Funding Source Research Articles

Phosphoinositide 3-Kinase C2alpha controls cardiac contractility through regulation of beta2-adrenergic receptor recycling

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Doctoral fellowship Introduction Phosphoinositide 3-kinase C2α (PI3KC2α) is a ubiquitously expressed class II PI3K isoform, which has been previously shown to be involved in the control of vesicular trafficking. However, its role in the myocardium has not been investigated. The primary aim of this study is to elucidate the mechanism by which mechanism PI3KC2α controls cardiac pathophysiology. Methods Cardiomyocyte-specific PI3KC2α knockout (PI3KC2α KO) animals were generated by crossing mice expressing a tamoxifen-inducible Cre recombinase under the control of the αMHC promoter with PI3KC2αflox/flox mice. Zebrafish embryos were injected with a PI3KC2α (PI3KC2α morphants) or a control morpholino (control morphants) at 1-cell stage. HEK293 with stable overexpression of GFP-tagged β2-AR were generated and transfected with either scramble or PI3KC2α siRNAs. Results Our findings indicate that PI3KC2α KO mice display a reduced cardiac contractility compared to wildtype animals. Similarly, PI3KC2α morphants zebrafish exhibit lower heart rate and fractional shortening compared to controls, both at baseline and after isoproterenol (ISO) stimulation. A similar unresponsiveness to ISO was found in vivo in PI3KC2α KO mice where chronic treatment with the β-adrenergic receptor (β-AR) agonist failed to induce the classical β-AR-mediated remodeling, characterized by an increase of the left ventricular mass and of cardiomyocyte area. These findings suggest that PI3KC2α plays a critical role in the regulation of β-AR signaling. In agreement, cAMP levels failed to increase in response to ISO treatment in PI3KC2α morphants. Furthermore, silencing of PI3KC2α in HEK293-GFP-β2-AR cells resulted in an increased GFP-β2-AR internalization compared to control cells, both at baseline and after ISO stimulation. Interestingly, preliminary findings indicate that overexpression of constitutively active Rab11Q70L induced a redistribution of GFP-β2-AR at the plasma membrane in PI3KC2α-silenced cells. Conclusion Overall, we identify a key role for PI3KC2α in the control of cardiac contractility through the regulation of β2-AR trafficking to the plasma membrane through a Rab11-dependent mechanism.

Preoperative examination of inflammatory biomarkers in relation to the prognosis of postoperative complications after heart transplantation

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Semmelweis University Heart transplantation (HTX) is the definitive therapy for end-stage heart failure. Although complications have drastically decreased with modern immunosuppressive therapy, surgical and anesthetic techniques, significant complications such as graft failure, acute rejection or infection must still be expected. The purpose of the study is to examine cytokine pathways linked to inflammation from direct preoperative serum samples, which can serve as prognostic factors in relation to septic events and mortality in the early postoperative period. The study was conducted using the blood samples of 102 patients who underwent HTX. Blood samples were taken from the patients immediately before HTX. The amounts of a total of 32 cytokines and related proteins were determined using LEGENDplex assays. After that, we correlated the biomarker amounts determined in the serum samples with the end points we indicated. In patients undergoing HTX who developed septic events during postoperative intensive care, the preoperative MMP2 serum concentration was significantly higher compared to other patients undergoing HTX (n=23, p=0.04). Independent predictors of mortality in the intensive care unit (n=5) were preoperative MRP8/14 (AUC=0.8), NGAL (AUC=0.75), IGFBP-4 (AUC=0.73), cystatin C (AUC=0.7) and the MMP2 (AUC=0.74) serum concentrations. Patients transplanted from left ventricular mechanical circulatory support (LVAD) (n=11) were examined as a separate group, where early postoperative mortality was significantly higher (n=4, p=0.02), the independent predictor of which was the concentration of IGFBP-4 (p=0.04 , AUC=0.73). Based on our results, it can be said that the differences in the preoperative concentration of certain inflammatory biomarkers that can be measured in the serum show correlations with the postoperative septic events and mortality of patients undergoing HTX.

Ectopic Pitx2 expression and sinoatrial node dysfunction in mice recapitulating a novel cardiac syndrome identified in unrelated families with deletions in a gene desert on chromosome 4q25

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Research Councin/NWO Introduction Several unrelated families presenting with a complex, heterogeneous cardiac syndrome including sinoatrial node dysfunction and atrial fibrillation were found to share overlapping deletions in a 1.5 Megabase pair gene desert on chromosome 4q25. These overlapping regions contain evolutionarily conserved CTCF binding sites that modulate the separation of topologically associating domains containing the transcription factor-encoding gene PITX2 and noncoding RNA genes. Aim To understand mechanistically how the deletion in the gene desert causes sinoatrial node dysfunction and atrial arrhythmias. Methods Mice lacking the orthologue of the minimally overlapping genomic region deleted in affected patients were generated. Electrophysiology, morphology, tissue composition, and transcriptomes were analysed in this mouse model. Results These mice recapitulated major morpho-functional features of the syndrome, including sinoatrial node dysfunction and atrial arrhythmogenesis . Out of the 15 genes flanking the gene desert, only Pitx2 expression was deregulated in the sinoatrial node. During development, cardiac Pitx2c expression is normally restricted to the left side where it drives left sinus venosus and left atrial morphogenesis and prevents the formation of a left-sided sinoatrial node. The PITX2 locus has also been associated with atrial fibrillation in GWAS. Immunohistochemistry together with 3D volume analysis showed that Pitx2c was ectopically expressed in half of the pacemaker cardiomyocytes of the developing and postnatal sinoatrial node while its expression in the left atrium was maintained. Key transcription factors that drive pacemaker cell differentiation, Tbx3, Isl1 and Shox2, were lost where Pitx2c was ectopically expressed. Moreover, a conserved long non-coding RNA (Playrr) previously linked to Pitx2 regulation in the developing dorsal mesentery, was downregulated in the sinoatrial node of homozygous mutants. The downregulation of the pacemaker gene program additionally coincided with the activation of the atrial myocardial gene program in half of the pacemaker cardiomyocytes. Conclusion We generated a mouse model of a novel human cardiac syndrome including sinoatrial node dysfunction associated with the deletion of critical CTCF binding sites in a gene desert on chromosome 4q25. This deletion induced ectopic Pitx2c expression in the sinoatrial node alongside a substantial loss of pacemaker cardiomyocyte identity and a gain in a working atrial myocardium-like phenotype in the sinoatrial node of affected mice.Loss of pacemaker cardiomyocyte identitySinoatrial node dysfunction in mutants

