Stabilization Of Vulnerable Plaques Research Articles

Stabilization of vulnerable plaque in the ACS patient: evidence from HUYGENS studies.

The introduction of PCSK9 inhibitors in addition to statin therapy allowed better control of LDL-C plasma levels with a subsequent reduction of cardiovascular events. Human atherosclerosis has been previously considered an irreversible condition; studies firstly based on angiography imaging and secondly with intra-coronary imaging-mainly IVUS based-have demonstrated that lipid-lowering therapy based on statins can stabilize and even reduce atherosclerotic burden of coronary circulation. While plaque stabilization and/or reduction with PCSK9 inhibitors have already been demonstrated in the GLAGOV study, the HUYGENS study showed a positive effect not only on atherosclerotic burden but also on plaque phenotype, with an increased FCT, decrease in maximum lipid arch, and reduction of macrophages infiltration. Further studies need to assess the clinical impact of the reduction of plaques displaying high-risk features with PCSK9 inhibitors.

Downregulation of GSK-3β Expression via Ultrasound-Targeted Microbubble Destruction Enhances Atherosclerotic Plaque Stability in New Zealand Rabbits

Accumulating evidence suggests that atherosclerosis (AS) is the underlying cause of vascular diseases, including heart disease and stroke. Ultrasound-targeted microbubble destruction (UTMD) technology provides a tolerable, efficient and effective system for drug delivery and gene transfection, which has broad application prospects in the treatment of AS. In addition, glycogen synthase kinase (GSK)-3β has been implicated as a potentially valuable therapeutic agent for AS treatment; however, the specific molecular mechanisms remain unknown. Therefore, this study was conducted to explore the effect of downregulation of GSK-3β expression via UTMD on atherosclerotic plaque stability. We established a THP-1 macrophage-derived foam cell model in vitro and an atherosclerotic plaque model in the right common carotid artery of New Zealand rabbits. We determined levels of the relevant vulnerable plaque stability elements. The results indicate that GSK-3β was upregulated in the foam cells and in atherosclerotic rabbits. Downregulation of GSK-3β expression by UTMD suppressed vulnerable plaque factors and inflammation in vitro and in vivo, changed the cytoskeleton of the foam cells in vitro, increased Young's modulus and decreased the peak intensity of atherosclerotic plaque in vivo. Moreover, GSK-3β inhibition by UTMD did not influence the viability of the foam cells. Collectively, our results indicate that GSK-3β could be a potential target for anti-atherogenic interventions and, in particular, can improve the stability of AS plaques in combination with UTMD.

Therapeutic ultrasound combined with microbubbles improves atherosclerotic plaque stability by selectively destroying the intraplaque neovasculature.

Objective: The current antiangiogenic therapy for atherosclerotic plaques was mainly achieved by the use of antiangiogenic drugs, but serious side effects have limited the clinical application. The present study investigated whether therapeutic ultrasound (TUS) treatment with appropriate pressure could selectively deplete the neovasculature in vulnerable plaques to improve its stability with no side effects on the body; the underlying mechanisms were also explored.Methods and Results: A mouse model of advanced atherosclerosis was generated by maintaining apolipoprotein E-deficient (ApoE-/-) mice on a hypercholesterolemic diet (HCD). Plaque, skeletal muscle, mesentery and skin tissue from 114 atheroma-bearing mice were subjected to sham therapy, an ultrasound application combined with microbubbles at four different ultrasound pressures (1.0, 2.0, 3.0, 5.0 MPa), or ultrasound at 5.0 MPa alone. Microvessel density (MVD) was assessed by immunofluorescence and immunohistochemical methods. The plaque necrotic center/fiber cap (NC/FC) ratio and vulnerability index were calculated to evaluate plaque vulnerability. Twenty-four hours after TUS treatment at 3.0 MPa, the MVD in the plaque was substantially decreased by 84% (p < 0.05), while there was almost no change in MVD and neovessel density (NVD) in normal tissues, including skeletal muscle, mesentery and skin. Additionally, a marked reduction in the number of immature vessels was observed in the plaques (reduced by 90%, p < 0.05), whereas the number of mature vessels was not significantly decreased. Furthermore, TUS treatment at 3.0 MPa significantly improved plaque stability, as reflected by the NC/FC ratio and vulnerability index, which may be due to the selective destruction of intraplaque neovascularization by TUS treatment, thereby decreasing the extravasation of erythrocytes and leading to vascular inflammation alleviation and thin-cap fibroatheroma reduction.Conclusions: TUS treatment at 3.0 MPa selectively depleted plaque neovessels and improved the stability of vulnerable plaques through a reduction in erythrocyte extravasation and inflammatory mediator influx, with no significant effect on normal tissue.

