherosclerosis (100). Previous research has demonstrated that salusin-β mediates the NF-κB signaling pathway and is involved in the inflammatory response of endothelial cells (101), enhancing the expression of inflammatory factors including VCAM-1, MCP-1, IL-6, IL-8, IL-1β, and NADPH oxidase 2 (102). Notably, a clinical trial revealed a significant difference in salusin-β levels between CAD patients and the control group, highlighting its potential as a biomarker for atherosclerosis (103). Recent research has further shown that Salusin-β outperforms salusin-α as a biomarker for atherosclerosis (104). Serum Salusin-β levels are significantly associated with the incidence and severity of CAD (105), suggesting that Salusin-β in serum may serve as a potential biomarker for diagnosing and reflecting the progression of CAD. It is noteworthy that coronary artery ectasia (CAE) is a condition closely associated with atherosclerosis, and Salusin-β predicts CAE with a sensitivity of 78.9% and specificity of 75.0% (106). ANRIL and circANRIL are known to be closely linked to endothelial injury and inflammatory responses associated with atherosclerosis (55). Recent studies indicate that a clinical diagnostic model incorporating ANRIL and conventional risk factors has a sensitivity of 84% and specificity of 96%, which can be utilized for the early diagnosis and treatment of CAD (107). FOXO3a is involved in regulating the inflammatory response and apoptosis in endothelial cells by modulating alternative splicing and gene expression (108). Interestingly, studies have identified an association between the risk of CAD and the rs12196996 polymorphism located in the flanking intron of circFOXO3 (109).

Milk Fat Globule-EGF Factor 8 (MFGE8) is a protein that encodes epidermal growth factor 8, mediating the inflammatory response in atherosclerosis linked to risk factors such as hypertension and hyperglycemia (110). It plays a critical role in the calcification and senescence of VSMCs induced by high-glucose human umbilical vein endothelial cell exosomes, closely associated with inflammatory responses mediated by IL-1β, IL-6, and IL-8 (111). Another study shows that MFGE8 participates in the Angiotensin II-mediated inflammatory response associated with the NF-κB signaling pathway, and its knockout reduces levels of MCP-1, TNF-α, ICAM-1, and VCAM-1 produced as a result of NF-κB activation (112). Notably, recent research has identified that the intronic insertion rs534125149 and splice site variants (splicing receptor variant rs201988637) in MFGE8 are linked to the prevention of coronary artery atherosclerosis (40). Moreover, MFG-E8 levels correlate with the Thrombolysis in Myocardial Infarction (TIMI) risk score (113). The aforementioned RECK plays a role in the inflammatory response in atherosclerosis, and its various splice variants can act as biomarkers for CAD. Long RECK and short RECK exhibit differential expression in patients with stable and unstable angina pectoris, with short RECK being expressed at lower levels in acute myocardial infarction, potentially linked to RECK’s function as an MMP inhibitor and its anti-inflammatory effects (88). Recent research has additionally shown that empagliflozin can inhibit the proliferation and migration of VSMCs by increasing RECK expression (85). Serine-arginine protein kinase (SRPK) modulates the function of Serine/Arginine-rich (SR) proteins through phosphorylation, thereby altering the balance of vascular endothelial growth factor (VEGF) splice variants (114).Research indicates that the SRPK1 inhibitor DBS1 effectively disrupts the binding of SRPK to its substrates (115), resulting in a shift in VEGF splicing from pro-angiogenic to anti-angiogenic forms, highlighting its significant potential in the treatment of cardiovascular diseases. These findings suggest the potential of splice event-related molecules as targets for the diagnosis and treatment of atherosclerosis ( Figure 2 ). However, further research on splice events associated with AS inflammatory responses is still lacking. Continued investigation into RNA splicing mechanisms and the development of new intervention strategies will facilitate advancements in AS diagnosis and treatment.

The inflammatory response is a key driver of atherosclerosis and will likely become one of the primary approaches for treating cardiovascular diseases in the future. Our study elucidates the molecular mechanisms linking abnormal splice events to the inflammatory response in atherosclerosis, offering a novel perspective on the role of splice events in this condition. Specifically, various splice events mediate endothelial cell injury, macrophage differentiation, and the proliferation and migration of VSMCs in atherosclerosis through the inflammatory response. Their interrelated interactions contribute to the progression of atherosclerosis, further underscoring the significance of splice events in the inflammatory response associated with atherosclerosis. Nonetheless, several unresolved questions persist. While molecules associated with splice events are implicated in the inflammatory response in atherosclerosis, their specific mechanisms of action and the ways in which they influence the functions of other cells remain unclear. Further research is needed to understand how modulating splice events affects other cell types, presenting a significant challenge for future studies. Additionally, we observed a correlation between splice molecules and the risk of atherosclerosis, which supports their potential as diagnostic biomarkers for atherosclerosis. However, future validation through large-scale studies will be necessary. Despite the significant therapeutic potential of targeting splice events in the future, several challenges exist in their clinical application. The effective delivery of splice-targeted therapies remains a primary obstacle, highlighting the need for new carrier systems to improve the delivery and efficiency of these treatments. Splicing factors generally engage in the splicing of multiple genes, meaning that targeting these factors could simultaneously influence various splice events and other biological processes, which raises important considerations regarding treatment specificity. Additionally, prolonged interventions could induce immune responses and impact cellular functions, necessitating further research into the safety of long-term applications. In summary, future research needs to tackle these challenges to ensure the efficacy, specificity, and safety of splice-targeted interventions in atherosclerosis.

Overall, our research elucidates the molecular mechanisms through which abnormal splicing events mediate inflammation and immune responses in atherosclerosis from multiple perspectives. Furthermore, it investigates the potential of splice factors as diagnostic biomarkers and therapeutic targets for atherosclerosis. offering a fresh outlook that could provide valuable insights for future treatments. While existing clinical and basic research has validated the crucial role of splicing events in the inflammatory response associated with atherosclerosis, the specific mechanisms of action still necessitate additional foundational and clinical studies for confirmation. Conversely, we need to further explore the relationship between splice event-mediated inflammatory responses and other pathological mechanisms in atherosclerosis to provide new therapeutic strategies that can enhance treatment outcomes.