Human in vitro disease modeling of ATTR cardiac amyloidosis

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Pfizer Alnylam Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive disease with deposition of TTR amyloid fibrils in the myocardium and cardiac dysfunction with dismal prognosis. In ATTR-CM, either genetic mutations (variant; v) or ageing (wild-type; wt) leads to TTR instability. Late diagnosis and a lack of human disease models limit disease understanding and therapeutic discovery. This study aimed to model ATTR-CM in vitro by exposing various cardiac cell types and multicellular 3D cardiac spheroids to TTR fibrils, characterizing disease phenotypes and providing insights into the cellular mechanisms of disease progression. Human recombinant TTR (WT, V30M, V122I) and acid induced fibrils were generated and characterized. Seeding hiPSC-cardiomyocytes (CMs) and endothelial cells (ECs) on TTR fibrils resulted in cell viability reduction. Confocal microscopy revealed the extracellular attachment of TTR fibrils, leading to sarcomere disorganization, prolonged calcium transients and disrupted electromechanical coupling in hiPSC-CMs, and declined migration capacity of ECs showing aberrant cell morphology. Similarly, cardiac spheroids incorporating TTR fibrils resulted in decreased cell viability and prolonged calcium transients with lower amplitude. Our models show the discovery of early cellular ATTR-CM phenotypes, providing a novel approach to study the disease progression, potentially facilitating the identification of novel therapeutic targets and biomarkers.Cytotoxicity of TTR fibrils on hiPS-CMs

Untangling the inflammatory responses of liver x receptor (LXR) activation in human macrophages

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Rembrandt Institute for Cardiovascular Science (grant 2022) The regulation of cholesterol and fatty acid homeostasis is essential and the Liver X Receptor (LXR) plays a crucial role in this process. When activated, LXR promotes cholesterol efflux and suppresses the transcription of pro-inflammatory genes in mouse macrophages, making it a promising therapy against atherosclerosis. Studies indeed have shown that LXR agonism is effective in pre-clinical atherosclerotic mouse models. However, the limited data on human macrophages suggests that LXR activation may have additional pro-inflammatory effects in humans, and the mechanisms contributing to this are not yet fully understood. To investigate the inflammatory properties of LXR activation in human macrophages, monocytes were isolated from buffy coats of healthy donors and differentiated into macrophages using M-CSF. The macrophages were exposed to synthetic and endogenous LXR ligands, such as GW3965, T0901317, and desmosterol, respectively, followed by stimulation with lipopolysaccharide (LPS) for six hours. We used qPCR and ELISA to analyze experiments and plan to supplement our data with RNA-Seq and multiplex assays. Preliminary results show that LXR activation reduces LPS-induced activation of interferon-mediated genes like CXCL9 and CXCL10, similar to mice. However, it promotes the transcription of NF-kB target genes like IL1B and IL12B upon LPS activation. These findings suggest that LXR activation in human macrophages not solely suppresses inflammatory responses in macrophages and that LXR activation has different effects on the regulation of genes mediated by interferon or NF-kB. Our research aims to further uncover the regulatory mechanisms behind LXR activation in human macrophages as central regulators in atherosclerosis.

Asporin expression is associated with human atherosclerotic plaque integrity

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): This work was supported by the Swedish Research Council, the Swedish Heart and Lung Foundation, Skåne University Hospital funds Background Calcification serves as a clinical marker of atherosclerotic plaque burden. Recent studies have also shed light on its intricate association with plaque vulnerability, likely depend on calcification structures and the surrounding environment. Asporin (ASPN) is a member of the small-leucine-rich proteoglycans that contains a unique and well-conserved stretch of aspartate (D) residues, which mimic the role of glycosaminoglycans. Via its D-repeat, ASPN can interact with calcium and several other extracellular matrix molecules, thus influencing collagen mineralization and TGF-β signaling. ASPN expression has been shown to be higher in asymptomatic compared to symptomatic atherosclerotic plaques, suggesting a potential protective role. However, the role of ASPN in maintaining plaque integrity remains unknown. Purpose Here we aimed to explore the role of ASPN in atherosclerosis, by investigating if ASPN was expressed in human carotid plaques and by determining if ASPN is associated with risk for postoperative cardiovascular events and death. Methods ASPN and TGF-β protein levels were measured by ELISA and Milliplex in 176 human plaque tissue homogenates obtained from the Carotid Plaque Imaging Project (CPIP) biobank. Plaque tissue sections were stained for ASPN, destabilizing (CD68, oil red O, glycophorin A) and stabilizing plaque components (Movat, α-actin). Plaque tissue RNA expression levels were assessed in 82 plaques using bulk RNA sequencing. Plaque levels of phosphate, elastin and collagen were measured using ELISA. Results ASPN protein levels were higher in plaques from asymptomatic patients compared to symptomatic patients (p=0.011). ASPN RNA levels correlated positively to RNA levels of the smooth muscle cell markers ACTA2, MYH11 and TAGLN. Moreover, protein levels correlated with plaque levels of phosphate (r=0.258, p=0.001), elastin (r=0.423, p<0.001), collagen (r=0.248, p=0.002) and stability factors like the TGF-β family members, TGF-β1 (r=0.176, p=0.035), TGF-β2 (r=0.581, p<0.001) and TGF-β3 (r=0.396, p<0.001). Furthermore, plaque ASPN protein concentration, correlated inversely with a histological plaque vulnerability index (r=-0.265, p=0.0029), which is ratio between the plaque area of destabilizing (macrophages, lipids, intra-plaque hemorrhage) and stabilizing plaque components (collagen and smooth muscle cells). Additionally, above median ASPN levels were associated with lower risk for postoperative cardiovascular events (p=0.008) and death (p=0.009). Conclusion Our findings suggest that elevated levels of ASPN might have a crucial role in maintaining plaque stability, affecting plaque calcification.