An Innovative Method for Endovascular Stabilization of Vulnerable Plaque in Coronary Arteries: An Opinion

Despite all of the available diagnostic and treatment modalities atherosclerosis remains one of the most common healthcare problems worldwide with an estimated annual mortality rate of approximately 17,5 million cases

Atorvastatin Inhibits Inflammatory Response, Attenuates Lipid Deposition, and Improves the Stability of Vulnerable Atherosclerotic Plaques by Modulating Autophagy.

Atherosclerosis is a chronic disease comprising intima malfunction and arterial inflammation. Recent studies have demonstrated that autophagy could inhibit inflammatory response in atherosclerosis and exert subsequent atheroprotective effects. Our previous study also demonstrated the role of autophagy in the inhibition of inflammation by atorvastatin in vitro. Therefore, in the present study, we aimed to determine whether atorvastatin could upregulate autophagy to inhibit inflammatory cytokines secretion, lipid accumulation, and improve vulnerable plaque stability, both in vitro and in vivo. First, we established a vulnerable atherosclerotic plaque mouse model through partial ligation of left common carotid artery and left renal artery to explore the effect of atorvastatin on vulnerable plaques. The results showed that atorvastatin could enhance the stability of vulnerable atherosclerotic plaques and reduce the lesion area in the aorta. Atorvastatin could also inhibit NLRP3 inflammasome activation and inflammatory cytokines, such as IL-1β, TNF-α, and IL-18 secretion in vivo. Atorvastatin treatment upregulated the expression of autophagy-related protein microtubule-associated protein light chain (LC3B) and downregulated the expression of SQSTM1/p62, which suggested that autophagy was activated in vulnerable plaques. Transmission electron microscopy further demonstrated the atorvastatin-induced increase in autophagy activity in vulnerable atherosclerotic plaques. We employed oxidized low-density lipoprotein (ox-LDL) to stimulate RAW264.7 cells with atorvastatin, which showed that atorvastatin could attenuate lipid deposition, ameliorate inflammation, inhibit NLRP3 inflammasome activation, and enhance autophagy in vitro. All these beneficial effects were abolished by 3-methyladenine treatment, an autophagy inhibitor. Atorvastatin also significantly inhibited the phosphorylation of mTOR, which strongly suggested the involvement of the mTOR pathway. Our study proposed a new role for atorvastatin as an autophagy inducer to exert anti-inflammatory and atheroprotective effects, to stabilize vulnerable atherosclerotic plaques.

MicroRNA Let-7g and Atherosclerosis Plaque Stabilization

Vascular atherosclerotic vulnerable plaque rupture is the primary cause of acute myocardial infarctions and strokes. Thus, stabilization of vulnerable plaques is of important clinical endeavor to decrease the fatal risk of atherosclerosis. Inflammatory infiltration, apoptosis of endothelial cells (ECs) and vascular smooth muscle cells (VSMCs), destruction of extracellular matrix (ECM) or collagen, and neovascularization all contribute to the formation and stability of plaque. Let-7g, one miRNA of let-7 family, is related to retardation of the progress of vulnerable atherosclerosis plaque. First of all, let-7g induced preservation on vascular diseases through regulating on the intracellular Ca2+- activated protein kinase C-oxLDL-LOX-1 pathway, which resulted in reduced leukocyte adhesion to and migration across endothelium. Over expression of let-7g negatively regulated apoptosis in the ECs by targeting lectin-like oxidized LDL receptor-1(LOX-1)/CASP3 expression, therefore made the fibrous cap of plaque integrated and thick, increased the density of vascular atherosclerotic plaque. In addition, let-7g might stabilize the atherosclerotic plaque through other aspects. In this review, we focus on current and potential importance of let-7g on the stabilization of atherosclerosis plaque which might lead to the future development of an alternative strategy of CAD.

