Free cholesterol in atherosclerotic plaques: where does it come from?

PURPOSE OF REVIEW: Free cholesterol in plaques is an emerging contributing factor to lesion instability and, until recently, apoptosis of lipid-laden macrophages was considered the major source of free cholesterol. The validity of this concept is beginning to be challenged since there is recent evidence of erythrocyte membrane-derived cholesterol in plaques. Therefore, intraplaque hemorrhage may not be a passive event, as once considered as studies continue to support the relationship of intraplaque hemorrhage and necrotic core expansion. RECENT FINDINGS: The association of intraplaque hemorrhage, accumulated free cholesterol, and necrotic core expansion is beginning to unfold and recent MRI studies suggest the value of intraplaque hemorrhage as a predictor of recurrent cerebrovascular events. The amount of erythrocyte membrane-derived cholesterol is also suggested to be a measure of lesion vulnerability in acute coronary syndromes. Recent inhibitors studies of vascular permeability factors further emphasize the importance of intraplaque hemorrhage in plaque progression. Finally, DNA microarray analysis is starting to reveal key molecules involved in the accumulation of free cholesterol that are selectively induced in high-risk plaques. SUMMARY: These recent findings emphasize the importance of intraplaque hemorrhage as a contributor of free cholesterol in plaques and point to its provocative role in lesion destabilization.     

Vasa vasorum in plaque angiogenesis, metabolic syndrome, type 2 diabetes mellitus, and atheroscleropathy: a malignant transformation

Background

Vascularization is an exciting and complex mechanism involving angiogenesis and arteriogenesis. The metabolic syndrome (MS) and type 2 diabetes mellitus (T2DM) are associated with multiple metabolic toxicities, which result in reactive oxygen species (ROS) due to an elevated tension of oxidative-redox stress and an accelerated atherosclerosis termed atheroscleropathy.

Results

This atheroscleropathy is associated with accelerated angiogenesis within the vulnerable, thin-cap fibro-atheroma, prone to rupture resulting in acute coronary syndromes (ACS). The resulting intimopathy with its neovascularization due to angiogenesis of the adventitial vasa vasorum (Vv) is prone to intraplaque hemorrhage (IPH). These IPH are associated with destabilization of the vulnerable plaques resulting in plaque erosion and plaque rupture resulting in ACS. In atheroscleropathy the adventitial Vv invades the plaque in a malignant-like fashion and concurrently is associated with chronic inflammation, as macrophages are being deposited within the shoulder regions of these vulnerable plaques. These angiogenic Vv provide a custom delivery vascular network for multiple detrimental substrates, which further accelerates the growth of these vulnerable plaques and atheroscleropathy. There exists a vascularization paradox in MS and T2DM, in that, angiogenesis within the plaque is induced and arteriogenesis is impaired.

Conclusion

This review will attempt to provide a database of knowledge regarding the vascularization process (angiogenesis and arteriogenesis) and its mechanisms to better understand the increased cardiovascular risk and the increased morbidity and mortality associated with MS and T2DM.     

Rate of nitric oxide scavenging by hemoglobin bound to haptoglobin

Cell-free hemoglobin, released from the red cell, may play a major role in regulating the bioavailability of nitric oxide. The abundant serum protein haptoglobin, rapidly binds to free hemoglobin forming a stable complex accelerating its clearance. The haptoglobin gene is polymorphic with two classes of alleles denoted 1 and 2. We have previously demonstrated that the haptoglobin 1 protein–hemoglobin complex is cleared twice as fast as the haptoglobin 2 protein–hemoglobin complex. In this report, we explored whether haptoglobin binding to hemoglobin reduces the rate of nitric oxide scavenging using time-resolved absorption spectroscopy. We found that both the haptoglobin 1 and haptoglobin 2 protein complexes react with nitric oxide at the same rate as unbound cell-free hemoglobin. To confirm these results we developed a novel assay where free hemoglobin and hemoglobin bound to haptoglobin competed in the reaction with NO. The relative rate of the NO reaction was then determined by examining the amount of reacted species using analytical ultracentrifugation. Since complexation of hemoglobin with haptoglobin does not reduce NO scavenging, we propose that the haptoglobin genotype may influence nitric oxide bioavailability by determining the clearance rate of the haptoglobin–hemoglobin complex. We provide computer simulations showing that a twofold difference in the rate of uptake of the haptoglobin–hemoglobin complex by macrophages significantly affects nitric oxide bioavailability thereby providing a plausible explanation for why there is more vasospasm after subarachnoid hemorrhage in individuals and transgenic mice homozygous for the Hp 2 allele.     