Sex differences in cardiac ferroptosis after acute myocardial infarction in wild type and aryl hydrocarbon receptor knockout mice

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): MICIN/Agencia Estatal de Investigación (DOI: 10.13039/50110001103) (NextGeneration, EU/PRTR) Background and Purpose Ferroptosis is a new regulated programmed cell death pathway, driven by iron-dependent phospholipid peroxidation, that plays an important role in the development of cardiovascular diseases. The aryl hydrocarbon receptor (AhR) is a ligand-activated transcription factor of the basic Helix-Loop-Helix-PER-ARNT-SIM superfamily. Upon ligand binding, AhR translocates into the nucleus and dimerizes with the AhR nuclear translocator; the heterodimer then binds to dioxin-response elements located in the promoter region of receptor-regulated genes, most of which are involved in xenobiotic metabolism. Beyond its role in metabolizing exogenous toxins as part of an adaptive chemical response, it is well known that AhR is activated by endogenous ligands and it has been postulated that AhR has important functions in physiological and/or pathological conditions. Here we studied sex differences in cardiac ferroptosis after acute myocardial infarction (AMI) in mice and the implication of defective AhR signalling on this process. Methods and Results AMI was induced in 8–10-weeks-old males and females AhR+/+ and AhR-/- mice by ligation of the left anterior descending coronary artery. Animal care and experimental procedures followed the principles of animal care (NIH publication Nº85-23 revised 1985) and the guidelines for ethical care of experimental animals of the European Union (2010/63/EU). Survival analysis showed that 16% of AhR+/+male mice and 14% of AhR+/+ female mice died 72 h after AMI surgery whereas the mortality was 100% in AhR-/-male mice and only 17% in AhR-/- female mice group. The treatment of AhR-/- AMI male mice with ferrostatin (1 mg/kg i.p) increased survival to 40%. Immunofluorescence analysis of cardiac staining levels of 8-hydroxy-2’-deoxyguanosine revealed higher oxidative stress in AhR+/+AMI male mice compared with AhR+/+AMI females, 24 h after surgery. The absence of AhR in AMI males showed an increased oxidative stress that was similar to that obtained in AMI AhR+/+ males but significantly greater than that observed in AhR-/- AMI females. Finally, analysis of differential expressions of classical genes related to ferroptosis in AhR-/- AMI male and AMI female mice, 24 h after surgery, showed, only in males, a reduced expression of ferritin heavy chain 1 and ferroportin, and an increased expression of phospholipase A2. Conclusion Our results show that loss of AhR in males but not in females favours the ferroptosis process associated with myocardial ischemia, highlighting a possible role for this nuclear receptor in cardiac remodelling and survival after AMI.

Increased perivascular fibrosis and pro-fibrotic cellular transition in intramyocardial blood vessels in patients with myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): China Scholarship Council Background Myocardial infarction (MI) is pathologically characterized by irreversible myocardial necrosis caused by ischemia. Intramyocardial vascular dysfunction is believed to increase the risk of MI. In this study, we investigated intramyocardial blood vessels in deceased patients during the early and chronic phases of MI to explore the involvement of perivascular fibrosis and pro-fibrotic cellular transitions in the pathological process of MI. Methods Left ventricular tissue (LV) was obtained from the infarction area of autopsied patients with early-phase MI (3-6 hours old; n=23), chronic-phase MI (5-14 days old; n=12), and from non-infarcted controls (n=14). We quantified perivascular fibrosis using EVG staining and fibroblast activation protein (FAP) expression using immunohistochemistry. Co-localization of smooth muscle actin (SMA) or CD31 with fibroblast marker S100A4 indicative of transition of smooth muscle cells (SMC) and endothelial cells (EC) toward fibroblast-like cells in intramyocardial vessels was quantified using immunofluorescent microscopy. Results Compared to controls (61.03%), perivascular fibrosis was significantly elevated in MI patients (early-phase 77.20%; chronic-phase 82.58%)(p<0.0001), with the highest level observed in the infarct cores of chronic-phase patients (95.18%). Compared to controls, FAP expression was 3.5-fold higher in early-phase- and 15.3-fold higher in chronic-phase MI patients (p<0.05), wherein FAP expression again was highest in the infarct cores. Furthermore, in both early- and chronic-phase MI, SMC- and EC fibroblast-like cellular transition was increased. The fraction of SMA+S100A4+ vessels was significantly higher in early-phase MI (31.96%) and chronic-phase MI (21.9%: border zone; 37.25%: infarct core) compared to controls (8.95%)(p<0.05). Similarly, the fraction of CD31+S100A4+ area was significantly increased in early-phase MI (10.14%) and chronic-phase MI (8.31%: border zone 10.15%: infarct core) compared to controls (2.67%)(p<0.05). Conclusion We observed increased perivascular fibrosis, fibroblast activation and fibroblast-like cellular transition toward a pro-fibrotic phenotype of vascular cells in intramyocardial blood vessels in MI patients, that may contribute to the development of MI. The further increase of FAP expression and perivascular fibrosis, particularly in the infarct core, in the chronic-phase suggest that MI itself can exacerbate fibroblast activation and perivascular fibrosis, theoretically increasing the risk of reinfarction.FAP expression and perivascular fibrosispro-fibrotic vascular cellular transitio

The effects of siRNA-mediated knockdown of AP-1 on pulmonary arterial and right ventricular dysfunction associated with cardiac and pulmonary fibrosis in cardiopulmonary disease

