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Cellular interactions with macrophages in an advanced lesion. Foam cells accumulate in the intima and undergo apoptosis that is triggered by cytokines. Efferocytes do not function properly, and apoptotic cells secondarily become necrotic cells, contributing to the formation of a necrotic core. Necrosis of macrophages and SMCs decrease collagen synthesis to diminish the collagen content of the fibrous cap, triggering rupture and thrombosis.
