ATEROESCLEROSIS

Physiol Rev 93: 13171542, 2013
doi:10.1152/physrev.00004.2012
MOLECULAR BIOLOGY OF ATHEROSCLEROSIS

Paul N. Hopkins
Cardiovascular Genetics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
Hopkins, Paul N. Molecular Biology of Atherosclerosis. Physiol Rev 93: 13171542,
2013; doi:10.1152/physrev.00004.2012.At least 468 individual genes have been
manipulated by molecular methods to study their effects on the initiation, promotion,
and progression of atherosclerosis. Most clinicians and many investigators, even in
related disciplines, find many of these genes and the related pathways entirely foreign.
Medical schools generally do not attempt to incorporate the relevant molecular biology into their
curriculum. A number of key signaling pathways are highly relevant to atherogenesis and are
presented to provide a context for the gene manipulations summarized herein. The pathways
include the following: the insulin receptor (and other receptor tyrosine kinases); Ras and MAPK
activation; TNF- and related family members leading to activation of NF-B; effects of reactive
oxygen species (ROS) on signaling; endothelial adaptations to flow including G protein-coupled
receptor (GPCR) and integrin-related signaling; activation of endothelial and other cells by modified
lipoproteins; purinergic signaling; control of leukocyte adhesion to endothelium, migration, and
further activation; foam cell formation; and macrophage and vascular smooth muscle cell signaling
related to proliferation, efferocytosis, and apoptosis. This review is intended primarily as an
introduction to these key signaling pathways. They have become the focus of modern atherosclerosis research and will undoubtedly provide a rich resource for future innovation toward intervention and prevention of the number one cause of death in the modern world.
INTRODUCTION
OVERVIEW OF ATHEROGENESIS
FUNDAMENTAL SIGNALING...
INITIATION OF ATHEROSCLEROSIS:...
CYTOKINES AND INNATE VERSUS...
EFFECTS OF SELECTED RISK FACTORS...
PROMOTION OF ATHEROSCLEROSIS
PROGRESSION OF ATHEROSCLEROSIS
FURTHER PLAQUE DESTABILIZATION...
PERSPECTIVES
1317
1319
1320
1355
1383
1392
1403
1430
1438
1454
1483
1484
I. INTRODUCTION
During the past 10 15 years, understanding of the molecular biology of atherosclerosis and related signaling pathways has progressed so rapidly that the field has become
essentially unrecognizable to most clinicians, many students of the life sciences, and even veteran investigators in
related disciplines, a lamentable knowledge gap that undoubtedly hampers progress in the field. For those interested persons who find themselves in this situation, this
review is intended to fill a portion of that gap, which may
have formed from lack of formal training, inattention to the
field, or merely the passage of time.
Much of the text may be considered as an introductory
primer or overview for a number of the signaling pathways
now central to investigations into the molecular biology of
atherosclerosis. Because the field is now so extensive, an

in-depth review is precluded. While the listing of atherosclerosis-related genes herein is relatively exhaustive, the discussion surrounding each one is, of necessity, limited and
focused on pathophysiology. Indeed, the purpose of the
effort to find as many manipulated genes as possible was to
identify relevant pathways and general mechanisms potentially related to atherosclerosis rather than to attempt an
exhaustive review of the methodologies, treatment implications, or controversies. Indeed, only passing attention is
given to treatments, molecular biology of standard atherosclerosis risk factors, or to results from human genetic association studies.
Reluctance to delve into the pathways presented herein may
arise from their sheer complexity, the number of components, or failure to recognize their relevance, but perhaps
also from the impression that the numerous abbreviations
and sometimes fanciful names given to signaling molecules
implies some kind of inherent transience in the field. Some
of the most imaginative names come from fly genetics (e.g.,
Sos, son of sevenless; Boss, bride of sevenless; MAD, mothers against decapentaplegic; Shh, sonic hedgehog; Dbs,
Dbls older sister where Dbl stands for diffuse B-cell lymphoma; Mam, master mind; Mib1/2, mind bomb 1 and 2).
Historically, many names were given before much was
known about the proteins function or were based on the
appearance of fruit flies with a mutation in the gene (such as
Groucho). Commonly, only the abbreviation is communicated since the full name is frequently cumbersome and
0031-9333/13 Copyright 2013 the American Physiological Society
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PAUL N. HOPKINS
With the use of yeast as a eukaryotic test organism, a remarkable 73% of 6,000 genes making up the yeast genome
were found unnecessary for survival (when tested one gene
at a time) and only 50% affected growth even in extreme
test conditions (613). When tested two genes at a time,
extensive interactive networks can be identified. One study
reported 117,000 significant interactions affecting yeast
growth out of 5.4 million potential interactions among the
1,700 genes tested. Informatics techniques allowed organization of many of these apparent interactions into overlapping networks with known functional utilities (RNA processing, mitochondrial activity, etc.) (352). In this study,
there were 39 interactions per gene on average and for only
10 genes were no interactions identified (C. L. Myers, personal communications).
Networks can act to buffer defects in single genes, distributing their effects to closely interacting network neighbors.
1318
Among the strongest effects on atherosclerosis in animal

studies was knockout (KO) of the gene CCR2 (chemokine,
CC motif, receptor 2) in the atherosclerosis-prone, ApoEdeficient mouse (see FIGURE 1). CCR2 is the cognate receptor for the ligand CCL2 (chemokine, CC motif, ligand 2),
also known as MCP-1 (monocyte chemoattractant protein
1). Other ligands for CCR2 (either in humans or mice)
include MCP-2 through 5, but these have been much less
studied in relation to atherosclerosis, although both MCP-1
and MCP-3 are required for monocyte mobilization from
marrow and homing to lesions. After just 5 wk of atherogenic diet, there was a clear CCR2 gene-dose effect, as
shown in FIGURE 1. By 9 wk, however, any difference between the heterozygous KO and wild type was gone. Furthermore, there was only a 4-wk lag in the extent of atherosclerosis when comparing the strongly protected homozygous CCR2 KO mouse to the wild-type mouse (compare
weeks 9 and 13, FIGURE 1) (179). Later studies tended to
show lesser percent differences, perhaps because of assessments at later times or more aggressive atherogenic dietary
protocols.
Diminishing single gene effects with aging in studies such as
the above may be due to the multiple pathways and genes
that promote atherosclerosis in the face of severe hyperlip-
350
CCR2-/- in apo E -/300

250
CCR2+/- in apo E -/CCR2+/+ in apo E -/p = 0.003
200
150
100
Gene dose effect

at week 5
p <0.0001
50
0
13
Weeks on atherogenic diet

FIGURE 1. Gene-dose effect of CCR2 deficiency in apoE-deficient
mice. CCR2 is the receptor for MCP-1 (also known as CCL2) as well
as MCP-2 to -5. [Data from Boring et al. (179).]
Physiol Rev VOL 93 JULY 2013 www.prv.org
While considering a number of these pathways, this reviewer was struck by one remarkable feature: redundancy.
In a redundant system, a duplicate or similar element may
take over the function of another element or provide a
somewhat different but overlapping utility. Often built into
cleverly designed mechanical or informatics systems, redundancy can ensure the operation of critically important activities even when one or more key components fail. In
living systems, the phenomenon of gene duplication, allowing the original or duplicated gene to diverge somewhat or
greatly in function, provides a mechanism for redundancy
to arise naturally. Alternate transcriptional start sites and
particularly alternate splice sites are found in 75% of
human genes and provide numerous isoforms with analogous flexibility of expression (861). The multiplicity of cytokines and multiple isoforms of various enzymes (such as
the thioredoxin and glutaredoxin systems) certainly illustrate redundancy, often showing overlapping if not entirely
duplicated functions. However, rather than simple linear
pathways with a few key back-up elements, the notion of
redundancy is taken to an entirely new level when considering the series of enormously interacting, branching networks that better describe living systems.
Networks may also broaden the functionality achievable by

any one protein, thereby providing substantial increases in
robustness and resiliency (429, 1107). Mathematically defined network interactions may provide insights into unexpected relationships, such as the key role that HMOX1
(heme oxygenase 1, also abbreviated HO-1) was found to
play in the response of human endothelial cells to oxidized
phospholipid exposure (1501). The degree to which redundancy or network behavior dilutes the effects of any one
gene on a complex trait like atherosclerosis is a particular
challenge to human genome-wide association studies (GWAS)
and related statistical methods of gene discovery.
Mean lesion area
sheds little or no light on function (e.g., Keap1 is Kelch-like,

erythroid-derived, cap-n-collar-homology-associated protein 1). Yet most of the signaling pathways related to
atherogenesis and presented herein are canonical, along
with their frequently odd names and abbreviations. Where
there is an alternative abbreviation or name suggested by
the HGNC (HUGO Gene Nomenclature Committee), the
most commonly encountered abbreviation is generally
used. Further details regarding individual signaling components, protein structure, domain arrangements, and activation mechanisms are available in recent texts (634, 947,
1141) or a notable on-line, freely accessible textbook of cell
signaling (136) (http://www.biochemj.org/csb/).

idemia (and probably other major risk factors for atherosclerosis). Surely, redundancy and compensation through
networked interactions will greatly dilute measurable effects from any single gene, and such single gene effects will
likely be less pronounced in the face of overwhelming risk
factor exposure, such as severe genetic hyperlipidemia exacerbated by high-saturated fat, high-cholesterol diet.
Statistical modeling of gene-gene or gene-environment interactions may be more realistic but runs the risk of greatly
reduced power and false positives due to the problem of
multiple testing, even if interactions are restricted to
known, physiologically defined networks. Undoubtedly, redundancy contributes greatly to the difficulty of discovering
atherosclerosis-related genes by statistical methods in human populations.
II. OVERVIEW OF ATHEROGENESIS

Clinically manifest atherosclerosis may be viewed as the
culmination of four major steps, a scheme adapted from the
cancer literature and successfully used to classify risk factors for over 30 years (784). The steps include 1) initiation
of endothelial activation and inflammation; 2) promotion
of intimal lipoprotein deposition, retention, modification,
and foam cell formation; 3) progression of complex plaques
by plaque growth, enlargement of the necrotic core, fibrosis, thrombosis, and remodeling; and 4) precipitation of
acute events. Acute clinical events, such as acute myocardial
infarction (MI), unstable angina, ventricular fibrillation, or
sudden coronary death are generally due to plaque destabilization and thrombosis but may also occur when acute
ischemia is imposed on an electrically unstable myocardial
substrate, precipitating ventricular fibrillation. As an illustration of precipitating risk factors, there is a clear increase
in the risk of acute coronary syndromes when fighting fires
(874), while shoveling snow after a snowstorm (843), or
after other strenuous exertion, but primarily in those otherwise unaccustomed to vigorous exercise (373, 1219).
Earthquakes have been reported to trigger sudden cardiac
death (1007). Increased risks were seen within hours after
elevations in air particulates and ozone (481). Even watching a stressful soccer match (1961) or rooting for the losing
Super Bowl team seems to have its risks (920). Recently,
risk of MI or CHD death was found to rise 21-fold during
the 24 h following the loss of a spouse or other close loved
one (1238) and 5.6-fold within the first week after the di-
In this scheme, major risk factors frequently act at more

than one step of atherogenesis. For example, various forms
of hyperlipidemia can contribute to endothelial activation
(with or without oxidation of the lipoproteins) (1716), impair nitric oxide (NO) synthesis or availability (26), lead to
foam cell formation (after a variety of possible modifications) (1732), increase platelet activation and thrombotic
potential (e.g., oxidized phospholipids, found in excess in
hyperlipidemic serum, interacting with platelet scavenger
receptor CD36) (1426), and lead to reversible plaque destabilization (927, 1042). Obviously, factors that increase
thrombotic potential may also help precipitate an acute
event if they lead to an occluding thrombus. Factors that
aggravate inflammation also associate with unstable plaque
(1041).
Initiation occurs in predisposed areas where slow flow induces partial endothelial activation (especially when there is
flow direction reversal, however subtle). Indeed, atherosclerosis essentially develops only in areas of slow or so-called
disturbed flow, and mathematical models predict such
areas precisely (940, 1343). In humans, vascular smooth
muscle cells (VSMC) accumulate early at predisposed sites
to cause intimal thickening prior to foam cell formation,
possibly in response to platelet-derived growth factor
(PDGF) production by activated endothelial cells (49). Indeed, the contribution of VSMC to multiple stages of
atherogenesis may have been underappreciated in the past.
Endothelial activation is further aggravated by other risk
factors. Once endothelial cells are activated, initiation proceeds essentially as described for early stages of the innate
immune response (1). Activated endothelial cells elaborate
adhesion molecules such as E-selectin, P-selectin, and vascular cell adhesion molecule-1 (VCAM-1) and the chemokine MCP-1. Monocytes and probably neutrophils are
among the early inflammatory cells to attach to the endothelium at first loosely then firmly and move into the subendothelial space. Monocytes transform into macrophages
and are further activated by encounters with pathogen-associated molecular patterns (PAMPs), damage-associated
molecular patterns (DAMPs), and various cytokines including tumor necrosis factor- (TNF-), interleukin (IL)-1,
and IL-6. T-helper 1 (Th1) cells secrete interferon- (IFN-)
and other cytokines to amplify the innate immune response.
Concomitantly, PDGF (mostly dimers of A and B isoforms
in humans) from adherent platelets and activated endothelial cells is released. Traditionally, PDGF was thought to act
on differentiated, contractile vascular VSMC to cause
transformation from a contractile to a synthetic phenotype
with transmigration into the intima (580). Recent data suggest there may be multipotent vascular stem cells residing in
the arterial media that are the actual cells that transmigrate
1319
While fascinating, genomic or proteomic approaches will

not be emphasized in this review; rather, it will focus on
individual genes and pathways. Included herein are all 166
unique genes listed in the Mouse Genome Informatics website listed under the phenotype atherosclerotic lesions
(http://www.informatics.jax.org/, accessed March 6, 2013)
as well as many more. Quantitative trait loci with no clearly
identified causal gene are not included.
agnosis of cancer (499). The associated risks for such events

are clearly contingent on preexisting coronary artery disease (CAD).
PAUL N. HOPKINS
and take on the VSMC phenotype once in the plaque
(1755). Surprisingly, the well-studied cellular make-up of
atherosclerotic lesions in animal models, including VSMClike cells and various immune cells, has only recently been
confirmed in human plaques (1933), demonstrating general
comparability.
As the lipid-rich plaque progresses, accumulating macrophages (and other migrating cells) as well as activated endothelial cells secrete a host of proinflammatory cytokines,
matrix metalloproteinases (MMPs), and cathepsins, causing plaque fragility. IFN- strongly inhibits collagen formation by VSMC, further weakening the plaque and newly
forming fibrous cap (1042). The result can be catastrophic
thrombosis and downstream tissue infarction; but more often, there is limited mural thrombosis with subsequent organization of the thrombus, leading to saltatory growth of
lesions with relatively high fibrous tissue content. Other
precipitating changes in the plaque include erosions and,
more especially, eruption through the endothelium of underlying cholesterol crystals (4). Prior to such episodes of
thrombosis, there may be little, if any, encroachment of the
plaque into the arterial lumen due to outward remodeling of
the arterial wall to accommodate the growing plaque.
In reference to the tables that accompany the following
sections, the percentage increase or decrease in atherosclerosis reported in the table represents differences in the extent of atherosclerosis in the genetically manipulated or
targeted animals compared with control animals at the
same point in time. The length of time of the experiments
varies widely, and these times have only occasionally been
noted in the tables. This limitation is balanced somewhat by
utilizing atherosclerosis extent measured at the same point
in time in the manipulated animals and their controls. As
nearly all the studies cited were conducted in animals,
mostly mice, relevance to the human condition may at times
be questioned. Recent reviews regarding the relevance of
animal models to humans note some limitations but empha-
1320
The measure of atherosclerosis generally utilized for this

review is the quantitative plaque area measured at the aortic
root if this measure was available. This site was chosen not
because it is representative of the typical location of human
lesions but because it is the most consistently quantified
lesion location in mouse models and quantification at this
location is relatively standardized. Indeed, humans essentially do not develop lesions in this location, except possibly
patients with homozygous familial hypercholesterolemia.
Aortic root atherosclerosis in mice is thought to be due to
the unique hemodynamics of this animal model, possibly
affected by the very rapid heart rate in mice. Nevertheless,
these hemodynamic forces are generally thought to act on
the endothelium in a way consistent with other hemodynamically predisposed areas. Assessement at multiple anatomic sites may provide a better assessment of disease involvement. Occasionally, discrepancies in disease responses
are reported between the aortic root and other predisposed
sites such as the aortic arch and brachiocephalic artery. No
attempt has been made to consistently provide data on all
these sites in this review, but a few exceptional differences
in disease are pointed out in the tables.
Percent increase or decrease in atherosclerosis is admittedly a
relatively crude measure of the effect size for a given manipulation. Nevertheless, there is a human counterpart. Plaque stability has gained much deserved attention as an extremely
important factor in determining which specific plaque may
cause an acute event. Indeed, most acute events, such as MI,
appear to occur at sites of relatively modest sized plaques (494)
or plaques poorly visualized by conventional angiography
(44). However, these considerations should not overshadow
the fact that accurate assessment of total plaque burden, as
with coronary CT angiography, provides almost complete
separation of future risk of coronary events ranging from near
zero for no detectable plaque to extremely high risk for extensive plaque (689, 1281). Such scoring also predicts all-cause
mortality (320). Even more crude assessment of plaque burden
by coronary artery calcium scoring provides a strong gradient
of risk (52, 224, 225, 1555).
III. FUNDAMENTAL SIGNALING

PATHWAYS RELEVANT TO MULTIPLE
STAGES OF ATHEROGENESIS
Some understanding of several basic signaling pathways, particularly in relation to inflammation in general, is a prerequisite to the study of atherogenesis. In this section, emphasis is
given to endothelial signaling, in part because of the major role
endothelial cells play in atherogenesis, and also because signaling transduction in endothelial cells is often neglected in reviews on atherogenesis. Nevertheless, the pathways presented
in this section are so frequently encountered in multiple rele-
Promotion proceeds as retained and modified lipoproteins

are taken up by macrophages and VSMC leading to formation of foam cells, the hallmark of the growing atherosclerotic lesion. While levels of LDL cholesterol (LDL-C), ApoB
(apolipoprotein B), HDL-C (HDL cholesterol), or ApoA1
(apolipoprotein A1 or A-I) are clearly relevant, factors affecting plasma levels of these major risk factors will not be
examined in this review. Recent studies with latex beadlabeled monocytes showed that changes in the rate of entry
of monocytes into the plaque primarily determined changes
in plaque size rather than impaired monocyte/macrophage
egress. These studies were performed in ApoE-deficient
mice before and after treatment with ApoE adenoviral vectors which rapidly normalized serum lipid levels and regressed plaques (1434).
size the value of these models in providing general insights

into shared common pathways (383, 609, 1300).

vant cell types (endothelial cells, smooth muscle cells, and leukocytes) that assignment to a specific stage of atherogenesis is
difficult or entirely arbitrary.
A useful general overview of signaling pathways (136) begins with extracellular signals impinging on various cell
receptors or sensors. These are linked to various intracellular signaling pathways through adaptor proteins or other
transducers. The pathways utilize a host of signaling mechanisms including phosphorylation and other protein or
membrane lipid modifications to transmit signals through
amplifiers, filters, and multiple messengers to cellular effectors. Effectors may control vesicular transport for release of
soluble signaling molecules such as cytokines or membrane
expression of other cell signals (such as adhesion molecules), cell movement, contraction, phagocytosis, replication, or apoptosis. Frequently, the effectors are transcription factors that alter gene expression involved in all of the
above functions. An attempt throughout this review will be
made to maintain this outside-in orientation in the presentation of the various pathways.
A surprisingly large number of signaling pathways occur on or

in relation to cell membranes and involve alteration in membrane lipid components and/or translocation of signaling proteins to cell membranes. This principle is clearly demonstrated
by the activity of receptor tyrosine kinases (RTK), illustrated
in FIGURE 2 by insulin receptor (INSR) signaling. Impairment
of insulin secretion as well as endothelial-specific KO of INSR
increased atherosclerosis (see TABLE 1) as did knockout in
other cells of the highly homologous insulin-like growth factor
I receptor (IGF-IR). Further confirmation of the importance of
these signaling pathways is seen in the multiple effects on atherosclerosis resulting from genetic manipulation of downstream molecules (TABLE 1).
One major feature of INSR and other RTK is inhibition of
apoptosis together with stimulation of growth and mitogenesis. Perhaps for this reason, insulin signaling may have
quite opposite effects in endothelium compared with macrophages and other bone-marrow derived cells. Thus antiapoptotic effects in endothelium seem to generally translate
to protection against atherosclerosis based on endothelialspecific knockout of INSR and results from manipulation of
downstream signaling molecules. On the other hand, impaired insulin signaling in macrophages often led to greater
apoptosis, impaired proliferation, and smaller plaques in
earlier stages, but potentially more complex and inflamed
plaques at later stages of plaque development (see TABLE 1).
Insulin, IGF-I, PDGF, epidermal growth factor (EGF),
VEGF vascular endothelial growth factor (VEGF), and
many other growth factors signal via RTK. Indeed, without
such signals, many cells in culture undergo spontaneous
An exception to the frequently anti-atherogenic effects of RTK

signaling in endothelium appears to be fibroblast growth factor receptor 2 (FGFR2). While FGF family members normally
promote angiogenesis, when a constitutively active form of
FGFR2 was overexpressed in endothelium of ApoE-deficient
mice, there was actually an overall antiproliferative and proapoptotic effect leading to increased atherosclerosis (288). The
overall balance of the numerous pathways activated by RTK
may therefore be critical for the outcome.
1. Tyrosine phosphorylation primarily provides
docking sites
Tyrosine kinases in general and RTK in particular are evolutionarily the most recent of signaling innovations. Only
90 or so of the 518 kinases in the human genome are
tyrosine kinases, with most of the remaining being serine/
threonine kinases (1036, 1137). The functions of tyrosine
kinases are much more limited than the far more abundant
and diverse serine/threonine kinases. The serine/threonine
kinases include mitogen-activated protein kinase (MAPK),
most of their activating upstream kinases as well as downstream kinases activated by MAPK, together with cAMPdependent protein kinase (PKA), protein kinase B (PKB,
also known as Akt), protein kinase C (PKC, a family with
several isoforms), and cGMP-dependent protein kinase
(PKG), calcium/calmodulin-dependent kinases (such as
CaMKII), and a number of other kinase classes. In contrast,
tyrosine kinases are divided into RTK (58 in 20 subfamilies)
and non-RTK (32 in 10 subfamilies). Examples of non-RTK
are the Src (short for sarcoma), JAK (Janus kinase), and Syk
(spleen tyrosine kinase) families. Non-RTKs often work
together with RTK or with other receptors that lack tyrosine kinase domains of their own. Both RTK and nonRTK typically activate downstream pathways by creating
phosphorylated tyrosine residues that provide binding sites
for assembly and activation of the next tier of signaling
proteins. Molecules that bind phosphotyrosines possess
requisite binding domains, such as phosphotyrosine binding (PTB) and Src-homology domain 2 (SH2) which recognize both the phosphorylated tyrosine and the surrounding
peptide sequence.
INSR signaling is instructive in that all RTK share many of
the same adapters and downstream signaling pathways. An
exception may be the insulin receptor substrate (IRS)
adapter proteins which are apparently restricted to insulin
and IGF-I receptor signaling. The specificity of the particular receptor readout often comes more with the complete
1321
A. Receptor Tyrosine Kinases
apoptosis. It is tempting to speculate that one of the antiatherogenic aspects of INSR and IGF-IR signaling relate to
inhibition of apoptosis. Other aspects of insulin signaling
likely contribute. For example, insulin was also found to
enhance endothelial cell-cell barrier function at adherens
junctions, and this could be seen as anti-inflammatory
(672).
PAUL N. HOPKINS
Insulin
O2
NOX1/2
Other?
Insulin receptor
GTP
Ras PI3K P IRS1/2

PI3K
Gab1
P
P
P
P
P
P
P
P
GDP Ras
(Shc) Grb2
IRS1/2
Sos
SHP2
GTP Ras
Src
PLC
Other adapters,
and targets
PIP2
PIP2
GTP Rac1
PIP3
SH2B1
RACK1
JAK2
STAT3
PIP3
O2
GDP Rac1
CIC3
O2
SOD1
Other effects
MAPK pathway
DAG
Other
effects
PKC
PDK
?Gef
IP3
PTP
SHP2
PIP3
P
P
P
P
Src
PTEN
MTM1
P
P
P
P
Ca2+
PKC
H2O2
ER
IP3R
PTP
Other effects
PTEN
MKP1
NOX activation
p47phox
GTP Rac1
CCND1
PIP3
PKB
GSK3
eIF2B
Peripheral actin assembly

Adherins junction
Barrier stabilization
eIF2
4E-BP
PHLPP
Rheb
eNOS
activation,
anti-apoptotic
effects
eIF4E
mTORC1
mTOR
Protein sythesis
Cell growth
S6K1
S6
TSC1
TSC2
FOXO1,3
AMPK
Autophagy
14-3-3
SIRT1
p53, LKB1, p66Shc
Nucleus
IRS1/2, iNOS, p21, p27Kip1, FASL, BIM, Noxa, MnSOD, GADD45, Egr1
FOXO1,3
CCND1, claudin 5, NF-B, eNOS

FOXO1,3
FOXO1,3:
cell cycle progression
inflammation
apoptosis
antioxidants
PKB, Bcl-XL, VEGF, p53

STAT3
FIGURE 2. Receptor tyrosine kinase signaling as illustrated by INSR (insulin receptor). Overall, cellular effects
are dependent on simultaneous activation of multiple pathways. The multiplicity of activation pathways is
achieved, in part, by binding of several different adaptor proteins (shown in amber) to either INSR or IRS1/2.
Not shown are specific pathways leading to increased expression of GLUT4 by insulin (as occurs primarily in
muscle and adipose). CCND1, cyclin D1; MTM1, myotubular myopathy 1, also known as myotubularin. See text
for other abbreviations.
1322
Other
targets
Table 1. Genes related to fundamental signaling pathways present in multiple cell types (78 genes tested)
Gene
Model
% A
Function, Comment
Insulin-signaling, Akt/PKB, and related pathways

INS2
INS2/ Akita in
LDLR/
1224% males,
130%
females
INS2/ Akita in
apoE/
1211%
Congenic 6T allele in
apoE/
188%
PAPP-A
PAPP-A/ apoE/
270%
INSR
SMC-specific Tg PAPP-A
o in apoE/
ESMIRO apoE/
1250%
152%
INSR/ BMT into

LDLR/
145%
MphIRKO in apoE/
Macrophage-specific
IGF-IR/ in apoE/
250%
157%
FGFR2
Endothelial cell-specific
Tg of constitutively
active FGFR2 in
apoE/
169%
IRS1
INSR/ IRS1/
apoE/
199%
IGF-IR
ESMIRO (endothelial-specific INSR knockout) effect may be due

to lack of normal insulin stimulation of eNOS (576).
Approximately threefold greater lesion volume was seen in
another study (1458).
Lesions had larger necrotic cores. INSR/ macrophages had
decreased PKB/Akt signaling and increased ER stress and
susceptibility to apoptosis (707).
Macrophage-specific knockout (Cre-lox) of INSR (116).
This model resulted in an increase in macrophage infiltration
while VSMC content decreased together with collagen
resulting in fibrous cap disruption and intraplaque hemorrhage
(762). Included here with other IGF-related genes though not
directly related to VSMC IGF signaling.
FGFR2 (fibroblast growth factor receptor 2) is also involved in
angiogenesis. Given here is the effect at the aortic sinus.
Increased expression of p21Cip1, a cell-cycle inhibitor, also
increased adhesion molecules. PDGF and the transcription
factor Egr-1 were also increased (288).
Shown are effects in aorta of female mice. Despite much higher
plasma insulin, eNOS phosphorylation and endothelialdependent vasodilation was reduced in these double
heterozygous mice. Oddly, baseline ERK1/2 activation was
reduced, but insulin-stimulated ERK1/2 activation was
increased in aortic wall homogenates. VCAM-1 expression
was increased. BMT studies showed vascular wall effects
predominated (582).
Continued
1323
IGF-I
The INS2 (insulin 2) Akita mutation (Cys96Tyr) causes misfolding

of insulin, beta-cell ER stress and apoptosis, and in
heterozygotes, type I DM by 45 wk of age. Serum lipids were
increased markedly as well compared to LDLR null controls.
Arterial wall expression of MCP-1, TNF-, and IL-1 were also
increased (2102), but the contribution of insulin deficiency
itself is unclear.
As in LDLR null mice, apoE-deficient Akita mice had marked
increases in serum cholesterol, complicating the
interpretation. Interestingly, there was no increase in VLDL
production and little increase in serum triglycerides but
elevated APOB-48 in the LDL density range (867).
The congenic 6T allele resulted in mild (41%) reduction in IGF-I.
The increase in atherosclerosis was on normal diet in the
aortic root but the difference was not significant on western
diet while overall aortic area remained increased. There may
have been differences in other, unknown genes in the mice
with the congenic 6T alleles (1599).
PAPP-A (pregnancy-associated plasma protein A) is a
metalloproteinase in the IGF system and leads to increased
lesional availability of IGF-I and increased VSMC proliferation
(722).
Overexpression increased atherosclerosis (350).
PAUL N. HOPKINS
Table 1.Continued
Gene
IRS2
Model
IRS2/ apoE/
FLC IRS2/ into
apoE/
Function, Comment
160
238%
Atherosclerosis difference in aortic root given. Whole body

IRS2/ mice had increased atherosclerosis while adoptive
transfer of IRS2/ fetal liver cells (FLC) into irradiated
apoE/ mice led to less atherosclerosis. In response to LPS,
IRS2 KO macrophages increased TNF- and MCP-1 normally
but production of IL-1 and IL-6 were completely abrogated
(116). Increase in atherosclerosis correlated with plasma
insulin levels in another study of whole-body IRS2/ (637).
Heterozygous deficiency modestly increased atherosclerosis only
on atherogenic diet. Associated with increased macrophage
uptake of acetylated LDL and higher expression of CD36,
SRA, and MCP-1. Pharmacological inhibition of Akt had similar
effects (638).
Mice were exposed to infused ANG II as well. Percent increase
in atherosclerosis was not reported in abstract (765, 766).
Also known as PI3KCG (phosphatidylinositol 3-kinase, catalytic,
gamma or the p110 gamma catalytic subunit). PI3K isoform
knockout not embryo lethal (others are) (277). While having
pro-survival effects with PKB activation, expression of
endothelial E-selectin appears to be dependent on PI3K
(1441). PI3K also regulates chemotaxis as PI3K is
activated by subunits of GPCR by various chemokines and
is required for neutrophil and other leukocyte migration.
Assessed at 35 wk in the aortic root. Less reduction at later
time points. BMT into LDL KO mice suggest macrophages and
T-cells effects explain much of the atherosclerosis reduction
(534). Macrophage PI3K is activated by oxLDL, inflammatory
cytokines, and ANG II.
Also known as PKB. Akt1 is the main endothelial isoform. Akt
phosphorylates and activates eNOS. BMT of Akt1-null
macrophages did not increase atherosclerosis. Extensive
coronary atherosclerosis seen (519). Impaired VSMC
function, vulnerable plaques result in acute MI (520).
Knock in of the KR allele of FOXO1 results constitutive
deacetylation and preferential accumulation in the nucleus
(thus, KR is a gain of function mutation). Insulin favors FOXO1
acetylation while SIRT1 deacetylates FOXO1. Insulin, through
Akt1, also increases FOXO1 phosphorylation and exclusion
from the nucleus (1442). Cons
The large effect from the EC-specific KO of all FOXOs suggest
that FOXO3 has an additional pro-atherosclerotic effect in EC
beyond that of FOXO1 alone (1817). FOXO transcription
factors in EC increase expression of IRS1 and IRS2 but
strongly suppress expression of eNOS while increasing iNOS.
Remarkably, the same KO model restricted to myeloid cells
resulted in a nearly twofold increase in atherosclerosis with
proliferation of myeloid cells and generation of increase RNS
through iNOS (1818).
FoxO4 null BMT also increased atherosclerosis (in C57Bl/6
mice). FOXO4 is a transcription factor that in macrophages
can inhibit several aspects of NF-B signaling including IL-6
production and transcription of ROS-scavenging enzymes.
Macrophage ROS and serum IL-6 were increased in FoxO4
null mice (2111).
HDAC3 (histone deacetylase 3) is phosphorylated by Akt/PKB in
areas of disturbed flow and promotes endothelial cell survival.
Model shown here involved lentivirus infection and knockdown
in the endothelial monolayer of aortic isografts transplanted to
carotid arteries. Knockout is embryo-lethal (2057).
SIRT1 (sirtuin 1) is also a deacetylase. BMT of SIRT cells
resulted in a 54% increase in atherosclerosis, suggesting
approximately equal contributions from endothelial and
macrophage effects. SIRT1 macrophages took up oxLDL
more avidly (1680).
IRS2/ apoE/
128%
142%
PI3K (PIK3CG)
EC-specific Gab1/
apoE/
p110/ apoE/
Akt1
Akt1/ apoE/
152%
FOXO1
FOXO1KR/KR LDLR/
139%
FOXO3
EC-specific FOXO1/,
FOXO3/, and
FOXO4/ in LDLR/
277%
FOXO4
FOXO4/ apoE/
1128%
HDAC3
shHDAC3 apoE/
1280%
SIRT1
SIRT1/ apoE/
1112%
Gab1
252%
Continued
1324
% A
Table 1.Continued
Gene
Model
% A
PKC/ apoE/
275%
PKC3
p47phox
PKC3/ apoE/
p47phox/ apoE/
250%
270%
NOX2 (gp91phox)
NOX2/y apoE/
248%
NOX1
NOX1/y apoE/
228%
PTEN
PTEN/ apoE/
G6PDH
G6PDH/y apoE/
243%
AMPK2
AMPK2/ LDLR/
148%
NS
Disturbed flow and oxLDL can lead to activation of PKC,

activation of JNK, and Egr-1; all blocked in PKC/ mice
(720). Inhibition of PKC by inhibitor or siRNA in macrophages
also prevents foam cell formation, possibly by reducing
scavenger receptor A expression (1355). PKC/ mice are
also immunodeficient.
17 wk, aortic root (1925).
Also known as Ncf1 (neutrophil cytosolic factor 1). Organizer
subunit for NOX2 complex assembly and function. p47phox/
mice are also a model of autosomal chronic granulomatous
disease. Total aortic plaque surface area decreased as
shown, but no decrease was seen in aortic sinus plaque
(113). Bone marrow-derived and vascular wall cells appear to
make equal contributions (1872). Also required for NF-B
signaling by TNF (and others) (1026). Upregulation of
p40phox may mitigate the effects of p47phox knockout (496).
NOX2 (NADPH oxidase 2) was clearly present in endothelial cells
and macrophages. Deficiency causes X-linked chronic
granulomatous disease (CGD). Given is plaque area reduction
in aorta (866). A prior study (914) found only a trend in total
lesion area reduction in male CGD mice and no effect in males
or females at the aortic sinus at 24 wk.
NOX1 (NADPH oxidase 1) is primarily expressed in VSMC.
Shown is percent reduction at the aortic sinus. Carotid ligation
promotes VSMC proliferation which was inhibited by NOX1
deficiency as well (1609).
Whole body heterozygous deletion of PTEN decreased aortic
PTEN about 50% and increased Akt/PKB activity 50% but
had no effect on atherosclerosis (64).
G6PDH (glucose-6-phosphate dehydrogenase) is a key (X-linked)
enzyme for the pentose phosphate pathway and production of
NADPH. The mutation caused 80% reduction of G6PDH
activity and 50% reduction NADPH in the aorta of male
hemizygous mice together with a marked reduction in
superoxide production by NOX (1155).
AMPK is increased by laminar flow. It phosphorylates and
activates eNOS, decreases superoxide, and suppresses ER
stress. The 2 subunit was most active in this regard (435).
Also important in macrophage ER stress.
MAPK-related pathways
/
Grb2
apoE
Grb2
Grb2/ BMT
and
ASK1
ASK1/ apoE/
AIP1
AIP1/ apoE/
p38
macrophage-specific
p38 deletion (Cre-lox)
in apoE/ mice
JNK1 (MAPK8)
JNK1/ apoE/
243%
1131%
186%
114% (NS)
NS
Grb2/ is embryolethal. Grb2 is an adapter protein that

couples activated (tyrosine phosphorylated) growth factor
receptors, integrins, or other adapters to the MAPK pathway
through SOS. Similar whole-body and BMT results suggest
most of effect is due to effects on hematopoetic cells. MAPK
activation is required for macrophage proliferation and uptake
of modified lipoproteins (1439).
ASK1-null mice showed less macrophage apoptosis resulting in
larger lesions and greater MMP expression but lesions
showed less necrosis. Similar results with ASK1/ BMT
(2005).
An anti-inflammatory effect was seen primarily in endothelial
cells (793).
p38 is a MAPK. While the increase in lesion size was not
significant, there was certainly no decrease as might have
been expected. Instead, there was marked increase in
apoptotic markers, necrotic areas, a decrease in collagen
deposition, and thinning of the fibrous cap (1583). Uptake of
apoptotic cells by macrophages (efferocytosis) triggers an antiinflammatory release of IL-10 and TGF dependent on p38
(473).
JNK2 but not JNK1 KO decreased atherosclerosis (1483).
Continued
1325
PKC
Function, Comment
PAUL N. HOPKINS
Table 1.Continued
Gene
Model
% A
JNK2/ apoE/
253%
Egr1
Egr1/ apoE/
286%
MK2
MK2/ LDLR/
256%
MKP-1
MKP-1/ apoE/
250%
NR4A1
NR4A1/ BMT in
apoE/
1114%
In JNK2 KO, macrophage SR-A was not phosphorylated and

activity was decreased with less foam cell formation. Other
aspects of inflammation are likely also affected (1483).
Lesions were also less complex. Egr1 is a transcription factor
activated by the MAPKs ERK1/2 and JNK. Egr1/ aorta
showed reduced MCP-1, ICAM-1, and VCAM-1 expression.
oxLDL activates Egr1 in macrophages as well (719). Egr-1
deficiency in bone marrow-derived cells reduced atherosclerosis
28%, suggesting both endothelial and macrophage effects. Egr-1
deficient macrophages expressed less VCAM-1 and tissue factor
which are Egr-1 target genes (43).
Both endothelial activation and macrophage foam cell formation
were affected (840) MK2 is a target of p38. It can
phosphorylate p47phox to activate NOX2 in angiotensin II
signaling (458). Also known as MAPKAPK2 (MAPK activated
protein kinase 2).
MKP-1 (MAPK phosphatase 1) inactivates several MAPKs. The
result seems paradoxical (1612). Confirmed by second study
(820). Both groups concurred that the atherosclerosis
protection was due to macrophage effects with less MCP-1
produced by MKP-1/ macrophages and less influx of
inflammatory macrophages into lesions. Transplant of wild
type bone marrow into MKP-1/ mice restored susceptibility
to atherosclerosis (1612).
NR4A1 (nuclear receptor 4A1, also known as Nur77) is an
orphan nuclear receptor phosphorylated by Erk5 that may act
as a transrepressor of NF-B signaling by binding p65.
NR4A1-deficient macrophages displayed greater classical
(M1) activation with greater TLR4 expression and more iNOS,
IL-12, IFN, and much greater CXCL12, but less IL-10
expression in response to LPS (702).
NF-B signaling including activation by TNF-

ADAM17
ADAM17FVB/FVB
LDLR/
250%
TNF-
TNF-/ apoE/
260%
LT
LT/ C57BL/6
262%
TACE (TNF cleavage enzyme)/ADAM17 cleaves TNF, TNFR1,

ICAM-1, VCAM-1, and CX3CL1 from the external side of their
membrane origins. ADAM17 also promotes shedding of
several EGFR ligands. Atherosclerosis-resistant FVB backcrossed with susceptible C57BL/6J in LDLR/ background
showed less atherosclerosis linked to increased ADAM17
expression and activity in FVB mice due to a 25TG
promoter variant (777).
Produced in EC (and other cells) in response to NF-B signaling.
Produced by monocytes and macrophages in response to IFN. Also secreted by mast cells. Strong activator of endothelial
cells. TNF- KO had a lesser or negative effect in some studies
(918, 919). TNF- knockout in atherogenic diet-fed C57BL/
6J did not result in a decrease in atherosclerosis (1565).
Similar reduction (69%) as shown here at aortic root seen at
6 wk in TNF-/ apoE/ in another study (1991). Only 27%
reduction at 12 wk with greater endothelial ICAM-1, VCAM-1,
MCP-1 expression and increased oxLDL uptake in
macrophages in TNF- KO mice in another (1333).
Differences in mouse lesion progression detectable by MRI
(926).
Lymphotoxin- (also known as TNF-) is a soluble cytokine in the
TNF family. Ligates both TNFR1 and TNFR2. Its presence in
atherosclerotic lesions was also confirmed (1565).
Continued
1326
JNK2 (MAPK9)
Function, Comment
Table 1.Continued
Gene
Model
% A
1130%
TNFR1/ carotid
arteries transplanted
into apoE/ mice
270%
TNFR2/ atherogenic
diet fed C57BL/6J
mice
NS
TNFR2/ apoE/
243%
TRAF1
TRAF1/ LDLR/
232%
TRAF5
TRAF5/ LDLR/
144%
NEMO
endothelial-specific Crelox NEMO ablation in

apoE/
Liver-specific IKK2 Tg in
apoE-Leiden mice
23047%
Macrophage-specific
IKK2 deletion (Cre-lox)
in LDLR/ mice
162%
Endothelial-specific,
degradation-resistant
IB in apoE/
260%
IB/ Cre-lox BMT in

apoE/
cIAP2/ apoE/
190%
TNFR2
IKK2
IB
cIAP2
1131%
247%
TNF- receptor 1 (p55). Controversial results (918, 919,

1565). Artery segments from wild type mice expressed more
TNFR1 with age and developed atherosclerosis more rapidly
after transplant.
Age did not affect atherosclerosis in TNFR1 deficient transplants
(2076). Shown is difference in intima areas. Lesser
differences were seen in young transplanted segments.
Correlative data on human variants given as well.
The TNFR2 (p75) receptor lacks death domains and can be antiapoptotic but can also generate active NIK (1565). TNFR2
activates the alternative NF-B pathway. TNFR1 does not.
TNFR2 only responds to membrane-bound TNF and
upregulates membrane TNF expression, thereby also
increasing TNFR1 signaling. TNFR2 can promote apoptosis by
recruitment of TRAF2 and cIAP1/2 from TNFR1 (1459).
TNFR2/ apoE/ mice had twofold elevations in plasma TNF and IL-17 (possibly inflammatory) and IL-10 (antiinflammatory). TNFR2 also mediated much of the TNF-induced E-selectin, ICAM-1, and VCAM-1 expression in EC as
well as leukocyte capture. TNFR1 and TNFR2 had different but
overlapping effects in EC (276).
Plaques showed marked reduction in macrophages. BMT
studies suggested roughly equal contributions to reduction in
atherosclerosis from endothelial and macrophage effects.
Reduced VCAM-1, ICAM-1 and leukocyte adhesion in
endothelial cells. Decreased monocyte expression of integrin
1 and adhesion to activated endothelial cells. TRAF1/
mice had reduced serum and tissue levels of IL-6 and TNF-
(1217)
Plaques had more macrophages. TRAF5/ endothelial cells
expressed more VCAM-1 and ICAM1. TRAF5/ monocytes
expressed more 4 integrin (CD49d) and greater acetyl-LDL
uptake. There was greater MCP-1 expression and JNK
activation upon stimulation by TNF- (1218).
Two endothelial NEMO ablation models were tested. NEMO
ablation blocked NF-B signaling. Less advanced lesions seen
(592).
Also known as IKBKB (inhibitor of kappa light chain gene
enhancer in B cells, kinase of, beta). The marked increase in
atherosclerosis was associated with only mild or minimal
evidence of additional systemic inflammation and there were
temporarily mild increases in LDL and VLDL-C(1975).
There was only 65% inhibition of IKK2 expression in
macrophages seen with 50% reduction in NF-B activation.
Lesions were more advanced and displayed greater necrosis.
Macrophages produced more TNF- upon stimulation and less
anti-inflammatory IL-10 (881).
Percent reduction in aortic sinus given. Marked reduction seen
in NF-B signaling with decreased adhesion molecule and
cytokine expression as well as reduced macrophage and T-cell
entry into plaques (592).
IB/ macrophages secreted more CCL5 and displayed
increased adhesion to endothelial cells (640).
cIAP2 (and cIAP1) are E3 ubiquitin ligases capable of
synthesizing either K48 or K63 chains and are involved in both
activation (TNFR1 signaling with RIP1 K63 target, CD40 with
K48 TRAF3 target, or TNFR2 signaling with K48 TRAF2
target) or inhibition (K48 NIK target) of NF-B signaling. See
Table 2. These results suggest net effect of cIAP2 is
proinflammatory (1643).
Continued
1327
TNFR1/ atherogenic
diet fed C57BL/6J
mice
TNFR1
Function, Comment
PAUL N. HOPKINS
Table 1.Continued
Gene
Model
% A
NF-B1
NF-B1/ BMT into

LDLR/
241%
NR4A3
NR4A3/ apoE/
252%
A20 (TNFAIP3)
A20/ apoE/
160%
GR
BMT of macrophagespecific GR/ into

LDLR/
NS
Function, Comment
NF-B1 encodes the p50 subunitone of the components that

can make up dimeric NF-B. Though atherosclerotic lesion
size was decreased the lesions had more inflammatory cells
but near absence of foam cells. There was decreased uptake
of oxidized LDL and reduced expression of SR-A (880). (Entry
placed here to keep NF-B signalosome together though effect
is predominantly on macrophages and could be considered a
promoter.)
NR4A3 (nuclear receptor 4A3, also known as NOR1) was
induced by NF-B and transactivated VCAM-1 and ICAM-1
expression in endothelial cells. Fewer macrophages were seen
in lesions of KO animals (2096).
Shown is effect in males. Only 23% increase was seen in
females (1971). Decreased atherosclerosis was seen with
A20 over-expression. A20 inhibits TRAF-mediated activation of
NF-B signaling (TRAF2 for TNFR1, TRAF6 for IL-1R and
TLR4) by degrading K63 ubiquitin chains.
GR (glucocorticoid receptor) deficiency in macrophages did not
affect lesion size but did decrease lesion calcification (1437).
Ceramide metabolism (relates to TNFR1 activity)

/
SCD1
SCD1
LDLR
LYPLA3 (PLA2G15)
LYPLA3/ apoE/
GLA
GLA/0 apoE/
178%
178%
1104%
Mice deficient in SCD1 (steroyl-CoA desaturase 1) had more

atherosclerosis despite less weight gain, lower triglycerides
and greater insulin sensitivity. 78% increase represents the
average of male and female in 2 separate SCD1 deficiency
models. The mice showed extensive skin inflammation as well.
BMT of SCD1-deficient cells did not affect lesions. (1105).
SCD1 may be important for preventing the production of highly
inflammatory ceramide from palmitate by converting palmitate
to palmitoleic acid instead or providing unsaturated fatty acids
for phosphatidyl choline synthesis to alleviate ER stress (484,
655, 760, 1410).
LYPLA3 (lysophospholipase 3) is also known as LLPL (LCAT-like
lysophospholipase), O-acyl-ceramide synthase (ACS), or
PLA2G15. Protective effect of normal activity thought due to
acylation of ceramide. Macrophages from LYPLA3 KO mice
were more prone to apoptosis upon exposure to oxLDL
(1758).
Deficiency of the X-linked GLA (-galactosidase A) causes Fabry
disease. Membrane-associated increases in
globotriaosylceramide. GLA deficient mice in this study had
greatly increased aortic iNOS expression and increased
nitrotyrosine (162). Alterations in endothelial caveolar
signaling may be involved with eNOS inhibition (1629).
NF-B signaling including activation by IL-1 and other TNF superfamily receptors
IL-1Ra
IL-1Ra Tg LDLR/
240%
IL-1
IL-1/ C57BL/6
256%
IL-1
IL-1/ apoE/
233%
IL-1R1
IL-1R1/ apoE/
293%
IL-1 receptor antagonist. A naturally occuring antagonist of IL-1

action. Knockout leads to massive inflammation (918).
Increases endothelial activation, elaboration of adhesion
molecules. Induces production of broad range of cytokines/
chemokines. Also produced by activated EC, VSMC, and Tcells (918).
Similar effects as IL-1 (918). Recent studies show IL-1
production by macrophages and IL-1R on endothelial cells are
main determinants of IL-1 mediated atherosclerosis (875).
IL-1 receptor 1. Included gingivitis in model to promote
atherosclerosis (918). Most important site is EC (875,
1610). Less marked effects reported previously without
gingivitis (270). Plaques in IL-1R1 null apo E deficient mice
reported to have fewer VSMC, less collagen, more
hemorrhage, and less outward remodeling in more distal
vessels (such as brachiocephalic artery), with reduced
expression of MMP3 (47).
Continued
1328
Table 1.Continued
Gene
Model
% A
MyD88
MyD88/ apoE/
273%
IRAK4
IRAK4 inactive knockin in

apoE/ carotid
ligation
TRAF6/ FLC into
LDLR/
289%
OPG/ apoE/
127%
TRAF6
OPG (TNFRSF11B)
NS
Function, Comment
An intracellular adapter for IL-1R1, IL-18R, and all TLR except

TLR3 (1207). Large reductions also seen also by others
(156).
IRAK4 is an essential kinase recruited with MyD88 upon
activation of IL1R and TLR2/4 (1473).
Transplant of FLC was also done into TRAF6 LDLR/ mice.
No differences in atherosclerosis was seen at any site.
Authors conjectured that TRAF6 may be involved in
transduction of anti-inflammatory signaling as well (as from
IL-33) (1675). Pellino may be a redundant E3 ubiquitin ligase
in IL-1R1 signaling.
OPG (osteoprogerin), also known as TNFRSF11B (tumor
necrosis factor receptor superfamily, member 11B) acts as a
decoy receptor for RANKL (receptor activator of NF-B ligand)
and thus inhibits signaling through the RANK receptor. Shown
is the mean effect of male and female mice at 60 wk (125).
Inflammatory GPCR signaling as exemplified by AT1R and the renin-angiotensin system

AGT
1300%
266%
ACE
soluble ACE apoE/
243%
ACE2
Tg ACE2 in high fat fed

rabbits with arterial
injury
258%
ACE2/y apoE/
1325%
ACE2/y LDLR/
138%
AT1R
AT1aR/ apoE/
254%
AT2R
AT2R/ apoE/ with

diabetes
223%
ROCK1
ROCK1/ BMT into

LDLR/
260%
ROCK2
ROCK2/ BMT into

LDLR/
245%
PYK2
PYK2/ apoE/
266%
Compared with C57BL/6J both fed atherogenic diet. Effects on

blood pressure were not controlled for (1697).
Though renin deficiency in bone marrow-derived cells decreased
atherosclerosis, the major pro-atherosclerotic effect of ANG II
appears to be through AT1R on endothelial cells (1080).
Mice homozygous for the soluble ACE mutation had an 86%
reduction in plasma ACE activity as well as reduced blood
pressure. The reduction in atherosclerosis was shown to be
dependent on the blood pressure (and presumable total body
ANG II production) rather than the specific location of the ACE
(1938). Similar results in heterozygous ACE deficiency in apo
E null mice (737).
Shown is reduction in intimal area at the aortic root. ACE2
cleaves ANG I into inactive ANG 1-9 and ANG II into
vasodilating ANG 1-7, thereby opposing the activity of ACE
(2066). ACE2 is on the X chromosome.
Increased expression of several inflammatory markers on
endothelial cells was seen and increased atherosclerosis was
inhibited by perindopril (an ACE inhibitor) (1786).
Increased atherosclerosis in both whole body and BMT studies.
ACE2 in lesions associated with macrophages. ACE2 deficient
macrophages secreted more ANG II and co-infusion of ANG
1-7 blocked excess atherosclerosis (1781).
Given here is the effect of whole body knockout. Decreased
plaque rupture seen in another model (68). Macrophagespecific AT1aR deficiency had only a small effect (563) or even
increase atherosclerosis (889) but a clear reduction in
atherosclerosis was seen with AT1R null BMT when
accompanied by ANG II-stress from uninephrectomy (2008).
Reduced plaque (by 86%) seen also with matched blood
pressure (384, 1929).
The apparent proatherosclerotic influence of intact AT2R was
seen with pharmacologic blockade as well (930). An earlier
study had found no effect in LDLR deficient mice (384).
ROCK1/2 as effectors of RhoA are involved in many
inflammatory effects as well as smooth muscle contraction.
Involved in leukocyte movement control through RhoA signaling
(1895).
ROCK2 KO macrophages showed increased PPAR and LXR
activation with greater expression of ABCA1 and cholesterol
efflux (2104).
Additional studies with BMT showed that arterial wall and bone
marrow-derived cells contributed similarly to the reduction in
atherosclerosis (890).
Continued
1329
Renin
human AGT/renin Tg
C57BL/6J mouse
renin/ BMT in
LDLR/
PAUL N. HOPKINS
Table 1.Continued
Gene
Model
% A
p21Cip1/ apoE/
253%
STAT3
endothelial-specific
STAT3/ C57BL/6
mice fed an
atherogenic diet
264%
GRK2
GRK2/ BMT in
LDLR/
231%
ARRB2
ARRB2/ LDLR/
240%
Bcl10
Bcl10/ apoE/ with

Ang II infusion
266%
APLN
APLN/ apoE/
150%
APLNR
APLNR/ apoE/
234%
HSD11B2
HSD11B2/ apoE/
11719%
Increased expression of cyclin-dependent kinase inhibitor

p21Cip1 was, in part, dependent on PYK2 and associated
JNK signaling and acted as a co-activator for VCAM-1 and
MCP-1 transcription in endothelial cells (890). Macrophage
apoptosis was increased while macrophages showed less
inflammation and greater efferocytosis capability with p21Cip1
KO. Fibrous caps were thicker. Results confirmed with
different diets and BMT studies (1196). Similar results (34%
reduction in atherosclerosis) was seen in apo E null mice with
ANGII infusion which increased p21Cip1 expression (961).
In this study, endothelial JAK2/STAT3 was activated by oxidized
phospholipid (610). JAK2 activation was dependent on Src but
likely also on PYK2 with signaling through CD36 (716). In
another study, increased expression of STAT3 by adenoassociated virus delivery of human STAT3 appeared protective
with a 15% reduction in atherosclerosis. Treg-associated
Foxp3 and SOCS1 expression were increased while
macrophage burden was decreased (901). Dual delivery of
both STAT3 and IL-10 were not additive in their antiatherosclerotic effects (252).
Complete GRK2 (G-protein coupled receptor kinase-2) KO is
embryo lethal. Macrophage-specific GRK2 KO did not affect
atherosclerosis (1359). GRK2 phosphorylation may mark
GPCR for chemokines or AT1R for -arrestin2 with
inflammatory coupling.
ARRB2 (-arrestin2) couples a number of GPCR including AT1R
and LPA receptors to the CBM signalosome. The reduction in
lesion area was largely due to fewer VSMC in plaques (907).
Bcl10 is part of the CARD-Bcl10-MALT1 (CBM) signalosome
(utilized by AT1R, PAR1 thrombin receptor, others). Bcl10/
mice also had many fewer aortic aneurysms. Reduction of
ANG II-induced NF-B activation in both EC and VSMC was
apparent without an effect on TNF--induced activation
(1164).
APLN (apelin) is a peptide secreted by EC as well as other cells
including adipocytes. APLN receptors (APLNR) are found on
EC, VSMC, and other cells. APLN infusion promotes
vasodilation in intact arteries but constriction in endotheliumdenuded vessels. In this study, APLN inhibited the
vasoconstriction and blocked the enhancement in
atherosclerosis and aneurysm formation caused by ANG II
infusion. Evidence was presented for a direct interaction
between the AT1R and APLNR (326). APLN KO also
significantly worsened hypoxia-induced pulmonary hypertension
with a reduction in eNOS and KLF2 expression (274).
APLNR is also known as APJ and AGTRL1 (angiotensin receptorlike 1). Despite results above for apelin, KO of its receptor
decreased atherosclerosis with greatly reduced numbers of
VSMC in lesions while treatment of cultured VSMC with apelin
promoted NOX activity and VSMC proliferation (729). Apelin
and APLNR expression were upregulated by carotid ligation
and promoted VSMC proliferation and increased neointimal
formation (931).
HSD11B2 (11-hydroxysteroid dehydrogenase 2) inactivates
cortisol by converting it to cortisone. Cortisol binds and
activates the MR (mineralocorticoid receptor) with affinity
similar to aldosterone. Mice were fed chow diet so
atherosclerosis was minimal in apo E null mice but substantial
in double KO. Endothelium showed activation with increased
VCAM-1 expression. Atherosclerosis was blocked by
eplerenone but not amiloride (416).
Continued
1330
p21Cip1 (CDKN1A)
Function, Comment
Table 1.Continued
Gene
Model
% A
Function, Comment
Miscellaneous general signaling components.

LPIN1
BALB-fld/fld mouse fed

Paigen diet
1109%
LPIN1 (lipin 1) is the gene defective in the fld mouse. These

mice develop lipodystrophy, fatty liver, and insulin resistance
but had lower VLDL and LDL and higher HDL compared to
BALB/c controls yet developed more atherosclerosis (1475).
LPIN1 converts phosphatidic acid to diacylglycerol but also has
direct signaling roles, interacting with a number of
transcription factors and regulating their activity. LPIN1 is
required for expression of fat synthesizing genes and acts as a
transcription coactivator with PPAR in adipose. LPIN1 also
appears to repress inflammatory signaling by NFATc4 (906).
network state and receptor kinetics than the product of any

single linear pathway (328, 1004).
INSR simultaneously and harmoniously activates a series of
pathways which interact as a networked web rather than a set
of discrete, linear chains (1004, 1630). Unlike many RTK,
INSR subunits (2 identical transmembrane and 2 identical
extracellular insulin-binding subunits) are covalently bound
by multiple disulfide bonds. When insulin binds the INSR, tyrosine kinase domains in the cytoplasmic tails of the receptor are
in some way activated. One tail then phosphorylates the other,
providing new tyrosine phosphate binding sites. A number of
adapter or docking proteins including IRS proteins as well as
some signaling enzymes then link the activated receptor to assorted canonical signaling pathways or cassettes.
Ligation of EGFR by, for example, heparin-binding epidermal growth factor-like growth factor (HB-EGF) is somewhat more typical of RTK, causing dimerization of two
separated but identical receptor subunits with relief of autoinhibition followed by self-phosphorylation of specific tyrosine residues in the receptors cytoplasmic tail. For the
particularly well-studied EGFR, as many as 90 potential
tyrosine phosphorylation sites may interact with some 80 or
more downstream signaling proteins. While EGFR ligation
promotes VSMC and macrophage proliferation, its overall
role in atherosclerosis is currently unclear.
2. Activation of PKB/Akt by INSR signaling: a focal
membrane event
Upon INSR tyrosine self-phosphorylation, adapters are recruited to phosphotyrosines on the receptors cytoplasmic
tail. Once bound, such adaptors may become targets of the

receptors activated tyrosine kinase domain become tyrosine phosphorylated themselves. This is the case with IRS
proteins (with isoforms IRS1 4). In contrast, serine phosphorylation of IRS can block downstream signaling, one of
the mechanisms of both insulin resistance and feedback
inhibition.
After tyrosine phosphorylation, IRS1/2 provides suitable
binding sites for a type 1A phosphatidylinositol 3 kinase
(PI3K) such as PI3K. PI3K generates phosphatidylinositol 3,4,5-trisphosphate (PIP3) from phosphatidylinositol 4,5-bisphosphate (PIP2) in cell membranes. This generates a localized gradient of increased PIP3 in the cell
membrane surrounding the activated INSR. PIP3 recruits
a number of signaling molecules that possess pleckstrin
homology (PH) domains or other PIP3-binding domains.
IRS proteins themselves contain PH domains which help
anchor them to the cell membrane. Importantly, immediate downstream signaling molecules PDK1 (PIP3-dependent kinase 1, also known as PDPK1 for PIP3-dependent protein kinase 1) and PKB/Akt are recruited to the
membrane by their PH domains. When bound to PIP3,
PDK1 self-activates and can then phosphorylate PKB/
Akt. PDK1 is involved in activation of PKC enzymes as
well. Not shown in FIGURE 2 is a second phosphorylation
that is also required for PKB activity which is probably
provided by mammalian target of rapamycin, complex 2
(mTORC2). mTORC2 utilizes the subunit Rictor (rapamycin-insensitive companion of mTOR) rather than
Raptor (regulatory associated protein of mTOR) used by
the mTORC1 depicted in FIGURE 2. mTORC1 is an im-
1331
This and most of the following tables detail gene knockout (KO) or transgenic (Tg) overexpression studies showing effects
on atherogenesis. Often a high-saturated-fat, high-cholesterol diet (Western diet) is fed, but this is not always indicated.
The Paigen diet adds cholate which promotes greater lipid elevations and atherogenicity. If available, the effect on
atherosclerosis in the aortic root is given (since it is the most consistently reported sites and quantification is reasonably
standardized). If multiple time points were reported, the longest follow-up time is generally presented here. If aortic root
quantification was not presented, the area of most advanced atherosclerosis was generally used. Percentage increases
or decreases are intended as only rough, semi-quantitative estimates for comparison. Reference numbers are given in
parentheses. EC, endothelial cells; VSMC, smooth muscle cells; DC, dendritic cells; BMT, bone marrow transplant (after
irradiation of recipient animals); Th1, type 1 T helper cell; Th2, type 2 T helper cell; Treg, regulatory T-cell; NS,
nonsignificant; % A, percent difference in atherosclerosis compared with control animal (e.g., a 100% increase is
equivalent to a twofold increase over control; a 75% decrease is equal to of the control).
PAUL N. HOPKINS
portant downstream target of PKB while control of
mTORC2 is less well understood.
Among the pro-proliferative effects of PKB is the inhibitory

phosphorylation of Ser9 on glycogen synthase kinase 3
(GSK-3). After priming by a casein kinase, GSK-3 tonically inhibits glycogen synthase. Inhibition of GSK-3 by
PKB thus promotes glycogen synthesis. But GSK-3 does
much more than inhibit glycogen synthase. Among its many
actions are blocking the cell cycle by inhibition of CCND1
(cyclin D1) and blocking protein synthesis by inhibiting the
translation factor eukaryotic initiation factor 2B (eIF2B).
Furthermore, GSK-3 is activated by endoplasmic reticulum (ER) stress which is aggravated in endothelial cells by
various atherosclerosis risk factors including hyperlipidemia. Recently, blocking GSK-3 by valproic acid was
shown to reduce atherosclerosis (1165), providing evidence
for at least one downstream target of INSR to explain its
anti-atherogenic effect.
PKB further promotes cell survival and proliferation by
phosphorylating FOXO (forkhead box O) transcription
factors. This inhibitory phosphorylation causes FOXOs to
be excluded from the nucleus. FOXO activity can also be
affected by acetylation and ubiquitination. Interestingly,
the FOXO transcription factors can influence transcription
both by binding traditional DNA response elements as well
as by protein-protein interactions with other nuclear proteins, independent of DNA binding (369). With regards to
the circulatory system, KO of FOXO1 is embryo-lethal due
to vessel malformation while conditional KO in adults
causes hemangiomas and angiosarcomas due to unchecked
proliferation of angiogenic cells. For FOXO3, KO phenotypes are more subtle, but enhanced vessel growth is seen
with hypoxia (1326). Control of excess proliferation is exerted by FOXO1/3 through both apoptosis and cell cycle
1332
3. Other adapters and enzymes link INSR

to multiple pathways
Other adapters that bind tyrosine phosphorylated INSR (as
well as other RTK) include growth factor receptor-bound
protein 2 (Grb2), Grb2-associated binder 1 (Gab1), and Src
homology collagen-like (Shc), as well as assorted signaling
enzymes such as Src (short for sarcoma) (probably by way
of IRS for INSR), SH2 domain-containing tyrosine phosphatase (SHP2), and phospholipase C, isoform (PLC).
Much like IRS proteins, Gab1 binds phosphotyrosine on
active INSR, is then tyrosine phosphorylated by INSR and
can then bind PI3K to further enhance PIP3 production. The
Src family kinases are an important class of non-receptor
tyrosine kinases that can phosphorylate the cytoplasmic tail
of RTK as well as other receptors which lack tyrosine kinase
activity, or various adapters (such as Shc). Src family kinases thereby act to initiate downstream signaling or amplify the activity of the RTK, particularly its mitogenic activity (for example, through the Shc, Ras, and the MAPK
pathway to be discussed below).
The tyrosine kinase Janus kinase (JAK) is brought to INSR
by way of the adapter SH2b adapter protein 1 (SH2B1),
while a substrate of JAK, signal transducer and activator of
transcription 3 (STAT3) appears to be carried by the
adapter receptor for activated C-kinase 1 (RACK1) (1630).
Upon phosphorylation by JAK tyrosine kinases, signal
The designations PKB or Akt are used interchangeably. The

name Akt derives from studies in an A strain of mouse,
originally identified in the 1920s which had given rise by
inbreeding to a k substrain particularly prone to spontaneous thymoma development. These mice were further inbred at Rockefeller University, giving rise to the AKR
mouse. A transforming cell line derived from AKR mice
gave rise to the name Akt (1674). Active Akt is a major
cellular signaling node with many downstream targets.
Knockout (KO) of Akt1 (PKB), the main endothelial isoform, resulted in clearly increased atherosclerosis while
bone marrow transplant (BMT) with Akt1-deficient cells
had little effect (see TABLE 1). The proliferative effects of
Akt/PKB are sufficient to clearly promote cancer when a
mutation results in constitutive activity. Anti-atherosclerotic effects of Akt1 in endothelial cells likely include barrier preservation, partial activation of endothelial nitric oxide synthase (eNOS) by direct phosphorylation, mitogenic
effects, and inhibition of apoptosis.
regulatory genes. In FIGURE 2 are several examples of genes

transcriptionally activated or inhibited by FOXO1 or
FOXO3. Active nuclear FOXO3 promotes apoptosis primarily by increasing transcription of BIM (Bcl-2-interacting
mediator of cell death) and Noxa (a latin word meaning
injury or damage), important components of the apoptosis
pathway. Entry into the cell cycle is limited by FOXO1/3 by
increasing expression of cell cycle inhibitors p21Cip1 (cyclin-dependent kinase interacting protein, encoded by
CDKN1A, cyclin-dependent kinase inhibitor 1A) and
p27Kip1 (p27 CDK interacting protein) and by blocking
transcription of CCND1 (cyclin D1) (369). Recent work
suggests that FOXO1 and -3 have net atherogenic effects in
endothelium (1817) but have a protective effect in myeloid
cells in part by limiting their proliferation (1818) (see TABLE
1). FOXO1/3 can also inhibit inflammatory NF-B signaling, increase production of protective MnSOD (manganese
superoxide dismutase, a mitochondrial SOD also known as
SOD2), induce DNA repair genes such as GADD45
(growth arrest and DNA damage-inducible gene 45), and
generally support longevity (369, 1326). FOXO3 was also
found to help limit lung damage from cigarette smoke, primarily due to direct blocking of NF-B signaling (811).
These observations sound a cautionary note for selecting
signaling molecules to block as a means to prevent atherosclerosis and illustrate the divergent effects the same genes
can have on endothelial versus leukocyte mediated mechanisms.

transducer and activator of transcription (STAT) proteins
form dimers and transmigrate to the nucleus to function as
transcription factors. The JAK-STAT pathway represents
one of the shortest and most rapidly acting of receptoractivated pathways. Some receptors (such as many for interleukins) are primarily JAK-STAT transducers.
When bound to phosphotyrosines on the INSR cytoplasmic
tail, PLC can cleave membrane-bound PIP2 to release free
inositol 1,4,5-trisphosphate (IP3), leaving diacylglycerol
(DAG) in the membrane. IP3 binds to and opens the IP3
receptor embedded in the endoplasmic reticulum (ER)
membrane, releasing into the cytoplasm calcium stored in
the ER. Free calcium can bind calmodulin (CaM) and many
other effectors. Furthermore, calcium and DAG together
activate conventional protein kinase C serine/threonine kinases (PKC, I, II, and ). Novel PKC enzymes (PKC,
-, -, and -) are activated by DAG but not calcium. Atypical PKCs, including PKC, -, and -, can be activated by
PIP3 or ceramide. All the PKC enzymes are further activated
by PDK1 in PIP3-enriched cell membranes.
Small G proteins, also known as GTP-binding proteins or

GTPases, are master signaling molecules, serving as on-off
switches. G proteins now number some 150 in five families.
Most are membrane bound. They mediate the assembly of
other signaling proteins or cascades when they are in their
on or GTP-bound configuration. This they do by facilitating conformational changes in their downstream binding
partners without direct enzymatic modifications. When
bound with GDP, small G proteins are off; they do not
bind to effectors. G proteins are activated by guanosine
exchange factors (GEFs), which replace GDP with GTP.
They are turned off by GTPase activating proteins (GAPs)
which supply a missing component to the GTP hydrolytic
site inherent to G proteins. The 800 human G proteincoupled receptors (GPCRs) are essentially GEFs for G, a
GTPase accompanied by and subunits when bound to
the GPCR. In GPCR signaling, GAPs for G are often referred to as regulators of G protein signaling (RGS) proteins.
Insulin signaling activates the prototypical small G protein,
Ras (named for a transforming oncogene found in rat sarcoma). The Ras superfamily includes Ras, Rho/Rac, Rab,
Rap, Arf, Ral, Ran, Rheb, Rad Rit, and Miro families. After
INSR activation and IRS1/2 phosphorylation, specific
phosphotyrosine residues are recognized on IRS1/2 by the
SH2 domain of the adaptor Grb2. In the case of EGFR
signaling, Grb2 binds directly to activated EGFR. The
adapter Shc (Src homology collagen-like) can bind phosphotyrosines on either INSR or EGFR and, once bound, Shc
can also act as an intermediary adapter to bind Grb2. Grb2
brings with it (bound to SH3 domains) the RasGEF Sos,
Ras is permanently and firmly anchored to membranes by

covalently attached lipid anchors (farnesol and palmitate).
Rho family G proteins, including RhoA (Ras homologous
A), Rac1 (Ras-related C3 botulinum toxin substrate 1), and
Cdc42 (cell division cycle 42), have geranylgeranyl anchors
but shuttle from cytoplasm to membranes, being held inactive and soluble in the cytoplasm with their anchor shielded
by various GDP dissociation inhibitor (GDI) proteins. The
Src family tyrosine kinases also depend on prenylation and
are normally membrane bound. Statins inhibit synthesis of
isoprenoid lipid anchors, and this can decrease signaling,
especially from Ras, RhoA, and other small G proteins,
explaining at least some pleiotropic effects of statins (1356,
1524, 2105). Pharmaceutical inhibition (with manumycin
A) of farnesyltransferase, which transfers the farnesyl moiety onto Ras, resulted in a 43% reduction in atherosclerotic
lesion size and a marked decrease in VSMC proliferation in
ApoE-deficient mice (1695).
G proteins of the Rab family (some 60 members in the
human genome) control vesicle transport. In muscle and
adipose cells, insulin signaling causes storage vesicles with
GLUT4 (glucose transporter 4) inserted in their membranes
to be translocated by cellular motors along microtubules
and then microfibers to the cell membrane where the
GLUT4 storage vesicles dock and fuse with the cell membrane, allowing glucose to then enter the cell. This process is
largely orchestrated by several Rab G proteins that are
found attached to the intracellular GLUT4 storage vesicles.
In unstimulated muscle and adipose cells, relevant Rabs are
maintained in a GDP-bound, inactive state by the Rab-GAP
AS160 (Akt substrate 160 kDa, also known as TBC1D4).
After insulin binding, activated Akt/PKB phosphorylates
AS160, causing it to bind to a 14-3-3 binding protein,
thereby rendering it inactive. The Rab G proteins become
activated by GTP binding and then direct translocation of
the vesicles and membrane fusion, thereby promoting glucose uptake (1009, 1687). While the GLUT4 pathway is
lacking in endothelial cells, it illustrates an important signaling tactic, inhibiting an inhibitor (AS160) of G protein
signaling.
Another example of inhibiting the inhibitor is the phosphorylation of the TSC1/2 complex (tuberous sclerosis 1
and 2). TSC1/2 is a GAP for the G protein Rheb. Active
1333
4. Multiple G proteins are activated

by insulin signaling
which then activates Ras. Sos activity is partially dependent

on PIP3. Active Sos mediates exchange of GDP for GTP on
Ras. Active, GTP-bound Ras can then bind and promote
activation of Raf1. Sos also has Rac1 GEF activity. PI3K
enzymes possess a Ras binding domain (RBD) which can
help approximate the catalytic subunit of the PI3K to its
substrate, PIP2, in the cell membrane. This is yet another
example of the interconnectedness of these pathways. Once
activated by Ras, active Raf1 promotes downstream MAPK
signaling (discussed further below).
PAUL N. HOPKINS
Rheb is required for activation of mTORC1 (mammalian
target of rapamycin, complex 1) (FIGURE 2). Active PKB
phosphorylates and inhibits TSC1/2 leading to GTP binding of Rheb and mTORC1 activation. Active mTORC1
then acts to increase protein synthesis by promoting phosphorylation of the ribosomal protein S6 (by S6K1), activating eIF4E, and inhibiting autophagy. mTOR is opposed in
all these actions by AMPK (AMP-activated protein kinase),
which senses low cellular energy levels as reflected by increasing AMP. AMPK activates a host of pathways to generally mobilize and increase cellular fuels and energy production while decreasing energy expenditure. AMPK signaling promotes production of new mitochondria and has
also been associated with longevity. Interestingly, knockout
of at least one isoform of AMPK increased atherosclerosis
(see TABLE 1), despite its opposition to at least some aspects
of insulin signaling.
5. Signaling cassettes activated by RTK are mutually

supportive: role of oxidases
Note that many of the seemingly disparate pathways activated by INSR are mutually supportive (see FIGURE 2). RTK
(and many other receptors) generally activate NOX isoforms and/or calcium-sensitive dual oxidase (DUOX) enzymes (or both) to generate superoxide and hydrogen peroxide, respectively. These ROS reversibly inhibit assorted
protein tyrosine phosphatases (PTP) as well as the lipid
phosphatase PTEN (phosphatase and tensin homolog deleted on chromosome ten). PTEN acts to cleave the 3 phosphate on PIP3. PTEN and the various tyrosine phosphatases
can be so active that, without inactivation, no signal can be
propagated. Therefore, most cellular activating systems
(whether proinflammatory or anti-inflammatory and including various growth factors, cytokines, antigen recognition, ANG II, thrombin, and even insulin) simultaneously
stimulate ROS production to prolong their signals. ROS
thus have the important signaling task of inhibiting the
inhibitors of RTK (and other) signal transmission. This is
accomplished by generating far less superoxide than fully
activated NOX2 in neutrophils and other phagocytes, although the same NOX2 (and other NOX isoforms) are
found on endothelial cell membranes.
1334
The active NOX2 complex consists of several subunits

(119). NOX2 is the catalytic subunit (also known as
gp91phox). It is permanently bound to the membrane with
six transmembrane domains while its cytoplasmic COOH
terminus binds FAD and NADPH. NOX2 is found constitutively bound to the p22phox subunit which stabilizes
NOX2. NOX2 activation requires phosphorylation of the
regulatory p47phox subunit which then moves from the cytoplasm to bind the p22phox subunit. This p47phox organizer subunit brings with it p67phox (the activator subunit) and p40phox (a modulatory subunit) to the membranebound complex. As noted above, activation of NOX2 also
requires the active, GTP-bound form of Rac1 which first
binds NOX2 then p67phox. Phosphorylation of p47phox
may be accomplished by PKC enzymes activated by DAG
supplied by PLC, also activated by INSR. As noted above,
INSR can supply active Rac1. In endothelial EGFR signaling, Rac1 can be activated by Vav2 (Vav1 is found primarily in hematopoeitic cells). The GEF activity of Vav2 is
partially dependent on PIP3, again supplied by the PI3K
cassette. There are many other Rac1 GEFs that are not
dependent on PIP3. PIP3 also mediates binding of the
p40phox subunit of NOX to the cell membrane.
In INSR signaling, yet another GEF, whose identity remains

somewhat uncertain (312), promotes GTP binding to Rac1,
with subsequent activation of NADPH oxidase 1 or 2
(NOX1/2) which then generates superoxide. Rac1 also regulates the cytoskeleton which may further promote proper
assembly of NOX components as well as direct GLUT4
vesicle transport. Although superoxide is a potent reactive
oxygen species (ROS), its controlled production by NOX
enzymes should not be viewed as an inevitably adverse
event, but a necessary and normal component of the signaling machinery.
The lipid phosphatase PTEN is among the most important

signal terminating enzymes. By removing phosphate from
the inositol-3 position of PIP3, PTEN acts in direct opposition to PI3K. Because PKB/Akt requires PIP3, PTEN also
inhibits cell proliferation and promotes apoptosis, yet it is
also anti-inflammatory in various circumstances. Indeed,
many tumors express diminished PTEN, allowing excess
PIP3 accumulation and PKB activity which promotes cell
proliferation and survival. VSMC-specific knockout of
PTEN leaves PI3K unopposed. Vascular injury in PTEN
KO animals results in markedly increased neointimal formation (from excessively proliferating VSMC) and greatly
increased production of cytokines by the activated VSMC
(569, 1292). In endothelial cells and macrophages, both
proinflammatory (e.g., priming of PKC, increase foam cell
formation in macrophages) and anti-inflammatory pathways (e.g., increased eNOS phosphorylation and activation) are, in part, dependent on Akt/PKB activity. In one
study, the plant alkaloid berberine was thought to increase
atherosclerosis in ApoE null mice by supression of macrophage PTEN causing an increase in the expression of scavenger receptor SR-A, uptake of modified LDL, and foam cell
formation (1027). Conversely, upregulation of PTEN in endothelial cells, either by specific alkaloids (810, 1816) or by
PPAR agonists (810, 838, 909) substantially attenuated expression of the adhesion molecule VCAM-1 in response to the
inflammatory cytokine TNF- and decreased monocyte adherence while inhibiting endothelial proliferation and angiogenesis. These findings suggest a complex and difficult to predict role for PTEN in relation to atherogenesis. Perhaps not
surprisingly, the overall effect on atherosclerosis of wholebody heterozygous PTEN KO was neutral (64).

While a low level of NOX activity is expected to be important for the apparently anti-atherosclerotic activity of endothelial INSR signaling, higher NOX activity is frequently
associated with atherosclerotic plaque. Such pro-atherogenic NOX signaling is found in activated macrophages and
other leukocytes as well as activated endothelial cells. Thus
genetic deletion or impairment of NOX2, p47phox, and the
main source of NADPH utilized by NOX enzymes, glucose
6 phosphate dehydrogenase (G6PDH), were all found to
clearly reduce atherosclerosis (see TABLE 1). In bone marrow transplant studies in ApoE-deficient mice, deficiency of
p47phox in the artery wall with normal bone marrow resulted in a 66% reduction in atherosclerosis and marked
reduction of VCAM-1, ICAM-1, and P-selectin adhesion
molecules expressed on both endothelial cells and VSMC as
well as relative insensitivity to thrombin signaling. Transplant of p47phox-defective, ApoE-deficient marrow into
ApoE-deficient mice with wild-type p47phox resulted in
53% attenuation of atherosclerosis, suggesting both vascular wall and macrophage production of superoxide contributes importantly to atherosclerosis progression (1872).
NOX1 and NOX4 are also present in endothelial cells and

contribute to ROS production (1911). NOX4 is constitutively active and seems little affected by at least some inflammatory signals (although possibly induced by others)
while NOX1 plays a greater role in VSMC superoxide production. In some circumstances, NOX4 may actually be
anti-inflammatory through chronic, background superoxide production leading to stimulation of cellular antioxidant defenses (1566). Remarkably, p47phox KO reduced
endothelium-dependent vasodilation in response to VEGF
due to impaired PI3K-Akt-eNOS signaling (515), suggesting a need for balance in ROS-producing pathways.
6. Signaling cassettes activated by RTK are mutually
supportive: role of Src and other components
Other mutual dependencies of signaling cassettes are apparent in FIGURE 2. The activity of PI3K is at least partially
B. An Introduction to MAPK Signaling

1. Why MAPK signaling cassettes?
As noted above and in FIGURE 2, MAPK signaling is one of
the major pathways activated by RTK ligation. FIGURE 3
illustrates some of the essential features of MAPK signaling
in this context. MAPK modules can be thought of as signaling bottlenecks that collect assorted signals from receptors,
G protein switches, ROS, integrins, and other cellular sensors and then transduce these diverse signals into a highly
controlled off/on signal which is passed on to numerous
cellular effectors and feedback controls (1141). For example, ERK1/2, the prototypical terminal MAPK, may phosphorylate over 100 proteins. These downstream effectors
mediate critical cellular functions including metabolism,
gene transcription in response to challenges, cell architecture, differentiation, cell survival, proliferation, and apoptosis. MAPK modules may be seen as key, controlling
guardians supervising these critical pathways. While only a
few MAPK-related gene knockouts have been directly
tested for effects on atherosclerosis, there are numerous
interventions which affect cell function through MAPK
pathways. Furthermore, MAPK are majorly involved in angiogenesis (607).
Each MAPK module consists of a series of three consecutively activated protein kinases, typically held in juxtaposition by a scaffold protein. Other regulatory proteins, including deactivating phosphatases, are also part of the complex. MAPK designates the terminal serine/threonine
kinase. The terminal MAPK is activated by a MAPKK
(MAPK kinase or MAP2K, also called a MEK for MAPK/
ERK kinase). This intermediate kinase may itself function
as a scaffold and is phosphorylated by an upstream MAPKKK (MAPKK kinase, or MAP3K also known as a MEKK
or MEK kinase). Terminal MAPK activation requires two
1335
NOX2 is upregulated in human coronary arteries from patients with CAD, even in areas without lesions (682).
NOX2 deficiency causes X-linked granulomatous disease.
Normal human subjects all experienced impairment of
flow-mediated dilation after 20 min of arm ischemia while
patients with NOX2 deficiency (or p47phox deficiency) did
not (1079), again demonstrating relevance of NOX2 in
short-term endothelial function. Endothelial NOX5 expression was sevenfold higher in early human coronary atherosclerotic lesions and contributes to ROS production (680).
The NOX5 gene was apparently lost in rodents and hence
cannot be studied by KO in mice. Hyperlipidemia appears
to contribute to age-related increases in arterial wall ROS
production, since endothelial NOX2 expression and superoxide levels markedly increased with age in ApoE-deficient
mice but not in wild-type mice.
dependent on active Ras. The tyrosine kinase Src (or another Src family kinase) is activated by INSR (and EGFR)
through the intermediary action of SHP2. Src amplifies
EGFR activation by phosphorylating EGFR tyrosines 845
and 1101, Gab1, STAT3, and STAT5a/b. Src also phosphorylates ADAM17, further activating its sheddase activity, which thereby releases more HB-EGF (89, 1004).
Similar amplification likely occurs with INSR. Perhaps not
surprisingly, insulin signaling through INSR acts synergistically with EGFR to increase the mitogenic effects of EGFR
signaling (180). Not shown in FIGURE 2 are a number of
INSR-interacting proteins (such as Cbl: Casitas B-cell lymphoma) or SOCS (suppressor of cytokine signaling) that initiate feedback inhibition and downregulation (89). Nor are the
complex pathways shown that regulate transport of GLUT4containing vesicles to and their fusion with the cell membrane,
since GLUT4 is not expressed on endothelial cells.
PAUL N. HOPKINS
phosphorylations in two separate hits on a Thr-X-Tyr
(TXY) motif in the activation loop. Thus MAP2K are rather
exceptional dual-function kinases with both serine/threonine and tyrosine kinase activities. Similarly, MAP2K acti-
vation requires the phosphorylation of two closely spaced

serines (SXXXS motif). MAP3K activation is far more diverse and generally requires multiple activating signals with
modulation by inhibitory modifications.
Insulin
HB-EGF
Insulin receptor
EGFR
GDP Ras
P
P
P
Sos
GTP Ras
PAK, S621
Src, Y341
PKA, S43
14-3-3
Many inputs
MAP3K
Raf1
ASK1
TAK1
MEKK2/3
MAP2K
MEK1/2
MKK4/7
MKK3/6
MEK5
MAPK
ERK1/2
JNK
p38
ERK5
Inputs
MAPK
filter
Many outputs
Ca2+
Cytoprotection
p47phox
mRNA stabilization
NOX5
p47phox
Fos
Elk1
Jun
ICAM-1, TF, PDGF
Fos
Egr1
P
ATF2
1336
RSK1
RelA
MSK1
MK2
MCP1, ET-1, IL-8, ICAM-1, HO-1, etc.

AP-1
14-3-3
Activation loop
PKC, S338
RBD CRD
P
P
P
P
Raf1, S494
GTP Ras
Raf1 N
MAPK activity
Grb2 (Shc) P
Sos
Raf1, T491
GDP Ras
(Shc) Grb2
PKA&B, S259
P
P
P
P
PKA, S233
P
P
P
P
ADAM17

Mammalian terminal kinases include ERK(17) (with
ERK1 and ERK2 nearly indistinguishable in function),
JNK(13), and p38(, , , and ). Traditionally, ERK1/2
are activated by mitogens while p38 and JNK are activated
by cell stress or cytokine-generated signals. JNK signaling,
in particular, can lead to apoptosis. In endothelial cells,
ERK5 signaling is generally anti-inflammatory and cytoprotective (see sect. IVD). Kinases that can phosphorylate
MAP3K are sometimes referred to as MAP4K and may be
involved in multiple interacting pathways.
3. Activation of Raf1, a prototypical MAP3K, and

other activators of MAPK pathways
Binding of active, GTP-bound Ras to Raf1 is necessary but
not sufficient for Raf1 activation. Indeed, the structure of
Raf1, shown in FIGURE 3, illustrates the multiple potential
inputs to a MAP3K in general. Activating phosphorylations
of specific serine (S), threonine (T), or tyrosine (Y) residues,
together with potential (not necessarily exclusive) activating protein kinases are shown in the black arrow boxes. The
red arrow boxes show inhibiting phosphorylations. Additional phosphorylations, which are not shown in FIGURE 3,
can add still greater complexity and feedback inhibition
(1510). Phosphorylations at S43, S233, and S259 sterically
inhibit Raf-1 binding to GTP-Ras and promote, instead,
binding to the adapter/chaperone protein 14-3-3 (named
In FIGURE 3 only one MAP3K is shown for the JNK and p38
modules, whereas, in reality, a number of MAP3K can activate either or both JNK or p38. These MAP3K include
MEKK1 4, MLK2/3 (mixed lineage kinases 2 and 3, also
known as MAP3K10 and MAP3K11), ASK1 (apoptosis
signal-regulating kinase 1), NIK (NF-B-inducing kinase or
MAP3K14), and TAK1 (TGF--activated kinase-1 or
MAP3K7). A number of these MAP3K as well as their activating MAP4K are involved with NF-B activation as
well, illustrating important network behavior or cross-talk
between MAPK and NF-B activation pathways. Surprisingly, KO of ASK1, either whole body or in bone-marrow
derived cells only, resulted in an increase in atherosclerosis
with greater macrophage accumulation and less macrophage necrosis (see TABLE 1).
Several MAP4K are particularly relevant to endothelial cell
activation. These include PKC (which has multiple targets), (GCK; or MAP4K2), and PAK1/2 (p21 activated kinase 1 and 2). Flow-induced PAK activation in endothelial
cells apparently activates JNK through the MAP2K MKK4
(285, 692, 1353). JNK induces bone morphogenic protein 2
(BMP2), BMP4, and Toll-like receptor 4 (TLR4) and has
numerous other proinflammatory and pro-apoptotic effects
in endothelial cells (285) yet only JNK2 appeared to be
atherogenic (see TABLE 1).
4. MAPK, MAPK targets, and atherosclerosis
Once active, one of the targets of ERK1/2 (and p38) is
MSK1 (mitogen- and stress-activated protein kinase 1).
MSK1 phosphorylates serine 276 of the NF-B p65 subunit
after translocation to the nucleus (1467). This is a key modification of p65 which facilitates CBP/p300 binding and
FIGURE 3. Mitogen-activated protein kinase (MAPK) signaling. Each MAPK module consists of a series of three protein kinases, often held in
juxtaposition by a scaffold protein (shown in amber for MAPK scaffolds as well as other scaffolds or adaptor proteins). Other regulatory proteins such
as protein phosphatases are often attached to MAPK scaffolds (not shown here). Many more signals than shown here can impinge on a MAP3K. In
addition, terminal MAPKs have many more serine/threonine phosphorylation targets than illustrated. Graph on left illustrates kinetic features of
MAPK modules which act as noise filters at low upstream input, followed by rapid, easy, and full activation above the activation threshold, and limitation
of downstream activity with higher inputs. The figure on the right suggests that MAPK modules act as funnels to collect many signals, bottle necks to
filter and process these signals, and then have many diverse targets.
1337
The unique architecture of MAPK modules, with their scaffolds, associated phosphatases, and requirements for two
closely spaced phosphorylations to activate the terminal
kinases all work together to impart uniquely useful kinetic
properties, indicated in FIGURE 3. Thus MAPK modules
remain inactive, acting as noise filters at low level inputs,
become rapidly activated once inputs rise above a specific
level, and then display a stable, limited output activity even
when inputs rise to very high levels (1140). Furthermore,
the scaffold proteins (and other regulatory proteins) can
dampen or amplify the output depending on cell status or
context (1067, 1742). All these properties are highly desirable features of a biochemical switch controlling crucial
downstream processes and help explain the preservation of
MAPK pathways in essentially all eukaryotic organisms.
Furthermore, cellular effects vary markedly depending on
cell type, duration, and location of MAPK signaling. For
example, transient cytosolic activation of ERK can lead to
cell proliferation, while sustained nuclear activity can cause
terminal differentiation (933).
for the separation fraction where it was discovered). Various 14-3-3 isoforms often hold proinflammatory client proteins like Raf1 inactive in the cytoplasm as shown in FIGURE
3 (1537, 2103, 2125). There is a suggestion that upregulation of 14-3-3 proteins may be protective in atherosclerosis,
although assignment of specific roles for the different isoforms is difficult (218, 1052). Remarkably, however, phosphorylation of S621 on Raf1 creates a binding site for 143-3 which is mandatory for Raf1 activity (by providing a
binding site for ATP and a shield against S621 dephosphorylation) (419). Once active, Raf1 phosphorylates MEK1 or
MEK2 which can then phosphorylate and activate the terminal MAPK, ERK1, or ERK2.
PAUL N. HOPKINS
acetylation of p65 Lys310, allowing full transcriptional
competency for NF-B (see below); yet another example of
cross-talk between MAPK and NF-B signaling. Also indicated in FIGURE 3 are the generally proinflammatory activities of JNK and p38. Thus JNK activates transcription
factors including early growth factor 1 (Egr1), activating
transcription factor 2 (ATF2), and activator protein-1 (AP1), which contains either c-Fos, c-Jun, or both. Egr1 and
AP-1 generally induce proinflammatory gene transcription.
ApoE-deficient mice with Egr1 knockout had a marked reduction in atherosclerosis (see TABLE 1).
MAPK phosphatase 1 (MKP-1) was found to be expressed

exclusively in arterial regions protected by high laminar
flow in mouse aorta (2056), but the mechanism of MKP-1
induction by flow is currently unknown. MKP-1 is a dualspecificity phosphatase that can deactivate all MAPK but
preferentially p38 and JNK. While inhibition of these
MAPK would seemingly be anti-inflammatory and therefore atheroprotective, MKP-1 deficiency was, in fact, found
to decrease atherosclerosis (820, 1612). MKP-1 KO mice
transplanted with wild-type bone marrow had slightly
greater (though nonsignificant) atherosclerosis compared
wild-type mice receiving wild-type bone marrow, suggesting only mild, if any, effects due to MKP-1 deficiency in the
vessel wall (1612). However, macrophages from MKP-1deficient mice were found to have impaired ERK1/2 expression and marked defects in their ability to spread and migrate, and reduced MCP-1 production, resulting in a reduction in lesion macrophage content (820, 1612).
In several studies of MAPK signaling components, the direction of the effect seemed paradoxical. Thus ASK1 KO
clearly increased atherosclerosis, with a lesser (nonsignificant) effect from macrophage-specific p38 KO, while
MKP-1 KO decreased atherosclerosis. These unexpected
results seemed to occur when the endothelial effect would
have been predicted to be anti-inflammatory and antiatherogenic (or proinflammatory and proatherogenic),
while at the same time, a seemingly opposite effect was seen
in macrophages or other leukocytes. MAPK generally have
1338
In MKP-1 deficiency, an unknown mechanism led to impaired ERK1/2 expression which was linked to defective
migration, an unexpected anti-inflammatory effect on macrophages (820, 1612). In ASK1 KO, there was less early
macrophage apoptosis and hence larger lesions (2005).
There was also less macrophage necrosis which might actually be an advantage in more advanced lesions (although
this possibility was not tested). If ASK1-deficient endothelial cells were less prone to inflammation, this tendency was
apparently less important for lesion size than the macrophage effects. This may be seen as a disadvantage to wholebody KO studies in general, since differences in endothelial
and macrophage effects, which may act in the opposite
direction, may not be separable.
Endothelial insulin signaling has been proposed to act as a
two-edged sword, with the potentially proinflammatory
Grb2-Sos-Ras-Raf1-MAPK cascade and production of the
vasoconstrictor endothelin-1 (ET-1) on the one hand and
the relatively protective, antiapoptotic, anti-inflammatory,
and vasodilatory PKB-eNOS pathway on the other (1251,
1432). The finding of increased atherosclerosis with IRS2
knockout in ApoE-deficient mice which was directly proportional to plasma insulin concentrations is supportive of
this view (637). Based on the increased atherosclerosis seen
in mice with endothelial-specific INSR deletion, the overall
endothelial effect of normal insulin signaling can be taken
as protective. However, as with the unexpected findings for
MAPK signaling noted in the prior paragraph, macrophage-specific deletion of INSR decreased atherosclerosis
(TABLE 1). In both cases, the direction of the effect could
potentially be explained by survival effects for the particular cell type. Moreover, the insights gained would probably
have been obscured if only whole body KO experiments had
been conducted.
C. NF-B Activation
1. General features of NF-B signaling
Some departure from the outside-in order of presentation
is taken here to first introduce NF-B itself and to illustrate
the central significance of this master proinflammatory, antiapoptotic transcription factor. Signaling pathways related
to NF-B are exceedingly complex. Indeed, in the year 2012
alone, there were 5,683 publications listed in PubMed that
included NF-B in an indexed field. Several excellent,
recent reviews are available (1639, 1841, 1944).
Like most transcription factors, NF-B is a dimer. Most
commonly, RelA (also known as p65) is paired with p50.
Activation of MAPK p38 in areas of disturbed flow also

appears to be an important means of ATF2 and AP-1 activation (529, 2011), thus priming endothelial cells for subsequent activation. Another target of p38 and ERK1/2
phosphorylation is MAPK-activated kinase 2 (MK2) which
can phosphorylate the p47phox to facilitate NOX activation
and ROS production. MK2 also appears to be involved in
mRNA stabilization for a number of proinflammatory proteins whose mRNA intrinsically has rapid turnover due to
AU-rich elements in their 3 untranslated regions (973).
MK2 KO reduces atherosclerosis (TABLE 1) but, unfortunately, also increases susceptibility to infection. Paradoxically, however, p38 KO nonsignificantly increased atherosclerosis (see below).
strong prosurvival effects on macrophages and can have

varied effects on scavenger receptor expression and foam
cell formation. The resulting effects on atherosclerosis can
be nuanced and difficult to predict.