Molecular mechanisms of plaque instability

PURPOSE OF REVIEW: Coronary artery thrombosis superimposed on a disrupted atherosclerotic plaque initiates abrupt arterial occlusion and is the proximate event responsible for 60-80% cases of acute coronary syndromes. This article provides a concise update on the evolving concepts in the pathophysiology of plaque rupture and thrombosis. RECENT FINDINGS: Over the past several years, the critical role of plaque composition rather than plaque size or stenosis severity, in plaque rupture and thrombosis have been recognized. The necrotic lipid core and plaque inflammation appear to be key factors. Extracellular matrix loss in the fibrous cap, a prelude to rupture, is attributed to matrix degrading enzymes as well as to death of matrix synthesizing smooth muscle cells; inflammation appears to play a critical role in both these processes. Inflammatory cell derived tissue factor is a key contributor to plaque thrombogenicity. Inflammation has also been implicated in plaque neovascularity, intraplaque hemorrhage and plaque expansion. Recent observations have also highlighted the important modulatory role of immune system in atherosclerosis and plaque composition. SUMMARY: Improved understanding of mechanisms causing plaque instability should provide novel insights into prevention of athero-thrombotic cardiovascular events.     

Degradation of Host Heme Proteins by Lysine- and Arginine-Specific Cysteine Proteinases (Gingipains) of Porphyromonas gingivalis

Porphyromonas gingivalis can use hemoglobin bound to haptoglobin and heme complexed to hemopexin as heme sources; however, the mechanism by which hemin is released from these proteins has not been defined. In the present study, using a variety of analytical methods, we demonstrate that lysine-specific cysteine proteinase of P. gingivalis (gingipain K, Kgp) can efficiently cleave hemoglobin, hemopexin, haptoglobin, and transferrin. Degradation of hemopexin and transferrin in human serum by Kgp was also detected; however, we did not observe extensive degradation of hemoglobin in serum by Kgp. Likewise the beta-chain of haptoglobin was partially protected from degradation by Kgp in a haptoglobin-hemoglobin complex. Arginine-specific gingipains (gingipains R) were also found to degrade hemopexin and transferrin in serum; however, this was observed only at relatively high concentrations of these enzymes. Growth of P. gingivalis strain A7436 in a minimal media with normal human serum as a source of heme correlated not only with the ability of the organism to degrade hemoglobin, haptoglobin, hemopexin, and transferrin but also with an increase in gingipain K and gingipain R activity. The ability of gingipain K to cleave hemoglobin, haptoglobin, and hemopexin may provide P. gingivalis with a usable source of heme for growth and may contribute to the proliferation of P. gingivalis within periodontal pockets in which erythrocytes are abundant.     

Cross-linking of hemoglobin, haptoglobin, and hemoglobin-haptoglobin complex with bifunctional imidoesters.

Dimethyl adipimidate was used to cross-link the polypeptides within hemoglobin, haptoglobin, and hemoglobin-haptoglobin complex. Cross-linked hemoglobin retained considerable ability to bind haptoglobin, although the amounts bound were reduced and the haptoglobin reaction could be used to fractionate the modified hemoglobin. With cross-links limited to intramolecular sites, hemoglobin showed four bands on polyacrylamide gel electrophoresis in sodium dodecyl sulfate, identified, with reference to the subunit polypeptides, as monomer, dimer, trimer, and tetramer. The dimer region consisted of at least two separable species. When hemoglobin-haptoglobin complex was cross-linked, a band of hemoglobin dimer was present, which demonstrates that at least two hemoglobin subunits have a close spatial relation when bound to haptoglobin. Some comparisons with adipimidate-reacted hemoglobin were made using malonimidate and suberimidate and some marked differences were noted.     