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Romania’s National Recovery and Resilience Plan, PNRR-III-C9-2022-I8, CF 93/15.11.2022, Financing Contract no. 760063/23.05.2023, and by the Romanian Academy Background Pulmonary hypertension (PH) is a complex multifactorial vascular pathology characterized by an increased pulmonary arterial pressure, vasoconstriction, remodelling of the pulmonary vasculature, thrombosis in situ and inflammation associated with right-side heart failure. Purpose Herein, we explored the potential beneficial effects of treatment with siRNA AP-1 on pulmonary arterial and right ventricular dysfunction and perivascular and interstitial fibrosis in pulmonary artery (PA), right ventricle (RV) and lung in an experimental animal model of monocrotaline (MCT)-induced pulmonary arterial hypertension. Methods Golden Syrian hamsters were divided into: (1) C group; (2) MCT group obtained by a single subcutaneous injection of 60 mg/kg MCT at the beginning of the experiment; (3) MCT- siRNA AP-1 group received a one-time subcutaneous dose of MCT and subcutaneous injections containing 100nM siRNA AP-1, every two weeks. All animal groups received water and standard chow ad libitum for 3 months. Results In comparison with the MCT group, siRNA AP-1 treatment had significant beneficial effects contributing to: (1) a reduction in TGF-β1/ET-1/IL-1β plasma concentrations; (2) a reduced level of cytosolic ROS production in PA, RV and lung, and ultrastructural improvements of these tissues; (3) a decrease of inflammatory and fibrotic marker expressions in PA (COL1A, Fibronectin, Vimentin, α-SMA, CTGF, Calponin, MMP-9), RV (COL1A, CTGF, Fibronectin, α-SMA, F-actin, OB-cadherin) and lung (COL1A, CTGF, Fibronectin, α-SMA, OB-cadherin), and an increase of endothelial marker expressions (CD31/VE-cadherin) in PA; (4) structural and functional recoveries of PA (reduced VTI/Vel, restored vascular response) and RV (enlarged internal cavity diameter in diastole, increased TAPSE/PRVOFs) associated with a decrease in systolic/diastolic blood pressure, and heart rate; (5) a reduced protein expression profile of AP-1S3/ pFAK/FAK/pERK/ERK and a significant decrease in the expression levels of miRNA-145, miRNA-210, miRNA-21, and miRNA-214 along with an increase of miRNA-124 and miRNA-204. Conclusion The siRNA AP-1-based therapy led to an improvement of pulmonary arterial and right ventricular function accompanied by a regression of perivascular and interstitial fibrosis in PA, RV and lung and a down-regulation of key inflammatory and fibrotic markers in MCT-treated hamsters.

DNMT3A-mutant clonal haematopoiesis and the recovery of patients with acute ST-elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart foundation Background Haematopoietic stem cells can acquire mutations and produce mutant blood cells. When this occurs in the absence of overt blood disease, it is clonal haematopoiesis of indeterminate potential (CHIP). CHIP is a novel, independent risk factor for ischaemic heart disease and heart failure (HF)(1). However, the molecular mechanisms are poorly understood. Myocardial infarction (MI) is a leading cause of HF due to ventricular remodelling and scar formation(2). We postulate CHIP mutations result in aberrant inflammation that contributes to maladaptive ventricular remodelling following MI. We investigated clinical outcomes and immune cell biology in CHIP and non-CHIP patients (pts) with acute ST-segment elevation MI (STEMI). Purpose Identify and quantify mutations with variant allele frequency (VAF)≥1% in STEMI pts. Assess leukocyte mutational burden. Investigate transcription profiles and leukocyte function in CHIP and non-CHIP STEMI pts. Methods 119 pts diagnosed with STEMI were prospectively recruited (REC19/SC/0362). We collected clinical data, including echocardiogram (echo) parameters and isolated plasma and peripheral blood mononucleated cells (PBMCs) from blood collected 48-96 hours post onset of chest pain. PBMCs were screened for mutations and analysed by flow cytometry. We assessed CHIP VAF with digital droplet PCR in flow-sorted monocytes (Mono), T and B-cells. We performed single-cell RNAseq (10x Genomics) on PBMCs. Luminex or ELISA kits were used to measure plasma proteins. Results 59/119 recruited pts had CHIP (VAF≥1%). CHIP pts were significantly older than non-CHIP pts. DNMT3A was the most commonly mutated gene (28%), followed by TET2 (17%) and ASXL1 (5.3%). 53 pts had impaired LV ejection fraction (LVEF) at admission and a follow-up Echo at median 4.6 months (2.5-8 IQR) post STEMI. They were classified as responder (R) n=24, Δ LVEF≥5% or non-responder (NR) n=29, ΔLVEF<5%. Pts with DNMT3A CHIP were 12 times more likely to be NR (p=0.02). Baseline LVEF was similar in CHIP and non-CHIP pts, but ΔLVEF was significantly reduced in DNMT3A vs non-CHIP pts (p<0.01). DNMT3A mutations were highest in Mono (mean VAF 6.3%), present in B cells (3%) but rare in T cells (1.7%). Within the Mono population, DNMT3A mutant pts had significantly higher proportions of classical Mono compared to non-CHIP (p=0.02). Using scRNAseq, we computed Mono trajectories and differential gene expression. Compared to non-CHIP, DNMT3A-mutant samples upregulated receptor for advanced glycation end-products (RAGE) and toll-like receptor signaling gene signatures. Despite this, we did not observe raised leukocyte count or detect increased levels of inflammatory cytokines in DNMT3A-mutant pts plasma samples. Conclusions DNMT3A CHIP is associated with poor LVEF recovery post-STEMI due to a dysregulated inflammatory response to acute myocardial injury. Furthermore, our data suggests that this may occur via different mechanisms than non-CHIP NR.

Impact of cardiac health status on bone marrow cell secretome and myocardial repair