Other Rel subunits (RelB, and c-Rel) and the p52 subunit
can also form NF-B transcription factors. The subunit p50
is the product of the NF-B1 gene and has p105 as its
precursor (processed to p50 constitutively) while the NFB2 gene encodes p52 and its precursor, p100. In nonstimulated cells, NF-B dimers are held inactive in the cytoplasm
by one of several IB (inhibitor of B), most frequently IB
and IB while other classes of IB can serve different functions (2009). In addition, the p100 precursor of p52 binds
RelB and holds it inactive. The p100 precursor also binds
and inhibits other NF-B dimers by way of the same domain shared by IB proteins (ankyrin repeats). In the canonical pathway, IKK2 (IB kinase 2 or IKK) is activated
and targets IB for phosphorylation, ubiquitination, and
subsequent proteosomal degradation, releasing NF-B
dimers for transport to the nucleus. IKK1 (IKK) is generally controlled by the noncanonical pathway (see below)
and leads to processing of p100.
The NF-B signalosome is somewhat analagous to the

MAPK module, especially since serine/threonine kinases
that activate the IKK complex, including TAK1, NIK
(NF-B inducing kinase), and MEKK3, can all serve as
MAP3K. IKK1 and IKK2 are comparable to MAP2K and
even share the same SXXXS activating motif. Finally, targeting of IB proteins by IKK1/2 leads to transcription factor activation. The pathways even share several common
MAP4K (such PKC) (87, 796).
A focal point of NF-B signaling is activation of IKK2 and
IKK1. Not only does active IKK2 phosphorylate IB, targeting it for ubiquitination and degradation, but IKK2 has a
number of other targets as well, both cytosolic and nuclear
(1325). Importantly, active IKK2 serine phosphorylates insulin receptor substrate 1 (IRS-1) and thereby promotes
insulin resistance in various tissues. Promiscuous activation
2. NF-B translocation: general features

Conversion of the inactive, bound, cytosolic NF-B to a fully
functional transcription factor involves two fundamental
steps, translocation to the nucleus, and transactivation. For
translocation, NF-B must be released from its inhibitors and
move to the nucleus. This occurs by canonical, noncanonical
(alternate), and atypical pathways. In FIGURE 4, canonical
and noncanonical activation is illustrated downstream of
TNF receptor 1 (TNFR1) and TNFR2, respectively. Both
the canonical and noncanonical pathways converge on the
IKK complex, composed of the kinases IKK1 (also referred
to as IKK) and IKK2 (or IKK) bound to their scaffold
NEMO (NF-B essential modulator, also known as IKK).
The canonical pathway leads to phosphorylation and activation of the IKK2 subunit, generally by the serine/threonine kinase TAK1. When activated, IKK2 phosphorylates
IB proteins (at serines 32 and 36 for IB), marking them
for ubiquitination with lysine 48-linked (K48) chains. K48
ubiquitination targets IB for degradation by the 26S proteosome, thereby releasing the NF-B dimer for transport to
the nucleus. The noncanonical pathway is characterized by
activation of NIK and IKK1 activation.
3. NF-B translocation by the canonical pathway:
TNFR1 signaling
Upon ligation of TNFR1 by soluble or membrane-bound
TNF-, the adapter TRADD (tumor necrosis factor recep-
1339
In endothelial cells, active NF-B induces transcription of

cell adhesion molecules such as ICAM-1, VCAM-1, and
E-selectin, as well as several chemokines and cytokines including MCP-1, M-CSF, GM-CSF, IL-1, IL-6, IL-8, and
TNF-. Given the generally pro-inflammatory gene targets
of NF-B, it is not surprising that many elements of upstream signaling leading to NF-B activation have been
found to be atherogenic (see TABLE 1). Nevertheless, NF-B
also has a number of antiapoptotic targets, including IB
(representing a form of feedback inhibition), cFLIP (cellular
FLICE inhibitory protein), cIAP1/2 (cellular inhibitor of
apoptosis 1 and 2), XIAP (X-linked inhibitor of apoptosis),
the adapter/binding protein 14-3-3 (some isoforms), A20,
Cezanne (cellular zinc-finger anti-NF-B enzyme), COX-2,
and eNOS. Why might NF-B be both proinflammatory
and anti-apoptotic? Teleologically, one might reason that
the bodys soldiers and sentinels (leukocytes and endothelial cells) should protect themselves while fighting the enemy.
of IKK2 and NF-B in adipose, macrophages, pancreas, and

liver may be one of the major features of metabolic syndrome and type II diabetes and may partly mediate some of
the associated cardiovascular risks (79, 431, 631). Liverspecific overexpression of human IKK2 in ApoE-Leiden hyperlipidemic mice led to a modest increase in IKK2 activation in liver and only a mild increase in systemic susceptibility to inflammatory signaling. Nevertheless, there was a
greater than twofold increase in atherosclerosis (1975). Perhaps some of the increased atherosclerosis was promoted by
a transient and mild increase in plasma very-low-density
lipoprotein (VLDL) and low-density lipoprotein (LDL) levels, but most of the effect was thought to be due to increased
NF-B activation. Inhibition of IKK2 (but not IKK1) can be
achieved by pharmacological levels of salicylic acid. The
nonacetylated forms of salicylate do not inhibit COX enzymes and appear to primarily exert their anti-inflammatory and insulin-sensitizing effects as well as improvement
of endothelial function through IKK2 inhibition (1417,
2040, 2051). Salicylate treatment decreased atherosclerosis
in LDLR/ mice by 40% (817). Furthermore, salsalate
(a dimer of salicylic acid) administration decreased insulin
resistance and inflammatory markers in obese young adults
(530) and was recently shown to improve glycemic control
and increase adiponectin levels in adult type II diabetics
(630).
PAUL N. HOPKINS
TNF (soluble)
TNF (membrane bound)

TNFR2
ASM
Ceramide
Sphingosine S1P PKC/
U
U
U
SODD
TNFR1
SPHK1
O2
O2
CIC3
O2
Rac1
O2
Grb2 Sos Ras

MADD
S1P
O2
O2
O2
RFK
O2
14-3-3
PKC
U U
26S
TRADD TRAF2
RIP1 U cIAP1/2
U LUBAC
U
U U
U U
U U
TAB1 TAB2
U U
TAK1
U U
U
U
U
U
U
U NEMO
cIAP1/2
NIK
PKC
NOX1/2
BMX
TRAF3
RACK1 EED nSMase
TRAF3
FAN
Lipid raft fusion
U
U A20
U
U U
p62 PKC
NIK
U
U
MEKK3
U
U
U
U
26S
NEMO
Ras
IRS1
SOD1
IKK2
IKK1
NIK
ERK1/2
JNK
p38
PAK1/2
Rho
ROCK
H2O2
RSK1
IB
RelA:p50
p100
U
U
U
RelB:p52
26S
ERK5
p52
AKIP1
p53
FAK
SIRT1
NIK
CBP
PKAc
ICAM-1, VCAM, MCP1, IL-1, IL-2,
PKC
NF-B
MSK1
S536: P
S311: P
K310: Ac
S276: P
K221: Ac
Y152: NO2
Y66: NO2
C38: Ox, SNO
IL-6, IL-8, Gro, TNF, E-selectin, P-selectin, LOX-1,

VEGF, IL-10, eNOS, cFLIP, MKPs, COX2, IB, cIAP1,
XIAP, A20, Cezanne, MnSOD, ...
IKK1/2
U K63-linked or linear ubiquitin chains

U K48-linked ubiquitin chains
N
1340
RHD
TAD
p65 (RelA)
U
U
GEF-H1
TRAF2
cIAP1/2

suggests that endosome formation may not be required for
activation.
Activated NOX2 produces superoxide within the endosome which can escape through anion channels such as
chloride channel 3 (ClC3) (1154) into the cytoplasm where
it is rapidly converted to hydrogen peroxide by superoxide
dismutase 1 (SOD1). Interestingly, oxidation of extracellular cysteines on TNFR1 and TNFR2 (which are intraendosomal after endocytosis) seems to enhance binding and subsequent signaling by TNF (1363). ROS and especially peroxynitrite increase PKC activity as well (551).
Subsequent downstream canonical signaling depends on E3

ubiquitin ligases. Indeed, ubiquitination is of key importance in all TNFR superfamily signaling. Most readers will
be familiar with ubiquitin tagging of proteins to target them
for proteosomal degradation. Such tagging usually involves
assembly of so-called K48 (lysine 48) ubiquitin chains on
the targeted protein. More recently, the formation of alternative ubiquitin structures serving very different functions
has been recognized. Three classes of ubiquitinases are required for ubiquitination (120, 1944). E1 ubiquitin activating enzymes utilize ATP to attach the glycine COOH terminus of ubiquitin to an E2 enzyme by a high-energy thioester
bond. Ubiquitin-charged E2 enzymes (ubiquitin conjugases) attach the COOH terminus of ubiquitin to the target
protein and extend the ubiquitin chain. E3 enzymes (E3
ubiquitin ligases) join in a complex with E2 enzymes, directing the E2 enzyme to a particular protein target. E1 and E2
enzymes are not shown in FIGURE 2. There are only a few E1
enzymes, less than 40 E2 conjugases, but over 600 E3 ubiquitin ligases in the human genome, providing greater signaling diversity than even the 518 or so known protein kinases
(1036). TRAF proteins as well as cIAP1/2 are E3 ubiquitin
ligases. When newly added ubiquitins are linked repeatedly
to ubiquitin K48 at the tail of the growing chain, the protein
is targeted for degradation. In contrast, if newly added
ubiquitin is linked repeatedly to lysine 63 (K63) of the terminal ubiquitin, a dynamic scaffold is produced which
serves to assemble downstream signaling components. Similarly, linkage to the NH2 terminus of the growing ubiquitin
chain by LUBAC (linear ubiquitin chain assembly complex)
yields so-called linear ubiquitin chains which also provide a
signaling scaffold (143).
Receptor-bound TRADD binds TRAF2 which recruits

cIAP1/2 (cellular inhibitor of apoptosis protein 1 and 2) and
RIP1 (receptor-interacting protein 1) to the cytoplasmic tail
of TNFR1, forming complex I. ROS derived from NOX2
activated in the prior step enhances binding of TRAF2 to
TRADD, probably by alterations of cysteine residues
(1321). This model is consistent with hydrogen peroxide as
an enhancer, but not necessarily an initiator of NF-B signaling (1345). It should be noted that creation of a microdomain with high hydrogen peroxide/ROS concentrations immediately surrounding the receptor complex may
provide adequate ROS stimulation without an absolute
need for endosome formation. Some experimental evidence
After assembly of complex 1 (TRADD, TRAF2, cIAP1/2,

RIP1, and associated E1 and E2 enzymes), TRAF2 and
cIAP1/2 decorate RIP1 and themselves with K63 ubiquitin
chains. These K63 chains, as well as linear ubiquitin chains
synthesized by LUBAC, emerge from TRAF2, RIP1, and
cIAP1/2 like a growing mop from the activated receptor
complex. K63 ubiquitin chains provide a transient and dynamic scaffold for strategic spacial juxtaposition of downstream adapters, kinases, ubiquitinases, and signaling targets, ultimately mediating the activation of the IKK complex and release of NF-B. Thus adapters TAK1-binding
protein 2 (TAB2) and NEMO bind the growing K63 chains
bringing the IKK complex (NEMO, IKK1, and IKK2) into
FIGURE 4. Introduction to NF-B signaling. Tumor necrosis factor- (TNF-)-mediated activation of NF-B signaling is representative of the TNF
receptor superfamily. Although not shown, MEKK1 recruitment and activation may be dependent on K63 ubiquitinated TRAF2 and RIP1. Also
not shown is the E3 ubiquitin ligase, SCF-TrCP (S-phase kinase-associated protein 1, Cullin1, F-box protein complex--transducin repeatcontaining protein) which mediates K-48 ubiquitin chain attachment onto IB after IB is phosphorylated by IKK2. Sphingosine-1-phosphate
(S1P) is a required cofactor for TRAF2 to function as a K63 E3 ubiquitin ligase. See text for additional details and abbreviations.
1341
tor 1-associated death domain protein) binds the cytosolic

tail of the receptor, displacing inhibitory SODD (silencer of
death domain). Subsequent activation appears to depend on
internalization of TNFR1 together with activated NOX2
into caveolar endosomes (1234). The mechanism for
NOX2 activation is not entirely clear but depends on displacing GDP in exchange for GTP on Ras which occurs
within 1 min of TNFR1 receptor ligation (1740), followed
closely by activation of PI3K and Vav1/2 (a GEF for Rac1
and RhoA). PKC (as well as PKC and PKC) activity is
increased seven- to eightfold by 5 min after TNF- challenge (550). Finally Rac1 is activated (796). NOX2 requires
active Rac1 (297) as well as phosphorylation of the p47phox
regulatory subunit, probably by PKC (796). Sos may also
act as a Rac1 GEF in TNFR1 signaling (1413). RhoA can be
activated by phosphorylation of GEF-H1 by ERK1/2 (873).
RhoA and ROCK1/2 (Rho-associated, coiled-coil containing protein kinase 1 or 2) activation increases endothelial
intercellular permeability by causing stress fiber reorganization with internalization or redistribution of the tight junction proteins occludin, junctional adhesion molecule A
(JAM-A), and zona occludens 1 (ZO-1) (1172). ZO-1 is a
scaffold protein that connects actin microfibers with transmembrane junctional proteins including occludins and
JAMs.
PAUL N. HOPKINS
juxtaposition with active TAK1. Additional ubiquitination
of TAK1 and NEMO seems to increase TAK1 activity and
amplify the signal (498). Phosphorylation of IKK2 by
TAK1 activates IKK2 which phosphorylates IB, marking
it for K48 ubiquitination and proteosomal degradation.
The decrease in IB liberates RelA:p50 dimers to translocate to the nucleus. At the same time, removal of IB
exposes Rel A Ser276 which becomes a target of activated
PKA subunits (designated PKAc). Translocation of RelA:
p50 to the nucleus ensues, apparently mediated by the
adapter protein A-kinase-interacting protein 1 (AKIP1)
with enhancement by hydrogen peroxide (588).
4. The noncanonical pathway for NF-B translocation
Different complexes held together by ubiquitin K63 chains

can separate from the receptor and continue signaling in the
cytoplasm (as can complex I described above). Deubiquitinating or ubiquitin editing enzymes such as A20, Cezanne,
and cylindromatosis (CYLD) control inflammation by degrading K63 chains and creating in their place new K48
chains, thereby targeting key signaling components for proteosomal degradation (1875). Not surprisingly, A20 deficiency increases atherosclerosis (see TABLE 1).
TNFR2 is highly expressed on vascular endothelial cells

(1958). When ligated, TNFR2 probably also forms a complex with NOX in endosomes like TNFR1. In unstimulated
cells, NIK is scarce due to a constitutive K48 ubiquitination
and proteosomal degradation. The ongoing K48 ubiquitination is carried out by a cytoplasmic complex of NIK,
TRAF3, TRAF2, and cIAP1/2 in which NIK is targeted by
cIAP1/2. TNFR2 ligation causes TRAF3 to bind the
TNFR2 cytoplasmic tail, disrupting the complex with NIK
and redirecting cIAP1/2 E3 ligase activity to TRAF2 and
TRAF3. Their subsequent depletion leads to increasing accumulation of active NIK (1459). Reduced TRAF2 and
TRAF3 also appears to promote complex II formation if
TNFR1 is ligated (1824). Thus TNFR2 signaling may promote apoptosis through TNFR1. Full NIK activation may
require phosphorylation and K63 ubiquitination (141,
853). Active NIK phosphorylates IKK1 which, in turn,
phosphorylates the p100 precursor of p52. K48 ubiquitination of p100 serves as a marker for only partial proteosomal
degradation, the product being mature p52. Reduction of
p100 and simultaneous provision of p52 yields functional
RelB:p52 dimers which translocate to the nucleus. Depletion of p100 also releases RelA:p50 dimers (2058). TNFR2
ligation additionally supports angiogenesis probably by release of constitutively bound bone marrow tyrosine kinase
on chromosome X (BMX), a tyrosine kinase which transactivates VEGFR2 and may lead to activation of PI3K
(1090).
Not shown in FIGURE 4 following TNFR1 activation is the

more delayed or alternative formation of complex II which
contains TRADD, RIP1, Fas-associated death domain
(FADD), and pro-caspase 8. Activation of caspase 8 leads to
caspase 3 activation and apoptosis. Complex II activation
may require receptor endocytosis through clathrin-coated
pits (as opposed to the caveolae with caveolin shown in
FIGURE 4). Endocytosis is followed by NOX-mediated generation of superoxide which is needed for activation of lysosomal acid sphingomyelinase and ceramide synthesis on
the outer leaf of the plasma membrane or the intraendosomal side (370, 1424, 1765). Prolonged exposure to high
levels of ROS and excessive NO from iNOS activation seem
to favor complex II activation and apoptosis. The ubiquination of RIP1 seems to be a key determinant of complex II
formation. The adaptor ABIN1 (A20 binding and inhibitor
of NF-B) binds ubiquitin chains on RIP1 and inhibits
caspase 8 binding to FADD, thus preventing formation of
complex II (1354). In contrast, free or nonubiquited RIP1
promotes formation of complex II and apoptosis. Increased
expression of ubiquitinases such as USP2a that target RIP1
K63 ubiquitin chains seems to enhance apoptosis following
TNF1 engagement (1115).
1342
High NIK activity not only activates IKK1 but also IKK2,
apparently by IKK1 phosphorylation of IKK2 (686). When
activated, IKK1 as well as IKK2 have effects well beyond
NF-B translocation with nuclear phosphorylation targets
including the RelA subunit as well as other transcription
factors and cytoplasmic signaling proteins (355, 623,
1405).
The contribution of NIK to NF-B activation is often underappreciated. Both TNFR1 and TNFR2 seem to mediate
adhesion molecule expression, yet TNFR2 appears to have
a greater role for E-selectin and ICAM-1 (275). Deficiency
of either TNFR1 or TNFR2 strongly inhibited atherosclerosis in hyperlipidemic mice (276) (see TABLE 1). Prolonged
cytokine or other signaling leading to ROS generation (as
IB virtually disappears from the cytoplasm within 10 15

min of TNFR1 activation (498). Maximal nuclear translocation of NF-B and DNA binding is seen by 15 60 min
(1740), and some induced gene transcription products (including new synthesized IB reappearing in cytosol) become detectable after 12 h (1741). ICAM-1 appears in
2 4 h (2109), and a number of other targets such as
cIAP1/2 and X-linked inhibitor of apoptosis (XIAP) increase for at least 24 h (1740).
The noncanonical or alternative pathway is said to respond

more slowly to upstream signals and requires continuing
protein synthesis; however, activation is more persistant.
Noncanonical NF-B translocation is dependent on NIK
activation. Fewer receptors (including TNFR2, CD40,
BAFF, and lymphotoxin receptors, among others) are
thought to activate the alternative pathway compared with
the canonical pathway but age-related accumulation of tissue-bound TNF, the only ligand for TNFR2 (1459), may
cause prolonged activation.

from ANG II, IL-1, or exposure to reactive aldehydes)
seems to lead to greater NIK activation (1030, 1069, 1440).
Depletion of cIAP1/2 predictably leads to an increase in
NIK. Such depletion occurs when apoptotic signals release
second mitochondria-derived activator of caspase (SMAC)
which causes cIAP1/2 auto-ubiquitination and rapid degradation (1639). With the use of an informatics approach,
NIK signaling was predicted to be a major activator of
NF-B in the artery wall 3 or more hours after initial TNF
stimulation (2024). Additional details of other TNF family
receptor signaling, including IL-1R, TLR4 (similar to TLR2
signaling), and CD40 (similar to TNFR2) are presented in
TABLE 2.
The finding of increased atherosclerosis in LDLR-null mice

with TRAF5 deficiency was also surprising (1218). As
TRAF5 may substitute for TRAF2 in the alternative pathway, TRAF5 deficiency may possibly lead to increased liberation of NIK. CD40, the receptor for CD40L has mixed
canonical and alternative pathway capabilities through a
single proximal binding site for TRAF6 and 2 distal sites
that can bind TRAF1, 2, 3, or 5. Genetic disruption of the
TRAF6 binding site nearly abrogated atherosclerosis (90%
reduction) in hyperlipidemic mice accompanied by an increase in IL-10 production by macrophages shifted toward
anti-inflammatory M2 differentiation. In contrast, mutating the TRAF1/2/3/5 binding sites, if anything, slightly aggravated lesions (1093). In prior studies, prolonged shear
stress in human EC was shown to increase TRAF3 (but not
TRAF2 or TRAF5) expression, presumably by mRNA or
protein stabilization since transcription was unchanged. Increasing TRAF3 expression, either by shear stress or by
transfection, blocked endothelial CD40 signaling (as manifest by reduced IL-8, MCP-1, and tissue factor production)
triggered by CD40L expressed on activated platelets. Interestingly, in EC, TRAF3 did not localize with the CD40
receptor but was instead shown to accumulate in the nucleus and directly block DNA binding by AP-1. In EC,
CD40-induced MCP-1 production was shown to be mediated by JNK, ERK1/2, and AP-1 rather than by NF-B
(1836). These observations illustrate the diversity of signaling pathways a single receptor may trigger and how the
emphasized pathway may differ from cell to cell.
Transactivation involves posttranslational protein modifications of the NF-B dimer, allowing it to function as a
competent transcription factor whose activity is further
modulated by other coactivators and corepressors. Phosphorylation of RelA at Ser276 is critical in facilitating RelA
binding and acetylation by the coactivator CBP (CREB
binding protein or closely related p300) and binding with
other coactivators (such as cyclin T1/CDK9) which can direct expression of a more inflammatory subset of NF-B
target genes (623, 1320). Ser276 also vies for attention from
the E3 ubiquitin ligase SOCS1 (suppressor of cytokine signaling 1) that targets RelA for degradation and the oncogenic
kinase Pim1 (proviral integration site murine leukemia virus)
that can maintain RelA active (1307). Several other posttranslational modifications are shown in FIGURE 4 (623). Various
kinases not generally considered part of the NF-B signalosome can contribute to activation of nuclear NF-B,
such as endothelial focal adhesion kinase (FAK) (1414).
Nitration by peroxynitrite (on RelA tyrosines 66 and 152),
or nitrosylation by NO of cysteine 62 of p50, inhibits
NF-B signaling by causing dissociation from DNA and
removal from the nucleus by IB (623).
NF-B complexed with CBP/p300 displaces inhibitory histone deacetylases (e.g., HDAC13) and promotes activity
of histone acetyltransferases (HATs). Histone acetylation
leads to transcriptional activation of target genes by relaxing the winding of DNA around histones, making the promoter more accessible to the RNA polymerase II complex.
Interestingly, cigarette smoke extract powerfully inactivates
HDAC enzymes to promote inflammation while GR (glucocorticoid receptor)-bound cortisol recruits HDAC2 to inflammatory gene promoters to repress inflammatory gene
expression (623). Additionally, cortisol-GR exerts powerful anti-inflammatory effects by acting at glucocorticoidresponsive elements (GREs) as a positive transcription factor to various anti-inflammatory proteins (such as annexin
A1) (1407) and by binding to other adaptor proteins, in
particular GR interacting protein 1 (GRIP1) which binds
and acts as a repressor to most NF-B and AP-1 responsive
proinflammatory genes (308, 1482). Estrogen also induces
annexin A1 with diminished adhesion to endothelium by
estrogen-treated neutrophils (1267). In cholesterol-fed rabbits and ApoE-deficient mice, glucocorticoid treatment decreased plaque size (81, 549), while no effect was seen in
ovariectomized monkeys without estrogen replacement
(11). However, medroxyprogesterone blocked the protective effective of estrogen treatment in these animals. Macrophage-specific deletion of GR did not affect lesion size in
LDLR-deficient mice but resulted in lesions with less calcification (1437).
Silent mating type information regulation 2 (Sir2) homolog
1 (SIRT1) is an anti-inflammatory deacetylase that can inactivate NF-B by removing acetyl groups. Endothelial-spe-
1343
Only a few TRAF proteins have been targeted for knockout

to study effects on atherosclerosis. Surprisingly, TRAF1 KO
reduced atherosclerosis in LDLR null mice even though
TRAF1 had been thought to inhibit TRAF2, particularly in
TNFR2 signaling (1217). The apparently pro-atherogenic
effect of TRAF1 may possibly be explained by observations
on oligomer formation. TRAF2 functions as a homotrimer
in its binding and activation of cIAP1/2 to form K63 chains
on RIP1. TRAF1 can replace a single TRAF2 chain resulting
in a heterotrimer that binds cIAP1/2 more avidly than the
TRAF2 homotrimer, thereby promoting more active signaling (2097).
5. NF-B transactivation
PAUL N. HOPKINS
Table 2. NF-B activation of nuclear translocation by representative members of the TNFR superfamily of receptors
Downstream Signaling
Proteins
(Transmembrane
Receptor Adaptors)
Receptors (Conformation, Extracellular or Transmembrane Adapters)

IL-1R (IL-1RAcP)
Primary intracellular
adapters
recruited to the
cytoplasmic tail of
the ligated receptor.
Additional adapters,
kinases, and E3
ubiquitin ligases may
bind to the activated
receptor.
SODD (inhibitory,
displaced by TRADD)
TRADD (recruits TRAF2,
RIP1)
TRUSS (recruits TRAF2,
IKK complex)
MADD [recruits Grb2
with Sos. Required for
ERK1/2 activation by
TNF- (963)]
FAN (recruits other
adaptors required for
neutral
sphingomyelinase
activation. FAN also
functions as a GPCR
adapter.)
MyD88 (recruits IRAK4

then IRAK2 and/or
IRAK1, Tollip, TRAF6)
Tollip (sequesters
inactive IRAK1,
becomes
phosphorylated,
ubiquitinated and
degraded at the
same time IRAK1 is
phosphorylated)
Secondary adapters
may serve multiple
roles as kinases and
ubiquitin ligases
TRAF2/5 (recruit
cIAP1/2, MLK3)
RIP1 (can recruit TRAF5.
With K63 chain also
binds p62. K63 chains
required to recruit
TAB1/TAB2/TAK1.)
p62 (scaffold that also
binds PKC and
MEKK3a)
NEMO (essential final
adapter in canonical
pathwaycomplex with
IKK1 and IKK2. Binds
K63 and linear chains.
Also involved in
recruitment of
MEKK1.)
ABIN1 (binds ubiquitin
chains on RIP1 and
inhibits caspase 8
binding to FADD, thus
preventing formation of
complex II.
TRAF6 (can act as

scaffold between
MyD88 and p62)
p62 (scaffold that also
binds PKC and
MEKK3)
NEMO (essential final
adapter in canonical
pathwaycomplex
with IKK1 and IKK2.
Binds K63 and linear
chains.)
Proximal kinases
(and targets)
recruited and
activated by
adapters or by each
other. May also
serve as E3 ligase
targets
RIP1 (AIP1)
PKC, PKC [TRAF2 Thr
117, directing K63
ubiquitination of TRAF2
and recruitment of
IKK1 and IKK2 (1033)]
IRAK4 (IRAK4, IRAK2,

IRAK1marks IRAK1
for K63
polyubiquitination by
Pellino)
IRAK2 (TRAF6main
activator)
IRAK1 (IRAK1, Pellino,
phosphorylation
marks for K48
tagging)
TLR4 (dimer, MD2, CD14, LBP,

RP105, MD1)
CD40 (trimer)
TIRAP/MAL (localizes receptor

in the membrane by a
required PIP2 membrane
binding domain; recruits
MyD88)
MyD88 (see for IL-IR)
Tollip (see for IL-1R)
TRAM (binds receptor at a
domain separate from
MyD88 and recruits TRIF)
TRIF (recruits TRAF3 which
recruits E3 ubiquitin ligases
MIB1/2 or Nrdp1 whose
targets include scaffolds
TANK and related as well as
TBK1. Also late recruitment
of RIP1 and TRAF6.)
TRAFs bind directly to

receptors
cytoplasmic tail.
Binding sites for
TRAF3 and TRAF2
(alternative) and
TRAF6 (canonical)
overlap causing
competitive
inhibition of
alternative versus
canonical signaling.
In the cytoplasm of
resting cells, TRAF3
recruits NIK and
TRAF2, TRAF2
recruits cIAP1/2
which links K48
chains to NIK
leading to
constitutive NIK
degradation.
TRAF6 (can act as scaffold
TRAF3 (Receptor
between MyD88 and p62)
activation recruits
RIP1 (additional scaffold
TRAF3, NIK,
between TRAF6 and p62)
TRAF2, cIAP1/2
CARD9-Bcl10-MALT1 (MALT1
complex to receptor
recruits cIAP1/2 and TRAF6
cytoplasmic tail.)
followed by K63 decoration
of MALT1, TRAF6, and
NEMO. These may be
activated by joint activation of
TLRs and ITAM-coupled
receptors.)
p62 (scaffold that also binds
PKC and MEKK3)
NEMO (essential final adapter
in canonical
pathwaycomplex with IKK1
and IKK2. Binds K63 and
linear chains.)
(TANK, NAP1, or SINTBAD
play an analgous role to
NEMO, binding IKK-related
kinase, IKK or TBK1 which
phosphorylate and activate
IRF3/7)
IRAK4 (IRAK4, IRAK2, IRAK1)
IRAK2 (TRAF6main activator)
IRAK1 (IRAK1, Pellino,
phosphorylation marks for
K48 tagging)
RIP1 (AIP1)
none known
Continued
1344
TNFR1 (trimer)
Table 2.Continued
Downstream Signaling
Proteins
(Transmembrane
Receptor Adaptors)
Receptors (Conformation, Extracellular or Transmembrane Adapters)

TNFR1 (trimer)
IL-1R (IL-1RAcP)
TLR4 (dimer, MD2, CD14, LBP,

RP105, MD1)
TRAF2/5 (TRAF2/5,
RIP1?, TAK1, ASK1,
MEKK1, K63)
cIAP1/2 (RIP1, K63)
LUBAC (NEMO, linear)
TRAF6 (TRAF6, TAK1,

NEMO, MLK3, K63)
Pellino (IRAK1, K63)
TRAF6 (TRAF6, TAK1, NEMO,

MALT1, RIP1, K63)
Pellino-2 (Bcl10, K63)
IKK activating
kinases (target)
activated by ubiquitin
scaffold in canonical
pathway
TAK1c (IKK2)
ASK1 (MAP2K)
MEKK1 (IKK2)
MEKK3a (IKK1, MKK4/7,
MKK3/6)
MLK3 (MKK4/7)
PKC (IKK2, others)
SCF-TrCP (IBs, p100,
major E3 producing K48
chains)
A20 (RIP1, TRAF, NEMO,
TAK1, K63 chains.
Induced by NF-B.)
USP21 [RIP1 (1998)]
CYLD (similar to A20.
Constitutively active.
Particularly important for
NEMO, TRAF2, TRAF6,
and Bcl-3 K63 chain
removal.)
Cezanne (removes K48
chains from IB, K63
from RIP1)
RNF11
ITCH, TAXBP1 (TAXBP1
mediates A20 binding to
RIP1 and TRAF6. ITCH
may be the E3 that K48
ubiquitinates RIP1 in an
A20 complex. ITCH also
promotes ubiquitination
of cFLIP which releases
caspase 8.)
TAK1c (IKK2)
ASK1 (MAP2K)
MEKK3a (IKK1,
MKK4/7, MKK3/6)
PKC (IKK2, others)
TAK1c (IKK2)
SCF-TrCP (IBs,
p100, major E3
producing K48
chains)
A20 (RIP1, TRAF,
NEMO, TAK1, K63
chains. Induced by
NF-B.)
USP21 [RIP1 (1998)]
Constitutively active.)
SCF-TrCP (IBs, p100, major

E3 producing K48 chains)
A20 (RIP1, TRAF, NEMO,
MALT1, TAK1 K63 chains.
Induced by NF-B.)
USP21 [RIP1 (1998)]
Constitutively active.)
Deactivating K48 E3
ligases and
deubiquitinases or
ubiquitin editing
enzymes (targets)
TRAF2 (receptor
binding causes K63
decoration by TRAF2
of cIAP1/2 which
alters target from
NIK to TRAF3, with
degradation of TRAF3
and release of NIK)
cIAP1/2 (TRAF3, K48)
ZFP91 (stabilizes NIK,
K63)
NIK (IKK1)
(Similar to others for

canonical. None
known for
alternative.)
General: IL-1RAcP (IL-1R activating protein) acts as a heterodimer with IL-1R. Oligomerization appears to be
required for activation of several components (such as the complex of 6 MyD88, 4 TRAF4, and 4 TRAF2 that
are recruited in that order to the activated TLR/IL-1 receptors) (1048). RIP1 appears not to be uniquely
required or is redundant for TNFR1 activation of NF-B (1976). IKK2 may only phosphorylate S32 on IB,
leading to its ubiquitination and degradation while IKK1 phosphorylates S36, followed by dissociation from
NF-B without degradation (2028). CD40 can signal through both the alternative and the canonical pathways
but alternative predominates and only this pathway is shown. E2 ubiquitin conjugating enzymes are not shown.
A role for the E3 ligase ZFP91 was recently shown for CD40 signaling (853). aMEKK3 bypasses TAK1
activation but requires p62 (which binds ubiquitin chains on TRAF6 or RIP1) to recruit PKC and MEKK3 to the
signalosome (1277). MEKK3 phosphorylation of IKK1 results in IB phosphorylation on Ser36 by IKK1 (as
opposed to Ser32 by IKK2) that leads to dissociation of IB but without ubiquitination and degradation (2028).
MEKK3 activation is primarily important in IL-1 signaling. bTRAF2 and TRAF5 each appear to largely compensate for absence of the other in NF-B signaling but knockout of both does arrest TNFR1 signaling to NF-B.
They may serve primarily as scaffolds for cIAP1/2. In this regard, TRAF2 appears more active (2075). They
also recruit RIP1 to the complex for K63 ubiquitination by cIAP1/2. This is thought to direct TNFR1 signaling
toward NF-B signaling rather than toward apoptotic signaling through FADD complex formation. TRAF2 E3
ubiquitin ligase activity may only be relevant for ASK1 activation. In TNFR1 signaling, cIAP1/2 is the main E3
ligase for RIP1, decorating it with K63 ubiquitin chains. cTAB2/3 binds only K63-linked Ub chains bringing
TAK1 in juxtaposition with NEMO. TAB1 is regulatory for TAK1 which self-activates. NEMO binds linear Ub
chains much more avidly than K63 chains. LUBAC is thought to bind K63 chains but produce linear chain for
NEMO.
1345
Activating E3
ubiquitin ligases
(targets, chain type)
also serve as E3
targets with self
ubiquitination or
from another E3
CD40 (trimer)
PAUL N. HOPKINS
cific (2079) and whole body (1680) overexpression of SIRT1
decreased atherosclerosis while decreased SIRT1 expression
increased atherosclerosis (1680). Heterozygous deficiency
caused greater endothelial NF-B activity, increased ICAM-1
and VCAM-1 expression, and greater sensitivity to TNF-
(1681). Overexpression of SIRT1 protected endothelial cells
from oxLDL induced apoptosis (2079). Importantly, 1-year
caloric restriction doubled SIRT1 in mouse aorta compared
with ad libitum feeding while 6 mo of high-fat diet decreased
SIRT1 by 50% (2079).
6. Canonical NF-B signaling through the
CBM complex
In T-cell signaling, PI3K recognizes specific scaffold phosphotyrosines produced by Syk and is activated, especially
when the costimulatory receptor CD28 is activated simultaneously, binding and activating additional PI3K. PI3K
generates membrane-bound PIP3, required for PLC activity, whereupon PLC cleaves membrane-bound PIP2 to generate free IP3 and membrane-bound DAG. IP3 opens the IP3
receptor to release calcium from the ER. Free calcium and
DAG together activate conventional and novel PKCs.
One of these PKC enzymes can then phosphorylate the
inactive cytoplasmic adapter CARD 11 (caspase-recruitment domain-containing adapter protein 11, also known
as CARMA1) causing translocation to the membrane,
formation of a trimer and recruitment of two copies of
the adapter Bcl10 which then bind mucosa-associated
lymphoid tissue I (MALT1) as a trimer. MALT1 recruits
and activates TRAF6 while also inactivating A20 (1462).
NIK may also be activated (142). Active TRAF6 deco-
1346
A number of receptors signal through the CBM complex by

way of different CARD adapters. However, all CBM complexes seem to share Bcl10. ApoE-deficient mice with Bcl10
KO had markedly attenuated atherosclerosis (see TABLE 1)
(1164).
7. Additional notes on NF-B signaling
The adapter, MADD (MAPK-activating, death domaincontaining protein) can bind TNFR1 after ligand binding
and direct signaling through Grb2 and Sos to Ras-Raf1ERK1/2 (963). One downstream target of ERK1/2 is RSK1
(ribosomal S6 kinase 1, also known as p90RSK1 or
RPS6KA1). RSK1 can phosphorylate IB (on serines 19
and 23), causing subsequent ubiquitination and degradation and delayed but prolonged NF-B activation (2001).
RSK1 activation by way of ERK1/2 and JNK is also mediated by ANG II signaling (705). Another RSK, RSK2, may
also be involved NF-B activation (1401). Still other kinases seem to be involved in TNFR1 signaling. Thus
MLK2/3 (mixed lineage kinases 2 or 3, or MAP3K10/11),
activated by germinal center kinase (GCK, or MAP4K2)
appear necessary for TNFR1 signaling to activate JNK
(2099).
Both TNFR1 and integrin signaling can activate Bcl-3 (a
protein unrelated to Bcl-2 family proteins or Bcl-10). Bcl-3
is an IB family protein which functions quite differently
from other traditional IB proteins. When active, apparently after K63 ubiquitination, it can bind to inhibitory,
DNA-bound p50 or p52 dimers and act as an activating
transcription factor. Bcl-3 also binds and activates the Srcfamily tyrosine kinase Fyn which becomes important for
clot retraction through de novo Bcl-3 synthesis stimulated
by thrombin signaling in platelets (736, 1841, 1952). Relevance to atherosclerosis appears to be unexplored.
For IL-1R and TLR signaling, the adapter myeloid differentiation primary-response protein-88 (MyD88) plays a
role analogous to TRADD for TNFR1 while interleukin-1
receptor-associated kinase (IRAK) proteins are analogous
to RIP1. Both MyD88 and IRAK4 deletions strongly reduce
atherosclerosis (TABLE 1). TRAF6 is the major E3 ligase for
IL-1R and TLR signaling as well as for the ITAM receptors
noted above.
Oligomerization of TNF family receptor components and
adaptors may be key to activation. Ligation of TNFR1,
Immune activating receptors such as T-cell receptor (TCR),

B-cell receptor (BCR), and activating IgG receptors such as
FcRI, have immunoreceptor tyrosine-based activation motif (ITAM) domains in the receptor or in associated adapter
or coreceptor proteins. ITAM-bearing receptors and adapters lack autocatalytic activity. Instead, receptor ligation
leads to recruitment and activation of the membrane-bound
tyrosine kinase c-Src (or a related family member such as
Lck) which phosphorylates the ITAM motif (and other targets) at two closely spaced tyrosines, thereby recruiting the
cytoplasmic tyrosine kinase Syk (spleen tyrosine kinase) or
a closely related tyrosine kinase (such as ZAP-70 in T-cells)
(1224). Binding of Syk leads to steric alteration allowing
further activation of Syk through tyrosine phosphorylation
by a SFK (Src family kinase). Activated Syk then phosphorylates target tyrosines on many proteins including various
scaffolds, allowing downstream inflammatory signaling.
Tyrosine phosphorylated Syk itself becomes a scaffold to
provide activating binding for a number of signaling molecules including PLC, PI3K, and Vav (a GEF for Rac).
Orally administered fostamatinib, a recently developed Syk
inhibitor, reduced atherosclerosis in LDLR-deficient mice
by as much as 58% (767). Both endothelial inflammation
and monocyte migration were inhibited.
rates MALT1, Bcl10, NEMO, and itself with K63 ubiquitin chains, leading to TAK1 recruitment, activation of
IKK2, IB degradation, and translocation of NF-B.
This activation pathway also explains the long observed
phenomenon that phorbol esters (which are thought to
activate PKCs by mimicking DAG) can activate NF-B
(1616). CARD/CARMA, Bcl10, and MALT1 are together known as the CBM complex.

IL-1R, or TLR triggers hierarchical oligomerization of receptors, adapters, and E3 ligases. For the typical TLR, the
transmembrane, question mark-shaped receptor acts as a
dimer and recruits six MyD88 adapters which in turn recruit 4 IRAK4 and 4 IRAK2 molecules, resulting in a complex described as a helical signaling tower (1048). There is
some question whether IRAK2 is redundant for IRAK1 or
whether IRAK2 is even an active kinase. Recent data, however, suggest IRAK2 is particularly important in human
monocyte/macrophage signaling and contributes to generation of active NF-B and, in some way, p38 (527). TRAF6
and Pellino-2 are major E3 ubiquitin ligases recruited to the
complex.
IL-1R (and other receptors) can also trigger NF-B translocation by activation of MEKK3. The scaffolding protein
p62 (also known as sequestosome 1) binds to polyubiquitin
chains on TRAF6, bringing with it MEKK3 and PKC
(1277). MEKK3 (being a MAP3K) has been variously reported to activate the IKK complex by phosphorylation of
NEMO, IKK1, or IKK2 (1715). MEKK3 can also activate
downstream MAP2K and MAPK.
D. ROS in Inflammatory Signaling

1. General ROS signaling mechanisms
H2O2 is now generally considered a facilitator or modulator of inflammatory signaling rather than a direct instigator
of NF-B signaling as had previously been thought (1345).
Furthermore, its effects are cell and context specific with arterial endothelial cells being generally more resistant to adverse
effects than a number of other cell types. H2O2 is also a major
endothelial-derived hyperpolarizing factor (EDHF) mediating
In recent years, signal transduction by ROS and RNS has

come to be recognized most often as the result of specific,
discrete, reversible, posttranslational modifications typically involving targeted cysteine sulfhydryl groups. Spontaneous or catalyzed conversions from reduced to oxidized
cysteine modify the activity, binding, or signaling properties
of numerous redox-sensitive proteins, generally in a context-appropriate and harmonious manner. Indeed, ROSmediated signaling is beginning to appear more akin to
phosphorylative signaling, involving a vast array of proteins in normal physiology (1006). To this should be added
effects of H2S (hydrogen sulfide) which also targets cysteine
sulfhydryl groups (see sect. IVF). Thus redox-sensitive signaling and ROS-induced protein modification may be
viewed as fundamental adaptations allowing cells to capitalize on an environment that inevitably includes ROS. This
is in stark contrast to the view that ROS and RNS are
demons to be squelched at all cost. Indeed, modest, controlled ROS production is required for numerous vital signaling pathways which include activation, cell survival,
proliferation, stress adaptation, cell motility, vasodilation,
and angiogenesis.
Progressively higher levels of ROS do lead to apoptosis and
eventually necrosis, but even these responses can be viewed
as physiological and adaptive in many contexts such as
phagocyte release of ROS to induce cell death of virally
infected, malignant, or otherwise irreparably damaged
cells. Indeed, there are numerous examples of mutations or
knockouts which are resistant to ROS-induced apoptosis
that also promote cancer, suggesting a delicate balance between the anti- and proapoptotic effects of ROS. A few
examples of proinflammatory redox mechanisms are illustrated in FIGURE 5 and described below.
An early recognized effect of ROS was the inactivation of
various enzymes that have a vulnerable, catalytically important cysteine in their active site. For example, glutathione
peroxidase (GPx) is inactivated by ROS through oxidation
of a key cysteine thiol (-SH) group, a reaction that is reversed by incubation with reduced glutathione (GSH)
(159). Later, it became clear that such reactions represent a
vast array of cysteine or thiol switches that are sensitive
to the redox potential of the cell (1398, 1517, 1997). Susceptible cysteines are those that easily lose their thiol hydrogen (i.e., with low pKa) due to surrounding side chains that
stabilize the thiolate anion (protein-Cys-S). This nucleo-
1347
A number of other means of NF-B activation are known.

Intracellular TLR and related receptors which recognize
and bind bacterial or viral structural patterns, such as double-stranded RNA, can signal to activate the IKK complex.
Of great significance to atherosclerosis is a connection between ER stress (also referred to as the unfolded protein
response) and NF-B signaling (1138). Three transmembrane transducers or sensors extend into the ER lumen and
bind various chaperone proteins. Chaperones assist in
proper maturation and folding of newly synthesized proteins. When chaperones are unavailable to bind the luminal
side of these sensors, due to over-utilization when protein
production rates are very high or because of other stresses
that interfere with protein folding, the transducers become
activated and initiate multiple signaling pathways. One of
these sensors is inositol-requiring enzyme 1 (IRE1) which,
in the face of ER stress, binds and activates TRAF2 thereby
triggering canonical NF-B signaling. ER stress and subsequent NF-B activation was seen in endothelial cells exposed to acrolein and a number of other reactive aldehydes
(687).
vasodilation by stimulation of a VSMC potassium channel

(255, 256). Nevertheless, ROS may promote activation of
other pathways that interact with NF-B, such as the ASK1JNK pathway as illustrated in FIGURE 5. Reactive nitrogen
species (RNS) may refer to NO or peroxynitrite formed from
the rapid reaction between NO and superoxide. RNS can react
with signaling proteins and have effects ranging from similar
to opposite those of ROS.
PAUL N. HOPKINS
Low oxidative stress

active
PTEN
JNK
Prdx1
Prdx1
inactive
Trx
H2O2
PTEN
inactive
ONOO
PDK1
PKC
Srx
Prdx1
Prdx1
O2
TrxR
Other chaperone
functions
Prdx1
SOK1
14-3-3
NO
JNK
Prdx1
active
inactive
Prdx1
ASK1 PP2A SOD1 TRADD

AIP1 RIP1 TRAF2
SH
ASK1
U U U U U U U
Trx
SENP1
Ras
SH
Higher oxidative stress
PKAc
Cezanne
ROS
Trx
ASK1
ASK1
GST
active
PTP
S
inactive
MEKK1 U U
Src
MAP3K
MEKK2/3
Raf1
ASK1
TAK1
SH
PTP
SH
active
Syk
MAP2K
MEK5
MEK1/2
MKK4/7
MKK3/6
MAPK
ERK5
ERK1/2
JNK
p38
IKK2
LC8
SH
LC8
S
LC8
SH
TRP14
LC8
IB
U
NF-B
U
26S
RSK1/2
PKC
GST
FIGURE 5. Selected MAPK and NF-B interactions with reactive oxygen species (ROS). Peroxiredoxin 1 (Prdx1)
is an effective peroxidase and also forms an inhibitor complex with JNK under low hydrogen peroxide/ROS levels.
However, as ROS increases, Prdx1 is rapidly and reversibly inactivated with formation of higher-order multimers,
allowing suppression of PTEN activity and activation of JNK to proceed. The other pathways are examples of the
many discrete, specific reactions whereby ROS may modulate or amplify some of the effects of MAPK and NF-B
signaling. AIP1, ASK1-interacting protein-1. See text for additional explanation and abbreviations.
philic thiolate can react with H2O2 to produce the relatively

unstable sulfenic acid (protein-Cys-SOH). Addition of nitric oxide (NO) or other RNS to thiolate can also yield
sulfenic acid after hydrolysis. Further oxidation to sulfinic
acid (Cys-SOOH) and finally sulfonic acid (Cys-SO3H) generally proceeds more slowly. Sulfonic acid derivatives are
generally regarded as irreducible by physiological systems
and lead to degradation of the protein. Sulfinic groups on
1348
peroxiredoxin (Prdx) peroxidases can be reduced by the

recently identified sulfiredoxin (Srx) (269).
For many proteins, oxidation to sulfinic or sulfonic acids
can cause protein dysfunction and prompt degradation.
However, sulfenic acid can react with Cys-SH to form internal or protein-protein disulfide bonds or disulfide bonds
with the key antioxidant tripeptide glutathione. Under ox-

idizing conditions, two glutathione moieties can spontaneously form a disulfide bond, yielding oxidized glutathione
(GSSG). Each of these sulfur oxidations yields electrons that
help quench ROS radicals and protect cysteine sulfhydryl
groups from further oxidation.
Protein glutathionylation may occur spontaneously or may
be catalyzed by a number of GST (glutathione-S-transferase) enzymes. Kinetic considerations suggest that, in
vivo, many of these reactions are probably catalyzed. In
addition, glutathione conjugation by GST enzymes promotes metabolism and elimination of a number of electrophilic compounds including reactive aldehydes or conjugated carbonyls (a carbonyl carbon or nitrogen group with
a double bond between the and carbons) (478).
An example of an important nonenzymatic sulfur switch is

the recently identified reaction between eNOS and GSSG
leading to reversible glutathionylation of two highly conserved cysteines which causes eNOS uncoupling (causing
eNOS to produce superoxide rather than NO) (290). This
mechanism could conceivably recruit eNOS for extra superoxide production when needed while simultaneously protecting the enzyme from undue oxidative damage.
In relation to general mechanisms of inflammation, among the
most important consequences of increased ROS or RNS is the
reversible inactivation of protein phosphatases. Most protein
tyrosine phosphatases (PTPs) are inhibited by ROS by formation of intraprotein disulfide bonds between cysteine at the
reactive site and a nearby back door cysteine. Alteration of
zinc binding sites may occur or an amide may be formed with
the reactive cysteine in some cases (208). Also inactivated by
cysteine oxidation are PTEN and SHIP (Src homology 2 domain-containing inositide phosphatase) enzymes. These are
important phosphatases that primarily inhibit activating pathways by cleaving the 3-phosphate of PIP3. While the widely
expressed serine/threonine protein phosphatase PP2A can also
be inactivated by sufficiently high ROS (208), in some circumstances ROS actually increases PP2A activity followed by dephosphorylation and inhibition of several proteins that control entry into the cell cycle and cell proliferation (327).
Newer understanding of peroxidase enzymes, particularly
Prdx1/2, demonstrates considerable complexity in the ability
2. MAPK signaling activation by ROS

With regard to MAPK pathways, inactivation of PTPs prolongs MAPK activation, particularly JNK, with increased
subsequent susceptibility to apoptosis (876). Ras activation
is enhanced by glutathionylation of Cys118 in the presence
of H2O2 and inhibited in a reducing milieu (9). ROS-stimulated disulfide bonding between caspase-9 and apoptotic
protease-activating factor 1 (Apaf-1) can promote initiation
of the apoptotic cascade (1398).
One of the major activators of both the JNK and p38
MAPKs is ASK1, which is held inactive when redox potential is low by a physical interaction with reduced Trx as well
as a 14-3-3 protein as illustrated in FIGURE 5. In this depiction, activation of TNFR1 provides a complex of TRADD,
TRAF2, RIP, ASK1-interacting protein 1 (AIP1), and a K63
ubiquitin scaffold. These all work together to activate
ASK1. The adapter protein AIP1 has an overall protective
effect in atherogenesis and can suppress both JNK and
NF-B signaling in endothelial cells (793). In an oxidizing
environment, both Trx and 14-3-3 dissociate from ASK1;
Trx because of internal disulfide bond formation and 143-3 because of PDK1 phosphorylation stimulated by ROS.
ROS also promotes ASK1 dimerization by disulfide bonding and oxidation of ASK1 Cys250 (prevented by Trx bind-
1349
Disulfide bonds generally protect vulnerable protein cysteines

from further oxidation but may simultaneously alter function
or inhibit enzymatic activity (1951). GSSG and protein-glutathione disulfides can be reduced by the Grx/GTR (glutaredoxin/glutathione reductase) system while intraprotein and
protein-protein disulfide bonds as well as sulfenic acid residues
can be reduced by the thioredoxin/thioredoxin reductase (Trx/
TrxR) systems. Some intraprotein disulfide bonds form and
are reduced reversibly and spontaneously based on the cells
redox potential or H2O2 concentration.
of the cell to fine-tune ROS-related signaling. Prdx1/2 and

Gpx isoforms are widely distributed throughout the cell and
have high affinity for H2O2. They are thought to act primarily
at low concentrations of H2O2 with Prdx1/2 particularly involved in maintaining PTEN active when ROS is low. At lower
H2O2, Prdx1/2 act primarily as dimers. Cysteine 50 or 51 is
the catalytically active site and is readily oxidized to sulfenic
acid by H2O2. Sulfenic cysteine 50/51 can be reduced by the
Trx / TrxR system while sulfinic cysteines are reduced by Srx.
Prdx1/2 dimers physically interact with and maintain PTEN
activity while also neutralizing low concentrations of H2O2. A
similar interaction apparently helps maintain JNK in an inactive state at low levels of ROS (1294). With higher ROS,
Prdx1/2 is rapidly oxidized and inactivated as a peroxidase. At
the same time, Prdx1/2 dimers aggregate to form decamers
that can act as chaperones for other cell signaling proteins
(such as several involved in cell division or apoptosis) (269).
The higher order oligomers allow increasing ROS to inhibit
PTEN so that PIP3 signaling can proceed while also releasing
JNK to be activated by upstream signaling (1294). Furthermore, Prdx1/2 can be variously phosphorylated, nitrated,
acetylated, or glutathionylated in ways that can inhibit or otherwise alter activity or affect oligomer formation (269). Catalase, which is largely restricted to intracellular peroxisomes,
has greater enzymatic capacity but lower affinity for H2O2. It
is thought to become more important at higher H2O2 concentrations (1294). Prdx1 KO mice have a 15% reduction in
lifespan. Prdx6 KO mice are also viable and do not display
obvious gross pathology, but are more sensitive to certain
exogenous sources of oxidative stress, such as hyperoxia.
PAUL N. HOPKINS
ing). Dimerized ASK1 then activates JNK (1398, 1424). As
depicted in FIGURE 5, ROS-mediated activation of SOK1
(Sterile 20/oxidant stress response kinase 1) may further
contribute to ASK1 activation through 14-3-3 phosphorylation (1314). Additionally, ROS dissociates SENP1 (sentrin/SUMO-specific protease 1 also known as stromal cellderived factor 1) from Trx, whereupon SENP1 moves to the
nucleus and desumoylates the serine/threonine kinase
HIPK1 (homeodomain-interacting protein kinase 1) which
translocates to the cytoplasm and further promotes activation of ASK1 (1234).
3. ROS effects on NF-B signaling

Many older reviews depict NF-B being activated directly
by ROS. In reality, a number of discrete systems can lead to
activation or inhibition depending on the stimulus and context (208, 1345). At physiological concentrations of ROS
NF-B signaling is generally stimulated, while with very
high ROS (such as exposure to activated phagocytes),
NF-B signaling is inhibited. Cys-179 of IKK2 provides an
interesting case in point. Exogenous addition of H2O2 led
to glutathionylation of Cys-179 of IKK2 causing reversible
inactivation (1478). Nitrosylation by RNS of this cysteine
residue also inhibits IKK2 as can adducts of several physiologically produced electrophiles including 4-NHE, the
prostaglandin 15-deoxy-(12,14)-prostaglandin J2 (15dPGJ2) formed spontaneously from PGD2, and many others
(208). With sufficient ROS exposure, irreversible oxidative
damage to cysteines and other susceptible amino acids, lipids, and DNA accrues with resulting apoptosis or necrosis
(1345). In the case of TNF- signaling, higher physiological
levels of H2O2 also seem to favor apoptotic signaling
through complex II (1345).
Cysteine 62 of the p50 subunit of NF-B must be reduced to
allow efficient DNA binding but the oxidizing environment of
the cytoplasm after cytokine activation ensures its oxidation.
However, upon entry into the nucleus, p50 encounters Trx
complexed with APE1/Ref1 (AP endonuclease 1/redox factor
1) which quickly reduces p50 Cys62, a mechanism of activation shared by other transcription factors (623). Interestingly,
both nuclear localization of Trx and APE1/Ref1 and transcrip-
1350
Tyrosine kinase Src and Syk families appear to be activated

by ROS, but inactivation of opposing phosphatases may be
a major mechanism. Indeed, experimental activation of
Src or Syk is often accomplished by pervanadate, which
essentially inhibits tyrosine phosphatases by oxidizing their
active site cysteine (809), suggesting a substantial degree of
constitutive activity for Src and Syk enzymes. Thus an increase in ROS in cells might allow Src and Syk activity to
become manifest in various ways that are particularly relevant for NF-B signaling (841).
TNFR1 is said to form a complex that includes constitutively
active c-Src, PI3K, and JAK2 that are further activated upon
TNF binding (1418). Both Src and Syk have been reported to
phosphorylate IB on tyrosine 42 which leads to nondegradative dissociation from the NF-B dimer, allowing its nuclear
translocation. Various ROS-generating stimuli enhance this
atypical activation including reoxygenation after hypoxia
(822), elevated glucose (which was inhibited by antioxidants
-lipoic acid or N-acetylcysteine) (2025), thrombin stimulation (145), and ANG II (2003). The IB phosphorylation on
tyrosine 42 induced by elevated glucose was redundant and
only apparent after inhibition of the p26 proteosome. Active
c-Src can also enhance IKK2 activation by phosphorylation of
Tyr188 and Tyr199, near the activation loop (795). ROS inhibition of phosphatases could also enhance Src and Syk family tyrosine kinase activation of CBM-mediated signaling and
NIK (1164).
Several additional discrete redox switches are depicted in
FIGURE 5. Type I PKA can be activated by ROS by disulfide dimerization of the regulatory subunits, yielding the
active PKA subunit (PKAc) (206) and phosphorylation of
p65/RelA Ser276 (842). Dynein light chain 8 (LC8) binds
IB under reducing conditions but is removed by ROS
through internal disulfide formation. Reduced LC8 is
then regenerated by the disulfide reductase thioredoxinrelated protein 14 (TRP14) (870). The deubiquitinase
Cezanne actively removes both K63 ubiquitin chains
from RIP1 and K-48 ubiquitins from IB, thereby increasing IB and retention of inactive NF-B in the
cytoplasm. Cezanne activity is inhibited by ROS (476).
4. The isoform p66Shc promotes mitochondrial
superoxide production, hyperglycemic memory,
and aging
Src homology collagen-like (Shc) is a versatile adapter protein that binds phosphotyrosines on the cytoplasmic tail of
receptor tyrosine kinases, other tyrosine phosphorylated receptors, and various adapters. It is the target of various
kinases as well. Three Shc isoforms are produced by alternate initiation sites. Shc isoforms p46 and p52 can function as
In nonstressed cells, JNK and TRAF2 are held inactive, complexed with glutathione-S-transferase 1 (GST or GSTP1).
Upon exposure to ROS, GST dissociates from JNK and
TRAF2 and forms GST oligomers (1997), freeing JNK to
activate c-jun and allowing TNFR1 signaling (see FIGURES 3
AND 4). GST also functions to actively glutathionylate target
proteins when activated by ROS, nitrosative stress (1804), and
tyrosine phosphorylation by EGFR (1340). Interestingly, arsenic appears to require glutathionylation for its detoxification. In a Korean study, the combination of an inactivating
variant (Ileu105Val) of GST with high exposure to arsenic in
well water was associated with a sixfold increase in the risk of
carotid atherosclerosis (1922).
tional activation of APE1/Ref1 are stimulated by ROS, allowing harmonious nuclear reduction of target transcription factors in the face of cytosolic redox stress (139).
E. Ceramide Promotes Endothelial

Activation
Ceramide often acts to enhance MAPK and other activating
pathways. The diverse functions of ceramide are explained
in part by the remarkable ability of ceramide to promote
coalescence of many small lipid rafts into large, stable signaling platforms (671). Thus ceramide might be considered
a relatively low-affinity, low-specificity activator. Ceramide
is converted by ceramidase to sphingosine which may also
be considered proinflammatory like ceramide. Phosphorylation of sphingosine by sphingosine kinase yields sphingosine-1-phosphate (S1P), a lipid signaling molecule that
acts through high-affinity GPCRs with generally anti-inflammatory effects that quite effectively oppose ceramide,
even though intracellular levels of S1P are 3,000-fold
lower than ceramide (711).
TNFR1 contains, in addition to the more familiar death domain (DD), a neutral sphingomyelinase domain (NSD) which
binds the adapter factor associated with neutral sphingomy-
elinase activation (FAN). FAN recruits other adapters, receptor for activated C kinase 1 (RACK1) and embryonic ectoderm development (EED), which finally recruits neutral sphingomyelinase, an important source of ceramide on the inner
leaflet of the cell membrane (1228, 1415). Rapid membrane
production of ceramide can be prompted by numerous additional receptors and activating signals. Possibly through redox
signaling, these receptors typically activate acid sphingomyelinase by a process involving translocation of quiescent acid
sphingomyelinase in cytoplasmic vesicles to the outer wall of
the cell membrane where the active enzyme cleaves sphingomyelin (671, 1408). Assembly of dispersed signaling proteins
such as receptors and NOX2 components (p47phox, NOX2
catalytic subunits) is then facilitated by ceramide-induced fusion of small lipid rafts into a functional, large, signaling platform.
The rate-limiting enzyme for de novo ceramide synthesis is
serine-palmitoyl-CoA transferase. Palmitate (the 16-carbon
saturated fatty acid, designated C16:0) is the preferred precursor to ceramide (as opposed to the unsaturated fatty acid
oleate, for example, which is generally incorporated into triglyceride) (839, 1574). Inhibition of serine-palmitoyl-CoA
transferase by the fungal product myriocin decreased atherosclerosis substantially in hyperlipidemic mice (774, 1384) and
even promoted regression (1385). Ceramide can be inactivated by several pathways including deacylation to sphingosine by ceramidase or by further acylation by O-acyl-ceramide synthase, also known as lysophospholipase 3 (LYPLA3).
LYPLA3 deficiency promoted atherosclerosis and sensitized
macrophages to apoptosis (1758) (see TABLE 1).
Interestingly, palmitate can activate JNK by way of mixed
lineage kinase 3 (MLK3). MLK3 activation was due to redundant signaling from multiple activated PKC isoforms (PKC,
PKC, PKC, and PKC), thought to be activated by DAG and
ceramide. Palmitate feeding, as well as obesity due to high-fat
diet, have been reported to cause increased endothelial superoxide production dependent on TLR4, BMP4, and upregulation of NOX4, all promoting NF-B signaling (1131). Release
of PKC from the inhibitory adapter protein 14-3-3 seems
also to be directly promoted by ceramide, allowing PKC to
phosphorylate and inactivate the predominantly anti-inflammatory PKB and ERK5 (535).
F. Modulation of Signaling by Electrophiles

The resilience and resourcefulness of cells in adapting to
oxidative stress is perhaps nowhere better illustrated than
the newly emerging understanding of electrophilic compounds as signaling molecules (208, 659, 660, 1517). Frequently encountered electrophiles include by-products of
polyunsaturated fatty acid peroxidation such as malondialdehyde, 4-hydroxy-2-nonenal (4-HNE) from omega-6 fatty
acids, 4-hydroxy-2-hexenal (4-HHE) from omega-3 fatty
acids, 4-oxo-2-nonenal (4-ONE), acrolein (also in cigarette
1351
adapters in many pathways leading to both ERK (by binding

Grb2 in Grb2-SOS-Ras-Raf signaling) and NADPH oxidase activation (1147). In contrast, the p66Shc isoform does not
mediate MAPK activation but instead moves to mitochondria when phosphorylated where it greatly increases mitochondrial superoxide production by diverting electrons
from cytochrome c to oxygen (608). Promotion of apoptosis through p66Shc occurs by superoxide production.
Transport to mitochondria and activation of p66Shc in the
setting of diabetes appears to be mediated through phosphorylation by PKCII (1377, 1378, 1398, 1801) but also
by electrophiles such as acrolein. An increase in glucose in
the medium bathing endothelial cells results in persistent
activation of PKCII and p66Shc with increased mitochondrial ROS production persisting even after glucose levels are
reduced (1377). Knockdown of p66Shc results in the loss of
so-called endothelial hyperglycemic memory (1377).
Various antioxidant defenses, including manganese superoxide dismutase and heme oxygenase, are also increased
with knockdown of p66Shc (2106). Mice deficient in
p66Shc live 30% longer and do not display increases in
endothelial iNOS, superoxide production, or nitrotyrosine
accumulation with aging as do wild-type mice (536). Furthermore, inactivation of p66Shc by mutating the NH2terminal CH domain unique to p66Shc (with no effect on
p46 and p52 isoform transcription) greatly reduces atherosclerosis in mice (see TABLE 2). Indeed, p66Shc seems to
signal cells to age generally (1809) and even promotes insulin resistance (1457). Interestingly, p66Shc expression is
specifically inhibited by SIRT1 (2106). Nevertheless,
p66Shc deficiency can lead to aggressive metastatic cancer
through resistance to apoptosis signals (1102, 1990), yet
another example of the need for balance in apoptotic signaling.
PAUL N. HOPKINS
smoke), nitro-alkene derivatives of fatty acids (NO2-oleate,
etc.), prostaglandin by-products such as 15d-PGJ2, and numerous natural products (isothiocyanate, cinnamaldehyde,
etc.). Once considered merely toxic byproducts of cell damage, these reactive electrophiles usually modulate signaling
by targeting cysteine thiolate or sulfenic acid groups, but
their effects are often distinct from H2O2 or other ROS. For
example, some aldehydes, such as malondialdehyde, primarily target lysine. Histidine residues may also be modified
in some instances.
Although cytotoxic at higher doses, electrophiles such as

4-HNE form reversible adducts with various signaling
proteins suggesting a broader role as ROS sensors and
adapters (1973). Ischemic preconditioning, resulting in
subsequent protection from ischemic insult, depends in
part on electrophilic modifications of signaling proteins
(1268). Nitro-fatty acids seem to have a number of potent
anti-inflammatory properties such as direct covalent modification and inhibition of IKK2 (660). Subcutaneous administration of nitro-oleate was recently shown to potently inhibit
atheroma formation in ApoE-deficient mice (1518). It is
tempting to speculate that the surprising anti-atherosclerotic
effects of so-called conjugated linoleic acid might be mediated by similar mechanisms (1166). 15d-PGJ2 can covalently
bind and activate the strongly anti-inflammatory PPAR. It
also binds and inhibits IKK1 and IKK2 as well as each of the
NF-B dimers (423).
One study found a surprising increase in longevity after
KO of a unique mitochondrial GST that targets 4-HNE
for glutathionylation and elimination (1636). The modestly increased but physiological levels of 4-HNE that
accumulated in the GST knockout mice induced an array
1352
In addition to its role in converting glucose to sorbitol,

aldose reductase (AR) metabolizes reactive aldehydes
formed during oxidative stress. AR was recently found to be
activated by the oxidation of Cys298 to sulfenic acid in
relatively mild oxidizing conditions. With more severe oxidative stress, AR cysteine298 is glutathionylated by GST.
While this modification inactivates AR, it allows later reduction by Grx, thus preserving AR from more severe oxidation and subsequent degradation (1951). Knockout of
AR increased atherosclerosis in ApoE-deficient mice (see
TABLE 4), suggesting a need for balanced exposure to reactive electrophilic aldehydes.
G. Inflammatory GPCR Signaling as Exemplified

by the ANG II Receptor, AT1R
In addition to blood pressure elevation, ANG II directly
promotes endothelial activation and inflammation of the
arterial wall. ANG II signaling leads to decreased eNOS
activity, increased vascular wall ROS production, expression of endothelial adhesion molecules and chemokines,
VSMC proliferation, vascular wall remodeling, and aneurysms and is prothrombotic (1556). Genetic manipulations
of the renin-angiotensin system consistently demonstrate
atherogenic effects (see TABLE 1). Chronic ANG II infusion
by implanted osmotic minipumps dramatically increased
atherosclerosis in hyperlipidemic mice and led to development of aortic aneurysms, effects entirely eliminated by KO
of the AT1R (263). Effects were predominantly due to arterial wall expression of AT1R, but hematopoietic expression of AT1R also affected atherosclerosis if arterial wall
AT1R was present (263, 563). Blood pressure was clearly
affected by these manipulations although not strongly correlated with plaque size. In a study controlling for blood
pressure effects, the blood pressure of control ApoE KO
mice was matched to the blood pressure of AT1R/ApoE
double-deficient mice using two different blood pressure
medications. Hydralazine, a vasodilator with no effect on
AT1R signaling, had no effect on atherosclerotic lesion size.
In contrast, irbesartan, an AT1R blocker, reduced atherosclerosis almost to the same extent as AT1R deficiency
(1929). It should be noted here that in human hypertension
intervention trials, cardiovascular endpoints were reduced
primarily in proportion to blood pressure reduction with
surprisingly little evidence for additional benefits from ACE
inhibitors or ARBs (ANG II receptor blockers) (1822,
1823).
There appear to be interactions between ANG II and lipids
in atherogenesis. ANG II (or adrenaline) increased uptake
High doses of several of the above-listed electrophiles (e.g.,

acrolein) can cause extensive protein alkylation leading to
apoptosis or necrosis. Somewhat lower doses can irreversibly deactivate key antioxidant enzymes such as Trx and
initiate inflammatory signaling (624). ER stress is promoted
by degradation of alkylated proteins by the p20 proteosome
(which recognizes misfolded proteins with external lipophilic groups) and degradation of ubiquitinated proteins by
the p26 proteosome (659, 687). Some electrophilic adducts
can cause proteosomal degradation of GTP cyclohydrolase
I (the rate-limiting enzyme for synthesis of the essential
eNOS cofactor tetrahydrobiopterin) as well as HSP90,
causing eNOS uncoupling and increased superoxide production (1956). Mitochondrial superoxide production may
be increased, possibly by uncoupling through direct sulfhydryl modifications of cytochrome c (660, 979) or activation
and nuclear transport of p66Shc (1780). Finally, reactive
electrophiles can lead to acute depletion of GSH and inactivation of Trx. Some of these effects may be physiological
responses promoting greater ROS generation when called
for by cellular activation.
of protective antioxidant genes, illustrating the important balance between pro-oxidant and antioxidant forces
(208). Hitherto, effects of genetic manipulation of GST
enzymes have apparently not been studied with regards
to atherosclerosis (738).

of LDL into the artery wall of rats (259), while ANG II in
plasma and expression of AT1R in the artery wall were
markedly increased by hyperlipidemia in mice (384). ANG
II content of the aorta was increased together with atherosclerosis in cholesterol-fed monkeys (1220). ANG II can be
generated from mast cell chymase in human and animal
arteries (75, 1168, 1799). Enzymatic ANG II-generating
activity was correlated with LDL levels in human arteries,
with more marked increase in atherosclerotic aorta (75,
1831), and was markedly increased in adventitia along with
chymase after cholesterol and saturated fat feeding in hamsters (1830). Arterial intimal ANG II increased fivefold with
age in non-human primates (1904). Chymase inhibition
was recently shown to decrease atherosclerosis in ApoEdeficient mice (187).
1. A brief introduction to GPCR signaling
Gs activation is often anti-inflammatory (with PKA having

several inhibitory targets, for example, on Raf1). The Gi
proteins are typically pro-inflammatory, both by inhibiting
AC and by sometimes stimulating PLC (phospholipase
C). They can also stimulate PI3K. The Gq/11 isoforms
strongly stimulate PLC. PLC releases DAG and IP3 from
PIP2 with IP3 acting on IP3R to release calcium and calcium
and DAG promoting activation of classical PKC isoforms.
G12/13 can activate several RhoGEFs including LARG
2. ANG II signaling through AT1R: the basics

ANG II signaling through AT1R results in a host of proinflammatory responses including a burst of ROS production
through NOX1/2 (with NOX1 primarily in VSMC), activation of NF-B in endothelial cells with increased expression of E-selectin, VCAM-1, ICAM-1, MCP-1, and promotion of monocyte adhesion, as well as potentially proinflammatory, proatherogenic effects on macrophages and VSMC
(263). These inflammatory effects are essentially all mediated by signaling apart from arterial contraction.
Initially, ANG II binding to AT1R causes GTP exchange for
GDP on bound Gq. GTP-Gq activates PLC with release
of DAG and IP3. The subunits also contribute to PLC
activation. PI3K is activated by subunits as well. IP3
binds the IP3R to release calcium from the ER. In VSMC,
calcium-CaM can then directly promote contraction by
binding myosin light-chain kinase (MLCK). However, little
contraction occurs without also inhibiting myosin lightchain phosphatase (MLCP). This is accomplished when
GTP-bound RhoA (generated as described below) binds
and activates one of its major effectors, ROCK1 or ROCK2
(Rho-associated, coiled-coil containing protein kinase 1 or
2) which inhibits MLCP by phosphorylating the subunit
MYPT1 (myosin phosphatase targeting subunit 1) (670).
Furthermore, ROCK1/2 can directly phosphorylate myosin
light chain to stimulate contraction while also stimulating
MLCK. Calcium-CaM would also be expected to enhance
eNOS signaling in endothelial cells.
Calcium-CaM also activates calcineurin which is a serine/
threonine phosphatase that dephosphorylates the nuclear
factor activated by T-cells (NFAT) family of transcription
factors, NFATc1 4. Dephosphorylation of NFAT allows
translocation to the nucleus. Interestingly, nuclear GSK-3
and JNK phosphorylate NFAT to stimulate transport back
out of the nucleus. The NFAT transcription factors mediate
pro-inflammatory gene transcription in a number of cell
types. The anti-inflammatory, antirejection effects of cyclosporin A and tacrolimus are due to their inhibition of calcineurin. Calcineurin is also activated by ANG II signaling.
Calcineurin in some way appears to directly stabilize
MCP-1 without increasing transcription (1542). Other po-
1353
The 748 human GPCR (683 of the Rhodopsin class, 33

Adhesion, 22 Glutamate, and 10 Frizzled) (952) are all
characterized by multiple transmembrane helical domains.
Commonly encountered GPCR (all in the Rhodopsin and
Frizzled classes) have seven transmembrane domains. In the
resting state with no bound extracellular ligand, the intracellular COOH terminus of these GPCR binds a G protein
with covalently attached GDP. The G protein is accompanied by a heterodimeric subunit. Extracellular binding of
a ligand to its specific GPCR generates a change in the
intracellular configuration of the receptor which triggers
the binding of GTP to the bound G protein. Visual receptors (rhodopsins) are GPCR with a covalently bound ligand, 11-cis-retinal, which is converted to 11-trans-retinal
after absorbing a photon. The shape change results in activation of the receptor and the release of the 11-trans-retinal.
Both the activated G protein and the accompanying
subunits can then participate in subsequent signaling. Heterotrimeric G proteins are all membrane bound with the 16
different G proteins being palmitoylated or myristoylated,
and the 5 and 11 isoforms being prenylated. Among the
commonly encountered G are those that stimulate (Gs)
or inhibit (Gi) AC (adenylate cyclase). The increase in
cAMP from Gs stimulation of AC goes on to activate the
serine/threonine kinase PKA (protein kinase A) with its
many targets. Additionally, exchange protein activated by
cAMP (EPAC) is a GEF, activated by cAMP, for the G
protein Rap1. GTP-bound Rap1 can activate PLC to produce IP3 and DAG.
(leukemia associated RhoGEF), p115RhoGEF, and PDZRhoGEF. The subunits released by activated GPCR can,
in turn, contribute to activation of PLC and PI3K, and
have a number of other targets. G protein receptor kinases
(GRKs) phosphorylate the activated GPCR to provide binding sites for various adaptor proteins, such as -arrestins.
Binding of -arrestins causes arrest of G protein signaling
and direction to clathrin-coated pits for endosomal removal
of the GPCR from the cell surface. However, -arrestins can
also serve as docking proteins for entirely different downstream effectors potentially leading to a complete shift in
the initial transduction activities of the GPCR.
PAUL N. HOPKINS
tential effects of NFAT on atherosclerosis remain poorly
understood (1310). Hereafter, AT1R signaling becomes far
more complex.
3. Inflammatory signaling through AT1R is largely
mediated by PYK2
Early studies clearly identified activation of ERK1/2 as a
downstream consequence of certain ligated GPCR, but the
mechanism remained obscure. The effect was seen primarily in Gi and Gq-coupled GPCR (including AT1R) and
required activation of PKC (usually atypical isoforms such
as and ) and/or increased intracellular calcium and ROS,
all potentially attributable to the PLC activated by these
receptors. Merely increased calcium and ROS, seen with
activation of many receptors and ion channels, can also
activate ERK1/2.
Stimulated PYK2, acting as a homodimer or higher order

oligomer, trans-phosphorylates Tyr420 on adjacent PYK2
molecules. This provides a binding site for Src or another
SFK which phosphorylates Tyr579 and Tyr580 for full activation of PYK2 (1487). Once tyrosine phosphorylated,
PYK2 acts not only as a tyrosine kinase but as a scaffold for
other signaling molecules which possess domains that recognize its phosphotyrosine motifs. As will be discussed below, similar signaling occurs with FAK. Thus the adapter
p130CAS (p130 Crk-associated substrate), which also figures prominently in FAK signaling, was one of the first
identified PYK2 binding partners. Subsequent tyrosine
1354
There are a number of other PYK2 targets. PYK2 activates

GSK-3 by tyrosine phosphorylation (1813). Additionally,
the PYK2-Src complex can apparently activate ADAM17
with release of HB-EGF and transactivation of EGFR signaling, providing an additional source of PI3K and Grb2Sos-Ras activation (616, 617) and a sustained release of
ROS (805). Other binding partners of PYK2 are Vav1 (in
leukocytes) (586) and Vav2 (in endothelium) (890). Vav is
the sixth letter of the Hebrew alphabet and was chosen as
the name for Vav1 since it was the sixth oncogene identified
in the laboratory of its Jewish discoverer. The Vav proteins
are GEFs for Rac1 or RhoA. They therefore provide GTPbound Rac1 for NOX1/2 activation.
In VSMC stimulated by ANG II, PYK2 directly binds and
activates JAK2 (539), which then stimulates ArhGEF1 by
tyrosine phosphorylation to activate RhoA with subsequent smooth muscle contraction mediated by ROCK1/2
(670). STAT3 may also be activated by JAK2 (1394). A
reduction of early atherosclerotic lesions was seen in fat
fed mice with endothelial cell-specific STAT3 KO (610).
AT1R may also bind JAK proteins directly, and several
STAT transcription factors, including STAT13, 5, and
6, have reportedly been activated by AT1R signaling
(805). ANG II activated PYK2 directly binds and activates PDZ-RhoGEF which serves as another major
source of active RhoA in VSMC (2042).
4. Physiologic and atherogenic consequences of
PYK2 signaling
The downstream consequences of PYK2 activation are
many and varied, and differ by cell type. In endothelial cells,
PYK2 signaling stimulated by ANG II was, in part, dependent on NOX2 and resulted in Tyr657 phosphorylation of
eNOS, decreasing its activity (1070). Activated ERK1/2 further promotes ROS production by phosphorylating NOX5
and p47phox (1375). CaMKII also activates NOX5 (1376).
Nevertheless, endothelial ERK1/2 activated by PYK2 partially overcomes ANG II-induced endothelial eNOS dysfunction by enhancing eNOS activity through phosphorylation of Ser633 (Ser635 in bovine endothelial cells) (1736,
1737, 1994). Endothelial PYK2 also mediates Ras and
ERK1/2 activation mediated by LPC (1488), and LPA (lysophosphatidic acid), as well as the bradykinin receptor
(426).
The tyrosine kinase PYK2 (proline-rich tyrosine kinase 2,

also known as FAK2 or PTK2B for protein tyrosine kinase
2, beta) was found to be the primary mediator of these
effects in many cells (426, 1011, 1520). While PYK2 is
highly analogous to FAK, it is primarily cytosolic while
FAK is mainly associated with integrin signaling and is activated by different signals. PYK2 is highly expressed in
leukocytes and brain, but is also found in endothelial cells
and VSMC. While initially thought to be directly activated
by calcium, subsequent studies found no calcium binding
sites on the enzyme, although some data suggest a potential
role for calcium-CaM binding (929). Most clearly, however, PYK2 is activated by PKC (particularly PKC) and
calcium/CaM-dependent protein kinase II (CaMKII) (616,
617, 1496, 1497, 1980). Both the calcium, released from
ER by IP3 acting on its receptor, and the DAG to activate
atypical PKC are supplied by PLC activated by AT1R. In
addition, an increase in ROS leads to Thr286 phosphorylation of CaMKII which enhances its activity and accounts for
the association of ROS with PYK2 activation and downstream signaling (189). The precise mechanism whereby
PKC and CaMKII, both serine/threonine kinases, stimulate
the activation of PYK2 remains unclear, but may be related
to relocation of inactive PYK2 bound to paxillin (associated
with integrins and microfibers) to a more vulnerable position or conformation (342, 1673).
phosphorylation of p130CAS by PYK2 leads to binding and

activation of a number of downstream effectors including
PAK and JNK (158, 1980). Direct binding of Grb2-Sos to
PYK2, Shc, or p130CAS provides a means to activate Ras
and the ERK1/2 cascade (1496), thus solving the riddle of
ERK activation. PI3K can also bind phosphotyrosines on
p130CAS and is activated, producing PIP3 for PDK1, PKB,
Ras, and NOX activation (1496).