Inflammation and neovascularization in diabetic atherosclerosis

Diabetes mellitus, the major cardiovascular risk factor, accentuates the inflammation and neovascularization processes leading to enhanced progression of atherosclerotic complications. Inflammation in diabetes mellitus is the key initiator of atherosclerotic process, which results in acute coronary events. Atherosclerosis evolves from the endothelial cell dysfunction and succeeding entry of hemodynamically derived leukocytes by migration, activation and production of lipid gruel leading to atheromatous plaque progression and subsequent regression. Diabetic plaque progression is associated with increased neovascularization, which is a nature's compliment in the sustenance of plaque growth by its nutrient supply. Neovessels may act as conduit for lipid debridment and alternative channel for inflammatory process. In addition, neovascularization induces intra-plaque hemorrhage due to the fragility of the neovessels and associated inflammation, resulting in plaque instability. The intra-plaque hemorrhage is a detrimental base, which begets the progress of atheroma by inducing oxidative stress and endothelial dysfunction. Intra-plaque hemorrhage is increased in diabetes with an associated increase in hemoglobin-haptoglobin complex (Hb-Hp2-2), which further induces oxidative stress and endothelial cell dysfunction. We conclude that inflammation and neovascularization of the plaque may act as major mechanism augmenting plaque instability in diabetes mellitus.     

Hemoglobin binding to deglycosylated haptoglobin

The carbohydrate portion of polymeric haptoglobin was gradually removed by exoglycosidases in order to investigate its role in complex formation between haptoglobin and hemoglobin. Total removal of sialic acid diminished the haptoglobin-hemoglobin complex formation 15%. Removal of about 25% of the galactose residues from asialohaptoglobin, i.e., about 40% of the total weight of the carbohydrate moiety, totally inhibited the ability of haptoglobin to form complex with hemoglobin and react with haptoglobin-specific antibodies. Liberation of further galactose residues resulted in slow precipitation of the protein. Removal of a similar part of the carbohydrate moiety from haptoglobin-hemoglobin complex did not liberate hemoglobin from it, and the complex reacted with haptoglobin antibodies. The combined data indicate that the carbohydrate portion is essential for the functionally active form of polymeric haptoglobin to complex with hemoglobin, but it hardly has any direct role in the binding event, and other factors are responsible for the stability of the complex.     

Angiotensin II-accelerated vulnerability of carotid plaque in a cholesterol-fed rabbit model-assessed with magnetic resonance imaging comparing to histopathology

This study sought to reveal the effect of angiotensin II (Ang II)-induced atherosclerotic vulnerability in rabbits and to determine whether in vivo magnetic resonance imaging (MRI) can determine the effect of Ang II on atherosclerotic development over time. In total, 24 elderly male New Zealand white rabbits underwent an intravascular balloon injury in the left common carotid artery (LCCA) and were subsequently fed a high cholesterol diet for 12 weeks. At 8 weeks, rabbits were randomly assigned to receive either Ang II (1.4 mg/kg/d, Ang II group) or vehicle (phosphate-buffered saline, control) via a subcutaneous osmotic minipump for 4 weeks. The rabbits were imaged three times: at baseline and at 8 and 12 weeks. After the 12-week MRI scanning, rabbits were euthanized to obtain pathological and histological data. Atherosclerotic plaques were identified in the 21 rabbits that survived the 12-week trial. Typical feature of vulnerable plaques (VP), intraplaque hemorrhage, were observed in 6 of 10 animals (60.0%) in the Ang II group. The Cohen K value of MR imaging between the AHA classifications was 0.82 (0.73–0.91; P < 0.001). MRI revealed that the change in carotid morphology were significantly different between the Ang II and control group plaques. Our results support an important role for Ang II in plaque vulnerability by promoting intraplaque neovascularization and hemorrhage as well as inflammation. The vulnerable features induced by Ang II in rabbit carotid plaques could be accurately monitored with MRI in vivo and confirmed with histomorphology.     

Hemoglobin-haptoglobin receptor in rat liver plasma membrane

The presence of a receptor specific for the hemoglobin . haptoglobin complex is demonstrated in rat liver plasma membranes. Hemoglobin . haptoglobin complex, administered intravenously to rats, was cleared from the circulation at a constant rate with exclusive incorporation of the molecule into hepatocytes. This incorporation was unaffected by the simultaneous injection of asialoglycoprotein or heme . hemopexin complex. In vitro experiments with isolated liver plasma membranes indicated the absence of competitive binding of these molecules to the membrane and suggested that this receptor might recognize an altered conformation of the haptoglobin moiety of the complex resulting from the binding with hemoglobin. These observations suggest that the mechanism of recognition and binding of hemoglobin . haptoglobin complex by the receptor is different from that of the asialoglycoprotein receptor or heme . hemopexin receptor.     