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): University of Fribourg Graduate assistant Background Restoring the damaged myocardium remains a significant clinical challenge. Administration of bioactive factors, exosomes, or cell secretomes has shown promising results in promoting angiogenesis, tissue repair, immunomodulation, and extracellular matrix remodelling, particularly for cardiovascular disease treatments. Bone marrow (BM) cells are an essential source of secretome-based therapies for myocardial infarction (MI). Harnessing the potential of the cellular secretome for therapeutic applications requires a comprehensive understanding of its composition, functions, and mechanisms of action. MI affects the entire hematopoietic hierarchy, from stem cells to myeloid progenitors in BM. The study investigates how the cardiac status healthy versus infarcted affects the BM cell compositions and the properties of their secretomes. Methods Bone marrow cells (BMC) were isolated from healthy male Lewis rats (hBMC) and infarcted one (iBMC) obtained 2 weeks post MI induced by coronary artery ligation and cultured for 2 weeks. Cells composition, particularly macrophages, was characterised using multiplex flow cytometry Cytek Aurora. (CD90, CD29, CD45. CD68, CD206, CD163, Arg1, CD80, CCR7, iNOS). Cell proliferation (Real-time cell analyser and EdU incorporation), metabolic assays (seahorse assays), PCR, MS proteomic, and potency assays for immunomodulatory properties were performed. Results Multiplex flow cytometry showed distinctions in the percentage of cells: CD34+ stem cells and hematopoietic CD45+ cells were significantly upregulated in hBMCs, while CD68+ cells were higher in iBMCs. Cell proliferation assay demonstrated that iBMCs had significantly lower proliferation rates compared to hBMCs. Cell Metabolism was also impacted, iBMCs showed increased basal respiration, ATP production, and maximal respiration compared to hBMCs. An increase in respiratory spare capacity in iBMCs suggests an increased potential for ATP production under increased energy demands. Relative to hBMC, iBMC significantly regulated the expression of genes involved in immune response, inflammation, angiogenesis, and ECM remodelling gm-csf, il-17, vcam1, stat6, mmp9, cam, arg1, mhcII, arg2 were downregulated and tlr2, cxcl10, il-6, timp1, rantes, mcp-1, vegf, il-1ra, il-1beta, mip-1alpha, tlr4, b2m, and mmp3 upregulated. Secreted proteins also varied. Finally, the secretome of iBMC showed an enhanced capacity to induce a phenotype switch of macrophages toward an anti-inflammatory profile. Conclusion Our study shows that MI significantly alters the properties of bone marrow cells, impacting their composition, proliferation, metabolism, gene expression and the immunomodulatory potential of the secretome. These findings highlight the importance of considering donor health status in developing restoring secretome-based therapies for cardiac repair and emphasise the need to incorporate potency assay of the biologics for a standardised therapy and quality control.

Long-term impact of postnatal nutritional programming on cardiac sensitivity to ischemia-reperfusion injury in vivo and on glucose metabolism

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Fondation de France Introduction Nutritional environment during intra uterine and postnatal period has a major impact on health and disease in adulthood. The early programming of cardiometabolic risk through a postnatal overfeeding in rodents leads to a permanent increase in body weight, associated with alteration of left ventricular contractility, higher cardiac sensitivty to ischemic or chemo-toxic stresses and alterations of glucose métabolism in adulthood. However, these data have mainly obtained in young rodents and less is known for older animals. Purpose Our aim was to evaluate the impact of postnatal overfeeding (PNOF) on cardiac function, on cardiac sensitivity to ischemia-reperfusion (I-R) injury in vivo, on glucose metabolism and on metabolic profile of pericardial adipose tissue (PAT) in young (4 months), adult (6 months) and old (12 months) male mice. Methods PNOF was induced by the reduction of litter size of C57/BL6 mice immediately after birth: normally-fed group (NF) was composed of 9 male pups/mother and overfed group (PNOF) of 3 pups/mother. Echocardiography and blood sugar tests (glucose tolerance and insulin resistance) were performed at all ages. An in vivo ischemia-reperfusion injury was induced by the ligation of the left anterior descending coronary artery for 45 minutes followed by 24 h of reperfusion. PAT was harvested and weighted, in order to investigate by rt-qPCR its inflammatory status. All experiments were performed in 4-, 6- and 12-months aged mice. Results PNOF induced an early and permanent increase in body weight in PNOF group, independently of mice’s age (+23% at 24 days of life, +14% at 4 months, +23% at 6 and 12 months, compared to NF group). Echocardiographic measurements showed an alteration of left ventricular ejection fraction in mice aged from 4 months up to 12 months (-11 % on average, compared to NF groups). PNOF mice presented glucose intolerance and insulin resistance from 4 to 12 months of age. Moreover, PNOF mice had a higher PAT mass indexed to body weight with increased inflammatory status and decreased activin A mRNA expression at 6 and 12 months. Finally, PNOF induced a significant increase of infarct size at 4 months (+37%, p<0.01, n=8), 6 months (+32%, p<0.05, n=9) and 12 months (+38%, p<0,05, n=9) after cardiac surgery. Conclusion Nutritional programming through short-term PNOF induced an early and permanent overweight, an increase in pericardial fat mass with a greater inflammatory status, associated with alterations of glucose metabolism, alteration of systolic function and a higher sensitivity to ischemia reperfusion injury induced in vivo. The cellular mechanisms of these pathological modifications induced by PNOF need further exploration but could involve alterations in cardiomyocyte pathways and/or modification of global inflammatory status. Therefore, the PNOF mice model corresponds to a relevant experimental model of programmed metabolic syndrome as we known in humans.

Human induced pluripotent cardiomyocytes as a model for cardiomyopathy with a Myozap gene mutation

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): 1- Central Department of Missions, Egyptian Ministry of Higher education and Scientific Research. 2- small fund from Tampere University. The contractility of the heart is based on cardiomyocytes (CM). These cardiomyocytes are connected through a complex network of proteins forming the intercalated disc (ID) which is crucial to ensure mechanical and electrochemical coupling. Dilated cardiomyopathy (DCM) is a disease of the myocardium that can lead to heart failure and life-threatening arrhythmias. Up to 30% of DCM cases are caused by mutations in genes encoding proteins of the sarcomere (the basic contractile unit) or desmosome (a cell-to-cell adhesion structure) and the structural cytoskeleton. Myozap (Myocardium-Enriched Zonula Occludens-1-Associated Protein) is a distinctive cardiac-enriched ID protein. It is crucial for biomechanical stress adaption in CMs due to its outstanding role in the Rho/SRF (Serum Response Factor) signalling pathway. In this study, we have identified two Finnish families with DCM and carrying a novel variant in myozap. Our aim is to characterize myozap gene mutation-both heterozygous and homozygous truncating variants-as well as its implication in DCM. We have established patient-specific human induced pluripotent stem-cell lines and derived cardiomyocyte (hiPSC-CM) to study the disease at the cellular level. Myozap expression, compared to the control cell line, was evaluated by immunohistochemistry. Electrophysiological methods, including microelectrode array (MEA) and patch clamping, were implemented to measure various parameters with emphasis on those ones related to cell-cell connection e.g., the conduction velocity. Moreover, metabolic stress indicators, including oxygen consumption rate (OCR), were estimated by Seahorse. Additionally, qPCR and ELISA were performed to measure the colocalised and closely related genes to ID and protein level of troponin, respectively. Immunohistochemistry revealed downregulation and absence of myozap expression in heterozygous and homozygous cell lines, respectively. Compared to the control one, differences in BPM, FPD were observed. Metabolic analysis of the myozap mutant elucidated mitochondrial impairment compared to the control. Some SRF and sarcomeric target genes, including MYH7, MYH6 and Myl-2 were downregulated. On the contrary, apoptotic genes (e.g., caspase 3) were upregulated. Tight junction protein (TJP) was upregulated, and this is very importance since it is closely related to the myozap in the ID proteins network. Moreover, troponin protein level, measured by ELISA, showed upregulation in mutant myozap. In conclusion, our study provides a new insight into understanding myozap’s significance in cardiac biology and in cardiomyopathy pathophysiology.

