Copyright © Polskie Towarzystwo Kardiologiczne INTRODUCTION In the famous ‘Atlas of atherosclerosis: progression and regression’, Herbert Stary [1] outlines in remarkable detail the development of human atherosclerosis. The photographs depicting lesions at all stages of development, from newborns to the elderly, capture in stunning detail the complexity of an evolving disease. Type I lesions develop, Stary explains, at sites of non-laminar flow and low shear stress, which disturbs endothelial function. Type II lesions are defined by macrophage foam cells, and type III preatheromas feature small pools of extracellular lipids. As the disease worsens, an easily discernible core of extracellular lipid marks a type IV atheroma, fibrous thickening corresponds to a type V atheroma, the appearance of fissures, haematoma, and thrombi denote type VI atheroma, and finally, calcification is a type VII complicated atheroma [1]. Each of these histological observations reflect a biological process; each has its corresponding cluster of scientists and clinicians devoted to understanding how it can be harnessed to prevent or treat disease. As the underlying pathology causing most myocardial infarctions and strokes, atherosclerosis is, after all, the deadliest disease in the world [2]. Among the many mechanisms that contribute to the development and complications of atherosclerosis, macrophage accumulation occurs early and persists throughout most of a lesion’s evolution. The best evidence that macrophages are functionally important — rather than simply markers — can be found in animal studies. The most widely-used murine models of atherosclerosis, the Apoe–/– and Ldlr–/– mice, though far from perfect reflections of human disease, are nevertheless fair approximations to show how lesions develop. In both models, macrophages are prominent in early and advanced lesions, where they ingest oxidised lipoproteins via scavenger receptors and, as lipid-rich foam cells, become part of the disease’s physical bulk [3]. Although many of the functions by which macrophages influence atherosclerosis have been deciphered, their ontogeny has continued to perplex. On the one extreme, lesional macrophages may be developing from resident precursors or stem cells through local differentiation and proliferation, requiring no input from the circulation. At the other extreme, macrophage accumulation may be the exclusive consequence of replenishment from blood monocytes, requiring no input from resident cells. Identifying the mechanisms can be therapeutically relevant. If macrophages are harmful to disease and originate only from local precursors, then approaches targeting the vessel wall and its environment should be explored. If, however, macrophages originate exclusively from blood monocytes, then targeting environments where monocytes arise, such as the bone marrow or spleen, may be the more effective strategy.
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