PYK2 supports leukocyte adhesion to fibronectin (through
integrin 3) (586), macrophage migration (1341), IL-10
production in macrophages in response to zymosan (which
signals through the ITAM-containing Dectin receptor with
Syk activation) (894), macrophage activation through
CD36 binding of oxidized phospholipids (716), and neutrophil degranulation (877). VSMC proliferation induced
by PDGF is dependent on PYK2 (1404). ANGII can also
activate p38 with downstream activation of MK2. MK2 phosphorylates the regulatory p47phox subunit and thereby activates NOX2 (458). MK2 deletion decreased atherosclerosis,
particularly in the setting of continuous ANGII infusion
(see TABLE 1). Not surprisingly, NF-B signaling through
ITAM-containing receptors is synergistic with AT1R or
TNFR superfamily receptors in promoting atherosclerosis
(834).
While originally identified only as mediator of cell cycle

arrest, p21Cip1 has more recently been recognized to form
complexes with the transcription machinery of many genes
and may act as either a corepressor or coactivator (295,
523). Additional support of endothelial atherogenic signaling attributable to p21Cip1 came from a recent study in
which the FGFR2 receptor was specifically overexpressed in
endothelium with resulting 2.5-fold increase in p21Cip1
and 2.0-fold excess atherosclerosis in ApoE-deficient mice.
Several aspects of atherogenic signaling were attenuated by
siRNA suppression of p21Cip1 (288). In the case of endothelial PYK2 and JNK signaling, increased p21Cip1 bound
the histone acetylase p300 and enhanced its activity, promoting transcription of VCAM-1, MCP-1, and other genes
dependent on TNF-, presumably through NF-B (890).
ANG II-induced p21Cip1 also promoted senescence in
VSMC (961). Not surprisingly, atherosclerosis was markedly reduced by PYK2 KO in ApoE-deficient mice (890).
5. GRK2 and -arrestin2 mediate activation

of NF-B by AT1R through the CBM
complex
Like other GCPR, AT1R is subject to phosphorylation of its
cytoplasmic domain by GRKs. GRK2 is known to phosphorylate the AT1R cytoplasmic domain to allow binding
of -arrestin adapter proteins. AT1R can bind either -arrestin1 or -arrestin2 with high affinity (1322). Once
bound to AT1R, -arrestin2 in some way promotes activation of CARD10 (also known as CARMA3) followed by
assembly of other members of the CBM complex and canonical activation of NF-B (443). A similar mechanism
operates in thrombin signaling (405), a presumed LPC receptor (1708), the IL-8 receptor, and CXCR2 (1148). Additionally, receptor-bound -arrestin1/2 binds Raf1 and
ERK1/2 and promotes their activation while also sequestering active ERK in the cytoplasm (337). In HEK cells, 40%
of the ERK1/2 activity appeared dependent on this -arrestin2 pathway while the remainder was PKC dependent, presumably through PYK2 signaling (1935). Knockout of
-arrestin2 decreased atherosclerosis modestly in LDLR
KO mice but primarily by a decreased accumulation of
VSMC (907). Similarly, BMT of hemizygous deficient
GRK2 into LDLR KO mice modestly decreased atherosclerosis (1359).
IV. INITIATION OF ATHEROSCLEROSIS:

ARTERIAL FLOW PATTERNS
ESTABLISH THE DISTRIBUTION OF
ATHEROSCLEROTIC LESIONS
Endothelial cells stand as either a barrier to inflammation or
its earliest facilitator. Only when activated will endothelial
cells express the directing signals that control access of leukocytes to underlying tissues. Arterial flow patterns largely
determine whether endothelial cells stand poised for facile
inflammatory activation or will resist activating signals.
Atherosclerosis develops almost exclusively in areas of slow
flow or low shear stress, often with eddy currents, characterized by slow, oscillating (back and forth) flow (283,
1343). Such a pattern is described as disturbed flow and
even predicts locations where plaques will progress in individual human subjects (1942). Turbulence is not a feature
of flow at these sites. Indeed, turbulence, defined as blood
flow exceeding the critical Reynolds number, occurs almost
nowhere in the normal human circulatory system. The coronary circulation is uniquely predisposed to atherosclerosis
(804), probably because of high intraluminal pressure and
complete flow cessation and possible reversal during systole, a likely cause of the greatly suppressed eNOS activity
observed in coronary compared with aortic endothelial cells
(377).
1355
PYK2 signaling in the endothelium is clearly atherogenic

(890). PYK2 directly activates JNK and supports the ROS
production required for JNK activation in ApoE KO mice
(890). This study provided further important insights into
inflammatory signaling stimulated by PYK2 and JNK. Both
JNK and especially ERK1/2 activate the transcription factor
Ets-1 by serine/threonine phosphorylation. Ets-1 plays a
major role in arterial inflammation (1327), promoting transcription of p21Cip1, E-selectin, P-selectin, VCAM-1,
ICAM-1, MCP-1, CXCL1, PAI-1, Sm22, and fibronectin
(516, 792, 890, 1302). In addition, all the components of
the NOX2 complex, including NOX2, p22phox, p47phox,
p40phox, and p67phox, were induced by ANG II signaling
through Ets-1 (516). Ets-1 expression is itself upregulated
by various proinflammatory signals (516), particularly
TNF--mediated ERK1/2 activation (628). In endothelial
cells, JNK was found to be required to induce transcription
of the cyclin-dependent kinase inhibitor p21Cip1 and
TNF- (890), possibly through Jun activation together with
activated Ets-1.
Deficiency of p21Cip1 more modestly diminished atherosclerosis (961).
PAUL N. HOPKINS
A. Endothelial Activation by Hemodynamic

Factors: General Features and
Phenotypic Effects
Endothelial activation has been conceptualized as type I
(rapid, without new protein synthesis) and type II (requiring
signaling to control transcription factors which induce new
protein synthesis with increased expression of adhesion
molecules and cytokines) (1424, 1425). Type I activation
has been typified by responses to histamine while type II
responses are exemplified by TNF- signaling. Initial hemodynamic responses and longer term responses to disturbed
flow demonstrate aspects of both type I and type II activation.
Importantly, when endothelial cells cultured without flow

are then exposed to onset of flow, or to sudden stepped
increases in flow, or especially a change in flow direction,
there is transient activation (311). However, after several
hours of continued, unidirectional, laminar high shear
stress flow, even if pulsatile, these initial proinflammatory
responses are suppressed below beginning levels. Thus endothelial cells cultured in a medium without flow are essentially activated to some degree. After prolonged exposure to
unidirectional flow (10 12 h, but especially after 24 h),
endothelial cells display an anti-inflammatory, antioxidant,
antiproliferative phenotype, remaining in a relatively quiescent state but active in production of protective NO and
PGI2 (prostacyclin). They also become elongated, aligning
the long axis of their cytoskeleton in the direction of flow. In
contrast, where there is repetitive flow reversal, however
slight, endothelial cells never suppress their proinflammatory response as evidenced by translocation of NF-B to the
nucleus, increased expression of cell adhesion molecules,
secretion of MCP-1 and endothelin, and production of su-
1356
B. Endothelial Activation by Hemodynamic

Factors: GPCRs and Ion Channels
1. GPCR, PLC, G proteins, and NOX
Within milliseconds after abrupt onset of flow or flow reversal, signals can be measured from GPCR and ion channels with mechanosensory capabilities (FIGURE 6A). This
phase of endothelial activation is similar to the rapid, socalled, type I activation of endothelial cells by histamine.
Incidentally, the H1 histamine receptor, a GPCR, appears
to promote atherosclerosis by increasing vascular permeability for LDL (1515). Calcium channels are also involved in
activation of endothelial cells by disturbed flow. Dramatic,
rapid increases in intracellular calcium were seen primarily
with flow reversal with much lesser effects from stepped increases in unidirectional flow (1188). Several aspects of flowrelated type I signaling are depicted in FIGURE 7.
Several GPCR may be involved in mechanotransduction of
endothelial shear stress, but the best characterized is the
bradykinin receptor B2 (BDKRB2) (267). Activation of B2
receptors by flow is ligand-independent. Mice made deficient in B2 receptors develop salt-sensitive hypertension
(48), but effects on atherosclerosis have apparently not been
tested. The signaling described below is illustrated in FIGURE 7. A number of the steps are redundant with AT1R
signaling described above but are presented again here for
didactic clarity. Signal transduction from BDKRB2 is mediated by the Gq/11 family of heterotrimeric G proteins;
hence, it may expected to be inflammatory. Both the active
GTP-bound Gq/11 and its partner activate PLC. In addition, shear-induced release of can also lead to a 10-fold
elevation of activated (GTP-bound) Ras within 5 s, considerably faster than many other mechanisms of Ras activation
(667). Despite the short duration of the Ras signal (510
min) with onset or directional change in flow, it leads to
ERK1/2 and JNK activation (after 30 min) followed by
increased surface expression of E-selectin and VCAM-1,
together with secretion of MCP-1 after 90 min (307).
Active PLC cleaves IP3 from membrane-bound PIP2, leaving DAG to act as a membrane-associated signaling molecule. Liberated IP3 acts on the IP3 receptor (IP3R) to release
Multiple transduction mechanisms endow endothelial cells

with exquisite sensitivity to changes in shear stress, controlling endothelial cell migration, mitosis, apoptosis, endothelial layer permeability, inflammation (including white cell
adhesion), nitric oxide release, and thrombosis (388, 693).
The prevailing flow pattern determines the endothelial phenotype. Sophisticated, direct measurement of flow patterns
in atherosclerosis-prone versus resistant areas revealed
marked differences in endothelial response and function as
shown in FIGURE 6 (375). Endothelial cells exposed to disturbed flow (FIGURE 6A) develop a proinflammatory phenotype with increased production of ROS, higher cell turnover, increased cell-cell permeability, and excess apoptosis.
They express leukocyte adhesion molecules and chemokines. In contrast, the flow pattern in areas protected from
atherosclerosis is rapid (high shear stress with laminar flow)
and unidirectional, although pulsatile as shown in FIGURE
6B. Endothelial cells exposed to such flow become quiescent
and resistant to inflammatory signals with low intercellular
permeability.
peroxide. NO production is reduced and bioavailability impaired. These endothelial cells do not align with the flow.
They have disorganized cytoskeletons and develop other
features characteristic of lesion-prone areas including increased apoptosis, frequent mitoses, greater permeability
(particularly at sites of mitosis), and a shorter glycocalyx. In
addition, endothelial cells exposed to disturbed flow increase production of subendothelial matrix components
such as fibronectin, resulting in enhanced inflammatory responses and thickening of the basement membrane (282,
693).
Shear Stress (dyn/sq-cm)
A
50
40
Atherosclerosis-prone waveform
30
20
10
0
-10
500
1000
2000
1500
2500
3000
3500
4000
atherosclerosis
Susceptibility to
Shortened glycocalyx
permeability
Monocyte adhesion
Fibronectin synthesis
10
100
0.1
0.01
apoptosis
mitosis
BMP-4
NAD(P)H Ox
superoxide, ROS
NF-B, ERK1/2
Erk, JNK,
Rho GTP
tyrosine kinases
ICAM-, VCAM-1
MCP-1 release
TLR-2
GPCR, Ca, K channels

Ras GTP (very transient)
PGI2 & NO release
PECAM-1 phosphorylated
Rho GTP, Rac1, Cdc42
Inflammatory Response
Time (ms)
1000
Hours
50
45
40
35
30
25
20
15
10
5
0
Athero-protective waveform
0
500
1000
2000
1500
2500
3000
3500
4000
0.01
0.1
10
100
1000
Athero-protection
Cyclins decrease
anti-oxidant genes
ROS, NF-B, JNK,

other pro-inflammatory
signals return to
baseline or lower
ARE genes ( HO-1)

MKP-1, TRAF3
KLF2, KLF4
COX-2, PGIS
PGI2
NF-B continues
Nrf2, Nrf1
Organization of actin
cytoskeleton,
alignment with flow
NO release
Rho, Rac1, Cdc42
Time (ms)
Inflammatory Response
Shear Stress (dyn/sq-cm)
10000
Time (hours)
FIGURE 6. Overview of hemodynamic effects on signaling related to atherogenesis. A: characteristics of a
highly atherogenic waveform (slow flow with directional change during each cardiac cycle) together with
approximate order of resulting signals. B: atheroprotective waveform (rapid flow, high shear stress with
pulsatory but unidirectional flow) and associated signaling. There is an initially pro-inflammatory response,
similar to early signaling in A, followed by prolonged active suppression of inflammation.
1357
PAUL N. HOPKINS
Cilium
Onset of flow or directional
change in shear stress
vWF
ANGPT2
P-selectin
B4 GPCR
P2X4
TRPV4 &
TRPC1
PKD2
CD44
Glypican-1
Caveolin-1
Arg
Kir2.1
PKD1
Ras Ral PLD1
RasGRP RalGDS
Caveola
ATP
PI3K
Vm
PKG
q
Calmodulin
NO
ONOO
O2
CaMKII
DAG
PLC
WPb
Calmodulin
eNOS
PKG
sGC
PKC
PYK2
IP3R
MnSOD
H2O2
cGMP
RyR
Ca2+
IP3
Mitochondria
PKG
PC
DAG
cPLA2
ER
PDK1
COX1
COX2
AA
LPC
PGIS
PGI2
CYP2C/J
MNK1
EETs
p47phox,
p22phox,
eNOS,
Integrins,
VE-cadherin
PKC
Raf1
PYK2
inhibition,
acivation of
MAPK & IKK
PAF
acetylase
PLD
RKIP
LPC
Extracellular matrix
LPA
PAF
ATX
Vasodilation
Inflammation
Thrombosis
FIGURE 7. Early mechanotransduction of shear stress in endothelial cells, characterized by type I inflammatory
signaling through G protein-coupled receptors (GPCR) and ion channels. The downstream signaling from the B2
bradykinin GPCR is typical for many GPCR, but its activation by shear stress without substrate binding is unique to a few
GPCR. Shown in yellow boxes are other mechanical shear-stress transducers. COX-1 is a constitutive but low-capacity
enzyme. COX-2 is induced by proinflammatory signals generally and by prolonged laminar flow specifically in endothelial
cells and has greater overall capacity than COX-1. Endothelial H2O2 has vasodilatory effects on coronary arteries but may
have different effects in different arterial beds. AA, arachidonic acid; LPA, lysophosphatidic acid; LPC, lysophosphatidylcholine; PLD, phospholipase D; ATX, autotaxin; PC, phosphatidylcholine; sGC, soluble guanylate cyclase; Vm, membrane
potential (negative inside, thus decrease in Vm means hyperpolarization); vWF, von Willebrand factor; WPb, WeibelPalade body. Expression of purinergic ATP receptor P2X4 is much greater in veins than arteries; its conductivity for
calcium is markedly increased by flow but also requires ATP. Without the effect of angiopoietin 2 (ANGPT2), released
from WPb to block the highly anti-inflammatory signaling of ANGPT1 through its receptor Tie2 (not shown), endothelial
cells would remain largely unresponsive to subsequent activating signals.
1358
O2
PIP2

calcium stored in the ER. Cytosolic calcium itself then leads
to opening of the ryanodine receptor (RyR) and further
opening of IP3R, a process dubbed calcium-induced calcium release. Both IP3R and RyR exhibit negative feedback from sufficiently elevated cytosolic calcium, leading to
oscillating calcium signals with the possibility of frequency
modulation of downstream effectors. Calcium and DAG
activate PKC, a conventional PKC (which, by definition,
requires both calcium and DAG for activation). Calcium
may facilitate a conformational change in PKC resulting in
greater affinity for DAG and membrane phosphatidylserine. Membrane localization then allows phosphorylation
by PDK1 followed by two self-phosphorylations and full
activation.
Active PKC inhibits eNOS by phosphorylating threonine

495 and increases NOX2 activity by phosphorylating both
the p47phox regulatory subunit and the catalytic p22phox
subunit (1413). Rac1 (and RhoA) can be activated by
p114RhoGEF which, in turn, is activated by subunits from
activated GPCR (1312). Vav2 may also possibly activate
Rac1 in this pathway.
2. Calcium signaling, ion channels, and
Weibel-Palade body exocytosis
Ion channels in the plasma membrane also contribute to
flow-mediated intracellular calcium influx. Several of these
are shown in FIGURE 7. Recently, a contribution from the
TRPV4 calcium channel was confirmed which appears to
function in conjuction with the TRPC1 channel (1101,
1192). Polycystin-2 (PKD2 gene), a calcium channel which
acts in cilia together with the mechanosensory protein polycystin-1 (PKD1 gene), also contributes significantly to these
inward calcium currents (5, 1287, 1814). While most arterial endothelial cells are not ciliated, cilia are found frequently in atherosclerosis-prone areas, and their formation
The increase in intracellular calcium stimulates eNOS

through calmodulin. Thus the onset of flow results in a
sudden initial burst of NO production that is calcium and G
protein dependent (through Gq/11 and as noted above)
(1954). In addition, the transient calcium elevation appears
to stimulate more prolonged eNOS activation through
ERK1/2 (1994). A likely mechanism is through CaMKII
activation of PYK2 which can serve as a scaffold to bind
and activate the Grb2-Sos pathway for ERK1/2 activation
(894, 1736). CaMKII also directly phosphorylates endothelial NOX5 to promote superoxide production (1376).
There may also be a mechanical effect of shear stress on
glypican and CD44 to assist in caveolin-1 phosphorylation
and removal of its suppressive effect on eNOS (1760). Increased NO production is generally considered anti-inflammatory. However, if eNOS is uncoupled from normal NO
production by GSSG as noted above, or if sufficient peroxynitrite has oxidized the zinc-thiolate complex of the enzyme or its essential cofactor BH4 (tetrahydrobiopterin), or
if there is deficiency of BH4, then normal stimulation of
eNOS may yield a net increase in superoxide production
(101).
Increased intracellular calcium can stimulate production of
superoxide by mitochondria. Nearly all the enzymes of the
tricarboxylic acid cycle are upregulated by calcium, linking
enhanced ATP generation to muscle contraction in muscle
cells. In endothelial cells, however, such calcium signaling is
tied to enhanced mitochondrial superoxide production,
possibly by inhibition of respiratory chain complex I and
III. Furthermore, NO can inhibit complex I (211) while
peroxynitrite strongly inhibits complex IV (708). Released
ROS may lead to even greater intracellular calcium by stimulating both IP3R and RyR and impairing calcium uptake
by sarcoplasmic-endoplasmic reticulum calcium ATPase
(SERCA) with potential adverse cellular effects such as promotion of ER stress aggravated by low ER calcium levels
(435).
1359
Once active, PKC acts in endothelial cells largely as an

amplifier of inflammatory signaling. Particularly important
in this regard is phosphorylation of Raf-1, and more recently recognized, Raf kinase inhibitory protein (RKIP)
(921). In its nonphosphorylated form, RKIP binds to and
blocks activation of Raf-1, MEK, and ERK, all three kinases
of the ERK signaling cassette. Unphosphorylated RKIP also
inhibits IKK2. RKIP phosphorylation by PKC relieves the
inhibition of both Raf-1 and IKK2, allowing activation by
upstream signals. Also, once phosphorylated, RKIP moves
to bind and inhibit GRK2 which, when active, promotes
phosphorylation and binding by adapters such as the -arrestins noted above or targeted degradation of GPCR in
general, presumably the B2 receptor as well. Knockout of
PKC is strongly antiatherosclerotic. Atherosclerosis reduction is mediated not only by endothelial effects but also
by strong inhibition of macrophage function (see TABLE 3).
Interestingly, PKC/ animals are lean, resistant to obesity, and hyperphagic (104), but immunodeficient.
may be induced by disturbed flow (1847). ATP is released to

the extracellular space by endothelial cells in response to
flow followed by autocrine stimulation of the purinergic
P2X4 calcium channel (encoded by the P2RX4 gene).
P2RX4 knockout increased blood pressure, markedly decreased flow-mediated dilation, and impaired arterial remodeling (2007), but effects on atherosclerosis are apparently not known (see sect. VIA for further discussion of
purinergic signaling). Rapidly acting, inwardly rectifying
potassium channels, Kir2.1 and Kir2.2 and possibly IKCa1
(202) lead to hyperpolarization in response to shear stress
and would further enhance inward calcium flux (761). Outwardly rectifying chloride channels (causing depolarization) are activated after the hyperpolarization by potassium
channels. It would be of interest to explore the effects on
atherosclerosis of targeted deletion of some of these ion
channels.
PAUL N. HOPKINS
Table 3. Hemodynamic effects on endothelial cells and other early steps in initiation (55 genes tested)
Gene
Model
% A
Function, Comment
Endothelial activation by disturbed flow

Sdc-1/ apoE/
153%
PFN1
PFN1/ LDLR/
261%
PECAM-1
PECAM-1/ apoE/
241%
PECAM-1/ LDLR/
284%
VEGFR2
VEGFR2 DNA vaccine in

LDLR/
266%
Shc1
(p66Shc)
p66Shc/ apoE/
260%
PLC2/3
PLC2/3/ apoE/
251%
ADAM15
ADAM15/ apoE/
261%
FN
FN EIIIA/ apoE/
253%
nmMLCK
nmMLCK/ apoE/
231%
BMP2
VSCM-specific BMP2 Tg
in apoE/
NS
BMP4
Fc-ALK3 intra-peritoneal
adminstration into
LDLR/ mice
243%
MGP
MGP human Tg in
apoE/
237%
MGP/ apoE/
296%
BMPER/ apoE/
131%
BMPER
Sdc-1 (syndecan-1) was also expressed on macrophages but flow-induced protection

of endothelium is a likely mechanism (699). While protective, Sdc-1 is listed here
as it is a major component of mechanotransduction, directly linking the glycocalyx
to cytoskeletal stress fibers.
PFN1 (profilin 1) is a key molecule for actin microfiber assembly by binding and
priming globular actin with ATP in exchange for ADP. Homozygous deficiency is
embryolethal by the 2-cell stage. Nevertheless, increased expression appears
proinflammatory while heterozygous deficient mice had reduced p38 and ATF2
signaling, decreased VCAM-1 expression, and enhanced eNOS activity.
Macrophages in heterozygous mice had reduced CD36-mediated uptake of oxLDL
and inflammatory signaling. Fewer, macrophages accumulated in lesions (1503).
Higher levels are associated with plaque and plaque-prone areas while laminar
shear stress lowers PFN1 expression (325). Diabetes and oxysterol increases
PFN1 expression through STAT3 signaling (1502).
siRNA knockdown of PECAM-1 decreased NF-B and VCAM1 expression in
endothelial cells exposed to disturbed flow (726).
Atherosclerosis decreased markedly at the inner curvature of the aorta (major area
of disturbed flow in mice) with KO, but may actually be increased in other areas
(626).
Shown is the decrease in rate of progression for established lesions (vaccine at 22
wk). Also, 77% reduction in initiation of new lesions caused by carotid collars
(734). Some report similar results (1412), while others report no change in
lesions with anti-VEGFR2 (Flk1) treatment (1097).
Mutation of only the N-terminal CH domain unique to p66Shc did not modify
production of the p46 and p52 isoforms which have alternative, downstream
initiation sites (1147). p66Shc mediates mitochondrial ROS production by many
stimuli. 75.5% reduction in lesions was seen in mice without genetic
hyperlipidemia fed a very high fat, high cholesterol diet (1283).
Strong effects on macrophage function seen as well (BMT suggests most of effect
is macrophage-related) (1925).
ADAM15 associates with VE-cadherin. Its cytoplasmic tail binds Src and Yes which
promote disruption of the adherens junction with increased endothelial
permeability (1705).
Adhesion of endothelial integrin 51 to FN (fibronectin) primes endothelial cells for
an inflammatory response. The EIIIA domain also serves as a monocyte adhesion
molecule and can be presented by the endothelial cell by apically expressed 41
integrin. Complete fibronectin KO is embryolethal. Increased fibronectin content of
extracellular matrix is seen in areas of disturbed flow. EIIIA is a key domain of
fibronectin (1751).
nmMLCK (nonmuscle isoform(s) of myosin light-chain kinase, encoded by MYLK1) is
an effector of Rho/ROCK and other upstream kinases. nmMLCK phosphorylates
myosin to activate actinomyosin contraction in endothelial cells (and leukocytes)
and by a nonkinase mechanism activates Src with both effectors leading to
increased endothelial permeability as well as monocyte diapedesis (1706).
But greater intimal calcification seen due to induction of osteoblast-like cells (1276).
Included here (though VSMC associated) because of BMP4.
BMP4 expression is increased by disturbed flow and induces NOX1 in endothelium
(413). Inhibition of BMP2/4 signaling by a recombinant BMP ligand trap, FcALK3, had a greater proportional effect than BMP2 over-expression, though this
was in VSCM (above)
MGP (matrix Gla protein) is one of several endogenous inhibitors blocking BMP
interaction with extracellular receptors (others include noggin and chordin).
SMAD1/5/8 phosphorylation was decreased and much less calcification seen in
these Western diet-fed mice (2029).
MGP deficient, chow fed mice showed increased arterial calcification, but
surprisingly, very little atherosclerosis with very few macrophages and nearly
absent expression of ICAM-1, VCAM-1, or E-selectin (2029).
BMPER (BMP endothelial cell precursor-derived regulator) deficiency allowed
increased BMP signaling and inflammation with markedly greater ICAM-1 and
VCAM-1 expression (1416).
Continued
1360
Sdc-1
Table 3.Continued
Gene
Model
% A
Function, Comment
Endothelial protection with prolonged laminar floweNOS related

ANGPT2
Tie1
ERK5
ANGPT2 adenoviralinduced overexpression in

apoE/
endothelial-specific Tie1
deletion (tamoxifenresponsive Cre-Lox) in
apoE/
240%
ANGPT2 (angiopoietin 2) is generally thought to promote inflammation by blocking

anti-inflammatory effects of ANGPT1 at the Tie2 receptor (86). However, NO
production was stimulated and mediated the protective effect of ANGPT2 (20).
270%
Tie1 (tyrosine kinase with immunoglobulin and EGF factor homology domains 2) is an
angiopoietin (ANGPT) receptor that is upregulated in endothelium exposed to
disturbed flow. Reduction in plaque shown is progression in aortic regions
exposed to disturbed flow. Little change seen at aortic root (1978). Tie1
activation by shear stress appeared to block the anti-inflammatory signaling of
Tie2.
In the same study, either elevated glucose plus low-dose hydrogen peroxide or
higher hydrogen peroxide activated RSK1/2 binding to ERK5 with inactivating
phosphorylation of ERK5 S496 by RSK1/2 (986).
KLF2
KLF2/ apoE/
131%
Arg2
endothelium-specific Tg
human Arg2 in
apoE/
Arg2/ apoE/
179%
eNOS
(NOS3)
eNOS/ apoE/
180%
nNOS
(NOS1)
nNOS/ apoE/
131%
GTPCH
GTPCH Tg apoE/
228%
Cav1
Cav1/ apoE/
233%
NPR1
NPR1/ apoE/
164%
267%
SENP2 (sentrin/SUMO protease 2) desumoylates p53 and ERK5. Sumoylated p53

binds BclII and is pro-apoptotic whereas sumoylation of ERK5 is inhibitory. BMT
experiments showed effect was due to vascular wall expression of SENP2. Much
larger effect in areas of disturbed flow where sumoylation of p53 and ERK5 is
increased (749).
Effect of KLF2 placed here to emphasize endothelial effects even though hemizygous
KLF2 deficiency was accompanied by a 39% increase in endothelial KLF4 which
may have largely compensated for any deficit in KLF2. No changes in eNOS or
VCAM-1 expression were seen. There was an increase in FABP4 expression in
macrophages that may have contributed to the increase in lesions (85).
Hematopoetic cell-specific KLF2 deficiency in LDLR KO mice resulted in increased
atherosclerosis with greater macrophage and neutrophil adherence to
endothelium and activity (1050).
Endothelial-cell-specific expression of human Arg2 (arginase II) decreased arginine
availability for NO production by eNOS (1837). Arg2 is a mitochondrial emzyme.
Arg2/ macrophages were less responsive to proinflammatory stimuli and fewer
entered plaque (1214). Arg2 in macrophages in some way facilitates
mitochondrial ROS production and is part of the M1 response.
NO produced by eNOS mediates some of the protective effects related to flow as
well as inhibition of cell adhesion. Deficiency also results in higher blood pressure
(923). Transgenic over-expression of human eNOS lowered blood pressure (20
mmHg) and decreased atherosclerosis by 40% (1855).
Double KO mice lacked the isoform of nNOS. Total en face plaque area was
increased only in females at 24 wk (as shown). No effect on aortic sinus lesions
seen (959). Interestingly, mice lacking eNOS, nNOS, and iNOS have greatly
elevated LDL due to decreased hepatic LDLR expression and markedly
accelerated atherosclerosis (2030). nNOS was recently shown to be a major
source of hyperpolarizing, vasodilating hydrogen peroxide in response to shear
stress while nNOS production of hydrogen peroxide was diminished with
GTPCH (GTP cyclohydrolase I) is the rate limiting enzyme for BH4 synthesis. BH4
levels increase 3- to fourfold in endothelial cells of Tg mice (56). Lower levels of
BH4 and increased eNOS uncoupling were seen in aging arteries (2013, 2027).
Re-expression of Cav1 (caveolin) only in endothelium restored level of
atherosclerosis. Less LDL penetration and greater NO production was seen in
Cav-1/ mice (522). Endothelial-specific overexpression increased
atherosclerosis (521). Even greater reduction in atherosclerosis seen in a more
recent study (477).
NPR1 (natriuretic peptide receptor 1) is a membrane-bound guanylate cyclase with
actions presumably mediated through PKG). It serves as the receptor for both
atrial and brain natriuretic peptides. NPR1 KO mice had higher blood pressure
which may have accounted for increased plaque size. Plaques also had more
VSMC, thicker fibrous caps, more calcium, but more cholesterol clefts (46).
NPR1 KO mice also have hypertension and cardiac hypertrophy.
Continued
1361
SENP2
endothelial-specific
1130%
ERK5 deletion
(tamoxifen-responsive
Cre-Lox) in LDLR/
SENP2/ LDLR/
197%
PAUL N. HOPKINS
Table 3.Continued
Gene
Model
% A
Function, Comment
Endothelial protection with prolonged laminar flowprostaglandins and related

/
apoE/
COX-1
COX-2
Inducible Cre-lox COX2/ in apoE/
ER (ESR1)
ER/ LDLR/
CYP7B1
CYP7B1/ apoE/
172%
mPGES-1
mPGES-1/ LDLR/
234%
IP
IP/ apoE/
132%
TP
TP/ apoE/
274%
DP1
DP1/ apoE/
DP1/ LDLR/
FP
FP/ LDLR/
238%
fat-1
fat-1 Tg in apoE/
238%
UCP1
Endothelial protection
Aortic VSMC-specific
1350%
overexpression of
UCP1 in apoE/
UCP2
UCP2/ C57BL/6J
mice fed Paigen diet
LIAS
LIAS/ apoE/
274%
145%
1280%
140%
144%
1321%
143%
Reduction in lesions was even greater in some measures (1167). COX-1 deletion
virtually eliminated plasma TXA2 (more so than complete platelet COX-1 inhibition
with aspirin), suggesting alternate sources of synthesis. Similarity to protection
from TP KO (below) is striking.
Inducible whole body COX-2 KO did not result in blood pressure or lipid changes.
There was no excess atherosclerosis in mice with combined COX-2 and FLAP KO
(2050). Macrophage-only KO by Cre-Lox in LDLR-null mice decreased
atherosclerosis 25% at 6 mo but BMT of COX-2 KO marrow showed no effect in
apoE KO mice (1284).
Shown is the increase in lesion area in ovariectomized ER KO given the larger
estrogen supplement (from subcutaneous pellets). BMT and Cre-Lox endothelialspecific KO studies showed the protective effect of the ER was due endothelial
effects (146). AMPK activation may be involved (2084). Estradiol in
ovariectomized LDLR KO mice increased COX-2 and benefit was dependent on
PGI2 signaling through IP receptor (462).
CYP7B1 converts 27-hydroxycholesterol (27HC) to 7,27-dihydroxycholesterol in the
pathway to chenodeoxycholate synthesis. CYP7B1 deficiency results in accumulation
of 27HC which inhibits both transcriptional and nonnuclear effects of ER and ER
(1833). Increased atherosclerosis also with 27HC administration (1832).
mPGES-1 (microsomal prostaglandin E synthase 1) is an inducible enzyme. It was
primarily expressed in lesional macrophages and KO decreased PGE2 synthesis
mainly in macrophages with subsequent depletion of lesional macrophages. KO
also resulted in increased PGI2 synthesis by VSMC (1906). Data is placed here
rather than table 6 because of the increased VSMC PGI2 and to group this data
with other prostaglandin-related genetic interventions
PGI2 receptor (IP) is present on multiple cell types besides endothelial cells (925).
Similar average increase seen in a study with LDLR KO mice (462).
TXA2 prostanoid receptor (TP) placed in this table because of marked proinflammatory endothelial signaling (925).
The PGD2 receptor, DP1, is the target of the failed drug laropiprant, a DP1
antagonist. Later time points in apoE KO mice were nonsignificant (1688).
Similarly, effect in LDLR KO mice was in females at 24 wk with lesser effects at
later time and males (1654). DP1 KO in apoE deficient mice also increased
aneurysm formation in the setting of prolonged ANG II infusion. Evidence was
presented that the vasodilating DP1 receptor also had anti-platelet effects in
humans (1654)
The F prostanoid receptor (FP), also known as PTGFR (prostaglandin F receptor)
binds PGF2. Deletion of the receptor primarily affected renal sodium/water
handling and thereby lowered blood pressure which appeared to explain the effect
on atherosclerosis (2049).
fat-1 is a round worm gene that converts n-6 to n-3 fatty acids (1893). Markedly
decreased inflammation was seen in lesions.
with prolonged laminar flowrelated to antioxidant defense
Expression of UCP1 (uncoupling protein 1) in aortic smooth muscle unexpectedly led
to increased ROS production (132). There was also a substantial increase in
blood pressure and aldosterone which may have contributed to the increase in
atherosclerosis.
UCP2 (uncoupling protein 2) is upregulated by oxidative stress or inflammation and
dampens stimulated mitochondrial ROS production by an unknown mechanism.
UCP2 KO mice fed a Paigen diet had increased VCAM-1 as well as other signs of
endothelial activation (1240). UCP2/ BMT into LDLR/ resulted in modestly
increased lesions with more macrophage apoptosis and signs of ROS-induced
protein modification (157). UCP2 has since been shown to be crucial for
macrophage efferocytosis as well (1380).
Lipoic acid synthase (LIAS) produces lipoic acid in the mitochondria, a potent
antioxidant which helps regenerate reduced glutathione. Homozygous lipoic acid
synthase (LIAS) deficiency is embryo lethal. Only male LIAS mice had an increase
in lesion area (value given, females 5% increased, NS) and displayed increased
TBARS and decreased erythrocyte GSH/GSSG which correlated strongly and
inversely with lesion area in males (2037).
Continued
1362
COX-1
Table 3.Continued
Gene
Model
Function, Comment
247%
Similar experimental design as for human catalase overexpression (above). Without

weekly benzo(a)pyrene (in oil) gavage, only catalase overexpression affected
atherosclerosis. With benzo(a)pyrene, there was a marked increase in aortic F2isoprostanes and reduction in atherosclerosis was signficant for SOD1
overexpression as shown and additive with catalase (2022). VCAM-1 and ICAM-1
were also reduced by overexpression. No effect seen in C57BL/6 SOD1 Tg fed
atherogenic diet (1807).
MnSOD (also known as SOD2) converts mitochondrial superoxide to H2O2. Flowmediated dilation was also reduced in these mice (2014). Homozygous knockout
is embryonic lethal.
EC-SOD (extracellular superoxide dismutase) KO had only minor effects. Decrease in
aortic surface area with lesions was only seen at 1 mo. By 3 and 5 mo there
were no differences. No differences in LDL oxidation in aortic wall detected
(1588).
HMOX1 (heme oxygenase 1) provides intracellular antioxidant defense in EC and
VSMC (2035). Also important in macrophages to limit activation and scavenger
receptor expression (1351). Induction of HMOX1 also appears to limit plaque
vulnerability in rabbits (1035)and mice (301).
Prdx1 (Peroxiredoxin 1) deficient mice also showed increase endothelial cell
activation and leukocyte rolling (915).
Up to twofold increases in aortic plaque area were seen. BMT experiments showed
similar contributions to atherosclerosis from either endothelial or leukocyte Prdx2
deficiency (1381).
Cu-Zn SOD
human SOD1 Tg in
apoE/ with added
benzo(a)pyrene
MnSOD
SOD2/ apoE/
1167%
EC-SOD
SOD3/ apoE/
238%
HMOX1
HMOX1/ apoE/
Prdx1
Prdx1/ apoE/
170%
Prdx2
Prdx2/ apoE/
125%
Prdx6
Prdx6/ apoE/
NS
GPx1
GPx1/ apoE/
diabetic mice
153%
GPx4
human GPx4 Tg in
apoE/
human catalase Tg in
apoE/
241%
GCLC
GCLC Tg in apoE/
233%
GCLM
GCLM/ apoE/
145%
Trx2
Trx2 Tg in apoE/
265%
TTPA
TTPA/ apoE/
142%
GULO
GULO/ apoE/
SVCT2/
1230%
Catalase
1269%
233%
In the apo E KO mouse Prdx6 KO did not affect atherosclerosis but atherosclerosis
was significantly increased in 1 of the 3 black-6 mouse strains tested (1916).
Aortic sinus at 20 wk in diabetic mice with GPx1 (glutathione peroxidase 1) KO
(1016). Difference in nondiabetic mice was NS. Increased signs of oxidative
damage seen.
Over-expression of GPx4 was also shown to decrease endothelial production of
adhesion molecules (677).
Over-expression of catalase reduced atherosclerosis. A twofold increase in catalase
activity was seen in the aorta (2021). Human SOD1 (superoxide dismutase 1,
also known as Cu/Zn SOD) overexpression alone or with catalase overexpression
showed small, nonsignficant reductions in atherosclerosis in this model. Aortic
sinus lesion area was strongly and directly proportional to aortic F2-isoprostanes.
GCL (glutamate-cysteine ligase) is the rate limiting enzyme in glutathione synthesis.
The enzyme consists of a catalytic subunit, GCLC, and a modifier subunit, GCLM,
encoded on separate genes. GCLM required for full activity. Whole body KO of
GCLC is embryo lethal. Effect of macrophage-specific overexpression is given here
(244).
BMT studies showed more than half the effect of GCLM deficiency could be
accounted for by hematopoeitic cells, presumably macrophages. Increased
apoptosis (caspase 9 activity) of macrophages seen when exposed to acrolein
(244).
Trx2 (thioredoxin 2) is the mitochondrial form in mice. VEGF promoter used for
endothelial-specific over-expression (2070).
TTPA (tocopherol transfer protein, alpha, also -TTP) is a vitamin E transfer protein
involved in loading of VLDL with dietary vitamin E (delivered to the liver by
chylomicrons and chylomicron remnants). Plasma and aortic tissue levels of
vitamin E were reduced in TTPA KO mice and lesions correlated with F2ispoprostanes (1772).
GULO (gulonolactone oxidase) is found only as an inactive pseudogene in humans,
primates, and guinea pigs. Increased atherosclerosis with dietary deficiency of
both vitamin E and vitamin C in GULO KO, apo E-null mice was also shown in this
study together with increased macrophage content. SVCT2 (sodium-vitamin C
transporter 2) is a sodium-dependent transporter mediating vitamin C transport
into many tissues including vascular cells. Prior studies in GULO KO, apo E-null
mice were negative regardless of vitamin C intake, suggesting more severe tissue
deficiency of vitamin C or combined vitamin C/vitamin E deficiency is required to
promote atherosclerosis (93)
Continued
1363
% A
PAUL N. HOPKINS
Table 3.Continued
Gene
SVCT2
Model
SVCT2/ BMT into

apoE/
% A
Function, Comment
242%
SVCT2 (sodium-dependent vitamin C transporter 2. Also known as SLC23A2). Fetal

liver cell BMT. Macrophage vitamin C normally 60-fold greater than plasma.
SVCT2-deficient macrophages were devoid of vitamin C, more prone to peroxideinduced mitochondrial dysfunction, and showed early apoptosis as well as
deactivation of HIF-1 and RAGE/NF-B pathways (96).
Endothelial protection with prolonged laminar flowH2S signaling

CBS
CTH
CBS
with zincinducible human CBS
Tg apoE/
apoE/ mice treated
with CTH inhibitor
propargylglycine
163%
1124%
Zinc-inducible CBS (cystathionine -synthase) transgene used to avoid high early

mortality. Zinc removed from water for atherosclerosis studies (2067). Increased
atherosclerosis likely due to impaired H2S synthesis (118, 1586, 1759).
Though not a purely genetic model chemical inhibition CTH is quite specific. Lesions
were decreased (by 38%) versus apoE/ control by sodium hydrosulfide
supplementation (1921).
Reference numbers are given in parentheses.
A mechanism for exocytosis has been proposed which provides a useful illustration of G protein signaling (1506). The
Ca2-CaM complex binds to Ral-GDP dissociation stimulator (RalGDS, a GEF), inducing a conformation change
that relieves autoinhibition and frees RalGDS from its cytoplasmic sequestration by -arrestin. RalGDS moves to
the membrane and binds active (GTP-bound) Ras, allowing
RalGDS to exchange GDP for GTP on membrane-bound
RalA (one of the Ras family of GTPases). Active RalA then
mediates exocytosis of the WPB by coordinating the exocyst
complex through enhancing activity of phospholipase D1
(PLD1). PLD1 cleaves choline from phosphatidylcholine to
yield phosphatidic acid which promotes fusion of the vesicle
and plasma membrane (1506).
3. Cytosolic phospholipase A2, platelet activating
factor, lysophosphatidylcholine, and
lysophosphatidic acid
Cytosolic PLA2 (cPLA2 or group IVA phospholipase A2) is
also depicted in FIGURE 7. Activation of cPLA2 depends on
calcium-induced translocation to cellular membranes (especially the nuclear envelope and Golgi) and interaction with
membrane PIP2 and/or ceramide-1-phosphate. Various kinases, such as PKC, CaMKII, or MAPK interacting kinase
1 (MNK1), can phosphorylate cPLA2 and thereby increase
1364
its activity (234). The products of cPLA2 are arachidonic

acid (the precursor of the prostanoids) and lysophosphatidylcholine (LPC). LPC can give rise to lysophosphatidic
acid (LPA), and both LPC and LPA can bind to different
GPCR and promote inflammatory signaling, although the
identity of the LPC receptor or receptors remains controversial. LPC is also an important find me signal produced
by apoptotic cells which summons phagocytes and promotes efferocytosis. Efferocytosis is normal endocytosis
and lysosomal digestion of apoptotic cells by phagocytes.
Surprisingly, knockout of cPLA2 led to a reduction in various inflammatory syndromes (916). This observation may
or may not be relevant to atherosclerosis. Virtually all the
prostaglandins can act as mediators or modulators of inflammation in various models. Even PGI2, typically thought
of as anti-inflammatory, classically promotes acute inflammation by increasing endothelial permeability in small vessels (1286). Decreased VSMC proliferation after placement
of a carotid cast was seen with cPLA2 deficiency, but the
relationship with atherosclerosis is unclear (816). Recent
data suggest that a calcium-insensitive PLA2 (iPLA2) may
actually be the predominant isoform responsible for PGI2
synthesis in endothelial cells (1603), but its relation to atherosclerosis is also unclear.
LPC may serve as a precursor for PAF synthesis. PAF was
noted to be expressed rapidly on the surface of endothelial
cells after various stimuli including histamine, thrombin,
TNF-, and leukotrienes (1075). Disturbed flow may also
increase PAF expression or a similar product (FIGURE 7)
(1152, 1425). Disturbed flow clearly increases expression
of PAF receptors on endothelial cells (1337). Surprisingly,
however, the relationship between atherosclerosis and expression of PAF or its receptor (which primarily affects
neutrophil adhesion) has apparently not been explored.
LPC (as well as oxidized LDL or secreted PLA2) also appears to induce expression of m-calpain in endothelial cells.
Another event occuring immediately after onset of flow is

exocytosis of Weibel-Palade bodies (WPB) with rapid cellsurface expression of presynthesized P-selectin (577).
Weibel-Palade bodies are cigar-shaped vesicles unique to
endothelial cells. In addition to P-selectin they contain von
Willebrand factor (vWF), IL-8, pro-endothelin, angiopoietin 2 (ANGPT2), and other substances. Besides flow and
histamine, agonists for WPB exocytosis include aldosterone
(848), fibrinogen (1587), VEGF (through VEGFR2 not
VEGFR1) (1996), chromogranin A (298), and peroxynitrite (632).

m-Calpain is a calcium-dependent, intracellular cysteine
protease which affects endothelial permeability by cleaving
VE-cadherin (also known as CDH5 for cadherin 5) and
thereby disrupting the adherens junction. Inhibitors of mcalpain reduced atherosclerosis in LDLR- and ApoE-deficient mice (1222).
Another product of LPC is LPA, the simplest phospholipid.
Endothelial cells produce LPA from LPC primarily by the
action of the secreted enzyme ATX (autotaxin) (see FIGURE
7). LPA effects will be further discussed in relation to endothelial activation in response to hyperlipidemia.
4. The role of prostanoids in atherogenesis
In the prostaglandin pathway, COX-1 and COX-2 both

yield PGH2 (through the intermediate PGG2). PGH2 is then
utilized by various prostaglandin synthases (or isomerases)
such as thromboxane synthase (TXAS) and prostacyclin
synthase (PGIS). In noninflammed endothelial cells, prostacyclin (PGI2) is the exclusive detectable prostaglandin synthesized (236), whereas platelets make mostly thromboxane A2 (TXA2) but no PGI2. PGI2 is a strongly vasodilatory,
anti-platelet, and often anti-inflammatory prostaglandin
acting through the I prostanoid receptor (IP). TXA2 promotes inflammation and platelet aggregation through
thromboxane prostanoid receptor (TP) signaling (1286).
The COX-1 isoform is constitutively expressed in many
cells, including platelets, macrophages, VSMC, and endothelial cells and is generally not affected by inflammation or
flow. The COX-2 enzyme is only expressed after induction
by inflammatory signals or in endothelial cells exposed to
prolonged laminar flow. Consequent to this endothelial expression, COX-2 seems to be the predominant source of
precursor PGH2 for endothelial prostacyclin synthesis in
humans without inflammatory disease (421, 662) and in
mice (304). In human atherosclerotic lesions, both COX-1
and COX-2 are expressed with substantial COX-2 expression by activated macrophages (1562).
All prostaglandins transmit their signals by way of GPCR.
Contractile prostanoid GPCR include TP, EP1, and FP. In
humans there are two TP isoforms with both TP and TP
expressed on platelets while only TP is expressed on endothelial cells. In VSMC, contractile prostanoid receptors
increase intracellular calcium and inhibit adenylate cyclase
(AC) to promote smooth muscle contractions. TP in plate-
Because of drug-related controversies, a great deal of attention has focused on COX-1 and COX-2 even though their
substrate and product are the same. Meta-analyses do show
a dose-dependent increase in risk of coronary events among
patients taking COX-2-selective inhibitors, presumably because the greater inhibition of the endothelial-predominant
COX-2 decreases protective PGI2 while leaving platelet
TXA2 synthesis relatively unaffected (618, 1651, 1806).
Recent advances in inducible knockouts show COX-2 deficiency usually does increase atherosclerosis while COX-1
deficiency resulted in a substantial reduction in lesions (see
TABLE 3). In the meantime, relatively little attention has
been paid to cell-specific signaling in relation to the individual prostaglandin receptors.
Effects of TXA2, or more specifically, TP signaling are not
simply restricted to platelets. Various endothelial stressors
such as age, diabetes, and hypertension can lead to increased ROS, elevated intracellular calcium, and decreased
NO production, all of which impair endothelial IP and increase TP expression and signaling. Furthermore, both of
the endoperoxides (PGG2 and PGH2) and even PGI2 (particularly when produced at high but physiologic levels) can
act as agonists for TP, causing endothelial-dependent arterial contractions and possibly promoting inflammation
(1866). Although PGIS predominates, endothelial cells
can express all the prostaglandin synthases. Their levels
of expression can vary by animal variety, with age, intracellular calcium, ROS, and NO exposure. Exposure of
endothelial cells to high glucose caused increased peroxynitrate formation, nitration and inhibition of PGIS,
and diversion of PGH2 to inflammatory TP signaling
with adhesion molecule expression (2123). Importantly,
endothelial TXAS expression and TXA2 synthesis increase with age and inflammation generally (albeit accompanied by increased PGI2 synthesis) regardless of
whether the precursors come from COX-1 or COX-2
(1866). In human embryonic kidney (HEK) cells and aortic VSMC, ROS production caused by TP ligation promotes intracellular TP maturation and a doubling of cell
surface TP expression in a positive-feedback pathway
(1966). In human vascular endothelial cells, TP ligation
also causes changes in cell-surface fractalkine (CX3CL1)
expression and release that promotes leukocyte adhesion
(1798). Such changes also have been associated with progressing atherosclerosis with increased TXAS and TP
seen in more advance lesions of LDLR KO mice (367).
1365
Arachidonic acid, released from phospholipids by PLA2

enzymes, can act as a substrate for enzymes representing
three major orthodox eicosanoid pathways (391):
1) cyclooxygenase (COX) enzymes leading to prostaglandins, 2) lipoxygenases which yield hydroxyeicosatetraenoic acids (HETEs) and leukotrienes, and 3) certain cytochrome P-450 (CYP) enzymes, particularly of the CYP2C
and CYP2J series, which yield epoxyeicosatrienoic acids
(EETs).
lets is coupled primarily to G12/13 (leading to RhoA activation which mediates shape change) and Gq (causing
PKC activation and subsequent aggregation). IP, DP1, EP2,
and EP4 are relaxant receptors and activate AC (adenylate
cyclase) through Gs coupling (1286). IP in platelets also
causes cAMP generation through Gs coupling which inhibits platelet activation (614).
PAUL N. HOPKINS
Genetic mouse models have clarified a number of additional
issues regarding prostaglandin synthesis, signaling, and atherosclerosis, although questions remain (662). Details of
prostaglandin-related studies are summarized in TABLE 3.
Whole body COX-1 KO did decrease atherosclerosis, but
COX-1 deficiency in hematopoetic cells only actually increased atherosclerosis, probably because of a compensatory increase in macrophage COX-2 production. Consistent with this notion, transplant of bone marrow or fetal
liver cells deficient for COX-2 mostly decreased atherosclerosis.
While COX-2 production of PGI2 and subsequent signaling

is associated with prolonged laminar flow, it is presented
here for continuity. Signaling through IP generally opposes
TP effects and is protective. Nevertheless, the increase in
atherosclerosis after IP KO in ApoE- or LDLR-deficient
mice was relatively modest (36%) (see TABLE 3) (462,
925). In LDLR-deficient mice, most of the atherogenic effect of IP KO was reported to be restricted to females (462).
Elevation in cAMP by IP signaling increases PKA activity
which can inhibit Raf activation (as shown in FIGURE 3) and
likely has other anti-inflammatory effects. IP ligation also
opposes IFN- actions in monocytes by inhibiting activation of JAK2 and STAT1 (1690). Other anti-inflammatory
effects of IP are known. PGI2 induces the strongly protective
antioxidant enzyme HMOX1 in endothelial cells after 6 h
of laminar flow by way of autocrine signaling through IP.
HMOX1 also downregulates endothelial TNF- release
(421). PGI2 released from endothelial cells promotes a selfperpetuating, spreading paracrine wave in VSMC of increasing COX-2 expression and PGI2 release, mediated by
PKA, Akt, and ERK1/2 signaling (887). Estradiol, acting
through ER, upregulates endothelial COX-2, PGI2 synthesis, and subsequent IP signaling. In ovariectomized LDLRdeficient female mice, estradiol administration greatly decreased atherosclerosis while this effect was nearly abrogated by deletion of IP (462).
Recent results suggest DP1 has modest antihypertensive,
anti-platelet, and antiatherogenic effects (1654, 1688)
which may provide insights into the failed HPS-THRIVE
study, a major clinical trial testing the combination of
niacin with the DP1 inhibitor laropiprant. The F prosta-
1366
Arachidonic acid is metabolized by CYP2C and CYP2J subfamily enzymes to 5,6-EET or 11,12-EET and 8,9-EET or
14,15-EET, respectively. These EETs increase cAMP (like
PGI2), but have additional strong anti-inflammatory effects,
including NF-B inhibition. They promote endothelial proliferation as well. The relevant intracellular signaling pathways are poorly understood. Some of their anti-inflammatory effects appear to be due to competitive inhibition of the
TP receptor (121). Soluble epoxide hydrolase (sEH), encoded by Ephx2, converts EETs to much less active dihydro derivatives (410, 411). KO of sEH decreased injuryinduced neointima formation in the femoral artery but not
in the carotid artery of ApoE-deficient mice (1476). Inhibitors of sEH, some of which are undergoing clinical trials,
appear to inhibit atherosclerosis in ApoE KO mice, particularly in the setting of infused ANG II (which downregulates CYP2C and CYP2J and increases sEH expression)
(411, 1923).
Importantly, n-3 fatty acids substituting for arachidonate in
most prostanoid pathways yield less active chemotactic,
proinflammatory, or vasoconstrictive products (391). The
n-3 fatty acids also appear to play a particularly important
role in synthesis of recently recognized inflammation-resolving lipid mediators named lipoxins, resolvins, and maresins. These novel prostanoid pathways involve lipoxygenases, cytochrome P-450 enzymes, and acetylated COX-2.
Typically, one cell type synthesizes a precursor which is
acted on by a different cell type to yield the final product
(1593, 1666). Lipoxin A4 is derived from arachidonate,
resolvin E1 from the n-3 eicosapentaenoic acid (EPA), resolvins D1 and D2 from docosahexaenoic acid (DHA), and
maresins from DHA. These resolving lipids will be discussed further in section VIIC5.
Most animals, including all mammals, lack the ability to
convert n-9 or n-6 to n-3 fatty acids. Transgenic expression
in mice of the roundworm fat-1 gene from Caenorhabditis
elegans, capable of conversion of n-6 to n-3 fatty acids,
increased n-3 levels five- to eightfold in ApoE-deficient mice
and decreased atherosclerosis by nearly 50% (1893).
TP KO potently inhibited early atherosclerosis (by 74%)

(925) and direct pharmacological inhibition of TP decreased atherosclerosis more effectively than aspirin in
ApoE KO mice and rabbits (510, 614). More established
atherosclerotic lesions may be less affected by TP inhibition
(463). While TXA2 is the most active, other TP agonists
include several other prostaglandins, PGH2, nonenzymatically generated 8-isoprostanes (whose production is increased in the presence of ROS), and HETE (510). Thus
aspirin cannot eliminate TP ligands altogether despite effective blockade of TXA2 synthesis.
noid receptor (FP) binds PGF2. FP was not detected in

aorta or atherosclerotic lesions, including macrophages.
Nevertheless, deletion of the receptor affected renal sodium/water handling with a reduction in renin granules
and mRNA in afferent arterioles and reduced renin release and plasma renin activity together with lowered
blood pressure. This may explain the modest reduction in
atherosclerosis seen with FP KO in LDLR-deficient mice
(2049). KO of the platelet PGE2 receptor EP3 greatly
decreased thrombosis after mechanical injury to plaques
in ApoE-deficient mice (661). In platelets, EP3 is coupled
to Gi and acts to reduce cAMP and therefore increases
platelet activation.
C. Endothelial Activation by Hemodynamic

Factors: Cytoskeleton-Associated Signaling
1. Structural components of endothelial
mechanotransduction
In addition to the GPCR and various channels discussed
above, transduction of shear stress is mediated by tension
transmitted from the glycocalyx on the luminal side through
the actin microfiber cytoskeleton, and possibly microtubules,
to the adherens junctions (formed largely by VE-cadherin)
between adjacent endothelial cells and to the focal adhesion
complex which includes integrins and syndecans which attach
the cell to the subendothelial extracellular matrix. Some aspects of this signaling are shown in FIGURE 8.
In addition to cytokines, the glycocalyx also provides sites

for binding the enzyme xanthine oxidoreductase (XOR).
XOR is present in two forms: xanthine dehydrogenase
(XDH) and xanthine oxidase (XO). Both XDH and XO
catalyze the oxidation of hypoxanthine to xanthine and
xanthine to uric acid by removal of two electrons at each
step. The prefered electron acceptor for XDH is NAD
(with conversion to NADH), while XO transfers electrons
primarily to O2 with resulting superoxide formation. XDH
is reversibly converted to XO by redox-sensitive formation
of an internal Cys535-Cys992 disulfide bond (and possibly
another internal disulfide bond), which alters the site where
NAD binds near the cofactor FAD and opens access for
Oscillatory (back and forth) sheer stress promotes conversion

of XDH to XO through activation of NADPH oxidase activity
as shown in FIGURE 8, whereupon XO becomes the major
source of superoxide (1177). Remarkably, both XO and compensatory antioxidant defenses are more abundant in large
veins than arteries (1724). XDH is generally thought to be the
more prevalent form intracellularly, as in hepatocytes, but increased intracellular oxidative stress also converts XDH to
XO (as seen in human ApoCIII overexpressing transgenic
mice which are hypertriglyceridemic and have greater liver fat
accumulation) (41). Intracellular XDH to XO conversion may
also be controlled by calcium and phosphorylation (1178,
1364).
XO activity promotes endothelial dysfunction which is
ameliorated by XOR inhibitors such as allopurinol (1364)
and more especially, febuxostat (1125). XOR knockout
studies are not feasible in mice as the pups are stunted and
live only 4 6 wk, presumably due to renal failure (1334).
Nevertheless, tungsten administration (a relatively specific
inhibitor of XOR) to ApoE-deficient mice fed a Western
type diet for 6 mo resulted in 83% reduction of aortic
atherosclerosis (1568). More recently, allopurinol was also
found to decrease atherosclerosis in ApoE null mice (by
45%) with further studies showing an important role for
XOR in promoting foam cell formation (964). Thus XOR
overexpression in macrophages increased lipoprotein and
scavenger receptors including VLDLR, SR-A1, SR-B1, and
SR-BII while decreasing expression of cholesterol transporters ABCA1 (ATP-binding cassette A1, the gene found
deficient in Tangier disease) and ABCG1. Effects essentially
opposite to these were seen with either XOR knockdown or
allopurinol. Furthermore, allopurinol inhibited expression
of IL-1, Il-6, Il-12, TNF-, VCAM-1, MCP-1, MMP2,
and MMP9 after activation by incubation of macrophages
with serum from Watanabe heritable hyperlipidemic rabbits (964). These findings suggest the participation of XOR
in multiple steps of atherogenesis and the opportunity for
further exploration of the use of inhibitors to prevent progression of atherosclerosis.
2. Endothelial mechanotransduction through the
adherens junction: sensitizing integrins from the
inside-out
Integrins are heterodimeric transmembrane proteins, at
least 30 in all, consisting of 1 of 15 types of chains and
1 of 7 types of chains (1). Integrins often aggregate in
1367
Native endothelial cells, which are themselves only 200 nm

thick, display a glycocalyx composed of stiff heparan sulfate
fibers extending typically 400 nm to as much as 4,000 nm into
the bloodstream from syndecan-1 (280, 1845). The glycocalyx
has important barrier functions and helps control adhesion of
leukocytes and platelets but also acts as an exquisite fluid flow
sensor. Extensive intracellular microfiber interconnections extend between the cytosolic domains of syndecan-1 to form the
actin cortical web (1784, 1936). Hyaluronan is secreted and
can associate with CD44 in caveolae but remains largely soluble, weaving in and out of the glycocalyx. Hyaluronan contributes to the fluid drag produced by the glycocalyx and helps
trap chemokines secreted by the endothelial cells (1472). Nevertheless, inhibition of hyaluronan synthesis was found to increase atherosclerosis (1273). Heparinase treatment selectively removes heparan sulfate but not the syndecan-1 core
protein and impairs NO release and many other signaling
steps in response to shear stress; COX-2 and PGI2 responses
are not affected, given their independent transduction reviewed above (281, 1369). The length of the glycocalyx inversely reflects the activation state of the endothelial cell, and
its expression is impaired in typical static cell cultures (280).
Indirectly measured glycocalyx length in humans was reduced
by hypercholesterolemia and lengthened in response to cholesterol reduction with statins (1202). Knockout of syndecan-1
resulted in increased atherosclerosis in ApoE-deficient mice
(699).
molecular oxygen to the same site (1311). Thus a positive

feedback or feed-forward pathway exists whereby superoxide, peroxynitrite, and other oxidizing electrophiles (1178)
can promote still greater superoxide production by converting XDH to XO. Also, XO has greater affinity for glycoproteins than XDH. Thus an oxidizing microenvironment
should promote increased glycoprotein-bound XO at the
surface of endothelial cells.
PAUL N. HOPKINS
Xanthine
Urate
XDH
Onset of flow
XO
Heparan
sulfate
fibers
Hyaluronan
O2

HSP60
Tight junction:
Occludins
Claudins
JAMs
Syndecan-1
Actin
cortical web
ZO1
Linkers
Linkers
SMADs
O2
ZO1
BMP4
Myosin
Actin
stress
fibers
Src
PKC
MLCK
Dense
peripheral
actin bands
JNK, p38,
MKK,
ASK1
PPI
MYPT1
ROS
Cx43
VE-cadherin
NF-B
ERK1/2
MEK1/2
Raf1
Adherens
junction
MAP4K4 Nck1
Rac1
PAK Rac1
Cdc42 PIX Git
RhoGDI
Dbl
Ack1
FAK
Rho
PIP2
Src
Rho
FAK
Talin
Shc
Paxillin
PI3K
PLC
Src
21
Syndecan-4
Collagen
PI3K
PECAM-1
p130CAS
FAK
Paxillin
PKC
Ras
Crk Grb2 Sos
Fibronectin,
fibrinogen, osteopontin
Grb2
Shc
Talin
NF-B
Talin
PKA
Raf1
VEGFR2
Dock180
ROCK2
Src
Shc
Src
Integrins
41, 51, V3
FIGURE 8. Mechanotransduction of shear stress: type II stimulation of proinflammatory pathways at onset of

flow or with oscillating (back and forth) disturbed flow. Note that not all proteins can be shown nor their actual
physical arrangement depicted for the focal adhesion, particularly for membrane-associated complexes. The term
linkers refers to the proteins of the focal adhesion which attach to the cytoskeleton. Linkers can include talin,
vinculin, tensin, actinins, and filamin, zyxin, and VASP. Filamin may be inhibitory. Besides the talin-paxillin-FAK complex
shown, talin-paxillin also binds PAK (p21 activated kinase) and PIX (PAK-interacting exchange factor), as well as Grb2,
p130CAS, Abl (Ableson protooncogene), and p120GAP (p120 Ras GTPase-activating protein). Rac1 and Cdc42 are
activated primarily on the downstream side of the cell. GTP-bound Cdc42 activates Ack (activated Cdc42-associated
kinase 1) which can phosphorylate p130CAS (among other targets) as can Src. Ack1 also activates the Rho-GEF Dbl
which promotes GTP exchange on Rho. Xanthine dehydrogenase (XDH) and xanthine oxidase (XO) are derived from the
same gene, xanthine oxidoreductase (XOR). Interconversion of XDH and XO as shown (upon exposure to ROS) is by way
of cysteine-cysteine disulfide bond formation which alters the preferred electron acceptor from NAD to O2 with resulting
increased production of superoxide in the setting of increased oxidative stress.
large arrays called focal adhesions which can also contain syndecans (particularly syndecan 4). Integrins are
unique in their ability to make switchable (on/off) links
with extracellular proteins (that is, the binding affinity of
1368
their extracellular domains can be controlled by signaling

from within the cell, so-called inside-out signaling)
while also being capable of transmitting signals resulting
from extracellular ligand binding to the cell interior
NIK

(outside-in signaling). The versatility of integrin signaling and control is perhaps best illustrated by white cell
diapedesis. Chemokines first turn on the integrins by
inside-out signaling (think of 2 folded arms moving to an
outstretched position exposing grasping hands). Then,
turned on integrins further activate the cell (outside-in
signaling) as they alternatively clasp and release specific
extracellular proteins. During this process, integrins and
chemokines mediate intracellular signaling that guides
the cell toward a chemotactic signal. As integrins have no
intrinsic enzymatic activity, these feats are achieved by
binding an array of adapter proteins to the relatively
short intracellular tails of the integrin and subunits.
Endothelial integrins are key to flow-mediated signaling.
In white cells and platelets, inside-out signaling proceeds

when chemokines bind their cognate GPCR or thrombin
cleaves and thereby activates its receptor. These receptors
then activate PI3K and PLC followed by IP3 and DAG production, calcium release, and PKC activation. Calcium and
DAG (possibly assisted by PKC) activate a CalDAG which
acts as a GEF for Ras-related protein 1 (Rap1). Acting
through the adapter RIAM (Rap1-interactiing adapter molecule), Rap1 then activates talin by relieving autoinhibition
(66). The role of this pathway in endothelial integrin activation with flow remains uncertain, but may occur through
a different Rap1 adapter (261). Another major pathway for
talin activation is through generation of the membrane
phospholipid PIP2 or PIP3 which can also relieve talin autoinhibition.
A model of flow-induced endothelial integrin activation is
presented in FIGURES 8 AND 9. Abrupt onset of flow results
in torsional forces transmitted through the cytoskeleton to
mechanoreceptors in adherens junctions and to integrins
and syndecans at the base of the cell (388, 1784). Laminar
flow drags the luminal surface of the endothelial cells, caus-
Traction on PECAM-1 causes release of Gq/11 from the

bradykinin receptor B2 within milliseconds. While described as an apical receptor in the prior section, an important portion, or perhaps most of the Gq/11 activation by flow
occurs because of a physical association between the extracellular domains of PECAM-1 and the bradykinin B2 receptor (1358, 2033). In areas of disturbed flow, Gq/11 is generally found apart from the PECAM-1 complex, whereas in
areas of rapid laminar flow it is found near PECAM-1.
PECAM-1 KO decreased atherosclerosis substantially, but
primarily in areas of disturbed flow (see TABLE 3). Indeed,
the arteries of PECAM-1 KO mice lacked inflammatory
markers in areas of disturbed flow (1828), and their endothelial cells showed no nuclear translocation or transactivation of NF-B nor elaboration of adhesion molecules in
response to disturbed flow (300). Interestingly, endothelial
PECAM-1 deficiency results in increased atherosclerosis in
areas normally protected from atherosclerosis by laminar
flow (725). As discussed below, this may be due to the dual
role for PECAM-1 in sensing flow generally with inflammatory signaling predominating at onset of flow or with flow
reversal but anti-inflammatory signaling taking hold after
persistent laminar flow. Furthermore, PECAM-1 on leukocytes was atherogenic for all areas of the vasculature, probably due to the role of PECAM-1 in facilitating homophilic
interactions between endothelial cell and leukocytes during
migration (725).
Bradykinin B2 receptor stimulation could theoretically activate IKK2 and NF-B through the CBM pathway discussed in section IIIB5. However, a quantitatively more
important pathway seems to involve inside-out integrin signaling, apparently through activation of PI3K. Besides
generation of PIP3, PI3K enzymes can also act on PIP to
generate PIP2 directly or after phosphatase action on PIP3
(1141, 1274). Identification of the PI3K isoform as the
main source of flow-mediated PIP3 synthesis (625) clearly
implicates a GPCR as the upstream signal, since other PI3K
isoforms (that is type 1A isoforms, with type II and III forms
less common or not relevant) are activated when their regulatory subunits bind phosphotyrosine residues. Activation
of PI3K would presumably result in PIP2 formation as well
as PIP3, activation of talin and binding to the cytoplasmic
domain of integrins, completing inside-out integrin activation. Interestingly, blocking PI3K activity abrogated
1369
In endothelial cells exposed to disturbed flow, the most

proinflammatory signaling appears to emanate from integrins, including activation of JNK and NF-B. But for this to
occur, inside-out signaling must first activate integrins to
their high-affinity state. Only activated integrins recognize
and respond to protein ligands in the extracellular matrix
(ECM). The adapter talin is considered to be the major
mediator of integrin inside-out signaling. Binding of talin to
the integrin cytoplasmic tail disrupts electrostatic binding
between integrin and cytoplasmic domains, thereby
altering the external configuration (1605). Some prior reviews proposed the adapter vinculin as a mediator of insideout signaling. However, vinculin does not bind integrins
directly but instead binds activated talin. Both talin and
vinculin bind actin microfibers, with mechanical tension on
talin exposing more vinculin binding sites, increased talin
integrin binding, and stabilization of the focal adhesion
(653, 1389).
ing a measurable leaning of cells in the direction of laminar

flow. This tilt is not seen in areas of disturbed flow. Onset of
flow abruptly changes the angle between cells, transmitting
tension to the proteins that form the adherens junction
(1188). Signals are then generated which require platelet
and endothelial cell adhesion molecule 1 (PECAM-1), VEcadherin, and vascular endothelial growth factor receptor 2
(VEGFR2, also called Flk-1) (1064, 1828). PECAM-1 appears to act as the true mechanical transducer and generates
an array of signals.
PAUL N. HOPKINS
flow-induced JNK activation, but not ERK activation, demonstrating at least two separate MAPK activation pathways
emanating from PECAM-1, consistent with the model in
FIGURES 8 AND 9.
Activation of tyrosine kinases through PECAM-1 mediates
the activation of ERK with onset of flow. The mechanism is
instructive and is relevant for subsequent flow-mediated
signaling. Tyrosine phosphorylation of the integrin cytoplasmic tail is also presumably required for talin binding
and regulates competitive binding of inhibitors (66, 67), but
the connection between PECAM-1 activation and integrin
tyrosine phosphorylation is unclear.
As noted above, mechanical traction on PECAM-1 causes

direct activation of the Src family kinase, Fyn found complexed with PECAM-1. Active Fyn phosphorylates a tyrosine in the PECAM-1 immunoreceptor tyrosine-based inhibitory motif (ITIM) domain, recruiting SHP2. The phosphatase activity of SHP2 on PECAM-1 leads to further
downstream ERK activation (313, 1737), possibly by dephosphorylation and inhibition of Tie2 signaling (86, 565).
Additional aspects of VEGFR2 signaling are relevant. A
particular VEGFR2 phosphotyrosine (Tyr1173 on mouse)
can recruit either PI3K or PI3K (class IA isoforms) or
may serve as a docking site for PLC with release of DAG
and IP3 followed by highly inflammatory PKC signaling.
Interestingly, VEGFR2 phosphorylated on Tyr1173 can
also transmigrate to the nucleus and induce its own transcription (1057). The E3 ubiquitin ligase Cbl (Casitas B-cell
1370
In addition to VEGFR2 and VE-cadherin, Shc also binds

tyrosine phosphorylated integrin tails. Indeed, Shc activation seems to be a focal point of endothelial activation by
disturbed flow (1720). Although p52Shc binds integrins
as soon as integrins are activated, Shc does not cause insideout signaling (66). The PTB domain of Shc primarily binds
integrin 3 phosphotyrosine 759 while the critical binding
site for integrin activation by talin is phosphorylated Tyr
747 (66, 414).
3. VEGFR2 signaling also controls endothelial
permeability
VE-cadherin homophilic interactions between endothelial
cells largely control permeability of the endothelial layer.
Disruption of the interdigitating VE-cadherin interactions
allows both blood fluids and leukocytes to pass between
endothelial cells, inciting inflammation and its four cardinal
features: calor (heat), dolor (pain), rubor (redness), and
tumor (swelling). Reduced levels of VE-cadherin at cell-cell
junctions and increased endothelial permeability are seen in
areas of disturbed flow and can be induced by back and
forth, reciprocating flow in endothelial monolayers (1205).
Besides the signaling reviewed above, VEGF binding to
VEGFR2, as well as other inflammatory signals trigger Src
and Src family kinases to tyrosine phosphorylate VE-cadherin, leading to disruption of catenin binding, activation of
the Arf-GEF ARNO (Arf nucleoside binding site opener,
also known as cytohesin 2), and activation of Arf6 (ADP
ribosylation factor 6, a small G protein) which controls
endocytosis of VE-cadherin and disruption of the adherens
junction (see FIGURE 9). These junction disrupting activities
are counteracted by signaling from the Robo4 receptor
which binds extracellular Slit2 protein (863, 1068). Src activity alone is insufficient to disrupt the adherens junction
(10). Catenins include -catenin which binds F-actin, tying
the adherens junction to the cytoskeleton, -catenin which
together with -catenin (junction plakoglobin) binds
-catenin, and -catenin (p120) which stabilizes VE-cadherin at the adherens junction (453). Free -catenin, released by dissolution of the adherens junction, can translocate to the nucleus where it functions as a transcription
co-activator in Wnt signaling (discussed below), supporting
endothelial proliferation and migration in response to
VEGF angiogenesis signaling. In tight junctions, active
PKC, generated from VEGFR2 signaling, phosphorylates
occludin, disrupting its binding with ZO-1 and promoting
occludin ubiquitination and endocytic removal from the
cell-cell junction (1253). ZO-1 redistributes away from the
Onset of flow causes PECAM-1 to activate the intrinsic

tyrosine kinase activity of the VEGFR2 cytoplasmic domain
without VEGF binding. Association of the Src family tyrosine kinase, Fyn (Fgr/Yes related novel protein) with PECAM-1 is required for this mechanotransduction (313), but
further details are apparently unknown. In resting cells,
both the tyrosine kinase COOH-terminal Src kinase (Csk)
and inactive Src are bound in close proximity by phosphotyrosines on VE-cadherin. Csk maintains Src inactive by
phosphorylating Src Tyr530 (in humans), causing Src to
fold upon itself, masking its own catalytic site. (Thus Csk is
a rather exceptional example of an inhibitory tyrosine kinase.) Activated VEGFR2 phosphorylates a specific tyrosine on VE-cadherin allowing recruitment of SHP2 (Src
homology 2 domain-containing phosphatase 2) to VE-cadherin. SHP2 dephosphorylates the tyrosine which binds Csk
and possibly also Src Tyr530. With the inhibitory activity of
Csk relieved, Src further self-activates (684). Active Src then
phosphorylates additional tyrosines on VEGFR2 and VEcadherin, providing binding sites for the adapter protein
Shc. Shc itself is also tyrosine phosphorylated by Src and
possibly by Fyn. Phosphorylated Shc (the p46 and p52 isoforms) can then recruit the Grb2-Sos complex followed by
Ras-Raf1-MEK1/2-ERK activation (1064, 1827, 1828).
lymphoma) binds at nearby pY1052 on VEGFR2 and

serves as an inflammation limiting factor by ubiquitinating
PLC and targeting it for degradation (1450, 1533). Additionally, the VEGFR2 receptor can form a complex with
integrins and its proximity may, in some way, facilitate
integrin activation (1720).
Endothelial cell
Endosomal removal
of VE-Cadherin
Arf6
ARNO
Src activation
SH4
ulin
SH3
Vin
c
Raf1
MEK2
ERK1/2
Csk
SHP2
SH4
Catenins

P
VE-cadherin
P
Shc
Src
Inhibitory filamin
binding
SH3
SH4
Kinase
SHP2
VEGFR2
Activated integrins
talin, kindlin bound
Shc
PLC
PI3K
SHP2
Pro
Targets
Csk
Sos Grb2
Ras
Kinase
Src
Yes
SH3
ADAM15
PECAM-1
Fyn
Targets
PKC
Actin
B2
cul
Vin
Filamin
Talin
Shc
Kindlin
Filamin
in
Targets
Talin
Kindlin
PIP2/3
PI3K
Integrins
V3 or 51
FIGURE 9. Detail of endothelial integrin inside-out activation (right) by signaling through VE-cadherin,
VEGFR2, and PECAM-1. Steps (13) in mechanotransduction are indicated by black circles with white numbers. Fyn (Fgr/Yes related novel protein) is a Src-family tyrosine kinase. For a more detailed structural model
of integrin-linker protein-actin interactions, see Legate KR and Fassler R. J Cell Sci 122: 187, 2009. Also
shown is a model for activation of Src (left). Note that Src is constitutively bound to membranes.
cell membrane with disturbed flow while occludin expression actually decreases (1796).
stimulate further examination of other proteins that control endothelial permeability.
Direct studies regarding effects on atherosclerosis of the

above endothelial permeability regulating proteins are
lacking. Recently however, ADAM15, another transmembrane protein that associates with VE-cadherin, was
identified as having proatherogenic signaling effects that
increased endothelial permeability (1705). ADAM15 expression is upregulated by cytokines and increased in
areas of atherosclerotic plaques. KO of ADAM15 resulted in a 61% reduction in aortic sinus atherosclerosis
area in ApoE-deficient mice. Surprisingly, the extracellular metalloproteinase or disintegrin domains did not mediate the atherogenic effects. Rather, the COOH-terminal cytoplasmic domain was found capable of activating
Src and and Yes (Yamaguchi Y73 virus, Esh avian sarcoma oncogene, a Src family tyrosine kinase) which mediate disruption of -catenin binding to VE-cadherin and
dissolution of the adherens junction. These results should
4. Sensitized integrins signal from the outside-in

through switchable scaffolds
Specific activated integrins recognize and bind different extracellular proteins and transmit various downstream signals back into the cell in outside-in signaling. When integrins bind their cognate ECM molecules, they aggregate
(in phases) into large arrays called focal adhesions with
numerous signaling and linker proteins (598). A very much
simplified depiction is given in FIGURE 8 showing just one
aspect of integrin signaling. In a recent review, focal adhesion proteins numbered at least 180 with 742 reported interactions (2055). The cytoplasmic tails of integrins directly
bind at least 12 adapters (only 2 are shown in FIGURE 8)
with layers of adapters, GEFs, GAPs, G proteins, tyrosine
kinases, serine-threonine kinases, and assorted phosphatases binding thereafter. Some members of this adhesome
act as signaling molecules while also dynamically linking
1371
PAUL N. HOPKINS
the focal adhesion to actin microfibers, intermediate filaments, and microtubules.
An important theme illustrated by integrin signaling is the
action of tyrosine kinases creating switchable scaffolds
(1389). Scaffolds or adapter proteins recruited into these
pathways are reversibly tyrosine phosphorylated, allowing
subsequent signaling molecules to attach and generate
downstream signals. Not shown in FIGURE 8 are the various
inhibitors and scaffold phosphatases which turn off focal
adhesion signaling.
The pathway for PAK activation may be outlined as follows. High-affinity binding of activated 51 or V3
integrins to fibronectin or vitronectin promotes binding
of paxillin to the integrin cytoplasmic tail and FAK to
talin and paxillin. FAK then self-phosphorylates, provid-
1372
For maximum sensitivity to stretch stimulation, tensioning

of actin stress fibers is required through RhoA-mediated
tonic activation of myosin (552). The tyrosine kinase Ack
(activated Cdc42-associated kinase) appears to have a role
similar to FAK but is activated by Cdc42 and can activate
RhoA through the RhoGEF Dbl (578, 1825).
Phosphorylated p130CAS recruits Crk (chicken tumor virus regulator kinase, erroneously named since it is actually
an adapter with no kinase activity) which is also phosphorylated by Src. Phosphotyrosines on p130CAS and particularly Crk provide docking sites for numerous additional
effectors and adapters. Among these are the DOCK180ELMO1 complex (with DOCK180 acting as a GEF for
Rac1 and ELMO1 inhibiting ubiquitination and degradation), Grb2-Sos, and Git (G protein-coupled receptor kinase-interacting protein). Git binds PAK-interacting exchange factor (PIX) and inactive PAK (1389). PAK ultimately self-activates after it is released by PIX. First,
however, PIX mediates GTP exchange with Cdc42, then
Cdc42-dependent release of PAK, followed by activation of
Rac1. Thus PIX serves as a sequential GEF for both Cdc42
and Rac1 (1767). PIX and Rac1 also mediate generation
of oxidative stress in response to arterial stretch from high
blood pressure (1868). Once active, PAK can serve as a
MAP4K for the JNK pathway and enhances NF-B signaling by directly promoting activity of NIK while enhancing
the sensitivity of NIK to ROS (1353).
FAK is a remarkable signaling modulator, particularly in
migrating cells. Its release from the focal adhesion leads to
transactivation of the p65 subunit of NF-B in the nucleus
(1414). FAK also seems to control several aspect of cell
polarity. Rac1 and Cdc42 promote protrusion of the cell
membrane by stimulating actin polymerization at the leading edge of migrating cells. These G proteins are also activated on the downstream side of endothelial cells at onset of
flow. In contrast, RhoA causes contraction of the uropod at
the trailing edge through stimulation of ROCK1 and
ROCK2. Changes in paxillin phosphorylation over time
may promote a transition of FAK conformation and binding affinities such that, in newly formed adhesions at the
leading edge, FAK initially inhibits RhoA by activating
RhoGAPs while activating Rac1 and Cdc42 as above. As
the cell moves forward over the stationary focal adhesion,
FAK switches to a RhoA activator by binding RhoGEFs,
thereby promoting uropod retraction (399, 1800).
The particular makeup of the ECM to which endothelial

cells are attached has a dramatic effect on subsequent integrin signaling. Integrins 51 and V3 generate proinflammatory outside-in signaling when bound to fibronectin, vitronectin, or fibrinogen. Without these proteins in the
ECM, integrin activation does not lead to inflammatory
signaling (692, 1352). Normal ECM consists primarily of
collagen IV and laminin. When endothelial cells were plated
on collagen, the collagen-binding integrin 21 was activated by onset of flow and led to increased production of
PKA which was found, through inhibition of PAK, to be a
major inhibitor of proinflammatory 51 and V3 signaling (568). This contrasts with platelet activation mediated
by collagen binding to integrin IIb3. Deletion of the 2
integrin subunit did not affect atherosclerosis in ApoE KO
mice (658), possibly due to overwhelming signaling
through 51 and V3 integrins as fibronectin accumulated in atherosclerosis-prone areas with age. Conversely,
stimulation of the 51 and V3 integrins by onset of flow
over endothelial cells grown on fibronectin resulted in activation of PKC, NF-B, p38, and JNK which inhibited the
anti-inflammatory signaling from integrin 21 (568, 692,
1352, 1353, 1878). Resulting JNK expression primes endothelial cells for apoptosis in atherosclerosis-prone areas
(285). Importantly, these inflammatory signals are largely
mediated by G proteins Rac1 and Cdc42 and the tyrosine
kinase PAK (1353). Also, PAK can tyrosine phosphorylate
VE-cadherin and thereby increase endothelial permeability.
In response to disturbed flow, JNK1 was recently shown to
upregulate transcription of RelA through the action of the
transcription factor ATF2, thus priming subsequent NF-B
activation and showing important cross-talk between these
inflammatory pathways. Both slow flow as well as slow
combined with oscillatory flow led to increased RelA expression, but slow/oscillatory flow markedly increased nuclear localization of RelA together with nearly threefold
greater expression of VCAM-1. High shear flow completely
suppressed VCAM-1 expression (361).
ing docking sites for proteins with SH2 and PTB domains
including Src, PI3K, PLC, Grb2, and p130CAS. Src and
FAK further phosphorylate each other. Shear stress subtly stretches p130CAS and progressively exposes additional phosphorylation sites for Src (1544). Extensive
p130CAS tyrosine phosphorylation is measurable within
300 ms (1265).

Syndecan-4 acts synergistically with integrins in focal adhesions as a strain- or flow-sensing molecule (123, 1235).
Syndecan-4 attaches to fibronectin extracellularly while the
cytoplasmic tail binds and is phosphorylated by Src and
also binds paxillin and FAK. PKC is recruited to syndecan-4 and is activated by a unique mechanism through PIP2
rather than by DAG and calcium. Active PKC can then
phosphorylate and thereby inhibit a G-nucleotide dissociation inhibitor (GDI) for RhoA, allowing RhoA activation
(442).
5. Fibronectin synthesis and other alterations of the

ECM in areas of disturbed flow
The alteration of the ECM, with an increase in fibronectin,
occurs early in atherosclerosis prone areas in both wild-type
and ApoE-null mice as part of the cellular response to disrupted flow while deposition of fibrinogen seems to occur
later. Increased ECM fibronectin and fibrinogen is found in
human atherosclerotic lesions as well (693). Endothelial
fibronectin production is controlled, at least in part, by Wnt
signaling. Proliferation, migration, and survival of VSMC
and other cells also can depend on Wnt signaling.
In canonical Wnt signaling, extracellular Wnt proteins (19
isoforms) bind to 1 of 11 mammalian Frizzled receptors
with LDL receptor-like protein 5 (LRP5) or LRP6 acting as
a coreceptor. In the absence of Wnt signaling, the intracellular -catenin destruction complex actively phosphorylates free -catenin, targeting it for proteosomal destruction, thus keeping free intracellular -catenin levels very
low. The -catenin destruction complex is composed of
scaffold proteins axin and adenomatous polyposis coli
(APC), together with GSK-3 and CK1 casein kinase 1
(CK1, which primes GSK-3) and PP2A. Note that
-catenin bound to the adherens junction apparatus is not
targeted by the destruction complex. With a Wnt protein
binding to Frizzled and LRP5/6, the intracellular domain of
Frizzled binds Dishevelled which inhibits the phosphorylat-
Disturbed flow promoted fibronectin production through

increased -catenin signaling in human umbilical vein endothelial cells (600). Fibroblasts also produce fibronectin in
response to Wnt signaling (650). ECM fibronectin is found
to be increased after injury and inflammation and may facilitate subsequent inflammatory responses in such areas.
Fibronectin knockout markedly decreased atherosclerosis
(see TABLE 3). NF-B and JNK induce endothelial fibronectin secretion through NF-B and AP-1 binding elements in
the promoter (505), suggesting multiple means for positive
feedback as the artery ages or after various insults.
In areas of slow flow, there is proliferation of VSMC and
inward remodeling. This appears to be mediated, at least in
part, by HB-EGF signaling (see FIGURE 2) with activation of
NADPH oxidase, NF-B, and Erk1/2 (2072). Rather similar signaling and promotion of vascular VSMC migration
result from ANG II signaling with transactivation of the
EGFR receptor (465, 1187, 1245). While such signaling
was thought particularly relevant to posttransplant arteriopathy, intimal VSMC could conceivably produce fibronectin that contributes to proinflammatory responses
for endothelial cells and migrating white cells generally.
Inflammatory cytokines such as IL-1 can also stimulate vascular VSMC to produce fibronectin (334).
A surprising source of fibronectin is the liver with deposition from plasma into atherosclerosis-prone areas of the
arterial tree. Liver-specific deficiency of fibronectin substantially reduced atherosclerosis by 50%, but also suppressed proliferation of VSMC and prevented formation of
fibrous caps (1499).
6. Bone morphogenic protein signaling associated
with disturbed flow
The more than 20 bone morphogenic protein (BMP) cytokines are members of the TGF superfamily and use SMADs
for intracellular signaling. Initially, BMPs were shown capable of inducing ectopic bone formation, but further stud-
1373
In FIGURE 8, activation of PKC by ROS is shown. Specifically, disturbed flow was found to increase peroxynitrite,
which then promotes activation of PKC (by several possible direct or indirect means). Activated PKC can, in turn,
bind to and activate the SUMO ligase PIAS4 (protein inhibitor of activated STAT4), thereby promoting sumoylation
of nuclear p53, with translocation of sumoylated p53 to the
cytoplasm where it binds Bcl-2 and Bcl-xL and promotes
apoptosis (750, 1738). The sumoylation state of p53 may
thus determine whether the net effects of p53 accumulation
are cytoprotective or apoptotic. PIAS4 also promotes sumoylation of NEMO with subsequent greater activation of
NF-B (1103). Disturbed flow also promotes sumoylation
and inhibition of ERK5, impairing its protective effects
(749). The SUMO deconjugating enzyme SENP2 acts on
p53 and ERK5 and has protective effect on atherosclerosis
(749).
ing activity of the -catenin destruction complex while

LRP5/6 binds axin, leading to axin degradation. The phosphorylation of -catenin is thereby stopped while PP2A is
freed to dephosphorylate -catenin. The result is an increase in cytoplasmic and nuclear free -catenin. Nuclear
-catenin displaces the corepressor TLE1 (transducin-like
enhancer of split, or Groucho in Drosophila) from T-cell
factor (TCF) and recruits XIAP to ubiquitinate TLE1 and
target it for degradation (712). TCF and -catenin can then
promote transcription of multiple genes such as cyclin D1,
myc, survivin, and IGF-I which facilitate proliferation, migration, and survival. Besides canonical Wnt signaling, noncanonical pathways can include G protein activation (much
as a GPCR), and signaling through other coreceptors. Production of fibronectin and other ECM proteins by VSMC is
also controlled by Wnt signaling (1208).
PAUL N. HOPKINS
BMP4 expression and release is greatly upregulated by oscillatory, disturbed flow, whereas BMP2 is not. As such,
BMP4 may be an important means of maintaining oxidative
stress and inflammatory activation of endothelium at atherosclerosis-prone sites. In contrast, BMP2 is produced in
response to inflammation (such as in response to TNF-) or
high pressure (278). Both BMP2 and BMP4 were induced by
JNK1 in mice at atheroprone sites (285). Also, incubation of
human aortic endothelial cells in high glucose increased expression of both BMP4 and BMP2; their type I receptors
ALK1, ALK2, ALK3, and ALK6; the type II BMP receptor
BMPRII; and at least two extracellular inhibitors of BMP
receptor binding, Noggin and MGP. Similar effects were
seen in aortic endothelium of diabetic mice or rats accompanied by vascular calcification (185). BMP2 was also upregulated in endothelial cells incubated with oxLDL (413).
Interestingly, prolonged laminar shear leads to SMAD6 and
-7 phosphorylation which leads to greater SMAD6/7 inhibition of signaling by SMAD1, -5, and -8, thereby blocking
the effects of BMP4 and BMP2 (855). In contrast, disturbed
flow upregulates endothelial production of BMP ligand
traps listed above (though not proportionately as much as
BMP4), possibly as means to partly mitigate the effects of
increased BMP4 production (278).
1374
Recent manipulations of BMP signaling suggest a potentially promising means of mitigating atherosclerosis. MGP
overexpression modestly decreased atherosclerosis (2029).
Yet, surprisingly, MGP deficiency almost entirely blocked
endothelial production of ICAM-1, VCAM-1, and E-selectin and almost entirely abrogated atherosclerosis (2029).
These results suggest MGP may be acting in some role beyond a mere BMP ligand trap. In contrast, BMPER hemizygous deficiency clearly increased atherosclerosis (1416).
Specific inhibition of BMP type I receptors (such as ALK2)
using a small molecule (LDN-193189) reduced atherosclerosis 43% in LDLR-deficient mice with a similar reduction
by use of recombinant ALK3-Fc which bound and inhibited
BMP2 and BMP4 (413). Both interventions were well tolerated by these mice, and clinical trials may be warranted
after further testing. Interestingly, VSMC-specific transgenic overproduction of BMP2 in ApoE-deficient mice did
not increase atherosclerosis but greatly increased intimal
calcification of arteries, demonstrating separability between
atherogenic and calcific effects of BMPs (1276).
7. ER stress in endothelial cells
ER stress, also called the unfolded protein response, occurs in
cells with increased or excessive protein synthesis demands
and is aggravated by increased ROS. In general, ER stress is
triggered by a relative deficiency of ER chaperones which direct normal folding of newly synthesized proteins within the
ER. In times of lower demand, plentiful chaperones occupy
binding sites of several ER membrane-bound receptors. These
receptors transmit stress signals when not occupied as in times
of increased utilization of chaperones. These signals can help
compensate for the demands of increased protein synthesis or,
if extreme, they can promote apoptosis. ER stress is discussed
in more detail in section XC3.
Endothelial ER stress was found in areas of disturbed flow
in both swine (329) and mice (506). BiP (immunoglobulin
heavy chain-binding protein, also known as GRP78), the
best studied ER chaperone and mediator of ER stress, could
be induced by exposing cultured endothelial cells to disturbed flow with upregulation dependent on MAPK p38
and integrin 21 signaling (506). BiP upregulation is generally a protective, compensatory response to ER stress.
X-box binding protein 1 (XBP1), another key regulator of
the ER stress response, was also found to be upregulated in
atherosclerosis-prone branch points in mice. Prolonged
XBP1 signaling promoted apoptosis which was counterbalanced by overexpression of VE-cadherin (2060).
AMP-activated protein kinase (AMPK) is the master energy
sensor and regulator of the cell. It is activated by an increase
in the ratio of AMP/ATP as well as by hypoxia, ROS, peroxynitrite, hyperosmolarity, and certain drugs including
metformin and thiazolidinediones. Activation of AMPK
has numerous effects with multiple protein targets, but
among these is suppresion of ER stress, possibly by decreas-
ies showed more extensive effects in regulation of development, cell proliferation, differentiation, and apoptosis in
various cell types. BMPs are involved in promotion of angiogenesis and can promote osteoblast-like differentiation
in dedifferentiated VSMC and other cells. BMP2 and BMP4
have been most extensively studied for their vascular effects.
Extracellular BMP2/4 binds dimers of type II receptors, such
as BMPRII, and instigates juxtaposition of type I receptor
dimers such as activin receptor-like 1 (ALK2) followed by
serine/threonine phosphorylation by the constitutively active
type II receptor of the cytoplasmic tails of ALK2. Activated
ALK2 then serine phosphorylates SMAD1, -5, and -8, which
form active transcription factors after dimerizing with
SMAD4. BMP signaling is also characterized by the existence
of a series of ligand traps or extracellular endogenous inhibitors which sequester BMPs and block interaction with the
cognate receptors. These inhibitors have varying affinity for
the different BMP proteins and include Noggin, follistatin,
chordin, BMP endothelial cell precursor-derived regulator
(BMPER, called cross-veinless 2 in Drosophila), Cerberus,
gremlin, twisted gastrulation homolog 1 (TWSG1), and matrix Gla protein (MGP). Further controls are imposed by intracellular E3 ubiquitin ligases, SMAD ubiquitination regulatory factors (SMURFs), and phosphorylation by MAPKs.
BMP signaling in endothelial cells clearly induces NOX1 (not
NOX2) and promotes proinflammatory changes including expression of adhesion molecules, primarily attributable to the
induction of ROS production (310, 855). BMP4 signaling can
also induce HMOX1, thus providing some antioxidant balance (278).

ing mitochondrial ROS, suppressing NOX, and activation
of eNOS (435, 2084). Depletion or deletion of AMPK led to
oxidative modification (at Cys674) and suppression of
SERCA2 activity resulting in depletion of ER calcium, increased intracellular calcium, increased ER stress, and accelerated atherosclerosis in LDLR KO mice (435). This increased atherosclerosis could be attenuated by giving a
small molecule chaperone, tauroursodeoxycholic acid, that
inhibited ER stress.
ApoE-deficient mice given an inhibitor (which blocked the

ATP binding site) of HSP90, possibly due to a decrease in
inflammatory client proteins (including STAT3 and IKK) together with a compensatory increase in HSP70 (1109).
8. Overall effect of slow or disturbed flow on
endothelial activation
Another consequence of ER stress is activation of heat shock

proteins (HSPs) (771). HSPs act generally as protein chaperones to promote proper folding and other functions involving
the active modification of protein configuration. Some HSPs
act in the ER to promote protein folding for proper maturation
of nascent proteins. Others may act in the cytosol or elsewhere. For example, consecutive, ATP-dependent modifications of steroid receptor configuration, first by HSP70, then by
HSP90, are necessary to prime these receptors before they
can bind the steroid hormone. HSP60 chaperones certain cytosolic proteins into the mitochondria. When cells are not
under stress, HSPs are bound to heat shock transcription factor 1 (HSF1) in the cytoplasm. When misfolded proteins are
present or the cell is stressed by a number of factors [including
ROS (2094), oxidized lipids, or cytokines] HSPs bind to the
misfolded protein (or are otherwise utilized in the cell), becoming separated from HSF1. HSF1 then forms a trimer, moves to
the nucleus, and stimulates transcription of HSPs. In the case
of HSP60, levels are clearly upregulated in endothelial cells in
atherosclerosis-prone areas of slow flow, with increased expression on the luminal surface. Cell surface HSP60 has been
proposed as a trigger for an autoimmune response which may
be important in promoting atherosclerosis (1957).
D. Transition to an AtherosclerosisResistant Endothelial Phenotype
HSPs are generally considered protective (1829). Indeed, an

increase in HSP90, with its ability to stimulate eNOS, is considered one of the pleiotropic beneficial effects of statins (557).
Unexpectedly however, atherosclerosis was decreased in
Prolonged exposure of endothelial cells to rapid laminar

flow results in a quiescent, atherosclerosis-resistant pheno-
100000
Integrin 3 mRNA
Integrin V mRNA
2048
350
p65 mRNA
10000
1000
Percent of baseline
Percent of baseline
Percent of baseline
1024
300
250
200
150
100
50
P-FAK
P-p38
P-MSK1
P-p65
10
Hours of Flow
15
20
256
128
64
32
IL8 low flow
IL8 high flow
GRO- low flow
GRO- high flow
16
8
4
2
1
100
512
Hours of Flow
10
12
14
16
18
Hours of Flow
FIGURE 10. Measured changes in endothelial signaling molecule activation and cytokine production with
exposure to flow. A: marked changes as a result of slow flow in mRNA of integrins V and 3 (one of the integrin
partners that recognizes fibronectin) and mRNA for the p65 (RelA) subunit of NF-B in human vascular
endothelial cells (HUVEC). Increase in activated phospho-3 was also seen. Treatment with anti-3 antibody
partially blocked subsequent increase in cytokine production (not shown). B: changes in phosphorylated
(activated) signaling molecules seen after onset of slow flow in HUVEC. The initial change was in FAK (P-FAK
signifies active, phosphorylated FAK), followed by p38, then MSK1, and finally the p65 (RelA) subunit of NFB.
C: changes in mRNA of chemokines in HUVEC as a result of slow or high flow. [Data from Shaik et al. (1600).]
1375
The net effect of slow flow on endothelial signaling and activation was elegantly demonstrated by Shaik et al. (1600) (see
FIGURE 10). Slow flow was seen to rapidly activate first FAK,
then the terminal MAPK p38, then the downstream effector
MSK1, and finally phosphorylation of the p65 unit of NF-B
(FIGURE 10A). Levels of these activated, phosphorylated signaling molecules diminished over time, suggesting negative
feedback. At the same time, mRNA encoding the 3 integrin,
and especially the p65 unit of NF-B, were greatly increased.
The 245-fold increase in p65 mRNA was reflected only partially in the much lesser increases of active p65 or nuclear
NF-B. Nevertheless, the large pool of p65 mRNA illustrates
the heightened sensitivity of the pathway, poised for markedly
enhanced activation in areas of slow flow. A marked increase
in cytokine and chemokine production was also seen, both as
tracked by cellular mRNA and as cytokines and chemokines
released into the medium (see FIGURE 10C). Conversely, rapid
flow resulted in a virtually complete suppression of these same
cytokines and chemokines. Besides the changes in IL-8 and
GRO illustrated in FIGURE 10C, a whole host of cytokines
and chemokines were found to be similarly regulated, resulting in a net proinflammatory signal induced by slow flow and
an anti-inflammatory response to rapid flow (1600).
PAUL N. HOPKINS
type with frank unresponsiveness to even potent inflammatory cytokines such as TNF- (1390, 2012) or IFN-
(1812). The molecular mechanisms which mediate this
transition have been the subject of intensive investigation
(see FIGURE 11).
1. Endothelial quiescence through PKA and PKB
activities
Phosphorylation by PKA is one of the major negative controls on PAK, thereby suppressing NF-B activation (568).
PKA is activated when integrins containing 1 bind to collagen and other normal basement membrane proteins
(568). PKA inhibits BMP4 signaling and its subsequent activation of NOX1 (358). Upregulation of COX-2 by laminar flow with generation of PGI2 and autocrine signaling
through the IP receptor activates PKA by generating cAMP.
PKG, activated by cGMP (after NO activates soluble guanylate cyclase), can also phosphorylate PAK, disrupting PAK
association with Nck1 (noncatalytic region of tyrosine kinase adapter protein) and altering inflammatory signaling
through MAP4K4 and other pathways dependent on Nck1
(556).
Akt/PKB inhibits forkhead box protein O3a (FoxO3a),
FoxO1, as well as GSK-3 by serine/threonine phosphorylation as noted above under INSR signaling. Active GSK-3
phosphorylates cyclin D1, marking it for degradation and
causing cell cycle arrest with increased susceptibility to apoptosis. Both these effects were blocked when GSK-3 was
phosphorylated by PKB in response to VEGF2 signaling.
Furthermore, PKB blocked endothelial susceptibility to apoptosis as well as induction of IL-1 and TNF- in response
to IL-1 administration, demonstrating an anti-inflammatory, prosurvival effect (1057).
Endothelial PKB activity stimulated by VEGFR2 signaling
is protective in yet another way. HDAC3 can shuttle in and
out of the nucleus and serve as a scaffold for assembly of
1376
PKB phosphorylation also excludes HDAC7 from the nucleus. In the nucleus, HDAC7 blocks transcription of protective MEF2C (989). In the cytoplasm, phosphorylated
HDAC7 binds -catenin and prevents its translocation to
the nucleus (2100).
2. Endothelial quiescence through Tie2 signaling
Tie2 (tyrosine kinase with immunoglobulin and epidermal
growth factor homology domain 2) is a receptor tyrosine
kinase structurally similar to VEGFR2 (86). Tie2 signaling
between adjacent cells, stimulated by angiopoietin 1
(ANGPT1), strongly supports endothelial quiescence and
stability. Laminar shear stress promotes Tie2 phosphorylation and activation in direct proportion to the speed of flow
(991). VEGFR2 can further promote Tie2 activation by a
complex mechanism involving cleavage of Tie1 (1635).
Remarkably, in isolated endothelial cells, ANGPT1 binding
to Tie2 promotes activation and angiogenesis, whereas only
in confluent cells (with intact cell-cell junctions) does
ANGPT1 promote quiescence. The difference depends on
NOTCH signaling and, apparently, the juxtaposition of
vascular endothelial protein tyrosine phosphatase (VEPTP), both of which only occur at intact cell-cell junctions.
VE-PTP limits ERK1/2 activation by Tie2 signaling (1967).
Active Tie2 does bind Grb2-Sos which could activate the
ERK1/2 pathway (86). In confluent endothelial layers,
ANGPT1 ligates and bridges Tie2 receptors on adjacent
At the onset of flow, the adherens junction PECAM-1VEGFR2-VE-cadherin complex was introduced as the
proximate instigator of integrin inside-out signaling (with
resultant JNK and NF-B activation). With continued unidirectional flow, subsequent binding of Gab1 to the complex (through Grb2) may mark one of the earliest steps
toward the transition to quiescence. Gab1 directs assembly
and activation of a signaling complex that includes Src,
PI3K, SHP2, PLC, and Akt/PKB (854, 982). This complex
is also critical for protective ERK5 activation (see below)
(1627) and is inhibited by cigarette smoke which inactivates
VEGFR2 (460). Gab1 and subsequent SHP2 binding is critical for activation of PKA and activation of eNOS by flow
(428). While its signaling is complex (1968), the net effect
of Gab1 appeared protective as deletion of Gab1 led to a
significant increase in atherosclerosis in ANGII-stressed,
ApoE-deficient mice (765) (TABLE 1).
signaling complexes. With disturbed flow, expression of

HDAC3 is increased in both cytoplasm and particularly in
the nucleus (989). In contrast, laminar flow increases
HDAC3 primarily in cytoplasm, since PKB phosphorylates
HDAC3 thereby excluding it from the nucleus (2057). Nuclear HDAC3 can associate with nuclear factor erythroid
2-like related factor 2 (Nrf2), deacetylate Nrf2, and reduce
Nrf2 DNA binding, thereby suppressing the transcription
of antioxidant genes. During prolonged, rapid, unidirectional, pulsatile flow, deacetylation of Nrf2 by HDAC3
ceased with a marked reduction in HDAC3 expression generally, allowing full expression of antioxidant genes. Furthermore, activated PKB forms a complex with HDAC3
which promotes more prosurvival, anti-inflammatory signaling, such as repression of c-Jun and NF-B. In some way,
HDAC3 also increases the expression of the p85 subunit
of PI3K (39). HDAC3 is critical for enhancing differentiation of endothelial progenitor cells and promoting survival
of mature endothelial cells (39). Part of these effects are
apparently mediated by deacetylation of p53 to increase its
activity together with increased expression of the p53 target
p21Cip (2059). The net effect of HDAC3 on atherosclerosis
was tested by lentivirus knockdown of endothelial HDAC3
in aortic isografts transplanted to the carotid artery. There
was marked endothelial cell loss, greatly increased formation of atherosclerosis-like lesions, and, in some cases, vessel rupture (2057).