Tanshinone II A stabilizes vulnerable plaques by suppressing RAGE signaling and NF-κB activation in apolipoprotein-E-deficient mice.

Tanshinone II A (TSIIA) is a diterpene quinone extracted from the roots of Salvia miltiorrhiza with anti-inflammatory and anti-oxidant properties that is used to treat atherosclerosis. In the current study, morphological analyses were conducted to evaluate the effects of TSIIA on atherosclerotic vulnerable plaque stability. Additionally, receptor of advanced glycation end products (RAGE), adhesion molecule, and matrix-metalloproteinases (MMPs) expression, and nuclear factor-κB (NF-κB) activation were examined in apolipoprotein E (apoE)-deficient mice treated with TSIIA. Eight-week-old apoE−/− mice were administered TSIIA and fed an atherogenic diet for 8 weeks. TSIIA exhibited no effects on plaque size. Analysis of the vulnerable plaque composition demonstrated decreased numbers of macrophages and smooth muscle cells, and increased collagen content in apoE-deficient mice treated with TSIIA compared with untreated mice. Western blotting revealed that TSIIA downregulated the expression levels of vascular cellular adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and MMP-2, −3, and −9, suppressed RAGE, and inhibited NF-κB, JNK and p38 activation. The present study demonstrated that the underlying mechanism of TSIIA stabilization of vulnerable plaques involves interfering with RAGE and NF-κB activation, and downregulation of downstream inflammatory factors, including ICAM-1, VCAM-1, and MMP-2, −3 and −9 in apoE−/− mice.

Abstract 3: Targeting Macrophage Necroptosis for Therapeutic and Diagnostic Interventions to Treat Atherosclerosis

Background: Atherosclerosis results from maladaptive inflammation driven primarily by macrophages, whose recruitment and proliferation drive plaque progression. In advanced plaques, macrophage death contributes centrally to the formation of plaque necrosis, which underlies the instability that promotes plaque rupture and myocardial infarction. As such, targeting macrophage cell death pathways may offer promise for the stabilization of vulnerable plaques. Necroptosis is a recently discovered pathway of programmed cell necrosis regulated by RIP3 and MLKL kinases that in contrast to apoptosis, induces a pro-inflammatory state. We hypothesize that atherogenic ligands within the plaque promote macrophage necroptosis and this process underlies necrotic core formation and drives atherosclerotic plaque instability. Results: In humans with unstable carotid atherosclerosis, expression of RIP3 and MLKL is increased and MLKL phosphorylation, a key step in the commitment to necroptosis, is detected in advanced atheromas. Investigation of the molecular mechanisms underlying plaque necroptosis showed that macrophages treated with oxidized LDL have increased expression of necroptotic genes RIP3 and MLKL through ROS-dependent activation of the promoter region and increased RIP3 and MLKL phosphorylation. Combined treatment with oxLDL and DAMPs (damage associated molecular patterns) amplified macrophage necroptotic cell death, indicating that additional inflammatory stimuli present in the lesion could act synergistically to promote necroptosis. Using a radiotracer developed with the necroptosis inhibitor Nec-1, we show that 123 I-Nec1 localizes specifically to atherosclerotic plaques in Apoe-/- mice, and its uptake is tightly correlated to lesion areas by ex vivo nuclear imaging. Furthermore, treatment of Apoe-/- mice with established atherosclerosis with Nec-1 reduced lesion size and markers of plaque instability, including necrotic core formation. Conclusions: Our findings offer molecular insight into the mechanisms of macrophage cell death that drive necrotic core formation in atherosclerosis and suggest that this pathway can be used as both a diagnostic and therapeutic tool for the treatment of unstable atherosclerosis.