Reaction of haptoglobin with hemoglobin covalently cross-linked between the alpha beta dimers.

Hemoglobin tetramers which cannot split into alphabeta dimers, because they are covalently cross-linked between the beta chains across the polyphosphate binding site, form complexes with haptoglobin. The reaction is biphasic as measured by fluorescence quenching and peroxidase activity. A complex in which one of the alpha beta dimers of the cross-linked hemoglobin is bound to one of the sites in the divalent haptoglobin molecule, is formed reversibly during the initial fast phase. In the subsequent slower step, this product then either polymerizes, adds another cross-linked hemoglobin molecule or, in the presence of excess haptoglobin, combines with a second haptoglobin molecule. This latter complex, in which two haptoglobin molecules are bridged by a cross-linked hemoglobin tetramer, can still combine with normal alpha beta dimers at the vacant haptoglobin combining sites. In spite of the very low oxygen affinity of the cross-linked hemoglobin, combination with haptoglobin shifts if oxygen affinity to the very high value of the normal hemoglobin-haptoglobin complex.     

Mast cells in vulnerable coronary plaques: potential mechanisms linking mast cell activation to plaque erosion and rupture

PURPOSE OF REVIEW: A novel link between inflammation and acute coronary syndromes is emerging, in that infiltrating inflammatory cells may convert a clinically silent coronary plaque into a dangerous and potentially lethal plaque. The majority of acute atherothrombotic events now relate to erosion or rupture of such unstable plaques. Here we summarize the molecular mechanisms by which activated mast cells may contribute to plaque erosion or rupture. RECENT FINDINGS: In-vitro experiments have revealed a multitude of paracrine effects exerted by activated mast cells. By secreting heparin proteoglycans and chymase, activated mast cells efficiently inhibit the proliferation of smooth muscle cells in vitro, and reduce their ability to produce collagen by a transforming growth factor beta-dependent and -independent mechanism. Mast cell chymase and tryptase are capable of activating matrix metalloproteinases types 1 and 3, causing degradation of the extracellular matrix component, collagen, necessary for the stability of the plaque. Activated mast cells also secrete matrix metalloproteinases types 1 and 9 themselves. Furthermore, chymase induces SMC apoptosis by degrading fibronectin, a pericellular matrix component necessary for SMC adhesion and survival, with the subsequent disruption of focal adhesions and loss of outside-in survival signaling. By secreting chymase and tumour necrosis factor alpha, activated mast cells also induce endothelial cell apoptosis. SUMMARY: Locally activated mast cells may participate in the weakening of atherosclerotic plaques by secreting heparin proteoglycans, chymase, and cytokines, which affect the growth, function and death of arterial endothelial cells and smooth muscle cells, thereby predisposing to plaque erosion or rupture.     

Single‐cell transcriptional profiling of human carotid plaques reveals a subpopulation of endothelial cells associated with stroke incidences

The differences in plaque histology between symptomatic and asymptomatic patients have been widely accepted. Whether there is a heterogeneity of cells between symptomatic and asymptomatic plaques remains largely unclear. To reveal the potential heterogeneity within different plaques, which may contribute to different stroke incidences, we obtained the scRNA‐seq data from symptomatic and asymptomatic patients and identified eight cell types present in plaques. Further analysis of endothelial cells (ECs) revealed three distinct EC subpopulations appeared to be endowed with specific biological functions such as antigen processing and presentation, cell adhesion, and smooth muscle cell proliferation. Of note, the differentially expressed genes of the EC 2 subpopulation showed that the genes involved in cell adhesion were up‐regulated in asymptomatic plaques compared to symptomatic plaques. Integrating the data of intraplaque haemorrhage and plaque stability, the 5th top‐enriched biological process was cell adhesion in the stable or non‐haemorrhaged plaques compared to unstable plaques or haemorrhaged plaques. Among these cell adhesion‐related genes, the intersection gene AOC3 may play a vital role in plaque haemorrhage and plaque stability. Targeting cell adhesion and the specialized genes may provide potential new therapeutic directions to prevent asymptomatic patients from stroke.     