cells. The phosphorylated Tie2 cytoplasmic domain binds
and activates PI3K followed by PKB. Active PKB then inhibits GSK-3, decreasing the phosphorylation and degradation of -catenin. In endothelium, besides Wnt signaling,
-catenin can serve as a transcriptional coactivator to amplify NOTCH signaling by enhancing transcription of the
NOTCH ligand DLL4 (delta-like 4). Transcription of
Kruppel-like factor 2 (KLF2) and connexin 40 (Cx40) are
increased with powerful antiapoptotic and anti-inflammatory effects (565, 2073). However, NOTCH signaling is
remarkably diverse. In macrophages, NOTCH1 supports
proinflammatory activation (69). Pharmacological inhibition of NOTCH signaling decreased atherosclerosis in
ApoE-deficient mice apparently by decreased macrophage
activation and reduced accumulation in lesions (69), while
anti-DLL4 antibodies decreased atherosclerosis in LDLR
KO mice (562).
ANGPT1 is synthesized in VSMC and other perivascular

cells. In contrast, ANGPT2, which mainly acts as an inhibitor to ANGPT1, is synthesized in endothelial cells. Indeed,
without ANGPT2 release from Weibel-Pilade bodies, endothelial cells would possibly remain unresponsive to most
inflammatory signals. PKB is additionally anti-inflammatory by phosphorylating Fox01, excluding it from the nucleus and thereby blocking the induction of ANGPT2 by
FoxO1 (86). Nuclear FoxO1 also induces endothelial
ICAM-1 and TNF- expression in LDLR-deficient mice.
Surprisingly, however, adenoviral overexpression of
ANGPT2 in ApoE KO mice was atheroprotective, apparently through increased PKB and eNOS activity (20), while
overexpression of ANGPT1 increased atherosclerosis in
these mice, possibly by activation of leukocyte Tie2 (19).
The interpretation of these results is complicated by potential differences in outcomes when angiopoietins are induced
by adenoviral-induced overexpression versus more physiological levels. In humans, ANGPT2 correlated with other
markers of inflammation and rheumatoid arthritis patients
who subsequently developed cardiovascular disease had
higher ANGPT2 levels at onset of their arthritis, but causality cannot be demonstrated in this study either (1948).
The Tie1 receptor seems to generally inhibit Tie2 effects,
possibly through dimer formation with Tie2. Tie1 is upregulated in areas of disturbed flow (86). Endothelial-specific Tie1 deletion reduced atherosclerosis substantially in
areas of disturbed flow (see TABLE 3) (1978).
While excess or prolonged superoxide production promotes cellular damage and apoptosis (1345, 1686), controlled production of superoxide and other ROS is critical
for adequate induction of cellular antioxidant systems (FIGURE 11). Physiological ROS sources include NOX enzymes
and mitochondria as reviewed above. Mild oxidant stress
activates a host of antioxidant defense genes which share an
antioxidant responsive element (ARE) in their promoters.
The newer term electrophile response element (EpRE),
rather than ARE, reflects the importance of electrophilic
reactions in triggering this system (208). The transcription
factor Nrf2 is the major inducer of genes containing promoter ARE sequences. Importantly, nuclear Nrf2 accumulation is equally upregulated by laminar and slow oscillatory (back and forth) flow, but subsequent signaling appears to be impaired in cells exposed to oscillatory flow,
resulting in greatly diminished expression of ARE-containing genes.
Nrf2 is bound in cytoplasm by Keap1 (Kelch-like erythroidderived Cap-N-Collar-Homology-associated protein 1) in a
complex that includes a Keap1 dimer together with the E3
ligase Cullin 3 (528, 1722). This complex directs ubiquitination of Nrf2, targeting it for proteosomal degradation.
Covalent modification of key cysteines on Keap1 by reactive electrophilic compounds disrupts the Keap1 complex
with release of Nrf2. Relevant electrophiles include 4-HE
and other oxidized membrane lipids, 15d-PGJ2, nitrated
fatty acids, peroxynitrite, NO, and numerous naturally occuring substances such as cinnamaldehyde (see sect. IIIC1)
(208). Recall that all these electrophiles also promote mitochondrial ROS production. Laminar flow induces COX-2
(1336) followed by increased 15d-PGJ2 availability. In turn,
15d-PGJ2 can covalently bind and inactivate Keap1, allowing nuclear accumulation of Nrf2 (788, 1329). Remarkably, 15d-PGJ2 also covalently binds to and activates the
PPAR receptor as well as covalently modifying NF-B to
prevent its DNA binding (1517). Enhanced eNOS activity
and NO availability leads to NO nitrosylation of Keap1
and Keap1 inactivation (709). Excessive inhibition of ROS
formation or blocking at least modest accumulation of electrophilic byproducts results in reduced Nrf2 availability
and inadequate induction of cellular antioxidant defenses.
Nevertheless, if ROS or reactive electrophile concentrations
rise excessively, then proinflammatory and proapoptotic
signaling is stimulated through ASK1 and other signaling as
reviewed in section IIIC.
Nearly all cellular antioxidant defenses are induced by
Nrf2. These are only alluded to in FIGURE 11. Many of these
antioxidant proteins are required for transition to a quiescent state. For example, glutaredoxin (Grx) was essential
for flow-mediated upregulation of eNOS (1899), and
HMOX1 induction decreased TNF- release by endothelial
1377
Tie2 signaling through RhoA leads to downstream activation of mammalian diaphanous (mDia) which sequesters
Src, thereby limiting endothelial permeability by blocking
VEGFR2-mediated internalization of VE-cadherin. Active
Src can also reduce expression of KLF2 (1907). Tie2 also
inhibits NF-B translocation by promoting A20 activity
through A20-binding inhibitor of NF-B (ABIN2) (86).
3. Controlled oxidant signaling induces antioxidant

defenses, leading to endothelial quiescence
PAUL N. HOPKINS
O2
NOX1/2
Prolonged laminar flow
SOD3
ONOO
NO,
electrophiles
NO
Caveolin-1
p66Shc
O2
Arg
HSP90
O2
eNOS
SIRT1
TXNIP
NO
PKB
H2O2
Trx
CaMKII
PKA
O2
SOD1
Prdx, Gpx,
Cat
PI3K
Pr-SH, H2O
AMPK
Ras
Raf1
MEKK2/3
ASK1
TAK1
MEK1/2
MEK5
MKK4/7
MKK3/6
lipoic acid
H2O2
H2O
Pr-SOH, Pr-SS
PAK
SOD2
Trx
Grx
TrxR
GSR
Pr-SSG
Pr-SH
+
GSH
NO,
electrophiles
IKK
SHP2
Grb2 Gab1
Grb2 Sos
Grb2 Gab1 VEGFR2
signaling
mDia
ERK1/2
ERK5
JNK
Rho
IB
p38
A20 ABIN2
NF-B
PI3K
PI3K
Bad
NO, electrophiles
MKP1
HDAC5/7
Keap1
Cul3
U U
FOXO1,3
15d-PGJ2
PKB
Nrf2
Keap1
SIRT1
SMRT
HDAC3
FOXO1,3
CBP
HDAC5/7
PPAR
Altered response: F eNOS,
NF-B
anti-apoptosis genes, inflammation genes
GSK3
miR-92a
TXNIP
CBP
PCAF
KLF2/4
MEF2A/C
-catenin
PCAF
HDAC3
CBP
anti-proliferation, CD59, TM, eNOS, Tie2,
KLF2/4
Nrf2, inflammation, ET-1, TF, vWF, PAI-1, PAR1, ANGPT2, ACE
CBP
Maf
1378
anti-oxidant genes, Ets-1

Nrf2
NOTCH signaling,
vascular quiescence
DLL4
-catenin
Bcl2
Tie2
signaling
Src
Gadd45

cells (421). Interestingly, several major classes of stressresponse transcription factors induce HMOX1, including
hypoxia-induced factor 1 (HIF1), NF-B, Nrf2, and AP-1
(from MAPK signaling) (38).
clear localization are repressed by prolonged laminar flow,

dependent on increased NO production (1571, 2012). Finally, RNS can directly nitrosylate Trx and increase its
binding to and inactivation of ASK1 (130).
A number of studies have shown increased inflammation and

atherosclerosis after deletion of many antioxidant proteins (or
protective effects with over-expression) (see TABLE 3). Surprisingly, however, whole body Nrf2 KO in mice fed a high-fat
diet did not increase but rather decreased atherosclerosis,
apparently because Nrf2 also supports expression of the
CD36 scavenger receptors in macrophages with increased
foam cell formation (1717). In a subsequent study with
chow-fed mice, reduced atherosclerosis in Nrf2 KO was
again seen, together with reduced CD36 in macrophages,
fewer macrophages in plaques, but also lower plasma lipid
levels and reduced hepatic lipid production. (106). Because
the predominant effects on atherosclerosis for Nrf2 KO
seem to relate to foam cell formation, results of these studies
are included in TABLE 8.
4. eNOS upregulation by laminar flow is critical for

endothelial quiescence
Enhanced NO production with prolonged laminar flow is

mediated by a gradual increase in eNOS mRNA as well as
multiple posttranslational modifications of the eNOS enzyme (such as binding to HSP90, calcineurin, and certain
phosphorylations) all of which decrease the dependence on
calcium and calmodulin, and increase activity overall. Induction of eNOS is mediated by KLF2, ERK1/2 signaling,
and surprisingly, NF-B (101). Calcium-CaM seems to displace or disrupt inhibitory caveolin binding of eNOS (101).
Activating phosphorylations of eNOS include Ser1177 (by
Akt/PKB, AMPK, PKG, CaMKII), Ser615, Ser633 (by
PKA), and Tyr81. Dephosphorylation of Thr495 also promotes activity (101). ERK1/2, whose activity is stimulated
by even transient calcium elevations by way of CaMKII and
PYK2, can also directly phosphorylate eNOS Ser633 to
promote activity (1994). At low levels of intracellular calcium, plasma membrane calcium ATPase (PMCA) is bound
in a complex to eNOS and calcineurin and can apparently
phosphorylate eNOS Thr495 while also inhibiting calcineurin. As calcium rises, PMCA may be redirected to
pump calcium out of the cell, leaving calcineurin free to
dephosphorylate Thr495 on eNOS (780). Calcium-CaM
bound to calcineurin can then activate NFAT as well.
NFATc2 may promote eNOS transcription (2023).
Deacetylation of eNOS by SIRT1 further activates eNOS
(1157). The target(s) of SIRT1 on eNOS are one or more
specific lysines (possibly K494 and/or K504) in the calmod-
FIGURE 11. Pathways leading to a quiescent, anti-inflammatory, antioxidant state after prolonged exposure to unidirectional, rapid laminar
flow (high shear stress). Besides catalase (Cat), a number of the antioxidant systems have a net effect of converting H2O2 to water. Most
important for quiescence are induction of KLF2/4 and release of Nrf2 with subsequent transcription of genes induced by KLF2/4 and Nrf2.
Electrophiles can covalently bind cysteines on target proteins. Electrophiles include 15d-PGJ2 (which inactivates Keap1 and NF-B while it
activates PPAR), 4-hydroxy-2-nonenal (4-HNE), peroxynitrite, and others. H2S can act as an electrophile and also induces rapid release of Nrf2.
In excess, electrophiles can be toxic. CREBP binding protein (CBP) represents p300 or CBP. Both are histone acetylases (HATs) and therefore
promote transcription. ERK1/2 can phosphorylate CBP to facilitate Nrf2 signaling as well (not shown for clarity). FoxO1, FoxO3a, and HDAC3
are phosphorylated by PKB causing translocation to the cytoplasm. ABIN2, A20-binding inhibitor of NF-B; Cul3, Cullin 3; GSR, glutathione
reductase; mDia, mammalian diaphanous; SMRT, silencing mediator for retinoid and thyroid hormone receptors; SOD1, copper-zinc superoxide
dismutase, the cytosolic SOD; SOD2, manganese SOD, the mitochondrial SOD; SOD3, extracellular SOD.
1379
Among the most important antioxidant defense mechanisms is the Trx-TrxR system. Trx has a dual role as an
antioxidant enzyme (capable of regenerating reduced cysteine from protein cysteine disulfide bonds and reducing
sulfenic acid) and as a redox-dependent inhibitor of ASK1
(289). Importantly, in oxidizing conditions, Trx is bound
by thioredoxin-interacting protein (TXNIP) through disulfide linkage, allowing ASK1 to activate the JNK pathway.
TXNIP is a scaffold protein belonging to the -arrestin
family. TXNIP can shuttle from the nucleus to either cytoplasm or mitochondria where it can inhibit different isoforms of Trx. TXNIP is markedly increased in endothelial
cells in areas of disturbed flow (1918). In the nucleus during
conditions of disturbed flow, TXNIP acts as a corepressor
of KLF2 expression (possibly by recruiting transcription
repressors like HDAC1/3 to the KLF2 promoter). Indeed,
endothelial KO of TXNIP completely reversed the proinflammatory expression of ICAM-1 and VCAM-1 and inhibited leukocyte adhesion in areas of disturbed flow while
overexpression abrogated the upregulation of KLF2 activity seen with laminar flow (1918). Furthermore, overexpression of TXNIP promotes apoptosis. In pancreatic beta
cells, TXNIP was dramatically induced by high glucose and
was a major mediator of glucotoxicity through a TXNIPTrx2-ASK1 pathway (1546). TXNIP expression and nu-
Immediately after initiation of flow, there is a surge in the

production of both NO and superoxide. For 2 h after
initiation of flow or with prolonged slow, oscillatory flow,
the balance favors superoxide production with neutralization of the vasodilating effects of NO. After several hours of
laminar flow, however, NO is favored through multiple
mechanisms (see FIGURES 11 AND 12) (451). Indeed, enhanced production of NO is one of the hallmarks of the
atheroprotective state (105).
PAUL N. HOPKINS
Complete suppression of NF-B, however, does not seem to

be advantageous, since NF-B can also act to support an
increase in eNOS synthesis and has anti-apoptotic effects
(389). This Yin-Yang behavior is modified in the setting of
prolonged laminar flow, where the proinflammatory actions of NF-B are almost entirely abrogated or uncoupled
(as seen by a marked suppression of VCAM-1, E-selectin,
and IL-8 production in response to TNF-), leaving the
cytoprotective effects of NF-B (including induction of MnSOD and eNOS) intact (1390). Recent insights into the
mechanism of this transition suggests phosphorylation by
PKB of the histone acetylator, p300/CBP (CREB binding
protein, a homolog of p300) may lead to an alteration of the
genes targeted by NF-B, together with marked increase in
1380
While caveolin acts as an inhibitor of eNOS when bound to

the enzyme, it has been suggested that caveolin may also function as a scaffold to assemble activating proteins, thus resulting in more effective activation of eNOS when the proper
signals are transmitted (101). This may indeed be the case in
some settings, but decreased atherosclerosis was seen after
knockout of caveolin (522). An adaptor protein, striatin, can
bind caveolin and appears to mediate binding of the estrogen
receptor ER (and probably other steroid receptors such as
MR) to caveolae together with juxtaposition of a Gi protein,
possibly from the GPCR GPR30. Estradiol binding promotes
assembly of this complex followed by activation of Src, PI3K,
Akt/PKB, and phosphorylation of eNOS at Ser1177 (1190),
one of the major nonnuclear endothelial signaling effects of
estrogen. Administration of estradiol bound to a large nondegradable molecule which excluded it from the nucleus but
allowed signaling through the striatin complex led to increased
eNOS activity and reduced atherosclerosis in ApoE KO mice
(271).
NO downregulates NADPH oxidase subunits after prolonged
exposure to laminar flow. The decline in superoxide production with prolonged laminar flow, shown in FIGURE 12, was
accompanied by an 50% decrease in the expression of the
activity-limiting gp91phox subunit of NADPH oxidase
while eNOS protein expression was increased 3.5-fold. The
reduction in gp91phox expression was shown to be NOdependent, although the specific signal transduction pathway was not demonstrated (451). Laminar flow also inhibited activation of caspase 3 which in cells unexposed to flow
2000
1800
Nitric oxide
Superoxide
Percent of baseline production
NF-B expression is generally low in atherosclerosis-resistant regions, while it is elevated in predisposed segments in
mouse (696, 864) and pig (1391), and it increases with age
in humans (432). Nitrosylation of NF-B by NO directly
inhibits IKK, stabilizes IB, induces IB mRNA, decreases
NF-B transport to the nucleus, and inhibits NF-B binding
to DNA (1477). Various electrophiles, particularly nitrofatty acids, can also inhibit NF-B activation. Increased
SIRT1 expression with flow promotes deacetylation of the
p65 subunit of NF-B, making it more susceptible to degradation. SIRT1 deacetylation of p300 results in sumoylation of NF-B which may selectively decrease transcription
of a subset of NF-B target genes (197).
eNOS transcription (294). In addition, increased expression of the transcription factor Erg was found in quiescent
endothelium with downregulation by inflammation. Erg
was found to bind promoter regions of multiple inflammatory genes and block NF-B action at these sites (447).
1600
1400
1200
1000
800
600
400
200
0
0
24
Hours of laminar shear stress

FIGURE 12. Effect of laminar shear stress on endothelial production of nitric oxide and superoxide anion. [Data from Duerrschmidt et
al. (451).]
ulin binding domain of eNOS. When these lysines are acetylated by an as yet unidentified acetyltransferase, there is
decreased calmodulin binding and diminished eNOS activity. Cigarette smoke inhibits this effect of SIRT1 and
increases eNOS acetylation (80). Laminar flow clearly
increases SIRT1 activity. Furthermore, there is a physical
association of SIRT1 with eNOS which is enhanced by
flow-dependent phosphorylation of eNOS (at S633 and
S1177) by AMPK2 (299). Increased SIRT1 activity with
laminar flow may be stimulated by the modest pro-oxidant environment and increased NOX2 activity which
lead to increased NAD utilized by SIRT1 in deacetylation reactions. Generally, NAD/NADH is a major determinant of SIRT1 activity. Other protective activities
of SIRT1 with laminar flow include upregulation of mitochondrial biogenesis through activation of PGC-1
and increased activities of Nrf1 and liver X receptor
(LXR) (299) as well as repression of p66Shc (2106) and
inhibition of pro-inflammatory NF-B signaling. Aging
leads to diminished SIRT1 and increased eNOS acetylation in mouse arteries and in human endothelial cells
isolated from the brachial artery (433). Interestingly,
low-dose aspirin appears to nonenzymatically acetylate
another lysine residue (K609) in the calmodulin autoinhibitory domain of eNOS leading to enhanced calmodulin binding. The deacetylase HDAC3 reverses this acetylation (869).

cleaved PKC into a more active catalytic subunit termed
CAT() which could then activate JNK (594).
Yet another NO-dependent pathway contributing to endothelial quiescence is the downregulation of AT1R by NO,
together with upregulation of AT2R. Indeed, AT1R was
found to be expressed exclusively in atherosclerosis-prone
areas in mice while prolonged shear stress in human endothelial cells downregulated AT1R expression and abolished
the ANG II-induced induction of VCAM-1 (1456). Phosphorylation of eNOS by both PKA and PKG supported
these effects.
5. MAPK cross-talk in the transition to a quiescent
state
6. KLF2/4, atheroprotective molecular switches

turned on by laminar flow
Numerous studies have pointed to the induction of the transcription factor KLF2 (with KLF4 more recently added) as a
critical step in the conversion to and maintainance of an
athero-protective state (1106, 1332, 1881), even in microvessels (330). Indeed, KLF2 (and possibly KLF4) and Nrf2 are
thought to act together to control as many as 70% of the genes
upregulated by laminar flow (1291). In human, mouse (403,
404), rat (1907), and swine (500) arteries, KLF2 (and KLF4
when examined) was found to be expressed by endothelial
cells in areas of normal laminar flow but nearly absent in areas
of slow or disturbed flow. KLF2 is also important in embryonic vascular and hematopoietic development. The molecular
effects of KLF2/4 are protean and include the following: inhibition of ATF2 (activating transcription factor 2), a potential
component of pro-inflammatory AP-1 (activator protein-1)
(529); induction of inhibitory SMAD7 which blocks TGF-
signaling (177); enhanced transcription of eNOS and the enzyme dimethylarginine dimethylaminohydrolase which degrades the eNOS inhibitor ADMA (asymetrical dimethyl arginine); increased transcription of protective thrombomodulin
(TM) while inhibiting transcription of tissue factor (TF), vWF,
plasminogen activator inhibitor 1 (PAI-1), and the thrombin
receptor protease activated receptor 1 (PAR1) (1049); increased expression of CD59 which blocks effects of complement activation on endothelial cells (911); inhibition of inflammatory effects of endothelin-1 (ET-1), MCP-1, IL-1,
TNF-, and other inflammatory cytokines through inhibition
of NF-B; and a number of other major effects (1291). In one
study, KLF2 decreased by 80 90% the expression of the following genes after exposing cells to IL-1: IL-1, IL-1, IL-6,
IL-8, IL-15, MCP-1, E-selectin, TNF-, CXCL10, CXCL11,
IFN-, COX-2, and CCL5 (1388). Inhibition of NF-B by
KLF2 occurs, at least in part, by KLF2 competing for CREBbinding protein (CBP) which is required for full NF-B activity. Conversely, the p65 subunit of NF-B seems to inhibit
transcription of KLF2 (but not KLF4). This suggests that the
balance of NF-B and KLF2 may control the overall inflammatory status of endothelial cells (1291). Interestingly, statin
drugs are potent inducers of KLF2 and KLF4, possibly by way
of PKB activation (1332, 1388).
KLF2 upregulation by flow in endothelial cells resulted in increased expression of miR-143 by 17-fold and miR-145 by
12-fold, microRNAs known to be involved in control of
1381
Cross-talk between different MAPK pathway kinases appears to be another important mechanism whereby prolonged laminar flow induces a protective endothelial phenotype. ERK1/2 is increased by flow, and although it can
support inflammation, its antiapoptotic effects (such as activating Bcl-2 and eNOS by phosphorylation) may be relevant for transition to a quiescent state. Nevertheless, activation of the ERK5 module is considered most important in
this regard. As depicted in FIGURE 11, activation of MEK5
by flow inhibits activation of the pro-apoptotic, inflammatory JNK (130, 1029). MEK5 activates ERK5 which interferes with signaling downstream of JNK (130). Of primary
importance is the upregulation of KLF2 and KLF4 by ERK5
signaling through phosphorylation and activation of the
transcription factor MEF2C (MADS box transcription enhancer factor 2C) (330, 1332, 1881). Laminar flow further
supports MEF2C action by calcium/CaM-dependent export of inhibitory HDAC5 from the nucleus (1912). Inhibitory HDAC7 can be excluded from the nucleus by PKB
phosphorylation (989). ERK5 also phosphorylates and activates eNOS, inactivates the proapoptotic factor Bad, and
displaces the corepressor SMRT (silencing mediator for retinoid and thyroid hormone receptors), thereby allowing
transcription mediated by PPAR (154). PKC, which is
activated by TNF-, binds and inhibits ERK5 by phosphorylation (1306). ROS and advanced glycosylation end-products (AGE) appear to promote ERK5 sumoylation and inactivation, a potentially important mechanism for diabetesrelated endothelial dysfunction (1977). High blood sugar
and mild hydrogen peroxide exposure together or high hydrogen peroxide alone increased direct physical binding of
RSK1/2 to ERK5. RSK1/2 then phosphorylated ERK5 on
S496 and inhibited ERK5 transcriptional activity followed
by increased VCAM-1 and E-selection expression while
eNOS was decreased. Inhibition of RSK1/2 activity with the
specific inhibitor fluoromethyl ketone-methoxyethylamine
resulted in reduced atherosclerosis in ANG II-treated ApoEdeficient mice (986). In contrast, endothelial-specific, tamoxifen-induced conditional KO of ERK5 led to a 130%
increase in atherosclerosis in LDLR/ mice (986).
Despite the importance of the MEK5-ERK5 pathway, the

mechanism of activation by laminar flow remains unclear
but includes activation of AMPK (2046). A proposed pathway includes increased NO which binds and activates soluble guanylate cyclase (sGC) with production of cGMP and
presumed activation of PKG, phosphorylation and activation of an L-type voltage-operated calcium channel, increased intracellular calcium and activation of CaMKII
which can then phosphorylate and activate AMPK (2074).
PAUL N. HOPKINS
VSMC phenotype (472). These microRNAs are packaged in
vesicles which are secreted by endothelial cells and taken up by
VSMC, followed by induction of a more quiescent, contractile
phenotype in VSMC. Infusion of such vesicles into ApoEdeficient mice resulted in a reduction of atherosclerosis (752).
Factors that inhibit KLF2 expression (but not KLF4 which

tends to be increased by inflammatory signals) include multiple pro-inflammatory cytokines which mediate translocation of active NF-B to the nucleus, as noted above (1291).
In addition, active Src decreases expression of KLF2 and
may be another means whereby KLF2 is downregulated by
disturbed flow (1907). Recently, miR-92a was shown to
inhibit KLF2 and KLF4 translation and was found to be
downregulated by laminar flow (500, 1988).
Many of the observations regarding KLF2/4 signaling have
thus far been made in vitro or in artificial systems. Because
KLF2 KO is embryo lethal, one study examined KLF2 hemizygous KO in ApoE-deficient mice. Surprisingly, there was
little effect on KLF2 target genes in endothelium, presumably because of an apparently compensatory upregulation
of KLF4. However, there was a mild increase in atherosclerosis associated with increased macrophage lipid accumulation (85). More recently, hematopoietic deficiency of
KLF2 increased atherosclerosis more substantially due to
increased neutrophil and macrophage adherence and entry
into lesions and increase neutrophil activity together with
accelerated apoptosis (1050). Greater understanding of the
1382
E. Hydrogen Sulfide Signaling

Hydrogen sulfide (H2S) is now recognized as a third gaseous
transmitter/signaling molecule (after NO and carbon monoxide) (1264). The gas is produced from cysteine by the
enzymes cystathionine -synthase and cystathionase. Although H2S is a lethal toxin at higher exposure levels (by
inhibition of cytochrome c and cellular respiration), accumulating evidence suggests an anti-inflammatory, antioxidant signaling role at lower, physiological concentrations.
Like NO, exposure to high H2S (100 250 M) causes oxidative stress and impairs survival in both endothelial cells and
VSMC. Conversely, H2S at low concentrations (30 M for
example) protects cells from various stressors such as lysophosphatidylserine (LPS), ischemia-reperfusion, H2O2, and
high homocysteine, while reducing NFB signaling, cell ROS
production, increasing antioxidant enzyme expression, and
markedly improving cell viability (1028, 1098). Endothelial
release of H2S can parallel and complement NO.
H2S promotes Nrf2 localization to the nucleus, inducing expression of multiple cellular antioxidant systems (1028). Providing exogenous H2S in various in vitro studies reduced multiple aspects of early atherogenesis including endothelial inflammatory signaling and elaboration of adhesion molecules,
monocyte adhesion and activation, as well as foam cell formation (1098). The primary mechanism of H2S signaling seems
to be protein cysteine sulfhydration (1263, 1264), although it
is not clear that sulfhydration explains all its effects. For example, H2S causes vasodilation by opening VSMC KATP channels (it is therefore an endothelial-derived hyperpolarizing factor). Phosphodiesterase inhibition with persistance of cGMP
and cAMP signaling may be an additional important mechanism (1263, 1909). Notably, the type 3 phosphodiesterase
inhibitor cilostazol was recently reported to cause carotid intima-medial thickness (CIMT) regression among type 2 DM
patients (888). H2S reacts with intracellular S-nitrosothiols to
form the smallest S-nitrosothiol (HSNO), and a role for hydrogen sulfide in controlling the intracellular S-nitrosothiol
pool has been suggested.
Among the most exciting byproducts of H2S signaling research have been major insights into hyperhomocysteinemia as a coronary risk factor. Despite numerous observational studies reporting increased CAD risk associated with
elevated Hcy (homocysteine) (802, 1368, 1782), vitamin
interventions have been universally negative despite effective Hcy lowering (333). A likely explanation for the apparent discrepancy is that elevated Hcy is not the culprit but
rather a marker for defective H2S synthesis (118). Two of
the major enzymes of the transsulfuration pathway not only
metabolize Hcy but are major sources of H2S. Deficiency of
Several aspects of the regulation of KLF2 expression are

shown in FIGURE 11. As noted above, a major inducer of
KLF2 (1291) and KLF4 (330) is ERK5 which phosphorylates the transcription factors MEF2A (MADS box transcription enhancer factor 2, polypeptide A) and MEF2C
among numerous other targets. HDACs generally act as
corepressors by removing acetyl groups from histones, thus
promoting a compact configuration of chromatin, preventing transcription. HDACs also remove acetyl groups from
transcription factors and other proteins which may deactivate the target or may allowing tagging the same site with a
phosphate to mark the protein for ubiquitination and degradation. HDAC5 is a corepressor of MEF2A-mediated
transcription of KLF2. Endothelial HDAC5 is phosphorylated and transported out of the nucleus by a calcium/CaMdependent mechanism which is stimulated by laminar shear
stress (1912). Cilia on endothelial cells can generate calcium
signals under flow and recently were shown to be important
for flow-induced upregulation of KLF2/4 (464). An additional mechanism to upregulate KLF2 activity involves activation of PCAF (p300/CBP associated factor) by a PI3Kdependent but PKB-independent mechanism (799). Tie2
signaling is thought to contribute to PCAF activation
through activation of PI3K. Activated PCAF acts together
with CBP/p300 to acetylate histones and greatly increase
transcription of KLF2 and KLF2-regulated genes.
role of KLF2 and KLF4 on endothelial-mediated pathways

in atherosclerosis await additional studies such as conditional KO in endothelium.

either cystathionine -synthase (CBS) or cystathionase or
cystathionine -lyase (CTH) markedly impairs cellular H2S
production. CTH KO caused hypertension mediated by impaired H2S production (2020).
A number of human intervention trials are underway utilizing various H2S donors (1028, 1098). Interestingly, naturally occuring sulfur compounds in garlic yield biologically
meaningful levels H2S by interacting with GSH in red blood
cells (124). These insights may help explain positive cardiovascular outcomes of several smaller, randomized controlled trials that utilized garlic or garlic extracts. Results
were largely independent of any effects on standard risk
factors (222, 223, 247, 939).
F. Genomic Studies of Flow-Mediated

Change in Endothelial Phenotype
Several groups have examined RNA expression profiles of
10,000 or more genes simultaneously in endothelial cells
exposed to the atherosclerosis-prone versus protective flow
patterns (212, 324, 375, 403, 528, 529, 590, 1391, 2045).
While results generally confirmed the findings of candidate
gene and molecular studies, there were many differences
between the studies in specific genes identified as up- or
down-regulated, possibly owning to differences in technical
approach. Genes known to be associated with inflammation and susceptibility to atherosclerosis tended to be increased in cells exposed to the slow-flow, oscillatory pattern
(disturbed flow), whereas they were suppressed in the cells
In one of the studies, endothelial cells were harvested from

atherosclerosis-prone and atherosclerosis protected areas of
aorta from normal pigs (387, 1391). This in vivo approach
suggested that while pro-inflammatory genes were frequently increased in the atherosclerosis-prone areas, several
compensatory genes were also upregulated, including several antioxidant genes such as glutathione peroxidase
(Gpx). Arteries from these normocholesterolemic pigs
showed little evidence of frank inflammation, even at predisposed sites. Nuclear NF-B levels were not elevated nor
were several key adhesion receptors overexpressed on cell
surfaces. Similarly, in chow-fed mice there was no excess
nuclear NF-B seen in endothelial cells taken from areas of
disturbed flow. However, substantially greater levels of cytoplasmic NF-B bound by IB were evident. There was
much greater activation of NF-B and its inducible gene
products in these same hemodynamically prone areas after
the mice were treated with lipopolysaccharide or after feeding LDLR-deficient mice a high-fat diet to induce hyperlipidemia (696). Thus frank inflammation may not be present
in areas of disturbed flow without additional initiating factors. Instead, disturbed flow seems to prime the endothelium for an enhanced response to activating or inflammatory stimuli.
V. INITIATION OF ATHEROSCLEROSIS:
ENDOTHELIAL ACTIVATION BY
DYSLIPIDEMIA
Striking electron micrographs reveal monocytes adhering to
endothelium in atherosclerosis-prone areas just days after
inducing severe hypercholesterolemia by feeding animals
high saturated fat diets (with butter, lard, or coconut oil)
enriched with added cholesterol (492, 493, 1511, 1577).
Such hyperlipidemia clearly provides one or more signals
for activation of already primed endothelial cells found
in atherosclerosis-prone areas (26, 365, 696, 1023). Furthermore, lowering serum cholesterol, even if by only dietary means, rapidly decreases endothelial activation and
1383
In one recent study in ApoE KO mice (2067), high early mortality seen in prior studies of CBS/ mice was avoided by
utilizing a zinc-inducible human CBS transgene in otherwise
CBS-deficient, apoE/ mice. During pregnancy and weaning,
zinc was added to the drinking water, the transgene was activated, and Hcy levels were only slightly elevated, preventing
early mortality. After weaning, zinc was removed from drinking water and the mice developed severe hyperhomocysteinemia and accelerated atherosclerosis, confirming prior observations in conventional CBS/ apoE/ mice (1896). Furthermore, lesion size and elevations in TNF-, MCP-1, and
Ly-6Chi monocytes/macrophages were all proportional to
Hcy levels. However, insights from other studies suggest that
impaired H2S was likely the underlying causal factor. Thus in
vitro studies showed that elevated plasma Hcy inhibited CBS
and impaired H2S production while H2S supplementation
completely reversed inflammation caused by hyperhomocysteinemia (1586). Chemical inhibition of CTH in ApoE KO
mice caused a marked increase in atherosclerosis. This excess
lesion formation was decreased (by 38%) by sodium hydrosulfide supplementation (1921). In another study, sulfur dioxide supplementation markedly decreased lesion development
in atherogenic diet-fed rats (1037). Thus much of the prior
work on Hcy in animal models of atherosclerosis needs to be
reconsidered in light of newer understanding of H2S signaling.
exposed to rapid, unidirectional pulsatile flow. For example, after exposure to disturbed flow there was increased
mRNA for IL-1a, IL-1a receptor, IL-6, IL-8, Cx43,
VCAM-1 (with enhanced response to IL-1 stimulation), Eselectin, MCP-1, fibronectin, vWF, NADPH oxidase,
MMP-1, and MMP-10 while some protective genes such as
eNOS, IL-10, and chemokine CXCR4 were downregulated. A host of antioxidant genes were upregulated by the
concerted actions of laminar flow, and these changes were
associated with greater expression of KLF2 and Nrf2 (528,
529). Besides confirming effects on genes with known links
to inflammation, these studies also provided many new candidate genes to be considered for their potential roles in the
already complex molecular biology of endothelial responses to hemodynamic factors and subsequent atherosclerosis susceptibility.
PAUL N. HOPKINS
myeloperoxidase in activated macrophages or neutrophils
also results in characteristic tyrosine modifications. These
molecular signatures are found in abundance in LDL from
advanced human plaques, whereas modifications characteric of metal-catalyzed oxidation are not (740, 996, 997).
Furthermore, myeloperoxidase-generated reactive nitrogen
species convert LDL into a form avidly taken up by macrophages with conversion to foam cells (1427).
Not only do lipoproteins preferentially accumulate in atherosclerosis-prone areas, but hyperlipidemia itself clearly
increases the permeability of the endothelium and total area
of susceptibility, suggesting direct activation (1577, 1578).
Mechanisms for increased permeability include alterations
in adherens junction function with increased paracellular
permeability, greater susceptibility to apoptosis with increased cell turnover resulting in physical gaps in the endothelium, diminished glycocalyx height, and other factors
(1843). Activation of endothelial RhoA by multiple mechanisms is known to assist in opening endothelial paracellular junctions (1172). Even modest hyperlipidemia induced
by a high-cholesterol diet in pigs (increasing total serum
cholesterol from 74 to 187 mg/dl) tripled endothelial labeled thymidine uptake, an index of endothelial cell turnover (531). Several possible mechanisms for endothelial activation by hyperlipidemia are presented below, and relevant genes are presented in TABLE 4.
The question then arises whether preformed oxLDL activates endothelium to summon the macrophages and/or neutrophils initially or whether oxLDL are formed mainly after
macrophages and neutrophils have arrived and become activated. Yet even if formation of tyrosylated, chlorinated, or
nitrosylated oxLDL requires the presence of activated macrophages or neutrophils, once formed these modified LDL
could then perpetuate endothelial activation and otherwise
promote atherosclerosis (1303, 1304). Unfortunately, the
near absence of myeloperoxidase in experimental mouse
atherosclerotic lesions will make clarification difficult, although humans with myeloperoxidase deficiency are apparently protected from atherosclerosis (1303).
A. LDL Oxidation: An Uncertain Role

Despite continuing skepticism (1685, 1686), much evidence
supports a role for LDL oxidation in endothelial activation
(1288, 1303). In human fetuses, native LDL appeared to
accumulate in the intima before macrophages were found.
LDL bearing oxidation-related epitopes seemed to accumulate only after native LDL were present, and such oxidized
LDL were most frequently seen together with macrophages,
although they could also be observed in the absence of
macrophages (1282). In classic in vitro studies, severely
oxidized LDL (oxLDL) (produced usually in vitro with nonphysiological exposure to copper or iron ions) was shown
to stimulate adhesion of both macrophages and T-cells to
endothelial cells, promote diapedesis into the subendothelium, and lead to the arrest of egress (1288, 1445).
Despite the potential to initiate endothelial activation, oxLDL are thought to be found primarily in more advanced
lesions, primarily in association with macrophages. Furthermore, oxidized LDL in human plaque appears to be
formed primarily by exposure to myeloperoxidase and peroxinitrite from activated macrophages or neutrophils (740,
996, 997). Thus myeloperoxidase-derived HOCl (hypochlorous acid) results in tyrosine radical formation and tyrosine cross-linking or di-tyrosine formation (tyrosylation),
as well as characteristic patterns of chlorinated tyrosine
residues. Peroxynitrite derived from iNOS and ROS from
1384
The decrease in atherosclerosis seen after immunization of

animals with various forms of oxidized LDL or malondialdehyde-treated LDL (148, 547, 1371) has been forwarded
as an argument in support of the LDL oxidation hypothesis.
However, immunization with oxLDL and other antigens
can have mixed effects, including stimulating production of
protective natural IgM or promotion of immune tolerance by activation of regulatory T-cells (see sect. VIC, 5 and
6). Given these considerations, there remains a need to explain how the endothelium is activated to attract the monocytes and neutrophils in the first place.
Aside from oxLDL, endothelial and VSMC can mildly oxidize LDL in culture and such minimally modified LDL
(mmLDL) can also activate endothelial cells and initiate
monocyte adherence and transmigration. These events were
prevented by the presence of HDL or antioxidants (1289).
In these studies, monocyte rather than neutrophil adhesion
and migration seemed to be stimulated. Hypothetically,
LDL trapped in the subendothelial space would be exposed
to sufficient ROS from activated endothelial cells to result in
such minimally oxidized LDL. Formation of oxidized LDL
in the plasma is thought to be unlikely due to potent antioxidant factors there. And, some have questioned whether
even mmLDL are formed in vivo in the surprisingly antioxidant rich intima (1686). However, the observations in human fetuses cited above would suggest at least some oxidation is possible and occurs prior to the arrival of macrophages. Thus there might be microenvironments in the
intima or surrounding ECs and VSMCs that might be depleted of hydrophilic (vitamin C, urate, and bilirubin), hydrophobic (vitamin E) and enzymatic (e.g., PON-1) antioxidants.
inflammation (1023). As early as 2 h after injection of human LDL into rabbits, grapelike clusters of aggregated LDL
could be seen enmeshed in focal areas of the subendothelial
matrix (1305). VCAM-1 and MCP-1 were expressed by
endothelial cells within 3 wk of starting a high-cholesterol,
coconut oil-based diet in rabbits (1023). The events occuring during these weeks have been the object of intense investigation.
Table 4. Endothelial activation by hyperlipidemia, other risk factors (20 genes tested)
Gene
Model
% A
Function, Comment
TLR1/ LDLR/
NS
TLR1 acts as a coreceptor to TLR2. No change with high-fat diet feeding

(endogenous ligand), but deficiency markedly reduces the excess
abdominal atherosclerosis induced by exogenous ligand Pam3 (363).
TLR2
TLR2/ LDLR/
232%
TLR4
TLR4/ apoE/
255%
TLR6
TLR6/ LDLR/
NS
RP105
RP105/ BMT in
LDLR/
243%
CD14
CD14/ apoE/
NS
TRIF
TRIFLPS2/LPS2
LDLR/
221%
LOX-1 (OLR1)
OLR1/ LDLR/
250%
RAGE
RAGE/ apoE/
DN-RAGE apoE/
252%
278%
AGE-R3
LGALS3/ in fat-fed
C57BL/6J
155%
AR
AR/ apoE/
Clearly involved in endothelial activation. Upregulated in areas of

disturbed flow while TLR4 is not. BMT from TLR2/ had a lesser
effect on atherosclerosis (1248).
Involved in endothelial cell activation by mmLDL as well as macrophage
activation. Percent reduction in aortic sinus given (1207). Recent study
confirms greater effect for TLR4 while TLR2 also significant (764). A
prior study showed no effect of a TLR4 defective mutation (1983).
TLR6 acts as a co-receptor to TLR2. Results similar to TLR1 KO but
exogenous ligand was MALP2 (363).
RP105 (radioprotective 105, also known as CD180) is a TLR4
homologue that forms homodimers and then forms a complex with
TLR4 homodimers. TLR4 binds the LPS-binding protein MD2 while
RP105 binds MD1 (2043). RP105 facilitates LPS recognition in B
cells but also facilitates recognition of other microbial lipoproteins in
macrophages (160). Decreased atherosclerosis also seen with
hematopoetic deficiency (883), together with reduced splenic B cell
proliferation and a marked reduction in intimal T cells.
Lack of effect suggests this LPS recognizing, transmembrane adapter,
which is part of the TLR4 complex, does not influence atherogenesis
(156).
The LPS2 mutation causes a truncated and nonfunctional TRIF protein.
Significant reduction in atherosclerosis seen only after 15 wk of highfat diet (1484).
Involved in endothelial cell activation by oxLDL and TGRL as well as
macrophage activation (1185).
RAGE (receptor for advanced glycosylation end-products) is generally
considered specifically relevant primarily for diabetes but also is activated
by hyperlipidemia. DN-RAGE mice expressed a dominant-negative RAGE in
endothelial cells only. oxLDL were shown to have AGE epitopes and bound
RAGE. RAGE/ EC were unresponsive to oxLDL (718).
LGALS3 (lectin, galactoside-binding, soluble, 3) is the preferred gene
name for galectin 3, the alternative name of AGE-R3. AGE-R3 is
considered a clearance receptor for AGE. Increased Th1 cells also
seen in lesions (813). Conflicting results in apo E KO model (1266).
Although AR (aldose reductase, also known as AKR1B1 for aldo-keto
reductase family 1, member B1) converts glucose to sorbitol in the
polyol pathway, it also detoxifies reactive lipid aldehydes and
precursors of AGE. Shown are data for nondiabetic mice whose
arteries accumulated 4-hydroxy-trans-2-nonenal (HNE) (1671).
Increased plasma HNE and hexanal were seen as well. In diabetic, apo
E null mice, increase in atherosclerosis was similar while glyoxal-lysine
adducts were particularly increased (90). Greatest effect in both
models was on early atherosclerosis.
1180%
Human AR Tg in
diabetic LDLR/
115%
G2A
(GPR132)
G2A/ LDLR/
243%
LPA1/3
LPA1, LPA3 specific

Abs in apoE/
240%
Overexpression of human AR increased atherosclerosis only in diabetic

mice (not normoglycemic LDLR/), presumably due to depletion of
NADPH and impaired glutathione regeneration (1879). Diabetes itself
increased lesion size by 93% overall compared with nondiabetic mice.
G2A is a GPCR that recognizes LPC and LPS as well as certain oxidized
fatty acids. The reduction in atherosclerosis was seen after Westerntype diet feeding (1386). Essentially opposite effects on endothelial
inflammatory signaling was seen with G2A KO in normolipidemic mice
(174). In apo E-null mice, G2A deficiency in macrophages actually
increased atherosclerosis, suggesting a modulating role specifically in
macrophages and possibly in the absence of apo E (171). G2A
signaling in macrophages appears to enhance efferocytosis (542).
Further conflicting results have been published (1387).
LPA administration also increased atherosclerosis in these mice (2110).
Continued
1385
TLR1
PAUL N. HOPKINS
Table 4.Continued
Gene
Model
% A
Function, Comment
Endothelial activation by other risk factors

/
LPL
LPL
GPIHBP1
GPIHBP1/
PON1
PON1/ apoE/
PON2
PON2/ in C57BL6/J
fed Paigen diet
human PON cluster Tg
in apoE/
PON1, 2, 3
in aged mice
11,000%
1933%
142%
1166%
221%
ANGPTL2/ apoE/
238%
PARP-1
PARP1/ apoE/
251%
HDL related. Reduction in inflammation and increased markers of plaque

stability seen as well. Both endothelial effects (presumably due to
increased PON in HDL) as well as macrophage effects (thought due to
PON2) likely contributed (1607).
Obesity, diabetes related. ANGPTL2 (angiopoietin-like 2) deficiency
decreased atherosclerosis while endothelial-specific transgenic overproduction increased inflammation (787). ANGPTL2 is a link between
obesity and inflammation, being released by enlarged adipocytes,
especially when incubated with palmitate. It binds integrin V1 of
various cells including endothelial cells and thereby activates Rac1 and
NF-B (1733).
Diabetes related. Involved in DNA repair but also promotes increased
ROS production and inflammation. Particularly increased in diabetes
(1889).
With regard to the mechanism whereby mmLDL might activate endothelial cells, several investigators have suggested
that arachidonic acid in the sn-2 position of phospholipids
in trapped LDL becomes oxidized, resulting in abnormal
phospholipids with structures similar to PAF (1288). This
simplistic model is complicated, however, by findings that
anti-inflammatory electrophilic compounds are also formed
during LDL oxidation and that the above PAF-like lipids
probably do not act through the PAF receptor (131, 196,
871).
B. TLR2 and TLR4

Toll-like receptors are among the most fundamental and
best studied components of the innate immune system. The
10 known human TLRs recognize a host of exogenous
PAMPs as well as endogenous DAMPs. TLR4 signaling is
illustrated in FIGURE 13. TLR2 employs the same MyD88
adapter and downstream signaling components as shown in
FIGURE 13 for TLR4 but lacks binding domains for TRIF or
TRAM. Indeed, TLR4 is unique among TLRs in being able
to mediate both MyD88-dependent NF-B signaling as well
as binding TRIF/TRAM adapters to activate interferon regulatory factor (IRF)3 and IRF7 transcription factors and
1386
IFN- production (apparently a delayed feature which becomes active after TLR4 uptake into endosomes). The activation of IRF3/7 is analogous to the NEMO-IKK1/2 complex activation of NF-B (284). Upon binding to TRIF,
TRAF3 acts as an adapter to recruit E3 ubitin ligases (including Mib1/2) as well as a complex consisting of the scaffold TRAF family member-associated NF-B activator
(TANK) and IKK-related kinases, IKK or TANK-binding
kinase 1 (TBK1). Other scaffolds, NAP1 (NF-B activating
kinase-associated protein 1) and SINTBAD (similar to
NAP1 TBK1 adapter) can act like TANK to bind IKK or
TBK1. K63 ubiquitination of TANK and TBK1 are involved in activation of TBK1, while IKK may be activated
somewhat differently (1032). Such ubiquitination may allow cross-talk between the IRF3/7 and NF-B activation
pathways. Once activated, IKK and TBK1 serine phosphorylate IRF3 or IRF7 causing their activation and nuclear
translocation, followed by transcription of the type I interferon IFN- (which also requires binding of NF-B and
ATF2 to other domains of the promoter). Interest in this
pathway has recently been piqued with findings that knockout of IKK or chemical inhibition of IKK and TBK1 elevates energy expenditure and results in resistance to obesity
or weight loss in fat-fed mice (1470).
ANGPTL2
Hypertriglyceridemia related. LPL wild type and heterozygotes did not

develop atherosclerosis in this study. Atherosclerosis developed slowly
in LPL KO. Chylomicrons from these mice activated human endothelial
cells and showed increased oxidation markers (2083). See also
macrophage LPL in Table 8.
Hypertriglyceridemia related. GPIHBP1 is required for binding LPL to the
endothelial surface. GPIHBP1/ mice develop severe
hypertriglyceridemia and cannot clear either chylomicrons or VLDL
normally. Atherosclerosis in these mice develops slowly, similar to
LPL/ mice (1937).
HDL related. Increases in indices of macrophage oxidative stress and
NOX2 expression were increased as well (1516).
HDL related. Only female mice used (1297).

TLR2 forms heterodimers with TLR1 or TLR6, whereas
TLR4 typically acts as a homodimer. TLR2 can also utilize
the scavenger receptor CD36 as a coreceptor. Classical exogenous PAMPs recognized by these receptors include LPS
for TLR4 and bacterial lipoproteins or peptidoglycan for
TLR2. Endogenous molecular patterns recognized by TLRs
include certain oxidized lipids as found in oxLDL and
mmLDL. Oxidized or otherwise altered phospholipids can
also mark cells by protruding abnormally (much like whiskers) from the cell membrane and trigger innate immune
receptors including TLR. Oxidized phospholipids also bind
natural antibodies that act to clear the cells or particles
displaying these damaged phospholipids (657, 1210). Such
clearing activity may be most relevant to macrophage function rather than endothelial activation. Another endogenous ligand for TLR4 and TLR2 is the extracellular domain
A (EDA) of fibronectin, whose expression is increased with
aging (1563).
There is considerable cross-talk between the TLR receptors.

Activation of TLR4 can induce increased expression of
TLR2 in endothelial cells (495). Inflammatory signaling
through both TLR2 and TLR4 is increased in endothelial
cells from type I diabetics without increased TLR2 or TLR4
protein levels, apparently due to greater expression of
NF-B (1024). Nevertheless, TLR2 is often thought to be
more important for endothelial cell activation in atherogenesis while TLR4 appears to play a major role in macrophages and VSMC.
Evidence for a specific role in atherogenesis for TLR2 is
plentiful. Whole body deficiency of TLR2 in high-fat fed
LDLR KO mice reduced atherosclerosis significantly at 10
wk by 50%, whereas transplant of TLR2-deficient bone
marrow had no effect on atherosclerosis (1248). Nevertheless, if TLR2-deficient mice transplanted with TLR2/
bone marrow were exposed to an artificial TLR2 ligand,
then atherosclerosis was markedly increased. In another
study, when fed normal chow diet, TLR2 deficiency clearly
reduced atherosclerosis in whole body KO (by 6570% at 7
mo) (1062) as well as in mice transplanted with bone mar-
In contrast to the above observations regarding TLR2,

whole body TLR4 KO in ApoE-deficient mice on a high-fat
diet appeared to have less of an effect (24% reduction in
atherosclerosis) (1207), or even no effect in another study
(1983). However, yet another study reported a 50% reduction in atherosclerosis in C3H mice with ApoE deficiency
fed a high-fat diet. C3H mice have a point mutation in the
TIR domain of the cytoplasmic tail of TLR4 which blocks
MyD88 binding and downstream signaling. In the same
report, BMT studies showed a profound effect for vessel
wall TLR4 expression when C57BL/6J or C3H mice (without ApoE deficiency) were fed a high-fat diet with cholate
(1617). Importantly, the C3H endothelial cells were found
to be unresponsive to mmLDL while exposing wild-type
C57BL/6J endothelial cells to mmLDL caused marked activation. Interestingly, TRIF-defective LDLR KO mice had
reduced atherosclerosis (1484), demonstrating that even if
TLR4 receptors in C3H continued to signal through TRIF,
they should not become protective. The possibility might
have been considered reasonable considering TLR3, which
signals only through TRIF, was found to be mildly protective (339, 1484). Macrophage accumulation and cytokine
production in early plaques was reduced to a greater extent
in TLR4 than TLR2 deficiency in a study that directly compared both in chow-fed ApoE-deficient mice. VSMC accumulation of lipid and secretion of MCP-1 was strongly dependent on TLR4 in the same study (764).
While several of the studies cited above, particularly for
TLR4 and TLR3, seem most relevant to macrophage and
VSMC activation, they remain relevant to the more general
theme of initiation through activation of the innate immune
response by hyperlipidemia and may apply to endothelial
activation as well. Further research regarding TLR4 signaling in endothelial cells would be necessary to confirm this
generalization. Nevertheless, TLR activation by hyperlipidemia in general is discussed here in a single section. Of
considerable importance in this regard is the role of
mmLDL in activating TLR4. In macrophages, mmLDL
transmitted signals via TLR4 after specific binding to CD14
(1211), whereas for oxidized phosphatidylcholine, a different TLR4 adapter appeared to be involved (1892). Monoand polyoxidized cholesteryl arachidonate was found to be
a key component of mmLDL that mediated TLR4 activation. Such oxidized cholesteryl esters could be generated by
exposure to 12/15-LO (721). In addition, mmLDL led to
1387
Both TLR2 and TLR4 are present on endothelial cells and

can mediate inflammatory signaling. For example, both receptors were shown to induce endothelial expression and
secretion of bone morphogenic protein 2 (BMP2) through
NF-B and ERK1/2 activation after exposure to oxLDL
(1692). TLR4 binds LPS (and some other ligands) by way of
the coreceptor CD14 after LPS is bound in serum to the
acute phase reactant LPS binding protein (LBP, produced in
liver). The LPS is then presented to the extracellular adapter
MD2 (also known as lympocyte antigen LY96) to facilitate
TLR4 signaling. CD14 is expressed by human endothelial
cells but at considerably lower levels than in monocytes, yet
it is upregulated in endothelial cells by LPS as well as LPA
(849).
row deficient in TLR2 (731). Localized application of a

synthetic TLR2-specific ligand to the femoral arteries of
ApoE KO mice increased atherosclerosis at that location
(1564). Importantly, endothelial expression of TLR2 was
increased in areas of disturbed flow while that of TLR4 was
not (1247). Furthermore, TLR2 blocking antibodies had a
greater effect in mixed cell cultures from human carotid
plaques to decrease NF-B, MCP-1, and MMP production
compared with blocking TLR4 (1226).
PAUL N. HOPKINS
RAGE
WBC, platelets,
bacteria
CRP, HSP70,
apoptotic
bodies
oxLDL, oxHDL
electronegative LDL
carbamylated LDL
TGRL remnants
AGE, lyso-PC
TLR2
oxLDL, gly-LDL, AGE
TLR4
HSP60/70/90 RP105
oxLDL
NOX1/2
TLR4
mmLDL
PEIPC
LPS, SFA,
FN-EDA
MD1
MD1
MD2
MD2
LBP
CD14
LOX-1
MMP1
Rho
Rac1
Ras
Rac1
ARHGEF1
TNF
TIRAP
BMP4
SMADs
MyD88
PKC
ERK1/2
ROCK2
CASP8
TRIF
IRAK1
RIP1 TRAF3
FADD
TRAF6
U
U
U
U
TANK
UU
U
IKK
U TBK1
ROS
Src
TRAM
IRAK2
NF-B
PKC
Syk
IRAK4
MIB1/2
Oct1
PI3K
Bcl2
Bcl-xl
Bad
PKC
Bax
JNK
SOD1
TAK1
IKK2
p38
Apoptosis
JAK
JNK
STAT3
IB
NF-B
IRF3/7
NF-B
STAT3
IFN / etc.
IRF3/7
MCP1, ET-1, IL8, ICAM-1, HO-1, etc.

AP1
Dyslipidemia, HTN, DM,

ANGII, ET-1, AGE, disturbed flow
NF-B
ICAM-1, VCAM-1, MCP1, IL-1, IL-6,
IL-8, Gro, TNF, E-selectin, P-selectin, LOX-1,etc.
LOX-1, NOX4, CD40, CD40L; CYP, ARE genes

Oct1
1388
JNK
U
U
ECSIT MEKK1
eNOS
PKB

TLR4 tyrosine phosphorylation, binding and activation of
Syk, with downstream activation of the GEF, Vav1 which
can activate Ras, Rac1, Rho, and Cdc42. Other effectors
including PLC and PI3K are also activated. These led to
macrophage cell membrane ruffling and promoted NOX2,
ERK1/2, and JNK activation and associated proinflammatory signaling (318, 319, 1210).
Saturated fatty acids have been reported to activate TLR4
while polyunsaturated fatty acids, particularly n-3 appear
inhibitory (1088). However, further study suggests that
palmitate and to a lesser extent, stearate, rather than binding directly to TLR4, are converted to ceramide with activation of PKC, ERK1/2, JNK, and p38 which then act to
amplify downstream TLR4 responses to LPS by threefold
(as measured by IL-6 and IL-8 production) (1574). Incubation of aortic explants from wild-type and TLR4 KO mice
with palmitate for 6 h also led to TLR4-dependent activation of PYK2 (890).
C-reactive protein (CRP) (561, 1621). Note, however, that

transgenic CRP overexpression studies and a recently reported CRP knockout have failed to demonstrate any
proatherogenic effect for CRP (see TABLE 9) (1778), consistent with the lack of causal effects in human Mendelian
randomization studies (474).
Importantly, LOX-1 is not expressed constitutively but is
induced by most of its ligands, including oxLDL, as well as
factors which upregulate NADPH oxidase, such as ANG II.
LOX-1 is strongly expressed on endothelial cells over human atherosclerotic plaque or associated vaso-vasorum as
well as other cells in plaques (1184). LOX-1 expression is
increased by high-cholesterol diet in ApoE KO mice, in
hyperlipidemic rabbits, diabetic rats, hypertensive rats, and
after exposure to various cytokines, particularly TNF-
(1020, 1182, 1184) as well as acute, but apparently not
chronic laminar shear stress (403, 1255).
Early studies with oxLDL demonstrated powerful proinflammatory and apoptotic effects when incubated with endothelial cells. Subsequent studies identified lectin-like oxidized LDL receptor 1 (LOX-1), coded by the OLR1 (oxidized LDL receptor 1) gene, as a scavenger-type receptor
expressed on the surface of endothelial cells which likely
mediated these effects (1545). LOX-1 is also expressed on
monocyte/macrophages and platelets, but unlike macrophages, LOX-1 is the only scavenger-type receptor expressed highly on endothelial cells. LOX-1 is yet another
PAMP-recognizing receptor with a key role in innate immunity (728), being activated by certain gram-positive and
gram-negative bacteria, apoptotic bodies, senescent red
blood cells, activated white blood cells (WBC) and platelets,
advanced glycation end-products (AGEs), lysolecithin, and
LOX-1 ligation also results in powerful proapoptotic and inflammatory responses due to inactivation of PI3K and PKB
(1040, 1082). A major mechanism for these effects appears to
be formation of a complex on the receptor cytoplasmic tail
which includes ARHGEF1 and ROCK2. ARHGEF1 and
MMP1 together activate RhoA (not found in the complex)
which then activates ROCK2. Direct phosphorylation by
ROCK2 inhibits eNOS and PI3K activity (1158). RhoA
may also suppress PI3K through an effect on the actin cytoskeleton. Serine phosphorylations by ROCK2 (and
ROCK1) directly activate MLC while inhibiting MYPT1,
leading to increased myosin phosphorylation, endothelial
contraction, and opening of paracellular junctions to facilitate leukocyte transmigration. Importantly, ROCK2 is
known to activate NF-B in endothelial and other cells.
FIGURE 13. Activation of endothelial cells through LOX-1, RAGE, and TLR4 signaling. 1-Palmitoyl-2-epoxyisoprostane-sn-glycero-3-phosphorylcholine (PEIPC) is one of several oxidized phospholipids that can activate TLR4. Comparable pathways are present in macrophages which can
lead to activation and foam cell formation. CASP8, caspase-8; FN-EDA, fibronectin extra domain A, also termed EIIIA. FN-EDA is an alternatively
spliced FN seen accumulating in artery walls and even plasma of aging mice which can bind and activate TLR4. See text for other abbreviations
and additional explanation.
1389
C. Role of the Oxidized LDL Receptor 1
More complete understanding of LOX-1-mediated intracellular signaling has been frustrated by the lack of usual cytoplasmic domains (1081). Some of the identified pathways
are depicted in FIGURE 13. Octamer binding transcription
factor 1 (Oct1) is an apparently proatherogenic transcription factor activated by LOX-1. PKC activation appears
key in activating Oct1 (1792). Overlapping DNA binding
sites between Oct1 and Nrf2 may lead to suppression of
antioxidant responses generally (627). Oct1 also appears to
repress several CYP enzymes (CYP1A1, CYP2A6/7,
CYP2B6, CYP2C8, CYP2C9, CYP2J2) which can synthesize vasodilatory products such as 11,12-EET. Oct1 may
also be the means through which PKC increases CD40 and
CD40L expression (1019).
ECSIT (evolutionary conserved signaling intermediate in

Toll pathways) is importantly involved in TLR signaling
through effects mediated by TRAF6. ECSIT is thought to
act as an adapter to directly promote MEKK1 activation.
More recently, ECSIT was recognized as a component of
mitochondrial electron transport complex I. TRAF6 can
ubiquitinate ECSIT, the two forming a complex on mitochondria which can promote association with phagosomes
and greatly increase mitochondrial superoxide production
(1945). Its relationship with atherosclerosis is apparently
unknown.
PAUL N. HOPKINS
sclerosis progression (829). Generalized KO of LOX-1 reduced atherosclerosis 50% in a high cholesterol/fat fed
LDLR KO model and preserved endothelial function
(1185). Overexpression of LOX-1 in coronary arteries in
ApoE KO mice leads to an atherosclerosis-like vasculopathy (825).
LOX-1 activates Rac1 with a burst in NADPH oxidase

activity by an unknown pathway (1694), but the increased
ROS further activated JNK which promotes an oxidizing,
proapoptotic milieu by stimulating ubiquitination and degradation of SOD2 (1739). The ROCK inhibitor fasudil led
to a 54% reduction in atherosclerosis in ApoE-null mice
(1984), confirming a prior observation using another
ROCK inhibitor in LDLR KO mice which resulted in a 35%
reduction in aortic sinus lesions (1128). Finally, activation
of the Ras, Raf, ERK1/2 cascade leads to increase PAI-1
expression in response to oxLDL through the LOX-1 receptor (1536).
Other modification of LDL may also be sufficient for endothelial activation. Thus exposure of LDL to a proteinase
and cholesteryl-esterase resulted in LDL that stimulated
IL-8 release by incubated endothelial cells, an effect that the
investigators attributed to free fatty acids (1716). Possibly,
the treatment caused conversion of LDL to an electronegative LDL and activation of LOX-1. On the other hand, these
findings may be consistent with recent studies demonstrating that exposure of endothelial cells to saturated fatty acids
leads to a somewhat delayed activation of endothelial cells
through a mechanism dependent on TLR4 and NADPH
oxidase as well as downstream activation of NF-B (1131).
Feeding mice a diet high in saturated fat resulted in similar
activation (905). Incubation with LDL at concentrations of
220 mg/dl (LDL-C), isolated with scrupulous care to avoid
oxidation or other modification, also activates endothelial
cells in culture (2114). However, whether such high concentrations may have included nonoxidatively modified
LDL, such as electronegative LDL, is not clear.
If oxLDL were the only lipoprotein to bind to the LOX-1

receptor, its relevance to early endothelial activation would
not be so readily apparent for reasons noted above. However, in addition to oxLDL, LOX-1 is bound and strongly
activated by electronegative LDL (1082). This finding is
consistent with a substantial literature demonstrating the
endothelial activating and apoptotic potential of electronegative LDL. These particles can be formed by a number of
nonoxidative mechanisms as well as by oxidation (1535).
Electronegative LDL are found in a much higher proportion
of plasma LDL (up to 10% of normolipidemic LDL) than
oxidized LDL. A variety of relevant mechanisms may be
responsible for their formation. For example, in addition to
oxidation, glycation, enrichment with nonesterified fatty
acids, treatment with cholesteryl esterases, phospholipase
A2, PAF-AH (platelet activating factor acyl hydrolase, also
called LpPLA2), and, importantly, sphingomyelinase all
lead to electronegative LDL (1348, 1535).
LDL themselves seem to carry a sphingomyelinase activity
that promotes formation of electronegative LDL and that
promotes LDL aggregation as seen in subendothelial,
trapped LDL (103). Furthermore, sphingomyelinase and
other enzymes capable of modifying LDL and promoting
aggregation, are present in the artery wall and likely promote aggregation of LDL (1348).
Additional potential mechanisms for the atherogenicity of

TGRL remnants have been reported. TGRL may activate
endothelial cells or promote increased responsiveness to
subsequent activation without any need for modification (2,
430, 1319). Apo CIII, which accumulates on TGRL, in
some way appears to activate PKC and thereby inhibits
protective Akt signaling in endothelial cells (891). Postprandial TGRL isolated after a cream meal (as compared
with fasting TGRL) were particularly pro-inflammatory
(1316). Apo CI, which inhibits removal of TGRL, elevates
levels of these lipoproteins when over-expressed and increases atherosclerosis in ApoE-deficient mice (346), but
pro-atherogenic alterations in TGRL composition with increased apo CI expression is also a possibility.
D. RAGE Is Activated by Hyperlipidemia
LOX-1 can also mediate inflammatory responses to triglyceride-rich lipoproteins (TGRL) and their remnants (1382,
1626). Interestingly, pioglitazone, through PPAR, blocked
LOX-1 signaling and the LOX-1 mediated increase in
monocyte binding to endothelial cells (1183).
RAGE (receptor for advanced glycation end-products) is

present on endothelial cells, and, like TLR4 and LOX-1,
can activate endothelial cells by overlapping intracellular
signaling pathways (see FIGURE 13). Knowledge of the actual transduction pathways through the cytoplasmic tail of
RAGE remains incomplete, but receptor ligation by a number of RAGE ligands activates NF-B, JNK, and the JAKSTAT3 pathway (1486).
Particles that bind to LOX-1 appear to be relevant in vivo

because overexpression of LOX-1 in the liver to remove
such particles from plasma led to virtual arrest of athero-
RAGE is generally considered in the context of diabetesrelated modifications to proteins or LDL. AGE accumulates
as products of nonenzymatic reactions between glucose and
1390
Thus LPA binding to its G13-coupled GPCR on endothelial cells activates a RhoGEF followed by RhoA activation
of ROCK2. ROCK2 then phosphorylated its immediate
substrates within 5 min, followed by peak Ser536 phosphorylation of the p65 subunit of NF-B at 30 min and
ICAM-1 and VCAM-1 expression within 4 h (1623).

the lysine on proteins (yielding carboxy-methyl lysine adducts) or the more reactive methylglyoxal reacting with
arginine (with the latter also found in tissues of fat-fed mice)
(1803). Diabetes and glucose-derived AGE clearly contributes to endothelial activation and atherosclerosis (1275,
1660). However, hyperlipidemia without diabetes also generates a substantial load of ligands for the RAGE. Indeed,
52% reduction in atherosclerosis was seen in nondiabetic,
ApoE KO mice that were also deficient in RAGE while
those expressing endothelial cell-specific dominant-negative RAGE mutations had more than 70% reduction (718).
Similar reductions were seen for RAGE-LDLR double KO
mice (1711). Activated inflammatory cells in early lesions
can release other ligands for RAGE including S100/calgranulins and high-mobility group box 1 (HMGB1) (718).
Thus RAGE represents yet another pathway for endothelial
cell activation.
AGE-R3 (also known as galectin-3) may serve as both an

AGE clearance receptor and a mediator of macrophage endocytosis of modified LDL (1266). In fat-fed C57BL/6J
mice, AGE-R3 deletion increased atherosclerosis and was
associated with increased Th1 cell infiltration into lesions
(813). However, after 36 44 wk in ApoE KO mice athero-
E. LPC- and LPA-Mediated Signaling in

Endothelial Activation
Generation of LPC in trapped LDL may be among the earliest relevant pathways of endothelial activation through
activation of PYK2 (1488). LPC content of LDL is increased
markedly by oxidation (with subsequent hydrolysis by
PAF-AH), but LPC is also formed from nonoxidized precursor by sPLA2 activity. Which of these potential pathways is quantitatively most important is unknown. LPS
may be similarly formed. LPC signaling resulted in PYK2
activation which was evident in endothelial cells of the
aorta as soon as 7 days after starting a Western-type diet in
ApoE-deficient mice (890). However, this study did not
identify the particular GPCR that activated PYK2 by LPC,
only that it was coupled to Gi.
G2A (also known as GPR132 and having higher affinity)
and GPR4 were reported as GPCR which were thought to
recognize LPC and LPS as ligands. Certainly, LPC seems to
mediate a great deal of proinflammatory signaling in a number of relevant cells, including endothelial cells (1156). But
apparently, early evidence on LPC binding to G2A and
GPR4 could not be reproduced, followed by retraction of
the original articles (1156). Which GPCR mediates LPC
induced PYK2 activation apparently remains unknown.
One study reported that G2A was inhibited by LPC and
that G2A is activated instead by an extracellular reduction
in pH (1252). G2A deficiency has been reported to decrease
atherosclerosis (1386) or increase it (171). Apparently,
macrophage G2A is protective because normal G2A activity promotes early apoptosis of macrophages with less accumulation. Yet G2A also enhances efferocytosis and a less
inflammatory M2 phenotype (171).
Based on the observation that LPC is converted to LPA by
endothelial extracellular ATX, perhaps the proinflammatory effects attributed to LPC can be largely attributed to
LPA instead. Indeed, a great deal of interest has been devoted to development of ATX inhibitors but apparently
effects on atherosclerosis have not yet been tested (42).
Interest further intensified after the discovery of several (at
least 6) LPA receptors (LPA1 6 encoded by genes LPAR1
5). LPA1 6 show variable and overlapping G protein coupling and some can activate PYK2 as well as the CBM
complex (through -arrestin2 binding) with NF-B as a
downstream target (426, 1383, 1708, 1714). Adenosine
receptors P2Y5 and P2Y10 seem also to be LPA targets
(316). Unsaturated LPA species have generally been found
most active (316). LPA has long been known to both activate human platelets and to be released by activated platelets (1514, 1631). The platelet activating effect appears me-
1391
Besides the inflammatory RAGE receptor, there are two

AGE clearance receptors, AGE-R1 and AGE-R3 (1661).
Both promote endocytosis and removal of AGE. Additionally, an important anti-inflammatory mechanism for
AGE-R1 appears to be binding of EGFR and inhibition of
EGFR transactivation in response to AGE exposure (238,
239). AGE exposure results in a marked increase in tyrosine
phosphorylation status of the cytoplasmic tail of EGFR,
possibly by generation of active Src and/or ROS and resultant inhibition of phosphatases. Activation of EGFR results
in activation of PKC (through phosphorylation of tyrosines 311 and 332), phosphorylation and assembly of
adapter proteins p66Shc, Grb2/Sos, subsequent activation
of Raf and the ERK MAPK pathway as well as activation of
NF-B. Activated PKC phosphorylates the p47phox component of NOX, promoting its translocation to the membrane, NOX activation, and further increased ROS production. AGE receptor 1 (AGE-R1) forms a complex with
EGFR, binds AGE, and buffers or inhibits the activation of
EGFR (239). PKC would also be expected to activate
PYK2 with its numerous proinflammatory effects. Transgenic overexpression of AGE-R1-protected mice from diabetes induced by a high-fat diet and decreased intimal hyperplasia and inflammation caused by arterial wire injury in
fat-fed animals (1803). AGE-R1 expression can be upregulated by its ligands but is repressed by prolonged exposure
to pro-oxidant stress. Thus increased AGE-R1 expression
was seen with a diet low in AGE which also was found to
extend life in mice, while increased oxidant stress in diabetes or high AGE diet led eventually to downregulation of
AGE-R1 (239, 1661).
sclerosis was actually decreased in AGE-R3-deficient animals. However, there was a trend in the opposite direction
in younger animals.
PAUL N. HOPKINS
diated by adenylate cyclase-inhibiting LPA5 (with Gi coupling), probably together with effects from other LPA
receptors. However, in mouse, the predominant effect of
LPA is inhibition of platelet aggregation by LPA4 (with Gs
coupling).
These findings have important implications and should redirect therapeutic investigation to the LPA receptors. LpPLA2 actively converts oxidized phospholipids to LPC
(1129). An inhibitor of Lp-PLA2, darapladib, inhibited atherosclerosis in prior animal studies and was found to reduce
in necrotic core size in a human study (1594). Darapladib is
currently being tested in larger phase III clinical trials
(1509). A more direct approach may prove to be blocking
LPA formation by inhibiting ATX or development of specific LPA receptor inhibitors.
F. Redundancy in Endothelial Activation

Pathways
Perhaps the major message behind FIGURE 13 and the above
discussion is the redundancy of pathways potentially leading to endothelial cell activation. Modified lipoproteins
may activate endothelial cells by way of TLR2, TLR4,
LOX-1, RAGE, or LPA1/3. The TLR4 and RAGE responses may require oxidative changes, as found in
mmLDL or oxidized phospholipids, but may also be triggered by saturated fatty acids (for TLR4), while the LOX-1
response appears to include a broader array of triggers.
An intervention that focuses on only one of these redundant
proinflammatory endothelial pathways, such as oral antioxidants (even acknowledging the limitations of the antiox-
1392
VI. INITIATION OF ATHEROSCLEROSIS:

LEUKOCYTE TRANSMIGRATION AND
ACTIVATION
A. Purinergic Signaling
ATP, ADP, and adenosine are among the most ancient and
widely utilized extracellular signaling molecules. The relatively high ATP concentrations in living, viable cells (1,000fold higher inside RBC versus plasma) makes ATP a useful
alarm or danger signal when found at higher levels
outside of cells. ATP can act as a relatively short range
chemoattractant, a find me signal marking apoptotic
cells for phagocytosis (473), or stimulate endothelial cell
migration (759). ATP is released from vesicles as a cotransmitter by numerous neurons (235). It can potentiate acetylcholine-induced muscle contraction, mediate nociception,
control O2 sensing in the carotid body, and activate tubuloglomerular feedback in the kidney. ATP is hydrolyzed to
ADP, AMP, and adenosine by extracellular ectonucleotidases.
In migrating phagocytes, release of ATP through connexin
(Cx) or pannexin (Px) hemichannels at the leading edge
serves in an autocrine fashion to amplify chemoattractant
signals (955). Between adjacent cells, a connexin hemichannel on each cell joins to form a gap junction with the capability of transmitting between cells electrical, calcium, or
other chemical signals relevant to purinergic signaling. Finally, a series of purinergic receptors have been defined that
are activated by ATP, UTP, ADP, UDP, or adenosine. They
include four P1 family GPCR (metabotropic receptors) activated by adenosine (A1R, A2AR, A2BR, A3R), seven P2X
family ligand-gated cation channels (ionotropic receptors)
which only respond to ATP, and eight P2Y GPCR. A2AR
antagonism appears to be caffeines primary mechanism for
mediating alertness (797), although caffeine also has affinity for A1R and heterodimers of the two receptors may
better reflect complex effects and caffeine tolerance (524).
Perhaps most familiar to clinicians are the purinergic receptors for ATP (facilitating Ca2 entry via P2X1) and ADP
LPA accumulates in human atheroma (188) and promotes

monocyte-platelet aggregates (1631). LPC is generated in
mildly oxidized lipoproteins by the action of Lp-PLA2 (lipoprotein-associated phospholipase A2). LPA is synthesized from this LPC when endothelial cells or carotid arteries are incubated with mildly oxidized lipoproteins. LPA
was recently shown to stimulate elaboration of the cytokine
CXCL1 (also known as GRO), as well as stimulate
Weibel-Palade body exocytosis with expression of P-selectin on endothelial cells resulting in enhanced monocyte rolling and capture. CXCL1 is also important for neutrophil
capture and migration. These effects are apparently mediated by LPA1 and LPA3 which can both be coupled to Gi or
Gq/11 with LPA1 additionally coupled to G12/13 (316).
PYK2 signaling is also activated. Treatment of ApoE-deficient mice with LPA (with arachidonate as the fatty acid)
approximately doubled atherosclerosis while an inhibitor
of LPA1/3 or antibodies directed at either LPA1 or LPA3
reduced atherosclerosis 40% (2110). Since the implicated
LPA1/3 receptors are Gi-coupled, the results are consistent
with reported activation of endothelial cells incubated with
LPC activating PYK2 through Gi GPCR coupling (890).
idants tested thus far), might be expected to be ineffectual in

reducing coronary events. This holds even if lipoprotein
oxidation was causal. Redundancy seems to be the rule for
pathways vital to the survival of the organism. For the endothelium, the key roles that various forms of activation
play in defense against microorganisms, repair or angiogenesis, as well as in clearing the bloodstream of senescent or
apoptotic debris all seems self-evident. In this sense, it may
be disingenuous to describe the state of endothelial activation associated with dyslipidemia as dysfunction. Indeed,
the cells are likely performing admirably well and as expected in response to perceived threats.

(P2Y1, P2Y12) that trigger platelet shape change and aggregation, respectively. The widely used antiplatelet thienopyridine drug clopidogrel was developed before the purinergic receptors were recognized but is now known to irreversibly bind and inhibit the P2Y12 receptor. Newer
thienopyridines, prasugrel and ticagrelor, are also P2Y12
blockers. The remaining purine receptors represent a rich
and relatively untapped source of pharmacological opportunities for cardiovascular intervention (486).
sclerosis (see TABLE 5). CD73-deficient endothelial cells express more adhesion molecules (665).
Anti-inflammatory signaling by adenosine may largely be
through A2BR, with upregulation of CD73 expression on
the endothelial cell surface as well (1551). Deletion of A2BR
increased catheter-induced intimal VSMC hyperplasia, together with increased TNF- expression, effects probably
mediated by bone marrow-derived platelets (2019); yet increased expression of adhesion molecules was seen on endothelium of whole body A2BR KO mice (16). A2BR activation increases cAMP, which is generally anti-inflammatory
and also specifically downregulates expression P2Y1 ADP
receptors in platelets (2018).
In contrast to generally anti-inflammatory A2BR signaling, whole body A2AR deficiency resulted in a 24% reduction of atherosclerosis largely due to a marked reduction in macrophage numbers. Plaques, although smaller,
displayed markers of greater inflammation, with impaired PKA activity (1898). Other effects of A2AR signaling include increased ABCA1 transporter expression and
cholesterol efflux (149) and increased ANG II-induced
NOX2 activation (1779).
P2Y12
ADP
RBC
hypoxia
low pH
Platelet
Monoc
Monocyte
q
Monocyte
Cx37
P2Y1
i
cAMP
Ca2+
cAMP
ATP
Px1
NO
q
i
TPs
PARs
13
P2Y22
P2Y
P2X1
ATP
CD39
ATP
ADP, AMP
ADP
Adenosine
CD73
P 1& 2
P2Y
A2BR
PI3K
Flow
P2Y2
s AC
eNOS
PKB
ATP
VCAM-1
P2X4
eNOS
Cx40
Ca2+
cAMP
EET
PGI2
NO
NO
Cx43
Vasodilation
Vasoconstriction
Ca2+
Cx43
Cx43
Vascular
smooth muscle
K+
P2Y2
P2Y6
P2Y12
P2X1
FIGURE 14. Examples of purinergic signaling. CD39 is also known as NTPDase1 (nucleoside triphosphate
diphosphohydrolase 1). Endothelial P2Y receptors are Gq coupled and stimulate PLC and IP3 release, which
activates IP3R to promote release of ER-stored calcium. Calcium release activates cPLA2 with liberation of free
arachidonate followed by prostacyclin and EET synthesis and secretion. Px1, pannexin 1.
1393
The relevance of purinergic signaling to atherosclerosis has

been illustrated by a series of genetic mouse models (1551).
Monocyte Cx37 serves as a hemichannel for release of ATP
(see FIGURE 14). ATP and ADP purinergic signaling is proinflammatory (probably through endothelial P2Y1, P2Y2,
or P2X receptors), even though these receptors also mediate
rapid ATP-induced vasodilation (1059, 1596, 1646). Nevertheless, Cx37 KO mice had increased atherosclerosis (see
TABLE 5). The effect was entirely due to leukocyte release of
ATP, since endothelial-specific Cx37 KO had no effect on
atherosclerosis (1974). This protective effect of ATP appears to be due to rapid conversion of ATP and ADP to
adenosine by the sequential action of the two endothelial
cell-surface ectonucleotidase enzymes CD39 and CD73.
KO of either of these ectonucleotidases increased athero-
PAUL N. HOPKINS
Table 5. Purinergic signaling in endothelial and other cells (9 genes tested)

Gene
Model
% A
Cx37/ BMT into

apoE/
158%
CD39
CD39/ apoE/
1108%
CD73
Cx40
CD73/ apoE/
endothelial-specific Cre-Lox
Cx40/ in apoE/
mice
1150%
1117%
Cx43
Cx43/ LDLR/
250%
A2AR
A2AR/ BMT apoE/
232%
A2BR
A2BR/ apoE/
167%
P2Y1
P2Y1/ apoE/
224%
P2Y12
P2Y12/ in C57BL/6
Monocyte Cx37 serves as a hemichannel for release of ATP to endothelium.

Cx37 KO monocytes showed enhanced recruitment to atherosclerotic
lesions. Endothelium-specific Cx37 KO had no effect on atherosclerosis
(1974).
CD39 is an ectonucleotidase, converting ATP and ADP to AMP. The
heterozygous KO had a greater increase in plaque than the double KO
(just 33% increase) possible due to paradoxical 91% decrease in platelet
activity in the double KO (812)
CD73 is another ectonucleotidase. It converts AMP to adenosine (195).
Also known as GJA5 (gap junction protein alpha-5). Shown here is effect on
lesion area in thoracoabdominal aorta. No effect seen in aortic sinus
except very early lesions in chow-fed mice. Endothelial adhesion molecules
were increased. Whole body Cx40 deficiency causes hypertension which
was avoided by endothelial-specific expression (268).
Cx43 is upregulated in athero-prone areas and by onset of shear stress.
Heterozygous KO also had decreased inflammatory cell accumulation
(967).
Both whole body and hematopoeitic deficiency of A2AR KO showed modest
reduction in plaques. More macrophage apoptosis and greater
inflammation seen (1898). Net decrease in plaque even though A2AR
signaling upregulates ABCA1 and inhibits IFN- signaling in macrophages
(1884).
Increased atherosclerosis due to worse hyperlipidemia in these mice (data
for 16 wk shown). BMT of A2BR/ apoE/ marrow did not cause
hyperlipidemia or increase atherosclerosis. Hepatic A2BR-derived cAMP
normally suppresses SREB-1c. Unclear if an additional direct effect on
artery wall is present (941). Larger lesions with increased chronic TNF-
expression after catheter injury seen in A2BR/ mice (2019).
Effect due entirely to endothelial/VSMC expression, not platelets or other
leukocytes based on BMT experiments (741).
Less intimal proliferation in endothelial injury models. BMT studies
suggested importance of platelet P2Y12 and inhibition with clopidogrel
(490).
Cx homodimers form gap junctions between cells and can

transmit either pro- or anti-inflammatory signals, depending on the specific substrates transported by the channel
(such as electrical currents, ionized calcium, and even
cAMP). Permeability can be controlled by various intracellular signaling molecules. Cx40 may allow anti-inflammatory cAMP to diffuse between cells. Endothelial Cx40 is
widely expressed in the endothelium of mice and rats (268,
572) except in cells covering advanced atherosclerotic
plaques (268). Whole body Cx40 deficiency causes hypertension due to renal effects. Endothelial-specific Cx40
did not affect blood pressure, but nevertheless increased
atherosclerosis, suggesting a protective role for Cx40
(268). Decreased CD73 expression was also seen in these
mice (see TABLE 5). In contrast, in rat aortic endothelium,
Cx43 expression was increased in areas of rapid flow
such as flow dividers and was upregulated at the narrowest point of a surgically placed ligature (572). Nevertheless, Cx43 expression was seen in intimal VSMC from
early in human plaques and was increased in VSMC
found in shoulder regions of plaques in hyperlipidemic
mice (1551). Cx43 is thought to transmit proinflamma-
1394
tory calcium signals between various cells (1551).

Heterozygous KO of Cx43 decreased atherosclerosis and
also suppressed inflammatory cell accumulation in
plaques (967) (see TABLE 5).
Potential effects of purinergic P2 receptors are only beginning
to be explored using genetic mouse models (see TABLE 5).
P2Y1 deficiency modestly decreased atherosclerosis in
ApoE-deficient mice. Interestingly, the effect was due entirely to vessel wall expression, rather than hematopoetic
cells including platelets (741). P2Y1 signaling upregulates
eNOS in endothelial cells, but the intermediate pathways
are not well understood (372, 759). As P2Y1 is Gq coupled
(1950), one might expect activation of PYK2 and subsequent ERK1/2 activation as the explanation for eNOS activation together with an overall proatherogenic effect.
P2Y12, although prothrombotic, had a neutral effect on
atherosclerosis (see TABLE 5). The P2Y6 receptor, a Gqcoupled receptor activated by UDP, seems to be important
in promoting macrophage accumulation and activation in
atherosclerotic plaques and selective pharmacological inhibition reduced atherosclerosis in ApoE KO mice (673).
Cx37
Function, Comment
B. Adhesion Molecules, Chemokines, and

Leukocyte Transmigration
1. Activated endothelium induces leukocyte rolling
then firm adhesion
The activation pattern of selectins, chemokines, and integrins controls the migration activity of leukocytes and provides a kind of address for their homing to specific tissues.
Activated endothelial cells express on their surface the adhesion molecules P-selectin and E-selectin. These loosely
capture passing monocytes (as well as other leukocytes),
causing rolling along the endothelium due to alternate
forming and breaking of relatively loose bonds with cognate leukocyte receptors, PSGL-1 (P-selectin glycoprotein
ligand 1) and ESL-1 (E-selectin ligand 1), as depicted in
FIGURE 15. PSGL-1 is also expressed on activated endothelial cells. In addition to both P- and E-selectin, PSGL-1
recognizes L-selectin which is found on virtually all leukocytes. Genetic deletion of selectins and their receptors
causes modest reductions in atherosclerosis (see TABLE 6).

Genetic models of chemokines and their receptors, together
with integrin binding and their target binding molecules,
are also reviewed in TABLE 6.
The selectins and their ligands should not be viewed as
inert hooks and loops like some kind of cell-surface Velcro. Rather, binding of E-selectin and PSGL-1 (the best
studied binding pair) causes clustering of both receptors
and selectin ligands, followed by bidirectional signaling
in both the endothelial cell and the leukocyte, as indicated in FIGURE 15. Adaptor molecules which bind the
cytoplasmic tails of the selectin or PSGL-1 molecules
mediate the signaling. For E-selectin, intracellular adaptors and their effectors are reminiscent of those found in
focal adhesions and include -actinin, filamin, vinculin,
and paxillin with subsequent activation of FAK followed
by activation of Src, Rho, MAPKs, and NF-B. For the
leukocyte, PGSL-1 interacts intracellularly with ERM
proteins (ezrin, radixin, moesin) which generally link
transmembrane proteins with the actin cytoskeleton and
may assist in transmitting an activating signal to Syk and
other downstream effectors (1842). This signaling prepares the leukocyte for subsequent interactions by causing partial activation of integrins but without high-affinity integrin binding (2004).
2. Chemokines induce high-affinity integrin binding
and set the stage for transmigration
While partially tethered and rolling along the endothelial surface, the leukocyte brushes through the glycocalyx and there
encounters sequestered chemokines (chemotactic cytokines).
Chemokines activate integrins to mediate firm adhesion and
diapedesis and provide a concentration gradient to guide the
direction of leukocyte movement. Systematic names classify
chemokines by the cysteine spacing in their NH2 terminus,
followed by an L for ligand or R receptor and a number. Thus
CC refers to two consecutive cysteines; CXC is two cysteines
with one intervening amino acid, etc. (1764). Among the most
important of chemokines is CCL2 (commonly referred to as
MCP-1). Some of the surface-immobilized chemokines noted
above include CXCL1, CXCL2, CXCL4, and CCL5 in addition to MCP-1 (CCL2). CX3CL1 (fractalkine) is a membranebound chemokine. Some chemokines act to guide leukocytes
into various areas of immune organs (lymph nodes, spleen) for
further maturation. Various combinations of chemokines
work to selectively recruit specific leukocyte subsets to the
inflammatory site. FIGURE 15 depicts some chemokinereceptor pairs that help recruit monocytes, but several are
shared by other leukocytes, particularly neutrophils (580,
2065). The combined deletion of CCL2, CCR5, and CX3CR1
almost entirely abrogated atherosclerosis in ApoE-deficient
mice in proportion to the marked reduction in circulating
monocytes (345).
1395
One additional aspect of purinergic signaling is illustrated

in FIGURE 14, the role of red blood cells in controlling tissue
blood flow. This is of particular interest to investigators
performing studies of endothelial function based on flowmediated dilation. The most commonly used methodology
to stimulate brachial blood flow is to impose ischemia
downstream of the brachial artery. Typically, a blood pressure cuff inflated well above systolic pressure is applied for
5 min, followed by sudden release of the cuff. Ischemia,
imposed by the cuff, is known to cause vasodilation of
resistance vessels. Release of the cuff then leads to rapid
flow through the brachial artery. The increased flow stimulates endothelial-dependent vasodilation, typically monitored by brachial ultrasound. Surprisingly, vasodilation in
ischemic tissue is dependent on the presence of red blood
cells (RBC). This fundamental insight solves years of inquiries regarding how tissues match blood flow with oxygen
demand (475, 486). In the face of hypoxia, G signaling
(both s and i stimulate cAMP production through the
adenylate cyclase type II found in RBC) leads to an increase
in RBC cAMP. This increased cAMP triggers, in a complex
fashion, release of ATP through the Px1 hemichannel
(1670). ATP has an acute vasodilatory effect which requires
P2Y1 and P2Y2 ligation on endothelial cells as shown in
FIGURE 14 (475). In addition, recent studies point to a major vasodilating role for NO released by red cells. Remarkably, deoxyhemoglobin acts as a catalyst to rapidly produce
NO from nitrite in the face of hypoxia, as in exercising
muscle (454). How these newly recognized pathways, together with other mechanisms of local control of blood flow
such as myogenic responses (335), relate to long-term blood
pressure control are questions that remain essentially unexplored and deserve careful attention, particularly with regard to autoregulation as referenced in the Guyton model
of hypertension (6, 679, 928),.
PAUL N. HOPKINS
Monocyte rolling
cAMP
ERM
PSGL-1
E-selectin
Fibronectin
51
P-selectin
Rho
41
ERK1/2
?
Src
Filamin ERM
PYK2
JAMs
Src
Rho
PKC
CysLT1
PLC
Leukocyte
focal adhesion
MyD88
BLT1
ICAM-1
VCAM-1
NF-B
JAK2
-arrestin STAT1

L2
41
NF-B
MAPK
ICAM-1
Rho
Src
PI3K
PLC
Chemokines
i/q
LTC1
12-HETE
LTC4S
LTA4H
13-HODE
LTA4
MAPK
5-LO
12/15-LO
Ca2+
LDL
FLAP
AA
Th1: IFN, TNF, IL-2

Th2: IL-4, 5, 10,13
Th17: IL-17A/F, IL22
CTL: PRF1, GZMB, TNF
LTB4
PI3K
PKC
Mast cell
Cytokines
PLC
cAMP
MMPs
cPLA2
T-cells
Histamine,
Renin, IL-6,
TNF, PAF
AA
BLT1/2
Macrophage
TNF, IL-1,IL-6,
IL-12, IL-12,
IL-15, IL-18
FIGURE 15. Leukocyte recruitment to the endothelium. While monocyte recruitment is depicted, neutrophils
and several other leukocytes follow similar steps. After entry into the intima, monocytes undergo differentiation
into macrophages, represented by the large cell on the left. Other leukocytes and some of their contributions
to the inflammatory milieu are shown. Leukotrienes and 12/15-LO products act as lipid amplifiers of early
inflammation, much like cytokines. ERM, ezrin, radixin, moesin proteins.
Activated endothelial cells secrete CCL2 (MCP-1) which captures passing monocytes. T-cell receptor (TCR) recognition of
antigens presented by endothelial cells can also incite T-cell
integrin activation and T-cell capture. After transmigration
and transformation, activated macrophages or foam cells
themselves secrete MCP-1, providing a positive feedback signal for additional macrophage recruitment. Th1 cells express
CCR5 and CXCR3 and adhere to activated endothelium expressing CCL5, CXCL9, CXCL10, and CXCL11 (without the
need for TCR activation). Th1 cells enter plaque and secrete
1396
IFN which stimulates expression of CXCL10 by VSMC and

CXCL9 and CXCL11 by macrophages and endothelial cells.
Endothelium covering human atherosclerotic plaque was confirmed to express MCP-1, GRO (CXCL1), and IL-8
(CXCL8), and these chemokines could induce attachment and
spreading of test monocytes, demonstrating the relevance of
prior, mostly mouse-based models (1379).
The GPCR which transduce the signals from chemokines are
mostly coupled to G proteins of the Gi type with some Gq
Cathepsin-G
Azurocidin,
Proteinase-3,
TNF, INF,
IL-8, MPO,
LL37, NETs,
Chemerin
Neutrophil
NF-B, 5-LO, LTA4H,

MCP-1, CD36, SRA,
differentiation
Endothelial
signaling
GPR31
BLT1
IL-6, TNF,
MCP-1, MMPs
Chemokines
Outside-in
signaling
Cdc42
ESL-1
MCP-1
(CCL2)
Diapedesis and
transmigration
: Recptor
: CCR1
: CCR2
: CCR5
: CX3CR1
Rac1
LTB4
Syk
CCR2
Inside-out
signaling
Rh
o
BLT1
Chemokine
CCL5
CCL2 (MCP1)
CCL4
CX3CL1
Table 6. Ligands and corresponding cognate receptors in endothelial-leukocyte interactions (43 genes tested)
Endothelium
Model
% A
Leukocyte
E-selectin
(SELE)
E-selectin/ apoE/ (343).

P- & E-selectin/ LDLR/
(at 37 wk) (436).
224%
245%
ESL-1, PSGL-1,
KN1A
P-selectin
P-selectin/ LDLR/
(assessed at 37 wk, NS)
(862).
P-selectin/ apoE/ (343).
P-selectin/ in C57BL/6
(1272).
BMT confirms a modest role
for platelet P-selectin (232)
220%
PSGL-1 (CD24,
CD34)
Model
% A
CD44/ apoE/ (360). CD44 also

binds to hyaluronic acid and
promotes leukocyte attachment to
endothelium and helps regulate
VSMC proliferation. Both bone
marrow derived and endothelial or
VSMC sources apparently
contribute to atherosclerosis
(2090).
PSGL-1/ apoE/ (1089). PSGL-1
(P-selectin glycoprotein ligand) is a
ligand for P-, E-, and L-selectins
and is highly expressed on Ly6-Chi
monocytes. BMT studies showed
PSGL-1 deficient monocytes
actively suppressed endothelial
activation by IL-1.
270%
FucT-VII/ BMT into LDLR/ mice.

Selectin ligands ESL-1 and PSGL-1
express glycans tipped with a
fucosylated and sialylated
tetrasaccharide which is critical for
binding to the lectin domain of the
selectins. Addition of fucose is
mediated by (1,3)fucosyltransferases
(FucT)-IV and VII, also known as Fut7
(619).
C2GlcNAcT-I/ apoE/
Glucosaminyltransferase-I
(C2GlcNAcT-I) adds carbohydrate
groups to many adhesion
molecules. Strongest effect
possibly on PSGL-1. Whole body
C2GlcNAcT-I KO given here. BMT
experiments show most of the
effect is due to leukocyte adhesion
molecules with lesser endothelial
effects (1897).
L-selectin/ apoE/ leads to
reduced lymphocyte entry into
aorta. No assessment of
atherosclerosis (580, 581).
234%
Tethering or rolling
(SELP)
245%
265%
FucT-VII
PSGL-1 (CD24,
CD34)
PSGL-1/ apoE/ (1089)

(see above)
265%
L-selectin (on
multiple cell
types)
250%
Activation (inside-out signaling to activate integrins) and chemotaxis by chemokines

CCL2 (MCP-1)
CCL2/ apoE/ (1443).

CCL2/ apoE/ (1443).
CCL2/ LDLR/ (666).
CCL2/ in human apoB
transgenic mice (644).
Note: MCP-2,-3,-4, and 5
(CCL8, 7, 13, and 12
respectively) also bind
CCR2 in either mouse or
human but direct effects on
atherosclerosis have
apparently not been
studied.
278%
298%
279%
260%
CCR2
CCR2/ apoE/ (666).