Octanoylated ghrelin attenuates angiogenesis induced by oxLDL in human coronary artery endothelial cells via the GHSR1a-mediated NF-κB pathway

ObjectiveLow concentrations of oxidized low-density lipoprotein (oxLDL) promote the in vitro angiogenesis of endothelial cells and play an important role in plaque angiogenesis, which may cause plaque vulnerability and enhance the risk of intravascular thrombosis. The aim of this research was to investigate the effects of octanoylated ghrelin on oxLDL-induced angiogenesis and the underlying molecular mechanisms involved in this process. Materials/MethodsHuman coronary artery endothelial cells (HCAECs) were incubated with 5μg/ml oxLDL and treated with various concentrations of octanoylated ghrelin (10−9–10−6M) with or without inhibitors for 24h. Cell proliferation, migration, and in vitro angiogenesis were analyzed by bromodeoxyuridine (BrdU) staining and BrdU enzyme-linked immunosorbent assay (ELISA), transwell assay, and tube formation on Matrigel, respectively. NF-κB (nuclear factor κB) expression was determined by Western-blot analysis. ResultsTreatment with oxLDL at 5μg/ml enhanced the proliferation, migration and tube formation of HCAECs. In contrast, pretreatment with octanoylated ghrelin significantly attenuated in vitro angiogenesis in oxLDL-induced HCAECs. In addition, Western blot analysis indicated that NF-κB expression was increased after oxLDL treatment, and that this effect was significantly reversed by pretreatment with octanoylated ghrelin. However, the NF-κB inhibitor PDTC or the GHSR1a inhibitor [D-Lys3]-GHRP-6 abolished the effects of octanoylated ghrelin on the inhibition of angiogenesis and NF-κB p65 expression induced by oxLDL. ConclusionsThese findings suggest that octanoylated ghrelin attenuates angiogenesis induced by oxLDL in HCAECs via the inhibition of GHSR1a-mediated NF-κB pathway. Furthermore, octanoylated ghrelin may promote the stability of vulnerable plaques by inhibiting plaque angiogenesis.

Abstract 14864: Risk Markers for Coronary Plaque Progression and Destabilization Beyond LDL-Cholesterol in Patients with Acute Coronary Syndrome

Introduction and Purpose: In acute coronary syndrome (ACS) patients, it is important to stabilize pan-coronary vulnerable plaques as early as possible in ACS patients, in addition to revascularization of the culprit lesion by percutaneous coronary intervention (PCI). Although statins are effective for regression and stabilization of vulnerable plaques in ACS patients, several patients experience plaque progression and/or destabilization despite aggressive control of low-density lipoprotein (LDL)-cholesterol by statins. Therefore, we should do further efforts to research new risk markers beyond LDL-cholesterol and to intervene in them. Methods and Results: In 57 patients with ACS, who underwent emergent percutaneous coronary intervention (PCI), we performed a virtual histology (VH)-IVUS for a non-culprit lesion, at baseline and at the follow-up time (8-10 months), to assess plaque regression/progression and plaque stabilization/destabilization. At the follow-up time, we measured specific biomarkers. All of the patients received aggressive treatment with statins. Change in the total plaque volume by the gray scale IVUS was correlated positively with derivatives of reactive oxygen metabolites (d-ROMs) level (0.32, P&lt;0.05). Change in the volume of destabilized components, i.e., necrotic core plus fibro-fatty compositions, was correlated negatively with the eicosapentaenoic acid to arachidonic acid (EPA/AA) ratio (R=-0.39, P&lt;0.01) and positively with the levels of interleukin (IL)-8 (R=0.31, P&lt;0.01) and d-ROMs (0.32, P&lt;0.01). Multivariate logistic regression analysis showed that only the d-ROMs level was an independent discriminative biomarker for plaque progression (hazard ratio; 1.018, 95% confidence interval; 1.005-1.032, P&lt;0.01) and plaque destabilization (hazard ratio; 1.022, 95% confidence interval; 1.005-1.038, P&lt;0.01). Conclusions: The d-ROMs would be a powerful biomarker to predict plaque progression and destabilization as the residual risk marker beyond LDL-cholesterol. Intervention to oxidative stress state would be the most important residual target beyond LDL cholesterol lowering for plaque regression and stabilization.