Cholesterol lowering and the vessel wall: new insights and future perspectives.

The basis for most acute coronary events is either rupture or fissuring of unstable atherosclerotic plaques with subsequent thrombosis leading to coronary artery occlusion. The development of atherosclerotic plaques takes several decades, but the mechanical features determining its stability and the risk of rupture can change very rapidly depending on a number of internal factors. Unstable plaques have a large lipid core, a thin overlying fibrous cap and an abundance of inflammatory cells. The most important factor determining the plaque stability is the plasma level of atherogenic LDL particles. Increased levels of these particles cause endothelial dysfunction with impaired vasodilatation capacity and prevalence of vasoconstriction, maintain inflammatory infiltration of the plaque, impair the strength of the fibrous cap and facilitate aggregation and coagulation. Effective lowering of plasma cholesterol by pharmacological and non-pharmacological means can revert most of these processes and increase the plaque's mechanical stability within several hours to days. Lipid lowering therapy can therefore decrease the risk of acute coronary events within a very short space of time. Thus a radical decrease in lipid levels, along with modification of other risk factors, may become the cornerstone for treatment of acute coronary syndromes, in addition to being an effective treatment in primary and secondary prevention of coronary heart disease (CHD).     

Hypertension exacerbates coronary artery disease in transgenic hyperlipidemic Dahl salt-sensitive hypertensive rats

BACKGROUND: The mechanisms underlying the known interaction of two complex polygenic traits, hypertension and hyperlipidemia, resulting in exacerbation of coronary artery disease have not been elucidated. Identification of critical pathways underlying said exacerbation could identify mechanism-based targets for intervention and prevention. MATERIALS AND METHODS: To investigate hypertension- atherosclerosis interaction, we studied the inbred transgenic atherosclerosis-polygenic hypertension Dahl salt-sensitive (S) rat model (Tg53), which over-expresses human cholesteryl ester transfer protein (hCETP) in the liver, and exhibits coronary artery disease and decreased survival compared with control non-transgenic Dahl S rats. Using serial-section histopathological and immunohistochemical analyses, we analyzed the coronary artery disease phenotype of Tg53 rats at end-stage marked by cardio-respiratory compromise as the experimental equivalent of acute coronary syndromes, and determined the effects of reduction of blood pressure through low salt diet (0.008% NaCl) on the coronary artery disease phenotype and survival. RESULTS: End-stage Tg53 rats exhibit coronary artery lesions in the proximal right coronary artery system which exhibit "culprit plaque" features such as plaque inflammation, matrix degradation, apoptosis, neovascularization, thrombosis and hemorrhage recapitulating said features and heterogeneity of human coronary "culprit plaques". Comparative analysis of 6 month vs end-stage lesions reveals distinct lesion development profiles of proximal coronary lesions which quickly progress from eccentric non-occlusive foam-cell rich lesions at 6 months to occlusive "culprit plaques", compared with more distal coronary lesions which exhibit occlusive thick-cap atheroma that remain relatively unchanged from 6 months to end stage. Reduction of hypertension through a low-salt (0.008% NaCl) diet increased survival (P < 0.0001) of Tg53 rats and significantly attenuated the coronary artery disease phenotype detected at 10 months of age marked by diminished apoptosis, neovascularization, matrix degradation compared with end-stage lesions detected at <8 months of age. CONCLUSIONS: End stage coronary lesions in the Tg53 rats recapitulate many, albeit not all, features of "culprit plaques" in humans supporting proposed paradigms of plaque vulnerability implicating lesion macrophage enrichment, apoptosis, matrix degradation and pathological neovascularization. Comparative time course analysis of coronary lesions reveals that plaques which develop into end-stage "culprit plaques" are distinct from "stable plaques" by location and early lesion morphology, suggesting distinct lesion development and progression pathways. The significant effects of low-salt diet-induced decrease in hypertension on right coronary disease phenotype provides compelling evidence that polygenic hypertension accelerates coronary plaque progression and complication independent of cardiac hypertrophy, and more importantly provides paradigmatic support for public health policy.     