CCR2/ apoE/ (179).
CCR2/ apoE/ (390)
CCR2/ apoE Leiden (8 wk high-fat
diet) (675).
CCR2/ bone marrow transplanted
to apoE/ mice (1871).
CCR2 expression and interaction with
ligands MCP-1 and MCP-3 are
critical for monocyte egress from
bone marrow in response to
inflammatory signals (1815).
262%
247%
267%
286%
262%
Continued
1397
C2GlcNAcT-I
265%
PAUL N. HOPKINS
Table 6.Continued
Model
% A
CCL3
(macrophages,
activated
platelets,
neutrophils,
and mast
cells)
CCL5 (RANTES)
(also in VSMC,
platelets)
Also known as MIP-1

(macrophage inflammatory
protein 1). BMT of
CCL3/ marrow into
LDLR/. Marked
reduction of CCL3 seen
(393)
CCL5/ apoE/ early
(965). NS. CCL5/
apoE/ late stage. Also
decreased with BMT
(1446). Another BMT
study found less
inflammatory lesions with
more collagen early; no
difference at 35 wk
(1433). Also involved in
activating medial VSMC to
become lymphoid tissue
organizers in adventitia
(1077).
Also known as MIP-3
(macrophage inflammatory
protein 3). Increased
plasma levels in humans
with hyperlipidemia and in
atherosclerotic plaque.
Increased expression by
VSMC exposed to LDL,
dependent on NF-B (245).
231%
CCR1, 4, 5
CCR1/ apoE/ (205). CCR1 is

found particularly on T-cells. See
below for CCL5.
25%
258%
CCR1, 3, 5
See above for CCR1. CCR5/

apoE/ (205). Increase in
endothelial progenitor cells seen.
CCL5 can be deposited on
endothelial cells from platelets and
then cause neutrophil migration
into early lesions dependent on
CCR5. Neutrophil depletion
decreased 4-week lesions 50%
but not later lesions (445).
1140%
238%
CCR6
230%
145%
lymphorganogenic
chemokines (also CXCL13).
Secreted by cells in lymph
nodes to promote homing
of DC and naive T-cells
(1077)
CXCL1/ LDLR/ (167).
Effects primarily seen for
macrophage accumulation
in established fatty streaks,
not earlier lesions.
CCR6 / apoE/. Similar

reduction with CCR6 / BMT into
apoE/. Reduction of
macrophages in plaque paralleled
reduced monocyte counts in blood.
Required for macrophage
mobilization from bone marrow
(1894).
Adoptive transfer of CCR6/ B-cells
into B-cell deficient (MT) mice.
CCR6 is also required for proper
homing of B cells to aortic
adventitia (437).
Expressed by DC and naive T-cells to
promote homing to lymph nodes.
Also required for T-cell entry into
inflammed plaque. (1084)
CXCR2
(neutrophils,
mast cells,
monocytes)
CXCR2/ BMT into LDLR/

(168).
262%
CXCR2
see above
CXCR3B
splice variant of CXCR3 (see below)
CXCR2
see above
CCL20
(activated
VSMC)
CCL19, CCL21
(activated
VSMC)
CXCL1 (GRO)
CXCL2 (GRO)
CXCL3 (GRO)
CXCL5-8
CXCL4 (platelet
factor 4in
platelets)
CXCL8 (IL-8)
222%
PF4/ in C57BL/6 (1521).

PF4/ apoE/ (1521).
CCL5 and CXCL4 can form
heterodimers and promote
monocyte adhesion to
endothelial cells (2064).
Stored in Weibel-Palade
bodies in endothelial cell.
Mediates both monocyte
and neutrophil adhesion.
KC (CXCL1 is often
considered the mouse
analog).
280%
263%
Leukocyte
CCR7
Model
% A
234%
Continued
1398
Endothelium
Table 6.Continued
Endothelium
CXCL9,10,11
CXCL12 (SDF-1)
CXCL16 (also on
VSMC,
monocytes)
CXCL19, 20
CX3CL1
(fractalkine
expressed
primarily in
VSMC rather
than EC)
% A
CXCL10/ apoE/ (745).

Increased Treg seen in
CXCL10 KO mice. CXCL9,
10, and 11 are all Th1
chemoattractants and
induced by IFN-. CXCL10
is also known as IP-10. It is
produced by EC, VSMC,
and macrophages. CXCL9
(Mig) and CXCL11 (I-TAC)
are produced by EC and
macrophages.
Perivascular siRNA CXCL12
in apoE/ mice after
partial carotid ligation.
CXCL12 attracts SMC
progenitor cells to lesions
with differentiation to
lesional VSMC and
increased fibrous cap
thickness and reduced
macrophage area (34).
However, diseaseassociated human variant
associated with higher
CXCL12 expression
(1186). Role in
atherosclerosis remains
controversial.
VSMC are stimulated by LT
to express CXCL13 and
CCL21 which then direct
lymphoid organogenesis in
aortic adventitia (649).
CXCL16/ LDLR/ (83).
CXCL16 also acts as a
scavenger receptor on
macrophages and this
function may be
atheroprotective. When
cleaved by ADAM10 it can
act as a chemoattractant.
Antibodies to CXCL19 and
CXCL20 decreased
regression after
transplanting
atherosclerotic carotid
arteries from apo E KO
mice into wild-type mice
(1810)
CX3CL1/ apoE/
CX3CL1/ LDLR/
Reductions given for
brachiocephalic artery
(apoE/ NS at aortic root,
while LDLR/ was
significant at both sites.)
(1777).
Combined CX3CL1/ and
CCL2/ in apoE/ mice
showed additive reductions
in atherosclerosis, even
though CX3CL1 is thought
to recruit less inflammatory
monocytes (1525).
240%
Leukocyte
Model
% A
CXCR3
(monocytes,
Th1, mast
cells)
CXCR3/ apoE/ (1871). A clear

reduction was seen early but no
effect at the final time.
0%
1320%
CXCR4
CXCR4/ BMT apoE/

CXCL12/CXCR4 signaling mediates
retention of neutrophils and VSMC
progenitor cells in bone marrow.
KO results in increase neutrophil
count. Helped demonstrated that
neutrophils are involved in
136%
CXCR5
CXCR5/ in C57BL/6 model of

transplant arteriosclerosis (480).
NS
CXCR6 (Th1,
NKT, VSMC)
CXCR6GFP/GFP apoE/ (579).
CXCR7
Induced when carotid arteries from

apo E KO mice were transplanted
into wild-type mice (1810). Also a
receptor for CXCL12 but is not
expressed on human or mouse
leukocytes (127).
CX3CR1
CX3CR1/ apoE/ (344).

Adhesion to CX3CL1 thought to
promote macrophage retention in
artery wall. Exposure to oxLDL
results in increased expression of
CX3CR1 and decreased expression
of CCR2, mediated by PPAR,
thereby promoting retention (111).
CX3CR1/ also decreased DC in
lesions in proportion to reduced
157%
285%
250%
222%
250%
Continued
1399
CXCL13
Model
PAUL N. HOPKINS
Table 6.Continued
Endothelium
M-CSF (also
known as
CSF1.
Secreted by
activated
macrophages
as well.)
ICAM-2
Model
M-CSF/
M-CSF/
M-CSF/
M-CSF/
apoE/ (1648).
apoE/ (1443)
apoE/ (397)
LDLR/ (1454)
% A
Leukocyte
286%
284%
271%
299%
CSF1R
(monocytes)
MAC1, LFA1
Model
% A
anti-CSF1R mAb apoE/

Decreased atherosclerosis seen only
if antibody started early (1257). A
specific inhibitor of CSF1R also
decreased atherosclerosis in
LDLR/ mice (1602).
272%
Slow rolling and firm adhesion (generally after integrin activation), further activation through adhesion molecules
VCAMD4D/D4D LDLR/
(VCAMD4D/D4D has 2-8% of
VCAM/ VCAM-1.
VCAM/ is embryo lethal)
(366).
242%
fibronectin
See table 3 for fibronectin

EIIIA domain defective in
apo E KO mice (1751).
ICAM1/ LDLR/ (366).
ICAM1/ apoE/ (343).
ICAM1/ in C57BL6
(1272).
See above
ICAM-1
E-selectin
ICAM-1, ICAM-2,
fibrinogen,
collagen, iC3b,
LPS
See above for ICAM-1
vWF
See Table 10
collagen,
fibronectin
See above for fibronectin.
collagen
266%
253%
41 integrin
4 or 1 KO IS embryolethal. An 4
(VLA4,
binding peptide (connecting
CD49D/CD29)
segment 1 of fibronectin) was
infused into LDLR/ mice to block
VLA4 binding and signaling (1622).
Decreased neointimal growth with
VLA4 antibody (581). (Note: 47
also binds VCAM-1.)
51
see above for 1
0%
230%
260%
L2 integrin
(LFA1,
CD11a/CD18)
ITGB2/ in C57BL/6. This

effectively knocks out all 4
2containing integrins (1272).
(Note: M2 also binds ICAM-1.)
M2 integrin
ITGAM/ BMT into LDLR/ (957).
(MAC-1,
MAC-1 also bound by GPIb/GPIX/
CD11b/CD18)
GPV complex, possibly CD40L.
X2 integrin
ITGAX/ apoE/ (1986). CD11c
(CD11c/CD18)
can also be considered a marker
for DC. Also see increase in
CD11c positive monocytes in
peripheral blood and greater
activation markers of monocytes
with high fat diet.
GPIb
GPIb/ apoE/ (1689). Some GP
(glycoprotein) receptors are not
integrins while some are.
GPIb()/GPIX/GPV complex is a
nonintegrin receptor complex
which signals through Src family
activation and serves as the main
vWF receptor on platelets.
GPVI
GPVI, complexed with FcRI, is the
main platelet collagen receptor.
Adenoviral over-expression of
soluble or free GPVI (which inhibits
normal GPVI binding) in carotid
artery of cholesterol fed rabbits
decreased atherosclerosis (as
shown). Even greater effect was
seen for anti-GPVI antibody in apoE
KO mice. GPVI binding to
fibronectin also shown (227).
245%
11 integrin
ITGA1/ apoE/ (1550).

Macrophage content of plaques
was decreased and collagen and
VSMC increased. Macrophages
from 1/ mice were unable to
migrate on collagen IV. Similar
phenotype to DDR1 deficiency (see
Table 6)
NS
224%
NS
238%
242%
Continued
1400
VCAM-1,
fibronectin
Table 6.Continued
Endothelium
collagen
Model
% A
Leukocyte
21 integrin
See Table 10 for vWF. See

above for fibronectin.
IIb3 integrin
(platelets)
vitronectin (VN),
Thbs1
VN/ carotid stenosis

intimal proliferation model.
Increase intimal hyperplasia
seen in one study of VN/
mice (398) but less in
another (1402).
Thbs1/ apoE/ (1244).
Thbs1 (thrombospondin 1)
and Thbs2 are type A Thbs
which are endothelialsecreted extracellular
matrix proteins. Initial more
rapid progression then
possible later benefit
cancelled effect. Thbs1
deficient macrophages
showed impaired
phagocytosis (efferocytosis)
and plaques showed more
necrosis and elastic lamina
degradation, and increased
MMP9. Also binds CD36,
and CD47. It may form a
bridge between V3
integrin and CD36 to
promote efferocytosis.
Thbs4/ apoE/ (553). A
type B Thbs. Increases EC
activation also neutrophil
migration, activation
(1423)
(Also bound by L-selectin).
Apparently no studies in
atherosclerosis-prone mice.
V3 integrin
Thbs4
MADCAM1
NS
232%
M2 integrin
47 integrin
% A
ITGA2/ apoE/ In platelets, 21

integrin acts together with GPVI to
promote hemostasis but without
effect when deleted solely (1678).
Anti-inflammatory signaling in EC but
no effect on atherosclerosis (658).
ITGA2B / apoE/ (1150). Aortic
lesion area given. Greater effect on
carotid area (251%).
ITGB3/ apoE/ and LDLR/
(1941). While involved in
transduction of slow flow to
increase endothelial cytokine
production (e.g., IL-8, GRO)
(1600), this integrin is also utilized
in efferocytosis by macrophages
which appears to predominate as
protective (31).
NS
This integrin also binds VCAM-1
220%
1160%
Transmigration
JAM-A/ apoE/
Decreased neointimal
formation after wire injury
(2063).
JAM-A
JAM-B
JAM-C (also in
VSMC)
CD99
PECAM-1
Ab blocking in apoE/ mice

led to decrease monocyte
entry (1597).
antibody to CD99 (1865).
see Table 3
LFA1, JAM-A
VLA4, JAM-C
MAC1, JAM-B
238%
CD99
PECAM-1
see Table 3
Ligands and receptors may be shared by several leukocytes and platelets, but monocyte interactions are
generally emphasized. Several of the chemokine interactions are also involved in leukocyte/VSMC cross-talk in
advanced lesions as indicated. Reference numbers are given in parentheses.
and G12/13 (1604, 1950). Gi, when GTP bound, actively

suppresses adenylate cyclase (AC) activity and thereby reduces
cellular cAMP levels. While neither Gq nor G12/13 proteins
directly inhibit AC, they do not promote cAMP formation and
have downstream signaling effects that, in a number of instances, are directly opposite those of Gs-coupled receptors
and cAMP (1950). The subunits released by these receptors
have a number of effectors of their own including PI3K and
1401
fibrinogen, vWF,
fibronectin
Model
PAUL N. HOPKINS
PI3K (followed by Akt/PKB activation and downstream signaling) and PLC (releasing IP3 and DAG, followed by calcium release and activation of conventional PKCs). PLC is
further activated directly by active Gq/11 binding while
G12/13 directly activates several Rho GEFs (1950). PI3K
production of PIP3 can lead to activation of downstream tyrosine kinases with phosphorylation of Shc followed by Grb2SOS binding to Shc and then ERK1/2 activation. PYK2 activation by Gq/11 receptors has not been examined extensively
in chemokine receptors, at least in relation to atherosclerosis.
PYK2 increases endothelial permeability after leukocyte binding to endothelial ICAM-1 (54). Most chemokine receptors
are found on the leading edge of migrating cells, and the PIP3
formation helps provide polarization and directionality to the
cell.
The global effect of raising cAMP on expression of inflammation-related proteins was recently examined in an insightful
study (1672). Human neutrophils were activated by a cocktail
including LPS, formyl-methionyl-leucyl phenylalanine, GMCSF, TNF- and IL-1. Then, either an A2AR agonist, PGE2,
or a phosphodiesterase inhibitor were added separately to elevate cAMP. Results were remarkably similar for all three
cAMP elevating agents. Transcription of several anti-inflammatory proteins was increased by cAMP elevation, including
A20, COX-2, SOCS3, phosphatases DUSP1 and 2 (dualspecificity phosphatase 1 and 2, which can inactivate MAPK
by dephosphorylating both tyrosine and serine residues),
NR4A3 (nuclear receptor 4A3), and IER-2 (immediate early
response 2, a GAP for G proteins). Downregulated proteins
included pro-inflammatory transcription factors Egr2/3 as
well as TNF-, CCL3, and endothelin-1. While only neutrophils were examined, a variety of anti-inflammatory effects
can be expected as a result of elevating cAMP in other cells as
well. NR4A3 is a transcription factor whose expression is
induced by NF-B. NR4A3, in turn, can induce endothelial
VCAM-1 and ICAM-1 expression but may also provide feedback inhibition in macrophages or other leukocytes (175,
2096). Whole body KO of NR4A3 decreased atherosclerosis,
suggesting the endothelial effect may be predominant (2096).
3. Leukocyte transmigration
The mechanism for inside-out signaling in leukocytes induced by chemokines was reviewed previously. Firm ad-
1402
Activated integrins on leukocytes bind VCAM-1 and

ICAM-1 presented on activated endothelial cells. Macrophages express integrins that specifically bind fibronectin
which is presented by endothelial integrins. Like the selectins, endothelial cell adhesion molecules should not be considered as passive Velcro as binding triggers endothelial cell
intracellular signaling. For example, PYK2 activation, stimulated by leukocyte binding to endothelial ICAM-1, was
shown to help mediate endothelial permeability and leukocyte transmigration (54).
TCR activation leads to integrin activation by a series of
adapters and tyrosine kinases followed by PKC, protein
kinase D (PKD), and Rap1 activation by Rap1 GEFs (231).
Similarly to endothelial cell signaling reviewed previously,
leukocyte integrin binding to various adhesion molecules,
fibronectin, fibrinogen, or other activators result in activation of Src or Src family tyrosine kinases, together with FAK
and PAK which mediate outside-in signaling. Extended lamellipodia and filopodia seek an opportune site for penetration and diapedesis or transmigration of the leukocyte
into the subendothelium. This may occur by passage of the
leukocyte between endothelial cells utilizing interactions
with various gap junction proteins (paracellular migration)
or directly through thinned segments of endothelial cells
(transcellular migration).
Leukocyte transmigration between endothelial cells requires leukocyte integrins and other receptors to interact in
a complex fashion with endothelial gap junction proteins
such as JAMs, PECAM-1, and other transmembrane proteins listed in TABLE 6, sometimes with binding to the same
protein expressed on the leukocyte and endothelial cell (ho-
Newer insights disclose more diverse signaling capabilities of

GPCR (150, 1372). Binding of several different adapter proteins to phosphorylated receptors couples GPCR to numerous
pathways. Thus Src and JAK-STAT signaling can be activated
downstream of -arrestin binding to Gi-coupled receptors.
The adapter CNK1 (connector enhancer of ksr) links G12/13
receptors to simultaneous Rho activation and activation of the
JNK cascade. Gq can bind and activate Rho and Rac1 GEFs.
Activation of MAPK together with intracellular calcium mobilization can activate cPLA2 with release of arachidonic acid
for eicosanoid synthesis.
hesion and diapedesis requires leukocyte integrin activation as shown in FIGURE 15. Briefly, GPCR binding by
chemokines frees subunits to activate PI3K, PI3K,
and PLC followed by generation of DAG and IP3 which
releases ER calcium after binding IP3R. Mobilized calcium can activate the sequence CalDAG-GEF1-Rap1RIAM-talin- integrin (66, 1605). This signaling occurs
in 1 s. Integrin clustering and up-down polarization are
established within 30 s, while spreading, lamellipodia
formation, and crawling with formation of a clear leading and trailing edge occur in 30 300 s (1783). At the
leading edge of the leukocyte, oriented toward the
chemokine gradient, activated G proteins Rac1 and
Cdc42 mediate lamellipodia and filopodia extension by
serving to both orchestrate the machinery of actin microfiber polymerization, which drives membrane protrusion, and to anchor the growing chains to the cell membrane. Toward the rear, active RhoA mediates uropod
retraction. Firmly adherent integrins anchor the cell to
endothelial adhesion molecules in the middle. As the cell
advances, integrins are detached toward the rear of the
cell and recycled by cellular motors to the front.

mophilic binding, such as PECAM-1 on one cell binding to
PECAM-1 on an adjacent cell). Such binding occurs for
PECAM-1, the JAMs, and CD99. In this process, endothelial cells essentially exchange endothelial-endothelial cell
linkages for similar homophilic binding with migrating leukocytes. Actin-myosin contractions in the endothelial cells
(controlled by RhoA signaling analogous to that in leukocytes) further facilitate the opening of endothelial junctions
to allow the transmigration of leukocytes (1018).
VII. CYTOKINES AND INNATE VERSUS

ADAPTIVE IMMUNITY IN ATHEROGENESIS
A. General Features of Cytokine Signaling
The general classes of cytokine receptors include TNFR

superfamily receptors, JAK/STAT receptors, and receptors
that utilize SMAD signaling. TNF-, IL-1, IL-18, and LT
signal through the TNFR superfamily which was reviewed
previously and summarized in TABLE 2. IL-17 receptors are
analogous to TNF receptors, with activation of NF-B, but
use a different adapter, ACT1 (activator 1 of NF-B) rather
than MyD88 or TRADD to recruit TRAF6 (574). ACT1
also acts as an E3 ubiquitin ligase to add K63 ubiquitin
chains to TRAF6. IL-17 receptors can also activate MAPK
pathways independently of ACT1.
Interferons and interleukins other than IL-1, IL-17, and
IL-18 signal through JAK/STAT pathways (1766). JAK/
STAT receptors exemplify receptors that lack intrinsic
tyrosine kinase activity but which utilize non-receptor
tyrosine kinases for activation. Some receptor tyrosine
TGF- receptors activate SMAD signaling, a particularly

ancient pathway. The term SMAD is an amalgam of abbreviations for two homologous proteins, namely, MAD
(mothers against decapentaplegic, a Drosophila signaling
protein that directs correct formation of the 15 imaginal
discs in the embryo that give rise to subsequent structures
such as the abdomen, legs, wings, etc.) and Sma (short for
small, with mutations resulting in short tail size and body
length in the roundworm, C. elegans); others consider
SMAD to signify sons of mothers against decapentaplegic. Active TGF- is a dimer which binds type II (TRII)
and type I (TRI) TGF- receptor components, causing
their oligomerization. The approximation of TRII and
TRI allows the constitutively active serine/threonine kinase of the TRII cytoplasmic tail to phosphorylate and
thus activate TRI. In conjunction with SARA (SMAD anchor of receptor activation), the activated cytoplasmic serine/threonine kinase of the TRI then phosphorylates
SMAD2 and SMAD3 which join with SMAD4, translocate
to the nucleus, and there act in a complex fashion as transcription factors or co-activators (subject to additional controls and modifications by other signaling pathways). Bone
morphogenic protein (BMP) receptors utilize SMAD1/5/8
rather than SMAD2/3 but also interact with SMAD4.
SMAD6/7 serve as inhibitors of several steps in the pathway
while SMURF1/2 (SMAD ubiquitylation regulating factors
1 and 2) are SMAD-specific ubiquitin ligases that act to
terminate SMAD signaling.
Intracellular signaling downstream of cytokine receptors is
complex. Several aspects of TNF- signaling were presented
previously. Gene expression profiling identified 400 genes that
were up- or downregulated at least twofold after exposure of
endothelial cells to IL-1, IFN-, and TNF- (540). Expression of 600 1000 genes significantly increased or decreased
during the transition of monocytes to macrophages in response to cytokines (1000, 1963). Further details of the molecular biology of cytokine signaling in relation to atherosclerosis has been extensively studied and is the focus of several
recent, excellent reviews (61, 580, 1766).
1403
While chemokines are often considered a subtype of cytokines, the following discussion focuses on cytokines other
than chemokines. During the ongoing recruitment of macrophages and other leukocytes to the subendothelial space,
numerous cytokines amplify and modulate the inflammatory response. In the context of T-cell activation, the T-cell
receptor recognizes a specific antigen, which, when combined with costimulator activation leads to proinflammatory cytokine production. The expression of the costimulator receptors are often influenced by the cytokines present.
Many cytokines promote leukocyte activation, differentiation, or proliferation while actively inhibiting apoptosis.
Some have inhibitory effects. Cytokines may be secreted or
presented on the cell surface. They may lead to autocrine,
juxtacrine, and/or paracrine signaling. Cytokine classification schemes may be based on structure, post-receptor signaling, proinflammatory or anti-inflammatory effects, or
physiological function. In one notable review, cytokines
were designated as pro-atherosclerotic or anti-atherosclerotic (1766). Others operate in innate or adaptive immunity
pathways or both (1). Results of numerous genetic interventions are reviewed in TABLE 7.
kinases seem also to be able to activate JAK/STAT pathways. Typical JAK/STAT receptors are dimeric. Ligand
binding activates bound JAK tyrosine kinases which
phosphorylate tyrosines on the receptors cytoplasmic
tail. Several signaling molecules can then bind to these
phosphotyrosine sites (such as Grb2-Sos with downstream MAPK activation), but in particular there is binding of STAT transcription factors. JAK then phosphorylates the STAT followed by STAT dimerization and
translocation of the active STAT dimers to the nucleus.
Suppressors of cytokine signaling (SOCS) proteins are
negative feedback inhibitors that can both block the catalytic domain of JAK and ubiquitinate the receptor for
proteolytic degradation.
PAUL N. HOPKINS
Table 7. Initiation and perpetuation of inflammation through cytokine and immune cell signaling (91 genes tested)
Gene
Model
% A
Function, Comment
Cytokines or proteins primarily related to macrophages (for TNF-, IL-1, and related, see Table 1)
/ apoE/
255%
FcRIII (FCGR3,
CD16)
Fcgr3/ LDLR/
230%
FcRIIb
FcRIIb/ apoE/
140%
FcRIIb/ BMT into

LDLR/
IL-6/ apoE/
IL-6/ LDLR/
1318%
IL-6
228%
185%
173%
127%
gp130 (IL6ST
in humans)
liver-specific
gp130/ in apoE/
243%
IL-12
IL-12/ apoE/
252%
IL-18
IL-18/ apoE/
235%
IL-20
intramuscular plasmid
cDNA injection into
apoE/
122%
KO of chain affects both the FcRI (CD64) and FcRIII receptors. Each
have ITAM domains in their cytoplasmic tail. Both are activating IgG
receptors responsible for antibody-dependent phagocytosis and other
signaling in macrophages and other leukocytes. FcRI can act as a
co-receptor with platelet GPVI. Intermediate reductions in
atherosclerosis were seen in apoE/ mice (757). While
opsonized LDL may be a target, these KO mice showed generalized
reduction in inflammation and NF-B signaling which is triggered
through a CARD9-Bcl10-MALT1-TRAF6 pathway (714). Also
confirmed in mice receiving Fc chain deficient BMT (1298).
An increase in IL-10 as well as IFN- production by CD4 cells was
seen. Lipids were slightly higher in double KO mice despite reduced
atheroslerosis (895).
FcRIIb is an inhibitory IgG receptor with a cytoplasmic ITIM domain on
monocyte/macrophages, DC, B-cells.
Only male mice were affected. Shown is effect at 34 wk; earlier effects
were stronger. Inflammatory cytokines in aorta were higher as were
plasma IgG directed against modified LDL (1191)
Only abdominal aorta area at 12 wk assessed. Increase in anti-oxLDL
IgG also seen (2093).
IL-6 is induced by IL-1. Synthesized by macrophages, activated EC,
VSMC, and mast cells in response to PAMPs, IL-1, and TNF. In liver,
IL-6 binding results in release of acute phase reactants including CRP
and SAA. IL-6 signaling, with STAT3 activation, combined with TGF
leads to Th17 differentiation which may be protective. Though IL-6
infusion appears to increase atherosclerosis, effects of KO on
atherosclerosis are variable. Effects were NS for both models in one
study (228%) (918), but atherosclerosis was signficantly increased
in an apoE knockout by 85% (468) and 73% (1552) in other studies.
IL-6 signal transducer (IL6ST) is the human homolog of gp130, a
transmembrane subunit present in all IL-6 related receptors and also
a component of other IL receptors. Marked reductions in serum SAA
seen. Greater relative reduction of plaque earlier. Association of
variants with human disease also reported (1085). IL-6 transsignaling involves complex formation between IL-6 and soluble IL-6R in
plasma followed by binding and signaling through gp130. Transsignaling may be responsible for the most pro-inflammatory aspects
of IL-6 signaling, including suppression of Treg differentiation. A
soluble form of gp130 acts as a natural inhibitor of trans-signaling
and decreased atherosclerosis when infused as a sgp130-Fc fusion
protein. EC ICAM-1 and VCAM-1 were decreased with decreased
macrophage infiltration (1569).
Produced largely by macrophages and DC in plaque and promotes Th1
differentiation and proliferation. Can upregulate CCR5 expression.
Other studies confirm pro-atherosclerotic effects. Potentiates IFN-
production. Shown is atherosclerosis reduction at 30 wk. Effect NS
by 45 wk (918).
IL-18 induces both Th1 and Th17 cells to produce IFN- (together with
IL-12) (471, 918). IL-18-deficient mice have much higher cholesterol
than wild-type mice, and this may modulate the expression of
atherosclerosis. Another group reported more atherosclerosis in IL18 knockout, but this was only true in mice fed the high cholesterol
diet (1400). Overexpression decreases collagen content and
promotes rupture (1300).
IL-20 clearly increased angiogenesis (see Table 6) and may promote
T-cell recruitment to lesions (296).
Continued
1404
FcRI/III
(FCGR1/3)
Table 7.Continued
Gene
Model
Function, Comment
MIF (macrophage migration inhibitory factor) deficiency greatly inhibited

progression of lesions, decreased VSMC, MMPs, and cathepsins
(1373). MIF is a noncognate agonist of CD74/CD44, as well as
CXCR2 and CXCR4, recruiting both macrophages and T-cells. In
addition to chemokine GPCR effects, ERK is activated through
-arrestin1 and Src signaling (135, 1995). Inhibition caused
atherosclerosis regression in apo E KO mice (135). MIF potentiates
actions of TNF- and LPS and induces P-selection in endothelial cells
(302). Increased expression in endothelial cells, VSMC, monocyte/
macrophages by oxLDL. Endothelial expression increased by ANG II,
CD40L, ROS, and, unexpectedly, corticosteroids (2061).
DLL4 (delta-like 4) is a NOTCH ligand that can be expressed on
macrophages as well as other cell types, including endothelial cells.
Inhibition by DLL4 antibody decreased several markers of
macrophage activation, decreased adiposity, and improved insulin
sensitivity (562).
OPN (osteopontin, also known as SPP1 for secreted phosphoprotein 1)
is secreted by proliferating EC, VSMC, and especially active
macrophages and Th1 cells. OPN is found in extracellular matrix and
acts as a chemoattractant, a stimulus of phagocytosis, and an
inflammatory adhesion molecule through adherence to V3 and
other integrins (803, 1547). A marked decrease in atherosclerosis
was seen in ANG II-accelerated model which was attributed entirely to
leukocyte effects by BMT (217). ANG II was shown to induce
macrophage OPN expression. In mice without ANG II infusion and fed
a regular chow diet there was no significant effect of OPN KO. OPN
also induced by high glucose in diabetes. Other studies showed
effects consistent with a proatherogenic effect of OPN (1547).
MIF
MIF/ LDLR/
278%
DLL4
anti-DLL4 antibody in
LDLR/
221%
OPN (SPP1)
OPN/ apoE/ with

ANG II infusion
267%
GDF-15
GDF-15/ BMT into

LDLR/
269%
CB2
CB2/ BMT into

LDLR/
113%
(NS)
Ntn1
Ntn1/ BMT to
LDLR/
245%
GRK5
GRK5/ apoE/
150%
NFAT5
NFAT5/ apoE/
BMT into apoE/
mice
286
GDF-15 (growth differentiation factor 15) is in the TGF- superfamily

produced largely by macrophages but also liver. 4-week data shown.
Reduction in atherosclerosis was NS by 12 wk but a decrease in
lesion macrophages seen (392).
CB2 (Cannabinoid receptor 2) deficiency in bone marrow had mildly
significant effect on early atherosclerosis but minimal effect on more
advanced lesions as shown here (409). Prior studies had suggested
mild anti-inflammatory effects for tetrahydrocannabinol.
Ntn1 (netrin-1) is an axonal guidance cue during development.
Macrophages activated by oxLDL synthesize and secrete Ntn1.
Binding of Ntn1 to its receptor Unc5b inhibited macrophage
migration (1854).
GRK5 has multiple activities. Major anti-atherosclerotic activities include
phosphorylation with increased ubiquitination and degradation of
CCR2 in macrophages. Also marks PDGF receptor in VSCM and
inhibits tyrosine phosphorylation activity of the CSF1R in macrophages
(1987).
NFAT5 can be activated by hypertonicity but its regulation in lesional
macrophages is poorly understood. Haploinsufficient macrophages
showed impaired migration. Given is percent reduction in en face
aortic atherosclerosis (700).
Sphingolipid and eicosanoid signaling in macrophages

S1PR2
S1PR2/ apoE/
282%
S1PR3
S1PR3
NS
apoE/
Sphingosine-1-phosphate acting through S1P receptors 1-5 (S1PR1-5,

also known as S1P1-5) can be pro- or anti-inflammatory depending on
the receptor. S1PR2 activates Rho and promotes endothelial
permeability but also stimulates macrophages to produce IL-1 and
IL-18. Bone marrow transplant with S1PR2-deficient cells resulted in
65% reduction in lesions suggesting most of the reduction in
atherosclerosis was from macrophage effects (1640).
Lesions had many fewer macrophages but increased VSMC. S1PR3-null
macrophages showed less chemotaxis and less inflammatory
activation while VSMC showed greater migration and proliferation
(898).
Continued
1405
% A
PAUL N. HOPKINS
Table 7.Continued
Gene
Model
Function, Comment
NS
250%
Effect seen with EP4, not EP2 (91).

EP4 is a macrophage GPCR for PGE2 having strong survival signaling
through PI3K and PKB as well as decreased cytokine production. BMT
of EP4 KO cells showed increased apoptosis of macrophages and less
atherosclerosis (91). Others show increased lesion inflammation with
greater MCP-1 and IFN- with BMT of EP4 null cells but without a change in
lesion size (1753) despite increased aneurysm formation (1754).
FLAP (5-lipoxygenase activating protein) is a scaffold for 5-LO. Whole
body FLAP deficiency had no effect on its own but decreased to
control level the excess atherosclerosis seen in inducible COX-2deficient mice (2050). FLAP inhibition by MK-886 decreased lesion
size 42% in combined apoE/LDLR-deficient mice (845) as well as in
mice with dominant-negative TGF- receptor II (which caused a
marked increase in FLAP expression) (98).
5-lipoxygenase (5-LO), also known as ALOX5 (arachidonate 5-lipoxygenase)
is the rate-limiting enzyme in leukotriene (LT) synthesis. Note: mice may
not be a good model for the leukotriene pathway in humans (1428). No
effect on atherosclerosis seen for 5-LO KO in either LDLR or ApoEdeficient mice though association with aneurysms seen (2091) with
confirmation (253, 1429). These studies do not support a much
smaller prior study with just 4 mice. These animals that did not survive
well on the atherosclerotic diet given with only heterozygote 5-LO mice
surviving (1181). Mice in that study appeared to have been derived from
congenic strain that had potentially many other differences in genes
immediately surrounding 5-LO (611, 1180). A relatively specific inhibitor
of 5-LO was recently reported to reduce atherosclerosis in LDLR-null by
43% (315).
EP2
EP4
EP2/ LDLR/
EP4/ LDLR/
FLAP
(ALOX5AP)
FLAP
5-LO (ALOX5)
5-LO/ LDLR/
5-LO/ ApoE/
NS
BLT1 (LTB4R1)
BLT1/ apoE/
236%
12/15-LO
(ALOX15 in
human, 12LO in mouse)
12/15-LO/ apoE/
12/15-LO/
LDLR/
12/15-LO/ in
apobec/ LDLR/
12/15-LO/ BMT
into apoE/
human 15-LO Tg in
WHHL rabbit
263%
277%
macrophage-specific
12/15-LO Tg in
apoE/ mice
231%
12/15-LO/ BMT
into apoE/
12/15-LO/ apoE/
170%
ApoE/
macrophage-specific
12/15-LO Tg in
apoE/ mice
12/15-LO/ BMT
into LDLR/ mice
fed high PUF or SAT
NS
246%
256%
245%
227%
NS
262%
BLT1 (B leukotriene receptor 1) is a major LTB4 receptor. Shown is 12week difference at aortic root; no difference in aortic area by this time.
Earlier effects were stronger (744). Others similarly show early effects
only (1693). BLT1 KO macrophages expressed BLT2 and still showed
chemotaxis to LTB4 (1693). Specific BLT1 inhibitor decreased
atherosclerosis in apoE- and LDLR-deficient mice (21). Intermittent
hypoxia greatly accelerated atherosclerosis in apoE-null mice and BLT1
KO essentially eliminated the excess lesion development (1031).
Assessed at 15 wk (aortic sinus) (368)
Assessed at 9 wk (aortic sinus) (605)
Assessed at 8 mo (aortic surface area) (2089). Reduced urinary
isoprostanes in 12-LO KO which correlated with lesions. Marked
reduction of IL-12 by 12/15-LO KO macrophages.
Assessed at 12 wk (aortic surface area). All atherosclerosis effect was
due to bone marrow cells (807).
WHHL rabbits were fed a high-fat, high-cholesterol diet and assessed at
13.5 wk. Enzyme was expressed essentially only in monocytemacrophages (1613)
In chow-fed mice, overexpression of human 12/15-LO in macrophages
increased production of LXA4 (sixfold), protectins (PD1), and resolvins
(RvD1) thought to help resolve inflammation. RvD1 and PD1 also
showed strong anti-inflammatory effects in cultured endothelial cells
(1197).
BMT of 12/15-LO null cells increased atherosclerosis in chow-fed mice
(1197).
Mice fed high fat Western diet for 10 wk (1198). Became
nonsignificant at 14 wk. Similar results with BMT (less
atherosclerosis in recipients of 12/15-LO deficient bone marrow).
Animals fed high fat Western diet in contrast to chow feeding in prior
studies by this group (1198).
In mice fed a high-PUF diet, BMT of 12/15-LO null cells clearly
decreased atherosclerosis (1507). Whole body KO of 12/15-LO was
also clearly protective in mice fed either high PUF or high SAT.
Continued
1406
% A
Table 7.Continued
Gene
Model
% A
Function, Comment
Costimulatory and coinhibitory receptor-ligand pairs

B7-1/2
CD28
237%
B7-1/2/ BMT into

LDLR/
CD28/ BMT into
LDLR/
1133%
B7-1/2
LDLR
1107%
ICOS/ BMT into

LDLR/
143%
PD-1
PD-1/ LDLR/
173%
PD-L1/2
PD-L1/2/ LDLR/
190%
CD40
CD40/ LDLR/
CD40L
(CD154)
CD137
(4-1BB)
OX40L
(TNFSF4)
NS
CD40/ ApoE/
242%
CD40/ BMT into

LDLR/
CD40L/ apoE/
245%
CD137/ apoE/
239%
CD137/ LDLR/
231%
OX40L/ apoE/
259%
282%
Expressed on activated EC, CD4 and CD8 T cells, resting monocytes,

and DC. Expression increased by TNF-. CD137 ligation by CD137L
(on stimulated monocytes/macrophages, DC, activated B cells)
stimulates IFN- production by T cells and VCAM-1, ICAM-1, MCP-1,
and IL-6 by EC (1346). Monocyte adhesion decreased to CD137/
EC and aortic endothelium. BMT studies showed most of the
reduction in atherosclerosis in CD137 deficient mice was due to bone
marrow-derived cells. Macrophage expression of CD137 may be
induced by oxLDL (847).
Costimulatory or bidirectional signaling shown by incubating CD137Lexpressing macrophages with cell-free CD137 protein (CD137-Fc)
which led to marked increase in macrophage production of TNF- and
MCP-1. CD137/ mice had lower levels of TNF- and MCP-1 in
lesions (847).
No genetic atherosclerosis model reported for CD137L.
Considered underlying gene of Ath-1 locus (1917). OX40L is expressed
on activated EC, B-cells, and macrophages. OX40L KO supressed
VEGF expression and vaso vasorum neovascularization. OX40L/
BMT had no effect (1278). Similar results with anti-OX40L antibody
treatment (1864).
No genetic atherosclerosis model reported for OX40 (also known as
CD134).
Continued
1407
ICOS
Whole body KO of both B7-1 (CD80) and B7-2 (CD86). B7-1/2 are
constitutively expressed on antigen presenting cells and were found
on plaque macrophages. Their common ligands are CD28 (activating)
and CTLA4 (inhibitory) on T cells. Decrease in atherosclerosis shown
was for intimal area at 20 wk but surface area was NS. Impaired
IFN production by triple KO mice suggested maily Th1 cell reduction
(230).
Opposite results seen with BMT (33). In this model, mostly Treg cells
appeared to affected (647).
Again, Treg proliferation seemed to be most impaired by CD28
deficiency in BMT. Tregs transfer reversed the increase in
atherosclerosis and markedly decreased Th cells in plaques (33).
ICOS (inducible co-stimulator), a positive co-stimulator receptor on
differentiating T-cells that binds ICOSL on antigen presenting cells.
Promotes Treg proliferation especially (less so Th cells). ICOS-deficient
mice had fewer Treg cells and increased Th cells with greater IFN-
and TNF- production (646). No genetic atherosclerosis model
reported for ICOSL.
PD-1 (programmed death 1 receptor) is the receptor for PD-L1/2.
Both CD4 Th and CD8 CTL cells were more activated in PD-1 KO
mice (221).
PD-L1 (programmed death ligand 1) and PD-L2 are coinhibitory ligands
to PD-1 expressed on antigen presenting cells and Treg that bind
their receptor PD-1 expressed on activate Th cells. Aortic root at 19
wk shown. KO mice had many more active T-cells and macrophages
in lesions and higher serum TNF- (645)..
On EC, VSMC, T-cells, B-cells, DC, and macrophages. CD40L
interaction with Mac1 may explain the lack of effect with CD40/.
Treatment of LDLR/ mice with anti-Mac1 antibodies resulted in a
50% reduction in lesion size with fewer macrophages (2119).
Reduction in atherosclerosis quite variable (not significant in thoracic
aorta, only abdominal). Plaques had fewer macrophages and T-cells
and more collagen (1093).
Slightly more significant reduction in atherosclerosis than whole body
CD40 knockout (1093).
Mostly on activated T-cells and platelets but also DC, macrophages, EC,
VSMC. Absence of CD40L had the greatest effect on advanced
lesions and resulted in a more stable plaque phenotype (1092).
PAUL N. HOPKINS
Table 7.Continued
Gene
Model
% A
Function, Comment
Related to neutrophils
/
IRF8
IRF8
BMT into
apoE/
1142%
MPO
Human MPO Tg BMT

into LDLR/
1136%
MPO/ BMT into

LDLR/
CRAMP/ BMT into
LDLR/
152%
FAAH/ apoE/
221%
CRAMP
FAAH
252%
Related toNK or NKT (natural killer or natural killer T-cells)

Ly49A
Ly49A Tg
(overexpressing) BMT
into LDLR/
270%
KLRK1
KLRK1/ apoE/
280%
CD1d1
CD1d1/ apoE/
267%
CD1d1/ LDLR/
247%
J18/ LDLR/
224%
J18
Ly49A is a NK receptor that inhibits NK activation when bound to class

I MHC. There was a marked decrease in number as well as NK
activity in Ly49A Tg transplanted mice. This model was thought to an
improvement over the beige mouse which also lacks NK cells but has
other phenotypes (1051, 1955).
KLRK1 (killer cell lectin-like receptor, subfamily K, member 1; also
known as NKG2D for NK cell lectin-like receptor subfamily K) is a
membrane-bound receptor expressed on NK cells, NKT cells, T
cells, and CD8 T cells. Ligands are proteins expressed on
damaged or virus-infected cells. IL-6, IL-12, and IFN- were reduced
in KLRK1 KO mice (1989).
CD1 receptors present lipid antigens to various T cells. CD1d1 is
recognized by NKT cells. Injection of -galactosylceramide, a synthetic
glycolipid, nearly doubled lesions in apoE/ but not in CD1d/
apoE/ (1119). Similar but less marked changes reported by
another group (1821).
Reduction in atherosclerosis seen only at 4 wk and NS at 8 and 12 wk
(82)
A subset of NKT have an invariant T-cell receptor (TCR) with the -chain
composed of V14 joined with J18. This chain can join with any
one of 3 chains. This invariant TCR binds CD1d. Less IFN-, was
seen in lesions as well (1498). Invariant NKT express less Ly49A and
are the major contributors of increased atherosclerosis as compared
to other (CD4-CD8-) NKT (1797).
Secreted by or related to mast cells

/
HDC
HDC
HRH1
HRH1/ apoE/
260%
HRH2
Kit
HRH2/ apoE/
KitWsh/Wsh LDLR/
NS
283%
apoE
240%
HDC (histadine decarboxylase) is the rate-limiting enzyme for histamine

synthesis (1900).
HRH1 (histamine receptor H1) deficient mice had decreased vascular
permeability to LDL. Transplant of HRH1/ bone marrow did not
affect atherosclerosis (1515).
No effect on atherosclerosis with H2 antagonist (ranitidine) as well (1515).
Kit is a transmembrane tyrosine kinase receptor for stem cell factor
(SCF), a growth factor required for mast cell differentiation (1709).
Continued
1408
IRF8 (interferon regulatory factor) deficiency in mice leads to a chronic

myelogenous leukemia-like phenotype with increased neutrophils in the
circulation. Larger necrotic core seen. Similar increase with IRF8
deficient BMT into LDLR KO mice. Macrophages had impaired
efferocytosis capacity and secreted less IL-10 but atherosclerosis
normalized with depletion of neutrophils (440).
MPO (myeloperoxidase) is not expressed in mouse macrophages or
neutrophils. Interestingly, transplant of MPO KO cells resulted also in
increased atherosclerosis in this study (1176).
The low MPO activity seemed to be associated with protective signaling
in this and the above study (207).
CRAMP (cathelicidin related antimicrobial peptide), released by
neutrophils in extracellular nets complexes with self-DNA to activate
plasmacytoid dendritic cells through TLR9 (439).
FAAH (fatty acid amide hydrolase) catabolizes the endocannabinoid
anandamide, a fatty acid amide. Though plaques were smaller, there
was an increase in neutrophil content and decreased VSMC, suggesting
a more vulnerable phenotype. Increased neutrophil recruitment
appeared to be due to local increased production of the neutrophil
chemokine CXCL1. Additionally, fewer Treg were found in spleens of
FAAH-deficient mice. Findings were thought to be consistent with
decreased atherosclerosis by rimonabant treatment in LDLR-null mice
(1005).
Table 7.Continued
Gene
Model
% A
Function, Comment
GM-CSF
GM-CSF/ LDLR/
GM-CSF/ apoE/
Average of LDLR/ studies shown (918). Injection of GM-CSF

promoted proliferation of intimal cells, particularly dendritic cells in
LDLR/ mice (2112).
Genes with general effects on adaptive immunity
242%
Only chow fed (with lower serum cholesterol) showed a significant effect
212%
on lesion size (379). In another study, early (8-week) atherosclerosis
was reduced in Rag1/ apoE/ mice (54% reduction) but
differences diminished to NS with time (1653). Estrogen-deficient
female mice showed 50% or greater reduction of atherosclerosis,
but estrogen-replete mice had reduced lesions with no effect of Rag1
(470).
281%
Of note, the Rag2 deficient mice had considerably lower plasma
257%
triglyceride levels. There was no difference in brachiocephalic lesions
(1466). In another study, lesions in Rag2 and Rag2/ mice were
not significantly different. Despite lack of B and T-cell derived
cytokines (including IFN- and IL-4 which stimulate expression of MHC
II on macrophages), foam cell formation was not affected (382).
266%
A spontaneous mutation in PRKDC (protein kinase, DNA-activated,
catalytic subunit) causes the scid/scid (recessive severe combined
immunodeficiency) trait in mice. The gene allows antigen receptor
diversification by V(D)J recombination by opening blunt-end hairpins
created by Rag1/Rag2. The mice have virtually no T or B cells (76).
The marked reduction in atherosclerosis was largely reversed by Thelper cell transfer (2107).
Rag1
Rag1/ apoE/
Chow fed
Western diet
Rag2
Rag2/ apoE/
27 wk
40 wk
PRKDC
scid/scid apoE/
CD4
CD4/ apoE/
TCR
TCR/ apoE/
249%
TCR
TCR/ apoE/
249%
235%
1100%
CD4 is a TCR co-receptor or adapter which defines the Th (CD4)

lineage. CD4 KO mice had no Th cells and much less IFN- in lesions
(2108).
Another group found no effect (469, 470).
In female mice fed chow diet. TCR is a subunit of the TCR found in
CD4 and CD8 cells (469). Confirmed in a separate study (470).
In female mice fed chow diet. TCR is a subunit on a small subset of T
cells (469). Confirmed in a separate study (470).
Related to Th1 cells. Listed cytokines are increased after activation, typically by antigen presentation (DC or macrophage),
reenforced by CD40-CD40L costimulation.
T-bet (Tbx21)
T-bet/ LDLR/
STAT4
STAT4/ in BALB/c
fed Paigen diet
IFN (IFNG)
IFN/ apoE/
260%
IFN/ LDLR/
243%
IFNGR1
IFNGR1/ apoE/
258%
IL-2
IL-2 mAb apoE/
220%
229%
NS
T-bet (also known as Tbx21 for T-box21) is a transcription factor

required for T-cell differentiation into Th1 rather than Th2 (228). Tbet KO had more Th2 and almost no IFN production by Th (CD4)
cells, suggesting near absence of Th1 cells.
Like the control BALB/c mice, the STAT4 KO in this study had no
atherosclerosis. STAT4 is required for development of more
atherogenic Th1 and STAT4 KO resulted in a greater Th2 response
(798).
Secreted primarily by Th1 but also natural killer T-cells (NKT), mast cells
and activated macrophages. Activates endothelial cells, increases
macrophage production of TNF- and MCP-1 (918). LT
The interferon- receptor is a heterodimer of the high-affinity IFNGR1
subunit and the accessory IFNGR2 subunit. Presumably, IFNGR1 was
deleted in this study. Plaques had more fibrous tissue, fewer
inflammatory cells (678).
In cited study, monoclonal antibody (mAb) was administered
intraperitoneally (1835).
Related to Th2 cells

/
IL-4
IL-4
apoE
IL-5
IL-5/ BMT into

LDLR/
227%
or NS
150%
Produced by Th2 lymphocytes and mast cells. Required for Th2

differentiation and M2 macrophage phenotype. Can be pro- or antiinflammatory with mixed effects on atherosclerosis generally (913,
918, 1766).
Produced by Th2 lymphocytes and mast cells. Appears to be antiatherosclerotic. IL-5 stimulates innate B1-cells to produce an IgM
natural antibody against oxidized phospholipid (147). Also promotes
eosinophil differentiation.
Continued
1409
270%
NS
PAUL N. HOPKINS
Table 7.Continued
Gene
Model
% A
Function, Comment
IL-13
IL-13/ BMT into

LDLR/
191%
IL-33
IL-33 infusion in
apoE/
262%
ST2
Infusion of sST2 (decoy

receptor) in apoE/
189%
STAT6
STAT6/ in BALB/c
fed Paigen diet
1400%
Administration of IL-13 decreased macrophage content, markers of

inflammation, and increased collagen content of established lesions
while deficiency led to increased plaque size (258).
Increased atherosclerosis seen in mice infused with a soluble receptor
for IL-33 which blocked IL-33 signaling (1209). Stimulates IL-5
secretion (1130).
ST2 (supressor of tumorigenicity 2) is the receptor for IL-33. ST2L is
the active, membrane-bound receptor, while sST2 is a soluble decoy
receptor which binds IL-33 and suppresses ST2L signaling (1209).
The control BALB/c mice display a predominantly Th2 immune
response and had no detectable atherosclerosis despite the Paigen
diet. STAT6 is required for Th2 differentiation (798).
Related to Th17 cells

IL-17A
250%
IL-17A (the first identified of 6 IL-17 family members) secreted by newly

designated Th17 activates endothelial cells and macrophages (293).
Prior antibody or transgenic expression studies controversial (1748).
162%
IL-17R
IL-17R/ BMT
LDLR/
246%
SOCS3
T-cell-specific SOCS3/
(Cre-Lox) BMT
LDLR/
250%
In apo E null mice, plaques in IL-17A deficient animals had more

macrophages, fewer VSMC, less collagen. Splenic CD4 cells had
more IFN early on and less IL-5 throughout lesion development.
Exogenous IL-17A administration decreased atherosclerosis (380).
The IL-17 receptor (IL-17R) is found in mutliple bone-marrow derived
cell types as well as endothelial cells. Mice transplanted with IL-17R
KO cells had decreased IL-6 and increased IL-10 production (1853).
SOCS3 (supressor of cytokine signaling 3) deficiency in T-cells led to
surprising decrease in atherosclerosis, increased IL-10 and IL-17 but
decreased IFN- production and induced an anti-inflammatory
macrophage phenotype. Transplant of T-cells overexpressing SOCS3
into Rag2/, ApoE/ mice greatly increased atherosclerosis. IL-17
possibly protective in some settings (1747).
Related primarily to T-regulatory cells (Treg)

CD3
anti-CD3 antibody in
LDLR/
259%
CD3 is an ITAM-containing co-receptor of the TCR complex. Shown are

results when given iv for 5 days before starting high fat diet. When
given after 13 wk of diet, there was 71% less progression over 11
wk. The antibody used was engineered to be missing the Fc portion
and so was not pro-inflammatory (1677). Similar antibodies can
stimulate TCR generally but cause a net increase in Treg number and
suppress several autoimmune conditions.
CD25
anti-CD25 antibody in
apoE/
150%
Depletes Treg but not a definitive proof (33).
Foxp3
vaccination with activated

DCs overexpressing
Foxp3 in LDLR/
TGF-1 conditional Tg
expressed in heart
controlled by
doxycycline in apoE/
dominant negative TGF
receptor II in
apoE/
134%
The vaccination reduced Treg cells specifically by about 30% in various tissues
by sensitizing CTL with 1.ninefold increase in splenic T-cells (1852)
220%
Shown here is aortic root atherosclerosis in animals overexpressing

TGF-1 versus doxycycline-suppressed controls (555). In another
study, heterozygous TGF-1 deficiency increased atherosclerosis in
fat-fed C57BL/6 mice (651).
This model resulted in disruption of TGF- signaling in T-cells only
(1494). TGF- supports Treg differentiation by acting as a
costimulatory factor for Foxp3. Expression of a dysfunctional TGFBR2
only in CD11 DC also increased atherosclerosis (1043).
Also produced by Th2, alternatively activated (M2) macrophages, CD8
cells, and B-cells. Anti-inflammatory. Promotes increase in antiinflammatory Th2 cells relative to Th1 and tolerance. Several studies
show anti-atherosclerotic effects (918).
CYP24 is vitamin D3 hydroxylase. 24-hydroxylation by CYP24 of 1,25
dihydroxy D3 leads to inactivation. These transgenic rats constitutively
overexpress CYP24, had mild hyperlipidemia, and developed albuminuria.
Normal rats even on high-fat diet had very little atherosclerosis (886). A
CYP24A1 variant was associated with coronary calcium but directional
effect on vitamin D is not yet known (1611).
TGF-1
TGF- receptor
II (TGFBR2)
IL-10
IL-10/ BMT into

LDLR/
CYP24
CYP24 Tg rats on high

fat diet
1200%
135%
14336%
Continued
1410
IL-17A
in C57BL/6
fed high fat diet and
infected with C.
pneumoniae
IL-17A/ apoE/
Table 7.Continued
Gene
MHCI
CD8
TAP1
PRF1
GZMB
Secreted IgM
Id3
BAFFR
% A
Function, Comment
Related to CD8 CTL (cytotoxic T lymphocytes)

273%
The added MHCI locus (1.9 Mb duplicated) included a number of other
genes, complicating interpretation. 4N duplication was embryolethal.
Potential mechanisms for effect were not explored (487).
CD8/ apoE/
NS
CD8 is a TCR co-receptor or adapter which defines the cytotoxic T
lymphocyte (CTL CD8) lineage. In female mice fed chow diet in 2
studies by the same group (469, 470). Others report a significant
reduction in atherosclerosis with depletion of CD8 by antibodies
(972).
TAP1/ apoE/
NS
TAP1 (transporter associated with antigenic processing 1) had no
effect on atherosclerosis (932). TAP1 transports cytosol-derived
antigens into the ER to be loaded onto MHCI which presents antigen
to the TCR with the CD8 adapter (expressed on CTL)
PRF1/ CTL BMT into
234%
PRF1 (perforin, also known as PFP for pore forming protein) replete
lymphocyte-deficient
(wild-type) CTL increased atherosclerosis when transplanted into
apoE/
lymphocyte-deficient animals. Shown is the difference between these
two models (972).
GZMB1/ CTL BMT
244%
GZMB (granzyme B)-deficient CTL were compared with wild-type CTL
into lymphocytetransfer as in the PRF1 study above (972).
deficient apoE/
Related to B-cells
IgM-transmembrane
129%
B-cell receptor function of IgM depends on normal transmembrane
defective BMT into
sequence. Mice with disrupted exons encoding the transmembrane
LDLR/
sequence (so called MT mice) had complete absence of B-cells and
increased atherosclerosis (1117). Nonsignificant effect in female
ApoE-deficient mice fed chow diet (470).
Secretory IgM-defective
129%
B-cells from secretory IgM-defective mice could not secrete natural IgM
LDLR/
antibodies derived from B1a cells. Given here are data from high-fat
diet. There was a 6.1-fold increased on chow diet. Lesions showed
more apoptosis and cholesterol crystals. Simultaneous deletion of
C1q did not make lesions worse (1015).
Secretory IgM-defective
198%
Adoptive transfer study. Splenectomy decreased B1a cells and
B1a into
increased plaques. Adoptive transfer of wild-type B1a cells (used as
splenectomized
comparator here) was strongly anti-atherosclerotic, but not transfer
apoE/
of secretory IgM-deficient B1a cells (970).
Id3/ BMT into
1210%
Id3 (inhibitor of DNA binding 3) is a inhibitory transcription factor that
apoE/
appears to be required for normal homing of B-cells to the aortic
adventitia, possibly through (indirect?) upregulation of CCR6 and
other effects (437). Protective effect was not mediated by IgM, but
rather a reduction in macrophage accumulation, suggesting possible
release of a suppressive chemokine or cytokine such as a Breg cell
function.
244%
BAFF (B cell activating factor belonging to the TNF family) and BAFFR,
BAFFR/ apoE/
its receptor, are required for B2 cell development. BAFFR/
BAFFR/ BMT into
233%
/
animals
were deficient in B2 cells but had normal B1a cell numbers
LDLR
with a decrease in IgG1 and IgG2c antibodies in plasma and lesions
but much lesser effect on IgM. VCAM-1 expression was decreased as
well (968). Similar results for LDLR null animals with BMT with
marked reduction IgG against malondialdehyde-modified LDL (1528).
duplicated MHCI locus
(3N) in apoE/
Related to dendritic cells (DC). Can be defined as CD11c, MHCIIhi and includes conventional DC derived from nonmonocyte, preDC
and nonconventional DC which include monocyte-derived DC and plasmacytoid DC.
CD74
CD74/ LDLR/
274%
FLT3
FLT3/ LDLR/
168%
CD74, also known as invariant chain, acts as chaperone in endoplasmic

reticulum and cell trafficking of the MHC II receptor. CD74 deficient
mice have impaired antigen presentation and greatly reduced CD4
and NK1.1 cells in plaque as well as decreased IgG production in
response to either MDA-LDL or bacterial HSP65 (1707). Would be
expected to affect all populations of DC.
FLT3 (FMS-related tyrosine kinase 3 where FMS refers to feline
McDonough sarcoma) is a cytokine receptor tyrosine kinase for
cytokine FLT3L. FLT3 promotes proliferation of a CD103 subset of
conventional DC that were protective and promoted increased Treg
(314).
Continued
1411
B-cell receptor
IgM
Model
PAUL N. HOPKINS
Table 7.Continued
Gene
Model
Function, Comment
CCL17E/E E represents enhanced green fluorescent protein

replacing then normal CCL17 allele by gene targeting. While CCL17
is a chemokine, it is included because of unique, cytokine-like effects
on other cells. Apparently produced by a subset of conventional DCs
that enter the plaque after onset of inflammation. Fewer
macrophages and marked reduction in T-cells seen in lesions from
CCL17-deficient mice. CCL17 was shown to restrain Treg
proliferation, while CCL17E/E DC caused increased Treg proliferation
and nonTreg CD4 T-cell apoptosis. Similar results seen with
CCL17E/E apoE/ BMT into apoE/ mice (1932).
An additional receptor besides CCR4 was thought to mediate the
effects CCL17 based on above results (1932). CCR4 unequivocally
promotes CTL (CD8 cytotoxic T lymphocytes), Th (CD4), and Treg
cell chemotaxis toward CCL17 producing DCs. CCR4 is involved in
pulmonary inflammation from cigarette smoke (1491). CCR4 ligation
can activate platelets and increases P-selectin expression. CCR4
antagonism was reported to inhibit Treg function in another study
(533).
CCL22 is another ligand for CCR4. CCL22 is also known as MDC
(monocyte-derived cytokine) and is produced by DC, macrophages,
and NKT and is induced by IFN. CCL22 antagonism had no effect on
enhanced Treg proliferation (1932).
IFN- is a type I interferon produced by activated plasmacytoid DC that
has strong inflammatory effects. Every other day injections of IFN
increased plasma lipids modestly but significantly. Interpretation is
therefore complicated (1014). A recent confirmation in apoE KO mice
did not report a change in lipids (439).
Similar properties as IFN-. No increase in serum lipids in this study. IFN
increased macrophage adherence to endothelium through increased
CCL5 secretion by macrophages. Atherosclerosis was also increased in
apo E KO mice with carotid collar placement. Increased atherosclerosis
was seen despite increased IL-10 secretion as well (639).
Cre-lox, myeloid-specific deletion of the main receptor for IFN-/ (type I
interferons). Involved in myeloid interferon signaling. Necrotic core
size and apoptosis were particularly decreased. IFN treated
macrophages showed increased CCR5 expression, CCL5 secretion,
and endothelial adhesion despite higher IL-10 production. Endothelial
adhesion was not inducible by IFN- in macrophages from STAT1-/or INFAR1del mice. IFN- treatment increased atherosclerosis in
apoE/ and LDLR/ mice. IFNAR1del mice had 70% reduction in
plasma IL-6. (639).
BST2 is a tetherin that can bind budding viruses. Its function remains
obscure but anti-BST2 depleted pDC (plasmacytoid DC). (439).
Why opposite results were seen with this study using a similar pDC
depletion approach remains unexplained (376).
CCL17
CCL17E/E apoE/
250%
CCR4
CCR4/ BMT into

LDLR/
NS
CCL22
in vitro anti-CCL22
antibody
NS
IFN-
peritoneal injection of
IFN- into LDLR/
165%
IFN
daily injections of IFN-

into LDLR/
178%
IFNAR1
IFNAR1del BMT into

LDLR/
234%
BST2
Anti-BST2 antibody: in
apoE/ in LDLR/
with carotid collar
250%
186%
Definitions are as in Table 1.
In TABLE 7 is provided a list of cytokines manipulated by

molecular methods as well as related genes affecting early
stages of endothelial activation, leukocyte infiltration of the
intima, other aspects of early inflammation, and their effects on atherosclerosis. Among the most important benefits
of these studies has been clarifying the importance of innate
versus adaptive immunity in atherosclerosis and the roles
that specific types of leukocytes may play.
B. Innate Immunity: An Overview

The distinction between innate and adaptive immunity was
formally first presented just over 20 years ago (844) and is
1412
now a guiding principle in immunology (1). Innate immunity refers to a system of inherited defenses activated by
pattern recognition receptors (PRR) which bind pathogenassociated molecular patterns (PAMPs) that are invariant
features of invading microbes. Innate responses need no
prior exposure or learning or memory to be fully functional. Innate immune responses are found (at least to some
degree) in virtually all multicellular organisms (836). Adaptive immunity is found only in jawed vertebrates and essentially involves activation of mature T and B lymphocytes.
For an adaptive immune response to be mounted, a protein
or peptide derived from a perceived invader must be recognized as foreign, and this signal must be paired with a pro-
% A
Innate immune responses are triggered by transmembrane

receptors, intracellular receptors, and secreted proteins.
Transmembrane PRR can mount responses before cell infection. One class of transmembrane PRR, the Toll-like
receptors, has already been presented. Other transmembrane PRR include scavenger receptors, C-type lectin receptors, and N-formyl Met-Leu-Phe receptors. (Bacteria make
proteins with formyl-methionine as the initiating amino
acid, rather than the methionine utilized by mammals and
other higher organisms.) Intracellular PRR can be cytoplasmic or mitochondrial. Secreted PRR include collectins (e.g.,
mannose-binding lectin), ficolins, and pentraxins (1, 1088).
When secreted PRR coat invaders, they provide recognizable patterns to various innate receptors allowing phagocytosis and destruction. Toll-like receptors and scavenger receptors also recognize damage-associated molecular patterns (DAMPs), which occur endogenously without
infection such as on apoptotic cells. These are particularly
important in atherogenesis (1088).
Also to be included in the innate immune system are natural antibodies which are IgM antibodies coded by inherited, invariant DNA sequences and secreted spontaneously
by a specific subset of B-cells (B1a cells) without prior exposure to any specific antigen or stimulation by T-cells. B1a
cells are present and secreting their natural antibodies by
birth or shortly thereafter, although increased secretion can
be induced. Some natural antibodies bind phosphocholine which loosely refers to various phosphorylated choline motifs found in bacterial cell walls but also present in
oxidized phospholipids (554, 728).
PRR that activate the transcription factors NF-B, interferon regulatory factors (IRFs), and MAPK pathways can
help trigger an adaptive immune response by stimulating
both cytokine release and expression of transmembrane costimulatory receptors. Thus, when LPS binds TLR4 on dendritic cells (DC), macrophages, or endothelial cells, NF-B
is activated, TNF- is secreted (peaking at 1 h), followed
by IL-1 release (peaking at 2 h) and chemokine secretion.
Endothelial cells are stimulated to display selectins and adhesion molecules, while chemokines are trapped in their
glycocalyx. Leukocytes are captured and move toward the
site of inflammation, guided by a chemokine gradient. All
this is in the realm of innate immunity. Macrophages summoned and activated by such an inflammatory stimulus, or
activated DC, typically display costimulatory receptors and
will activate T-cells if the antigens presented match the TCR
of the T-cells present, thereby triggering an adaptive immune response.
Belonging to both innate and adaptive immunity are Fc
receptors that can recognize antibodies bound to antigen.
Some Fc receptors stimulate phagocytosis and cell activation while others mediate inhibition. The response depends
on whether the receptor is linked to a coreceptor that contains an activating ITAM motif (such as FcRI/III) or contains an inhibiting ITIM motif in its cytoplasmic tail (e.g.,
FcRIIb). As reviewed in TABLE 7, ITAM-containing FcRI
and FcRIII were associated with increased atherosclerosis
while FcRIIb, with its ITIM linkage, was protective.
C. Characteristic Cytokines and Responses

by Cell Type
1. The mouse Ly6C hi monocyte subset preferentially
gives rise to more inflammatory macrophages
which become foam cells
Circulating monocyte subsets can be defined by cell-surface
markers. High expression of the mouse cell-surface marker
Ly6C (Ly6Chi) identifies the most prevalent monocyte subset. Ly6Chi monocytes also expresses CCR2, the receptor
for MCP-1 (CCL2). Humans have an analogous subset
(599). Ly6Chi monocytes are preferentially recruited to inflammed areas (including actively developing plaques), in
part through MCP-1, and preferentially give rise to classically activated (M1) macrophages (see below) and foam
cells (1721). In contrast, Ly6Clo monocytes lack CCR2 but
display more CX3CR1 (the fractalkine recepetor) and seem
adapted to crawl along endothelial surfaces for general surveillance, with preferential recruitment to become tissue
resident macrophages, myeloid DC (dentritic cells), and alternatively activated (M2) macrophages (see below). In the
circulation, Ly6Chi monocytes can also be converted to
Ly6Clo monocytes. Interestingly, during the course of
atherogenesis in both ApoE/ and LDLR/ mice, progenitors of Ly6Chi monocytes progressively relocate from bone
1413
inflammatory innate immune response. Thus a foreign

signal must be combined with an innate danger signal for
adaptive immune responses to be triggered. On a molecular
level, this elaborate control of adaptive immunity by innate
responses is accomplished by an array of receptors which
form an immune synapse between antigen presenting
cells and antigen recognizing T cells. Antigen presenting
cells include macrophages, dendrocytes, B-cells, and sometimes endothelial or other cells. In immune synapses, a series of costimulatory or coinhibitory receptors are found
closely associated with the TCR. When an appropriately
presented antigen binds to a TCR, a series of receptorassociated tyrosine kinases are activated, phosphotyrosine
binding sites are created to which various adapters and
signaling molecules attach, followed by activation of downstream signaling. Simultaneous activation of innate responses leads to upregulation of costimulatory receptors,
and these further promote tyrosine kinase activity and
downstream phosphorylations. In contrast, coinhibitory receptors activate highly effective phosphatases which quell
the signal by removing the activating tyrosine and PIP3
phosphate groups. Various cytokines may promote or inhibit adaptive immune responses.
PAUL N. HOPKINS
marrow to splenic red pulp. These cells give rise to M1 type
macrophages and eventually ingest lipid to become foam
cells (1493).
2. Macrophage phenotypes: artificial but useful
constructs based on in vitro cytokine, PAMP, and
DAMP exposure
Incubation of macrophages with different PAMPs, DAMPs,
cytokines, scavenger receptor ligands, and various lipids is
followed by characteristic changes in expression of surface
markers, cytokine and signaling molecules, as well as
changes in lipid handling and propensity toward foam cell
formation. The resulting macrophage phenotypes may have
apparently opposite functions (such as pro-inflammatory
versus anti-inflammatory, or tissue repair promoting).
While recognition of macrophages with widely differing
functions or phenotypes is useful, macrophages in vivo actually display plasticity in modulating between not only
these polarized phenotypes but activation states with intermediate features, depending on stimuli encountered (1237).
With regard to intracellular signaling, the M1 phenotype is

characterized by NF-B and MAPK activation, typically
through various TLR (such as TLR4 activated by LPS).
IFN- priming begins as IFN- binds as a dimer to its receptor, a heterodimer consisting of IFNGR1 and IFNGR2.
Intracellularly, IFNGR1 binds JAK1 and IFNGR2 binds
1414
Further efforts have been made to characterize the separate

and combined effects of IFN- priming and LPS stimulation
(213). In M1 activation, both p38 and ERK activation appear to be important to stimulate MNK1 which then phosphorylates the transcription factor eIF4E, allowing full induction of interferon regulatory factor 8 (IRF8). IRF8, in
turn, is a transcription factor for such M1 genes as IL12a,
IL12b, and iNOS but may also be involved in M2 activation. IFN- may also increase expression of IRF8.
There is cross-talk between TLR4 and NOTCH signaling.
NOTCH signaling is an ancient, conserved signaling pathway that controls cell proliferation and differentiation of
many cell types, particularly during embryogenesis.
NOTCH is actually not an abbreviation but refers to a
characteristic notch in the wings of fruit flies with a
NOTCH receptor mutation. The pathway noted here illustrates NOTCH signaling generally, but its activation as part
of M1 activation was not suspected until recently. Apparently, activated macrophages express a cell-surface bound
NOTCH ligand which when bound to the NOTCH1 receptor on a neighboring macrophage leads to ADAM10-mediated cleavage of the extracellular domain of the NOTCH1
receptor. Immediately thereafter, there is cleavage of the
NOTCH intracellular domain just below the inner leaflet of
the cell membrane by the action of -secretase. This twostep proteolysis releases NICD1 (NOTCH intracellular domain 1) which translocates to the nucleus and binds its
target RBP-J, changing RBP-J from a repressor to an active
transcription factor. Among the effects is augmented
MAPK activation through increased IRAK2 expression, as
well as increased induction of IL-6. RBP-J also actively suppresses M2-type activation (791, 1999). Interestingly, other
Classical macrophage activation involves incubation with

IFN-, which primes macrophages so that subsequent TLR
activation upon exposure to various organisms such as
Leshmania or Toxoplasma parasites or the intracellular
bacteria Listeria monocytogenes or Mycobacterium tuberculosis triggers vigorous activation and killing. Without
prior IFN- exposure, these organisms can survive intracellularly in macrophages (1261). IFN- plus LPS (to activated
TLR4) or IFN- plus TNF- triggers similar activation,
suggesting JAK-STAT signaling from IFN- together with
activation of NF-B mediate classical macrophage activation (1237). Classically activated macrophages are said to
display the M1 phenotype, so named because IFN- is characteristically secreted by activated Th1 cells (but also by
stimulated natural killer or CD8 cytotoxic lymphocytes).
In addition, M1 macrophages secrete cytokines like IL-12
that further promote the Th1 response. M1 macrophages
secrete TNF-, type I interferons such as IFN- (with further autocrine activation of these macrophages by both
TNF- and IFN-), IL-1, IL-6, IL-12, IL-23, CCL15,
CCL20, CXCL9, CXCL10, and CXCL11. M1 macrophages also express increased MHCII, costimulatory receptors, NOX2 and ROS, NO from iNOS, arginase-2 and
prostanoids from increased COX2 expression (153, 1237).
All these, but particularly IL-12, CXCL9, and CXCL10,
further enhance the Th1 (and NK) response. Most cytokines that promote M1 activation were clearly atherogenic
(see TABLE 7).
JAK2. Typical of JAK/STAT signaling, both JAK1 and

JAK2 tyrosine phosphorylate the receptor cytoplasmic tail,
providing a binding site for STAT1, followed by phosphorylation of Y701 of STAT1 by the JAKs. Tyrosine phosphorylated STAT1 dimerizes and translocates to the nucleus,
stimulating transcription of hundreds of genes. Signaling
other than through STAT1 is stimulated after IFN- binds
its receptor. JAK2 appears to activate PYK2 followed by
activation of the MEKK4/MEK6/p38 cascade (698). The
adapter protein Cbl may bind to the activated IFNGR followed by tyrosine phosphorylation by JAK with subsequent
activation of PI3K and downstream stimulation of the PKB/
Akt cascade. PKB provides anti-apoptotic effects and can
support subsequent protein synthesis through mTOR activation. In addition, PIP3 formation promotes activation of
PKC through PDK1 as well as NOX2 activity. JAK1 and
JAK2 also activate PLC with release of IP3, DAG, and
IP3-mediated calcium release. Calcium binds calmodulin
followed by CaMKII activation. Both PKC and CaMKII
can serine phosphorylate S727 on STAT1 which is required
for full transcriptional activity of the STAT1 dimer (418,
1420).

targets of RBP-J are the transcription repressors Hes1 and
Hey1 which act as feedback inhibitors of IL-6 and IL-12
transcription. IFN- inhibits Hes1 and Hey1 transcription,
allowing unfettered production of IL-6 and IL-12.
IL-4 and IL-13 can both signal through the IL4RA/

IL13RA2 receptor, a JAK-STAT receptor that activates
STAT6 (153). In addition, IL-13 has nonredundant effects
by uniquely signaling through IL13RA2. Rather than a decoy receptor as previously thought, IL13RA2 appears to
have greater anti-inflammatory effects than IL4RA (258).
Transplant of IL-13-deficient bone marrow into LDLR-null
mice clearly increased atherosclerosis (258), whereas effects
of IL-4 deficiency were more ambiguous (see TABLE 7). GMCSF, IL-4, and IL-13 all induce increased expression of
PPAR which seems to characterize the M2 phenotype
(194, 1324, 1601). In addition, transcription factors KLF4,
LXR, PU.1, and IRF8 are also key in M2 differentiation.
For example, LXR was found to bind the promoter of
IRF8 to increase its transcription while IRF8 and PU.1 interact at a composite response element in the promoter of
arginase-1 (1262, 1435).
Interestingly, M2 macrophages are first to appear in developing plaques in ApoE-deficient mice. M1-type macrophages only appear in more advanced, progressing lesions
associated with greater inflammation (900). Human carotid
atherosclerotic lesions were also noted to display a mixture
of M1 and M2 phenotypes (194). The early appearance of
M2 macrophages is consistent with the view that the usual,
steady-state status of tissue macrophages is anti-inflammatory and immunosuppresant, accompanied by copious se-
Several other macrophage phenotypes have been described.

Incubation of macrophages with oxidized phospholipid
stimulates Nrf2 activation with increased expression of redox control genes (such as HMOX1) with an overall different gene expression pattern than either M1 or M2 macrophages. These so-called Mox macrophages had decreased
phagocytic and chemotactic capacity. In aortic atheroma
from LDLR-null mice, 39% of the macrophages appeared
to have an M1 phenotype, 21% were M2, and 30% had an
Mox phenotype (872). The Mres resolving phenotype may
be thought of as a subtype of M2, developing after exposure
to resolvins with increased cAMP (12). The proposed M4
phenotype has a number of features in common with M1
and develop in response to CXCL4 (621). M4 macrophages
suppress expression of protective CD163 and HMOX1
(622). KO of CXCL4 decreased atherosclerosis in ApoEdeficient mice (1521).
Among the most interesting of macrophage phenotypes is
Mhem (199). Mhem develop upon exposure of nonpolarized, peripheral monocytes to hemoglobin/haptoglobin
complexes (HbHp) which bind CD163, the macrophage
HbHp scavenger receptor. Red cell phagocytosis also contributes to the Mhem phenotype. Resulting signaling leads
to a marked upregulation of CD163, HMOX1, macrophage mannose receptor, ABCA1, ABCG1, and IL-10, together with reduced expression of MHCII, SR-A, and
CD36. IL-10 was necessary for autocrine stimulation of the
positive feedback loop leading toward differentiation of
this phenotype (199, 200). Moreover, such cells did not
accumulate lipid yet were clearly present in human plaques
that had undergone intraplaque hemorrhage. The Mhem
were found next to but were distinct from foam cells (200,
201).
Intracellular signaling leading to the Mhem phenotype has
been partially worked out. Intracellular heme accumulates
1415
Incubation of macrophages with the Th2 cytokines IL-4

and/or IL-13 or GM-CSF with IL-4 was first proposed to
cause alternative activation, leading to the M2 phenotype (641, 642). IL-4 and IL-13 signaling are characterized
by downstream LXR and PPAR activation (1324). M2
macrophages are important for fighting parasitic infections
but are also referred to as wound healing macrophages
and appear to be involved in inflammation resolution. Some
consider the parasite-killing but wound-resolving M2 macrophages as a separate phenotype from IL-10 producing
regulatory macrophages or Mreg which develop after
exposure to IL-10 (1237). Alternatively activated M2 macrophages express increased MHCI and MHCII, the macrophage mannose receptor, dectin-1, arginase-1, and secrete
IL-1Ra (IL-1 receptor antagonist), CCL13, CCL17,
CCL18, CCL22, and CCL23 (which are chemoattractive
for Th2 lymphocytes and other cells), IGF1 (which stimulates fibroblast proliferation and survival), and display increased endocytosis activity and parasite killing but greatly
decreased iNOS. They also secrete several proteins that
bind the extracellular matrix and promote would healing
and can secrete the highly anti-inflammatory IL-10 and
TGF (642, 1237).
cretion of IL-10 (what some might call Mreg macrophages).

Such a state allows normal housekeeping activities such as
efferocytosis to proceed without inflammation (1262). Immunosuppressive Mreg type macrophages are particularly
important in the gut where exposure to foreign antigens
from digested food or bacteria is common. M2 activation
may be viewed as an early, less aggressive activation with
perhaps more rapid transition to resolution. M1 activation
appears to be reserved for the most vigorous assaults, triggered by cooperation between IFN--producing Th1 and
activation of TLRs or other pathogen pattern recognition
receptors. A number of signals promote reversion of M1
macrophages to the less inflammatory phenotypes such as
various lipid ligands (such as electrophilic nitro fatty acids
which activate PPAR), certain signals from apoptotic cells,
and interestingly, ApoE binding its own receptor expressed
on macrophages (APOER2, also known as LRP8), or
VLDLR (the VLDL receptor ) (99, 1448).
PAUL N. HOPKINS
after HbHp-CD163 uptake or erythrocyte phagocytosis
with lysosomal degradation. Mild to moderate oxidative
stress ensues, apparently activating Nrf2 and possibly the
transcription factor ATF1. PKA activation may also be involved. Active PKA can activate ATF1 as well. Additionally, heme or even the iron-free protoporphyrin ring of
heme can inactivate a transcription repressor, Bach1 (Btb
And Cnc Homology 1), which blocks ARE sites activated by
Nrf2 (1144). Both Nrf2 and ATF1 then induce HMOX1,
ferritin, and ferroportin. Active ATF1 additionally increases expression of LXR, followed by LXR and PPAR
activation, with downstream induction of ABCA1 and
ABCG1 and presumably other markers of Mhem such as
IL-10 (199, 201).
phages. Such segregation avoids an otherwise highly inflammatory setting since both heme and hemoglobin are
strong oxidizers of LDL and cellular lipids as are the ROS
generated by M1 macrophages, especially in the presence of
iron. Excess lipid oxidation would generate ligands for
TLR, LOX1, and RAGE as well as cause direct damage to
cellular proteins and DNA, further exacerbating the inflammation.
Accumulating iron further promotes translation of ferritin

and ferroportin and blocks translation of transferrin receptors through IRP/IRE control. Iron response elements
(IREs) are stem/loop structures in mRNA which occur in 5
or 3 untranslated regions of many iron-related genes. In
low iron states iron regulatory protein 1 or 2 (IRP1/2) binds
IREs. In the proximal 5 region, IRP binding to an IRE
blocks ribosome attachment and polysome formation,
thereby inhibiting protein translation. In the distal 3 region, IRP binding to IREs leads to stabilization of the
mRNA, apparently by blocking RNase recognition sites,
resulting in increased translation. This elegant control allows 1 protein (an IRP) to control expression of different
target proteins in opposite directions. When cellular iron is
high, the IRP proteins bind iron which promotes their ubiquitination and degradation. For the proteins of concern
here, as cellular iron increases IRP1/2 is bound by iron and
degraded leaving 5 IREs in ferritin and ferroportin unbound with increased translation, thereby providing safer
intracellular storage (by ferritin) and more transport of iron
out of cells (by ferroportin). At the same time, unoccupied
IREs in the 3 region of transferrin receptor mRNA lead to
increased mRNA lysis and downregulation of transferrin
receptors that would otherwise further increase uptake of
iron into the cell.
Fe2 H2O2 Fe3 OH OH (Fenton reaction)
1416
Fe3 O2 Fe2 O2
with the following net effect in the presence of iron:

O2 H2O2 O2 OH OH (iron catalyzed HaberWeiss reaction)
A highly pro-inflammatory effect might therefore be expected if increased iron accumulated after the stimulation of
M1-type macrophage activation (with increased superoxide
production already present).
An interesting example of inhospitable iron accumulation
in previously activated macrophages occurs with heme iron
overload in chronic venous stasis ulcers, resulting in an
unrestrained M1-like phenotype together with increased
production of the higly reactive hydroxyl anion and peroxynitrite. The presence of such highly activated macrophages were found to impair wound healing. Some M2 or
Mhem markers were expressed as well, suggesting an incomplete switch to the Mhem phenotype (1634).
In another study, macrophages initially activated by oxLDL
showed even greater M1-type activation after erythrophagocytosis. This activation was inhibited by iron chelators and markedly exaggerated by hepcidin, the small, hormone-like peptide that binds the extracellular side of ferroportin, promoting its internalization and degredation. Thus
the effect of hepcidin in macrophages is to reduce iron release and increase the intracellular iron load. Additionally,
hepcidin production by macrophages was transiently upregulated by inflammation (for example, after exposure to
oxLDL). This might be expected since hepcidin production
by hepatocytes is well known to be upregulated by IL-6
through production of active STAT3 (585). The result was
highly activated, inflammatory macrophages that were
both lipid and iron loaded, possibly reflecting a macrophage
phenotype that would be expected in advanced atherosclerotic lesions with intra-plaque hemorrhage. In the same
study, carotid arteries were treated with viral vectors to
transgenically overexpress hepcidin in ApoE-deficient mice.
Mhem is a macrophage specialized in taking up HbHp complexes and effete red blood cells while rapidly excreting
accumulated free iron through ferroportin without excess
production of ROS. At the same time, it suppresses surrounding inflammation and promotes repair by secreting
IL-10. Such polarization would be particularly advantageous in areas of hemorrhage or traumatic wounds. Furthermore, this Mhem phenotype actively mobilizes intracellular cholesterol to HDL through upregulated ABCA1 and
ABCG1, thereby elegantly dealing with the cholesterol derived from phagocytosed erythrocytes while being resistant
to additional lipid accumulation by downregulation of
SR-A and CD36. Thus handling of heme and iron by Mhem
is physically segregated from the lipid accumulation and
superoxide production that occurs in M1-type macro-
Safe storage of iron in ferritin is important in Mhem since

free iron catalyzes the following reactions resulting in production of highly reactive hydroyxl radical:

Plaques that developed were only slightly larger but clearly
more vulnerable and showed substantially greater accumulation of oxLDL and greater expression of inflammatory
cytokines including IL-6, MCP-1, TNF- as well as MMP2.
In contrast, hepcidin knock-down greatly decreased oxLDL
and the cytokines in plaque macrophages (1025). In the
setting of an advanced atherosclerotic plaque with secondary intraplaque hemorrhage, the potentially anti-inflammatory effects of heme are probably too little, too late. Instead, the increased cellular iron may just contribute to the
inflammation (199).
These studies provide insights into why hemochromatosis

has not been associated with an increased risk of coronary
atherosclerosis, and may even decrease risk in some circumstances, despite whole-body iron overload (1702). Elucidation of the hepcidin-ferroportin axis obtained over the last
15 years is key to this understanding. Normally, hepatocytes sense total body iron status by their own iron content
and by the amount of plasma holotransferrin (transferrin
carrying its full complement of 2 iron atoms) encountered
by transferrin receptor 2 (TFR2) on hepatocytes. Rising
intracellular hepatocyte iron causes, by an unknown mechanism, an increase production and extracellular release of
BMP6. In autocrine fashion, BMP6 binds a BMPR (BMP
receptor) which serine phosphorylates SMAD1/5/8. Active
SMAD1/5/8 then combines with SMAD4 and translocates
to the nucleus to increase hepcidin synthesis. Hepcidin is
released and circulates around the body, binding to and
promoting degradation of ferroportin. The activity of the
BMPR is greatly modified by the coreceptor hemojuvelin
(HJV) which, in turn, forms a complex with HFE (the
hemochromatosis protein) and TFR2 when TFR2 is occupied by holotransferrin (371, 491, 585). Normally, iron
binding sites on circulating transferrin are only 30 35%
occupied. HFE, in some way, acts to further enhance BMP6
signaling when TFR2 is bound. Other factors that modify
hepcidin transcription are IL-6 acting by STAT3 activation
which increases hepcidin transcription, while decreased
hepcidin expression is independently mediated by bone
marrow-derived signaling proteins that are released in the
face of anemia, and by hypoxia through HIF signaling proteins.
Recently, the effect of hepcidin reduction by pharmacological means was tested for its affect on atherosclerosis in
ApoE-deficient mice (1526). A small molecule inhibitor of
SMAD1/5/8 activation (LDN 193189) was used to reduce
hepatic expression of hepcidin. Macrophage ferroportin expression was increased and atherosclerosis area in the aortic
sinus and aorta were decreased 4350%. Furthermore, lesional macrophages had less lipid, expressed more ABCA1
and much more ABCG1. In vitro, peritoneal macrophages
from the treated mice demonstrated greater cholesterol efflux together with reduced hydrogen peroxide production.
These in vitro macrophage findings were reversed by incubation with hepcidin. Certainly, before such a compound
could be considered for human use, longer term testing for
effects on iron homeostasis in vulnerable tissues such as
liver, pancreas, and myocardium would be necessary.
3. Other cytokines associated with macrophages
As suggested by the above discussion, certain cytokines are
classically associated with specific leukocytes. Those studied for effects on atherosclerosis are included in TABLE 7.
1417
Reduced inflammatory responses by iron-depleted macrophages have also been reported. In mice with hepcidin deficiency due to KO of the hemochromatosis gene (HFE), an
oral Salmonella challenge resulted in much less intestinal
inflammation (1901). Macrophages from these HFE/
mice showed increased ferroportin expression and decreased intracellular iron with reduced inflammatory responses when challenged in vitro with Salmonella or LPS.
These diminished inflammatory responses to Salmonella or
LPS were reproduced in wild-type macrophages by iron
depletion with iron chelators or by overexpression of ferroportin.
Hereditary hemochromatosis is caused by inherited defects

in hepcidin production. By far the most common cause of
hemochromatosis is homozygosity for a common HFE mutation (C282Y) present in heterozygous form in nearly 10%
of northern European populations. The absence of HFE
leads to greatly reduced hepcidin production regardless of
liver iron status. Hepcidin normally travels to the gut and
causes internalization and degredation of ferroportin on
intestinal brush-border cells, thereby inhibiting release into
the bloodstream of the iron absorbed by these cells. Thus,
when iron stores are sufficient, iron that is internalized by
enterocytes from the gut lumen is simply lost back into the
intestine as these cells are sloughed off. Hepcidin also reduces transferrin saturation by blocking iron release
through ferroportin by reticuloendothelial macrophages,
which actively remove and ingest aged red blood cells. In
hemochromatosis, abnormally reduced hepcidin allows unrestrained iron absorption through ferroportin in enterocytes. This leads to iron overload in liver, pancreas, and
myocardium. However, hepcidin deficiency and continued
high ferroportin expression in macrophages leads to unregulated release of iron from these cells. Macrophages thus
become essentially iron deficient in hemochromatosis despite the iron overload in the liver and certain other tissues.
Adipocytes also express ferroportin and show marked reduction in intracellular iron in hemochromatosis, interestingly with improved insulin sensitivity and increased production of adiponectin (573). As noted above, relatively
iron-depleted macrophages from HFE/ mice appear to be
less responsive to inflammatory signals. In addition, an
iron-deficient diet, which naturally leads to marked reductions in hepcidin, reduced atherosclerosis in ApoE KO mice
and was associated with reduced LDL oxidation in the lesions (995).
PAUL N. HOPKINS
Besides atherogenic TNF- and IL-1, macrophages secrete
IL-6, IL-12, and IL-18 in response to LPS (3 h peak). IL-6
causes synthesis of acute phase reactants (and hepcidin) in
the liver but was only variably associated with atherosclerosis in genetic models (see TABLE 7). IL-12 and IL-18 were
atherogenic. They stimulate T-helper 1 cells (Th1) to secrete
IFN-. KO of IFN- or its receptor IFNGR1 decreased atherosclerosis (see TABLE 7 under Th1 cells). IL-12 also stimulates cytotoxic CD8 T lymphocytes (CTL) and NK cells
to increase their cytotoxic activity. Other interleukins secreted by macrophages include IL-23 and IL-27, but their
effects on atherogenesis have apparently not been studied.
Growth differentiation factor 15 (GDF-15) is an atherogenic cytokine in the TGF- superfamily. GDF-15 is secreted by macrophages and promotes macrophage accumulation in a CCR2-dependent manner (392).
Several miscellaneous cytokine-like macrophage activators

are also reviewed in TABLE 7. Those increasing atherosclerosis include osteopontin (OPN), macrophage migration
inhibitory factor (MIF), the NOTCH ligand DLL4, and
netrin 1 (Ntn1), which increases atherosclerosis by possibly
causing macrophage retention in plaques. The tetrahydrocannabinol receptor CB2 has neutral effexcts. Protective
GRK5 is not a cytokine, but it phosphorylates proinflammatory receptors CCR2 and CSF1R, marking them ubiquitination and degradation.
Certain lipid mediators of inflammation may be considered
complementary to chemokines or cytokines. For example,
S1P acting through S1PR2 increased atherosclerosis while
S1PR3 had no effect. Eicosanoids can have profound effects
on macrophages and other leukocytes with both cytokine and
chemokine-like effects. PGE2, produced by macrophages
themselves, can bind Gs-coupled receptors on themselves or
nearby macrophages and promote survival, leading to larger
plaques. The EP2 receptor had little effect, but KO of EP4
reduced atherosclerosis lesion size (see TABLE 7). Another
group of lipid mediators of inflammation, the leukotrienes,
1418
Much that is said regarding macrophages might also apply

to dendritic cells. Indeed, one dendritic subtype is derived
from monocytes. However, because dendritic cells appear
to be the first foam cells, they are discussed in section IXA.
Genes that have been manipulated in regard to dendritic
cells remain, however, at the end of TABLE 7.
4. 5-LO and the leukotrienes
As depicted in FIGURE 15, the leukotrienes are products of
lipoxygenase enzymes that can act as lipid counterparts to
the peptide cytokines and chemokines. As such, they are
essentially amplifiers of early inflammation. The leukotrienes are strongly pro-inflammatory eicosanoids synthesized
from arachidonic acid (AA) primarily by macrophages and
other activated leukocytes. Various inhibitors of the pathway have long been marketed for treatment of asthma. The
initial step in leukotriene synthesis occurs when free AA,
released by cPLA2, is presented by the adapter 5-lipoxygenase activating protein (FLAP) to the enzyme 5-lipoxygenase
(5-LO). This step occurs on the nuclear envelope with localization of 5-LO provided by FLAP. AA is converted by
5-LO to the unstable product leukotriene A4 (LTA4) which
is converted to LTB4 by LTA4 hydrolase (LTA4H). LTB4 is
then transported out of the cell by a specific transporter.
Alternatively, LTA4 can be converted to LTC4 by conjugation with glutathione through the action of LTC4S (LTC4
synthase). LTC4 is then transported out of the cell and
further acted on by extracellular peptidases to produce
LTD4 and LTE4. LTC4, LTD4, and LTE4 are referred to as
cysteinyl-LTs and bind to CysLT1, CysLT2, or CysLTE
which are Gq-coupled GPCR. These receptors promote
endothelial permeability, among other pro-inflammatory
effects. Anti-asthma drugs montelukast, zafirlukast, and
pranlukast all inhibit the CysLT1 receptor. However, LTB4
is actually the most inflammatory leukotriene through binding its receptors BLT1, a Gi-coupled GPCR found mainly
on hematopoetic cells but also on activated endothelium
such as that overlying atherosclerotic lesions. A second
LTB4 receptor, BLT2, is widely expressed.
As shown in FIGURE 15, LTB4 acting through BLT1 amplifies early inflammatory signaling. LTB4 is clearly chemotactic for neutrophils and macrophages, in part by reducing
cAMP levels in migrating cells, similar to chemokines. Of
note, elevation of cAMP by various agents inhibits cell migration generally, apparently by PKA phosphorylation of
MLCK with a reduction in myosin light-chain phosphorylation and other actions to inhibit lamellipodia formation
and extension (292, 1076). Other inflammation-amplifying
effects of LTB4 were recently demonstrated in the setting of
intermittent hypoxia (1031). Exposure of ApoE KO mice to
intermittent hypoxia clearly increases atherosclerosis, possibly by increasing ROS generation by mitochondria from
M-CSF is a chemokine-like cytokine whose cognate receptor is CSF1R (see TABLE 6). M-CSF production is induced
by oxLDL in endothelial cells and VSMC. It appears to be
key for growth and survival of macrophages. M-CSF also
stimulates production of other cytokines and may induce
transformation of VSMC into foam cells (918). Deficiency
of M-CSF results in macrophage-deficient mice which also
lack osteoclasts and are osteopetrotic (op). The op/op
mouse is homozygous for a naturally occurring base pair
insertion in M-CSF leading to a premature stop codon with
marked reduction in M-CSF. Op/op mice are highly resistant to atherosclerosis. M-CSF/ also showed substantial
reduction of atherosclerosis as did KO of its receptor (see
TABLE 6). Almost all the effect of M-CSF on atherosclerosis
was attributable to vascular wall production or other cells
other than bone marrow derived (1602).
have received considerable attention as discussed in the following section.

