Figure 3 (a) Aorta with fatty streaks, a precursor of atherosclerotic plaques. (b) Severe atherosclerosis with calcifications and large areas of plaque
formation. (c) Ulcerated plaques with adjacent early aortic aneurysm formation.
Lipids
Fibrous cap
degraded, but oxLDL are less susceptible to degradation. Thus macrophages near ruptures of plaque shoulder regions supports the
a macrophage transitions into a foam cell when it becomes notion that macrophage are involved in matrix degradation and
inundated with cholesterol faster than it can be degraded. plaque instability.9 TNF-a also upregulates CAM expression and
The role of high density lipoproteins (HDL) and reverse stimulates VSMC migration.9 IL-1 is auto-inflammatory in that it
cholesterol transport on atherosclerosis has received attention. increases TNF-a, CAM, chemokines and IL-6 levels. IL-6 has been
Torcetrapib, a cholesteryl ester transfer protein inhibitor, increases implicated in angiogenesis, re-vascularization, and induction of C-
HDL and decreases LDL cholesterol levels but does not signifi- reactive protein expression and vascular endothelial growth factor.
cantly reduce coronary atheroma volume in patients with coronary IL-18 stimulates VSMC proliferation and migration through a MMP-
artery disease.6 Another recent approach involves synthesizing 9 dependent mechanism. Thus a large variety of inflammatory cells
fusion proteins of oxLDL binding receptors and the Fc domains of and cytokines are involved at all stages of atherosclerosis.
immunoglobulins.7 Zeibig et al (2011) created a soluble dimeric
fusion protein Fc-CD68 capable of specific high-affinity binding Smooth muscle cell migration
with oxLDL in atherosclerotic plaques, reducing foam cell forma-
Vascular smooth muscle cells (VSMCs) also play an important
tion and oxLDL uptake. This compound reduced lipid deposition
role in atherosclerosis. Rat and mouse VSMCs have the ability to
by one third and aortic plaque extension by nearly 50%.8
shift between two phenotypic states, termed the contractile
and synthetic states in response to extracellular matrix (ECM),
Inflammation
cytokines, shear stress, ROS, as well as lipids.10 Synthetic VSMCs
Inflammation is a complex immune response to pathogens or contribute to plaque growth through ECM production and
other detrimental stimuli. Clinicopathological and experimental fibrotic cap formation. A stable plaque with calcifications, a thick
studies have shown the importance of inflammation in athero- fibrous cap and smooth muscle migration is seen in Figure 4. A
sclerosis. The tissue damage caused by oxidized lipids in early proinflammatory phenotype whereby cytokines and CAMs are
lesions elicits compensatory responses, which increase endo- expressed also contributes to atherosclerosis.
thelial adhesiveness to leukocytes and platelets via cell adhesion VSMCs express adhesion molecules, including vascular cell
molecule (CAM) upregulation. The ensuing inflammatory adhesion molecule-1 to facilitate monocyte and lymphocyte
response attracts smooth muscles cells (SMC), which proliferate migration.10 Moreover, VSMCs produce cytokines that attract
and thicken the arterial wall. and activate leukocytes, induce VSMC proliferation, promote
Circulating monocytes and leukocytes initially bind CAMs on endothelial cell dysfunction, and stimulate production of extra-
the endothelial surface, but chemokines are required for recruit- cellular matrix.10 These cytokines include: platelet derived
ment into the subendothelial space. Among the most commonly growth factor (PDGF), transforming growth factor-b (TGF-b),
expressed chemokines in these atherosclerotic lesions are: macrophage inhibitory factor (MIF), IFNg, and MCP-1.10
monocyte chemoattractant protein-1 (MCP-1), macrophage VSMC migration is also influenced by physical factors, such as
colony-stimulating factor (MCSF) and interferon-g (INF-g). blood flow, sheer stress, and matrix stiffness.11 Of note, PDGF
MCP-1 activates leukocyte integrin, resulting in firm initial and osteopontin are both considered agents that promote VSMC
monocyte attachment.9 MCSF promotes scavenger receptor migration. PDGF activates smooth muscle progenitor cells that
protein synthesis and differentiation of monocytes into macro- migrate and form blood vessels, and also induces synthesis of
phages. While INF-g promotes plaque development and foam cell epidermal growth factor and fibroblast growth factor-2, both of
formation, it also functions as an anti-atherogenic biomolecule.9 which enhance cell migration.11 Osteopontin expression
Once monocytes enter the subendothelial space, they may increases during atherogenesis, and is thought to enhance VSMC
mature into macrophages. Upon the uptake of oxLDLs and migration via avb3 integrin signalling.11 Collagens I and IV, as
cholesterol, macrophages become foam cells. As lesion severity well as laminin have similar promigratory effects.11 On the other
progresses into a fibroatheroma, macrophages, T-cells and mast hand, antimigratory influences include focal adhesions, tissue
cells infiltrate the cap edges and stimulate the proliferation and inhibitors of metalloproteinases, and heparin.11
migration of vascular SMCs (VSMCs) through the production of As atherosclerotic lesions progress, ECM accumulates in the
proinflammatory cytokines. Interleukin-1 (IL-1), IL-6, IL-18 and lesion due to atherogenic cytokines stimulating VSMCs to
tumour necrosis factor-a (TNF-a) are common to this process and produce proteoglycans and fibronectin.10 Proteoglycans in the
reduce plaque stability.9 The release of IFN-g and TNF-a by acti- vessel wall have the ability to entrap LDL and oxidize them to
vated T-cells induces macrophage apoptosis, contributing to oxLDL, which then stimulates VSMCs to secrete more proteo-
cellular debris aggregates of the necrotic core. The localization of glycans and increase the affinity for LDL.10 VSMCs have the
Diagram 1 (a) Normal artery with occasional circulating lipids. (b) Early fatty streak formation with dysfunctional endothelial cells, lipid insudation and the
macrophages transformation into foam cells. (c) Early atherosclerotic plaque with a fibrous cap, smooth muscle migration, and macrophage infiltration.