Intravenous infusion of mesenchymal stem cells can stabilize vulnerable atherosclerotic plaque

Objective To establish the vulnerable atherosclerotic plaque model with rabbits and treat them with intravenous infusion of bone marrow mesenchymal stem cells(MSCs),so as to verify the impact of MSCs on the stability of vulnerable plaque(VP).MethodsTotally 24 healthy male New Zealand white rabbits were randomly divided into three groups.Carotid vulnerable atherosclerotic plaque models were made with rabbits in VP group(n=8) and VP+MSCs group(n=8);VP+MSCs group was given intravenous infusion of 1×107 MSCs immediately after modeling and VP group was infused with phosphate buffer.Stable atherosclerosis plaque model was made with rabbit in SP group(n=8).Animals in all groups were sacrificed at the end of the 12th week,and the right common carotid arteries were collected and subjected to H-E staining and Masson staining,and the cap/core ratio of atherosclerotic plaque was measured.MMP-2 content was examined by immunohistochemistry.ResultsH-E staining.In VP group the plaque showed a large lipid core and thin fibrous cap,remnants of foam cells and many inflammatory cells were seen in the plaque shoulder,and some showed rupture plaques and/or thrombosis.In SP group,the structure of plaque was in integrity,with thick fibrous cap and fewer inflammatory cells,and with no plaque rupture.The plaque structure of VP+MSCs group was between those of the other two groups.The order of cap/core ratio was SP group VP+MSCs group VP group,with that of VP group being significantly different from those of the other two groups(P0.01).Masson staining.The contents of muscle fiber and elastic fiber were the highest in SP group,followed by VP+MSCs group,and then by VP group.The level of MMP-2 in VP group was significantly higher than those in the other two groups(P0.01),and that in VP+MSCs group was significantly higher than that in SP group(P0.01).ConclusionIntravenous infusion of MSCs can improve the stability of plaques in VP rabbit model,which may be associated with the reduction of inflammatory cells and MMP-2 level,and the subsequent reduction of collagen fiber degradation.

Pancoronary plaque vulnerability in patients with acute coronary syndrome and ruptured culprit plaque: A 3-vessel optical coherence tomography study

Recent studies described different clinical and underlying plaque characteristics between patients with and without plaque rupture presenting with acute coronary syndrome (ACS). In light of the systemic nature of atherosclerosis, we hypothesized that nonculprit plaques might also express different morphological features in these 2 groups of patients. Thirty-eight patients with ACS who underwent 3-vessel optical coherence tomography imaging were identified from the Massachusetts General Hospital Optical Coherence Tomography Registry. Based on culprit plaque morphology, the study population was divided into 2 groups: patients with plaque rupture at the culprit lesion (group 1) and patients with nonruptured plaque at the culprit lesion (group 2). Prevalence and features of nonculprit plaques were compared between the 2 groups. A total of 118 nonculprit plaques were analyzed. Patients in group 1 (n = 17) had nonculprit plaques with higher prevalence of thin-cap fibroatheroma (52.9% vs 19.0%, P = .029) and disruption (35.3% vs 4.8%, P = .016) compared with patients in group 2 (n = 21). Nonculprit plaques in group 1 showed wider maximum lipid arc (198.9° ± 41.7° vs 170.2° ± 41.9°, P = .003), greater lipid length (7.8 ± 4.4 mm vs 5.1 ± 2.4 mm, P = .003), higher lipid index (1196.9 ± 700.5 vs 747.7 ± 377.3, P = .001), and thinner fibrous cap (107.0 ± 56.5 μm vs 137.3 ± 69.8 μm, P = .035) compared with those in group 2. The present study showed distinctive features of nonculprit plaques between patients with ACS caused by plaque rupture and patients with ACS caused by nonruptured plaques. Patients with plaque rupture had increased pancoronary vulnerability in nonculprit plaques, suggesting that a more aggressive treatment paradigm aiming at the stabilization of vulnerable plaques may offer additional benefit to these patients.