spillover and promiscuous loss of free electrons from the
electron transport chain when acceptor O2 is limited, followed by greater activation of NF-B, p38, and JNK. Interestingly, LTB4 and BLT1 were also increased by intermittent hypoxia, while KO of BLT1 eliminated the excess atherosclerosis associated with intermittent hypoxia. Further
studies showed that BLT1 ligation by LTB4 upregulated
MAPK and NF-B activity, resulting in increased transcription of 5-LO, LTA4H, and MCP-1, a positive feedback
loop. At the same time, foam cell formation was promoted
by increasing CD36 and SRA expression while macrophage
differentiation was also stimulated. BLT1 signaling also
promotes secretion of cytokines, MCP-1, and MMPs in
other leukocytes as shown in FIGURE 15, further amplifying
the inflammatory cascade.
Atherosclerosis was clearly reduced by blocking BLT1 either by genetic deletion (as in the intermittent hypoxia
model noted above as well as in other studies of genetically
hyperlipidemic mice), or by pharmacological inhibition of
BLT1. Surprisingly, however, most of these studies showed
effects only at early time points with little or no atherosclerosis reduction at later time points (1428) (see TABLE 7).
Inhibition of CysLT1 with montelukast also decreased atherosclerosis in hyperlipidemic mice in a relatively shortterm (16-wk) study (1428). Follow-up of a very large Swedish drug registry found only suggestive effects for prevention of stroke or MI associated with montelukast use (824).
Why inhibition of BLT1 (or possibly CysLT receptors) does
not result in more durable inhibition of atherosclerosis remains difficult to explain. Certainly, redundancy of chemokine signaling, with effects restricted to early progression,
may explain findings in mice. Nevertheless, 5-LO is increased in unstable human lesions, and further studies in
human populations may still be fruitful (1428).
Since FLAP facilitates AA loading onto 5-LO, inhibition or
deletion of FLAP and/or 5-LO might be expected to decrease atherosclerosis. Nevertheless, recent studies with genetic deletion of 5-LO or FLAP consistently resulted in little
or no effect on atherosclerosis (see TABLE 7) (253, 1428).
Pharmacological inhibition of FLAP in hyperlipidemic mice

did reportedly reduce atherosclerosis, although secondary
effects of the drugs used cannot be excluded (315, 1428). A
phase II human trial with veliflapon (DG-031, DECODE
Genetics) suggested modest anti-inflammatory effects
(697), but a larger endpoint follow-up study was suspended
without apparent explanation. Perhaps most encouraging is
a small imaging substudy of a phase III trial of the potent
5-LO inhibitor atreleuton. Short-term (24-wk) follow-up
suggested fewer new plaques and a reduction in noncalcified plaque volume in those treated with atreleuton (1761).
5. 12/15-LO as an effector of early inflammation as
well as late resolution
In comparison to 5-LO, the physiological function of 12/
15-LO is less clear, yet it is one of the most studied genes in
atherosclerosis research. While there are several enzymes
with lipoxygenase activity that can add peroxyl groups to
the 8, 12, or 15 positions of AA, the enzyme of interest here
is variously called leukocyte-type 12-LO (in mouse), 15lipoxygenase-1 (in human), or simply 12/15-LO (567). 12/
15-LO introduces a peroxyl group at the 12 or 15 position
of AA, yielding 12-S-HPETE or 15-S-HPETE (hydroperoxyeicosatetraenoic acid). This transient product is acted
on by cellular peroxidases to yield the more stable 12- or
15-HETE. In the mouse, the 12-LO activity predominates,
whereas in rabbits and humans, 15-HETE is the main product. When acting on linoleate (which can include cholesterol-linoleate in LDL supplied in an incubation medium with
intact macrophages), the main product is 13-HPODE with
rapid peroxidase hydrolysis to 13-HODE (hydroxyoctadecadienoic acid). Secretion of IL-12 by activated macrophages appears to be dependent on 12/15-LO as well. Thus
stimulation of IL-12 production by LPS or IFN- was markedly attenuated (7590%) in 12/15-LO-deficient macrophages (2089).
Much earlier thinking focused on the notion that oxidized
LDL was to blame for the proatherogenic effect of 12/15LO. Indeed, multiple studies showed marked reduction of
atherosclerosis with whole body KO of 12/15-LO (see TA-
1419
Additional proinflammatory signaling is mediated by

BLT1. In macrophages, and presumably in activated endothelium as well (as shown in FIGURE 15), activation of BLT1
is thought to lead to -arrestin binding to the cytoplasmic
side of the BLT1 receptor followed by Src activation. Src
generally provides phosphotyrosines on scaffolds or adapter proteins for subsequent binding and activation of downstream effectors. In the case of BLT1 signaling, this action
appears to result in JAK2-STAT1 signaling. Active STAT1
dimers were found to act as transcription factors to stimulate MyD88 transcription which would facilitate NF-B
activation through most TLR as well as IL-1R. Gi signaling through BLT1 also blocked SOCS1, a major inhibitor of
JAK2 (1589).
One exception was in the setting of inducible total-body

COX-2 KO. COX-2 and 5-LO apparently compete for free
AA. Presumably, loss of COX-2 competition in COX-2 KO
animals increased AA supply to the leukotriene pathway
and then allowed KO of FLAP to decrease atherosclerosis
(2050). Alternatively, lack of COX-2 could also result in
decreased PGE2 production in leukocytes during later
stages of inflammation. PGE2, though apparently proatherogenic in early lesions by promoting macrophage survival, may block some of the effects of LTB4 signaling in
more advanced lesions and also promotes a switch of signaling toward inflammation resolution in leukocytes (see
below). A loss of PGE2 action could conceivably increase
the observable effects of FLAP deficiency.
PAUL N. HOPKINS
BLE 7),
question, however. Incubation of endothelial cells with high

glucose, as might be seen in diabetes, led to an increase in
12-S-HETE production and a similar presentation of fibronectin by endothelial integrins which appeared to be
dependent on 12/15-LO expression (1395, 1396). Interestingly, both 12/15-LO products and ANG II can stimulate
VSMC to produce fibronectin (1034).
The notion that 12/15-LO seeds lipoproteins with oxidized

fatty acyl free radicals which propagate further free radical
damage was largely dispelled by a recent study. Instead,
fatty acids in intact cholesteryl esters derived from intracellular pools or external LDL can be directly oxidized by
12/15-LO, followed by hydrolysis of the cholesteryl ester
and reesterification of the oxidized fatty acids into phospholipids. The stereospecificity of the products (12-S-HETE
and 12-S-HODE) showed that the oxidized fatty acids were
generated enzymatically with minimal nonspecific, spontaneous oxidation (808).
The above paragraphs briefly summarize the apparent proinflammatory, proatherogenic effects of 12/15-LO. Thus, in
activated cells, this enzyme appears to produce 12-S-HETE
which may act through a specific GPCR to activate MAPK
and NF-B with markedly increased endothelial expression
of adhesion molecules. KO of 12/15-LO reduced atherosclerosis in most studies while nonphysiological transgenic
overexpression, especially in endothelial cells, markedly increased atherosclerosis. If these were the only effects, the
discussion of this intriguing enzyme could have been much
abbreviated.
If 12/15-LO generates specific signaling molecules, what are

they and what is the nature of their effects? 12-HETE generated by 12/15-LO was shown to critically affect monocyte
adhesion to aortic endothelium by increasing active RhoA,
PKC, and NF-B leading to increased cell-surface expression of ICAM-1 (173). However, where the 12-HETE is
generated, whether in macrophages, other leukocytes, or
activated endothelial cells could not be shown. Presumably,
the BMT studies reviewed above suggest hematopoetic cells
as the normal primary source. Perhaps this explains the
severe atherosclerosis seen in transgenic models with endothelial overexpression of 12/15-LO (170, 173, 715, 1469).
These investigators showed that 12/15-LO stimulated the
presentation of fibronectin by endothelial 41 integrins on
the apical (luminal) side of the cells, leading to monocytespecific capture through monocyte 51 integrins which
recognize fibronectin (1469). Whether 12/15-LO is normally expressed in activated endothelial cells remains a
However, newer studies reveal a major role for 12/15-LO in

the resolution of inflammation. Thus 12/15-LO can hydroxylate LTA4, produced by 5-LO, on carbon 15 (or 5-LO
can act on 15-HETE) to yield the anti-inflammatory lipoxin
LXA4. Resolvins, protectins, and maresins are similar to
lipoxins but are derived from n-3 fatty acids. Each of these
pro-resolving lipids acts through its own GPCR (1592). The
importance of 12/15-LO in inflammation resolution is
clearly demonstrated in mouse arthritis models, where 12/
15-LO KO results in severe, uncontrolled, prolonged inflammation with increased tissue damage (954). Interestingly, PGE2 production, primarily by COX-2, was essential
for the switch to resolution induced by LXA4 in a mouse
arthritis model (272). Anti-inflammatory effects of lipoxins
include stimulation of macrophage differentiation into inflammation-resolving subtypes (such as M2) having greater
ability to clear apoptotic debris (951), reduced cytokine
production, decreased endothelial activation, and other ef-
1420
Recently, the orphan GPCR GPR31 was found to be a

specific 12-S-HETE receptor. In endothelial cells, GPR31
ligation with 12-S-HETE increased MAPK and NF-B activity (676). GPR31 signaling may explain the previously
hypothesized GPCR which appeared to mediate endothelial
effects of 12-HETE, including activation of PKC, RhoA,
NF-B, and increased ICAM-1 expression (as shown in FIGURE 15) (173, 567). Whether this receptor can explain both
the paracrine and apparent autocrine effects of 12-S-HETE
remains to be explored. Another group identified specific
Src activation followed by cell migration in VSMC stimulated with 12-S-HETE (1468). Such signaling might be expected if GPR31 ligation led to PYK2 activation. 12/15-LO
was found to promote proliferation of VSMC and neointimal formation after arterial injury (407). 12-HETE was
also recently reported to promote ER stress in adipocytes
(338).
some with correlation between atherosclerosis and

urinary levels of isoprostanes (2089) or inhibition of atherosclerosis with very high doses of vitamin E only in mice
having intact 12/15-LO (though the vitamin E may have
inhibited the enzyme itself) (2092). However, in a subsequent study, whole body KO versus BMT of 12/15-KO cells
into wild-type mice equally reduced atherosclerosis (807).
Furthermore, this study showed that urinary isoprostane
levels were the same in 12/15-LO replete mice transplanted
with either 12/15-LO-deficient or wild-type bone marrow,
but atherosclerosis reduction was seen only with 12/15-LO
deficiency in hematopoetic cells. These results suggest a
more specific signaling role, particularly in macrophages.
These investigators went on to show in a two-chamber experiment that the medium from wild-type macrophages incubated with native LDL (not oxidized or otherwise modified) in the top chamber markedly increased subsequent test
monocyte attachment to endothelial cells cocultured in the
bottom chamber. Thus, even though only fluid from the
incubated macrophages could bathe the endothelial cells, it
still transmitted one or more endothelial activating substances. In this same experiment, macrophages from 12/
15-LO KO mice did not induce endothelial monocyte attachment (807). These results suggested a specific product
of 12/15-LO was acting as a soluble cytokine-like molecule.

fects (1592). Furthermore, phagocytosis of apoptotic cells
may provide the appropriate precursor(s) (for example,
LTA4 from apoptotic neutrophils) as well as other triggers
for the switch to greater LXA4 synthesis in macrophages.
Thus the accumulation of lipoxin precursors during inflammation may help stimulate the later increased production of
lipoxins.
In the most recent study of 12/15-LO KO animals, the mice

were fed either high saturated fat (SAT) or high polyunsaturated (PUF) diets. Deletion of 12/15-LO clearly decreased
atherosclerosis for both diet groups, but the decrease was
greater in PUF-fed group (1507). This phenomenon may
have been explained by a substantial reduction in serum
cholesterol and triglycerides due to 12/15-KO that was seen
only in the PUF-fed animals. 12/15-LO replete Kupffer cells
(which are derived from monocytes) appeared to generate a
product from a PUF precursor that acted on hepatocytes to
upregulate fatty acid synthesis, promote fatty liver, increase
VLDL production, and increase plasma cholesterol and
triglycerides, explaining at least some of the reduction of
atherosclerosis when 12/15-LO was knocked out (1507).
However, proinflammatory products of 12/15-LO in artery
To summarize findings regarding 12/15-LO and atherosclerosis, the major effect of the gene may be protective in the
setting of a low-fat diet due to the role of 12/15-LO in
lipoxin production. The fact that 5-LO can supply a precursor for lipoxin production may help explain the generally
negative results from 5-LO and FLAP deletion studies as
well. However, at least early in the course of rapidly progressing atherosclerosis produced by high-fat feeding in hyperlipidemic animals, the pro-inflammatory signaling effects from 12-HETE produced by 12/15-LO seem to predominate. This assessment would suggest that in the human
setting, where hyperlipidemia is generally much less severe
and plaques develop over decades, one might expect a protective role for 12/15-LO activity. Indeed, this seems to be
the case as manifest by a 1.3- to 1.6-fold increase in risk of
CAD associated with carrying a single copy of a low-activity 12/15-LO variant in two large epidemiological studies
(84). Yet even here, the ambiguity continues since the rare
homozygotes were, if anything, protected.
6. Neutrophils are involved in atherosclerosis: at
least in early stages
Many of the same receptors and chemokines reviewed in
relation to monocyte recruitment and transmigration also
mediate neutrophil recruitment into atherosclerotic
plaques. CXCR2 is more strongly related to neutrophil recruitment and was strongly atherogenic as was at least one
of its ligands, CXCL1 in hyperlipidemic mice (see TABLE 6).
In ApoE-deficient mice, neutrophil recruitment to larger
arteries early in atherogenesis seemed to depend on CCL5
from platelets being deposited on endothelial cells and then
being recognized by CCR5 on neutrophils. A high-fat diet
increased neutrophil production in the marrow and mobilization into the bloodstream while also decreasing removal
rate from the circulation. Furthermore, neutrophil depletion inhibited plaque development in these mice at 4 wk but
not at later time points (445).
Earlier studies often lacked the ability to specifically detect
neutrophils in plaques but more recent techniques clearly
disclose the presence of neutrophils in early plaques of hyperlipidemic mice (1649, 1858). Neutrophils were strongly
associated with unstable plaques in coronary arteries in a
human autopsy series (1285). Similar evidence was presented for human carotid plaques (827). Neutrophil extracellular traps (NETs) have recently been observed in and on
human plaques (1179). Neutrophils recruited to early
plaques are found in shoulders near macrophages, but undergo apoptosis and efferocytosis relatively rapidly after
they move into plaques (1649). Neutrophils adhering to
endothelium release azurocidin which facilitates monocyte
adhesion. Furthermore, proteins released from neutrophil
granules, such as proteinase 3, directly activate chemokine
1421
Considering these inflammation resolving effects, it may be

less surprising that several studies have reported evidence
for atherosclerosis protection by 12/15-LO. Transgenic
WHHL (Watanabe heritable hyperlipidemic) rabbits (an
LDLR/ model) which overexpressed human 15-LO were
protected from atherosclerosis (1613). Later, macrophagespecific transgenic overexpression of the human 15-LO in
ApoE null mice led to marked increase in production of
LXA4 and a reduction in atherosclerosis when the mice were
fed a low-fat chow diet (1197). Furthermore, BMT of 12/
15-LO deficient cells into ApoE-deficient animals fed a lowfat diet increased atherosclerosis compared with BMT of
12/15-LO/ cells, again suggesting protection mediated by
12/15-LO (1197). In these studies, the low-fat chow diet
appeared to be of key importance. Thus the same group
using the identical transgenic and BMT mouse models reported later that the apparently beneficial effects of 12/
15-LO were essentially reversed by feeding a high-fat,
Western diet. Indeed, at 10 wk, the 12/15-LO KO animals were protected when fed a high-fat diet, but this effect
was largely gone by 14 wk. Furthermore, no benefit for
transgenic overproduction of 15-LO was seen on the highfat diet. Human endothelial cell (HUVEC) production of
ICAM-1 was increased fivefold by serum from 12/15-LO
deficient animals (when compared with wild type) but only
when the mice were fed a low-fat chow diet. On a high-fat
diet, serum-stimulated production of ICAM-1 was nearly
the same. Plasma LXA4 was much higher in 12/15-LO
transgenic animals when fed a chow diet, but on a high-fat
diet, plasma LXA4 was similarly elevated in both transgenic
and wild-type animals (1198).
wall macrophages could have acted directly to promote

atherosclerosis as well.
PAUL N. HOPKINS
production by endothelial cells and appear capable of
greatly increasing the affinity of certain chemokines for
their receptors on monocytes. Neutrophil cathelicidin
(LL37) promotes differentiation of monocytes into more
inflammatory macrophages (1846); surprisingly, LL37 also
promoted endothelial recovery after injury and limited neointimal hyperplasia (1650). Neutrophils also help promote
macrophage activation by secreting TNF-, IL-8, and
IFN- as well as myeloperoxidase (444). Neutrophil phagocytosis is triggered by innate cues followed by prodigious
release of MPO (myeloperoxidase).
7. Natural killer T-cells and related
NK, NKT, T, and CD8 T cells express a receptor

named KLRK1 (killer cell lectin-like receptor, subfamily K,
member 1; also known as NKG2D for NK cell lectin-like
receptor subfamily K). KLRK1 is a membrane-bound receptor that binds a number of danger signal ligands expressed at very low levels on healthy cells but greatly upregulated on infected or injured cells. In humans, KLRK1
ligands include two major histocompatibility complex class
I chain-related family members (MICA and MICB) and 5
UL16-binding protein family members (ULBP1 4 and
RAET1G). Expression of MICA/B was shown to be clearly
increased in human atherosclerotic plaques (on EC and
macrophages) with soluble receptors detected in plasma of
diabetic subjects. Expression of KLRK1 ligands were markedly increased in hyperlipidemic as well as diabetic mice.
KLRK1 KO markedly decreased atherosclerosis by 80%
(1989). The KLRK1 receptor and ligand system seems to
work similarly to TLR ligation to induce rapid and generous production of inflammatory cytokines including IFN-,
TNF-, CXCL1, IL-1, IL-6, and IL-12 (1118).
Histamine appears to be proatherogenic. In older studies of

immune injury, antihistamine administration decreased atherosclerosis in hyperlipidemic rabbits (1). More convincingly,
KO of histidine decarboxylase (HDC), the rate-limiting enzyme for histamine synthesis, was protective. Nuclear NF-B,
inflammatory cytokines, and MMPs were reduced in HDCnull mice despite higher cholesterol levels (1900). Histamine
receptor H1 (HRH1)-deficient mice had reduced atherosclerosis together with less vascular permeability to LDL. Furthermore, a 40% reduction in atherosclerosis was seen with an H1
antagonist (mepyramine) in this study. Endothelial HRH1
seems to be central to this effect as transplant of HRH1/
bone marrow did not affect atherosclerosis (1515). In contrast, no effect on atherosclerosis was seen with HRH2 KO or
an H2 antagonist (ranitidine) (1515).
Kit is a transmembrane tyrosine kinase receptor for stem
cell factor (SCF), a growth factor required for mast cell
differentiation. The name Kit seems not to be an abbreviation and its naming is unexplained (138). KitW-sh/W-sh mice
have no mast cells. They had reduced atherosclerosis but
apparently because of combined deficiency of IL-6 and
IFN-, which are normally secreted by mast cells (1709).
Deficiency of mast cell chymase decreases aneurysm formation but apparently not atherosclerosis (1710) despite elaborate hypotheses regarding potential contributions of chymase to atherogenesis (943).
GM-CSF is an important growth factor secreted by mast
cells. GM-CSF is a major stimulus for neutrophil development and also appears to support DC in atherosclerotic
lesions. GM-CSF clearly promoted intimal DC proliferation in early lesions, but entry of monocytes was not affected (2112). GM-CSF can also be secreted together with
M-CSF by activated EC. Even though GM-CSF with IL-4
can promote an M2-type macrophage phenotype, KO of
GM-CSF reduced atherosclerosis in LDLR-null mice (918).
D. Innate Versus Adaptive Immunity in

Atherogenesis
8. Mast cells in atherosclerosis

1. Adaptive immunity: an introduction
While activated by IgE antibodies which are directed against
specific antigens (particularly found on helminths), mast cells
are discussed here because they secrete several products that
might be rightly classed as innate immune mediators and because they are activated in response to essentially any antigenbound IgE regardless of the antigen. Th2 cells are required for
the production of such IgE (1). Their IgE receptor (FcRI) is
analogous to the activating, ITAM-containing Fc receptors
on macrophages and also utilize -chains that mediate inflammatory signaling. When activated they released preformed his-
1422
In contrast to innate immune responses, adaptive immunity

depends on the presentation of antigenic peptides by multiple histocompatability complex (MHC) receptors and
their steric recognition by T-cell receptors. There are two
classes of MHC receptors. Class I MHC (MHCI) receptors
are found on all nucleated cells. Only dendritic cells (DC),
macrophages, B-cells, and thymic epithelial cells constitutively express class II MHC (MHCII) receptors. Certain
cytokines, particularly IFN-, can induce expression of
Natural killer T-cells (NKT) with an invariant TCR (also

referred to as CD1d-restricted NKT) can respond to glycolipids presented on the CD1d receptors of antigen presenting cells. When thus activated, NKT quickly release copious
amounts of TNF-, IFN-, MCP-1, IL-5, and IL-6, with
lesser quantities of IL-2 and IL-4 (1821). These cytokines
presumably further activate nearby NK, Th1, Th2, macrophages, and endothelial cells.
tamine stored in their characteristic granules but also CCL3,

IL-4, IL-5, IL-6, IL-13, PAF, TNF-, IFN-, renin, PGD2,
LTC4, LTD4, LTE4, and GM-CSF.

MHCII in certain other cells such as endothelial cells, epithelial cells, and fibroblasts (317). VSMC too were found to
express MHCII in human atherosclerotic plaques (61). In
humans, the MHC receptors correspond to human leukocyte antigens (HLA). HLA-A, HLA-B, and HLA-C are
MHCI receptors while MHCII receptors comprise HLADP, HLA-DQ, and HLA-DR subclasses. The HLA loci are
among the most polymorphic in the human genome. To be
activated, T-cell receptors must sterically match the particular inherited HLA product (MHC receptor) as well as the
presented foreign peptide.
Th (CD4) cells generally respond to extracellular antigens

such as extracellular bacteria that have been phagocytosed
by macrophages (but can also respond to cytoplasmic proteins taken up by autophagy), while CTL (CD8) typically
respond to intracellular antigens (such as those generated in
virus-infected cells), often leading to killing of the infected
cell. Activation after TCR recognition of antigen is contigent on the expression level of costimulatory and coinhibitory receptors on the presenting cell.
The TCR incorporates variable immunoglobulin-like sequences into its extracellular antigen-binding site, but its
cytoplasmic tail contains no ITAM or ITIM and is not covalently modified after antigen binding. Instead, TCR antigen binding activates CD4 or CD8-bound Src-family tyrosine kinases which then phosphorylate ITAM sequences
in invariant adaptor proteins found in the TCR complex.
Adaptors for the TCR complex include -chains and multiple copies of CD3. The BCR is composed of a plasma membrane-bound IgM or IgD accompanied by heterodimers of
the invariant transmembrane adapter proteins Ig and Ig,
both of which contain ITAM sequences. Similar to the
TCR, when the IgM of the BCR binds a foreign protein, a
membrane-bound Src-family tyrosine kinase is activated to
phosphorylate tyrosines in the ITAM sequences of Ig and
Ig. IgM and IgD of the BCR and the TCR variable sequences are synthesized during cell differentiation by a pro-
The TCR recognizes only relatively small peptides bound

to MHC receptors. In contrast, the BCR can recognize
and bind more complex shapes or sequences on the surface of foreign cells or proteins in their native state (without the need for prior digestion and presentation). When
the B-cell binds such a native, foreign protein, it begins
activation followed by phagocytosis and endosomal digestion of the invader or protein bound to its BCR. Foreign peptides derived from this process can then be
loaded onto the B-cells MHCII receptor and presented to
CD4 Th cells. Th cells previously activated by the same
antigen presented to their TCR by nearby DC will then
present sufficient costimulating receptors and secrete activating cytokines to promote efficient proliferation of
the B-cells. The antibodies eventually produced by the
active clone of B-cells will match the antigenic specificity
of the original BCR IgM or IgD rather than the antigen
(peptide) presented by the MHCII receptor. Absence of
activating costimulatory signaling blocks activation and
may signal for apoptosis as may the binding of coinhibitory receptors (122, 646).
After antigen recognition, IL-2 becomes critical for proliferation of activated T cells and further differentiation into
various subsets. In chronic inflammation, Th1 and Th2 subsets predominate, with Th1 considered the main Th subtype
in both human and mouse atheroma based primarily on
observations on predominant cytokines present, such as
IFN-, the prototypic Th1 cytokine (61, 713). IFN- enhances the immune response in part by stimulating an increase in class II MHC receptors on antigen-presenting
cells. After IFN- binds its JAK/STAT receptor, there is
activation of STAT1. STAT1, together with other transcription factors, upregulates expression of the master regulator
of MHCII receptors, CIITA (or C2TA, class II transactivator). By acting as a kind of scaffold to assemble necessary
transcription factors in a specific order, but without binding
DNA itself, CIITA induces transcription of MHCII receptors (1471). KO of CIITA in ApoE-deficient animals has
been reported to increase abdominal aortic aneurysms, with
excess Th2 activation and metalloproteinase expression,
but no effect on atherosclerosis was mentioned (1625).
IFN- also stimulates the transcription factor T-bet and
IL-12 to promote Th1 development. Furthermore, IFN-
stimulates Th1 cells to become major IFN- producers
themselves, with IFN- promoting classical macrophage activation (resulting in M1 macrophages) and enabling infected macrophages to kill phagocytosed invaders. M1
1423
MHCII receptors are loaded in the Golgi with peptides

(antigens) derived from endosomal digestion of phagocytosed cells or organelles engulfed during autophagy. In
contrast, MHCI receptors are supplied with peptides derived from cytosolic proteins (for example, from viruses)
that have undergone ubiquitination and proteosomal
degradation in the cytoplasm and then delivered to the
endoplasmic reticulum by transporter associated with
antigenic processing 1 (TAP1). MHCII receptors only
interact with T-cell receptors (TCR) that are accompanied by the CD4 adapter, while TCR that bind MHCI
must have the CD8 adapter. Both CD4 and CD8 bring
Src family tyrosine kinases to the TCR complex, bound
to their cytoplasmic tails. CD4 T-cells include Th1,
Th2, Th17, and T-regulatory cells (Treg). CD8 T-cells
are cytotoxic T lymphocytes (CTL).
cess of random shuffling of specific DNA sequences. Once

mature, these rearrangements are preserved in selected
clones of cells (836, 1053). One particular clone of T- or
B-cells expresses only one specific variable sequence on its
TCR or BCR. Proliferation of a particular clone after antigen recognition and activation constitutes immunologic
memory.
PAUL N. HOPKINS
macrophages and DC present antigens through the MHCII
receptor, secrete cytokines TNF-, IL-6, IL-12, and produce large amounts of NO through iNOS and ROS through
NOX2 (286).
In contrast to Th1, Th2 develop in response to IL-4 stimulation and go on to produce more IL-4, a cytokine important in promoting B-cell antibody production (with permission from antigen-specific activated Th2 cells). A major function of Th2 cells and IL-4 appears to be local
stimulation of macrophage proliferation (846). IL-4, as well
as IL-13, also cause alternative macrophage activation to
M2 cells. M2 were often considered anti-inflammatory.
However, M2 are induced to express MHCII as well as
phagocytic receptors and different chemokines (CCL2,
CCL7), all in addition to the anti-inflammatory IL-1 receptor inhibitor IL-1Ra. In M2, arginine is diverted by arginase-1 away from NO production to reparative ornithine
and polyamines (286). Th2 can produce IL-5 which seems
to be important to activate eosinophils in helminth infections, but importantly for atherosclerosis, IL-5 also promotes B1a production of natural antibodies.
2. Which predominates in atherogenesis: innate or

adaptive immunity?
For a number of years it was thought that macrophages
were so predominant in plaques that essentially only the
innate immune response was relevant to atherogenesis
(580). Indeed, many if not most components of the innate
immune system are critically involved in atherogenesis
(580, 1088). After all, marked reductions in atherosclerosis
had been seen after interfering with many aspects of innate
immunity, including TLR signaling (TABLE 3); scavenger
receptors (to be reviewed below), adhesion molecules and
chemokines (TABLE 6); various aspects of cytokine signaling
including TNF, IL-1 signaling, MIF, and IFN- (TABLE 7);
NKT activation by innately recognized glycolipids (TABLE
7); and neutrophil activity (1649, 1933).
The notion that adaptive immunity was unimportant
seemed to be supported by a report that deficiency of Rag1
(recombination activator gene 1) or Rag2 in fat-fed ApoE
KO mice led to only a very early reduction in atherosclerosis
which diminished with time (379, 382). Interestingly, the
1424
Rag1 and Rag2 form a tetramer known as V(D)J recombinase with Rag1 making a nick in the DNA at coding/noncoding junctions of variable (V), diversity (D), and joining
(J) gene segments of immunoglobulins or corresponding
receptors in developing lymphocytes. DNA rearrangements
and annealing follow. Rearranged DNA then directs transcription and translation of both mature Ig and T-cell receptors (TCR). Without normal surface expression of Ig or
T-cell receptors, developing lymphocytes undergo apoptosis. Rag1 or Rag2 deficiency thus leads to complete absence
of both T and B lymphocytes and immunodeficiency. However, knockout of Rag1 or Rag2 would have also eliminated
the anti-inflammatory T-regulatory (Treg) cells together
with Th cells.
Later, other models clearly showed that suppression of
adaptive immunity (particularly Th cells) led to protection
from atherosclerosis (e.g., scid/scid mice, CD4 KO, TCR
subunit KO see TABLE 7). CD8 CTL seem to have less of
a role as CD8 KO had little effect on lesions in ApoE or
LDLR-deficient mice (TABLE 7) (469, 470). Adoptive transfer, transplant, and several knockout studies in mice further
demonstrate that both arms of the immune system are major contributors to atherosclerosis (61, 580, 1130, 1933).
Indeed, current models of atherosclerosis depict not only a
variety of immune cells in the plaque (particularly macrophages and T-cells), but an inflammatory lesion richly endowed with numerous B-cells in adjacent adventitia as well
(580).
Th1 cells appear strongly proatherogenic given the marked
reduction in atherosclerosis in mice with KO of the costimulatory CD40L as well as models of IFN- signaling interruption (see TABLE 7). Deletion of T-bet, a transcription
factor for differentiation of the Th1 subset, reduced atherosclerosis signficantly but modestly. Markedly decreased
atherosclerosis was seen in another study in which ApoE
KO mice were treated with a chemical agent that inhibits
Th1 differentiation (984).
IL-4 is a key Th2 cytokine that promotes M2 macrophage
activation. Effects of genetic manipulation or infusion have
been quite mixed. Some studies show some reduction in
atherosclerosis with blocked IL-4 signaling, while a more
recent study using multiple models (IL-4 KO in ApoE- or
LDLR-deficient mice, with or without ANG II infusion, and
IL-4 infusion). None of the models showed an effect on
atherosclerosis (913). Other Th2 signaling, namely, release
Macrophage deactivation occurs in response to Treg cytokines TNF- and IL-10 with downregulation of MHCII
receptors. Importantly, ingestion of apoptotic cells (if these
targeted cells do not themselves express or contain danger
signals) also leads to macrophage deactivation and production of TNF- and IL-10 (286). Macrophages and neutrophils can recognize targets coated by antibody by their
Fc receptors, while other receptors recognize complement
or lectin-coated invaders. Receptor binding is followed by
phagocytosis and killing. Thus macrophages and neutrophils are effectors for both innate and adaptive immunity.
protective effects of estrogen in ovariectomized mice were

lost in Rag2-deficient mice or mice transplanted with Rag2deficient marrow but could be restored by normal Rag2/
marrow transplant. No specific subset of B or T lymphocytes could be identified that were responsible for this effect
(470).

of IL-5 and IL-33, appears to be more anti-inflammatory
and antiatherogenic (see TABLE 7).
Th17 cells differentiate from naive CD4 cells when stimulated simultaneously by TGF- and inflammatory cytokines such as IL-1 or IL-6. Their net contribution to atherosclerosis remains controversial. KO of the IL-17 receptor
decreased atherosclerosis while KO of as at least one IL-17
isoform (IL-17A) clearly increased atherosclerosis in ApoEdeficient mice (see TABLE 7).
E. T-regulatory Cells in Atherosclerosis

1. Evidence for the atheroprotective effects of Treg
Treg cells are critical for normal immune self-tolerance and
are generally anti-inflammatory. Overexpression of IL-10,
the key anti-inflammatory cytokine secreted by Treg, effectively reduced atherosclerosis in LDLR KO mice (1885).
However, Th2, B1a cells, as well as M2 and Mheme macrophages also produce IL-10, so these data do not prove a
specific role for Treg. In the first study to provide clear
evidence for Treg inhibiting atherosclerosis, ApoE KO mice
were initially injected subcutaneously with either saline or
ovalbumin in complete Freunds adjuvant. Mice given the
ovalbumin developed strong Th1 and IgG responses against
In contrast to the above study showing suppression of atherosclerosis by a bolstered Treg response, adoptive transfer
of bone marrow that was deficient in Treg into irradiated
mice led to increased atherosclerosis (33). The transcription
factor Foxp3 is critical for differentiation to and maintenance of the Treg phenotype. Artificially inducing a cytotoxic response toward Foxp3-bearing cells (by vaccination
with DC transgenically modified to over-express and present Foxp3) decreased Treg and increased atherosclerosis
(1852). Multiple additional genetic manipulations that impair Treg activity also promote atherosclerosis (see TABLE
7). More recently, tolerance to specific human APOB-100derived peptides was induced in ApoE-deficient mice by
subcutaneous delivery of relatively low doses of the peptides subcutaneously without adjuvant. This was achieved
by an osmotic minipump implanted for 14 days. This
tolerogenic protocol led to increased Treg activity and a
reduction in atherosclerotic plaque development as well as
arrest of further progression of plaques. Treg from APOB100 tolerant mice specifically suppressed proliferation of
Th1 cells from mice that had been sensitized to the same
APOB-100 peptides. Thus tolerogenic Treg suppress cells
that actively present the specific antigen recognized by the
Treg. Depletion of Treg abrogated the antiatherosclerotic
effect of the treatment (751). These studies also identify
APOB-100 as a likely target of proatherogenic adaptive
immune responses.
Increasing the number and activity of Treg appears to be the
main mechanism whereby repeated oral or nasal administration of low to moderate doses of various antigens (induction of mucosal tolerance) leads to a reduction in atherosclerosis. Targets for tolerance induction have included oxLDL (with decreased atherosclerosis after an oral tolerance
protocol), malondialdehyde treated LDL (no effect) (1859),
HSP60 (reduced atherosclerosis) (1860), HSP65 (reduced
atherosclerosis) (1142), and 2-glycoprotein I (reduced
atherosclerosis) (606) in addition to the APOB-100 studies
1425
The role of CTL in atherosclerosis may need to be reassessed based on recent data. Consistent with older evidence
that CTL are less important for atherosclerosis, deletion of
TAP1 or CD8 in ApoE-deficient mice had no effect on atherosclerosis (932). However, complete absence of CTL or
TAP1 during development may lead to compensatory increases in Th, NK, or T cell responses or absence of a
strongly anti-inflammatory CD8 regulatory CTL (972).
CD8 CTL are said to be the predominant leukocyte in
advanced human plaques, constituting up to 50% of such
cells (972). In ApoE-deficient mice, antibodies against either the or isoform of CD8 decreased atherosclerosis
while reconstitution of lymphocyte-deficient mice with
CTL increased atherosclerosis. Transfer of CTL deficient in
either perforin, granzyme B, or TNF-, however, resulted in
much less of an increase in atherosclerosis compared with
transfer of wild-type CTL. In this study, CTL appeared to
target macrophage, VSMC, and endothelial resulting in increased indexes of apoptosis, necrosis, several markers of
inflammation (such as MCP-1) and increase necrotic core
size (972). The authors suggest that in developing plaque,
MHCI may present peptides derived from oxLDL (although no MHCI antigenic peptides promoting atherosclerosis have been identified directly) to CTL promting release
of their granules containing perforin and granzyme B, the
main cytotoxic molecules utilized by CTL. The resulting
necrotic cells could promote sterile inflammation and increased apoptosis of surrounding macrophages and other
cells.
ovalbumin. Both of the two groups of mice were then given

intraperitoneal infusions of either saline or clones of
ovalbumin-specific Treg, which had been expanded in vitro
(with each mouse receiving just 1 million cells). Only in the
mice previously sensitized to ovalbumin would the adoptively transferred, ovalbumin-specific Treg be expected to
proliferate (being stimulated by specific antigen-presenting
cells). This group developed 30% less atherosclerosis
than the other three groups including the group that had
received the Treg that had not been previously sensitized to
ovalbumin. Importantly, the ovalbumin-specific Treg injected into sensitized mice found their way into growing
plaques and adjacent adventitia where IL-10 production
was greatly increased together with a marked reduction of
macrophage and T-cell accumulation. In addition, there
was reduced IFN- production by lymph T-cells when stimulated by ovalbumin (1126).
PAUL N. HOPKINS
above. In addition to these self targets which had been
hypothesized to be involved in the atherogenic sensitization
of Th1 cells, mucosal tolerance protocols directed against
pneumococcus, or even measles virus envelope resulted in
reduced atherosclerosis, suggesting there may be multiple,
unsuspected potential antigenic targets as well the possibility of nonspecific effects from simply increasing Treg numbers with increased secretion of IL-10 (30, 241). Indeed, the
ovalbumin sensitization study reviewed above would suggest that the Treg stimulus need not be directly involved in
atherosclerosis.
2. Effects of costimulatory and coinhibitory
receptors on Treg and atherosclerosis
T-cell CD28 interacts with B71 (CD80) or B72 (CD86)

found on antigen presenting cells as well as on Th cells.
Activation of innate immune responses in antigen presenting cells increases the surface expression of B71/2. Whole
body knockout of B71 and B72 decreased atherosclerosis
modestly and was accompanied by a reduction of Th1 cells.
In contrast, bone marrow transplant of B71/2-deficient
cells greatly impaired production of Treg with less effect on
Th1, resulting in increased atherosclerosis.
Inhibitory cytotoxic T-lymphocyte antigen 4 (CTLA4) receptors on Treg are also important. CTLA4 has much
greater affinity for B7 receptors than CD28. When antigenpresenting cells are not strongly activated, the relatively few
B7 receptors may be fully occupied by CTLA4, thereby
blocking activating signals to Th effector cells by out-competing CD28 receptor binding. Also, the CTLA4 cytoplasmic tail activates protein phosphatase 2A (PP2A), which
dephosphorylates and limits PKB activity, thereby supporting Treg differentiation. Recently, feeding active 1,25-dihydroxyvitamin D3 to ApoE-deficient mice was found to decrease atherosclerosis together with a marked increase in
Treg cells and increased CTLA4 signaling (1745). Interestingly, CTLA4 deficiency also causes autoimmune disease.
Programmed death ligand 1 (PD-L1) is a major inhibitory
ligand expressed on antigen presenting cells, endothelial
cells, Treg, and a number of other body cells. The receptor
1426
If the TCR of a naive T-cell binds the antigen-presenting

MHC II of an unstimulated antigen-presenting cell (such as
a DC), then the naive T-cell will find PD-L1 on the DC
binding to PD-1 on its own cell surface. Without counterbalancing costimulatory signaling, this naive T-cell will undergo either apoptosis or become anergic. If TCR binding
and PD-1 ligation is combined with exposure to TGF-, the
cell can differentiate into a Treg (537). PD-L1/2 or PD-1
(221) deletion increased atherosclerosis together with a reduction in Treg cells and an unopposed increase in Th1
activity.
In an important recent study, DC were rendered tolerogenic
to APOB-100 by exposing the cells to APOB-100 together
with IL-10. Such cells, when administered as a single injection into hyperlipidemic mice, decreased atherosclerosis by
70%. These mice were transgenic for human APOB-100
and LDLR-deficient. In vitro, the tolerogenic DC displayed
modestly reduced TNF- and MCP-1, but had almost no
IL-12 production. Furthermore, the APOB-100/IL-10
pulsed DC specifically inhibited CD4 Th1 cell proliferation and reduced IFN- production in response to APOB100. At the same time, they stimulated differentiation of
antigen-specific Treg cells that also suppressed Th1 responses to APOB-100 (755). In contrast, injection of DC
pulsed with malondialdehyde-modified LDL (without concomitant IL-10 treatment) actually aggravated atherosclerosis (769).
3. Treg stimulation and differentiation
Due to the studies showing an anti-atherogenic role for Treg
as well as increasingly recognized roll for impaired Treg
function in autoimmune disease, intense research efforts
have led to increased understanding of Treg differentiation
and related signaling. The expression of the transcription
factor Foxp3 is now considered a defining feature of Treg
(537). Treg generally express CD25 (the IL-2R chain) as
well. There are other Treg subsets, including CD8 Treg,
The initially confusing results of genetic deletion studies for

a number of costimulatory and coinhibitory receptors are
harmoniously explained when effects on Treg cells are considered (see TABLE 7). For example, CD28 is the best-studied activating costimulatory receptor on T-cells. Without
CD28 or other costimulation, Th cells become anergic or
unresponsive when their TCR binds an antigen-presenting
MHCII receptor, even if the antigen is foreign. But CD28 is
also required for Treg differentiation. As it turns out, the
net effect of CD28 loss was a dramatic reduction in thymic
Treg numbers and an increase in atherosclerosis. The same
was found for the costimulator ICOS (inducible costimulator) (see TABLE 7).
for PD-L1, PD-1, is found on naive CD4 cells and Treg.

PD-1 on Treg seems to be critical for stimulating and maintaining peripheral Treg differentiation when combined with
TCR signaling (537). Indeed, TCR signaling upregulates
PD-1 expression on all T-cells and BCR stimulates PD-1
expression on B-cells. Thus the potential for inhibition is
enhanced at the same time Th-cells and B-cells are stimulated. Binding of PD-1 on these effector cells by PD-L1/2
tends toward inhibition of further inflammatory responses
while increasing Treg activity. The cytoplasmic tail of ligated PD-1 activates the phosphatases SHP1/2 and PTEN
which effectively block PI3K and PIP3 signaling, respectively. Th1 cell activation through TCR binding is dependent on PI3K activity and its product PIP3, with subsequent
PKB and mTOR signaling, all of which are supported and
amplified by costimulatory receptors.

but the focus here will be on CD4/CD25 Treg cells
expressing the transcription factor Foxp3.
Treg can be broadly divided into natural Treg (nTreg), derived from thymus selection during development (mostly
completed before birth in humans), and peripheral or induced Treg (iTreg). Self antigens are presented without
costimulator receptors by thymus cells throughout development, triggering apoptosis in those developing T-cells that
have a TCR which strongly binds these antigens. However,
a number of developing CD4 cells with modest binding
are selected and differentiate into nTreg. Interestingly,
nTreg differentiation in the thymus is dependent on low
levels of NF-B activation and IL-2 production as well as
the calcineurin-NFAT pathway. nTreg development is
obliterated by CARMA1 deficiency (part of the CBM complex that activates NF-B in T-cells, reviewed previously)
(1225).
In vivo, iTreg production can be produced by tolerogenic

antigen administration (often by oral administration or systemic administration in water without adjuvants). This type
of antigenic exposure is presumably not accompanied by
innate activation and thus should allow antigen presentation without costimulatory receptor activation. In contrast,
at high levels, stimulation of both the TCR and the activating costimulatory receptor CD28, naive CD4 resist other
signals to differentiate into Treg and instead become effector cells capable of secreting TNF-, IFN-, IL-9, and IL17. These changes are mediated by high level activation of
NF-B and subsequent production of TNF- and IFN-
(1225) as well as increased PI3K activation through CD28
(591, 1585).
Foxp3 is the master transcription factor leading to Treg
differentiation. Multiple different transcription factors control Foxp3 expresion by binding to four separate sites in the
5 end of Foxp3 (1199). On the first site NFAT, NF-B,
AP-1, SP1, Foxo1/3a, Runx, and STAT5 (from IL-2R JAK/
STAT signaling) all bind. At the next site, NFAT and
SMAD2/3/4 (from TGF- signaling) bind. Further downstream at the third site, NF-B, CREB, ATF, Foxo1/3a,
Runx, STAT5, and remarkably, Foxp3 itself bind. Foxp3
acting as its own positive DNA regulating factor suggests a
means for stable, continued expression. Finally, NF-B
How Foxp3 transforms CD4 Th cells into Treg and how

Treg exert their inhibitory effects on Th (and other effector
cells) remain major research questions. The field remains in
flux and full of complexity, so only a few, probably oversimplified answers to these two questions will be attempted
here. Of great importance is the balance between the activities of PI3K-PKB versus the E3 ubiquitin ligase Cbl-b
(Casitas B-lineage lymphoma sequence B). Increased PLC
and particularly PKC activity (followed by CARMA,
Bcl10, MALT1 activation of NF-B) also promote Th1 activation. Finally, the particular combination of transcription factors found together with NFAT influences activation.
Expression of Cbl-b is directly or indirectly increased by
Foxp3, and absence of Cbl-b causes severe Treg deficiency,
excess Th activity, and autoimmune disease (279). Targets
of Cbl-b monoubiquitination include PKC, PLC, Src and
Syk family kinases (such as ZAP70), the regulatory p85
subunits of PI3K (the p85 regulatory subunits are shared by
class Ia PI3Ks), and the TCR complex itself (by ubiquitinating ZAP70 and CD3 subunits). The result of monoubiquitination by Cbl-b is inactivation without degradation (for
p85) or targeting for endosomal delivery and lysosomal
(not proteosomal) proteolysis. In opposition to Cbl-b is
PKC, which, when activated by CD28 signaling, binds to
and phosphorylates Cbl-b, apparently targeting it for ubiquitination and degradation (1559). Thus high PKC impairs Cbl-b while high Cbl-b blocks Th cell activation. The
outcome of this tug-of-war seems largely determined by
PI3K activity and subsequent PKB activation, with both
controlled by the balance of costimulatory signaling
through CD28 versus coinhibitory signaling by CTLA4 and
PD-1 (537, 1559, 1585). Foxp3 plays a key role in this
balance.
When Foxp3 expression rises, nuclear Foxp3 forms a physical complex with NFAT and subverts NFAT signaling
from Th activation toward the anti-inflammatory Treg phenotype (1146, 1163, 1531, 1579). Production of Th1 and
1427
Induced differentiation of naive CD4 into iTreg can be

achieved in vitro by mild antigenic exposure (TCR and mild
CD28 stimulation) together with TGF- and IL-2 (potentially induced by internal NF-B activation or externally
supplied). A recently recognized receptor (glycoprotein-A
repetitions predominant, GARP) holds and activates surface latent TGF- and thereby helps perpetuate stable Treg
differentiation. GARP is uniquely expressed on Treg (and is
dependent on Foxp3) and may aid in positive identification
of human Treg (1438).
binds the fourth site. Elucidation of this remarkable and

elegant complexity, with multiple AND switches provides an explanation for the observed inhibition of Treg
differentiation by PI3K and PKB. PKB phosphorylates
Foxo1 and Foxo3a, thereby excluding these required transcription factors from the nucleus. Activation of PI3K followed by PKB through the combined signaling of the TCR
and CD28 is one way that typical, pro-inflammatory Th1
activation prevents transcription of Foxp3 and excessive
differentiation of CD4 cells into Treg (176). Understanding of Treg differentiation to this degree has been strongly
motivated by the hopes of developing Treg-based therapies
for autoimmune diseases such as multiple sclerosis, type I
diabetes, rheumatoid arthritis, and others, but may be relevant to atherosclerosis as well.
PAUL N. HOPKINS
Th2 cytokines is repressed while TGF- and IL-10 are induced. Although IL-2 production is supressed, CD25 (the
IL-2R subunit) is increased along with STAT5 activation,
facilitating Treg survival and proliferation. Expression of
the coinhibitory receptor CTLA4 is upregulated as is Cbl-b.
The micro-RNA miR-155 is increased which suppressed
SOCS1 and thereby increases STAT5 signaling (1083).
STAT5 signaling supports Foxp3 production as well as
many other functions including hematopoeitic cell proliferation.
F. Humoral Immunity and B Cells in

Atherosclerosis
2. The atherogenic effect of IgG appears to depend

on the target
Unlike production of natural antibodies, humoral immunity directed against most antigens consists primarily of IgG
produced by mature B2 B cells activated by adaptive immune responses. When directed against various self targets, these adaptive immune responses are generally proinflammatory and atherogenic (603). In contrast, immunization with certain aldehyde (MDA) modified APOB-100
peptides (including MDA-p45 and MDA-p74) led to a
marked increase in Th2-specific IgG1 antibodies directed
against these modified peptides and decreased atherosclerosis in ApoE-deficient mice (545). Furthermore, administration of human recombinant antibodies against these APOB100 peptides also decreased atherosclerosis in hyperlipidemic mice, possibly associated with facilitated removal of
oxidized LDL or decreasing associated inflammation
(1554). While much of the immunization benefit in mice
may have been due to Treg stimulation (1960), the potential for the recombinant antibodies to protect humans
is currently being investigated in a clinical trial [A Study
to Evaluate the Safety, Tolerability, and Activity of Intravenous MLDL1278A in Patients on Standard-of-Care
Therapy for Stable Atherosclerotic Cardiovascular Disease (GLACIER: Goal of Oxidized LDL and Activated
Macrophage Inhibition by Exposure to a Recombinant
Antibody); www.clinicaltrials.gov].
1. Natural IgM antibodies

The role of natural antibodies in atherogenesis will be further examined here, recognizing that these antibodies are
considered part of the innate immune system since they are
coded in germ cells and expressed without the need for
antigen presentation. Despite this innate production, moderately aggressive immunization against modified LDL or
certain other antigens (for example, with coadministration
of adjuvant) increases production of natural IgM antibodies
by B1a cells, complicating the interpretation of many earlier
studies of immunization with oxLDL. Most of these IgM
antibodies are directed at phosphocholine groups on oxidized phospholipids or bacterial cell membranes (59, 728).
Genetic ablation of genes required for B1a cells to produce
IgM clearly increases atherosclerosis, verifying the protective nature of these antibodies (see TABLE 7). Passive immunization studies also demonstrate that these IgM antibodies, which accumulate in plaques, were indeed protective
(59, 970). Natural IgM antibodies seem to coat modified
lipoproteins (such as oxLDL) and decrease macrophage uptake, possibly decreasing foam cell formation. In addition,
1428
Several additional studies address the role of specific IgG.

Intraperitoneal infusion of IgG from mice immunized
against HSP65 (which cross reacts with HSP60) led to increased atherosclerosis (604). Infusion of goat anti-human
apolipoprotein A1 (APOA1, or A-I) increased atherosclerosis compared with control goat IgG in chow-fed ApoEdeficient mice (1227). On the other hand, passive immunization of LDLR KO mice with a monoclonal mouse IgG2b
antibody directed against electronegative LDL decreased
atherosclerosis by 77% along with reduced circulating electronegative LDL (663).
Results regarding immune complexes with oxLDL, primarily containing IgG1 and IgG3, further complicate the picture. In one study, oxLDL-IgG immune complexes deposited on cultured human endothelial cells promoted adherence and activation of monocytes (1269). In macrophages,
oxLDL immune complexes are taken up mainly by the
FcRI receptor while scavenger receptors such as CD36
mediate uptake of free oxLDL. These oxLDL immune complexes are reported to promote greater foam cell formation,
Multiple mechanisms account for suppression of effector

cells by Treg. Treg bound by its TCR to the MHCII receptor
of an antigen presenting cell seems to result in a downregulation of B71/2 expression by the antigen-presenting cell.
This may be mediated, in part, through the CTLA4 receptor
on Treg. Thus antigen-presenting cells exposed to Treg are
suppressed in their ability to activate Th and CTL. Treg
express cell surface PD-L1 as well as PD-1 and can thereby
directly inhibit Th cells expressing PD-1 (1696). In contrast,
ligation of PD-1 on other Treg by PD-L1 helps support Treg
activity (537). Other suppressive Treg mechanisms include
sequestration of IL-2 by increased CD25 expression and the
elaboration of anti-inflammatory cytokines TGF- and
IL-10 (1531). In addition, Treg can cause cytolysis of antigen-presenting cells, NK cells, and CD8 CTL by release of
granzyme A and perforin. Finally, Treg can promote apoptosis by expression of FAS and decrease effector cell activation by hydrolysis of extracellular ATP by cell surface
CD73 and CD39.
efferocytosis by macrophages is promoted when natural

IgM opsonize apoptotic cells (which have phosphocholine
antigens exposed as oxidized phospholipids) (971). Other
circumstantial evidence suggests natural IgM are protective
(554). B1a cells can also secrete anti-inflammatory IL-10
(971).

release of active secretory acid sphingomyelinase, prolonged activation of lysosomal acid sphingomyelinase, and
release of more cytokines compared with oxLDL alone. Yet
oxLDL-IgG complexes also promote greater macrophage
survival with less ROS production, mediated by intracellular FcRI signaling including Akt activation (36, 704,
1811). The ultimate effect of oxLDL-IgG complexes on
atherosclerosis remains unresolved, however. In human
studies, there is a report of a positive association between
oxLDL immune complexes and coronary calcium in one
study (1071) but no association with new onset MI in another cohort (though an increased risk of MI in those with
greater MDA-modified LDL-immune complexes was reported) (1074). In another study, greater progression of
diabetic retinopathy and nephropathy were seen among patients with increased oxLDL immune complexes (1072,
1073).
With regard to immunization generally, tolerance protocols

must not be confused with immunization. In mice, tolerance
to an antigen is developed by repeated oral or nasal administration of a relatively low to moderate dose of the antigen.
Similar tolerance is the goal of allergy shots given to
humans as slowly increasing doses of a specific antigen
without combined adjuvant. In contrast, human immunization programs with oral polio vaccines or nasal administration of flu vaccine generally utilize much higher doses of
antigen, often combined with an adjuvant. Adjuvant is
composed of one or more substances that stimulate innate
immune responses to ensure that a stimulatory adaptive
response will be directed against the simultaneously administered antigen. Mucosal tolerance protocols against spe-
The example of HSP60 is illustrative. HSP60 expression on

the surface of endothelial cells may be atherogenic as suggested by the following evidence. T-cells sensitized to
HSP60 and anti-HSP60 antibodies were found in early and
advanced human plaques. Plasma titers of anti-HSP60 antibodies were elevated in CAD patients, and these antibodies cross-reacted with Cytomegalovirus HSP65 and were
cytotoxic to endothelial cells (114). Animals given oral or
nasal desensitizing doses of HSP60 or HSP65 prior to induction of hyperlipidemia showed an increase in Treg cells
directed against those antigens and a shift to fewer Th1 cells
relative to Th2 cells with increased IL-10 production and
greater self-tolerance or anergy toward HSP60. Reductions
in atherosclerosis of 50% to as much as 80% were reported
(1142, 1861). Whether such desensitization therapy may be
effective to prevent progression of human atherosclerosis is
unknown. Nevertheless, the results illustrate the principal
that adaptive (including humoral) immunity directed
against self has the potential to be pro-atherogenic, while
desensitization may be protective.
Attempts to address the role of humoral immunity have also
been made by depleting or replenishing B2 cells. However,
B-cells also actively present antigens and can stimulate both
T-cells and DC. Also, B-cells actively secrete TNF- (28,
190). Thus B-cell depletion studies cannot directly address
the issue of the role of IgG in atherosclerosis. They are,
nevertheless, illustrative of the importance of adaptive immune responses generally. Administration of a monoclonal
antibody directed against CD20 (paradoxically also known
as B1, a surface marker unique to B2-cells) caused selective
depletion of only mature B2-cells and clearly reduced atherosclerosis in high-fat and chow-fed ApoE-deficient mice
as well as LDLR KO mice (28). Besides profound reductions
in total IgG as well as anti-oxLDL IgG in these studies,
depletion of mature B2-cells led to reduced IFN- secretion
from T-cells and enhanced production of IL-17. Importantly, blocking IL-17 with a neutralizing antibody completely reversed the protective effect of B-cell depletion,
without a change in the number of B-cells or anti-oxLDL
antibodies (28). Thus effects of mature B-cell depletion on
T-cell or DC activation and resulting cytokine milieu may
be more important than effects on antibody production in
this study. Such an interpretation is consistent with another
study that confirmed reduction of atherosclerosis using antibodies against CD20 to deplete B2 B cells and further
showed a benefit in established lesions. In addition, a 72%
increase in atherosclerosis was seen with adoptive transfer
of B2 B cells into ApoE KO mice deficient in B, T, NKT and
NK cells (ApoE/ Rag2/ -c/ triple KO mice), but a
300% increase occurred with transfer into ApoE KO mice
1429
Utilizing a very different approach, transgenic mice expressing human APOB-100 were immunized with human oxLDL followed by generation of T-cell hybridomas. The investigators were surprised to find that none of the hybridomas recognized oxLDL epitopes, but only native LDL or
intact APOB-100 peptide. Nevertheless, the sensitized Th1
cells could apparently license mature B-cells to produce a
much wider array of antibodies against oxLDL as well as
native LDL. Inhibition of Th1 cells sensitized to LDL with
an antibody specific to the sensitized T-cell receptor decreased atherosclerosis by 65% in APOB-100 expressing
LDLR/ mice, suggesting but not proving a proatherogenic role for anti-LDL IgG or anti-oxLDL IgG (756). At
the very least, these results clearly contrast with the protection seen in studies using immunization protocols that actually ended up promoting production of anti-oxLDL IgM
natural antibodies. Possibly related to this finding, a proteolytic fragment of native APOB-100 present in human
atherosclerotic plaques was recently identified that could
activate macrophages and may lead to activation of both
innate and adaptive immune responses directed against
APOB-100 or a naturally derived proteolytic fragment
(897).
cific antigens, rather than inducing specific IgG antibodies,

are intended to reduce adaptive (and humoral IgG) responses and enhance iTreg activity, often resulting in reduced inflammation and atherosclerosis.
PAUL N. HOPKINS
deficient only in B cells due to absence of IgM chains
(MT/). This study showed B2 cells can increase atherosclerosis in the absence of T cells, but that a much greater
increase occurs when T cells are present (969).
Deletion of the BAFF receptor (BAFFR), necessary for B2
development, was also recently shown to be protective in at
least two studies (968, 1528). Like the anti-CD20 antibody
infusion studies, BAFFR deficiency resulted in marked selective reduction of B2 cells with little effect on B1a cells.
However, as noted above, these data cannot resolve the
issue of IgG secretion separately from other B-cell activities.
G. Redundancy in Leukocyte Signaling

Numerous examples of redundancy for macrophage and
lymphocyte signaling are provided in TABLES 6 AND 7. Redundancy potentially dilutes the effect of any single gene
manipulation over time. An example for CCR2 (the receptor for MCP-1) was given in the introduction. In another
study, there was a clearly protective effect of heterozygous
CXCR3 deficiency for early atherosclerosis but none for
more advanced lesions (1871). In contrast, for CX3CR1
(the fractalkine receptor), heterozygous deficiency resulted
in as great a reduction in atherosclerosis as complete deficiency, suggesting a sort of redundancy even in the number
of alleles (344). Indeed, redundancy is a recognized characteristic of cytokines generally (1). With few exceptions,
functions of a given initiating pathway are only partially,
not completely dependent on any one gene. As a result,
effects on atherogenesis from disrupting a single gene are
generally modest. The potential for intervention on multiple chemokine pathways is illustrated by KO of both CCL2
and CX3CR1, together with blocking CCR5 signaling
which almost entirely abrogated atherosclerosis in ApoEdeficient mice (345). However, in this model monocyte mobilization was severely impaired and the reduction in atherosclerosis was directly proportional to the reduction in
blood monocyte counts. These mice might therefore be expected to be immunodeficient as well.
Another important example of redundancy is an alternate
mechanism besides TLR to activate innate responses. Such
1430
Redundant systems generally govern functions that are vital

for survival. In the case of leukocyte transmigration and
activation, any intervention must be weighed against the
threat of severe infections due to immunodeficiency as well
as increased risk of cancer. Interventions that do not impair
essential pathways but which bolster natural defenses (as in
enhancing natural cellular antioxidant responses by various
biologics, supplying various cofactors such as lipoic acid, or
modestly increasing H2S availability) or which bring risk
factor levels to a more physiological range (such as control
of hyperlipidemia or reduction in blood pressure) will likely
have more success than efforts to impact a single genetic
element of inflammatory signaling. Nevertheless, creative
application of newly developed anti-inflammatory agents in
a limited or focused setting may well have major beneficial
effects.
VIII. EFFECTS OF SELECTED RISK

FACTORS ON INITIATION OF
ATHEROSCLEROSIS
A. Aging
Age is often cited as the most powerful atherosclerosis risk
factor. Accumulating evidence suggests the underlying
mechanism involves much more than merely longer exposure to other risk factors. One candidate may be increasing
fibronectin, which was shown to accumulate in the arteries
of aging rats along with collagen (1905). Both 12-HETE
and ANG II can stimulate VSMC to produce fibronectin
(1034). It is conceivable that increasing exposure to fibronectin with age could promote an inflammatory phenotype in endothelial cells and enhance susceptibility to atherosclerosis with age.
In a series of investigations from one laboratory, aging of
ApoE-deficient mice led to depletion of reparative, bone
marrow-derived, vascular progenitor cells. Emergence of
atherosclerosis correlated with an empirically derived gene
expression pattern suggesting depletion of these reparative
cells (884). Depletion of vascular progenitor cells capable of
inhibiting atherosclerosis appeared more rapid with prolonged exposure to other risk factors, including hyperlipidemia (1460). This group has begun to identify the subfraction of hematopoeitic stem cells that seems to be responsible
for the reparative effect and to develop specialized culture
conditions (incubation with IL-3, IL-6, and stem cell factor
At least some additional functions of B-cells remain unexplained with apparently protective effects from mature Bcells in certain contexts. Id3 (inhibitor of DNA binding 3,
also known as inhibitor of differentiation 3) is a protein
than can form heterodimers with various transcription factors and inhibit their binding to DNA. In B-cells Id3 apparently limits proliferation and Id3 mutations are frequently
found in Burkitts lymphoma. Deletion of Id3 resulted in
impaired homing of B-cells to the aortic adventitia, an increase in macrophage content of plaques, and increased
atherosclerosis (437). This effect was not due to a reduction
in B1a function or lower IgM. The mechanism of protection
from these adventitial B-cells remains to be explained.
alternatives include RAGE and LOX-1 previously reviewed. In addition, hyperlipidemia, diabetes, infection,
and injury can stimulate expression of various ligands of the
KLRK1 receptor on endothelial cells and macrophages,
among other cells. Activation of the KLRK1 receptor causes
vigorous production of cytokines by NK, NKT, and other
cells while KO of KLRK1 markedly reduced atherosclerosis
as noted previously (1118, 1989).

or SCF) to promote greater inhibition of atherosclerosis by
these cells (1655). More circulating endothelial progenitor
cells seemed to be associated with less atherosclerosis in the
Framingham study (303). These findings may be related to
some of the mechanisms of aging and enhanced atherogenesis reviewed below, but certainly no single explanation of
aging has yet emerged.
1. A need for balance in ROS and inflammatory
pathways
Despite reassurances that low-level ROS production is

adaptive (and this undoubtedly is the case), investigators
have long recognized increases in ROS and declines in antioxidant systems accompanied by declining proliferative
capacity in aging animals (1229, 1313). Endothelial cells
obtained from human subjects showed increased NOX activity and nitrotyrosine in the older subjects associated with
a decline in endothelial dependent flow-mediated dilation
(432). Knockout of the pro-oxidant adapter protein p66Shc
increased lifespan in mice (as noted above).
Mitochondrial production of ROS with subsequent mitochondria DNA damage likely contributes to age-related
changes in the vasculature. Some excess mitochondrial ROS
production may be driven by increasing accumulations of
electrophilic substances, while calorie restriction may ameliorate many of these changes (1834). Mitochondrial DNA
damage was found to be increased in human atherosclerotic
arteries compared with nonatherosclerotic arteries and also
correlated with increased atherosclerosis in ApoE/ mice
(102). Mitochondrial damage in the aorta was increased in
In many animal studies, modest caloric restriction with reduced insulin signaling increases life span and is associated
with improved mitochondrial biogenesis as well as greater
removal of defunct or impaired mitochondria by autophagy
(or mitophagy) (695). In 18 humans attempting to follow a
calorically restricted but nutrient-rich diet, carotid atherosclerosis appeared to be reduced compared with 18 controls
(532). The apparent benefit of caloric restriction, however,
may be most relevant to relatively overfed animals (or humans) as recent data suggest no survival benefit for caloric
restriction in already lean monkeys (1160).
2. Cell senescence: in part aggravated by excess
ROS and TNF- signaling
While still a controversial topic, cell senescence associated
with multiple cell divisions may be relevant. After several
replications, porcine endothelial cells showed increased
NF-B activity, increased oxidative stress, reduction of several antioxidant enzymes, and increased p53 and apoptosis
(993). Aging arterial VSMC tend to be modulated toward
the secretory phenotype (1903). In general, aging appears to
lead to marked increases in TNF- signaling (particularly
from membrane-bound TNF-), NF-B activation, and
ROS production in endothelial as well as other cells of the
arterial wall (1538, 1834). Even aging skin demonstrates a
gene expression pattern characterized by increased NF-B
signaling (14). One of the major contributors to the increase
in NF-B signaling with age may be accumulation of fibronectin (as documented especially in hypertensive rats)
(826, 976). Fibronectin might be expected to accumulate
particularly in vascular areas hemodynamically prone to
atherosclerosis. As noted above, high glucose, as seen in
diabetes, promotes increased ROS and mitochondrial dysfunction. Endothelial cells from Zucker diabetic rats were
strongly prone to premature senescence with evidence of
marked improvement after administration of the peroxynitrite scavenger ebselen (210). In general, evidence that endothelial senescence may contribute to vascular disease is
1431
A number of inflammatory pathways have feed forward or

positive feedback mechanisms to cause rapid and robust
responses. One might hypothesize that such control systems
might get out of hand over time. For example, TNF- stimulates a burst of superoxide production by NOX enzymes,
and resultant ROS promote inflammatory signaling including facilitated NF-B activation which then induces more
TNF-. There are a number of such positive feedback pathways in inflammatory signaling. That these pathways
would turn into vicious cycles, however, turns out to be a
simplistic, unfounded concern. Based on mathematical
models which also take into account the counterregulatory
and survival (antiapoptotic) pathways that are simultaneously stimulated (including Nrf2 and several ant-apoptotic,
anti-inflammatory pathways stimulated by NF-B itself), a
certain amount of proinflammatory stimulation may
even be protective. The master regulator of protein synthesis, mTOR, which also helps regulate autophagy, was also
taken into account in this model (950). In the final adaptive model, a low level of oxidative stress maintained a
balance between anti- and proinflammatory as well as survival pathways. Indeed, elimination of NF-B was unexpectedly predicted to cause a marked imbalance of these
pathways leading to accelerated aging.
ApoE-deficient mice compared with normolipidemic mice.

Both the absolute degree of damage and the excess mitochondrial damage seen in hyperlipidemic mice were greatly
exaggerated by exposure to second-hand cigarette smoke
(922). Hemizygous SOD2 deficiency in ApoE/ mice increased mitochondrial ROS production upon exposure to
TNF- (724). Incubation of human endothelial cells with
high glucose promotes mitochondrial ROS production and
mitochondrial damage (815) and high fatty acid levels in
diabetes is also likely to contribute to mitochondrial dysfunction (2000). Excess intracellular calcium levels associated with excessive aldosterone in the presence of relatively
high salt intake may also contribute to mitochondrial ROS
production (2116). Higher ROS may theoretically shift the
balance of tyrosine kinases and phosphatases toward the
inflammation-activating tyrosine kinases (868).
PAUL N. HOPKINS
accumulating, but its relevance to human disease has yet to
be demonstrated (488).
The above considerations regarding age-related changes in
the vasculature led to the hypothesis that there may be
greater susceptibility to atherosclerosis initiation, promotion, and progression in older versus younger arteries exposed to the same standard risk factors such as dyslipidemia
and hypertension. Recent evidence suggests this may indeed
be the case.
Mild to moderate oxidative stress normally upregulates

proteasomal activity while severe oxidate stress is inhibitory. Conversely, mild to moderate proteasomal activity
decreases oxidative stress while high activity is said to increase ROS production (758). Some evidence for anti-inflammatory effects of proteasomal inhibition early in
atherogenesis has been presented, but others find increased
endothelial activation and intimal thickening with proteasome inhibition even at this stage (758).
Despite the conflicting evidence, a great deal of effort has
been expended to examine pharmacological effects of proteasome inhibitors (originally developed as anti-tumor
agents). Pharmacological proteasome inhibition blocked
VSMC proliferation after arterial injury. Nevertheless, use
of the proteasome inhibitor bortezomib clearly made advanced plaques more unstable (758). The bulk of evidence
suggests relatively impaired proteasomal activity and inadequate removal of damaged proteins in advanced human
plaques which likely contributes to inflammation, a situation that would only be worsened by proteasomal inhibition (758, 1964).
4. New insights from rare laminopathies
Low-level superoxide production appears constitutive in

normal human arteries but is increased in human atherosclerotic lesions, both in the diseased vascular wall and in
plaque macrophages (1658). In nondiseased human saphenous veins, NOX superoxide production increased with the
number of standard CAD risk factors, particularly hypercholesterolemia and diabetes (683).
3. Might manipulation of proteosomal activity provide
a benefit?
Atherosclerotic carotid plaques from elderly subjects showed
more evidence of ubiquitination and proteosomal activity
than plaques from younger carotid endarterectomy patients
(1139). Several proinflammatory pathways are activated by
proteosomal activity. Proteasomal degradation of IB and
TRAF3 both promote NF-B signaling. The potent transcription factor Nrf2 which upregulates many cellular antioxidant
1432
Certain rare aging syndromes caused by mutations in the

LMNA (lamin A/C) gene have been associated with premature atherosclerosis (35, 1474). Markedly different phenotypes arise depending on where mutations occur in the
LMNA gene. In Dunnigan-type familial partial lipodystrophy (caused by R482Q, R482W, R482L, or R582H mutations) and atypical Werners syndrome (A57P, R133L, and
L140R), relatively severe and early onset of metabolic syndrome and insulin resistance results in sixfold or higher
CAD risk, with higher relative risks in women (35, 1474).
Hutchinson-Gilford progeria syndrome leads to devastating MI, stroke, valvular disease, and cardiomyopathy
(among many other abnormalities), without attending risk
factors or hypercholesterolemia. MI is common even by age
14, which is the median life span (35). This form of progeria
is generally due to de novo mutations in codon 608 of
In LDLR-null mice, hypercholesterolemia is not severe and

atherosclerosis does not progress appreciably until after institution of a western-style diet. When such a diet was initiated at different ages (3- and 12-mo-old mice), the older
mice experienced much more rapidly progressing atherosclerosis despite the same lipid levels. The older mice failed
to upregulate antioxidant enzymes as efficiently, although
this failure was improved by the PPAR agonist rosiglitazone (341). Older mice showed increased ROS production
stimulated by TNF- stimulation. When carotid arteries
from 2 and 18 wk normolipidemic mice were transplanted
into ApoE-deficient mice, the older arteries developed atherosclerosis about twice as rapidly but, in addition, showed
much greater intraplaque hemorrhage and buried fibrous
caps (suggestive of rupture and repair). Importantly, there
was a fivefold increase in the expression of TNFR1 in the
aged arteries. All these age-related differences were eliminated in carotid segments transplanted from TNFR1/
mice (2076). In the same paper, a variant of TNFR1 was
reported to be associated with CAD together with a significant interaction with age in a human population. The at
risk TNFR1 allele was associated with a more rapid increase in the extent of CAD in aging subjects (2076). Agerelevant changes in the artery wall, particularly accumulation of AGEs and oxidized or otherwise modified LDL, may
be a trigger of TNFR signaling and increased ROS production with impaired sirtuin activity (1170, 2071).
systems and the rate-limiting enzyme for tetrahydrobiopterin

synthesis (required by eNOS) are also targeted for degradation
by the proteosome. While these pathways might suggest a
benefit for general proteosome inhibition, the notion must be
balanced by other considerations. Increased oxidative stress
seen in aging can result in protein modification and misfolding, with targeted proteosomal degradation of the
misfolded proteins (through multiple proteosome subtypes). Inadequate proteasomal activity in the face of
excess unfolded or otherwise damaged proteins leads to
increased ER stress and inflammation (758, 949, 1213).
Aggregated, ubiquitinated proteins that are too large for
proteasomes are targeted for selective autophagy,
thought to be a protective process (1964).
B. Hypertension
Pressure and flow are the first risk factors to which the
endothelium is exposed. Blood pressure in the arterial range
is an essential requirement for the development of atherosclerosis. Venous atherosclerosis does not occur even in
patients with homozygous familial hypercholesterolemia
(226). The relatively rapid progression of atherosclerosis in
saphenous veins used in coronary artery bypass suggests
there is nothing uniquely resistant about veins themselves.
Normally, the pulmonary arterial circulation with its systolic pressures of 1222 mmHg is another entirely protected
site. Nevertheless, with pulmonary hypertension, atherosclerotic plaques are commonly seen (620). While other
mechanisms leading to altered permeability cannot be excluded, including pressure- or stretch-induced activation of
the proinflammatory protein BMP2 (359), the major mechanism whereby higher blood pressure promotes atherosclerosis appears to be through increased pressure-driven convection of LDL and other lipoproteins into the intima
(1713). LDL accumulation in the intima of pressurized rab-
bit aorta increased 44-fold when pressure was raised from

70 to 160 mmHg (362). A substantial portion of the increased LDL transport, especially at higher pressures, may
also be due to a stretch-induced increase in permeability of
the vessel (1203). Approximately 90% of the convection of
LDL into the subendothelial space is reportedly through
gaps created between mitotic endothelial cells in areas of
low shear stress with only 10% entering by way of transcellular vesicular traffic (248). A thinner glycocalyx, also
associated with atherosclerosis-prone areas with low shear
stress, also appears to contribute to greater LDL permeability (1844).
Many of the alterations in endothelial function related to
shear stress may also be activated by stretch (1489). In
addition, VSMC become activated to produce more superoxide in response to stretch (307, 998, 999), with activation
of TGF-, EGFR, and NF-B pathways (1003). Stretch of
isolated carotid arteries, equivalent to 180 mmHg, activated endothelial integrin/focal adhesion signaling, followed by assembly of a complex on the plasma membrane
consisting of paxillin and activated ILK-1 with colocalization and activation of the Rac1-GEF, PIX (PAK-interacting exchange factor ). Rac1 and NOX activation with
increased superoxide production ensued (1868). In another
study, exposure of carotid arteries to high pressure resulted
in activation of NF-B followed by MCP-1 expression and
enhanced monocyte adherence (1489).
C. Exercise
Even modest exercise serves as a potent stimulus to improve
endothelial function as measured by vasodilation in response to acetylcholine, particularly in older animals and
humans (415, 457, 1580). Exercise increases eNOS expression in animals and reduces restenosis induced by catheter
injury (823, 1979). Exercise stimulates phosphorylation of
eNOS by PKB (2078). Aged mice had much higher levels of
nitrotyrosine (a marker of chronic oxidative stress) in their
aortas compared with younger mice, and this was markedly
reduced by modest amounts of voluntary running on an
exercise wheel (457). FIGURE 11 illustrates several of the
mechanisms thought to mediate these benefits. Exercise
acutely increases flow, and hence the shear-stress experienced by endothelial cells in many vascular beds, not just
the exercising limb. Furthermore, the NO released alters
transcription of eNOS and leads to increased expression of
eNOS protein. Thus inhibition of eNOS activity abrogates
the exercise-induced increase in eNOS protein expression
(1335).
Recently, exercise was found to increase telomerase activity
in mice. Telomerase then synergized with eNOS to confer
impressive resistance to endothelial stress. In exercised
mice, LPS induced far less endothelial apoptosis, and this
effect was dependent on the presence of both telomerase
1433
LMNA. The mutation adds a cryptic splice site between

exon 11 and 12, resulting in a prelamin A with a 50-bp
deletion. This defective prelamin A is then farnesylated normally, but the subsequent required step of proteolytic processing with removal of the farnesylated end does not occur,
and the abnormal farnesylated product (called progerin)
accumulates in the nuclear envelope causing marked disruption of the normal nuclear lamina, distortion in the
shape of the nucleus, and altered function of the nuclear
envelop and associated interactions with intermediate fibers
and chromatin. There is impaired DNA repair, activation of
cyclin-dependent kinase inhibitors with cell cycle arrest,
impaired mitosis, meiosis, and gene transcription, and rapid
cellular senescence (254). Progerin also appears to disrupt
not only nuclear interactions with intermediate fibers but
also with actin-based microfibers and tubulin-based microtubules, resulting in general cell fragility, a feature also seen
in LNMA-deficient mice and apparently contributing to the
cardiomyopathy seen in this syndrome (254). Careful examination of the coronary arteries in humans with this syndrome show that there are atherosclerotic lesions with cholesterol crystals and activated macrophages, but the degree
of lipid accumulation is less and there is more fibrous tissue
and calcium in the intima compared with usual plaques.
There was also a unique adventitial thickening with pronounced fibrosis that may have contributed to the stenosis
(942, 1344). Whether impaired endothelial repair leads to
this remarkably premature atherosclerosis or some other
mechanism is the underlying cause remains unknown. Importantly, progerin was found to be present in plaques from
older individuals who did not have progeria, presumably
due to variable degrees of alternative splicing, raising the
possibility that progerin may contribute to atherogenesis
associated with aging generally (1344).
PAUL N. HOPKINS
and eNOS. Exercise also decreased p53 and associated
checkpoint kinases and increased the p70 component of the
DNA repair enzyme Ku in this study (1943). High shear
stress induces increased SIRT1 expression, suggesting exercise may potentially have anti-aging effects in arteries as
well. Other effects of exercise on endothelial function including increased PGI2, thrombomodulin, and plasmin production also accrue (1145).
Additional unexpected effects of hypercholesterolemia have

been identified. Hypercholesterolemia suppressed the inward rectifying potassium current in endothelial cells
(which might be expected to lead to diminished NO response to acute changes in flow) (501). Hypercholesterolemia seems to directly affect PIP2 sensing amino acids in
inwardly rectifying K (Kir2) channels (482). Interestingly,
patients with familial hypercholesterolemia were shown to
have reduced glycocalyx volume which could be partially
restored by treatment with rosuvastatin (1202). Diet-induced hyperlipidemia in LDLR-null mice led to impaired
Treg numbers both in the blood and in atherosclerotic lesions. Treg levels could be restored after 4 wk of chow diet
(1112). Oxidized LDL promoted FoxP3 gene methylation
by DNA methyltransferases 3a/b, thereby suppressing
FoxP3 expression, and may contribute to the decrease in
Treg seen in human CAD patients (851).
E. Diabetes
D. Hyperlipidemia
While several other risk factors can recapitulate a form of

endothelial activation which, in some settings would be
advantageous (such as in infection or physical injury), the
endothelial response in diabetes is essentially maladaptive
in any setting and finds few if any parallels in normal physiology. Therefore, the term endothelial dysfunction might
be considered most apt in diabetes. Unlike other risk factors, hyperglycemia leads to endothelial dysfunction that is
systemic, resulting in both aggravation of atherosclerosis
and a microvascular disease that is unique to diabetes.
Mouse models of type I diabetes in hyperlipidemic mice
clearly show an excess of atherosclerosis but also increased
hyperlipidemia which complicates the interpretation of the
isolated effect of increase blood glucose (867, 2102). In type
II diabetes, excess free fatty acid exposure and insulin resistance appear to further exacerbate endothelial dysfunction
(2000).
Extensive effects of hyperlipidemia to initiate atherosclerosis are reviewed above. Not only does hyperlipidemia activate the endothelium and otherwise promote atherosclerosis, but effects on circulating white blood cells are also apparent. Thus monocyte expression of CCR2, the cognate
receptor for MCP-1, was increased twofold when incubated
in serum from hypercholesterolemic patients with average
LDL of 167 mg/dl compared with persons with LDL of 80
mg/dl (706). This upregulation was thought to be due to
uptake of LDL through the LDL receptor and may have
been due to an increase in membrane cholesterol. Subsequent studies suggest calcium transients may be involved in
this activation with sensitization of monocytes so that they
have increased production TNF- and IL-8 when subse-
Incubation of human endothelial cells with high glucose

(770, 815, 2048) or fatty acids (2000) promotes mitochondrial ROS and peroxynitrite (and other RNS) production,
leading to ERK1/2 and JNK1 activation, mitochondrial fission and eventual apoptosis. Some of the apparent downstream consequences of this excess ROS and RNS production in the face of high glucose were previously noted and
include: uncoupling of eNOS and consumption of NO to
produce peroxinitrite; nitration and inhibition of PGIS with
diversion of PGH2 to inflammatory TP signaling and adhesion molecule expression (2123); inhibition of protective
ERK5 (1977); increased 12-S-HETE production by 12/
15-LO together with proinflammatory fibronectin presentation (1395, 1396); increased expression of BMP4 and
1434
The acute increase in blood flow with exercise results in a

transient increase in endothelial superoxide anion generation by mitochondria and NADPH oxidase (394). This superoxide is converted rapidly to hydrogen peroxide. This
modest, controlled burst of hydrogen peroxide, in turn, also
acts to promote increased expression and activity of eNOS,
possibly through altered expression of NF-B as well as
stimulation of HSP90 (which strongly supports eNOS activity) through stimulation of HNF1. Importantly, when
human catalase was overexpressed in endothelial cells of
exercising mice, thereby blocking hydrogen peroxide signaling, the expected increase in eNOS expression in response to exercise was entirely abrogated (983). Endothelial cells adapt to laminar flow by stimulating a number of
antioxidant defenses (at least in part through Nrf2 signaling) resulting in increased expression of ecSOD (SOD3) and
Cu/Zn SOD (SOD1) as well as a decrease in NADPH oxidase (394). Similar adaptive changes occur with exercise
training, explaining the longer term antioxidant effects of
exercise despite acute modest stimulation of superoxide and
hydrogen peroxide production during acute bouts of exercise (457, 983). Parallel benefits from exercise on insulin
signaling pathways in skeletal muscle appear to be blocked
by large doses of oral antioxidants, suggesting potential
deleterious effects of such interventions (1490). Finally, exercise was shown to clearly reduce atherosclerosis in ApoEdeficient mice together with marked reduction of macrophage and Th1 cell accumulation in the intima. This effect
of exercise was entirely blocked by inhibition of eNOS
(1335).
quently exposed to LPS (1293). Native LDL similarly

caused calcium transients in endothelial cells with increased
VCAM-1 and E-selectin expression (53).