Role of polymeric immunoglobulin receptor in glucose metabolism

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Fundación La Caixa 2022 HR22-0253. Comunidad de Madrid P2022/BMD-7333 INMUNOVAR-CM Background Type 2 diabetes and obesity are leading causes of death and disability worldwide, being both risk factors for cardiovascular disease. Intestinal immune system is being shown to have a key role in insulin resistance (IR). Polymeric immunoglobulin receptor (PIGR) is a transmembrane protein which facilitates the transcytosis of the soluble polymeric isoforms of immunoglobulin A (IgA) and is widely expressed in mucosal epithelial cells. IgA levels are reduced in obesity and the loss of IgA in mice worsens insulin resistance and increases inflammation in adipose tissue. However, the specific role of PIGR in IR has not been fully elucidated. Aim To analyze the role of PIGR in systemic glucose metabolism. Methods To determine the impact of global silencing of Pigr on whole-body glucose metabolism, we metabolically characterized the Pigr-/- female mouse 60% fat diet (HFD). We performed glucose and insulin tolerance tests. In vivo and ex vivo adiposity was measured by dual x-ray absorptiometry (DXA) and adipose tissue depots weight, fasting glucose and insulin plasma levels were determined at endpoint. Circulating IgA levels were measured by ELISA and IgA deposition in liver and adipose tissue of control and Pigr-/- mice was determined by western blot and immunohistochemistry. Results As previously described, we show that IgA serum levels were highly increased in Pigr -/- mice. Besides, we demonstrate that IgA deposition in liver and adipose tissue was increased in these mice. We demonstrate that global deletion of Pigr results in whole-body glucose intolerance and IR mice fed HFD. Fasting glucose levels (169.24±24.49 mg/dl in Pigr -/- mice vs 142±27mg/dl in control mice) and fasting insulin levels (1.27±0.42 ng/ml in Pigr -/- mice vs 0.92±0.37 ng/ml in control mice) were significantly increased in Pigr -/- mice fed HFD for 17 weeks. No differences were found in lipid profile levels (triglycerides, HDL-c, VLDL+LDL-c and NEFA). Interestingly, Pigr-/- mice show significant increased adiposity (46±4.11 % adiposity vs 50.6±4.9 in control) measured by DXA, which results in a significant increase in body weight (BW), compared to control (BW gain over 20 weeks on HFD: 21.85± 3.06 gr in Pigr -/- mice vs 17.93±2.1 gr). mRNA expression of the β isoform of carbohydrate responsive-element binding protein (ChREBPβ) is significantly reduced (0.5 folds vs control group) in Pigr -/- adipose tissue, which might link the whole-body metabolic phenotype to ChREBP-dependent glucose sensing by adipose tissue. Conclusion Global Pigr deletion results in whole-body glucose intolerance and IR in female mice fed HFD. Our results suggest cell-intrinsic mechanisms of Pigr deletion as well as extracellular components (increased IgA serum levels and deposition in tissues) as potential triggers of systemic glucose metabolism disruption. Management of PIGR levels might be key for glucose-metabolism-related pathologies.

Study of the cardiac sodium channel in a mouse model of Scn5a haploinsufficiency towards a novel approach of therapy

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Sorbonne Université doctoral scolarship INSERM Introduction Brugada syndrome (BrS) is an inherited cardiac arrhythmia that greatly increases the risk of sudden death as a result of ventricular fibrillation. Approximately 20% of BrS cases can be attributed to a mutation in SCN5A, the gene encoding the alpha-subunit Nav1.5 of the cardiac sodium-channel, which carries the sodium current INa. These mutations typically lead to loss-of-function of Nav1.5, resulting in a decrease in INa and most of them (»70 %) are responsible for haploinsufficiency. In the Scn5a+/- mouse model, a sodium-channel dysfunction phenotype is observed, characterized by conduction abnormalities (PR and QRS interval prolongation), a 50% reduction in INa, and an increased susceptibility to arrhythmias. Aim The aim of this study was to assess the impact of the overexpression of a Nav1.5-peptide, which has been found to enhance INa, in Scn5a+/- mice, as a novel approach of therapy. Methods We used AAV9-systemic injection to overexpress the Nav1.5-peptide into the heart of Scn5a+/- mice to gauge their susceptibility to arrhythmias induced by intracardiac pacing. We also examined the Nav1.5-peptide effects on endogenous Nav1.5 expression through molecular biology and biochemistry analyses. Results The duration of PR and QRS intervals in the hearts of Scn5a+/- mice was restored to normal by overexpression of the Nav1.5-peptide (PR interval = 46.3 ± 0.9 ms, n=22 in Scn5a+/- mice vs 40.4 ± 0.8 ms, n= 23 in WT mice, P<0.0001 and 42.6 ± 0.9 ms, n=11 in Scn5a+/- +Nav1.5-peptide, P<0.05; QRS interval = 15.2 ± 0.4, n=22 ms in Scn5a+/- mice vs 13.2 ± 0.4 ms, n=23 in WT mice, P<0.01 and 13.6 ± 0.4 ms, n=14 in Scn5a+/- +Nav1.5-peptide, P<0.05). Additionally, overexpression of the Nav1.5-peptide seemed to protect Scn5a+/- mice from induced arrhythmic events caused by programmed-ventricular stimulation (total premature beats = 1.3 ± 0.4 in Scn5a+/- mice, n = 13 vs 0.2 ± 0.2, n = 6 in injected Scn5a+/- mice, NS and 0.2 ± 0.2, n = 12 in WT mice, P< 0.05). There were no significant differences in total Nav1.5 expression between injected and non-injected mice as shown by RT-qPCR and Western-blots, but the expression of Nav1.5 at the plasma membrane appeared to be restored by overexpression of the Nav1.5-peptide (Nav1.5/N-cadherin ratio = 0.50 ± 0.08, n = 11 in Scn5a+/- mice vs 1 ± 0.15, n= 11 in WT mice, P< 0.05 and 0.94 ± 0.13, n = 11 in injected Scn5a+/- mice, P< 0.05). Conclusion Gene therapy with Nav1.5-peptide can attenuate both conduction defects and increased arrhythmia inducibility observed in Scn5a+/- mice. Although additional studies will be needed to confirm and explore further our results, this could be promising to treat patients with « sodium-channel dysfunction » such as BrS.