The vascular wall is starting to remodel to accommodate the plaque. (d) Unstable atherosclerotic plaque with extensive infiltration by T-lymphocytes,
a thin fibrous cap, and a necrotic core. (e) Older plaques can become stable after forming a thick fibrous cap with lots of calcifications. While these
plaques can be large, they have a relatively low risk of rupture. (f ) Plaque complication. An unstable plaque may erode or rupture This plaque shows
erosion of the surface that bulges into the blood stream. An acute thrombus is forming at the endothelial cell erosion- a collection of fibrin and platelets
is seen. This could lead to occlusion of the vessel. This erosion could lead to angina pectoris or an acute myocardial infarction, especially in regions with
insufficient collaterals. (g) Plaque complication. The unstable plaque has ruptured at one shoulder area, where the fibrous surface had become thin
(because of the effects of inflammatory cells), with release of plaque debris and haemorrhage into the plaque as well as the formation of overlying
thrombus. These changes can lead to occlusion and myocardial infarction.
ability to express various receptors for lipid uptake, and can form RANKL for binding of receptor activator of NF-kB on osteoclasts.
foam-like cells.10 OPG-null mice exhibit osteoporosis and arterial calcification.17
VSMCs also play a role in vascular remodelling in response to
atherosclerosis. Apoptosis and migration of VSMCs, along with Risk management and treatment
matrix metabolism, allows for expansion of the vessel lumen to
Despite our greater understanding of atherosclerosis pathogen-
accommodate growing atherosclerotic plaques.12 This expansive
esis, many challenges remain in the diagnosis and management
remodelling would serve to maintain luminal patency, at least
of this disease. Currently coronary angiography is still the gold
initially. Conversely, constrictive remodelling is pathological and
standard for identifying at risk lesions. However detection of
is a major contributor to restenosis of vessels after angioplasty.12
subtle but significant plaques is problematic due to lack of altered
Matrix metabolism coronary haemodynamics. To assist in diagnosis, risk assessment
and management of patients with atherosclerosis, the use of
Matrix metalloproteinases (MMPs) are a family of zinc- novel imaging modalities, statins, cardiac biomarkers and clin-
dependent endopeptidases whose primary function is the ical genetics are being considered.
degradation of extracellular matrices. The ECM of atherosclerotic Novel imaging modalities have the potential to provide valu-
lesions consists largely of proteoglycans with sparse fibrillar able information regarding the extent of lesions in a relatively
collagen capable of inhibiting cell proliferation. Not only are non-invasive manner. These techniques include intravascular
MMP genes inducible by such effectors as growth factors and ultrasonography, thermal imaging, and high-resolution magnetic
cytokines, they are also influenceable by intercellular and ECM resonance imaging.20,21 Magnetic resonance and nuclear imaging
interactions. Macrophages within lesions are the primary that harness molecular mediators of atherogenesis inflammation
producers of MMPs in atherosclerosis, but SMCs and endothelial as targets has generated considerable interest. Targets have
cells also contribute to its expression. included: VCAM-1, microparticulate phagocytosis markers,
Normally MMPs remove the ECM during angiogenesis, tissue glucose uptake markers such as fluorodeoxyglucose, integrin-
resorption and epithelium proliferation, creating space for repli- directed agents, modified LDL, and various proteinases.22 These
cating cells to migrate and resultantly liberating sequestered modalities, however, are not yet ready for clinical application.