BMP2 and their receptors (185); premature endothelial senescence with inhibition of SIRT1 (210); oxidation of vWF
preventing its proteolysis and causing predisposition to
thrombosis (1328); and induction of the inflammatory cytokine OPN (1547). Regarding OPN regulation, incubation
of VSMC with glucose ranging from 5 to 30 mM (90 540
mg/dl) resulted in increased release of UTP and UDP (by an
unknown mechanism) with a sigmoidal dose response such
that essentially the entire reponse occurred in the range of
11.5 mM (207 mg/dl) to 20 mM (360 mg/dl) (1309). Extracellular UTP and UDP act on purinergic P2Y2 and P2Y6
receptors to increase calcium entry, thus stimulating calcineurin and nuclear transport of NFATc3 which then stimulates transcription of OPN (1308). Many further insights
have emerged from a focus on the excess endothelial generation of ROS and RNS in diabetes.
1. Overabundance fuels the fire of endothelial
inflammation and dysfunction in diabetes
Not only does elevated glucose provide a substrate for oxidation and ROS production, but in some way, metabolism
of glucose prior to pyruvate entry into mitochondria causes
a major shift in mitochondrial morphology from elongated
tubelike structures to smaller fragments. Mitchondrial fission and fusion are fundamental features of mitochondrion
biology, being intimately involved in distribution of mitochondria into dividing cells, mitochondrion turnover, apoptosis, mitophagy, and ATP generation (583, 1615, 2044).
Fission is triggered by phosphorylation events on the cytoplasmic GTPase dynamin-like protein 1 (DLP1) causing
binding to its target Fis1 (fission 1) which is anchored on the
outer mitochondrial membrane. Inhibition of mitochondrial fragmentation by various measures prevents the increase in ROS produced by cells exposed to excess glucose
(1615, 2047, 2048). Glucose-induced mitochondrial fragmentation appears to involve rapid early calcium entry into
the cell leading to ERK1/2 activation, followed by phosphorylation of DLP1 and mitochondrial fission. Pyruvate
supplies the metabolic fuel to generate ROS by the fragmented mitochondria (2047, 2048). Mitochondrial fission
and ROS production occur within 1530 min after exposure of cells to high glucose, followed by a rapid reduction
in mitochondrial fission and ROS production only to be
followed by a more prolonged secondary rise in mitochondrial fragmentation and ROS production peaking at 16 h
(2048).
Remarkably, incubation of endothelial cells in high glucose
(2530 mM) for 16 h then returning the cells to normal 5
mM glucose resulted in elevated ROS production that persisted for as long as 6 days. With some cells, only 6 h
exposure was sufficient to cause persistent ROS production
(203, 467). This elevated ROS production was accompanied by altered histone methylation that favored induction
of the p65 component of NF-B and endothelial activation
(203, 467). The mechanism(s) responsible for this hyperglycemic memory is under intense investigation and may
include the following: mitochondrial dysfunction perpetuated by mitochondrial fission (583, 2044); activation of
PP2A by ROS, RNS, and ceramide (especially with increased availability of palmitate) followed by PP2A-mediated dephosphorylation and inhibition of Akt with activation of apoptotic proteins such as Bad (inhibited by Akt), as
well as inhibition of AMPK (450, 944); overactive GSK3
blocking assembly of a mitochondrial complex which consists of voltage-dependent anion channel (VDAC), hexokinase (HK), and adenosine nucleotide transporter (ANT)
which is responsible for normal shuttling of ADP back into
the mitochondria after phosphorylation of glucose (1392,
1495); mitochondrial localization of p66Shc after its phosphorylation by PKCII (246, 1377, 1712); and impaired
SIRT1 activity (2098) with impaired suppression of p66Shc
1435
An elegant, unified model to explain the seemingly disparate aspects of endothelial dysfunction in diabetes has
been forwarded (215, 216, 612). The endothelial cell is
one of a handful of cell types that are unable to regulate
glucose entry. Glucose moves into the cells through
GLUT1 transporters at a rate proportional to external
concentrations. Hyperglycemia thus leads to high intracellular glucose, a rapid flux of substrate through the
glycolytic pathway, and an abundance of pyruvate for
transfer into mitochondria. Synthesis of acetyl CoA ensues followed by ample generation of reducing equivalents (NADH, FADH2) by the citric acid cycle. The transfer of high energy electrons from NADH and FADH2 to
complexes of the electron transport chain provides energy to pump hydrogen ions from the matrix into the
mitochondrial intermembrane space, thereby generating
the hydrogen ion gradient which subsequently drives
ATP synthesis through F0F1 complexes. The high NADH/
NAD ratio would be expected to inhibit protective
SIRT1. In addition, with an overabundance of energy
substrate, the hydrogen gradient increases to a critical
level, at which point the final electron transport to complex IV is impaired (where water is normally formed
from controlled electron transport to oxygen). The
backed-up electrons begin to be transported from coenzyme Q10 (ubiquinone) to oxygen directly, forming
superoxide anion. Paradoxically, a similar phenomenon
occurs with hypoxia. This formation of superoxide anion
can be blocked by dissipating the hydrogen ion gradient
(for example, by overexpression of uncoupling proteins),
by preventing transfer of electrons into the transport
chain, or by inhibiting transfer of pyruvate into the mitochondria in the first place (2048). In larger arteries,
uncontrolled endothelial uptake and oxidation of free
fatty acids, which are excessively abundant in type 2
diabetes, further exacerbates the energy surfeit with even
greater generation of superoxide anion and the presence
of saturated fatty acids increases production of ceramide

with further adverse consequences.
PAUL N. HOPKINS
by SIRT1 (2106) and decreased FOXO1-mediated induction of MnSOD (1236). Clearly, excess ROS production by
mitochondria and probably other sources such as various
NOX enzymes is a critical step in triggering endothelial
dysfunction in diabetes, but further discussion of its mechanisms is beyond the scope of this review.
2. Consequences of ROS overproduction: genetic
damage
While superoxide anion does not penetrate membranes, a
substantial amount of the excess superoxide formed on the
outer side of the mitochondrial inner membrane can be
transferred to the cytosol through the VDAC which traverses the outer mitochondrial membrane (2068). The large
increase in endothelial ROS production in diabetes is sufficient to overwhelm SOD antioxidant defenses and results in
both nuclear and mitochondrial DNA damage such as single-strand breaks.
In response to DNA damage, the enzyme poly(ADP-ribose)

polymerase 1 (PARP-1) is activated. PARP-1 uses NAD as
a substrate to add long ADP-ribose chains to various proteins and transcription factors, to itself, and importantly, to
histones. ADP-ribosylation of histones alters their conformation and allows greater access to damaged DNA for
repair enzymes. Hydrogen peroxide, although less reactive
than other ROS, can also activate PARP-1 (perhaps through
formation of highly reactive hydroxyl radical), but to a
lesser extent than superoxide and peroxynitrite (1153).
PARP-1 is an intriguing enzyme that is rapidly activated
500-fold by binding to single-strand DNA breaks. PARP-1
seems to be a key determinant of three fundamental cellular
responses to DNA damage. After mild DNA damage,
PARP-1 promotes DNA repair and seems generally protective. With more severe damage, apoptosis is triggered and
caspases cleave and inactivate PARP-1, thereby sparing
NAD to function in metabolic pathways to generate ATP
to fuel subsequent apoptosis. However, with extensive
DNA damage, as apparently occurs with extensive expo-
1436
3. Compounded consequences of fuel overload in

diabetes
Overactivation of PARP-1 appears to be central to the endothelial dysfunction of diabetes (1104, 1659). Surprisingly, among the proteins ADP-ribosylated by PARP-1 in
the nucleus is the glycolytic enzyme glyceraldehyde 3-phosphate dehydrogenase (GAPDH). GAPDH shuttles in and
out of the nucleus and appears to function in some way in
nuclear DNA repair and NAD sensing. ADP-ribosylation
in diabetic endothelial cells results in GAPDH inhibition in
the face of high glycolytic flux, resulting in substrate spillover into a number of key, deleterious pathways. The substrate for GAPDH is glyceraldehyde-3-phosphate. Elevated
glyceraldehyde-3-phosphate leads to accumulation of
strongly reactive methylglyoxal. This abnormal byproduct
of impaired glycolysis results in rapid synthesis of AGEs by
chemical reactions that are far more efficient than glucosedependent pathways.
Glyceraldehyde-3-phosphate is maintained in equilibrium
with dihydroxyacetone phosphate, and in diabetes both are
converted at increased rates to glycerol-phosphate, the precursor to DAG. DAG is a direct activator of PKC (particularly the and isoforms but also, the more recently recognized atypical isoform which can also be activated by
palmitate infusion) (100). Among the numerous proinflammatory actions mediated by activated PKC are enhanced
activation of NF-B, stimulation of NADPH oxidase with
increased superoxide anion production and formation of
peroxynitrite, depletion of the essential cofactor for eNOS,
tetrahydrobiopterin, and resulting impaired NO synthesis
and uncoupling of eNOS leading to ROS formation (681).
Impaired movement of intermediates through the glycolytic
pathway also leads to elevated fructose-6-phosphate. This
leads to increased substrate flux through the hexosamine
pathway with production of N-acetylglucosamine (GlcNAc) and activated UDP-GlcNAc. UDP-GlcNAc can form
O-GlcNAc bonds with serine and threonine, thereby altering the function or activity of a variety of proteins including
transcription factors. The result in endothelial cells is decreased activation of eNOS, O-GlcNAc modification of
IRS-1 and IRS-2 leading to impaired insulin signaling
through PI3K and Akt to activate eNOS, increased expression of matrix metalloproteinases (MMPs) together with
Stimulating expression of Nrf2 (by inactivating Keap1 with

sulforaphane, a naturally occuring substance in broccoli)
upregulated antioxidant defenses and led to a marked reduction in the adverse effects of hyperglycemia, further supporting the role of ROS in mediating endothelial dysfunction in diabetes (2002). -Lipoic acid is an important mitochondrial antioxidant, and supplementation was shown to
decrease atherosclerosis in hyperlipidemic, diabetic mice
(2036). Heterozygous deficiency of lipoic acid synthase in
diabetic mice resulted in a 48% increase in atherosclerosis
extent (1111). Recent reviews continue to emphasize the
importance of lipoic acid in controling mitochondrial ROS
production (1367, 1959). Oral doses of 300 600 mg/day
have shown improved endothelial function and modest
benefit in diabetic peripheral neuropathy in human clinical
trials (1606).
sure to ROS, PARP-1 is overactivated, with the result that

cell stores of NAD become so extensively depleted that
energy generation fails and cellular necrosis ensues. There is
evidence that such excessive PARP-1 activation may be involved in myocardial and cerebral reperfusion injury and
several PARP-1 inhibitors are in clinical trials for these conditions (1365). Pharmacological inhibition or genetic deletion of PARP-1 leads to a decrease in inflammation and a
reduction in atherosclerosis in hyperlipidemic mice (1361,
1889).

decreased production of tissue inhibitor of metalloproteinase (TIMP), and increased cell mitogenesis (974). Glucosamine supplementation (5% in drinking water) was recently shown to increase ER stress similarly to the presence
of diabetes and markedly increased atherosclerosis in
ApoE-deficient mice (129). The effect was largely blocked
by valproate, an agent that decreases ER stress. Finally,
high intracellular glucose stimulates the sorbitol or polyol
pathway with depletion of NADPH which is needed to
regenerate intracellular gluthathione, further exacerbating
the pro-oxidant state (216).
4. Possible adverse signaling consequences of

insulin resistance
Not only does insulin resistance in adipose tissue lead to
excessive release of adipose free fatty acids and exposure of
the endothelium to excess free fatty acids, but, as noted
above, insulin resistance is imposed on endothelial cells,
both through ADP-ribosylation of IRS-1 and -2 and
through serine phosphorylations of IRS proteins by PKC
isoforms and IKK2. This leads to diminished signaling
through the PI3K and Akt pathway. But there is another
pathway for insulin receptor signaling in endothelial cells.
Insulin activates ERK1/2 through the Shc, Grb2-SOS, Ras
pathway independent of IRS1/2. While activation of
ERK1/2 appears to be protective in some contexts (for example, by phosphorylating eNOS), it can also result in stimulation of NOX5 as well as endothelin-1 release and vasoconstriction. Indeed, when NO production is blocked in
wild-type mice, insulin causes vasoconstriction (100).
There is growing evidence for selective insulin resistance
resulting in diminished vasodilation through the Akt pathway while the vasoconstricting ERK1/2 pathway is left intact. The vasoconstriction seems to be particularly promoted by the activation of PKC by fatty acids, such as
palmitate. PKC both inhibits insulin signaling through
IRS-1 and Akt and promotes signaling through the ERK1/2
pathway (100). However, as depicted in FIGURE 11,
ERK1/2 can also have antioxidant and anti-inflammatory
effects. Thus, whether this pathway promotes atherosclerosis in diabetes remains controversial. Additionally, insulin
was shown to induce expression of VCAM-1 in endothelial
In an important series of experiments, C57Bl6 mice were

fed a high-fat diet (45% calories fat, rich in lard). This
caused greater weight gain than chow, a nearly threefold
increased level of plasma free fatty acids, increased fasting
and stimulated insulin, and hypertension. In endothelium
from these animals, insulin was found to stimulate phosphorylation of ERK1/2 as expected, but surprisingly, phospho-Akt increased normally as well. However, there was
clearly impaired eNOS phosphorylation and production of
NO in response to insulin. In vitro studies further demonstrated impaired eNOS S1177 and S617 phosphorylation at
baseline and in response to insulin when cultured endothelial cells were exposed to saturated free fatty acids, particularly palmitate (1723). Again, impaired eNOS phosphorylation was seen despite normal insulin-induced Akt phosphorylation, suggesting either impaired signaling to eNOS
or possibly increased phosphatase activity directed at
eNOS. Further studies demonstrated that the impaired
eNOS phosphorylation was mediated by ceramide, whose
production was stimulated during high-fat feeding or after
incubation with palmitate. Ceramide was found to relieve
binding of phosphatase PPA2 from an inhibitory cytosolic
binding protein and facilitate the direct association of PPA2
with the Akt/eNOS/HSP90 complex. As a result, there was
a reduction in the phosphorylation status of eNOS S1177
and S617 and probably Akt as well, together with physical
displacement of Akt from the complex (2080). Thus ceramide signaling appears to impair transmission of an insulin signal through Akt to eNOS not by blocking upstream
Akt activation but by enhancing phosphatase activity directed at Akt and at least some of its targets.
F. Autoimmune and Inflammatory Disease

Increased risk of atherosclerotic disease has been documented for several autoimmune diseases including systemic
lupus erythematosis (SLE) (18, 456, 1500), rheumatoid arthritis or elevated rheumatoid factor (461, 615), systemic
sclerosis (904), and psoriasis (601, 635, 1086). It would be
reasonable to expect that the elevated plasma cytokines,
including TNF-, IL-6 (1171, 1492), and INF-/ (994)
seen particularly in SLE, would activate endothelial cells
(and/or monocytes) and thereby initiate atherosclerotic
processes, particularly at atherosclerosis-prone sites. Other
mechanisms have recently been forwarded. Multiple causes
of Treg dysfunction have been related to both atherosclerosis and autoimmune disease as reviewed above. Similarly,
dysfunction of macrophage or DC in clearing apoptotic
debris (efferocytosis), or impaired downregulation of in-
1437
If all these actions stemming from PARP-1 deactivating

GAPDH were not enough, several studies have pointed to
direct, potent proinflammatory and pro-oxidant effects of
PARP-1 itself, possibly by alteration of histones involved in
transcription of inflammation-related genes (1323). Cell
adhesion molecules VCAM-1, E-selectin, and P-selectin are
induced by such PARP-1 signaling (1889). Other endothelial changes accompanying hyperglycemia include loss of
glycocalyx, greater TXNIP-mediated inhibition of Trx
(1572), increased LOX-1 expression, increased signaling
through RAGE, and direct adverse effects of AGE (through,
for example, modification of extracellular matrix proteins).
cells by signaling through the insulin-like growth factor 1

receptor while induction of ICAM-1 by insulin was mediated by the insulin receptor. For both, induction could be
completely abrogated by inhibiting the MAPK, p38. MEK1
appeared to be involved for both but primarily by activating
p38 rather than ERK1/2 (1022).
PAUL N. HOPKINS
flammatory activation during efferocytosis can increase
both autoimmunity and atherosclerosis.
Several older studies illustrated synergism between immune
injury and hyperlipidemia. Thus immune injury to even
mildly hypercholesterolemic rabbits by horse serum aggravated atherosclerosis while antihistamines were protective
(1215). Increased antibodies to heat-dried cows milk and
boiled eggs were found in patients with CHD in an older
study (385). The display of HSP60 on endothelial cells in
association with activation of endothelial cells from a variety of initiating factors has been proposed to lead to autoimmune reactions, endothelial damage, and increased atherosclerosis, especially when coupled with hyperlipidemia
and other risk factors (1957).
More encouraging are findings from a post hoc analysis that

TNF antagonist therapy of rheumatoid arthritis was associated with lower risk of prospectively determined cardiovascular disease outcomes (656). Similar reduced risk in
psoriasis was recently reported with apparent benefit from
methotrexate as well (17). Other reports regarding methotrexate appear mixed (656, 1947).
G. Cigarette Smoking
Smoking has long been considered an endothelial cell stressor and activator. Cigarette smoke has 1017 free radicals
and many other ROS-producing chemicals per puff. Cigarette smoke extract can cause HDAC2 nitration, nitrosylation, and carbonylation, all leading to reduced HDAC2
activity which impairs the normal inhibition of inflammatory gene transcription by HDAC2. Greater NIK activation
is also seen (623).
Recently, the effects of exposing cultured endothelial cells
to cigarette smoke extract on expression of 35,000 genes
was reported (747). There was massive upregulation of
genes related to the unfolded protein response, thought to
be due to immense oxidative stress. Generation of free radicals was apparently mediated by metals as well as reactive
species in the extract. This was accompanied by mitochondrial dysfunction, upregulation of HSF1 and heat shock
proteins (including HSP60), and cell cycle arrest. These ob-
1438
IX. PROMOTION OF ATHEROSCLEROSIS

The promotion of atherosclerosis centers on the development of foam cells. Insudation of lipoproteins into the subendothelial space as well as lipoprotein retention and modification are major drivers of this stage of atherogenesis. The
concentration of LDL found in aortic intimal interstitial
fluid is proportional to the plasma concentration (2-fold
higher) (1647), consistent with the repeatedly validated loglinear relationship between risk of coronary events and
LDL plasma concentrations (with a 30% increase in risk
associated with a 30 mg/dl linear rise in plasma LDL) (985).
APOB-containing lipoproteins other than LDL are also proatherogenic with the order of atherogenicity, roughly as
follows (1873): smaller LDL larger LDL -VLDL
IDL smaller VLDL larger VLDL. Coronary disease
risks in human hyperlipidemias are consistent with this
scheme. Patients with homozygous familial hypercholesterolemia (FH) (due to LDLR mutations) have the highest risk
for CAD, followed by LDLR heterozygotes, type III patients, then type IV and possibly type V patients. In all these,
low HDL increases risk of atherosclerotic events. This
scheme is consistent with the markedly increased atherosclerosis of APOBEC-1-LDLR KO mice that not only have
increased LDL levels but, on average, smaller LDL particles
(1436).
Importantly, -VLDL, found in type III hyperlipidemia,
cholesterol-fed rabbits and dogs, and ApoE-defective mice,
are not simply TGRL remnants. Rather, they represent remnants that have remained in circulation sufficiently long to
have altered cholesterol-to-triglyceride ratios and have acquired -mobility on electrophoresis rather than pre--mobility normally seen for TGRL (including normal remnants)
in the VLDL density range. Furthermore, it is the cholesteryl
ester component of these abnormal TGRL that is atherogenic as demonstrated by the fascinating finding that
ACAT2 deficiency almost entirely abrogated atherosclerosis in ApoE null mice (see TABLE 8). In ACAT2 deficiency,
APOB-containing particle number (both for APOB-48 and
APOB-100) was actually somewhat increased, but the particles had markedly less cholesteryl ester but increased triglyceride content (1965). Such lipoproteins were apparently not atherogenic.
A substantial amount of literature suggests prior infections

could cause cross-reaction and sensitization to HSP60
(483). Infection of ApoE-deficient mice with Chlamydia
pneumoniae (1223) or herpesvirus (40) resulted in accelerated atherosclerosis. Nevertheless, treatment of coronary
patients with macrolide antibiotics has consistently failed to
alter subsequent event rates (249, 850, 1357). Thus causality for the infectious disease hypothesis remains to be
proven. Furthermore, if prior infection alone is sufficient to
increase subsequent risk, then the hypothesis may not be
provable by any antimicrobial intervention.
servations are consistent with prior reports of the pro-oxidant effects of smoking leading to activation of endothelial
cells (58). The rapid reversibility of cardiovascular risk after
smoking cessation suggests this activation not only affects
early endothelial activation but also precipitating factors
such as clotting and stability of advanced plaques as well
(probably also through inflammatory effects) (946). Nevertheless, some evidence suggests persistent inflammatory effects can last for years after smoking cessation (1927). More
recently, the stimulating effects of nicotine on vaso vasorum
development seem to contribute to atherosclerosis as well
(992) (see below).
Table 8. Genes related to promotion of atherosclerosis by foam cell formation (72 genes tested)
Gene
Model
% A
Function, Comment
Lipoprotein size and lipid composition

APOBEC-1/ LDLR/
ACAT2 (SOAT2)
ACAT2/ apoE/
298%
SREBP-1
SREBP-1 / LDLR/
271%
APOC1
human APOC1 Tg in
apoE/
142%
APOC3
human APOC3 Tg in
LDLR/
1165%
CETP
Simian CETP Tg in C57BL/6

fed atherogenic diet
1517%
1504%
APOBEC-1 (APOB editing catalytic polypeptide 1) deaminates a cytosine

in APOB mRNA causing change of glutamine 2153 to a stop codon
with the resulting APOB being 48% (APOB-48) the size of full length
APOB (APOB-100). APOBEC-1 LDLR double KO mice have sufficiently
increased LDL that plaques develop on chow diet (results in male
mice given) (1436). However, the LDL-size particles that accumulate
may also illustrate the greater atherogenicity of smaller LDL as
compared to larger TGRL and TGRL remnants.
ACAT2 (acyl-CoA:cholesterol acyltransferase 2, also known as SOAT2
for sterol O-acyltransferase 2) esterifies cholesterol with fatty acids
in intestine and liver whereas ACAT1 functions primarily in
macrophages and adrenal cortex. Particle numbers were relatively
unchanged in ACAT2 deficient, apoE-null mice but APOB-containing
lipoproteins lacked core cholesteryl ester while triglyceride content
was increased (1965). Results suggest cholesteryl ester in the
triglyceride-rich remnants that accumulate in apoE KO mice is the
atherogenic component rather than triglyceride.
TG levels were 71% lower in SREBP-1 deficient mice on Western diet
while total cholesterol was only modestly lower. The cholesterol
content of chylomicrons and VLDL was markedly reduced. In the
same study, hepatic over-expression of SREBP-1 increased
atherosclerosis 140% while BMT studies had no effect (882).
Increased TGRL generally likely led to the increase in atherosclerosis in
this model (346). Nevertheless, delayed clearance (by an effect of
free or HDL-bound apo CI to inhibit hepatic lipase) raises the
possibility of more atherogenic composition in humans.
Hyperlipidemia was clearly worsened in apo CIII Tg animals (1151).
Nevertheless Apo CIII increased susceptibility to pro-atherogenic
modification of LDL by sphingomyelinases with increased adhesion to
proteoglycans (768) and has other pro-atherosclerotic effects
independent of lipoprotein levels (892).
CETP (cholesteryl ester transfer protein) expression loaded VLDL and
LDL with cholesteryl ester at the expense of HDL in this study
(1143). Atherosclerosis extent was strongly and directly proportional
to the ratio (LDL-C VLDL-C)/HDL-C. In the setting of human LCAT
over-expression, CETP actually decreased atherosclerosis (137).
Thus, relevance to human is unclear.
Native lipoprotein affinity for the intimal ECM (extracellular matrix)lipoprotein and matrix properties
APOB
APOB Tg with proteoglycan

binding defect
LEPR
LEPRcp/cp rats fed 1%

choleseterol
Perlecan
perlecan/ apoE/
248%
Decorin
Decorin Tg apoE/
247%
265%
1290%
APOB-100 is the structural lipoprotein of VLDL and LDL. 3 forms of

proteoglycan binding-defective transgenic APOB with or without
defective LDL binding were compared. Proteoglycan binding
deficiency resulted in substantial reduction of atherosclerosis at
comparable LDL levels (1638).
Corpulent (cp/cp) rats have a natural mutation causing complete
absence of LEPR. The measure of atherosclerosis was
unconventional and consisted of the sum of reported myocardial
ischemic lesions. Increased binding and retention of intestinal
lipoproteins due to increased biglycan content of the arterial wall
seemed to be the major differences in this unusual model of severe
metabolic syndrome with high insulin levels (1133).
Given is the mean effect in males and females at 12 wk. Later
assessments were nonsignificant in both these apoE KO as well as
LDLR null mice (1880). Similar reductions seen in apoE KO mice
laking exon 3 of the perlecan gene (1805).
Adenovirus mediated transgenic over-expression was seen primarily in
liver with increased plasma decorin levels. Shown is the effect from
early treatment. Late treatment decreased atherosclerosis as well
(37).
Continued
1439
APOBEC-1
PAUL N. HOPKINS
Table 8.Continued
Gene
Model
% A
Function, Comment
Lipoprotein modification, enzymatic (can also affect affinity for ECM)

PLA2G2A Tg BMT into
LDLR/
sPLA2 (group III)
PLA2G3 Tg, apoE/
1125%
sPLA2 (group V)
PLA2G5/ BMT into

LDLR/
238%
sPLA2 (group X)
PLA2G10/ BMT into

LDLR/
SMS2
SMS2/ apoE/
252%
ASM (secreted)
ASM/ LDLR/
255%
157%
1107%
Macrophages from Tg group IIA sPLA2 overexpressing mice had 2.5fold greater rates of LDL oxidation, dependent on 12/15 LO
expression and increased foam cell formation. Urinary isoprostanes
were also increased (1793). Confirmatory of prior observations
(833, 1931).
Secreted phospholipase A2 (sPLA2) enzymes modify LDL and promote
foam cell formation. Transgenic over-expression of human GIII sPLA2
caused increased lysophosphatidyl choline in LDL and increased
atherosclerosis in animals fed an atherogenic diet (1540).
sPLA2 is thought to be largely secreted from activated macrophages.
Overexpression of the GV sPLA2 in this same study resulted in a
170% increase in lesion extent as well (186).
The main target of this isoform is phosphatidyl choline. Unexpectedly,
deficiency of the group X sPLA2 resulted in a marked increase in Th1
activity, IFN-, and macrophage necrosis while over-expression of
human PLA2G10 reduced plaque size, and enhanced Th2 and
macrophage IL-10 production (29).
Sphingomyelin synthase 2 (SMS2) KO mice had lower sphingomyelin
content in nonHDL lipoproteins, less aggregation of these
lipoproteins upon exposure to sphingomyelinase, and decreased
lipoproteins in the aortic wall (497). Similar results with
macrophage-only SMS2 deficiency in LDLR/ mice (1058).
Adenoviral delivery of SMS2 to apoE KO mice increased
atherosclerosis but also increased non-HDL-C and decreased HDL-C
(1914). Similarly, adenoviral expression of SMS1 and SMS2
increased sphingomyelin content and aggregation of APOB-containing
lipoproteins after sphingomyelinase treatment (434).
Acid sphingomyelinase (ASM [causes Niemann-Pick disease, type A
when deficient]) also has a secreted form besides the lysosomal
form. Secreted ASM cleaves sphingomyelin to ceramide, promotes
lipoprotein binding and retention, and greatly increases uptake and
foam cell formation for a number of lipoproteins (417).
Macrophage scavenger receptors, bridging proteins, extracellular peptides affecting lipoprotein uptake
LPL
LPL/ BMT in LDLR/
233%
Fhx2
BALB/cJ mice fed a high-fat

diet
297%
ANGPTL3
ANGPTL3/ apoE/
269%
ANGPTL4
ANGPTL4/ apoE/
275%
Macrophage-expressed LPL may promote remnant uptake and

retention by bridging between lipoproteins and proteoglycans (94).
Consistent with similar study in fat fed B6 mice (1850).
Fhx2 (zinc fingers and homeoboxes 2) is a transcription repressor of
many genes, including LPL in liver. The BALB/cJ strain of mouse
has a defect (a large intron insertion) in Fhx2 that results in very low
Fhx2 expression and marked increase in liver LPL expression. As a
result, VLDL are cleared more quickly, serum cholesterol is lower,
and HDL higher while on a high fat atherogenic diet and
atherosclerosis was reduced 30-fold. The degree of atherosclerosis
protection appeared greater than could be explained by the lipid
changes and there may have been macrophage effects as well (593,
1915).
ANGPTL3 (angiopoietin-like 3) is secreted by liver and inhibits LPL by
promoting its cleavage (by proprotein convertases furin and PACE4
paired amino acid converting enzyme 4) (1056). ANGPTL3 also
inhibits HL (hepatic lipase) and EL (endothelial lipase). The reduction
in atherosclerosis in this model appears almost entirely mediated by
the reduction in VLDL and remnants due to a marked increase in
LPL activity (62). However, limited human evidence suggests a
possible nonlipid mediated effect on carotid plaque (732). Loss of
function variants for ANGPTL3, 4, and 5 were associated with lower
triglycerides in human populations (1504).
ANGPTL4 inhibits LPL by reversing the dimerization of LPL (2041).
Reduction in atherosclerosis presumably was largely due to
decreased fasting and postprandial TGRL. However, macrophages
from ANGPTL4 KO mice were also shown to accumulate less
cholesteryl ester (8).
Continued
1440
sPLA2 (group IIA)
Table 8.Continued
Gene
Model
% A
LIPG/ apoE/
270%
APOE4 (human E4
isoform versus
E3)
human apoE4/4 with

humanized LDLR BMT into
apoE3/3 LDLR/
152%
HSP27
HSP27 Tg apoE/ females
235%
MSR1 (SR-AI and

SR-AII)
SR-AI/II/ apoE/
258%
SR-AI/II/ silenced BMT

into LDLR/
ApoB100/100
237%
CD36
CD36/ apoE/
245%
DGAT1
DGAT1/ apoE/
224%
VLDLR
VLDLR/ LDLR/
LDLR
NS
VLDLR/ BMT into

VLDLR/ C57Bl/6 fed
Paigen diet
LDLR/ BMT into C57Bl/6
fed Paigen diet
1170%
LDLR/ BMT into LDLR/
NS
266%
LIPG is EL (endothelial lipase). Mice with LIPG deficiency had higher

HDL-C but also higher VLDL-TG (though lower VLDL-C). Macrophage
adherence was decreased in vitro in LIPG KO mice (828).
Increase in atherosclerosis is compared with mice receiving apoE3/3
with humanized LDLR bone marrow. Thus macrophages with
humanized LDLR had twofold increased LDLR expression and apoE4/4
lead to increased atherosclerosis as compared with apoE3/3 (57).
HSP27 (heat shock protein 27) is secreted by macrophages but only
upon estrogen receptor stimulation. Also strongly expressed in
VSMC. HSP27 binds to SR-A and inhibits uptake of AcLDL. Also,
possibly down-regulates SR-A (1452). Tg overexpression resulted in
increased plasma HSP27 only in females and dependent upon the
presence of estradiol or estrogen receptor agonist (1464).
Atherosclerosis was inversely proportional to serum HSP27 (1463).
MSR1 (macrophage scavenger receptor 1) gene gives rise to SR-AI
and SR-AII by alternate splicing (1718).
Transfected BMT cells with adenovirus expressing a silencing short
hairpin RNA (shRNA). Used LDLR KO mice that expressed exclusively
APOB-100. Also found that silencing of SR-A upregulated CD36 and
vice versa (1121). Highly variable results in other studies (654).
CD36 is a class B scavenger receptor (507). As for MSR above,
results for KO with this receptor have been somewhat variable (654)
but generally confirmatory (716). Confirmed also in LDLR KO BMT
(1121). Also decreases thrombotic potential since platelet CD36
interacts with oxidized phospholipids in hyperlipidemia to promote
platelet activation (1426). CD36 signaling through Fyn leads to a
CD36: TLR4: TLR6 complex with downstream signaling through both
MyD88 and TRIF (1684).
DGAT1 (acyl-CoA:diacylglycerol acyltransferase 1) deficiency in other
mice leads to resistance to dietary fat-induced obesity and
inflammation. Much of the effect on atherosclerosis may have been
due to reduced serum cholesterol and triglycerides, but SR-A
expression and foam cell formation was reduced in isolated
macrophages from DGAT1 KO mice (273).
Increased necrosis in plaques in VLDLR KO despite no effect on size.
Endothelial over-expression had no effect (1734)
Only a nonsignificant 29% decrease in lesion size was seen comparing
VLDLR/ to VLDLR/ mice (459)
Many fewer macrophage foam cells were seen in lesions despite no
difference in plasma lipids. Cultured macrophages took up less VLDL (754).
Confirmed by 3 different teams (169, 503, 753).
Extracellular hormone peptides that promote foam cell formation

GLP-1
GLP-1 infusion for 4 wk in

apoE/
227%
GIP
GIP infusion in apoE/
239%
Salusin-
Salusin- infusion in apoE/
250%
Salusin-
Salusin- infusion in apoE/
190%
GLP-1 (glucagon-like peptide 1) increases cAMP through its receptor on

macrophages and VSMC. Effects of infusion of GLP-1 for 4 wk into 17wk-old apo E null mice on aortic root are shown. GLP-1 treatment
inhibited macrophage infiltration into artery walls and reduced
expression of CD36. Endothelial expression of MCP-1, VCAM-1, ICAM1, and PAI-1 were also all supressed by GLP-1 or GIP (1271).
GIP (gastric inhibitory peptide, also glucose-dependent insulinotropic
polypeptide) had effects comparable to GLP-1 (1271).
Salusins are peptides alternatively processed from the TOR2A (torsin
2A) gene. They are synthesized in a variety of tissues including the
vasculature and are found in plasma. Salusin- inhibits foam cell
formation in vitro and with infusion. Shown are results of 8 wk of
infusion (1270).
Salusin- promotes foam cell formation and VSMC proliferation but
also has pro-proliferative and anti-apoptotic effects on
cardiomyocytes. Shown are effects on aortic root atherosclerosis of
4 wk infusion starting at 13 wk. Macrophage CD36 expression was
upregulated (1270).
Continued
1441
LIPG (EL)
Function, Comment
PAUL N. HOPKINS
Table 8.Continued
Gene
Model
% A
Function, Comment
Macrophage and VSMC intracellular signaling affecting scavenger receptor expression or lipoprotein uptake
LXR ( and )
LXR/ BMT to LDLR/
LXR (NR1H3)
LXR (NR1H2)
LXR/ LDLR/
LXR/ LDLR/
1230%
173%
NS
241%
Arg1
Arg1 variant with increased

activity in cholesterol-fed
rabbits
241%
FXR
FXR/ apoE/ on high fat

diet
254%
FXR/ apoE/ on high fat

diet
1104%
PXR
PXR/ apoE/
240%
PPAR
PPAR/ BMT into

LDLR/
125%
PPAR
PPAR/ BMT into

LDLR/
262%
Bcl6
Bcl6/ BMT into LDLR/
157%
Continued
1442
iVP16LXR LDLR/
LXR has multiple effects both on both macrophage scavenger receptor

expression and lipoprotein uptake and efflux. LXR is also strongly
anti-inflammatory (1756). Others report an 83% reduction of
atherosclerosis in an LXR transgenic mouse (243, 1776).
Only LXR (also known as NR1H3 for nuclear receptor subfamily 1,
group H, member 3) KO increased atherosclerosis. LXR represses
ABCA1, ABCG1, and SREBP1c expression in the absence of LXR
agonists. Not all the increase in atherosclerosis was due to
macrophage deficiency in BMT studies (152).
Intestine-specific expression of a constitutively active LXR
(iVP16LXR) increased nonbile trans-intestinal cholesterol excretion
(TICE) and enhanced reverse cholesterol transport from
macrophages to intestine while decreasing liver fat content (1066).
Arg1 (arginase 1) variant in atherosclerosis resistant rabbits was
shown to have greater activity (1775, 1785). Arg1 is greatly
increased in regressing plaques and produces polyamines which
promote resolution of inflammation and reduces iNOS production of
NO in macrophages. Arg1 is a downstream target of LXR. LXR
first induces IRF8 which then acts as a transcription factor for Arg1
(1435).
FXR (farnesoid X receptor) is also known as NR1H4 (nuclear receptor
subfamily 1, group H, member 4). Female apoE KO mice have more
atherosclerosis and showed reduction with FXR KO (674).
Macrophages expressed less CD36 with FXR KO but more TNF-
and INF-. In LDLR KO model, males have more atherosclerosis and
showed reduction with FXR KO (2085).
In another study FXR/ apoE/ mice displayed severe
steatohepatitis, reduced weight gain, and lower survival. VLDL and
LDL were increased and HDL reduced (710). In both studies, only
high-fat, high-cholesterol fed mice showed differences in
atherosclerosis.
FXR effects on atherosclerosis are complex but appear primarily
dependent on resulting serum lipid levels (727). FXR KO may have
unexpected effects compared to FXR agonists (690).
PXR (pregnane X receptor) is a nuclear receptor that binds an array of
endogenous hormones, dietary steroids, pharmaceutical agents, and
xenobiotic compounds. PXR KO did not alter serum lipids but led to a
reduction in macrophage CD36 expression and oxLDL uptake
(1698). Chronic stimulation of PXR in apoE null mice decreased HDL
and increased atherosclerosis with increased macrophage CD36
expression (2101).
Given is approximate mean of male (44% increase) and female (3-5%
increase, NS) for proximal aorta (92). Greater effects for distal
aorta (both genders about 45% increase). Blood pressure
(decreased) and metabolic effects (higher triglycerides, more insulin
sensitive) made results difficult to interpret for whole body PPAR/
/
apoE
model (1802).
The decreased atherosclerosis was surprising given a substantial
decrease in atherosclerosis also seen with a PPAR agonist (988).
Additional studies led to a model in which unliganded PPAR binds
Bcl6 while PPAR ligand displaces Bcl6, freeing it to act as a
corepressor for many proinflammatory genes. Thus either PPAR
agonist or complete absence of PPAR results in more free Bcl6 and
greater co-repression of pro-inflammatory genes. This model has
been validated in subsequent studies (108, 286, 1743). Bcl6 acts
in opposition to NF-B for over 1000 genes (109)
Bcl6 (B-cell lymphoma 6) is a DNA binding protein which inhibits
transcription when interacting with SMRT, NCoR and other
corepressor complexes. These downregulate transcription of some
20-30,000 genes (with 50% overlap), many being pro-inflammatory
NF-B target genes (110). It is bound by unoccupied PPAR.
Table 8.Continued
Gene
Model
% A
PPAR/ BMT into

apoE/
PGC-1
PGC-1/ apoE/
NS
AEBP1
AEBP1 Tg BMT into

apoE/
1280%
Nrf2 (NFE2L2)
Nrf2/ apoE/
227%
ABCB4
ABCB4/ BMT into

LDLR/
181%
RIP2
RIP2/ BMT into APOB100 x LDLR/
137%
130%
The PPAR induces LXR and CD36 transcription while LXR induces
ABCA1 (287). Similar results in LDLR/ mice (97). PPAR also
promotes macrophage efferocytosis (286). PPAR signaling also
normally suppresses atherosclerosis-associated vascular calcification
by a newly recognized Wnt5a pathway in VSMC (1969).
No change in lesions despite more macrophages and increased ICAM-1
expression in plaques (1679). The PGC-1/ mice were lean and had
lower serum triglycerides but had much lower aortic PPAR and
PPAR expression.
AEBP1 (adipocyte enhancer-binding protein 1) is a transcriptional
repressor that downregulates LXR and PPAR activity in
macrophages (1116). Parallel studies including deletion of AEBP1
and studies in LDLR KO animals were confirmatory (165).
Nrf2, also known as NFE2L2 (nuclear factor erythroid type 2-like 2),
supports expression of CD36 and foam cell formation in
macrophages (1717). Chow-fed Nrf2 KO mice again showed less
CD36 in macrophages, fewer macrophages in plaques, but also
lower plasma lipid levels and reduced hepatic lipid production (106).
ABCB4 (also known as P glycoprotein 3) Foam cell formation was
greatly accelerated upon incubation with acetylated LDL due to
increased activity of scavenger receptors. Neither cholesterol nor
phospholipid efflux to HDL were affected (1403)
Appeared to promote macrophage spreading and macropinocytosis
(1012).
Macrophage and VSMC intracellular lipid trafficking

LIPA
injection of human LIPA into

LDLR/
NPC1
NPC1/ apoE/
1230%
ACAT1
ACAT1/ BMT LDLR/
1119%
Elovl6
Elovl6/ BMT LDLR/
236%
ADRP (PLIN2)
ADRP/ BMT apoE/
225%
ATGL
ATGL/ BMT into LDLR/
243%
NCEH1
NCEH1/ apoE/
170%
CEH
macrophage-specific NCEH1
transgenic LDLR/
250%
250%
LIPA (lipase A, lysosomal acid, also LAL) cleaves both CE and TG in

lysosomes. Another model with LIPA deficiency in apo E KO mice
may have had increased atherosclerosis but comparison with apo E
KO alone not given (449).
NPC1 (Niemann-Pick disease type C1) is involved in intracellular FC
trafficking. NPC1/ mice also displayed greatly increased
thrombosis (1940). However, heterozygous deficiency of NPC1
decreased atherosclerosis with less apoptosis associated with free
cholesterol accumulation in the ER (514).
Macrophage-specific KO of ACAT1 impaired cholesteryl esterification in
macrophages and decreased macrophage total cholesterol content
but greatly increased toxic free cholesterol and total plaque area
(504). Also known as SOAT1 (sterol O-acyltransferase 1).
Elovl6 is a fatty acid elongase and appears to provide preferred
substrate (mainly oleate) for ACAT1 to form cholesteryl esters in
foam cells (1529).
ADRP (adipose differentiation-related protein, also known as perilipin 2)
is a major lipid droplet protein required for foam cell formation.
Deficiency in macrophages decreased the number of lipid droplets
and increased cholesterol efflux in macrophages (1397).
Macrophages lacking ATGL (adipose triglyceride lipase) had massive
TG accumulation but showed less inflammation (978). Mechanism
unknown.
NCEH1 (neutral cholesteryl ester hydrolase 1) releases free
cholesterol (FC) from cytoplasmic lipid droplets and promotes FC
efflux. NCEH1-deficient macrophages accumulated more CE when
incubated with acetylated LDL, -VLDL, or oxLDL. Lesions also had
more FC and CE (1584).
CEH (cholesteryl ester hydrolase, also known as CES1 for
carboxylesterase 1) is another enzyme with neutral CEH activity but
is distinct from NCEH1. (2086). CEH accounts for 10% or less of
neutral CEH activity. Nevertheless, overexpression decreased
atherosclerosis and suppressed macrophage NF-B and AP-1
signaling with less secretion of IL-1, IL-6, and MCP-1 (144).
Continued
1443
PPAR
Function, Comment
PAUL N. HOPKINS
Table 8.Continued
Gene
Model
% A
HSL
HSL/ BMT into LDLR/
120%
GPR109A
GPR109A/ LDLR/
133%
Function, Comment
HSL (hormone-sensitive lipase, also abbreviated LIPE for lipase E) also

protected from foam cell formation but to somewhat less extent
than NCEH1. The 20% increase in atherosclerosis with HSL-null
bone marrow was not significant versus wild type. However, HSL/
NCEH1/ BMT (100% increase) versus NCEH1/ BMT only
(70% increase) was significant (1584). Thus, the effects of these
two lipases were roughly additive.
This is the niacin receptor, a GPCR expressed in macrophages, other white
cells, and adipocytes but not endothelial cells. Increased atherosclerosis
shown here is a comparison between GPR109A/ LDLR/ versus
LDLR/ mice with both on niacin. BMT with GPR109A/ cells
abrogated the anti-atherosclerotic effect of niacin (1087).
Foam cell cholesterol efflux, HDL related removal of cholesterol

/
APOA1
LDLR/
APOBEC1/
1110%
ROR
ROR/ in C57BL/6 fed

atherogenic diet
1504%
APOA2
human APOA1/AII Tg in
11367%
C57BL/6 fed atherogenic
diet
human APOA1I Tg in rabbits

fed high cholesterol diet
256%
ABCA1
ABCA1/ BMT apoE/
158%
TRPV1
TRPV1/ ApoE/
1300%
ABCA5
ABCA5/ BMT into

LDLR/
150%
ABCA7
ABCA7/ BMT into

LDLR/
NS
LDLR/APOBEC1-deficient mice express only APOB-100 in LDL. In

these APOA1-deficient mice, HDL-C was normal but the HDL lacked
APOA1 and instead had high apoE. The mice showed impaired
ABCA1- and SR-B1-mediated cholesterol efflux and decreased
reverse cholesterol transport (1232).
ROR (retinoic acid receptor-related orphan receptor ). This mouse
had a profound reduction in HDL, but of interest, this was due to
reduction of apoI production in intestine, not liver (1132).
Comparison was with the human APOA1 Tg. The nontransgenic
C57BL/6 had about 3 times more atherosclerosis than the
APOA1/AII transgenic (1570). Less striking results in another study
(1928). The relevance of these studies to human atherosclerosis
remains unknown but human APOA1I seemed to displace PON and
rendered mouse HDL proinflammatory and pro-oxidant (264).
The mean reduction in en face aortic lesions in males and females is given.
Coronary atherosclerosis was also seen and reduced. HDL of the APOA1I
Tg rabbits showed greater cholesterol efflux capacity and ability to reduce
inflammatory cytokine production by LPS-treated macrophages and CRP
levels were markedly reduced. -VLDL were less oxidizable. There was an
increase in pre- HDL compared to larger HDL (1920).
Whole body KO of ABCA1 did not affect atherosclerosis but cholesterol levels
were reduced. In contrast, bone marrow knockout did increase
atherosclerosis as shown here (22). More recently, whole body
overexpression decreased atherosclerosis, liver-specific KO increased
atherosclerosis (together a large reduction in HDL), while macrophagespecific KO had no effect (220). Infusion of apo E null mice with ABCA1
antibody increased atherosclerosis by 72% (1246).
TRPV1 (transient receptor potential vanilloid 1) is a calcium channel
that mediates burning pain in response to capsaicin stimulation. In
TRPV1-null mice there was a reduction of phosphorylated eNOS and
NO production, presumably through reduced endothelial calcium
entry and reduced CaMKII, PYK2, and ERK1/2 activation (309).
This signaling would be expected to be proatherogenic, however. In
another study, intracellular calcium elevation mediated by capsaicin
in VSMC resulted in downregulation of LRP1 and upregulation of
ABCA1 with decreased lipid accumulation. Apo E null mice treated
with capsaicin and high fat diet had 47% less atherosclerosis while
no effect was seen in TRPV1 deficient double KO mice (1100).
Given is increase lesion size at 6 wk in females. By 10 wk a NS 30%
increase was seen. No increase in males was seen. There was impaired
transfer of cholesterol to spherical HDL from ABCA5/ macrophages
with compensatory increase in ABCA1 but not ABCG1 (2031)
ABCA7 may promote cholesterol efflux and efferocytosis but no effect of KO
was seen on atherosclerosis (937). ABCA7 is upregulated by cholesterol
loading. However, ABCA7 deficiency leads to marked compensatory
upregulation of both ABCA1 and especially ABCG1 (1201). If anything,
ABCA1/ABCA7 double KO BMT had somewhat less atherosclerosis than
ABCA1 KO, presumably due to marked ABCG1 upregulation.
Continued
1444
APOA1
Table 8.Continued
Gene
ABCG1
% A
Function, Comment
ABCG1/ ABCA1/ BMT

into LDLR/
1141%
Shown is the comparison between mean proximal aortic lesion area in

ABCG1/ ABCA1/ BMT to ABCA1/ BMT, both in LDLR/
animals. BMT with ABCA1/ marrow showed modest increase in
atherosclerosis but no increase was seen for ABCG1/ only,
consistent with prior studies (2054).
Plaque increase given is for aortic root; 2.2-fold increase was seen in
the arch, both only after 23 wk (1946). Increased EC free
cholesterol increased Cav1 interaction with eNOS and impaired NO
synthesis which was reversed by HDL (1770).
ORP1L (oxysterol binding protein (OSBP)-related protein 1L) binds 22and 25-hydroxycholesterol. ORP1L over-expressing macrophages
displayed reduced ABCG1, ABCG5, and APOE expression with
decreased cholesterol efflux to spherical HDL2. PLTP secretion was
also increased (2015).
SR-B1 is an HDL receptor and can be involved in macrophage
cholesterol efflux as well as reverse cholesterol transport from HDL
to liver. Controls had essentially no lesions at 4-7 wk. SR-B1
deficiency also resulted in MI in mice (1808) possibly by activation of
platelets due to increased free cholesterol (938).
Macrophage-specific deficiency of SR-B1 contributed to the strong proatherogenic effect noted for whole-body knockout. However,
cholesterol efflux to HDL from incubated macrophages lacking SR-B1
was not different than wild-type macrophages (2081). Suggests
there may be a strong endothelial anti-inflammatory effect as well
and/or other macrophage signaling effects are important.
PDZK1 (PDZ domain-containing protein 1) is not a kinase but a
scaffold that helps organize various receptors and ion channels.
PDZK1 KO mice have a marked reduction in SR-B1 in liver but not in
macrophages or endothelial cells. A fourfold increase (to about 40%
of mice) in occlusive lesions (50-100% stenosis) was seen (2034)
besides the increased area of atherosclerosis given in this table.
GNMT (glycine N-methyltransferase) synthesizes sarcosine from glycine
with a methyl group donated from S-adenosyl methionine. GNMT KO
mice had higher cholesterol levels but isolated macrophages showed
increased cholesterol accumulation with downregulation of ABCA1,
ABCG1, and SR-B1, thus the mechanism for increased atherosclerosis
is unclear (291).
Adenovirus-apoM injection led to 3- to 4-fold increase in plasma apo M.
Lesions assessed 3 wk later. Apo M increased HDL, decreased HDL
catabolism, and promoted increased cholesterol efflux by enhanced
formation of pre- HDL (1970). Similar but less dramatic effects
confirmed in a later study using transgenic over-expression of human
APOM (321).
ABCG1/ LDLR/ with

BMT of wild type marrow
120%
ORP1L
ORP1L Tg BMT into

LDLR/
1108%
SR-B1 (SCARB1)
SR-B1/ apoE/
15000%
SR-B1/ BMT
apoE/
186%
PDZK1
PDZK1/ apoE/
126%
GNMT
GNMT/ apoE/
APOM
APOM adenoviral
transduction in LDLR/
278%
HL (LIPC)
HL/ apoE/
273%
LCAT
LCAT/ LDLR/
LCAT/ apoE/
235%
251%
PLTP
PLTP/ BMT into PLTP/

LDLR/ mice
248%
1500%
HL (hepatic lipase), also known as LIPC (lipase C). Primarily female

mice showed decreased atherosclerosis (1204).
LCAT (lecithin cholesterol acyltransferase) deficiency decreased
atherosclerosis despite a profound reduction in HDL-C (977).
Reduced LDL and VLDL-Cwere also decreased modestly. Reverse
cholesterol transport is increased by LCAT deficiency while overexpression of LCAT decreases availability of pre- HDL, decreases
reverse cholesterol transport and increases atherosclerosis (1447).
PLTP (phospholipid transfer protein) is induced by LXR and secreted
locally by macrophages where it interacts with ABCA1 and promotes
cholesterol transfer to APOA1 or pre- HDL. PLTP may also facilitate
local regeneration of pre- HDL. Shown here is effect of restoration
of normal macrophage PLTP production in otherwise PLTP-deficient
mice (1839). Higher systemic PLTP activity seems to promote
APOA1 loss, reduced plasma HDL, and increased atherosclerosis
(1856).
Reference numbers are given in parentheses. Not included are gene modifications which lead to changes in
lipoprotein plasma levels (see text).
1445
Model
PAUL N. HOPKINS
The notion of postprandial atherogenesis (2117, 2118) remains a strong possibility, particularly in light of the recent
report that much more APOB-48 was found in human
plaque than APOB-100 (1867). Furthermore, transgenic
overexpression of SREBP-1c in LDLR-null mice increased
VLDL production rate, VLDL size, and postprandial
plasma triglyceride levels, with greater overall exposure to
TGRL remnants. These animals suffered increased atherosclerosis. Conversely, double KO of SREBP-1 and LDLR
resulted in lower VLDL and less atherosclerosis compared
with LDLR KO controls (882). Other genes that may affect
lipoprotein size and composition due to effects on synthesis
or residence time are apo CI, apo CIII, and CETP with
proatherogenic effects demonstrated for all these except
CETP, which showed mixed effects (see TABLE 8).
An intriguing additional hypothetical mechanism related to
fat intake and chylomicrons is the possibility that these
intestinal lipoproteins carry sufficient LPS from intestinal
bacteria to promote inflammation in both adipose and the
artery wall (237, 1919). However, ApoE-deficient animals
had more atherosclerosis when raised in germ free conditions, at least when fed a low cholesterol diet, though there
was essentially no difference when the mice were fed a highfat diet (1683).
Somewhat related is the important recent observation that
the intestinal microflora decomposes dietary choline to the
gas trimethylamine which is efficiently absorbed and metabolized in the liver by FMO3 (flavin monooxygenase 3
and possibly other related enzymes) to a proinflammatory
agent, TMAO trimethylamine N-oxide (TMAO) which
1446
promotes inflammation and macrophage foam cell formation. ApoE KO mice fed a high-choline diet had three times
the atherosclerosis compared with either antibiotic-treated
mice or mice fed a regular diet. Atherosclerosis susceptibility also seemed to correlate with FMO3 activity in mice
with different genetic backgrounds. Data demonstrating a
strong positive association between CAD and TMAO in
human subjects was also presented (1924).
A. Dendritic Cells as the First Foam Cells

Dendritic cells (DCs) are the earliest inhabitants of the subendothelial intimal space, concentrated clearly in atherosclerosis-prone areas of disturbed flow, as first shown surprisingly in healthy young humans and rabbits (1212).
Their presence was already established in all specimens examined even in infancy or early childhood, in the absence of
any risk factors, well before the presence of any evidence of
macrophage accumulation or lipid-filled cells, and was universally extant in normolipidemic animals as well (161,
1212). Apparently, the degree of endothelial activation
with VCAM-1 expression at hemodynamically predisposed
sites was sufficient to signal DC to set up their surveillance
in these areas as professional antigen-presenting cells
(864). The DC in these networks were shown capable of
antigen presentation, and as other DC, were capable of
moving to nearby lymphatic tissue where phagocytosed antigens could be presented to T-cells (1851). Furthermore,
hypercholesterolemia does not diminish the ability of DC to
prime naive T-cells (1366).
All DC express CD11c (integrin X, encoded by ITGAX)
and MHCII (thus, DC are CD11c, MHCII). Temporary
ablation of subintimal DCs was achieved in LDLR-deficient
mice by selective expression of a diptheria toxin receptor
only in CD11c cells followed by diptheria toxin administration. When these mice were then fed a high-fat diet, there
was a marked reduction in intimal foam cell formation
compared with untreated mice, with the difference detectable in just 510 days. Thus subintimal DCs seem to represent the first foam cells to be formed in the face of hyperlipidemia (1399). Consistent with this observation, ITGAX
deficiency in apoE/ mice resulted in a modest 24% decrease in atherosclerosis (1986) (see TABLE 6). KO of CD74,
a chaperone required for normal expression of MHCII, decreased atherosclerosis over 70%, but such a defect would
have disrupted many aspects of adaptive immunity (see TABLE 7). The relevance of these findings to the role of DCs in
atherosclerosis must be considered in light of additional
complexities.
1. DCs as complex modulators of atherogenesis
The role of DCs in atherogenesis can be anticipated to be
complex, since DCs can orchestrate either the sensitization
or anergy of Th cells toward presented antigen as well as the
Interestingly, a subset of human FH patients who have both

heterozygous LDLR mutations and an ApoE2 variant (and
who clearly manifest type III hyperlipidemia in addition to
high LDL) do not have higher risk than other persons with
FH without type III hyperlipidemia (260, 783, 786). This
may be due to reduced conversion of remnants to LDL and
somewhat lower LDL levels in this combined lipid disorder.
These FH patients differ from combined LDLR/ApoE-deficient mice which have much more severe atherosclerosis
than LDLR KO mice, possibly due to impairment of macrophage efferocytosis imposed by ApoE deficiency and
other lipoprotein abnormalities (for example in HDL) seen
in ApoE deficiency (see below). Low levels of HDL are
clearly associated with elevated atherosclerosis risk. The
common combination of low HDL with elevated triglycerides has been associated with remarkably elevated risk in
some studies (782, 785). This repeatedly observed epidemiologic association between low HDL and increased risk of
CAD does not obviate the importance of HDL function in
addition to HDL concentration. Common variants in at
least 95 genes have now been shown in human GWAS studies to affect serum lipid with many also contributing to
CAD risk (1774), but these will not be reviewed here.

control of Treg, all depending on the array of displayed
costimulatory or coinhibitory receptors and the mix of secreted cytokines. DCs are broadly subdivided into conventional (derived from non-monocyte DC precursors) and
nonconventional DCs (consisting of plasmacytoid and
monocyte-derived DC).
A subset of conventional DCs was found to accumulate

later in lesions and secrete CCL17 which specifically restrained proliferation and promoted apoptosis of Treg
while directing atherogenic CD4 T-cell responses, all in
an antigen-specific manner (1932). Genetic deletion of
CCL17 reduced atherosclerosis in ApoE-deficient mice
(1932) (see TABLE 7).
Possibly, the conversion of DCs to early foam cells and the
reduction of atherosclerosis from general DC depletion
noted above represent the effects of monocyte-derived DCs
and/or CCL17-producing conventional DCs, but this has
not been demonstrated directly. Perhaps too, resolving
which DC subsets are most affected, which coreceptors are
expressed, and their interaction with various T-cells including Treg, may help explain another study which reported a
decrease in atherosclerosis from adoptive transfer of mature
DCs pulsed with oxLDL (688). Yet, in another study, there
was an increase in atherosclerosis with transfer of DC
treated with MDA-LDL (769). Both studies used DCs expanded from bone marrow by incubation with GM-CSF. In
another study, DCs were pulsed with both APOB-100 and
IL-10 and then transferred into apoB-100 expressing LDLR
KO mice. Treg were apparently activated, and atherosclerosis was reduced by a remarkable 70% (755).
Further complexity is illustrated by a study of DC engineered
to have an extended lifespan. Prolonged survival of DCs was
achieved by DC-specific transgenic expression of human Bcl-2
(595). Long-lived DC led to some signs of increased immunogenicity including greater Th1 activation (increased IFN-,
IL-1) and autoantibody production against oxLDL. How-
2. Neutrophils may interact with plasmacytoid DCs

to enhance atherosclerosis
Plasmacytoid DCs (pDCs) have recently attracted considerable attention. Besides expression of specific cell-surface
markers, pDCs are distinguished by endosomal expression
of TLR7 and TLR9. TLR7 responds to microbial RNA
while TLR9 is triggered mainly by single-stranded viral or
bacterial DNA. However, TLR9 can also respond to selfDNA if the DNA is complexed with cationic lipids or proteins (336, 981). Even greater pDC activation seems to occur in systemic lupus erythematosis when complexed DNA
is presented to pDC TLR9 via FcRII receptors which bind
anti-DNA antibodies bound to DNA (980).
Activated pDC vigorously secrete type I interferons, especially IFN- and IFN-. Increased levels of type I interferons have been correlated with instability in human plaque
(441). Repeated injections of IFN- or IFN- increased atherosclerosis in hyperlipidemic mice (see TABLE 7). In vitro,
IFN- stimulates vigorous production of IFN- and TRAIL
(TNF-related apoptosis inducing ligand) by Th1 cells sufficient to kill VSMC. In addition, IFN- amplifies innate
immune responses by inducing upregulation of TLR4 on
conventional DCs, as well as their production of TNF-,
IL-12, and IL-23 (441).
The TLR9 response is particularly of interest because of the
potential for encounters with self-DNA and evidence that
excess pDC stimulation and production of type I interferons
are involved in autoimmune diseases such as systemic lupus
erythematosis and psoriasis as well as in atherosclerosis.
TLR9 responds quite specifically to nonmethylated, singlestranded viral or bacterial DNA oligomers containing cytidine-guanosine sequence motifs. These are referred to as
CpG oligodeoxynucleotides (ODNs), where p refers
to the phosphodiesterase bond between the deoxyribonucleotides. For example, one such CpG ODN used in a recent
study was 5-TCGTCGTTCCCCCCCCCCCC-3. The relevant CpG sequences are underlined. Various synthetic
ODNs with bonds other than standard phosphodiester
linkages are being studied as adjuvants for various vaccination protocols. Methylation of the cytosines greatly diminished but did not entirely eliminate responses of pDCs to
CpG ODNs, but reversal of C and G (that is GpC instead of
CpG) did essentially eliminate the TLR9 response (336).
Importantly, TLR9 reactivity was greatly increased when
CpG-containing ODN were complexed with the cationic
1447
On the basis of recent work, prelesional, intimal DCs include similar numbers of conventional and monocyte-derived DCs. Plasmacytoid DCs seem to enter into the intima
later as lesions progress (314). In fact, all studied DC subsets seem to proliferate or enter the plaque in increased
numbers as lesions advance. Conventional DCs proliferate
in response to the cytokine FLT3L which binds the DC
receptor FLT3 (FMS-related tyrosine kinase 3 where FMS
refers to feline McDonough sarcoma). Conventional DCs
do not respond to M-CSF. In contrast, monocyte-derived
DCs proliferate in response to M-CSF but not FLT3L. Thus
administration of FLT3L in test animals only promoted
proliferation of prelesional conventional DCs, and these
could be tracked by cell-specific markers. Importantly, KO
of FLT3 increased atherosclerosis along with a reduction of
Treg (314).
ever, there was also increased IL-10 and markedly greater

expression of the coinhibitory receptor T-cell immunoglobulin
3 (TIM-3), typically seen on exhausted Th1, Th17, and CD8
cells, but also seen on Treg (589). Yet, no change in Treg was
seen in the mice with long-lived DC. There was a 20 25%
decrease in total cholesterol to further complicate interpretation of the study. Overall, the effect on atherosclerosis was nil,
with no change in lesion size or macrophage area (595).
PAUL N. HOPKINS
protein cathelicidin antimicrobial peptide (CAMP) (981).
CAMP is the human protein; also known as LL37, it is
referred to in mice as cathelicidin-related antimicrobial protein (CRAMP). Neutrophil granules contain large amounts
of CAMP. CAMP also acts as a bactericidal protein on
human skin where it is expressed by keratinocytes. CAMP
and to a lesser extent other cationic proteins found in neutrophil granules bind the negatively charged phosphodiester backbone of DNA and protect it from rapid degradation by DNAses normally found in the extracellular fluid
(980). Nevertheless, specificity for nonmethylated CpG and
the C-G order persists even after CAMP binding (336).
When incubated with CAMP, even human leukocyte DNA
produced a substantial IFN- response in pDCs (980), but
this response was only about one-sixth as great as bacterial
DNA complexed with CAMP, since unmethylated CpG
motifs are relatively infrequent in mammals (336).
NETosis seems to require input from simultaneous activating

signals such as TLRs, Fc receptors, and cytokines such as IL-8,
with subsequent PKC activation and production of superoxide
by NADPH oxidase. NETs are not only bactericidal but provide both a scaffold and activation stimulus for intravenous
thrombus formation (558, 559). Indeed, exposure to purified
histones from disintegrated neutrophils was found to be sufficient for platelet stimulation. Interestingly, neutrophils from
SLE patients seem predisposed to form NETs. Recently, NETs
were found within and protruding from both mouse (439) and
human (1179) atherosclerotic plaques. Higher plasma defensin levels were associated with greater risk of subsequent cardiovascular events and carotid intimal thickness progression
in SLE patients (1890).
In high-fat-fed ApoE KO mice, neutrophils, NETs, CRAMP,
and pDCs were found in atherosclerotic plaques. In one study,
depletion of pDC with a monoclonal antibody to BST2 (bone
marrow stromal cell antigen 2, also known as CD317 or
PDCA-1) led to a 50% reduction in aortic root lesion area
(439). Administration of a CpG ODN or CRAMP/DNA complexes increased atherosclerosis together with serum IFN-
but only in mice that had not undergone pDC depletion. Furthermore, ApoE-deficient mice fed a high-fat diet developed
anti-double-stranded DNA antibodies in a pDC-dependent
1448
As noted above, DNA complexed with CAMP and other

granule proteins from NETs clearly activated pDCs. However, stimulation of pDC may have different outcomes.
Thus activation of pDCs through TLR9 is reported to be a
normal, physiological response to DNA released in membrane microparticles from apoptotic cells (1553). CpG
ODNs able to activate Th1 responses in some settings may
also promote immune tolerance through Treg with enhanced IL-10 production in other contexts (541, 2122).
Perhaps further understanding of these complexities may
help explain why in another study, depletion of pDC using
a different anti-BST2 antibody was reported to increase
carotid atherosclerosis induced by colar placement in
LDLR null mice. The investigators reported twofold increases in early atherosclerosis and threefold increases if
depletion was begun 4 wk after the start of Western diet
feeding. Similar increases were seen in the aortic root (376).
These changes were accompanied by increased Th1 proliferation and production of associated cytokines, possibly
due to the removal of indoleamine 2,3-dioxygenase (IDO),
which is found in pDC and which was shown to inhibit
CD4 cell proliferation (376). Why opposite results were
obtained remains puzzling but may be related to differences
in the models, the antibody used to deplete the pDC, and
possibly the stage of atherosclerosis (441). Possibly too,
immune responses in ApoE versus LDLR null mice may
have been markedly different.
Others have noted that pDC can promote Treg proliferation but also modulate Treg activity in a complex fashion
(597, 1360). Possibly related was a doubling of atherosclerosis in response to DC-specific KO of the TGF- type II
receptor which resulted in a decrease in pDC but enhanced
proinflammatory DC signaling with increased TNF-, IL12, and markedly increased cytokine production by all the
CD4 subtypes (1043).
B. Lipoprotein Retention and Modification

Human autopsy specimens clearly show lipoprotein entry
and retention in the intima preceeding macrophage infiltration (1279). Once partially activated macrophages enter the
subendothelial space, they encounter trapped lipoproteins.
In classical in vitro studies, unmodified LDL, which binds
essentially only the LDLR, did not cause foam cell formation due to LDLR downregulation once cellular cholesterol
stores were replete. However, oxidized or acetylated LDL
Neutrophils are not only a source of CAMP (or CRAMP in

mice), but also of extracellular DNA. Neutrophils undergo a
specialized, pathogen-induced form of cell death (NETosis)
that results in the ejection of a sticky meshwork of nuclear
chromatin (including DNA, histones, and HMGB1) together
with embedded cationic granule proteins including bactericidal permiability proteins, defensins, and large amounts of
CAMP (209). These structures are called neutrophil extracellular traps (NETs) and are a major part of the neutrophils
armamentarium against bacteria. Mast cells can also form
NETs; and NET-like structures can be ejected from some intact cells by utilizing mitochondrial DNA (209).
fashion. In the same study, BMT of CRAMP-deficient marrow

into LDLR KO mice reduced atherosclerosis by 52%. These
investigators also demonstrated pDCs in advanced but not
early human atherosclerotic lesions nor in control samples
(439). Another group has recently confirmed an apparently
proatherogenic role for pDCs in ApoE-deficient mice with
similar reductions in atherosclerosis following repeated injections of anti-BST2 (1108).

could promote foam cell formation as they were bound by
various scavenger receptors that were not downregulated.
Unmodified -VLDL was found to induce foam cell formation without the need for further modification (115, 214).
Since these studies, a number of additional LDL modifications, many without oxidation, have been shown to also
suffice for foam cell formation (1727). VSMC underwent
similar transformation into foam cells when presented with
modified lipoproteins or -VLDL.
1. LDL trapping by proteoglycans
To promote atherosclerosis, LDL and other lipoproteins must
remain trapped in the intima long enough for modification
and macrophage uptake. The importance of retention of LDL
by binding to proteoglycans in the intimal extracellular matrix
(particularly to those bearing chondroitin sulfate) was clearly
demonstrated by the decrease in atherosclerosis seen in mice
whose APOB lacked a proteoglycan binding determinant
(1638). Other proteoglycan binding sequences appear to be
present in APOB-48 as well (1732).
Perlecan, the most abundant heparan sulfate glycosaminoglycan in the artery wall, also appears to promote LDL retention,
at least acutely. It may also suppress VSMC proliferation
(1805). Heterozygous deficiency of perlecan (1880) or excision of perlecan exon 3 (1805) reduced atherosclerosis significantly. In contrast, transgenic overexpression of decorin, a
smaller proteoglycan, actually decreased atherosclerosis in
2. Lipoprotein modification by phospholipases

Atherosclerosis appears to be strongly promoted by certain
secreted phospholipases (sPLA2), particularly groups III
and V sPLA2 (1540). Group V sPLA2 seems to be the major
sPLA2 enzyme and is released by activated endothelial cells
(133, 134). Group IIa sPLA2 may also contribute but are
less active than the group V enzyme (1981). LDL modified
by group V sPLA2 aggregates binds more avidly to proteoglycans and is rapidly taken up into macrophages leading to foam cell formation. Accelerated atherosclerosis was
seen in LDLR KO mice when group V sPLA2 was overexpressed. Reduced atheroslcerosis was seen in mice with
bone marrow transplants from mice deficient in group V
sPLA2, suggesting macrophages or other leukocytes may
also be a source of this enzyme (186). Interestingly, sphingomyelin inhibits group V sPLA2 and is found in greater
concentration in ApoE KO lipoproteins, which were poor
substrates for group V sPLA2. Furthermore, atherosclerosis
in ApoE-deficient mice was not affected nearly as much by
group V sPLA2 KO as it was in LDLR KO mice. Sphingomyelinase treatment further increased the activity of group
V sPLA2 toward LDL. TGRL remnants that accumulate in
ApoE KO mice may already be sufficiently modified or may
not need any further modification to promote foam cell
formation (198). Still, ApoE KO mice fed an atherogenic
diet and overexpressing human group III sPLA2 had more
than a twofold increase in atherosclerosis (1540).
In contrast to the above, transplantation of bone marrow deficient in the group X sPLA2 (PLA2G10) more than doubled
atherosclerosis in the aortic sinus of LDLR-null mice. At the
same time, there was a decrease in the number of macrophages
but a marked increase in macrophage necrosis and a fourfold
increase in necrotic core size. Transgenic overexpression of
human PLA2G10 reduced plaque size 50%. Enhanced Th1
response with increased IFN- was seen with PLA2G10 deficiency and suppressed by transgenic overexpression while Th2
and macrophage IL-10 production was increased by
PLA2G10 overexpression (29). The authors suggested that the
nonspecific inhibition of all sPLA2 enzymes by varespladib
may have been responsible for the premature ending of a recent phase III trial for futility.
3. Electronegative LDL and secretory acid
sphingomyelinase
Secretory acid sphingomyelinase and lysosomal acid sphingomyelinase are derived from the same gene with different
posttranslational processing. Secretory acid sphingomyeli-
1449
The corpulent rat (lacking the leptin receptor, LEPR due to a

naturally occuring nonsense mutation) is hyperphagic, obese,
and highly insulin resistant. It is unique among rat models in
that animals develop atherosclerosis when fed a balanced-fat,
high-cholesterol diet (1519). The atherosclerosis is unusual as
there is abundant smooth cell proliferation together with foam
cells and the rats develop intra-arterial thrombi in various
vessels including the coronary arteries with resulting MI. Recently, cholesterol-fed corpulent rats were found to express a
2.8-fold increase in arterial wall biglycans and lengthened
heparan sulfate chains. In addition, there was increased production of lipoproteins collected from intestinal lymph upon
feeding that had an altered composition, being both larger and
cholesterol enriched. In carotid arteries perfused ex vivo with
test remnant lipoproteins, the corpulent rats arteries retained
2.5-fold more cholesterol. These differences were accompanied by a nearly fourfold increase in total ischemic myocardial
lesions by 32 wk of cholesterol feeding (1133). Fasting plasma
insulin strongly correlated with arterial wall biglycan. The
investigators noted that biglycan production by VSMC is increased by fatty acids, ANG II, and TGF-. Biglycan was also
noted to be increased markedly in a porcine model of type I
diabetes (1169). Biglycan is found together with LDL in human coronary arteries as well (1279). Increase in sulfation or
glycosaminoglycan chain length, as found in this corpulent rat
model, had previously been noted to cause greater lipoprotein
retention.
ApoE-deficient mice (37). In this model, decorin production

occurred primarily in the liver resulting in higher plasma
decorin. Decorin was noted to bind and inhibit TGF-, which
can stimulate VSMC to synthesize larger proteoglycans that
more effectively bind LDL (1055).
PAUL N. HOPKINS
nase is released by activated endothelial cells and other
lesional cells and has been implicated in LDL modification.
Importantly, sphingomyelinase produces ceramide in the
lipoprotein which promotes greater retention by proteoglycans and greatly promotes uptake and foam cell formation
for several lipoprotein types. Deficiency of acid sphingomyelinase in LDLR KO mice resulted in a 55% decrease in
atherosclerosis (417). Not only might sphingomyelinase be
important within the subendothelial space, but a fraction of
plasma LDL appears to carry substantial sphingomyelinase
activity. These LDL were also electronegative and carried
PAF-AH (also referred to as Lp-PLA2). Electronegative
LDL, when incubated in vitro, were shown to degrade their
own phospholipids, rendering them highly subject to aggregation and macrophage uptake. Such LDL could also activate inflammatory responses from various cell types (103,
1535).
seem unlikely to be an initial cause of macrophage activation (and perhaps not even a necessary one). Furthermore,
the LDL could be oxidized after it was taken up into the
macrophage and only become available for (re)uptake after
apoptosis or necrosis of the primary phagocyte. Unfortunately, standard mouse models of atherosclerosis are not of
much help in resolving the issue of myeloperoxidase involvement as mice express much lower levels of myeloperoxidase in their macrophages than seen in human lesions.
Furthermore, knockout of mouse myeloperoxidase does
not decrease atherosclerosis. However, overexpression of
human myeloperoxidase in the mouse macrophages does
increase atherosclerosis (1304). These considerations support the notion that myeloperoxidase is potentially
proatherogenic but redundant, as mouse atherosclerosis
can progress extensively in its absence.
5. Other chemical modification of LDL
4. Oxidatively modified lipoproteins
Despite mechanistic support for oxidation in atherogenesis,

human clinical trials with antioxidants have been resoundingly negative (particularly the larger and more recent ones)
(155, 1573, 1595). A possible reason for this apparent discrepancy may be, once again, redundancy. Here, the redundancy involves multiple possible lipoprotein modifications
that could all lead to foam cell formation. One additional
consideration may be important. The chemical oxidative
footprint found predominantly on LDL from human atherosclerotic plaque clearly points to myeloperoxidase as the
source of pro-oxidant activity (740). This would suggest
that activated macrophages and possibly neutrophils are
the main cause of such oxidized LDL. This brings into question the primacy of oxLDL (or even mmLDL) in activating
the macrophage in anticipation of foam cell formation,
since activated macrophages or neutrophils would have to
already be present in the lesion to initiate such oxidation.
While oxLDL generated by myeloperoxidase would undoubtedly be atherogenic and promote further foam cell
formation, as well as inflammation and apoptosis, it would
1450
Carbamylation is a recently recognized form of LDL modification that may be particularly important in renal disease
and smoking. A small fraction of urea can spontaneously
and reversibly form highly reactive cyanate, which can then
bind to lysine residues in proteins forming homocitrulline.
Many proteins are altered in uremia, but carbamylated LDL
from uremic patients or prepared in vitro were found to
activate endothelial cells primarily by way of LOX-1 (70
72). Furthermore, carbamylated LDL binds macrophage
SR-AI receptors and causes foam cell formation (1926).
Importantly, thiocyanate, which is markedly increased in
the plasma of cigarette smokers, can be converted to cyanate by myeloperoxidase, also leading to carbamylation.
Protein homocitrulline levels were found strongly related to
cardiovascular risk with an odds ratio of 7 8 in the top
versus bottom quartile (1926). Indoxyl sulfate is another
uremic toxin that can modify LDL which then may cause
endothelial activation and inflammation (832).
C. Uptake of Modified Lipoproteins and

Foam Cell Formation
1. Bridging molecules facilitate lipoprotein uptake
Lipoprotein lipase (LPL) secreted by macrophages can provide a nonenzymatic bridge between lipoproteins and proteoglycans and promote retention in the arterial wall and
increased atherosclerosis (as shown by bone marrow transplant studies with LPL deficient macrophages) (94). LPL
may also promote uptake into macrophages. Conversely,
endothelial cell LPL is protective, consistent with more active removal of triglyceride-rich lipoproteins and increased
HDL (1624). ANGPTL3 and ANGPTL4, which can inhibit
endothelial LPL, were proatherogenic in hyperlipidemic
mice. Hepatic LPL also appears to be protective since KO of
Fhx2, a corepressor of LPL production in the liver, was
protective (see TABLE 8).
Much has been written regarding oxidative modification of

lipoproteins. Certainly when oxidized by various methods,
including incubation with cultured endothelial cells (which
are generally at least partially activated in most in vitro
settings), LDL and other lipoproteins are taken up avidly by
macrophages with resultant macrophage activation, proliferation, and foam cell formation (1682). Some of these
effects are likely mediated by oxidation of phospholipids
(131). Oxidation of cholesteryl esters (721), changes to
APOB characterized by chlorination of tyrosine by myeloperoxidase, tyrosine cross-linking, and oxidative nitration
may be important as well (1304). Furthermore, oxidation
of HDL clearly impairs its antiatherosclerotic function
(1304). These and many other observations make a persuasive argument that oxidation of lipoproteins contributes to
atherosclerosis (739, 1682).

Endothelial lipase (EL, also known as LIPG for lipase G),
while usually associated with remodeling and reductions of
plasma HDL can also serve as a bridge to bind LDL to cell
heparan sulfated proteoglycans, promoting uptake of both
native and oxLDL followed by cholesterol accumulation in
macrophages (1444). EL KO in ApoE null mice reduced
atherosclerosis 70% (828). Human ApoE4 expressed in
LDLR KO mice promoted uptake of LDL into macrophages
and increased atherosclerosis. Secretion by macrophages
and VSMC of HSP27 was protective by apparently blocking uptake of modified lipoproteins via scavenger receptor
A (SR-A) (see TABLE 8).
2. Scavenger receptors take up modified lipoproteins
and -VLDL
Results from studies deleting scavenger receptors have been

quite varied. Some investigators reported reduced atherosclerosis upon deletion of the macrophage SR-A (1530,
1718) while others did not (654). CD36 knockout seemed
In addition to traditionally cited scavenger receptors as mediators of modified lipoprotein uptake, recent evidence
points to non-scavenger receptor uptake as potentially a
quantitatively more important pathway. LDL treated with
group V sPLA2 is taken up by macropinocytosis which is
mediated by syndecan 4. This process is accelerated by macrophage activation and can lead to foam cell formation
(318). Unbound native LDL can also be taken up in substantial quantities by this process. In general, macropinocytosis is upregulated by pro-inflammatory signaling, such as
TLR4 and Syk activation which can be mediated by oxLDL,
acetylated LDL, mmLDL, LDL treated by 15-LO, PMA
activation of PKC and PKC, cholesteryl ester hydroperoxides, oxysterol-binding protein-related protein 2
(ORP2), and even viruses. In contrast, LXR agonists, which
are anti-inflammatory, block macrophage fluid-phase uptake of LDL. Unlike uptake of oxLDL through scavenger
receptors, macropinocytosis is blocked by inhibition of
PI3K (956). Thus foam cells can clearly be formed independent of scavenger receptors. In a sense then, scavenger
receptor uptake of modified LDL may be considered yet
another example of redundant pathways.
D. Intracellular Cholesterol Homeostasis in

Macrophages
1. Extracellular peptides and intracellular signaling
affecting scavenger receptor expression,
lipoprotein uptake, and cholesterol efflux
Part of the activation repertoire of macrophages, and
probably VSMC, is an increase in surface expression of
scavenger receptors together with greater uptake of mod-
1451
Oxidatively modified LDL as well as some other modified

LDL and -VLDL are taken up by a variety of scavenger
receptors (654, 1422). These include the class A receptors
(AI, AII, MARCO, SRCL, SCARA5), class B receptors
(CD36, SR-B1), class C (dSR-C1; in Drosophila only), class
D (CD68; an endosomal receptor), class E (LOX-1, others),
class F (SREC-I, SREC-II), class G (SR-PSOX; also known
as CXCL16), class H (FEEL-1, FEEL-2; primarily bacterial
binding), and class I receptors (CD163; which binds hemoglobin/haptoglobin complexes). A number of these receptors bind acetylated LDL and especially oxLDL (SR-AI/II,
MARCO, SRCL, SR-B1, LOX-1, SREC-I, FEEL-1/2).
CD36 also binds VLDL and TGRL remnants. LOX-1 was
discussed previously in the context of endothelial activation
but also serves to promote foam cell formation. Of the other
receptors, only SR-A and CD36 have been studied extensively. Importantly, all these scavenger receptors bind alternative ligands which may reflect their physiological roles.
Thus scavenger receptors bind various bacteria, bacterial
LPS, lipoteichoic acid (LTA), microbial diglycerides, apoptotic debris, amyloid, and AGEs. Macrophages from mice
deficient in SR-AI/II bound AGE much less avidly. Also, the
mice were more prone to death from infection with Listeria
and particularly with HSV-1 infections (1718). Thus macrophage scavenger receptors play a major role in recognizing PAMPs and hence participating in innate immunity.
Later it was shown that SR-A is the main scavenger receptor
for group B Streptococcus and Streptococcus pyogenes but
could also bind Neisseria meningitidis, Staphylococcus aureus, and E. coli (654). Binding of CD36 can trigger inflammatory activation of NF-B and MAPK cascade signaling
by interactions with Src kinases (1230). Nevertheless, scavenger receptors can also play an important anti-inflammatory role in clearing apoptotic debris. Genetic manipulation
of these and other promoting pathways are reviewed in
TABLE 8.
to achieve greater atherosclerosis reductions (4574%)

(507, 958) while combined absence of SR-A and CD36 was
similar to CD36 deficiency alone (958). Yet, in another
study in ApoE KO mice fed a high-fat diet for just 8 wk,
either CD36 or SR-A deficiency modestly increased plaque
sizes in the aortic sinus while aortic plaque area decreased
(1231). This was observed despite 80 90% reductions of in
vitro oxLDL uptake and foam cell formation by macrophages lacking both SR-A and CD36 previously seen by the
same group. Differences in the length of the studies may
have contributed to the differences in study outcomes, but
ultimately, the discrepancies remain unexplained. It should
be mentioned that CD36 appears to act as a long-chain fatty
acid transporter in muscle, heart, and adipose to facilitate
uptake of fatty acids. In small intestine it facilitates chylomicron synthesis (629). Recently, intraperitoneal administration of a small molecule inhibitor of CD36 in LDLR and
leptin doubly deficient mice was reported to reduce serum
triglyceride levels by 50% and decrease atherosclerosis to a
similar extent (602). These studies suggest that effects of
CD36 KO may be more complex than originally envisioned
and difficult to predict.
PAUL N. HOPKINS
tein (PLTP), SCD-1, LPL, Mertk, IRF8, and SREBP-1c.
All of these genes (with the exception of SREBP-1c and
LPL) either facilitate cholesterol efflux or are otherwise
protective against atherosclerosis (see TABLE 8). IRF8 is a
transcription factor that increases expression of protective Arg1 (arginase 1) that helps form inflammation-resolving polyamines (see TABLE 8). Overexpression of
LXR increased net cholesterol transport from macrophages to the intestine, promoted intestinal non-bile
transintestinal cholesterol excretion (TICE), and reduced
liver fat while reducing atherosclerosis by 41% (1066).
Of note, LXR was not protective apparently because
when it is not bound by agonist it represses protective
ABCA1 and AGCG1, although it also decreases SREBP-1
expression (152).
One of the main controllers of macrophage cholesterol

homeostasis is the nuclear receptor LXR which combines
as a heterodimer with retinoid X receptor (RXR) to function as a transcription factor. Pharmacological activation
of LXR inhibits atherosclerosis while KO results in increased atherosclerosis (243, 1618, 1756). Roughly in
proportion to its levels, intracellular cholesterol is spontaneously or enzymatically (by CYP27) oxidized to oxysterols (such as 25- or 27-hydroxycholesterol). These
bind to and activate LXR. At the same time, all the PPAR
nuclear receptors bind various fatty acids and oxidized
fatty acid derivatives taken up with modified LDL, other
lipoproteins, and phagocytosed apoptotic cells. These
oxidized fatty acids, or possibly some unchanged fatty
acids, act as endogenous PPAR ligands. Some of these
pathways are illustrated in FIGURES 16 AND 17. Active
PPAR specifically induces LXR as well as CYP27, thus
amplifying the LXR response. When bound to ligand,
LXR dimerizes with RXR and increases transcription of
a number of genes involved with cellular cholesterol balance including NPC1/2 (Niemann-Pick type C 1 and 2
which are involved in cholesterol intracellular trafficking), ABCA1, ABCG1, ApoE, phospholipid transfer pro-
Nrf2, although seemingly highly protective in endothelial

cells, supports expression of CD36 and foam cell formation
in macrophages. Thus atherosclerosis was reduced in fatfed or chow-fed hyperlipidemic mice with Nrf2 KO (106,
1717). The recent finding that Nrf2 supports NLRP3 inflammasome formation (546) (see below) provides further
insight into the role of Nrf2 in atherosclerosis.
1452
Activation of PPAR also upregulates CD36 expression

(287), leading to both increased uptake of lipid through
CD36 but also increased LXR-mediated efflux of cholesterol to HDL or other acceptors, with an overall increase in
net cholesterol flux and reverse cholesterol transport. KO of
PPAR in hematopoeitic cells modestly increased atherosclerosis (287) while deletion of its coactivator, PGC-1,
had a neutral effect (1679). Adipocyte enhancer-binding
protein 1 (AEBP1) is a transcriptional repressor that downregulates LXR and PPAR activity in macrophages. AEBP1
overexpression in a BMT study resulted in greatly accelerated atherosclerosis in ApoE null mice (1116). Macrophages from AEBP1 transgenic mice showed reduced LXR,
PPAR, ABCA1, ABCG1, and IB with increased translocation of NF-B to the nucleus followed by increased IL-6
and TNF- expression.
ABCB4 (also known as P glycoprotein 3) transports phospholipids into bile, thereby facilitating biliary cholesterol
secretion, but is also present on macrophages. Foam cell
formation in ABCB4-deficient macrophages was greatly accelerated upon incubation with acetylated LDL due to increased activity of scavenger receptors. Neither cholesterol
nor phospholipid efflux to HDL was affected (1403). These
findings raise the question of whether other cholesterol and
phosphlipid acceptors might be equally important as HDL
in macrophage cholesterol homeostasis.
Finally, despite less inflammatory signaling, RIP2 deficiency
increased atherosclerosis apparently because RIP2-deficient
macrophages took up more lipid and increased foam cell
formation due to constitutively active TLR4/Syk signaling
ified lipoproteins and enhanced activity of ACAT to esterify free cholesterol derived from engulfed lipoproteins.
Several classically proatherosclerotic cytokines including
IFN-, TNF-, and IL-1 promote foam cell formation in
this manner. They also contribute to enhanced foam cell
formation by downregulation of cholesterol efflux
(1174). To this list of well-known proinflammatory cytokines was recently added the TNF-family cytokine
TNF-like protein 1A (TL1A) which binds to its receptor
death receptor 3 (DR3). Activation of DR3 signaling in
macrophages results in increased uptake of acetylated
LDL (AcLDL) and oxLDL, presumably by the observed
upregulation of SR-A, CD36, SR-B1, and LPL. Simultaneously, cholesterol efflux was diminished together with
suppressed secretion of ApoE and downregulation of
ABCA1 and ABCG1 transporters (1173). This coordinated induction of scavenger pathways together with
downregulation of cholesterol efflux pathways has become apparent in a number of studies. Opposed to these
effects (with essentially mirror image activities) are cytokines which block foam cell formation and favor cholesterol efflux. These include TGF- and IL-10 (1174) to
some extent, but more specifically IL-33 binding to its
receptor ST2L on macrophages (1175). Elevation of macrophage cAMP may also be part of this response as glucagon-like peptide 1 (GLP-1) binding to its Gs-coupled
receptor GLP1R as well as gastric inhibitory peptide
(GIP) with its Gs GPCR both decreased foam cell formation and atherosclerosis during prolonged administration (1271). The peptide salusin- also decreased foam
cell formation and atherosclerosis while salusin- had
opposing effects (see TABLE 8).

which promoted macrophage spreading and macropinocytosis (1012).
2. Intracellular lipid trafficking in macrophages and
foam cells
Macrophage lipid droplets are surrounded by several proteins including perilipin 1, ADRP (also known as perilipin 2
or PLIN2), TIP47 (tail-interacting protein of 47 kDa), and
S312 (1397). Cholesteryl ester stored in these droplets can
be hydrolyzed by several enzymes with neutral cholesteryl
ester hydrolase activity. These enzymes include neutral cholesteryl ester hydrolase 1 (NCEH1), cholesteryl ester hydrolase (CEH), and hormone-sensitive lipase (HSL); interestingly, all three were found to be protective against atherosclerosis (see TABLE 8). Free cholesterol released by these
enzymes appears to be efficiently removed from macrophages through ABCA1 and AGCG1 transporters (1908).
The recently identified niacin receptor GPR109A is a Gi
type GPCR expressed on the surface of macrophages, other
white blood cells, and adipocytes but not endothelial cells.
One physiological function in adipose may be suppression
of free fatty acid mobilization and stimulation of adiponec-
E. Macrophage Cholesterol Efflux and

Atherosclerosis
Because excessive free cholesterol is toxic to cells, several
means to deal with this substance are available. ABCA1 is a
large protein with multiple transmembrane domains that
forms homotetramers or higher-order oligomers and facilitates free cholesterol and phospholipid efflux to lipid-poor
apo A-1 (often referred to as pre- HDL for its electrophoretic mobility). The more recently identified ABCG1 functions as a homodimer and can promote cholesterol and
oxysterol efflux to larger, spherical HDL2 and HDL3 particles. Further details regarding the mechanism of efflux to
HDL and related signaling will be provided in the section on
HDL below (see sect. XE). APOA1 KO clearly increased
atherosclerosis (see TABLE 8). In contrast, overexpression of
APOA2, another HDL apoprotein, increased atherosclerosis in a particular mouse model that may not be relevant to
humans (see TABLE 8). APOA1 is generally regarded as
primarily produced in liver, but KO of the transcription
factor retinoic acid receptor-related orphan receptor
(ROR) resulted in markedly increased atherosclerosis and
a profound reduction in HDL due to reduction of APOA1
production in intestine, not liver (1132).
Both ABCA1 and ABCG1 appear to be important for macrophage cholesterol efflux and prevention of inflammatory
and cytotoxic effects of macrophage cholesterol overload
(1447, 1749). ABCA1 and ABCG1 expression are induced
by LXR. ABCG1 can also be induced directly by PPAR.
Activation of AMPK caused posttranslational stabilization
of ABCG1 mRNA and prevented foam cell formation. Atherosclerosis was decreased by oral administration of
AICAR, an analog of AMP that activates AMPK (1021).
IFN- and ANG II downregulate ABCA1 and promote
foam cell formation (1884).
ABCG4 can also be induced by LXR and promote cholesterol efflux from macrophages but appears to be most important in brain. ABCA5 can promote cholesterol efflux to
HDL and may also be protective against atherosclerosis
while ABCA7 had no effect on atherosclerosis (see TABLE
8). Net transfer of cholesterol to HDL through macrophage
SR-B1 appears minimal in mice, so its antiatherogenic effect
is less likely to involve cholesterol removal from foam cells
in mouse models (1908). SR-B1 can mediate protective intracellular signaling in endothelial cells after binding HDL,
and this requires the adapter PDZK1 binding to the intracellular domain of SR-B1. KO of either SR-B1 or PDZK1
1453
As macrophages take up modified LDL and TGRL remnants, cholesteryl ester in lysosomes is hydrolyzed by lysosomal acid lipase A (LIPA). Deficiency of LIPA promotes
atherosclerosis, possibly due to lysosomal damage and necrosis caused by excess lipid accumulation (448, 2124). The
action of normal LIPA releases free cholesterol which is
transported between cell organelles by NPC1/2. ApoE-deficient mice with NPC1 KO have worse atherosclerosis, and
interestingly, severe, spontaneous thrombosis. The cause of
the pro-thrombotic state was not clear (1940). Released free
cholesterol is esterified by acyl-CoA:cholesterol acyltransferase 1 (ACAT1) and stored in intracellular lipid droplets.
Cholesteryl ester (CE) droplets contribute to foam cell formation, and ultimately the size of plaques but appear to be
less problematic than excess free cholesterol which is cytotoxic. Accordingly, bone marrow deficiency of ACAT1 in
hyperlipidemic mice caused a marked increase in atherosclerosis (see TABLE 8), presumably due to accumulation of
free cholesterol. Nevertheless, deletion of the enzyme
Elovl6 (elongation of very long-chain fatty acids family
member 6) from macrophages in LDLR-null mice decreased
foam cell formation and atherosclerosis (1529). Elovl6 provides the preferred substrate to ACAT1 (mainly oleate) by
elongation of palmitate and palmitoleic acids to stearate
and oleate, respectively. Adipose differentiation-related
protein (ADRP), another protein required for lipid droplet
formation, also proved to be mildly proatherogenic (see
TABLE 8). In contrast, triglyceride droplets do appear to be
benign as bone marrow specific deletion of adipose triglyceride lipase (ATGL) led to massive macrophage triglyceride
accumulation but decreased macrophage activation and
less atherosclerosis (978).
tin release when GPR109A is bound by the endogenous

ligand -hydroxybutarate, a ketone body (1419). Interestingly, the antiatherogenic effects of niacin in LDLR null
mice were entirely dependent on bone marrow expression
of GPR109A and were present despite a lack of effect on
serum lipids (1087).
PAUL N. HOPKINS
increased atherosclerosis (see TABLE 8). These signaling effects of HDL are reviewed further in section XE. Macrophages also constitutively secrete ApoE which can act together with phospholipid as a free-cholesterol acceptor,
forming disks much like nascent HDL (2082). ApoE also
acts in efferocytosis as reviewed below.
ABCA1 and ABCG1 (and probably ABCA5) show compensation for one anothers deficiency while macrophage-specific knockout of both ABCA1 and ABCG1 clearly increased atherosclerosis (2054). These insights help explain
variable results seen with knockout of only ABCA1 or
ABCG1 (22). Hepatic ABCA1 expression may be most important in atherogenesis through preservation of newly secreted APOA1. This may be followed by rapid minimal
lipidation of pre- HDL before leaving the liver, perhaps in
the space of Disse (220, 1249). Without such lipidation of
nascent particles, lipid-poor APOA1 is rapidly eliminated
by the kidneys and HDL levels are extremely low, as in
Tangier disease patients (who lack ABCA1).
F. Whole-Body Reverse Cholesterol

Transport and Atherosclerosis
Assessment of in vivo whole-body reverse cholesterol transport in mice involves injecting macrophages loaded with radiolabeled cholesterol into the mouse peritoneum and tracking appearance of the cholesterol label in blood and feces (400,
1447). This methodology may provide insights into the role of
reverse cholesterol transport in atherogenesis and may help
explain a number of seemingly paradoxical findings. Thus
whole-body or hepatic SR-B1 deficiency increased HDL but
decreased reverse cholesterol transport through HDL and increased atherosclerosis. Conversely, overexpression of hepatic
SR-B1 lowered HDL but increased reverse cholesterol transport and inhibited atherosclerosis (400).
The enzyme lecithin-cholesterol acyl transferase (LCAT) esterifies free cholesterol in HDL in the plasma space and is
often considered a means of increasing the capacity of HDL
to accept more free cholesterol. Surprisingly, however,
LCAT overexpression increased atherosclerosis. Very high
LCAT actually impaired whole body reverse cholesterol
transport by decreasing availability of pre- HDL. Conversely, LCAT KO may decrease atherosclerosis in some
mouse models. Furthermore, in LCAT-overexpressing
1454
Another interesting example of potential complexities in reverse cholesterol transport is the role of PLTP (364, 1350).
PLTP is found in plasma associated with HDL and mediates
complex HDL remodeling. Excess surface phospholipid and
unesterified cholesterol that remain on TGRL remnants after
delipidation (as well as some from LDL) are transferred by
PLTP to HDL. In addition, PLTP causes fusion of smaller
HDL3, yielding both larger HDL2 and smaller spherical HDL,
pre- HDL, or free APOA1. ApoM may also interact with
PLTP in regeneration of pre- particles. High plasma or systemic PLTP activity appears generally atherogenic, perhaps
because increased generation of pre- HDL or free APOA1 in
plasma would cause greater renal loss of APOA1, resulting in
low HDL and decreased overall APOA1 availability. Wholebody PLTP deficiency in two models of hyperlipidemic mice
led to reduced production of VLDL and LDL and marked
reduction of serum lipids, together with reduced atherosclerosis (852). Lower systemic PLTP activity predicted by a genetic
score in humans was also associated with reduced coronary
risk (975). In contrast, PLTP released locally by macrophages
appears protective since PLTP physically interacts with
ABCA1 and pre- HDL to promote cholesterol efflux (1350).
Furthermore, PLTP interaction with ABCA1, even when the
lipid transfer activity is eliminated by a PLTP M159E mutation, stimulates JAK2 and anti-inflammatory STAT3 signaling
in macrophages (1891). Thus whole-body KO of PLTP in
LDLR/ mice was atheroprotective (presumably by preserving APOA1 generally as discussed above). However, transplant of bone marrow from PLTP/ LDLR/ mice into
PLTP/ LDLR/ mice further reduced atherosclerosis,
demonstrating the protective role for normal local expression
of PLTP by macrophages (1839). This model resolves a number of seemingly discrepant observations regarding PLTP
(364, 1840, 1856). Interestingly, PLTP also binds and inactivates bacterial LPS, and PLTP-deficient mice tolerate endotoxemia poorly. The anti-inflammatory effect of PLTP may also
be important in regard to multiple sclerosis, as lower PLTP
activity was associated with more active disease (1891).
X. PROGRESSION OF ATHEROSCLEROSIS
A. Features of Unstable Plaques: Challenges
With Animal Models
As noted in the introduction, this phase of atherogenesis has
to do with growth of complex plaques, plaque rupture, and
subsequent thrombosis with precipitation of acute ischemic
Surprisingly, HL KO decreased atherosclerosis in ApoEdeficient mice (1204). HL is most active toward intermediate-sized lipoproteins, hydrolyzing both TG and phospholipid in larger HDL and in IDL (intermediate density lipoproteins). Even though HL/ ApoE/ mice had much
higher total cholesterol and -VLDL, they also had higher
HDL-C. Furthermore, HDL from ApoE/ are severely impaired in promoting efflux from cultured cells and HL deficiency partially restored this capacity.
mice, transgenic expression of cholesterol-ester transport

protein (CETP) appears to facilitate reverse cholesterol
transport and decrease atherosclerosis even though plasma
HDL-C is decreased (1447). In other studies, CETP expression in mice promoted reverse cholesterol transport with a
requirement for a functional LDLR for final delivery of
cholesterol to the liver (1757).
Silastic cuff placement around the carotid artery accelerates

atherosclerosis (1886). Ligation followed by cuff placement
on a carotid artery results in stenosis, rupture, and thrombosis in ApoE-deficient mice (1539). Endothelial activation
by disrupted flow likely accelerates atherogenesis and susceptibility to thrombosis in these models (1299, 1301). Hyperlipidemic SR-B1 and PDZK1 KO mice develop coronary
stenosis and MI (2034). Coronary occlusion occurred frequently in ApoE KO mice lacking CD59, an inhibitor of
later stages of complement activation and formation of the
membrane attack complex (1985). Fibrillin-1 (FBN1) haploinsufficiency leads to plaque instability and rupture
(1857). Coronary stenosis and MI was frequent in ApoEdeficient mice overexpressing urokinase-type plasminogen
activator (uPA) in macrophages (354). Effects on atherosclerosis of these and other studies, frequently using a combination of interventions or double KO models, are reviewed in TABLES 9 AND 10 and will be reviewed in more
detail below.
In human pathological studies, vulnerable plaque is characterized by greater cholesterol content, greater numbers of
activated macrophages and foam cells especially in the
shoulder area, increased markers of apoptosis, a thin fibrous cap, decreased collagen content, and more inflammatory activity including matrix metalloproteinase (MMP) expression. These features lead to rupture or fissuring in the
fibrous cap in 60 75% of cases of sudden death in humans (935). There is exposure of the highly thrombogenic
plaque substance to blood and precipitation of acute thrombotic events (351, 386, 1882). Approximately 25 40% of
acute coronary events in humans can be attributed to
thrombus formation on erosions (areas of endothelial cell

loss but without rupture) (935). More recently, markers of
red blood cell infiltration, hypoxia with release of hypoxia
inducible factors (HIF), and plaque penetration with vaso
vasorum have been related to enlargement of lesions and
instability (1162, 1644, 1826, 1882).
Abrupt crystallization of free cholesterol has recently been
proposed as the immediate precipitant for most acute obstructive events (4). Distinct volume expansion occurs with
cholesterol crystallization, possibly providing the underlying force to precipitate fissures or frank rupture of the fibrous cap (3, 1870). Typical tissue preparation techniques
use ethanol for fixation which dissolves cholesterol crystals
and eliminates their visualization. When pathological specimens were air dried, virtually all lesions associated with
acute coronary events were seen to have cholesterol crystals
penetrating through to the vessel lumen while none were
found in autopsy controls (4).
B. Macrophage and Smooth Muscle Cell

Trafficking and Proliferation
In a very basic sense, in order for plaques to increase in size,
become complex, and threaten acute coronary events, macrophages and/or VSMC must either continue to move into
the growing plaque or proliferate or both. These fundamental issues will be examined in this section.
1. Macrophage trafficking in atherosclerotic lesions
High lipid content in human plaques is one of the strongest
correlates of instability (511). All measures of plaque vulnerability including macrophage content and activation, indices of apoptosis, MMP activity, and collagen content are
improved rapidly in animal studies when plasma lipid levels
are reduced by change in diet (24, 26, 27, 927) or by statins
(25, 566, 1532).
Extensive egress of foam cells was seen within days of transplanting atherosclerotic vessels from genetically hyperlipidemic mice into wild-type mice (1810, 1962). This egress was
dependent on signaling in foam cells through the CCR7
chemokine receptor and could be blocked by antibodies
against the natural ligands to CCR7, namely, CCL19 and
CCL21. Furthermore, expression of CCR7 was increased
by LXR agonists and greatly impaired by genetic LXR deficiency (508).
Despite these fascinating results from transplant studies,
more recent studies with quantitative assessement of
macrophage entry and egress rates employing monocytes
labeled with latex beads revealed that macrophage recruitment and entry into the plaque is by far the most
important determinant of the number of macrophages in
a plaque (1434). These studies were performed using a
1455
events such as MI. While animal models of these processes

still have limitations, much progress has been made (837,
1300, 1576). Several models of complex plaque have been
developed and are being used in contemporary studies (see
TABLE 9). High-fat feeding of ApoE-deficient mice leads to
plaque ruptures in the brachiocephalic artery (857). A related but less widely recognized or utilized model is the
ApoE2 knock-in mouse which closely mimicks human type
III hyperlipidemia. These mice develop lesions with fibrous
caps, necrotic cores, and cholesterol clefts (1703). LDLRdeficient mice can be additionally engineered to only express APOB-100 by deletion of APOB editing catalytic
polypeptide 1 (APOBEC1) causing absence of APOB-48
expression. These mice have marked LDL elevations without requiring additional high-cholesterol, high-saturated
fat diets and develop severe, complex lesions (1121, 1534).
Mice with combined LDLR and ApoE deficiency suffer extremely accelerated atherosclerosis and experience spontaneous MI which may be related to endothelin signaling as a
precipitating event (242). Akt1 (PKB) deficiency in ApoEnull mice results in accelerated atherosclerosis with pronounced VSMC and macrophage apoptosis, friable fibrous
caps, and spontaneous MI (520).
PAUL N. HOPKINS
Table 9. Genes related to further plaque growth, progression of advanced atherosclerosis (54 genes tested)
Gene
ATM
p53
Rb
Kip1 (CDKN1B)
CDKN2B
MTAP
PDGF-B
LRP1
% A
Function, Comment
Macrophage and VSMC proliferation