Emerging approaches for imaging vulnerable plaques in patients

The diagnosis of vulnerable plaques, which have the propensity to develop atherothrombosis, remains an elusive goal in clinical medicine. The most accepted features of vulnerable plaques, such as a large lipid core, increased inflammatory milieu and thin fibrous caps, have been well characterized through pathological studies. The ability to image a vulnerable plaque in susceptible patients would theoretically result in useful prognostic information that can be used to either monitor or treat patients at risk more aggressively. Several invasive techniques, such as integrated backscatter, virtual histology, palpography, optical coherence tomography and thermal heterogeneity, have been validated ex vivo and are now being evaluated in clinical studies. Non-invasive techniques, such as nuclear imaging, show promise in identifying increased metabolic activity and characteristic features of vulnerable plaques in patients. Natural history and intervention studies will need to be performed to determine whether identifying and treating vulnerable plaques will lead to improved clinical outcomes.     

Oxysterols and symptomatic versus asymptomatic human atherosclerotic plaque

Atherosclerosis is the most common cause of mortality in the Western world, contributing to about 50% of all deaths. Atherosclerosis is characterized by deposition of lipids onto the coronary or carotid arterial wall and formation of an atherosclerotic plaque. Atherosclerotic plaques are categorized into two groups: symptomatic and asymptomatic. The symptomatic plaques tend to be unstable and prone to rupture, and are associated with an increase in ischemic events. Oxysterols, products of cholesterol oxidation, are cytotoxic materials. Their level and type may be associated with plaque formation, development and stability. Oxysterols stimulate the formation of foam cells, advance atherosclerotic plaque progression, and contribute to plaque vulnerability and instability due to their cytotoxicity and their ability to induce cell apoptosis. Studies indicate that plasma 7β-OH CH level can be used as a biomarker for detecting carotid and coronary artery disease. Further clinical studies are needed to evaluate the potential of oxysterols for use as biomarkers for plaque vulnerability and instability. The identification of biomarkers in the blood that can distinguish between symptomatic and asymptomatic plaques remains an unresolved issue.     

小型猪动脉粥样硬化斑块稳定性模型研究

目前已有的动物模型在研究动脉粥样硬化斑块破裂、破裂的可控性及量化研究方面均不能满足研究的需要.为了建立类似于人类动脉粥样硬化病变的斑块模型,体外研究斑块稳定性,应用传统的高脂高胆固醇膳食诱导建立了小型猪动脉粥样硬化模型,并从血脂水平和斑块病理形态学特征方面加以了证实.该模型中斑块与人类成熟斑块的高度相似性使其成为研究斑块稳定性和斑块破裂的较好模型.从量化比较这一出发点着手,建立了一个体外可控可量化诱导斑块破裂模型,方法简单易行,是一个较好的量化研究斑块破裂和破裂相关因素间关系的实验模型.     

Effect of modification on physicochemical and biological properties of haptoglobin. VI. Reaction with azlactone of p-nitrobenzoyl-valine.

The azlactone of p-nitrobenzoyl-valine (Nbz-Val) has been used for modification of xi-amino groups of lysine in haptoglobin type 1-1, in hemoglobin, and in the haptoglobin-hemoglobin complex. By the use of this reagent 95% of amino groups in haptoglobin and 90% in hemoglobin have been blocked without any changes in peroxidase activity of the formed complexes: Nbz-Val.haptoglobin with hemoglobin, Nbz-Val. hemoglobin with haptoglobin, and Nbz-Val.(haptoglonin-hemoglobin). After reduction and reoxidation, Nbz-Val.haptoglobin was found to retain 90% of peroxidase activity when complexed with hemoglobin. Beta chains separated either from haptoglobin or Nbz-Val.haptoglobin showed 15% of peroxidase activity in the complex with hemoglobin, alpha chains of the same origin were completely inactive. Whereas recombination of haptoglobin from alpha and beta chains resulted in 42% hemoglobin-binding capacity, renaturation of Nbz-Val.haptoglobin from separated subunits was found to proceed with almost 100% yield. In immunodiffusion with rabbit anti-haptoglobin or anti-Nbz-Val.haptoglobin sera, preparations of haptoglobin and Nbz-Val.haptoglobin after reduction and reoxidation or after recombination from separated subunits gave similar precipitation arcs showing the reaction of immunological identity.