Biomechanics of Atherosclerotic Coronary Plaque: Site, Stability and In Vivo Elasticity Modeling

Coronary atheroma develop in local sites that are widely variable among patients and are considerably variable in their vulnerability for rupture. This article summarizes studies conducted by our collaborative laboratories on predictive biomechanical modeling of coronary plaques. It aims to give insights into the role of biomechanics in the development and localization of atherosclerosis, the morphologic features that determine vulnerable plaque stability, and emerging in vivo imaging techniques that may detect and characterize vulnerable plaque. Composite biomechanical and hemodynamic factors that influence the actual site of development of plaques have been studied. Plaque vulnerability, in vivo, is more challenging to assess. Important steps have been made in defining the biomechanical factors that are predictive of plaque rupture and the likelihood of this occurring if characteristic features are known. A critical key in defining plaque vulnerability is the accurate quantification of both the morphology and the mechanical properties of the diseased arteries. Recently, an early IVUS based palpography technique developed to assess local strain, elasticity and mechanical instabilities has been successfully revisited and improved to account for complex plaque geometries. This is based on an initial best estimation of the plaque components' contours, allowing subsequent iteration for elastic modulus assessment as a basis for plaque stability determination. The improved method has also been preliminarily evaluated in patients with successful histologic correlation. Further clinical evaluation and refinement are on the horizon.

Heme oxygenase-1 inhibits progression and destabilization of vulnerable plaques in a rabbit model of atherosclerosis

Although heme oxygenase-1 (HO-1) has been implicated in protection against atherogenesis, its role in vulnerable plaques remains to be fully elucidated. This study was aimed to explore the effect of HO-1 on the progression and stabilization of vulnerable plaques and the possible mechanism. We established a vulnerable plaque model by local transfection with recombinant p53 adenovirus to plaques in rabbits fed a high-cholesterol diet. HO-1 activity was modulated by intraperitoneal injection of hemin or Sn-protoporphyrin IX (SnPP). HO-1 induction by hemin inhibited the progression of atherosclerotic lesions and changed the plaque morphology and composition into a more stable phenotype. In addition, hemin treatment is associated with a reduction in matrix metalloproteinase-9, interleukin-6 and tumor necrosis factor-α production, an increase in interleukin-10 level, as well as a decrease of TUNEL labeled apoptosis of smooth muscle cells in lesions. Compared with the control group, aortic nitric oxide (NO) production and inducible nitric oxide synthase (iNOS) activity decreased markedly, whereas endothelial nitric oxide synthase (eNOS) activity increased significantly in the Hemin group. In contrast, inhibition of HO-1 by SnPP induced reversed effects and augmented plaque progression and vulnerability. After pharmacological triggering, the incidence of plaque disruption in SnPP group was significantly higher than that in control group (79% vs. 33%, P < 0.05), while no plaque in Hemin group developed disruption (0% vs. 33%, P < 0.05). These findings suggest that HO-1 induction could delay progression and enhance stability of atherosclerotic plaques, possibly through the attenuation of plaque inflammation and apoptosis, and the suppression of iNOS/NO production.

CRP enhances soluble LOX-1 release from macrophages by activating TNF-α converting enzyme

Circulating levels of soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) play an important role in the development and progression of atherosclerosis. We hypothesized that the inflammatory marker C-reactive protein (CRP) might stimulate sLOX-1 release by activating tumor necrosis factor-α converting enzyme (TACE). Macrophages differentiated from THP-1 cells were stimulated with TNF-α and further treated with CRP in the absence or presence of specific inhibitors or small interfering RNA (siRNA). Our results showed that CRP increased sLOX-1 release from activated macrophages in a dose-dependent manner and that these effects were regulated by Fc γ receptor II (FcγRII)-mediated p47(phox) phosphorylation, reactive oxygen species (ROS) production, and TACE activation. CRP also enhanced sLOX-1 release from macrophages derived from peripheral blood mononuclear cells (PBMC) of patients with acute coronary syndrome (ACS). Pretreatment with antibody against FcγRII or with CD32 siRNA, p47(phox) siRNA, apocynin, N-acetylcysteine, tumor necrosis factor-α protease inhibitor 1 (TAPI-1) or TACE siRNA attenuated sLOX-1 release induced by CRP. CRP also elevated serum sLOX-1 levels in a rabbit model of atherosclerosis. Thus, CRP might stimulate sLOX-1 release, and the underlying mechanisms possibly involved FcγRII-mediated p47(phox) phosphorylation, ROS production, and TACE activation.

