Inflammation and atherosclerosis

Immune cells dominate early lesions Immune effector molecules accelerate lesion progression

Activation of inflammation elicits acute coronary syndromes

Atherosclerosis is an inflammatory disease in which immune mechanisms interact with metabolic risk factors to initiate, propagate and activate lesions in the arterial wall

The numbers

CAD causes 38% of all deaths in North America

Most common cause of death in men under 65 y.o. and second most common cause of women
Dispite advances in control of hypercholesterolemia (statins),CVD expected to be the main cause of death globally over the next 15 years due to rapidly increasing prevalence of obesity and diabetes

Pathogenesis of coronary artery thrombosis

Cellular players in atherogenesis and plaque rupture

The early lesion: modified lipoproteins and foam cell formation

Role of macrophages

MCSF induces monocytes entering lesion to differentiate into macrophages Macrophage differentiation associated with TLRs and scavenger receptors MCSF/apoE KO shows reduced atherosclerosis

Scavenger receptors bind bacterial endotoxins, apoptotic cells and oxLDL

SR/apoE KOs show reduced atherosclerosis

The macrophage as an inflammatory mediator

IL-1R

TNF-R

IFN-gR

Toll-like

NFkB IRF

MAP KINASE JAK/STAT

GENES

Inflammation, Anti-Microbial Response, Apoptosis,

TLR receptors and atherosclerosis

10 family members Recognize pathogen associated molecular patterns (e.g. LPS, dsRNA) as well as oxLDL, HSP60 etc.

Initiate signaling cascades leading to production of inflammatory cytokines, proteases, reactive oxygen species In addition to macrophages, expressed by dendritic cells, mast cells, endothelial cells

Macrophage-T cell interactions in atherosclerosis

T cells and atherosclerosis

Immune cells patrol tissues in search of antigen T cell infiltrate is common feature of atherosclerotic lesions

Predominantly CD4+ cells, recognize antigen/MHC II

CD4+ T cells reactive to oxLDL, HSP60, bacterial products detected in human lesions NK cells present in early lesions, recognize lipid antigens

NK activation increases athero in apoE KO mice

T cell responses

Th1 response activates macrophages and functions in the defense against intracellular pathogens Th2 response elicits allergic inflammation Atherosclerotic lesions contains cytokines that promote Th1 responses Activated Th1 effector cells in lesions produce macrophage activating cytokine IFNg

IFNg improves efficiency of ag presentation and augments synthesis of TNFa and IL-1
IFNg, TNFa and IL-1 in turn stimulate production of many other inflammatory mediators apoE mice lacking IFNg or downstream mediators such as IL-18 or T-bet show reduced athero

Anti-inflammatory factors and atherosclerosis

Anti-inflammatory factors such as TGFb and IL-10 are protective

IL-10 KO increases athero in mice and exacerbates thrombosis Abrogation of TGF signaling in T cells leads to large unstable atherosclerotic lesions

Immune cells and plaque rupture

Preferentially occurs where fibrous cap is thin Active immune cells are abundant at site of rupture Immune cells produce inflammatory molecules and proteolytic enzymes that weaken cap, activate cells in the core and transform stable plaque into vulnerable, leading to plaque rupture MMPs likely to play important roles

Systemic inflammatory markers in atherosclerosis

Systemic indicators of inflammation

Inflammatory process in lesions may lead to increased plasma levels of cytokines and acute phase proteins CRP and IL-6 are elevated in patients with unstable angina and MI Levels correlate with prognosis

TLR-3/4

MyD88 Independent

MyD88 Dependent

TANK
TBK-1 IKKi

NEMO
IKK-1 IKK-2

IkB IRF-3

NF-kB

Antiviral Response

Inflammatory Response

MyD88/apoE KO mice show reduced athero

MyD88/apoE Ko mice show reduced chemokine expression

MyD88/apoE KO macs show reduced chemokine expression and recruitment in response to inflammatory cytokines

Links between infection and atherosclerosis

Unlikely to be caused by single organism Diverse pathogens have been detected within lesions Bacteria and viruses accelerate athero in murine models

Potential mechanisms

Stimulation of inflammatory cytokines Alteration of adhesion molecule expression ? Lipid metabolism ?

oxLDL

CD36

cholesterol

Inflammatory stimuli
LPS, IL-1b, TNFa

CE

ABCA1

oxysterol

IL-1R TOLL4 TNFR

RXR LXR
CHOLESTEROL EFFLUX
PLTP ABCAI ApoE/CII LPL

INFLAMMATION
iNOS IL-1b IL-6 COX2 MMP9

MACROPHAGE

Synthetic LXR agonist reduces atherosclerosis inLDLR-/- and apoE-/- mice

LDLR-/- Aortic Sections
300000

ApoE-/- Aortic Sections

p < 0.005
250000

p < 0.005

Lesion area (mM2/section)

250000

Lesion area (mM2/section)

200000

197870

200000

150000

150000

136610
100000

134470
100000

70621
50000

50000

high fat

+ GW3965

vehicle

GW3965

Joseph et al. PNAS 2002

Loss of bone marrow LXR expression accelerates athero

Aortic Lesion Coverage (%)
C57Bl6 BMT

LXRab -/BMT

apoE -/BMT

0.0

2.5

5.0

7.5

Tangirala et al. PNAS 2002

Bacterial or viral infection blocks expression of LXR target genes in macrophages

Antonio Castrillo, Sean Joseph

E. Coli + GW

E. Coli + T

GW3965

E. Coli

T1317

ctrl

ABCA1 apoE SREBP-1c FAS iNOS 36B4

ABCA1 ABCG1 FAS MX-1 IFN-b 36B4

Castrillo et al., Molecular Cell 2003

ctrl

Infl A + T

GW3965

+/- E. coli

+/- Influenza A

Infl A + GW

T1317

Infl A

TLR3 and TLR4 ligands inhibit cholesterol efflux from macrophages

Cholesterol efflux
14 12

Ctrl LXR ligand

apoAI-dependent efflux (%)

10

**
4

*
2

**

Activation of TLR3 inhibits LXR signaling in vivo

Aorta
11 9

Spleen
5

ABCA1

ABCA1

vehicle

mRNA

mRNA

3 1

* *
apoE

Poly IC GW3965 Both

3 1
4

apoE
mRNA

3 2 1

mRNA

2
1 19

mRNA

13 9

mRNA

17

ABCG1

5 3 1

ABCG1

5
1 7

IFN-b
mRNA

mRNA

500 300 100

IFN-b

5 3 1

400

mRNA

300 200

mRNA

IP-10

50 30 10

IP-10

100
0

TLR-LXR crosstalk: potential implications for atherosclerosis

virus
bacteri a other signals
TLR-3/4 ABCA1

cholesterol efflux
C C

?
TANK TBK-1IKKi

Foam cell formation

C C C C

IRF-3

LXR

RXR

ABCA1, ABCG1, apoE

Immunization with pneumococus induces oxLDL-specific IgM

Immunization with pneumococus induces oxLDL-specific IgM

s. pneumo s. pneumo + s. pneumo block

s. pneumo + oxLDL block

E06 (ox PL)

Plasma from mice immunized with pneumococus inhibits macrophage binding of oxLDL

Immunization with pneumococus reduces atherosclerosis in LDLR-/- mice