Cardioprotective effects of Empagliflozin in cardiac volume overload-induced by aortocaval fistula in rats

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Slovak Research and Development Agency under the contract no. 21-0410 VEGA grants no. 2/0006/23 Heart failure is characterized by reduction in cardiac output and the occurrence of malignant arrhythmias, thereby contributing significantly to high morbidity and mortality worldwide. Myocardial structural remodelling is a key factor contributing to the development of these life-threatening events and belongs to unsolved clinical issues challenging to investigate in animal models. The aim of our study was to explore the impact of cardiac volume overload (VO) on structural remodelling and electrical coupling protein, connexin43 (Cx43) in the left and right heart ventricles as well as the efficacy of treatment with SGLT2i, Empagliflozin. Aortocaval fistula (ACF) was surgically induced in 6-month-old Wistar rats, to develop VO during 4 weeks, followed by oral administration of Empagliflozin 10 mg/kg/b.w. daily for 5 weeks. At the end of the experiment, biometric parameters were registered and left and right heart tissue samples were snap-frozen and kept at -80°C for western blot analysis and microscopic examination. Findings revealed an increase of heart, left and right ventricular mass due to ACF-VO versus sham controls, which was associated, with eccentric myocardial hypertrophy. Noteworthy, Empagliflozin reduced heart, left and right ventricular mass. Levels of myocardial protein Cx43, that determine electrical coupling among cardiomyocytes, were reduced by ACF-VO, while normalized by treatment with Empagliflozin. Moreover, treatment attenuated ACF-VO-induced increase of interstitial collagen visualized by van Gieson staining. It was in line with the protein expression of MMP-2, which is involved in structural remodeling. The protein levels of PKCε, concerned/associated with modulation of Cx43 and extracellular matrix, were decreased due to ACV-VO but normalized after treatment with Empagliflozin. On the other hand, protein levels of PKCδ, involved in proapoptotic and prohypertrophic pathways, were increased and normalized by Empagliflozin. The changes were more pronounced in the right ventricle compared to the left heart ventricle. In summary, our pilot results point out the benefit of Empagliflozin due to the suppression of myocardial structural remodelling and preservation of Cx43 in the rat ACF-VO model. Furthermore, this Empagliflozin-induced cardioprotection was associated with the normalization of Cx43, MMP-2, and PKC levels independent of glucose control. However, further analyses are needed to reveal the molecular mechanisms of the cardioprotective effects of Empagliflozin.

Drug-interacting gene expression levels differ between atherosclerotic plaque subtypes

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Dutch Heart foundation Recent transcriptomic-based clustering of human atherosclerotic plaques revealed that plaques have a diversity and complexity that cannot be accurately described by classical concepts. Previous plaque RNA sequencing that we performed in 654 lesions identified five major plaque types that reflect different mechanisms of progression of atherosclerotic disease. These include the following plaque subtypes: 0. Fibro-collagenous, 1. Intermediate, 2. Lipo-necrotic, 3. Fibro-inflammatory, and 4. Fibro-cellular. We hypothesize that these different plaque types may respond differentially upon drug treatment. Objective To assess differential expression levels of drug-responsive genes between the earlier described five plaque subtypes. For this in silico experiment, the differential expression of drug-responsive genes was examined after colchicine treatment in smooth muscle cells and endothelial cells. Methods To begin, a web-based search identified 46 published colchicine interacting genes. Then, colchicine was applied to cultured smooth muscle and endothelial cells to verify the publicly reported drug responsive genes. Next, we modelled the effect of colchicine on the five types of human atherosclerotic plaques for those genes that were considered drug responsive. This was achieved by projecting the in vitro derived expression changes onto the gene expression data from the carotid plaques of 654 patients who participated in the ATHERO-EXPRESS study. Besides colchicine, the same experimental approach was applied for atorvastatin and rofecoxib drug treatment. Finally, changes in drug responsive gene expression were validated with mice gene expression data. Results 34 out of the 46 publicly known colchicine interacting genes were differently expressed between plaque types (Figure 1). These genes included established determinants of cell motility and atherosclerosis development (SCD, ITGB1, Tubulins). Furthermore, in-silico colchicine treatment revealed colchicine's strong effect on the atherosclerotic plaques' transcriptome. We are currently assessing if these perturbations may lead to shifts in plaque subtypes and if these changes are reflected in mice transcriptomic data. Conclusion The pilot data demonstrated major differences in drug-interacting gene expression levels in advanced atherosclerotic lesions. Therefore, novel and standard drugs used to treat atherosclerosis may have varying effects depending on the atherosclerotic plaque subtype.