Probucol Attenuates Inflammation and Increases Stability of Vulnerable Atherosclerotic Plaques in Rabbits

Probucol, a lipid-lowering agent with anti-oxidant properties, has been implicated in protection against atherogenesis, whereas its effect on plaques stability remains to be fully elucidated. The present study was aimed to test the hypothesis that probucol may attenuate inflammation and increase stability of vulnerable atherosclerotic plaques using a rabbit model. After abdominal aortic balloon injury, 45 rabbits were fed a 1% cholesterol diet for 24 weeks. From week 12 to week 24, the animals were treated with probucol (1% by weight in the diet), simvastatin (5 mg·kg(-1), positive control) or no drugs (control), respectively. At the end of week 22, recombinant-p53 adenovirus was injected into the abdominal aortic plaques. Two weeks later, plaque disruption was induced by injection of Chinese Russell's viper venom and histamine. The results showed that the incidence of plaque disruption in probucol or simvastatin groups was significantly lower than that in the control group (7.15% or 14.29% vs. 71.43% respectively, both P < 0.01). Probucol significantly increased the thickness of fibrous caps and decreased plaque vulnerability index. Serum concentrations of inflammatory cytokines and matrix metalloproteinases, and expression levels of Toll-like receptor (TLR)-2, TLR-4, monocyte chemoattractant protein-1, intercellular adhesion molecule 1, scavenger receptor A, CD36 and oxidized low-density lipoprotein receptor 1 within the lesions were markedly lower in both treatment groups than in the control group. We conclude that probucol increases the stability of vulnerable plaques, possibly through its lipid lowering, anti-inflammation and scavenger receptors suppression effects, suggesting probucol as a promising pharmacologic approach to stabilize vulnerable plaques.

Traditional Chinese medication Tongxinluo dose-dependently enhances stability of vulnerable plaques: a comparison with a high-dose simvastatin therapy

This study was carried out to test the hypothesis that Tongxinluo (TXL) as a Chinese herbal medicine enhances stability of vulnerable plaque dose dependently via lipid-lowering and anti-inflammation effects, similar to a high-dose simvastatin therapy. After abdominal aortic balloon injury, 75 rabbits were fed a 1% cholesterol diet for 10 wk and were then divided into five groups for 8-wk treatment: control group, low-dose TXL group, moderate-dose TXL group, high-dose TXL group, and high-dose simvastatin group. At the end of week 16, an adenovirus containing p53 was injected into the abdominal aortic plaques. Two weeks later, plaque rupture was induced by pharmacological triggering. The incidence of plaque rupture in all treatment groups (14.3%, 7.1%, 7.7%, and 7.1%) was significantly lower than that in control group (73.3%; P>0.01). TXL dose-dependently lowered serum lipid levels and inhibited systemic inflammation. Corrected acoustic intensity and fibrous cap thickness of the aortic plaques were significantly increased, whereas plaque area, plaque burden, vulnerable index, and expression of oxidized low-density lipoprotein (ox-LDL) receptor 1, matrix metalloproteinase 1 (MMP-1), MMP-3, tissue inhibitor of MMP 1, and NF-kappaB in plaques were markedly reduced in all treatment groups when compared with the control group. Similar to high-dose simvastatin group, high-dose TXL group exhibited a low serum level of low-density lipoprotein cholesterol and ox-LDL, a low expression level of systemic and local inflammatory factors and a low plaque vulnerability index, with no differences in the incidence of plaque rupture among all treatment groups. TXL dose-dependently enhances the stability of vulnerable plaques and prevents plaques from rupture. Simvastatin and TXL offer similar protection in terms of lipid-lowering, anti-inflammation, and antioxidation effects.