agents, like cytokines and VEGF.13 Therefore, MMPs may directly Statins reduce LDL concentrations by blocking cholesterol
alter cellular behaviour and phenotypes to produce both proa- synthesis through inhibiting the 3-hydroxyl-3-methylglutaryl
therosclerotic and antiatherosclerotic outcomes. In humans, coenzyme A reductase. An additional function is inhibition of
MMP-1, -2, -3, -7, -9, -10, -11 and -12 have been identified in inflammatory pathways regulated by Ras and Rho, and increase
atherosclerotic lesions.14 Back et al (2010) has suggested that of NO production, which subsequently enhances endothelium
MMP-3 promotes collagen deposition and plaque stabilization, protection.23 Statins also lower cytokine production and inhibit
whereas MMP-1 and MMP-9 have proatherothrombotic roles. recruitment, migration and cell adhesion to endothelium.23 The
However, contradictory data have been reported for MMP-9, West of Scotland Coronary Prevention Study and the Prospective
claiming that elevated levels of it e and MMP-2 e precede posi- Study of Pravastatin in the Elderly at Risk both demonstrated
tive arterial remodelling.15 Macrophage migration and plaque reductions in LDL concentrations, cardiac mortality and coronary
destabilization are among the observed function of MMP-12.16 events at a dose of 40 mg/day.23
The importance of MMP in plaque destabilization and rupture is Biomarkers are measurable parameters, which can serve in
highlighted through its elevated presence in shoulder regions. diagnosis, treatment follow up, and prediction of disease prog-
ress. Due to the pivotal role of inflammation in atherosclerosis, C-
Calcification reactive protein (CRP) measured by a highly sensitive assay
It has long been known that atherosclerotic plaques undergo (hsCRP) has gained attention.22,23 CRP is chemically stable,
intimal mineralization as they increase in complexity. Tissue necessitates no specific precautions for sampling, and has a long
mineralization within the plaque lipid core is an active and half-life without diurnal variation. A recent study, Justification for
complex process regulated by enzymes that control both physi- the Use of Statins in Prevention: an Intervention Trial Evaluating
ological and pathological calcification and ossification. Histo- Rosuvastatin, demonstrated that those with an elevated hsCRP
logically, atherosclerotic plaques have been shown to express have high vascular risk, even when cholesterol levels are
mediators of bone metabolism e bone morphogenic protein 2 considered within the normal clinical range.22 Many other
(BMP-2), BMP-4, osteopontin, and osteonectin e in close prox- biomarkers associated with progressive atherosclerosis have been
imity to calcification or bone formation.17 investigated, including adiponectin, monocyte chemoattractant
BMPs are cytokines of the TGF-superfamily. BMP-2 can protein-1, and lipoprotein-associated phospholipase A2.24
induce ectopic bone and cartilage formation whereas BMP-4 However, none have become routine in clinical practice as of yet.
triggers endochondral bone formation.17 In the vasculature, Since a region on chromosome 9 has been identified as being
inflammatory stimuli and pressure are able to induce BMP-2 by associated with cardiovascular diseases, genetics may play
H2O2-mediated activation of NF-b.18 Similarly, BMP-4 expres- a future yet promising role in predicting the risk of atheroscle-
sion can be induced in endothelial cells exposed to sheer stress rosis.22 Genome-wide association screens (GWAS) has proven
and can further stimulate ROS production.19 Osteoprotegerin beneficial in identifying members of pathways known to partic-
(OPG) is an independent risk factor for coronary calcification and ipate in atherosclerosis. Some genetic loci contribute to tradi-
for plaque formation. OPG and OPG ligand are present in bone tional atherosclerotic risk factors such as hypercholesterolaemia
structures are found with calcification. OPG competes with or hypertension.25 Others, such as ADAMTS7 on chromosome
15, is involved in smooth muscle migration and vascular 16 Visse R, Nagase H. Matrix metalloproteinases and tissue inhibitors of
remodelling.25 The majority of loci identified by GWAS have no metalloproteinases: structure, function, and biochemistry. Circ Res
known function. Thus, considerable investigative effort in years 2003; 92: 827e39.
to come is still necessary. 17 Dhore CR, Cleutjens JP, Lutgens E, et al. Differential expression of
bone matrix regulatory proteins in human atherosclerotic plaques.
Conclusion Arterioscler Thromb Vasc Biol 2001; 21: 1998e2003.
The clinical outcomes of atherosclerosis constitute a major 18 Csiszar A, Smith KE, Koller A, et al. Regulation of bone morphoge-
source of mortality in the developed world. Advances in the netic protein-2 expression in endothelial cells: role of nuclear factor-
evaluation of tissue provide new knowledge on the cellular and kappa B activation by tumor necrosis factor-alpha, H2O2, and high
molecular structure of the cells and tissues in these lesions. intravascular pressure. Circulation 2005; 111: 2364e72.
Experimental modelling provides insights into the mechanism of 19 Sorescu GP, Song H, Tressel SL, et al. Bone morphogenic protein 4
plaque formation. Greater understanding of the pathogenesis of produced in endothelial cells by oscillatory shear stress induces
atherosclerosis may lead to identification of novel biological monocyte adhesion by stimulating reactive oxygen species produc-
checkpoints to interrupt this process. It is also clear that clini- tion from a Nox1-based NADPH oxidase. Circ Res 2004; 95: 773e9.
cians need improved non-invasive tools to identify and manage 20 Nissen SE, Gurley JC, Grines CL, et al. Intravascular ultrasound
patients with atherosclerosis. A assessment of lumen size and wall morphology in normal subjects and
patients with coronary artery disease. Circulation 1991; 84: 1087e99.
21 Casscells W, Hathorn B, David MM, et al. Thermal detection of cellular
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