Role of inflammatory populations and their intermediates in post-ischemic adverse remodeling in rat model of myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Junta de Andalucía- Fondos FEDER Background Compelling evidence demonstrated the critical role of inflammation in ventricular adverse remodeling after acute myocardial infarction. However, it remains unclear how inflammatory cell population and their intermediates participate in the progress of the disease. Purpose This study aims to elucidate the role of inflammatory population in cardiac remodeling after myocardial infarction in a rat model, focusing on their role in fibrosis. Methods We used a surgical procedure by transient ligation of the left descendant coronary artery, to evoke ischemia-reperfusion (I/R) in rats. We performed FACS analysis to evaluate counts of neutrophils and two monocytes’ subsets: CD43lowHis48high (classical monocytes), and CD43highHis48low (non-classical monocytes), which are the most pro-inflammatory subset in peripheral blood. Subsequently, we performed immunofluorescence to detect pro-inflammatory M1 and M2 macrophages (CD68+ and CD163+) in the rat infarcted myocardium. Moreover, we sorted the two monocyte subsets and performed genes and microRNAs Array. Results FACS analysis of neutrophils and monocytes subsets showed an increased level of these cells in the rat model of myocardial infarction, one week after the post-ischemic event. In parallel, the infiltration of M1 macrophages was increased in the myocardium until 1 week after surgery, indicating a long extravasation of inflammatory cells after the ischemic event. Moreover, co-culture of fibroblasts and cardiomyocytes with intermediates released by inflammatory cells subjected to I/R increased the expression of fibrotic and apoptotic genes. In addition, the analysis of genes’ Array by GSEA indicated that CD43highHis48low monocytes had an enrichment score in pathways associated with angiogenesis, fibrosis and inflammation, while CD43lowHis48high population exhibited an enrichment in cytokines and inflammation, apoptosis and fibrosis. Finally, we found significant overexpression of microRNAs, for instance, miR-27a-3p, miR-29b-3p, miR-30e-5p and miR-194-5p in CD43highHis48low 24h after the I/R procedure. Those miRNAs are predicted to modulate pro-fibrotic genes. Conclusions The level of inflammatory cell populations is increased in I/R rat model. Moreover, these cells infiltrate in the myocardium likely to change the transcriptome of resident cells towards a pro-apoptotic and pro-fibrotic phenotype.

Microtubule-induced restriction of nuclear deformability in hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Leducq foundation Background Hypertrophic cardiomyopathy (HCM) is characterized by abnormal thickening of the left ventricular (LV) wall in conjunction with diastolic dysfunction with a prevalence of ~1:200. HCM pathophysiology is incompletely understood. We hypothesized that misregulated mechanotransduction plays an important role in the disease process. Extensive cytoskeletal remodeling has been observed in HCM patients, with a robust increase in tubulin and desmin levels, with a concomitant increase in stabilizing post-translational modifications, which we previously showed contributes to diastolic dysfunction. Microtubules are connected to the nucleus by the LINC complex. Little is known about the interaction of the non-sarcomeric cytoskeleton with the nucleus and the role this may have in the development of HCM. Purpose Relate cytoskeleton changes to nuclear and chromatin morphology in HCM patient myocardium and assess nuclear deformability in contracting cardiomyocytes with and without microtubule destabilizing drugs. Methods Nuclear morphology and chromatin organization was assessed using electron microscopy in cardiac septal tissue from 19 patients with obstructive HCM and compared to samples from 4 non-failing donors (NF). Further nuclear changes were studied using wild type (WT) and homozygous Mybpc3 c.2373InsG mice (Mybpc3c.2373InsG, KI), which have a HCM phenotype. Nuclear morphology was assessed in slices of 6 WT and 6 Mybpc3c.2373InsG paraffin-embedded mouse hearts. To study nuclear deformability during contractions, adult cardiomyocytes were isolated, stained with live cell dyes and imaged live while electrically paced. Lastly, DNA damaged was assessed in 6 WT and 6 Mybpc3c.2373InsG paraffin-embedded mouse hearts. Results Cardiomyocyte nuclei of HCM patients had a significantly higher number of invaginations (0.32±0.09 invaginations/µm in HCM versus 0.18±0.03 invaginations/µm in NF hearts), were more irregular of shape and had altered chromatin organization compared to those from NF hearts. Nuclei of Mybpc3c.2373InsG mice were considerably larger (322±75 µm³ versus 221±24 µm³). While sarcomere shortening is similar (7.0±1.4% in Mybpc3c.2373InsG versus 6.5±1.7% in WT), nuclei from Mybpc3c.2373InsG mice are less deformable than WT nuclei (figure). Addition of microtubule destabilizer nocodazole or detyrosination inhibitor EPO-Y restored nuclear deformability to WT levels, indicating a role of detyrosinated microtubules in nuclear deformability. In addition, nuclei from Mybpc3c.2373InsG have more extensive DNA damage (19.7±3.4 foci in Mybpc3c.2373InsG versus 9.1±3.2 foci in WT). Conclusion Extensive nuclear changes are observed in HCM patients and a HCM mouse model. Cytoskeletal remodeling results in less deformable nuclei that might contribute to chromatin alterations and increased DNA damage. Nuclear deformability can be restored by microtubule modifying drugs, specifically those that decrease microtubule detyrosination.

Human atherosclerotic plaque macrophages associate with clinical presentation and follow diverse lineage differentiation routes

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Research Council Veni grant. Netherlands Heart Foundation Atherosclerosis is characterized by inflammation and lipid accumulation, leading to complications such as stroke and myocardial infarction. Various macrophage subsets are present in human atherosclerotic plaques. However, it is unclear how subsets are interrelated and contribute to the disease process and its clinical outcomes. Here, we employed single-cell RNA-seq (scRNA-seq) on blood and plaque material from carotid endarterectomy patients enrolled in the AtheroExpress (AE) cohort to define regulatory pathways of macrophage recruitment, differentiation, and development. Additionally, we used these scRNA-seq data to deconvolute a large AE bulk RNA-seq cohort to allow correlating cellular subsets in plaques with clinical traits. Interestingly, we found that macrophages and their subsets are the only cell population significantly associated with major adverse cardiac events (MACE) during a 3-year follow-up period. Subsequently, we could divide plaque macrophages into 3 populations: inflammatory, tissue-resident / lipid-associated (TREM2 high), and foamy macrophages (TREM1 high). While the latter two are correlated with MACE, the inflammatory macrophages are inversely correlated with statin use. Cellular fate analyses revealed two major paths of macrophage development in the plaque. First, non-classical monocytes entering the plaque, turning into inflammatory cells before becoming foamy and eventually dying. Second, resident-like macrophages that turn into either inflammatory- or lipid-associated macrophages, before meeting their foamy demise. Together, these findings provide important insights on macrophages in atherosclerosis and suggest new leads to discover therapeutic targets for this disease.