Enhanced Stabilization of Atherosclerotic Plaques in Apolipoprotein E-Knockout Mice by Combinatorial Toll-like Receptor-1 and -2 Gene Silencing

Because both Toll-like receptor-1 (TLR1) and TLR2 are expressed in atherosclerotic plaques, we hypothesized that TLR1 and TLR2 may play different roles in the formation of vulnerable plaques and that combinatorial knockdown of TLR1 and TLR2 genes may enhance the effects of isolated knockdown of the TLR1 or TLR2 gene on plaque stabilization. Lentiviruses carrying small interfering RNAs of TLR1 or TLR2 were constructed, which knocked down mRNA and protein expression of TLR1 or TLR2 significantly in vitro. One hundred and forty apolipoprotein E-deficient (apoE(-/-)) mice were randomly allocated to control, mock, TLR1 interference (TLR1i), TLR2 interference (TLR2i), and TLR1+2 interference (TLR1+2i) subgroups and a constrictive collar was placed around the carotid artery of these mice to induce plaque formation. TLR1i and TLR2i viral suspension was transfected into the carotid plaques separately in the TLR1i and TLR2i subgroups or together in the TLR1+2i subgroup. Four weeks after lentivirus transfection, expression of both TLR1 and TLR2 in the carotid plaques was remarkably attenuated. Plaques of the TLR1i subgroup showed lower macrophage content and interleukin (IL)-6 expression and a thicker fibrous cap compared with the control or mock subgroups. Plaques of the TLR2i subgroup showed a higher content of collagen and lower content of lipid and macrophages, a thicker fibrous cap, lower vulnerability index, and lower mRNA expression of IL-6 and monocyte chemoattractant protein-1 than the TLR1i subgroup. In the TLR1+2i subgroup, the macrophage and smooth muscle cell content, and the vulnerability index, were ameliorated as compared with those in the TLR2i subgroup. Lentivirus-mediated RNA interference can be used to efficiently knock down TLR1 and TLR2 genes in carotid plaques of apoE(-/-) mice. Although isolated knockdown of TLR1 or TLR2 is effective in attenuating plaque vulnerability, combinatorial interference with TLR1 and TLR2 exhibits enhanced improvement of plaque stability, and thus provides a useful approach to the stabilization of vulnerable plaques.

Statin, the black box

Despite a huge number of studies that have established the beneficial effects of statins in cardiovascular diseases, the mechanism of action of these drugs remains puzzling and indeed one of the most challenging research topics for clinicians and biologists in cardiology. Statins are highly effective in lowering concentrations of serum cholesterol through 3-hydroxymethylglutaryl coenzyme A reductase inhibition. But statins also exert numerous lipid-independent effects. These 'pleiotropic' actions include improved endothelial function, stabilization of vulnerable plaques, and anti-inflammatory and antithrombotic effects [1]. Myocardial effects have also been reported including modulation of signalling pathways involved in hypertrophic remodelling of the heart [2], together with cardioprotective effects, notably against oxidative stress [3]. These drugs also show antiarrhythmic effects that may result from a reduction of the arrhythmogenic substrate, notably fibrosis in the context of atrial fibrillation [4,5]. Cholesterol is an important determinant in the function of ionic channels and in the electrical properties of membranes. Recent studies report that alterations in membrane-cholesterol content are associated with marked changes in potassium channel activity both in endothelial vascular cells [6] and cardiac myocytes [7]. These effects of statins on ion channels could lead to vasodilatation or modulation of myocardial repolarization and antiarrhythmic properties.

Statin Therapy for Vascular Failure

There is increasing evidence that statins reduce cardiovascular events such as coronary artery disease or stroke in hypercholesterolemic patients in both primary and secondary prevention. The striking benefit achieved with statin treatments in patients with a wide range of cholesterol levels cannot be attributed to their cholesterol lowering effect alone. Substantial data has recently accumulated showing that statins exert various effects on multiple targets, namely pleiotropic effects, especially targeting the concept of 'vascular failure', including the improvement of vascular endothelial function, inhibition of vascular smooth muscle cell proliferation and migration, anti-inflammatory actions, anti-oxidative effects or stabilization of vulnerable plaques. These effects have potential in the treatments of coronary artery disease in various settings, such as prevention of its onset as well as its progression, or plaque rupture. Statin therapy should be more extensively applied even in normolipidemic patients if there are additional risk factors such as hypertension, diabetes mellitus, or others. Furthermore, statins may be used to intervene in earlier stage risk conditions such as postprandial hyperlipidemia or hyperglycemia, insulin resistant state, masked hypertension, or metabolic syndrome to further reduce mortality or morbidity of coronary artery disease and heart failure.