1244%
Whole body ATM KO mice also had increased body fat, higher blood
pressure, glucose intolerance, and insulin resistance. ATM
apoE/ had intermediate atherosclerosis. BMT resulted in 80%
increased atherosclerosis but with no metabolic effects (1561).
Similar results reported by another group (1195).
1101%
Increased macrophage proliferation was seen in p53 KO, not
p53/ apoE/
increased apoptosis (669). Similar results with apoE Leiden mice
(1862). Others report normal p53 expression in atherosclerotic
plaques limits plaque size by promoting apoptosis of macrophages
while protecting VSMC and stromal cells from apoptotic death
(1194).
Cre-lox macrophage p53/
NS
No change in lesion size but less macrophage apoptosis and fewer
in apoE/
cholesterol crystals in plaques (164).
Macrophage-specific Cre-Lox
151%
Macrophage Rb KO resulted in increased lesion size with more
Rb/ in apoE/
macrophages (163).
Kip1/ apoE/
1483%
Kip1 (CDK interacting protein also known as p27 or p27Kip1) is a
cell-cycle inhibitor by inhibiting CDK (cyclin-dependent kinases).
Macrophage and VSMC proliferation seen in Kip1 KO, but also
thicker fibrous caps. Intermediate increase for Kip1 apoE/
(424). Somewhat lesser increases in lesions but more
inflammation seen in Kip1/ BMT to apoE/ (425). Kip1
requires Ser10 phosphorylation for normal suppression of cell
proliferation. Ser10Ala mutation leads to increased
atherosclerosis with increased ROCK activity (571)
CDKN2A / apoE/
170%
CDKN2A (cyclin-dependent kinase inhibitor 2A) encodes INK4a (also
known as p16INK4a) and ARF (also known as p19ARF) through
alternative reading frames. Less macrophage apoptosis seen
(636). Bone-marrow deficient in INK4a did not affect
atherosclerosis (1982), suggesting ARF had the greater effect,
consistent with another study showing reduced VSMC and
macrophage apoptosis and increased atherosclerosis with ARF
deficiency (636).
CDKN2A/ BMT into
126%
The modest increase in atherosclerosis was accompanied by
LDLR/
increase in classically activated M1 macrophages (Ly6Chi) and
greater tissue accumulation presumably due to reduced INK4a
and especially ARF expression. Reverse BMT showed that arterial
wall expression of INK4a and ARF did not affect atherosclerosis
(962). Another study found decreased lesion size with CDKN2A
KO but no effect of heterozygosity in apo*E Leiden mice. CDKN2B
and MTAP expression were markedly upregulated in CDKN2A KO
mice (908). No effect was seen for ARF KO in that study.
CDKN2B/ in apo*E3
NS
Encodes INK4b. Variable compensatory effects in CDKN2A genes
Leiden transgenic mice
and MTAP were seen making interpretation difficult (908)
MTAP/ in apo*E3 Leiden
1163
MTAP (methylthioadenosine phosphorylase) loss or inactivity is
transgenic mice
associated with several tumors. MTAP is located near the
9p21.3 locus. (908)
PDGF-B/ fetal liver cells
NS
Only a temporary delay in VSMC accumulation and fibrous cap
transplant into irradiated
formation was seen. Macrophages more inflamed. Similar results
apoE/
seen with blockade of PDGFR signaling (945).
VSMC-specific LRP1/ Cre11510%
LRP1 (LDL receptor-like protein 1) is a transmembrane co-receptor
Lox in LDLR/ mice
that appears to target the PDGF receptor, PDGFR, for
lysosomal degradation. Increased aneurysm formation also seen.
With high-cholesterol, high-fat feeding mice generally died in 2 mo
with aortic and mesenteric atherosclerotic obstruction (191).
macrophage-specific LRP1/
1147%
Plaques had more macrophages and fibrosis (790). Similar results
Cre-Lox in mice with either
in LDLR KO mice with LRP1/ BMT (1362). Major effect may
LDLR/ or apoE/
be due to loss of LRP1 mediation of efferocytosis when activated
by apoE with much larger necrotic cores in LRP1/ LDLR/
mice (2016). BMT studies suggest macrophage LRP1 inhibits
apoptosis whether or not apoE is present (2017).
LRP1 internalization defective knock-in also had a 49% increase in
atherosclerosis (643). Hepatocyte-specific LRP1 deficiency was
atherogenic independent of effects on plasma lipids (489).
ATM/ apoE/
Continued
1456
CDKN2A
Model
Table 9.Continued
Gene
Model
% A
RAP/ LDLR/ with

chronic ANG II infusion
LRP5
LRP5/ apoE/
LRP6
LRP6 R611C in a human

pedigree
PKG
VSMC-specific CreLox PKG/

in apoE/
231%
TRAIL
TRAIL / apoE/
126%
TAGLN
VSMC-specific CreLox
TAGLN/ in apoE/
128%
DDR1
DDR1/ LDLR/
260%
CLU
CLU/ apoE/
252%
232%
1350%
11,000%
RAP (receptor associated protein) is an important chaperone for

LRP1 (and other receptors), escorting LRP1 from the ER to the
Golgi and simultaneously blocking premature ligand binding,
allowing effective delivery of LRP1 to the cell surface. RAP
deficiency generally leads to impaired LRP1 expression (1045).
The unexplained paradoxical decrease in atherosclerosis cited
here was shown not to be mediated by any bone marrow derived
cells and occurred despite elevations in LDL, VLDL, and probably
chylomicron remnants (1910).
Increases in TGRL remnants complicates interpretation. Potential
for Wnt signaling in VSMC was not examined (1113).
Risk estimated from report of Iranian pedigree (see text) (1134).
Later study showed the R611C LRP6 variant impaired targeting
of PDGFR for lysosomal degradation in VSMC (896).
PKG (cGMP-dependent protein kinase, also known as PRKG1 or
cGKI) can facilitate VSMC proliferation, migration, and PKB
signaling in VSMC. About 55% of VSMC cells showed effective
conditional elimination of PKG in this study and these selectively
remained in the media rather than migrating to the intima
(1972).
TRAIL (tumour necrosis factor-related apoptosis inducing ligand)
can have pro- or anti-apoptotic/proliferative effects depending on
concentration and context. Shown are results at 8 wk. By 12 wk
the effects was NS. TRAIL can support VSMC proliferation but
little difference in VSMC seen in lesions (1930).
TAGLN (transgelin, also known as SM22 or SM22) is an actin
binding protein expressed in vascular and other SMC. Increased
atherosclerosis here was associated with increased proliferation
of VSMC with activation markers (509). VSMC in SM22 KO mice
had increased NF-B activation upon carotid arterial injury with
greater adhesion molecule expression possibly related to greater
ROS production associated with cytoskeletal disruption (1614).
DDR1 (discoidin domain receptor 1) is a receptor tyrosine kinase
that recognizes triple helical collagen types I, VI, and VIII. In
VSMC, type I collagen binding to DDR1 inhibits collagen and
elastin synthesis as well as VSMC proliferation. In monocytes,
differentiation into macrophages is promoted together with
production of inflammatory cytokines. Plaques in DDR1/ mice
were smaller and had fewer macrophages through 24 wk (as
shown) and had more collagen and elastin at 12 wk (538).
CLU (clusterin) is also known as apo J and is found on HDL. CLUdeficient mice showed less VSMC proliferation with a reduction in
Egr-1 and TNF- (701).
Macrophage inflammation related to lipid accumulation, perpetuation of inflammation

STAT1
STAT1/ BMT into apoE/
245%
NLRP3
NLRP3/ BMT to LDLR/
269%
ASC
ASC/ BMT to LDLR/
270%
CASP1
CASP1/ apoE/
240%
STAT1 induced transcription for CD36 but not by the SR-A

scavenger receptor (15). Plaque apoptosis and necrosis was
greatly decreased (1047).
Activation of the NLRP3 inflammasome by cholesterol crystals leads
to formation of oligomers of NLRP3, ASC, and caspase 1 which
can then cleave pro-IL-1 (or pro-IL-18) to active cytokines.
NLRP3/ BMT animals have lower plasma IL-18 as well (452).
No effect in apoE KO mice or for caspase 1 deficiency (1193).
ASC (apoptosis-associated Speck-like protein containing a CARD
[caspase-associated recruitment domain]) is an essential adapter
protein in the NLRP3 inflammasome linking NLRP3 to proCASP1. Virtually identical reduction in atherosclerosis seen in IL1/ KO BMT (452). No effect in apoE KO mice (1193).
CASP1 (caspase 1) forms part of the NLRP3 inflammasome as
noted above. Reduction in atherosclerosis seen in ascending
aorta, not aortic arch and was accompanied by a reduction in IL1, IL-18, IFN-, and MHC-II-bearing cells (575).
Continued
1457
RAP
Function, Comment
PAUL N. HOPKINS
Table 9.Continued
Gene
% A
Function, Comment
AIF-1
VSMC-specific Tg in C57BL/6
fed Paigen diet
1151%
iNOS
iNOS/ BMT in apoE/
247%
S100A9
S100A9/ apoE/
225%
AIF-1 (allograft inflammatory factor 1) is a calcium- and actinbinding, cytoplasmic scaffold protein that may promote complex
formation with multiple signaling proteins including G proteins
such as Rac1 (1652). Increased expression of AIF-1 also leads to
greater phosphorylation of Akt, Erk1/2, and p38. Endothelial AIF1 promotes angiogenesis. Both macrophage and VSMC
expression of AIF-1 is increased in human plaques and by
incubation with oxLDL. AIF-1 promotes proliferation, migration,
and phagocytic activity in these cells. Whole body AIF-1
transgenic, apoE-null mice had a 20% increase in atherosclerosis
(1216).
Also known as NOS2. Shown are results in males.
Proatherosclerotic effects of iNOS appear to be primarily related
to leukocyte expression. iNOS was shown to produce both NO and
superoxide in the lesions (1430). iNOS deletion in normolipidemic
mice appears to cause hyperlipidemia and increase
S100A9 (also known as myeloid-related protein 14) stabilizes
S100A8; S100A9 KO leads to undetectable S100A8 as well.
SA100A8/9/12 are calgranulins which can act as TLR4 and
RAGE agonists. S100A9 KO macrophages had reduced cytokine
production in response to LPS (356) but VSMC (or endothelial)
production may be relevant as well (see S100A12 below). No
effect seen with S100A9/ BMT into LDLR/ (88)
S100A12
S100A12 vascular VSMCspecific Tg in apoE/
140%
Leptin
ob/ob apoE/
244%
VSMC-specific overexpression of human S100A12. Plaques showed

greatly increased calcification, ROS, and NOX1 activity (773).
Lep (leptin) deficiency decreased atherosclerosis only after 12 wk
with possible early increase of fatty streaks at 4 wk. The ob/ob
apoE/ mice had less fibrous lesions with fewer VSMC at 16
wk. Exogenous leptin increased atherosclerosis in apoE/ mice
(306). Mechanism was unclear. Increased hyperlipidemia and
atherosclerosis was seen in ob/ob LDLR/ mice (730).
Macrophage ER stress and apoptosis

/
FABP4
FABP4
248%
FABP5
FABP5/ BMT into apoE/
236%
CHOP
CHOP/ apoE/
235%
XBP1
Spliced (active) XBP1 Tg aorta

transplanted into apoE/
Bax
Bax/ BMT in LDLR/
BMT into apoE
1837%
149%
FABP4 (fatty acid binding protein 4) is found in macrophages as

well as adipocytes. Also known as aP2 (adipocyte protein 2).
Reduction in atherosclerosis with FABP4 deficient macrophages
(1122) was later shown to be likely due to reduced ER stress
(484).
FABP5 (fatty acid binding protein 5) is also known as Mal1 and
expressed at about equal molar ratios as FABP4 in
macrophages. Reduced macrophage activation seen with
decreased PPAR signaling (95). Combined FABP4/5 deficiency
decreased atherosclerosis similarly to FABP4 deficiency but with
greater improvement in insulin resistance and increased longevity
(178).
CHOP (C/EBP homologous protein) is a key mediator of apoptosis in
prolonged ER stress. Plaque necrosis decreased 50% and
apoptosis 35%. Similar results in LDLR KO (1789). In BMT
experiments, presence of CHOP in macrophages led to much
greater caspase 3 activation (a marker of apoptosis) and 4 times
more plaque rupture. LDL-derived unesterified cholesterol can
trigger ER stress (1819). Other studies suggested vascular wall
and particularly endothelial CHOP expression may contribute
importantly to atherosclerosis with CHOP-deficient endothelial
cells expressing less MCP-1 and VCAM-1 (587).
Inactive, unprocessed XBP1 (X-box binding protein 1) mRNA is
spliced by IRE1 during ER stress. Spliced XBP1 mRNA is
translated to an active transcription factor with multiple effects
depending on degree and duration of the signal (2060). ER stress
found in areas of disturbed flow (329, 1213, 1729).
Bax (Bcl-2-associated X protein) activation promotes apoptosis. Bax
KO mice had much less macrophage apoptosis in early lesions
which were therefore larger (1060).
Continued
1458
Model
Table 9.Continued
Gene
Model
Bcl-2
macrophage-specific Bcl-2
deletion (Cre-Lox) in
apoE/ mice
AIM
AIM/ LDLR/
% A
Function, Comment
NS
Bcl-2 (B-cell leukemia/lymphoma 2) inhibits apoptosis. More

macrophage apoptosis was seen in lesions generally. Increased
necrosis and cholesterol crystal formation seen in larger lesions
(1790). Overexpression of Bcl-2 in macrophages led to increased
lesion size early in atherogenesis but smaller lesions at a later
stage (596).
AIM (apoptosis inhibitor expressed by macrophages, also known as
CD5L) is induced by oxLDL through LXR/RXR. Deletion of AIM
promoted early macrophage apoptosis in lesions (74).
273%
Macrophage efferocytosisgeneral
HMGB1 neutralizing antibody
to apoE/
255%
Fas
Fas/ apoE/
170%
FasL
FasL/ apoE/
Mertk
Mertk/ BMT into LDLR/
Gas6
Gas6/ apoE/
Mfge8
Mfge8/ BMT into LDLR/
171%
TG2
TG2/ BMT into LDLR/
122%
APOE
ApoE/ BMT into C57BL/6

fed butter fat diet cholate
TLR3
TLR3/ apoE/
1207%
166%
NS
1892%
140%
HMGB1 (high-mobility group box protein 1) is a DNA binding protein

which, when released from necrotic cells (for secreted from
various activated cells) acts as a pro-inflammatory,
chemoattractant danger signal to surrounding cells or
phagocytes, possibly acting through RAGE, TLR2, and TLR4
(878).
These mice (lpr strain) show a lupus-like autoimmunity. Greater
apoptosis was seen in lesions which correlated with serum IgG
(517). Both increased apoptosis and impaired clearance of
apoptotic bodies seen. Similar results were seen in LDLR KO
mice transplanted with bone marrow from lupus-susceptible mice
(1676).
Another lupus model (gld strain). threefold increase in
macrophages and T-cells seen together with more apoptotic cells
and reduced efferocytosis (73).
Mertk (Mer receptor tyrosine kinase) interacts with Gas6 to
promote efferocytosis (473). Increased apoptosis and
inflammation in lesions in KO seen (32). Kinase defective (KD)
Mertk in apo E deficient mice showed more nonmacrophageassociated apoptotic cells, consistent with defective efferocytosis
(1788).
Gas6 (growth arrest specific gene 6) recognizes phosphatidylserine
on damaged cells and bridges with Mertk. Mice with Gas6
deficiency surprisingly had more fibrous, less inflamed plaques
with increased TGF production (1095). These findings may be
due to role of Gas6 to (through receptors Mertk, Tyro3, and Axl)
promote outside-in signaling in platelets (65).
Mfge8 (milk fat globule-EGF factor 8, also known as lactadherin)
bridges phosphatidylserine on apoptotic cells with the V3/5
integrin on phagocytes, promoting efferocytosis. Results at 8 wk
shown. Greatly increased apoptotic debris and markers of
apoptosis as well as formation of necrotic core seen in Mfge8 KO
mice (31).
TG2 (transglutaminase 2) also cross-links with integrin V3/5 and
promotes efferocytosis. More plaques with large necrotic cores
seen (166).
There was no difference in serum lipids in this model. Mice
transplanted with WT cells had very little atherosclerosis (502). A
later study showed greatly impaired efferocytosis in Apo E
deficient macrophages (652). Apo E also acts with ABCA1 and
ABCG1 receptors to promote cholesterol efflux and limit
monocyte and neutrophil precursor proliferation (1258). Apo E
signaling through macrophage VLDLR or APOER2 also promotes
macrophage conversion from M1 to the less inflammatory M2
phenotype (99).
May possibly relate to anti-inflammatory effects of efferocytosis.
Effect seen at 15 wk but became NS by 30 wk. TLR3 (Toll-like
receptor 3) detects double-stranded RNA (from viral replication)
but dsRNA did not mediate effect in this study. TLR3 ligation may
increase IL-10 secretion and expression of PDL1 and PDL2
(coinhibitory receptors) (339). Mild effect recently confirmed in
LDLR KO mice (1484).
Continued
1459
HMGB1
PAUL N. HOPKINS
Table 9.Continued
Gene
Model
% A
Function, Comment
Macrophage efferocytosis in relation to complement system

/
PTX3
PTX3
CRP
CRP/ in LDLR/ and

apoE/ mice
ADIPOQ
human ADIPOQ-adenoviral
overexpression in apoE/
mice
C1qa/ LDLR/
C1qa
apoE
150%
NS
230%
1238%
C3
C3/ LDLR/
C5
C5def/def apoE/
C6
C6def/def cholesterol-fed
rabbits
281%
C3aR1
C3aR1/ apoE/
234%
DAF
DAF/ LDLR/
CD59
CD59/ apoE/
130%
265%
1100%
NS
1159%
149%
more physiological model of adenoviral delivery of ApoE

into ApoE/ mice to rapidly normalize lipid levels. CE
content of plaques dropped within 2 wk followed by a
marked reduction in macrophage recruitment rates into
the plaques and greatly reduced macrophage content by 4
wk. Macrophage egress did not change over this period
and was quantitatively minimal while apoptosis rate continued steadily in both the newly normolipidemic mice
versus their counterparts with continuing hyperlipidemia. Furthermore, the reduction in macrophage content
did not depend on CCR7 as in the previous transplant
study. It was thought that adventitial inflammation from
1460
transplantation of the vessel may have somehow accelerated macrophage egress in that model, a condition
thought to be much less relevant to the usual human
situation. Thus, rather than coaxing faster macrophage
egress from plaques, lipid normalization leads to marked
reduction in macrophage recruitment as the main means
to effect plaque regression. These findings also suggest
that slowing monocyte/macrophage entry into lesions
would be an important means to facilitate regression.
As alluded to earlier in this review, apoptosis of macrophages early in plaque development seemed to minimize
CFB
MBL A/C/ BMT into

LDLR/ mice
CFB/ LDLR/ with chronic
intraperitoneal LPS
administration
MBL
PTX3 (pentraxin 3) can bind to apoptotic cells and promote

efferocytosis (opsonization function) (1317, 1663).
CRP (C-reactive protein) can also act as an opsonin. This was the
first CRP KO study. It included a large number of mice with both
LDLR/ and apoE/ backgrounds. The CRP/ apoE/
males actually had a significant (63%) increase in aortic root
lesion size. No group showed decreased atherosclerosis (1778).
Acute overexpression of human ADIPOQ (adiponectin) decreased
lipid droplets and macrophage SR-A in plaques and decreased
endothelial VCAM-1 (1339).
Shown are data from mice fed a regular chow diet. High fat feeding
increased lesions greatly but differences between C1qa groups
became nonsignificant. Lesions in C1qa deficient mice showed
much more apoptosis (140).
MBL (mannose-binding lectin) isoforms A and C were expressed in
early, not later lesions (1159).
CFB (complement factor B) is part of the alternative pathway.
Chronic LPS caused marked complement consumption and
presumably activation of later components with cell damage
(1124). Little effect without LPS is consistent with prior
observations (1409).
Lesions had more macrophages, fewer VSMC, and less fibrosis
(229). Similar results seen with combined apo E and LDLR KO
mice (1409).
Mice had a naturally occuring C5 deficiency (1393). C5a present in
human coronary lesions and induces macrophage MMP1 and 9
(1664).
These rabbits had a naturally occuring defect in C6 activity. Results
from 1st aortic cross-section given. (1557). Markedly decreased
(by 63%) atherosclerosis also seen in C6/ apoE/ mice
(1017)
C3aR1 is a so-called anaphylatoxin receptor for C3a. On endothelial
cells it mediates increased permeability in small vessels and
promotes oxidative burst in macrophages (1663, 2026).
DAF (decay accelerating factor, also known as CD55), found on
endothelial and blood cells, promotes decay of C3 and C5
convertase activity. Effect more apparent on low fat diet. DAF KO
lesions had fewer membrane attack complexes (MAC) and more
VSMC (1010). No effect was seen in DAF/ apoE/ (60).
CD59 blocks MAC formation. Humans have one CD59, mice have
2, termed mCD59a and mCD59b. These mice were mCD59a
and b deficient. Antibody inhibition of C5 decreased lesions as
well (1985). Similar but variable results in other studies (60,
1017, 2052).
Table 10. Plaque destabilization, thrombosis, and precipitation of acute events (46 genes tested)
Gene
Model
% A
Function, Comment
Matrix metalloproteinases (MMPs) and related

macrophage-specific MMP1
transgenic in apoE/
232%
MMP2
MMP2/ apoE/
249%
MMP3
MMP3/ apoE/
1343%
MMP7
MMP7/ apoE/
27%
MMP9
MMP9/ apoE/
1122%
MMP12
MMP12/ apoE/
252%
MMP13
MMP13/ apoE/
NS
MMP14
MMP14/ BMT into LDLR/
NS
TIMP1
TIMP1/0 apoE/
NS
TIMP2
TIMP2 adenoviral gene transfer at

7 wk in apoE/
260%
TIMP3
macrophage-specific TIMP3 Tg in
LDLR/
248%
CatK
CatL
CatK/ apoE/
CatL/ LDLR/
242%
277%
CatS (CTSS)
CatS/ LDLR/
230%
Cst3
Cst3/ apoE/
NS
Also known as collagenase. Mice do not possess a MMP1 homolog.

Over-expression of MMP1 decreased plaque size and collagen
though without rupture (1001).
Smaller plaque size seen but much greater reduction in VSMC than
macrophages with thinner fibrous cap (966)
Also known stromelysin-1. MMP3 activates other MMPs. Lesions
from MMP3 KO mice were not only larger but had fewer VSMC
and showed greater instability (860). Consistent with prior
findings of larger plaques but the MMP3 KO mice had fewer
aortic aneurysms (1633). MMP3 also appears necessary for
outward remodeling (47).
No significant change in lesion size or stability seen despite 78%
increase in VSMC (860).
Also known as gelatinase B. KO resulted in increased plaque size,
fewer VSMC, more macrophages, and apparent decreased
plaque stability (860). Overexpression of a self-activating form of
MMP9 did result in plaque disruption, however (648). In
moderate to advanced lesions, adenoviral expression in plaques
led to plaque neovascularization and intraplaque hemorrhage
(396).
In MMP12 KO mice, plaques had 2.5-fold more VSMC and a 53%
decrease in macrophage content as well as decreased overall
size. Plaques were also more stable (860). Other studies suggest
MMP12 is critical for macrophage migration. Selective inhibition
decreased plaque as well (859).
No difference in size or cellular composition but increased plaque
collagen (402).
Similar phenotype to MMP13 KO with increased plaque collagen
(1560).
TIMP1 is on the X chromosome. Female TIMP1 KO were generated
then male offspring lacking TIMP1 were used for studies. TIMP1
KO had no effect on lesion size but gelatinase activity was greater
with increased medial lamina ruptures (1002). Others showed
similar results (858, 1632).
Apparent arrest of atherosclerosis progression seen. Marked
decrease in apoptosis, macrophages, and buried fibrous caps,
with increased VSMC and fibrous tissue (858).
Macrophage-specific overexpression of TIMP3 reduced
atherosclerosis at 16 and 24 wk. Necrotic core was greatly
reduced and collagen content was increased. TIMP3 inhibits
ADAM17 as well as MMP2/9/14 (262).
Cathepsin K (1094).
Cathepsin L. Required for angiogenesis and presumably vaso
vasorum formation. Degrades extracellular matrix elastin and
collagen. Deficiency results in impaired VSMC, macrophage, and
T-cell migration (917).
Cathepsin S3 is one of the most potent elastases known. Deficiency
reduced macrophage, VSMC, lipid, and collagen content of
plaques. In vitro migration of macrophages impared (1701). May
also prime LDL for further modification by sPLA2-V and soluble
sphingomyelinase (1421).
Cst3 (Cystatin C), a cysteine protease inhibitor, is an endogenous
inhibitor of cathepsins. Cyst C KO did not affect lesion size but led
to plaques rich in collagen. However, there was evidence for
greater elastin degradation and progressive aortic dilation
(1700).
Continued
1461
MMP1
PAUL N. HOPKINS
Table 10.Continued
Gene
Model
% A
Function, Comment
Clotting factors and related

/
vWF
LDLR
240%
ADAMTS13
ADAMTS13/apoE/
160%
TF
TF/ apoE/
TF/ BMT into LDLR/
TFPI
TFPI/ apoE/
129%
Factor II
F2/ apoE/
244%
Factor V
F5 Leiden (equivalent) apoE/
157%
Factor VIII
PAR1
F8/ apoE/
PAR1/
240%
PAR2
PAR2/
PAR3
PAR3/
PAR4
TM
PAR4/ apoE/
TMPro/Pro apoE/
Protein C
PC/
Fibrinogen
Fbg/ apoE/
NS
Plasminogen
Plg/ apoE/
1620%
NS
NS
167%
Lesions in vWF/ were particularly less frequent at the usual

branch point locations. ApoE KO vWF/ mice showed a similar
early reduction in atherosclerosis but the protection did not
persist at later time points (1200). vWF could also be considered
an initiating factor since its adherence to athero-prone endothelial
sites can promote platelet adherence with subsequent endothelial
activation and leukocyte adherence (806){Gandhi, 2012 #48589.
ADAMTS13 is made in liver and by endothelial cells. Its only known
substrate are ultra large multimers of vWF. This form of vWF is
released from Weibel-Palade bodies and promotes platelet
adhesion which can, in turn promote monocyte and other
leukocyte adhesion (584).
Complete TF (tissue factor) deficiency is embryo lethal. There were
no differences in extent or composition of plaques in either model
(1794). A SMC Cre-Lox KO model showed reduced injury-induced
thrombosis, but possible effects on atherosclerosis have not yet
been reported (1902).
TFPI/ is embryonic lethal (as is tissue factor KO). TFPI/ mice
showed slower thrombus formation after photochemical injury to
plaques. Only carotid and iliac atherosclerosis was significantly
more extensive (shown is aortic atherosclerosis) (1949).
Homozygous FII (prothrombin) deficiency is embryonic lethal. About
50% reduction in plasma prothrombin seen with more stable
plaque in F2/ apoE/ mice (182).
Plaques were larger but had smaller necrotic cores, thicker fibrous
caps, more VSMC, fewer macrophages, and fewer ruptures
(1581).
Much less fibrin in lesions (899).
Tendency for increased neointimal formation after carotid injury
(305). PAR1 (protease-activated receptor 1) is not expressed on
mouse platelets as it is in humans (1120). It is also a target of
activated protein C.
Decreased neointimal thickness after arterial injury (1768) PAR2 is
expressed on endothelial cells and various leukocytes. May be
activated by factors VIIa and Xa while thrombin activates all other
PARs (1, 3, 4) (1120). Activation by trypsin caused endothelial
activation, ROS generation, and lymphocyte adhesion (1046,
1120).
Mice protected against thrombosis. Atherosclerosis not tested
(1939).
No effect at any site despite protection from thrombosis (703).
TM (thrombomodulin) proline mutation impairs activation of protein
C and increases thrombin activity. TM mutant mice had larger
nonobstructive plaques but they were more stable (1581). No
effect on atherosclerosis with human TM knock-in with defective
protein C activation (1451).
Increased inflammation of intimal proliferation with copper/silicone
arterial cuff model (265)
No difference at 31 wk. Slightly smaller lesions in Fbg/ mice were
seen at 22 wk (1992). Fbg overexpression had no effect in apo
E3-Leiden mice (1481). An 81% reduction in lesion size was seen
for fibrinogen deficiency in human Lp(a) transgenic mice (1078)
while a 15% increase in aortic lesion size were seen in LDLR//
APOBEC1/ mice (835).
Plasminogen may be protective in artery wall since fibrinopeptides
generated by plasmin may actively signal to VSMC to generate
anti-inflammatory TGF (1993). In another model, with scavenger
receptor promoter-driven macrophage over-expression of uPA,
plasminogen appeared pro-atherogenic and plasminogen KO
decreased atherosclerosis, though animals with uPA overexpression had much more atherosclerosis (948).
Continued
1462
vWF
Table 10.Continued
Gene
Model
Function, Comment
Advanced lesions were particularly decreased while there was an

increase in very early lesions in tPA (tissue-type plasminogen
activator) KO. Less collagen seen. tPA may be a VSMC mitogen
(1480). Slight increase in injury-induced carotid stenosis seen in
tPA-deficient (1549).
Whole body uPA (urokinase-type plasminogen activator) deficiency
had no effect on atherosclerosis in the aortic root (408, 1480)
but increased plaque size in some other areas and decreased
plaque stability (408). Macrophage-specific over-expression in
apoE/ mice increased plaque (142%) and greatly increased
coronary lumen narrowing with 62% stenosis in transgenics
versus just 2.6% in controlswith many myocardial infarctions and
early mortality (354). Later studies showed uPA over-expression
effect was dependent on plasminogen and could be evoked by
BMT into older apoE/ mice (789, 948). BMT with uPA KO led
to less atherosclerosis only in older mice with established lesions
(953). Generated plasmin can activate MMPs leading to fibrous
cap rupture and intraplaque hemorrhage (789).
2-AP (2-antiplasmin) is the main physiological direct plasmin
inhibitor. No effect on neointimal formation after electrical injury
to the femoral artery was seen (1044).
HCF2 (heparin cofactor 2) is an endogenous thrombin inhibitor. It is
also known as serpin D1. The ability of HCII to block thrombin is
greatly increased by dermatan sulfate or heparin. Besides larger
plaques, animals showed greater VSMC proliferation after
mechanical artery injury (1876). Similar results shown with
heterozygous deficiency (23).
tPA (PLAT)
tPA/ apoE3-Leiden
270%
uPA (PLAU)
uPA/ apoE3-Leiden
NS
2-AP
2-AP/
HCF2
HCF2/ apoE/
FBN1
FBN1 C1039G/ apoE/
HPS1
pale ear mice fed Paigen diet
172%
HPS3
HPS3/ apoE/ after FeCl3induced arterial injury
265%
HPS4
HPS5
light ear mice fed Paigen diet

maroon mice fed Paigen diet
253%
245%
HPS6
ruby-eye mice fed Paigen diet
259%
164%
1179%
FBN1 (fibrillin-1) haploinsufficiency due to this mutation can cause

Marfans (865). Cross with apoE KO leads to increased plaque
size and instability with frequent plaque rupture in advanced
lesions with cerebral infarction (1857).
HPS1 (Hermansky-Pudlak syndrome 1, the gene corresponding to
pale ear mouse) is a transmembrane protein in the BLOC-3
complex required for normal biogenesis of lysosome-related
organelles, including melanosomes and platelet dense granules
(801). HPS1 patients have a bleeding diathesis as well as occularcutaneous albinism and ceroid storage disease (which can result
in pulmonary fibrosis and granulomatous colitis). Mice were
congenic with C57BL/6 which served as control. Despite
abnormal platelet function, atherosclerotic lesions were larger
though area involved was not different in this strain (1370).
HPS3 (cocoa mouse) has platelet dysfunction but is otherwise
milder than other forms of HPS. Given here is the reduction in the
intima/media ratio (remodeling) 21 days after carotid injury
induced by surrounding the artery for 3 min with filter paper
soaked in 5% FeCl3. The HPS3/ mice also had greatly reduced
acute thrombus formation immediately after the injury (912).
HPS4 (light ear mouse) had reduced lesion area and size (1370).
HPS5 (ruby-eye 2 or maroon mouse) had reduced lesion area and
size (1370).
HPS6 (ruby-eye mouse) had reduced lesion area and size (1370).
Vaso-vasorum and angiogenesis related

VEGF
VEGF adenoviral gene transfer into

LDLR/ / ApoB-48-deficient
mice
NS
Adenoviral gene transfer of VEGF-A, -B, -C, or D with transient

strong plasma elevations had no effect on lesions (1008). A prior
study had shown marked increase in lesion area after a single
injection of human recombinant VEGF into apoE/ mice and
rabbits (266).
Continued
1463
% A
PAUL N. HOPKINS
Table 10.Continued
Gene
Model
Function, Comment
Placental growth factor (PlGF) is a VEGF homologue and acts

through its receptor VEGFR1. It promotes angiogenesis but also
causes macrophage proliferation. Given are results at 10 wk. By
25 wk a nonsignificant 13% reduction in mean plaque area was
seen, suggesting VEGFR1 signaling may only be important in early
stages of atherosclerosis. Adenoviral over-expression increased
lesions (903). Expression is increased by several inflammatory
signals including ANGII, possibly through NF-B signaling (1374).
VEGFR1 is also known as Flt1 (fms-like tyrosine kinase 1) is a
receptor tyrosine kinase that appears to mediate the proatherogenic, angiogenic signaling of PlGF but also binds VEGF-A.
Anti-VEGFR1 (1097) treatment decreased atherosclerosis in apo
E null mice. The extracellular domain can be generated separately
by alternative splicing and is found in plasma as a soluble factor
(sFlt-1). sFlt-1 acts as an endogenous inhibitor of PlGF. Reduced
levels of sFlt-1 were found in renal disease and were associated
with more human CAD. Infusion of sFlt-1 in 5/6 nephrectomized
apo E null mice decreased atherosclerosis (1347).
Mice treated for 8 wk on high fat diet (691). Increased adventitial
vascularity. Also 153% increase with GM-CSF injections in same
study. See Table 7 for GM-CSF.
nAChR1 (nicotinic acetylcholine receptor 1) mediates
angiogenesis induced by nicotine (which also promotes plaque
progression) and urokinase (2069). Endothelial cells store
acetylcholine and could be an autocrine source of activation
(992).
PlGF
PlGF/ apoE/
241%
VEGFR1
anti-VEGFR1 antibody in apoE/
250%
G-CSF
G-CSF sq injections into apoE/
1100%
nAChR1
Aortic RNAi knockdown of

nAChR1 in apoE/
242%
PAI-1
PAI-1/ apoE/ or LDLR/
113%
rPAI-123 intraperitoneal injections

in LDLR/ and ApoB-48deficient mice
273%
Hp
human Hp 2-2 Tg in apoE/
NS
HAMP
adenoviral HAMP Tg in carotid

artery of apoE/
NS
Col18a1
Col18a1/ apoE/
167%
Endostatin
Endostatin subcutaneous
injections into apoE/
285%
Angiostatin
Angiostatin subcutaneous
injections into apoE/
231%
PAI-1 (plasminogen activator inhibitor 1) KO had a nonsignificant

effect (1637). No effect of PAI-1 KO in apo E3-Leiden mice
(1480). Another group reported significantly increased
progression of advanced plaque in PAI-1 KO (1096).
rPAI-123 is a cleavage product of PAI-1 shown to be a major
stimulus of plaque angiogenesis. Intraperitoneal injections begun
at 14 wk and atherosclerosis measured at 14 and 20 wk. Shown
is reduction compared to control mice at 20 wk. Lesions in
treated mice at 20 wk were actually smaller than mice at 14 wk
and showed a 49% reduction in cholesterol content compared to
control, 20-week mice (446).
Hp (haptoglobin) binds hemoglobin and facilitates uptake of the
complex via the CD163 scavenger receptor. Related to
phagocytosis of Hgb from extravasated RBC. Only humans
express the Hp 2 allele which has been associated with much
lower stimulation of IL-6 and IL-10 by phagocytosing macrophages
in vitro as compared to Hp 1 (668). While there was no
difference in atherosclerosis extent, plaques in mice engineered
to express Hp 2-2 had more macrophages, iron, and lipid
peroxidation products, suggesting a greater potential for instability
(1013).
Extracellular HAMP (hepcidin antimicrobial peptide) binds the
plasma membrane iron transport ferroportin and promotes its
internalization and degradation causing retention of intracellular
iron. While plaques were not larger, they showed increased
inflammatory markers and vulnerability. (1025)
Col18a1 encodes collagen XVIII. Increased angiogenesis was seen
in the Col18a1 KO mice (1242).
Shown is the decrease in progression of already advanced lesions
(started at 20 wk) (1241). Endostatin is a naturally occuring
angiogenesis inhibitor derived from the carboxy terminal fragment
of collagen XVIII found in vascular extracellular matrix.
Shown are absolute differences 75 days after angiostatin injections
were began at 32 wk (1243). Angiostatin is a proteolytic
fragment of plasminogen and a natural angiogenesis inhibitor.
References are given in parentheses.
1464
% A

subsequent plaque growth, whereas increased apoptosis in
more advanced plaques may saturate removal mechanisms
for apoptotic cells and promote growth of lesions and
greater inflammation. Direct evidence for this hypothesis
comes from a study in ApoE-deficient mice with transgenic
overexpression of the antiapoptotic protein Bcl-2. At 5 wk,
lesions were larger and contained more macrophages while
by 15 wk, lesions were actually smaller and fewer macrophages were present (596). This principle of early apparent
benefit but long-term harm from increased macrophage apoptosis harmonizes a number of apparently contradictory
findings (1863).
In advanced lesions, both macrophages and VSMC proliferate. A series of newer studies have demonstrated interesting biological features of pathways controling cell
proliferation, but their direct clinical relevance to human
atherosclerosis remains somewhat uncertain. In general,
genetic manipulations resulting in greater macrophage
and VSMC proliferation typically increase plaque size,
but with regard to VSMC, such plaques may be more
stable. Also, proliferation is often accompanied by protection from apoptotic signals. In early atherosclerosis,
greater apoptosis generally leads to smaller plaques.
However, in advanced disease, increased apoptosis can
overwhelm efferocytosis pathways, promote secondary
necrosis, and lead to increased inflammation with unstable plaques. Pathways related to control of proliferation
are reviewed in the following paragraphs.
Cell replication is initiated by extracellular growth factors that signal to ultimately stimulate the transcription
of cyclin D together with a reduction of specific cyclindependent kinase (CDK) inhibitors (136). In general,
CDKs bind cyclins and then phosphorylate other proteins
to promote specific steps through the cell cycle. Cyclin D
binds CDK4/6 and remains high throughout the cell cycle
while discrete waves of other cyclins peak at specific
phases of the cycle. Presiding over this system is the transcription factor p53, whose elevation leads to increased
production of CDK inhibitors, other proteins that inhibit
the cell cycle, DNA repair enzymes, and proapoptotic
proteins. In its role, p53 has been dubbed the guardian
of the genome.
To replicate, the cell must pass through a series of checkpoints that are controlled by a series of serine/threonine
kinases known as checkpoint kinases. Ataxia telangiectasia
mutated (ATM) is a major checkpoint kinase that is central
to a network of proteins that control cell replication, energy
production, protein synthesis, autophagy, and apoptosis
(126, 1461). The kinase activity of ATM is controlled by
ROS and surveillance proteins which bind double-stranded
breaks in DNA and recruit and activate ATM. ATM then
phosphorylates and activates ChK1/2 (checkpoint kinases 1
and 2). These phosphorylate the transcription factor p53,
thereby inhibiting p53 ubiquitination and degradation.
ATM also directly phosphorylates and protects p53 and
phosphorylates LKB1 (liver kinase B1). Besides AMP or
ADP, LKB1 is the main activator of AMPK. Active phosphorylated LKB1 binds to the AMPK regulatory subunit,
rendering the AMPK subunit susceptible to other activating phosphorylation (45).
Active ATM and increased p53 generally limit cell growth
and mitogenesis while their reduction will promote proliferation. Accordingly, reduction of ATM promoted athero-
1465
A newly recognized function of ApoE relates to proliferation and mobilization of monocytes and neutrophils.
Several models of hyperlipidemia, including cholesterol
and saturated fat-fed pigs, rabbits, and especially ApoEdeficient mice are accompanied by pronounced monocytosis and neutrophilia. Monocytosis was also pronounced in mice with combined deficiency of the ABCA1
and ABCG1 receptors which are involved in export of
free cholesterol from various cell types. The monocytosis
in these mice was related to cell membrane accumulation
of free cholesterol, increased lipid raft formation, and
hypersensitivity to the proliferative effects of the GMCSF (also known as IL-3) receptor (CSF2RB) in hematopoietic stem cells, with CSF2RB ligation leading to ERK
and STAT5 activation (1258). Further studies in ApoE
KO mice fed a Western-type diet showed that the threeto fourfold increase in blood neutrophils and monocytes
was due to impaired cholesterol efflux from hematopoietic stem cells. Quiescence of these cells was normally
maintained by cholesterol efflux and controlled plasma
membrane cholesterol content through LXR-dependent
production of ApoE, ABCA1, and ABCG1. ApoE is normally released from the cell and bound to cell surface
heparan proteoglycans where it can immediately interact
with ABCA1 and ABCG1 transporters to promote cholesterol efflux. Treatment with heparinase impared this
pathway and promoted proliferation through increased
GM-CSF receptor activity leading to intracellular STAT5
and ERK activation. In ApoE-deficient mice, high doses
of a recombinant HDL having high cholesterol mobilization capacity (with APOA1 and phospholipid but no cholesterol) could also suppress proliferation. Interestingly,
transplant of ApoE-deficient bone marrow cells into
LDLR KO mice led to greater hematopoeitic cell proliferation, leukocytosis, and proportionately increased deposition of monocytes into atherosclerotic lesions despite
similar cholesterol levels (1258). Thus the monocytosis
of ApoE-deficient mice may directly contribute to the
rapid development of atherosclerosis in these animals.
These studies may provide additional insights into previously noted increased risk of CAD associated with higher
leukocyte and especially monocyte counts noted in epidemiologic studies (340, 378).
2. Control of proliferation: relationship to

atherosclerosis
PAUL N. HOPKINS
sclerosis with increased macrophage proliferation (and
JNK activation). In contrast, chloroquin, which activates
ATM, reduced atherosclerosis but only in ATM/
ApoE/ mice (1561), an effect that also required p53
(1465).
Prior to initiation of G1 (growth phase 1), hypophosphorylated Rb (retinoblastoma gene) sequesters the transcription dimer E2F/DP which is needed for transcription
of genes required in the G1 phase of cell replication,
thereby blocking growth and proliferation. At the beginning of the cell cycle, CDK4/6:cyclin D and CDK2:cyclin
E complexes hyperphosphorylate Rb which then releases
E2F/DP, allowing the cell to enter G1 (570). Macrophage
Rb KO resulted in increased lesion size with more macrophages (163).
Single nucleotide polymorphisms (SNPs) within the

9p21.3 locus have been the most consistently identified
gene variants associated with CAD in human GWAS
(776). Associations are also reported with atherosclerotic
stroke, peripheral artery disease, and aneurysms. The 3
portion of ANRIL (antisense noncoding RNA in the
INK4 locus) is the lone occupant of the 9p21.3 atherosclerosis association region. Nearby are the CDKN2A
(INK4a, ARF), INK4b, and methylthioadenosine phosphorylase (MTAP) genes. The proximity of 9p21.3 to
CDK inhibitor loci and the fact that several of these genes
are frequently deleted in a variety of tumor types lead to
early speculation that the 9p21.3 locus affects atherosclerosis by somehow controlling cell proliferation.
ANRIL is one of several long, noncoding RNA now described. While not encoding a protein, these segments of
DNA are transcribed by RNA polymerase II into RNA and
then spliced into various isoforms with many of the splicing
variants being polyadenylated. The RNA products of ANRIL
seem to direct the assembly of two polycomb protein
repressive complexes that are involved in methylating and
ubiquitinating histones to repress and maintain repression
of targeted genes. The control of splicing and isoform ex-
1466
The promoter region of ANRIL is rich in binding sites for

multiple enhancers. Importantly, several of the disease-associated alleles in the 9p21.3 region are located within these
enhancer regions. For example, STAT1 binds to the ANRIL
promoter where two human CAD-associated variants occur which impair STAT1 binding (717). In endothelial cells,
STAT1 normally increases transcription of ANRIL followed reduced expression of CDKN2B. However, very different effects can be seen in other cell types (349). Furthermore, ANRIL expression can affect the expression of numerous other genes that may be involved in atherogenesis
(347). This findings and the fact that mice do not have a
locus entirely orthologous to ANRIL make many animal
studies difficult to interpret.
Several human studies find reduced expression of ANRIL in
association with CAD, carotid atherosclerosis, or CADassociated 9p21.3 variants, but effects on proliferation of
various cells are quite variable (348, 775, 856, 1063). One
group reported that the type I interferon IFN21 was elevated 10-fold in human carriers of the at-risk alleles (55).
Another group reported increased expression of ANRIL
exons 15 in lymphocytes and greater DNA methylation of
INK4b in CAD patients and associations with a major
9p21.3 allele (2115). In primary cultures of human VSMC,
at-risk 9p21.3 alleles were associated with decreased ANRIL
long transcript expression together with a reduction in
INK4a and INK4b expression resulting in greater proliferation. Observations in human coronary plaques were consistent with these in vitro findings, with at-risk alleles being
associated with increased VSMC content. It was pointed
out that these results were consistent with prior studies
suggesting decreased expression of the ANRIL long transcript in association with at-risk 9p21.3 alleles while short
ANRIL transcripts were actually increased and suppressed
CDKN2A/B products and promoted proliferation (1239).
However, a recent report from the Framingham Heart
Study reported reduced ANRIL short isoforms in lymphocytes in association with at-risk variants (856). These reports are, as yet, difficult to reconcile.
In mice, transplant of bone marrow cells with heterozygous deficiency of CDKN2A (with its two products
INK4a and ARF which inhibit proliferation) was sufficient to modestly increase atherosclerosis (by 26%).
Only bone-marrow derived cells with the CDKN2A deficiency affected atherosclerosis. Mice heterozygous for
the defective gene showed an increase in the proportion
of classically activated, circulating monocytes (Ly6Chi)
as well as increased proliferation of activated macrophages (962). How these and other results in mice (see
A series of CKI (CDK inhibitor) proteins can bind to and

inhibit multiple CDKs throughout the cell cycle and cause
cell cycle arrest. Some of the more extensively studied CKIs
include Cip1 (also known as p21Cip1), Kip1 (also known as
p27Kip1), INK4a (inhibitor of kinase 4a, encoded by the
gene CDKN2A, also known as p16INK4a), ARF (alternate
reading frame, also known as p19ARF and encoded by
CDKN2A), and INK4b (encoded by CDKN2B, also known
as p15INK4b). ARF also inhibits MDM2 (mouse double minute 2 homologue) which is an E3 ubiquitin ligase that targets p53 for proteasome destruction. Thus active ARF both
directly causes cell cycle arrest as a CKI and promotes accumulation of p53 which also blocks replication and can
promote apoptosis.
pression and the gene targets are likely cell- and conditionspecific. Among the targets of these repressive complexes
are the CDKN2A/B loci (349).

TABLE 9) relate to the human 9p21.3 associations with
CAD remains to be fully demonstrated.
3. Newer insights into the role of VSMC in

atherosclerosis
VSMC are among the first cells found in the intima in locations destined to become atherosclerotic plaques, presumably in response to PDGF-BB produced initially by activated endothelial cells in regions of disturbed flow. Beyond
being a source for extracellular matrix and collagen, in an
activated, secretory state VSMC can elaborate chemokines
including MCP-1 and CX3CL1 (fractalkine), as well as adhesion molecules (VCAM-1, ICAM-1) which attract and
then capture macrophages within the intima. VSMC can
synthesize and secrete pro-inflammatory cytokines including IFN-, IL-1, IL-6, and IL-18. They can alter the extracellular matrix to further promote inflammation by producing fibronectin. They express various scavenger receptors
and take up modified lipoproteins to become foam cells
which can cause further activation. Thus VSMC can take on
characteristics of endothelial cells in recruitment of leukocytes, some of the functions of T-cells by producing cytokines to amplify the inflammatory response, and the properties of macrophages by conversion to foam cells and elaboration of similar cytokines. More recently, VSMC have
also been observed to recapitulate additional functions generally attributed to macrophages, such as efficient phagocytosis of apoptotic cells with secretion of inflammation-resolving (although pro-fibrotic) cytokines including PDGF
and TGF- (438).
On the basis of the above results, antiapoptotic signaling in

VSMC (and macrophages) might be expected to limit
atherogenesis through promotion of efficient efferocytosis.
Antiapoptotic signaling by activation of PKB is a primary
result of intracellular signaling stimulated by several
growth factors. PKB (Akt1) KO caused thinning of fibrous
caps, plaque rupture, and spontaneous MI in ApoE-null
mice (520). Binding of IGF-I to its receptor IGF-IR (a typical receptor tyrosine kinase) results in activation of PKB in
a fashion essentially identical to the insulin receptor. Infusion of IGF-I into ApoE-null mice modestly reduced atherosclerosis, decreased vessel wall ROS (probably by PKB
phosphorylation and stimulation of eNOS), and reduced
macrophage infiltration into the vessel wall (1699). However, VSMC-specific overexpression of IGF-I did not alter
atherosclerosis burden, although it did increase plaque stability (1598). Knockout of macrophage IGF-1R resulted in
a substantial increase in atherosclerosis, suggesting a protective effect of IGF signaling in these cells (762).
These results contrast with the consistent increase in neointimal formation after arterial injury that generally accompanied augmented IGF-I signaling, illustrating some of the
major differences between atherosclerosis and vascular injury repair (763). However, excessive IGF-IR signaling may
actually increase atherosclerosis as illustrated by studies of
modified pregnancy-associated plasma protein A (PAPP-A)
expression (350, 722). PAPP-A is a metalloproteinase that
degrades IGFBP-4 (IGF-I binding protein 4), thereby increasing local IGF-I availability and signaling. (There are 6
IGFBP proteins, with various controls and feedback mechanisms, bringing substantial complexity to IGF-I signaling.)
Another growth factor, PDGF, provides only limited additional insights. PDGF signaling clearly promotes postinjury
neointimal formation, but its role in atherosclerosis is am-
1467
The notion of platelets releasing PDGF after adhering to

areas of denuded endothelium with PDGF then causing vascular VSMC proliferation was a central feature of the original formulation of the response to injury hypothesis
(1512, 1513). Since that time, the focus on more traditional
inflammatory cells has perhaps obscured the role of VSMC
in atherosclerosis. Recently, data were put forward to suggest that most proliferating or secretory VSMC may actually be derived from stem cells residing in the arterial media.
These stem cells appeared to differentiate into cells with a
smooth muscle cell phenotype only after activation and
transmigration into the plaque (1755). Others have demonstrated that, in response to proliferation and phenotype
switching cues such as PDGF and oxidized phospholipids,
VSMC can lose cellular markers to the point that they are
virtually indistinguishable from macrophages. Furthermore, macrophages can acquire some markers generally
assigned to cells of VSMC origin (633). Continued research
will undoubtedly refocus attention on the importance of
lesional cells with apparent VSMC phenotype. No distinction regarding the origin of lesional VSMC is made in the
following discussion, although this may become an issue of
great interest in future research.
VSMC are normally potent, effective phagocytes of apoptotic VSMC. This capacity of VSMC for avid efferocytosis has
been previously unappreciated. Studies in mice engineered
with inducible, VSMC-specific diptheria toxin receptor
provide new insights into an important role for VSMC in
advanced plaques as active phagocytes. Low-level diptheria
toxin administration to these mice resulted in apoptosis in
1% of VSMC, a rate similar to human plaques. In normolipidemic mice, this degree of apoptosis resulted in no
obvious inflammation. However, in the face of hyperlipidemia, normal phagocytosis of apoptotic VSMC by other
VSMC was severely impaired (332). Failed phagocytosis of
apoptotic VSMC by surrounding normal VSMC resulted in
secondary necrosis and markedly increased production of
inflammatory cytokines by necrotic VSMC (including IL1, IL-1), followed by greater IL-6 and MCP-1 production
by surviving VSMC (332). A twofold increase in atherosclerosis with impaired outward remodeling and increased stenosis ensued (331).
PAUL N. HOPKINS
biguous (63). PDGF actually consists of homo- or heterodimers of four different PDGF gene products (PDGF-A,
-B, -C, or -D) while receptors are homo- or heterodimers of
PDGFR and PDGFR. Frank deficiency of PDGF or
PDGFR genes is generally embryo lethal as these growth
factors are intimately involved in various stages of organogenesis. PDGFR signaling is complex, with multiple adaptors and effectors. PDGFR ligation is generally pro-proliferative and antiapoptotic (in part through PKB and ERK
activation) as well as anti-inflammatory and profibrotic. In
one study, transplant of PDGF-B-null fetal liver cells into
irradiated ApoE/ mice resulted only in a delay of VSMC
accumulation and fibrous cap formation without a change
in lesion volume (945). In addition, macrophages appeared
more inflammed or activated in the PDGF-B-null chimeric
mice.
LRP1 restraint of PDGFR signaling in VSMC is not fully

understood. LRP1 interaction with PDGFR may occur in
endosomes after internalization of the two receptors (1256,
1296). Activated PDGFR can tyrosine phosphorylate the
cytoplasmic tail of LRP1 (possibly with assistance from Src
and PI3K activity), followed by binding of ShcA, then Grb2Sos, and ERK activation (1256, 1296, 1744). LRP1 also
binds the ubiquitin ligase Cbl and may also modulate Cbl
ubiquitination of PDGFR and therefore its expression or
degradation (1744).
Excessive PDGF signaling in LRP1-deficient VSMC is accompanied by enhanced TGF- signaling. Normally, LRP1
forms a complex with and is thought to sequester TGF-RI,
thereby reducing signaling through the TGF-RI/II complex, diminishing phosphorylation of SMAD2. SMAD2/3
activation induces both PDGF and PDGFR expression
(193). Interestingly, the PPAR agonist rosiglitazone re-
1468
Another LRP, LRP6, may act similarly to restrain PDGFR

signaling. LRP6 is considered to be a canonical coreceptor
in Wnt signaling. However, both the rare LRP6 R611C
variant and wild-type LRP6 were also found to interact
with PDGFR. Unlike wild-type LRP6, the R611C variant
failed to target PDGFR to lysosomal degradation (identified as the predominant means of degradation, rather than
via the proteosome) with a result that PDGFR signaling,
including ERK activation, was markedly increased in the
presence of the R611C variant. These results may also serve
to clarify the role of LRP1. Presumably, both LRP1 and
LRP6 serve in VSMC to target PDGFR to lysosomes for
degradation, possibly by Cbl-mediated monoubiquitination. In these studies, R611C acted as a dominant negative
inhibitor of normal LRP6 activity. These results may explain the dominantly transmitted, severe atherosclerosis
seen in a family with the rare LRP6 R611C mutation/variant (1134). Carriers of the mutant LRP6 also had moderately elevated LDL-C (mean 170 mg/dl in affected versus 98
in noncarriers), mild hypertriglyceridemia, hypertension,
and diabetes, all without obesity. Premature osteoporosis
was also apparent. However, the severity of premature
CAD seemed out of proportion to these risk factors. A
remarkable 29 of 59 pedigree members had CAD with onset
prior to age 50 in men and 55 in women. Of the 29 with
CAD, 23 died of CAD at a mean age of 52, while pedigree
members without early CAD had a mean age of death of 81
(1134). This is similar to or even greater than the 10- to
20-fold excess CAD risk seen with untreated heterozygous
FH (781). LRP6 R611C also failed to facilitate Wnt signaling in VSMC, although these results could not explain the
excessive proliferation seen in vivo and in response to
PDGF (896). However, classical Wnt signaling, besides promoting proliferation, may also block apoptosis of VSMC
exposed to ROS, RNS, oxLDL, and inflammatory cytokines such as IL-1 and IFN- (1208). Whether defects in
Wnt signaling might further contribute to the pro-atherogenic effects of LRP6 R611C and LRP1 deficiency has apparently not been examined.
The second coreceptor in canonical Wnt signaling, LRP5,
has been studied in hyperlipidemic mice. Absence of LRP5
clearly accelerated atherosclerosis (a 3.5-fold increase in
aortic area involved in lesions). This increase may have been
out of proportion to the 60% increases in VLDL and
The LRP1 receptor has major effects on VSMCs. Interestingly, LRP1 can mediate uptake of aggregated LDL and
subsequent cholesterol accumulation in VSMC. Aggregated
LDL seems to stabilize LRP1 and increase its expression by
decreasing ubiquitin-mediated degration (240). VSMC-specific deficiency of LRP1 in LDLR-null mice resulted in thickening of the media, dilation of the aorta, aneurysm formation, and accelerated atherosclerosis (191). Importantly,
feeding VSMC-specific LRP1-deficient mice a high-fat,
high-cholesterol diet led to dramatically accelerated atherosclerosis with massive foam cell formation and occlusion of
mesenteric vessels and even aortic occlusion followed by
death of the animals within 2 mo. LRP1 can bind at least 40
ligands and modulates signaling of other receptors. In liver,
together with LDLR, LRP1 mediates endocytosis of TGRL
into hepatocytes (192). In VSMC, LRP1 physically interacts
with and restrains the activity of both the PDGFR and the
TGF- receptors. Absence of VSMC LRP1 led to increased
cell-surface PDGFR expression, PDGF-BB signaling, and
VSCM proliferation.
strained TGF- signaling and decreased atherosclerosis in

mice with VSMC-specific LRP1 deficiency (193). LRP1 also
mediates endocytosis of thrombospondin-1 (Thbs1) and
several active MMP. Active MMP2 and MMP9 are increased in the aorta of mice with LRP1 deficiency in VSMC
and could contribute to aneurysm formation. Finally, LRP1
also appears to induce expression of Wnt5a which inhibits
cholesterol and cholesteryl ester accumulation in adipocytes and may also be involved with cholesterol accumulation in VSMC (1773).

LDL-C seen. Triglycerides after fat feeding were increased
to a greater extent with evidence that TGRL removal was
impaired. Nevertheless, the potential involvement of
VSMC Wnt signaling in this model might be a fruitful subject for future research (1113).
Proliferating VSMC can contribute to plaque size, and
VSMC may be transformed into foam cells and express an
activated, secretory phenotype. Yet, their ability to produce
collagen and thicken the fibrous cap helps stabilize plaques.
TGF- is both anti-inflammatory and promotes VSMC deposition of collagen. But it also promotes deposition of
LDL-binding proteoglycans. The net effect of interrupting
TGF- signaling was smaller in plaques with more activated
leukocytes, larger necrotic cores, and more ruptures (1091,
1127).
A newly recognized contribution of medial VSMC to inflammation in atherosclerotic lesions has recently been reported. VSMC stimulated simultaneously through TNFR1
and LTR ligation can direct lymphorganogenesis in the
adventitia, resulting in a collection of activated immune
cells which may contribute to the inflammation and progression of the nearby plaque (1077).
Finally, an additional, surprising feature of VSMC behavior
in advanced plaques should be mentioned. Culprit plaques
causing acute coronary syndromes in humans have been
consistently shown to rupture just proximal (upstream) to
the point of maximum stenosis. This is the area of most
rapid flow (560). This is true even though the area of slow
flow just downstream of the stenosis is where endothelium
is activated and foam cells accumulate. It appears that while
high shear stress promotes endothelial integrity and higher
NO production in the upstream area, the higher shear may
simultaneously promote plasmin production as well. Furthermore, NO appears to inhibit underlying VSMC proliferation and collagen synthesis as well as promote VSMC
apoptosis. Why this would be the case is not clear since
PKG, activated by NO, actually promotes VSMC proliferation and PKG deficiency led to smaller lesions with fewer
VSMC in hyperlipidemic mice (1972). Perhaps prolonged
C. Inflammation, Apoptosis, Necrosis, and

Efferocytosis in Advancing Lesions
Genetic animal models have provided many insights into
molecular mechanisms leading to advanced, vulnerable
plaques. Accumulation of excessive cholesterol or endocytosis of modified lipoproteins can promote inflammation in
macrophages and may lead to apoptosis. If limited, apoptosis of macrophages and neutrophils occurs without necrosis. Rapid removal of apoptotic cells can be accomplished
by both macrophages and VSMC through the process of
efferocytosis, with perhaps limited egress of lipid-laden
macrophages out of the plaque. These features are hallmarks of early, easily reversible lesions (1726). With continued recruitment of additional macrophages and other
inflammatory cells combined with local proliferation (846)
and lipid accumulation, the number of apoptotic cells increases and efferocytosis seems to slow or become insufficient. Cholesterol-laden macrophages are particularly
prone to both impaired efferocytosis and ER stress leading
to even greater accumulation of apoptotic cells. Apoptotic
cells that are not phagocytosed undergo secondary necrosis,
and these accumulate and promote even greater inflammation. Continuing accumulation of uncleared necrotic foam
cells leads to increasing release of inflammatory cytokines
and matrix-dissolving enzymes. At the same time, impaired
VSMC-mediated fibrosis may lead to a thinned fibrous cap
and vulnerable plaques. Interestingly, this process is similar
to certain chronic infections. Indeed, advanced plaque macrophages show striking similarities to those in tuberculous
granulomas (1582).
1. Macrophage inflammation through CD36 and
STAT1 signaling
CD36 has been listed as one of the major scavenger receptors that, on macrophages and probably VSMC, can mediate uptake of various modified lipoproteins including oxLDL, AcLDL, VLDL, and TGRL remnants. CD36 also recognizes specific oxidized phospholipids. CD36 is not a
passive player in the process of lipoprotein uptake. The
cytoplasmic tail of CD36 forms a complex with paxillin and
the Src family kinase Lyn. Upon ligand binding to CD36,
Lyn activates PYK2 which tyrosine phosphorylates
p130CAS leading to downstream activation of JNK1/2 and
ERK1/2 together with ROS production (716, 1691). Furthermore, active Lyn tyrosine phosphorylates CD36 which
promotes formation of a CD36:TLR4:TLR6 complex
1469
In contrast to TGF-, the effect of IFN- from T-cells to

suppress VSMC collagen production is generally considered destabilizing (1042). Additionally, localized overexpression of p53 in carotid plaques of ApoE-deficient mice
led to an increase in VSMC apoptosis in the fibrous caps,
thinning of the cap, and spontaneous rupture upon hemodynamic challenge with phenylephrine (1887). Activated
macrophages produce FasL which binds to Fas (the socalled death receptor) on VSMC, promoting VSMC apoptosis (821) and plaque instability. Importantly, infusion
of smooth muscle progenitor cells in ApoE KO mice decreased plaque size and macrophage content if given early in
life and led to increased plaque collagen content (2121).
rapid flow stimulates changes in VSMC that are analogous

to the normal compensatory vessel enlargement in areas of
rapid flow, particularly during embryogenesis, but in the
context of an advanced atherosclerotic plaque such changes
may lead to paradoxical weakening of the fibrous plaque
just under the area of endothelium exposed to the highest
flow rates (1641, 1642).
PAUL N. HOPKINS
which binds MyD88 with downstream signaling to activate
NF-B which increases production of pro-IL-1 and various chemokines. TLR4 further binds the adapter TRIF with
increased production of type I interferons, IFN-/ (1684).
CD36 can also form a complex with TLR2 with further
activation of NF-B. Src family kinases can also mediate
signaling through a PLC-DAG, IP3-calcium release-PKC
activation pathway, further promoting PYK2 activation.
Src family kinases simultaneously activate the GEF Vav1 to
exchange GTP for GDP on Rac1. Vav1 and Vav3 couple
with CD36 and are required for foam cell formation upon
incubation with oxLDL (1449). Active PKC and Rac1 promote assembly and activation of NOX2 to enhance ROS
production (1210). These pathways provide greater understanding of the marked reduction in atherosclerosis after
CD36 KO or pharmacological CD36 inhibition in mice
(716).
In addition to potentially generating FC intracellularly,

macrophages avidly phagocytose cholesterol crystals as
well as uric acid crystals. These preformed crystals are a
much greater threat than membrane-associated free cholesterol since they can trigger the NLRP3 inflammasome with
resulting IL-1 secretion as shown in FIGURE 16 (452,
1453). Briefly, cholesterol crystals activate the intracellular
pattern recognition receptor NLRP3 (NOD-like receptor
family, pyrin domain containing 3) to promote assembly of
the inflammasome with the adaptor protein ASC [apoptosis-associated Speck-like protein containing a CARD
(caspase-associated recruitment domain)] linking NLRP3
to pro-CASP1 (caspase 1). This complex generates active
CASP1 which can cleave pro-IL-1 to active, inflammatory
IL-1. Calcium mobilization also was shown to be important for NLRP3 activation (1254). Essentially all elements
of the NLRP3 inflammasome were pro-atherogenic in various mouse studies (see TABLE 9). Remarkably, the transcription factor Nrf2, essential for expression of antioxidant genes, was also required for NLRP3 activation by
cholesterol crystals in macrophages, possibly explaining the
surprising reduction in atherosclerosis with Nrf2 KO (546).
Several additional miscellaneous genes that may promote
inflammation in relation to lipid accumulation are also
listed in TABLE 9.
3. ER stress in foam cells
For years it has been known that macrophages can mitigate
the potential toxicity of FC by stimulating phosphatidylcholine (PC) synthesis with formation of cellular whorls
consisting of FC and PC. However, if the molar ratio of
FC:PC remains above 0.4, necrosis ensues (1728, 1730).
These older observations may help explain the intriguing
finding that infusion of cholesterol acceptors, such as PC or
phospholipid micelles, can cause remarkably rapid regression of atherosclerotic plaques (1962).
2. Free cholesterol and the NALP3 inflammasome

The toxicity of excess unesterified or free cholesterol (FC) is
of key importance in advanced lesions (1645, 1725). The
active macrophage, imbibing large amounts cholesteryl ester (CE) and some FC from modified LDL, TGRL remnants,
and phagocytosed cells, faces a major threat from within.
Foam cells can accumulate fairly large amounts of cytoplas-
1470
Increased PC synthesis by macrophages in response to excess FC has come to be recognized as part of the unfolded
protein response (UPR). Some elements of the UPR are depicted in FIGURES 16 AND 17. Excellent reviews of the UPR
in relation to cardiovascular disease are available (1213,
1505). Briefly, in unstressed cells, three key transmembrane
sensors (IRE1, PERK, and ATF6) extend through the ER
In atherosclerotic plaques, macrophages can be exposed to

substantial quantities of IFN- whose receptor, IFNGR2, is
coupled to JAK2-STAT1. After being phosphorylated at
Tyr701 by JAK2, STAT1 dimerizes and translocates to the
nucleus. However, nearly 80% of the transcriptional activity of STAT1 depends on a second phosphorylation at
Ser727 which leads to sumoylation at this site by PIAS,
STAT1 stabilization, and increased transcriptional activity
(112). This serine phosphorylation can be accomplished by
CaMKII in response to elevations of calcium. In macrophages, calcium elevations occur through multiple pathways, including TLR2/4 and CD36 binding as well as ER
stress, providing the calcium signals and increased ROS to
activate CaMKII and instigate STAT1 Ser727 phosphorylation. Macrophage STAT1 deficiency dramatically decreased apoptosis in advanced lesions as well as the accumulation of apoptotic debris in LDLR KO mice (15, 1047).
Modified lipoproteins, such as AcLDL, can lead to both
cholesterol overloading and CD36 ligation and are therefore especially toxic. Indeed, oxidized phospholipids binding to CD36, saturated fatty acids, oxLDL, and the lipoprotein Lp(a), which is particularly enriched with oxidized
phospholipids, can all activate CaMKII leading to increased
STAT1 signaling. In macrophage foam cells that are already
stressed from cholesterol overloading and attendant ER
stress, activation of CD36 or pattern recognition receptors
such as the TLR can provide a second hit that results in
apoptosis (1210, 1729). Activation of PYK2 through CD36
signaling will further increase the overall inflammatory response (716).
mic CE and triglyceride with seeming impunity. However, if

FC release from CE hydrolysis exceeds CE formation, FC
accumulates and can trigger apoptosis or necrosis. Thus
deficiency (or pharmacological inhibition) of ACAT1 increases atherosclerosis (see TABLE 8). Surprisingly, however, hydrolysis of CE is one of the rate-limiting steps of
cholesterol mobilization from macrophages to HDL and
inhibition of neutral cholesteryl ester hydrolase 1 (NCEH1)
or hormone sensitive lipase (HSL, also abbreviated as LIPE)
or both promoted foam cell formation and atherosclerosis
(1584).
oxLDL
CD36
SR-A
LOX-1
CD68
Src
Rac1
Vav1/3
FC
NCEH1
ACAT1
PL
C
HSL
Macrophage
CE
IB
FC
CD36
LXR
TLR2/4/6
AEBP1
FAB4/5
PPAR
PKC
mmLDL
Lp(a)
Necrotic cell
Fyn
Inflammatory signaling, cytokines
NF-B
88
Syk
yD
AP1
ERAD, PC, chaperones
XBP1
NF-B
ATF4/6
PYK2
CHOP
JNK
CaMKII
Bcl2
Bim
eIF2
TAK1
ASK1
Bip
PERK
ATF6
Bip
Bip
Ca2+
Tiam1
Bak
Bax
Rac1
ac1
ERO1
ROS
SERCA
IP3R1
Nox2
Unfolded protein response

pro-Casp-1
ASC
FC
IL-1
Inflammatory signals
Prior FC or oxLDL loading
Uric acid
DNA
HMGB1
Prior NLRP3 activation
ATP (large release)
Prior TLR activation
Pathogen derived factors
(LPS, flagellin, etc.)
Saturated fatty acids
Nrf2
NLRP3
Inflammasome
Cholesterol
crystals
FIGURE 16. Proinflammatory lipid-mediated signaling and efferocytosis in macrophages. Nrf2 is in some way
permissive for activation of the NLRP3 inflammasome and IL-1 production. ACAT1, acyl-CoA:cholesterol
acyltransferase 1, also known as SOAT1 for sterol O-acyltransferase 1; CE, cholesterol ester; FC, free
cholesterol; nCEH, neutral cholesteryl ester hydrolase; PL, phospholipid; PS, phosphatidylserine. Src refers to
Src or other Src-family protein tyrosine kinases and may include Src, Lyn, Fyn, Lck, Yes, Fgr, Hck, Blk, or Csk-1.
membrane and into the ER lumen where they bind plentiful

chaperones that promote protein folding. One such chaperone is BiP (immunoglobulin heavy chain-binding protein,
also known as Hsp70 for heat-shock 70-kDa protein 5 or
Grp78 for glucose-regulated protein 78). ER stressors
include excess protein synthesis, dysregulation of ER calcium, and excess or inadequate oxidative stress. An oxidizing environment in the ER is required for the disulfide bond
formation that is part of proper folding for many proteins.
Such disulfide bonding of nascent proteins is facilitated by
protein disulfide isomerase/oxidoreductase (PDI), one of
several similar proteins. To be active, PDI must be in an
oxidized form and after assisting in formation of disulfide
bonds it becomes reduced. Oxidized PDI is reoxidized by
H2O2 generated by ERO1 (ER oxidoreductin 1) which
utilizes GSSG and generates 2 GSH and H2O2 in the process.

FC loading stiffens the ER membrane which appears to
impair proper function of SERCA2b (513, 1039). Saturated
fat, particularly palmitic acid, has a similar effect while
unsaturated fats are protective (484, 830). One or more of
the key UPR sensors in the ER membrane (PERK, IRE1,
AFP6) seem also to directly sense disordered lipid composition of the ER membrane, an effect that was additive with
but independent of protein misfolding (1608). Steroyl-CoA
desaturase 1 (SCD-1) converts palmitate or stearic acid to
unsaturated fatty acids and also has a protective effect
against ER stress. Fatty acid binding proteins FABP4 (also
known as aP2) and FABP5 are induced by JNK/c-Jun and
1471
U U U U
TRAF2 IRE1
mito Ca,
JNK, Fas,
STAT1
PAUL N. HOPKINS
appear to deliver both FC and saturated fat to the ER,
promoting ER stress. Additionally, these FABP, in some
way, block desaturation of palmitate by SCD-1 and
block the protective activation of LXR, possibly by direct
physical interaction with and inhibition of PPAR or by
binding and sequestering away natural ligands of PPAR.
KO of FABP4 leads to greater availability of these ligands, greater stimulation of PPAR, and suppression of
atherosclerosis (1123). FABP5 deletion was also protective (95, 484, 800) (TABLE 9).
CHOP production is of particular importance as increased

levels push the cell toward apoptosis or a desperate attempt
to recover protein synthetic capacity. Thus CHOP induces
increased expression of pro-oxidant ERO1, pro-apoptotic
Bim and CHAC1, and GADD34 while acting as a corepressor to reduce expression of anti-apoptotic Bcl-2 and Bnip-3
(1213, 1250). GADD34 is a phosphatase that targets and
reactivates eIF2, allowing stressful protein synthesis to
continue. In the setting of ER stress, increased ERO1 can
increase ER oxidative stress sufficiently to promote calcium
loss through the oligomerization of Bax and Bak in the ER
membrane, opening of IP3R and inactivation of SERCA
(435, 1729, 1731). CHOP-induced calcium loss from ER
can lead to excess calcium uptake by mitochondria, increased ROS production by mitochondria, and mitochondrial damage which can help activate the NLRP3 inflammasome (1254). Oxidative inhibition of SERCA can be
counteracted by AMPK. This may be at least one reason
why AMPK deficiency increases atherosclerosis (TABLE 1).
Some UPR signaling results in an adaptive increase in the
production of certain select proteins such as chaperones,
cellular machinery for endoplasmic reticulum-associated
degradation (ERAD), and antioxidant genes (through
Nrf2). However, continued or severe ER stress with unsuccessful adaptation results in variable degrees of inflammatory signaling including activation of NF-B and JNK
through activated IRE1 (see FIGURE 16). Eventually, apoptosis can ensue. Apoptosis can be triggered by multiple
pathways, including JNK phosphorylation and inactivation
of Bcl-2, caspase-12 activation, and by excessive calcium
1472
X-box binding protein 1 (XBP1) is a transcription factor

whose mRNA remains unspliced until processed by activated IRE1 during the UPR. Functional XBP1 then mediates the transcription of genes that will increase PC synthesis, compensating for the excess cholesterol load. Increased
PC lowers the FC:PC ratio and results in expansion of the
surface area and capacity of the ER (1505, 1669). Nevertheless, overexpression of XBP1 was strongly proatherogenic in one study (2060), presumably due to other effects.
Genetic models involving studied components of UPR and
apoptosis are summarized in TABLE 9. Some of their effects
on atherosclerosis are complex and not easily predictable.
Thus deletion of apoptosis inhibitor expressed by macrophages (AIM) greatly decreased lesion size because of increased macrophage apoptosis in early lesions. Congruently, transplant of bone marrow from animals lacking the
pro-apoptotic protein Bax (Bcl-2-associated X protein) had
larger lesions due to more surviving macrophages. However, macrophage-specific deletion of anti-apoptotic Bcl-2
(B-cell leukemia/lymphoma 2) did not affect lesion size,
although more apoptotic macrophages were seen in plaques
together with more cholesterol crystals.
Despite the dire consequences of intense or prolonged UPR,
limited ER stress in early lesions, with adaptive increases in
BiP, actually enhanced macrophage survival (422). Other
examples of a need for balanced, modest activation have
been reported, as in the limited oxidative stress required to
activate Nrf2. Some NF-B pathway activity is protective
(as macrophage-specific IKK2 KO caused increased atherosclerosis) and the absence of the MAPK p38 in macrophages
greatly increased apoptosis and necrosis with accelerated
atherosclerosis (1583). This may also explain why KO of
MAPK phosphatase 1 (MKP-1), which inhibits p38, actually decreased plaque size (see TABLE 1). The protective
effect of p38 seemed to be mediated by increased PKB/Akt
signaling. Consistent with this observation, genetic impairment of insulin signaling decreased PKB signaling and promoted apoptosis in macrophages (1731). In addition, release of the anti-inflammatory cytokines IL-10 and TGF-
after efferocytosis is dependent on p38 (473). Unlike p38,
however, JNK2 was consistently proatherogenic in genetic
models as noted previously (see TABLE 1).
Not discussed in this review are the generally cytoprotective
and anti-inflammatory effects of autophagy. This process is
triggered by reduced energy supplies to the cell but also by
many of the same cellular stress pathways (such as ER stress
Under ER stress, excess protein production or inadequate

calcium can lead to over-utilization of chaperones, inadequate PDI activity, or other dysfunction of the protein processing machinery. Proteins misfold, chaperones become
scarce, and their absence triggers activation of IRE1, PERK,
and ATF6. PERK phosphorylates and inhibits eukaryotic
translation initiation factor 2 (eIF2), which releases the
transcription factor ATF4, freeing it to induce the transcription factor CHOP (C/EBP homologous protein). Phosphorylation of eIF2 by PERK also generally downregulates
other protein synthesis, a compensatory check to protect
the cell from the stress of protein overproduction. Activated
ATF6 also induces CHOP.
release from the ER. Besides stimulating the NLRP3 inflammasome as noted above, ER calcium escape can activate
CaMKII leading to serine phosphorylation of STAT1, and
activation of PYK2. ROS production by mitochondria as
well as Rac1 and NOX2 with general promotion of proinflammatory and apoptotic pathways follows (1729, 1731).

and UPR) experienced by macrophages in advanced lesions.
Autophagy is also thought to be of primary importance in
defense against pathogens (1704). Effects on atherosclerosis of genetic models of autophagy-related genes have apparently not been reported.
4. Macrophage-dependent resolution of
inflammation: an optimal outcome of
efferocytosis, PPAR, and LXR signaling
After being summoned, the phagocyte must encounter appropriate eat me signals displayed by the apoptotic cell
(such as phosphatidylserine and various opsonin-like proteins) which match a series of receptors on the phagocyte,
thus forming a synapse between the phagocyte and the target cell. Certain inhibitory dont eat me signals, generally
displayed on healthy cells, can strongly block efferocytosis.
In advanced plaques there appears to be an over-abundance
of efferocytosis signals with many awaiting apoptotic cells,
suggesting saturation of efferocytosis mechanisms (1791,
1863). Several efferocytosis promoting ligands and receptors, together with subsequent intracellular signaling, are
discussed below and are reviewed in TABLE 9 and depicted
in FIGURE 17.
Virtually all of the defects of efferocytosis listed in TABLE 9
(as well as those related to Treg function) promote autoimmune disorders as well as atherosclerosis (473, 2120). Interestingly, while Fas (fragment, apoptosis stimulating) is
often referred to as the death receptor, Fas, and its ligand
Recently, actual phagocytosis of the apoptotic cell was

shown to be strongly influenced by uncoupling protein 2
(UCP2). A decrease in the mitochondrial electron gradient
or mitochondrial potential was shown to be required for
efficient efferocytosis while a high gradient was inhibitory
(1380). Why this should be the case remains to be demonstrated. Nevertheless, impaired efferocytosis may be an additional explanation for the increased atherosclerosis seen
in UCP2 KO mice (1240) as well as the accumulation of
macrophages present in lesions of mice receiving UCP2 deficient bone marrow (157).
Efferocytosis can provide macrophages with a large influx
of lipids that can act as PPAR and LXR ligands, as noted
above. Besides increasing cholesterol flux through macrophages, ligand-bound LXR and PPAR nuclear receptors are
directly and profoundly anti-inflammatory. Most recently,
a remarkable insight regarding the key LXR ligand in foam
cells was presented. In the setting of increased cholesterol
content, SREBP2-mediated synthesis of cholesterol is
downregulated. However, 24-dehydrocholesterol reductase (DHCR24) is suppressed to 5% of its full activity,
while hydroxymethyl-glutaryl CoA reductase (HMGCR)
retains 30% of its activity. DHCR24 converts desmosterol to cholesterol. The resulting imbalance between
HMGCR (and other components of the cholesterol synthesis pathway) and DHCR24 is an accumulation of desmosterol. Desmosterol, in turn, was found to be a key ligand for
LXR. Surprisingly, desmosterol was found at concentrations 20 50 times those of oxidized cholesterol species that
are also LXR ligands. This was true in human plaque as
well. The effect of this abundance of desmosterol was a
profound suppression of inflammatory signaling as a direct
result of LXR signaling as depicted in FIGURE 17 (1662).
Not shown were alteration in fatty acid metabolism leading
to several anti-inflammatory fatty acids as well. Thus at
least some degree of FC accumulation in ER membranes
should actually be anti-inflammatory. These observations
may explain why in human plaque up to 20% of macrophage/foam cells display the noninflammatory, resolving
phenotype labeled M2 as opposed to proinflammatory M1
(1662).
One mechanism of this anti-inflammatory effect of LXR
involves large corepressor complexes. In macrophages and
other effector cells, nuclear corepressor (NCoR) and silencing mediator for retinoid and thyroid hormone receptors
(SMRT) physically interact with NF-B, AP1, and other
inflammatory transcription factors while they are bound to
1473
Efferocytosis (which literally means carrying the corpse to

the grave) is a process whereby phagocytes are attracted to
apoptotic, necrotic, or damaged cells followed by highly
controlled engulfment and endosomal/lysosomal digestion
of the effete cell. Besides macrophages and DC, endothelial
cells, VSMC, and other cells can be recruited to assist in the
task of cell corpse removal. Initial phagocyte attraction occurs by a host of find me chemoattractant signals (1411)
of which several have been examined in various atherosclerosis models. These include fractalkine which binds its receptor CX3CR1 on macrophages, LPC (released by a calcium-independent isoform of PLA, designated iPLA2) binding its GPCR GRA, and S1P. Microblebs released by
apoptotic cells also attract surrounding phagocytes. Necrotic cells can additionally release separate danger signals, such ATP (when released at high concentration)
binding to high-affinity P2Y2 and lower affinity P2X receptors, various heat shock proteins, mRNA and other RNA,
and a number of other products of necrotic cells (1411).
The DNA binding protein high-mobility group box protein
1 (HMGB1) is also released by necrotic cells. It acts to both
attract and activate surrounding phagocytes and can activate endothelial cells, possibly by interaction with the
RAGE receptor as well as TLR2 and TLR4 (1411). Administration of HMGB1 blocking antibodies decreased atherosclerosis in ApoE KO mice (878).
FasL, are also among the receptors and ligands that control
efferocytosis. Mice that lack functional Fas or FasL have
impaired ability to clear apoptotic debris and display features of autoimmune disease. When crossed with ApoEdeficient mice, these mice have increased atherosclerosis
(73, 517).
PAUL N. HOPKINS
pre- HDL
FC & PL
ABCA1/5
LXA4,RvD/E,
PD1, Ma
Modified LDL, TGRL

remnants, apoptotic cells
CE
TG
LIPA
15-LO
5-LO
FC, oxysterols
EETs
FC
CYP2C/2J
FcR
(DHCR24 > HMGCR)
LXA4
RvD/E
15d-PGJ2, etc.
S1PR1
Desmosterol
CRP
LRP1
+sumo
PI3K
GAS6
PS
Tim1/4
Inflammatory genes
NF-B
Mfge8
Bcl6 PPAR
PS
LPC, LPS
V3
Chaperones, PC
Rheb
mTOR
S6K1
eIF2
S6
PGE2
IRE1
PERK
ATF6
Bip
Bip
Bip
G2A
Efferocytosis
Anti-inflammatory signals
Adenosine, LPC, S1P
PS (phosphatidyl serine)
Lipoxin, resolvin, protectin,
maresin precursors
n-3 fatty acids (EPA, DHA)
RNA (through TLR3)
Lysophosphatidylserine (LPS)
Hemoglobin/haptoglobin 1-1
Compensated ER stress
FIGURE 17. Anti-inflammatory lipid-mediated signaling and efferocytosis in macrophages. Nuclear receptor corepressor 1 (NCoR) functions as an inhibitory deacetylase complex. An important anti-inflammatory function of LXR and PPAR is to block the removal of NCoR from the promoters of proinflammatory
genes. LPC binding to GPCR G2A may promote efferocytosis. Not shown is extensive anti-inflammatory
signaling that occurs with APOA1 binding to ABCA1. PC, phosphatidylserine; FFA, free fatty acids; LPC,
lysophosphatidylcholine; LXA4, lipoxin A4; Ma, maresins; PD1, protectin 1; RvD/E, resolvins of the D and
E series; S1P, sphingosine-1-phosphate.
DNA, thereby preventing transcription of inflammatory

gene targets (see FIGURE 17). Such cells are poised for rapid
activation when these corepressors are released by inflammatory signals. When bound by ligand, both LXR and
PPAR can be sumoylated and, as such, interact directly
with and prevent removal of NCoR and SMRT, a mechanism termed transrepression (286, 794, 819).
The anti-inflammatory mechanism of PPAR is less direct.
PPAR agonists are anti-inflammatory and antiatherosclerotic in hyperlipidemic mice. Yet, bone marrow transplant
with PPAR-deficient cells decreased atherosclerosis even
1474
more than did PPAR agonists (108, 988). Resolution of

this apparent paradox came when investigators found that
nonliganded PPAR binds and holds inactive the powerful
nuclear corepressor Bcl6 (B-cell lymphoma 6). Thus PPAR
is anti-inflammatory essentially only when ligand binding
causes release of Bcl6. When freed from PPAR, Bcl6 acts as
a corepressor to 2,500 genes by modification of their
chromatin. About half of the Bcl6 target genes are activated
by NF-B (NF-B affects over 3500 genes by binding to
some 31,000 sites on the genome!). When NF-B is activated, Bcl6 temporarily moves off its cis-acting sites then
rebinds later to again repress transcription. Mice lacking
TSC1 TSC2
Apoptotic
cell
PS
SCD-1, ApoE, LPL, Mertk
NCor
AP1
Mertk
ABCA1, ABCG1,
LXR
HDL
C1q, MBL,
adiponectin
ApoE
CD36, ABCG1,
PPAR
LXR, CYP27
PKB
PTX3
cAMP,
PKA,
PKB
RXR
Active
NFB, AP1
TGF,
IL-10,
PGE3
ABCG1
CYP27
FFA, FC
ALX
ChemR23
HDL3/2
PL

Bcl6 have hyperinflammatory responses to LPS and increased atherosclerosis (109, 110). PPAR also has direct
anti-inflammatory effects, but these mechanisms appear less
well defined (286).
While generally depicted as a means of promoting cholesterol efflux from macrophages, ApoE secreted by either the
phagocytosing macrophage or apoptotic macrophages promotes efferocytosis and downregulates inflammatory responses. These effects are mediated by binding to LDL receptor-like protein 1 (LRP1) which, in this setting, activates
cAMP, PKA, and PKB signaling followed by greatly reduced responsiveness to TNF- (2016).
An influx of lipids from ingested lipoproteins and efferocytosis may also promote synthesis of lipoxins (such as
LXA4), resolvins, protectins, and maresins with marked
downregulation of inflammatory pathways (1726). These
lipid mediators are analagous to PGI2 and other anti-inflammatory prostaglandins in that they mediate their effects
through GPCR (951). Furthermore, PGE2 and PGD2, produced by COX-2 in macrophages, cause increased expression of 15-LO, leading to a switch from production of proinflammatory prostaglandins and leukotrienes toward production of anti-infammatory lipoxins, resolvins, protectins,
and maresins. This is yet another means whereby selective
COX-2 inhibition may be detrimental. Indeed, NSAIDs
generally seem to slow resolution by blocking prostaglandins that signal the switch and possibly precursors for some
of these active lipid mediators of resolution (1590). Precursors to these lipids may be synthesized by endothelial cells,
platelets, or PMN. Macrophages, which arrive later in acute
inflammatory reactions, may use these precursors to synthesize the resolving lipid mediators. Alternatively, PMNs may
also produce lipoxins and resolvins.
Surprisingly, acetylation of COX-2 by aspirin, rather than

completely inactivating the enzyme, converts COX-2 to a
15-lipoxygenase-like enzyme, synthesizing 15R-hydroxyeicosatetraenoic acid (15R-HETE) from arachidonic acid.
The product of native 15-lipoxygenase is the chiral alternative, 15S-HETE. Both 15S- and 15R-HETE are substrates
for 5-lipoxygenase to produce highly anti-inflammatory,
pro-resolving lipoxins. Furthermore, the aspirin-triggered
lipoxins are more resistant to metabolic inactivation. In
addition, the modified COX-2 enzyme could support production of resolvin precursors from n-3 fatty acids such as
DHA (1330, 1593). Adenosine, potentially encountered in
apoptotic cells, can act through the purinergic receptor A3R
to block IFN--mediated activation of STAT1 (112).
In addition to anti-inflammatory signaling triggered by efferocytosis, phagocytes may encounter many activation or danger signals in apoptotic and especially necrotic cells. Thus the
prior history of an apoptotic cell, including microbe infection,
previous ligation of TLRs, cholesterol loading, an encounter
with cholesterol crystals, or in one study, prior exposure to
oxLDL (1280), can modulate the effect of its subsequent
phagocytosis by another cell from anti-inflammatory to proinflammatory (1431, 2120). Indeed, one can imagine that the
complex array of proinflammatory triggers encountered deep
within an actively growing atherosclerotic plaque could lead
to repeated cycles of apoptosis and necrosis followed by toxic
or proinflammatory efferocytosis, converting the necrotic core
into an immunological no-mans land.
D. The Complement Pathway and

Atherogenesis
The complement pathway was so named for its ability to
complement the action of antibodies in lysing bacteria. It
consists of a series of serine proteases or convertases (called
zymogens in their inactive, uncleaved form), with each activated protease capable of lysing and thereby activating
1475
LXR and PPAR also orchestrate prompt efferocytosis by

inducing genes involved in sensing eat me signals, secretion of proteins with an opsonizing effect, and production
of anti-inflammatory cytokines including IL-10. In addition
to LXR and PPAR effects, efferocytosis itself initiates other
anti-inflammatory signaling. Numerous studies demonstrate rapid downregulation of inflammation upon first
contact with early apoptotic cells (1431, 2120) or cell fragments (466). Some of this anti-inflammatory effect is mediated by phosphatidylserine receptors. For example, ligation
of Mertk (Mer receptor tyrosine kinase) led to rapid inhibition of NF-B signaling through activation of the PI3K/
PKB pathway (466). Mertk is induced by LXR and utilizes
Gas6 as a bridge to phosphatidylserine (286). Another
phosphatidylserine receptor on macrophages is the V3
integrin which utilizes milk fat globule-EGF factor 8
(Mfge8) or transglutaminase 2 (TG2) as bridging molecules. Genetic deficiency of most of these mediators of efferocytosis increased atherosclerosis and the number of apoptotic and necrotic cells in plaques (TABLE 9).
The lipoxins were identified first and are produced from

arachidonate. E-series resolvins are produced from EPA
and D-series resolvins from DHA. Maresins are produced
by macrophages and are the most recently identified of these
resolving eicosanoids. Importantly, their actions on specific
GPCR include inhibition of neutrophil diapedesis (thus signaling to end the acute phase of inflammation), decrease in
edema formation, antagonism toward TNF- and NF-B
signaling, and yet they are chemoattractant toward macrophages while stimulating them to take on an M2 phenotype
to promote prompt resolution of inflammation and removal
of apoptotic cells and cellular debris (544, 1590, 1591).
Acting through the GPCR ChemR23, for example, the resolvin E1 stimulated Gi-mediated activation of PI3K followed by PKB, mTOR, p70S6K, and ribosomal S6 phosphorylation, which were all required to support increased
macrophage phagocytosis (544).
PAUL N. HOPKINS
Emerging understanding of the complement pathway in atherosclerosis points to a protective role for early components
and related molecules which bind or opsonize apoptotic cells
(besides invading bacteria) and promote efferocytosis. In contrast, assembly of later components that promote cell damage
are atherogenic (1663). These findings are summarized in TABLE 9. Only a few orienting comments will be given here.
Pentraxin 3, long pentraxin (PTX3) and C-reactive protein
(CRP) are both acute phase reactants of the pentraxin family which act as part of the innate immune response to coat
or opsonize invaders such as certain bacteria. They are capable of subsequently triggering the classical complement
pathway when the opsonized invaders encounter the first
component of the complement pathway, C1q. Thus, in addition to the Fc portion of antigen-bound antibodies, C1qa
also recognizes and binds PTX3, CRP, the phosphatidylserine on apoptotic cells, and the membrane of certain bacterial cells, and can thereby activate the classical complement
cascade.
1476
Besides activating the classical complement pathway, invaders coated with IgG or IgM antibodies can be phagocytosed by interacting with Fc receptors, or when C1q is
bound by the calreticulin/CD91 complex on phagocytes
(1431, 1663). Apoptotic cells opsonize by C3b and C4b can
be phagocytosed through recognition by other macrophage
receptors (1663). C1q KO was atherogenic (TABLE 9). Importantly, both PTX3 and CRP can also bind apoptotic
cells and promote efferocytosis. CRP in particular recognizes oxidized phospholipids. PTX3 appears to be anti-atherosclerotic while most CRP manipulations resulted in little
or no change in atherosclerosis. The few significant effects
that were seen for CRP were consistently protective (see
TABLE 9).
C1q is also activated by enzymatically modified LDL containing free fatty acids together with phospholipid (151).
C1q enhanced the uptake of oxLDL into macrophages with
subsequent activation of the cells including increased
CD80, PECAM1, and MCP-1 release but also induction of
ABCA1 and ABCG1 with enhanced cholesterol efflux to
HDL (543). Remarkably, adiponectin has an analogous
structure to C1q, also opsonizes apoptotic cells and promotes their efferocytosis, binding to the same calreticulin/
CD91 receptor complex as C1q (1746). It should be noted,
however, that the main action of adiponectin appears to be
activation of ceramidase through binding its receptors AdipoR1 and AdipoR2, thereby causing the deacetylation of
ceramide with downstream formation of the anti-apoptotic
S1P (778). Overexpression of adiponectin decreased atherosclerosis (1339).
The alternate complement pathway is triggered when C3b,
continually produced at a low level, is activated when it
covalently binds apoptotic cells, enzymatically modified
LDL, cholesterol crystals or other atherosclerotic debris,
and other foreign surfaces (1663). Active C3b then binds
CFB (complement factor B) which is cleaved by factor D to
produce the alternative pathway C3 convertase consisting
of Bb and C3b. When BbC3b is joined by another C3b, it
becomes a C5 convertase. The alternative pathway thus
serves to amplify the classical pathway. Interestingly, no
effect of CFB KO was seen when mice were fed a low-fat
diet. During a high-fat diet, LDL-C was much lower in CFB
KO mice which likely explained the modestly decreased
atherosclerosis. However, CFB KO mice were almost entirely protected from an accelerated atherosclerosis that
was induced by chronic intraperitoneal LPS administration
(1124). These results demonstrate that enhancement of atherosclerosis by LPS or chronic infection need not be mediated solely by Toll-like receptors but that alternative complement pathway activation can also contribute.
Mannose- or mannan-binding lectin (MBL) is an initiating
factor in the lectin pathway of complement activation with
a structure highly analogous to C1q. It can coat and pro-
many copies of its target zymogen, resulting in an amplifying cascade that ends with the production of many copies of
active C9. Active C9 multimers are inserted through the cell
membrane to form numerous large pores causing osmotic
lysis of the targeted cell. Several of the lytic pieces generated
by zymogen activation are inflammatory or attach to cells
and target them for phagocytosis, a process called opsonization. The classical, alternative, and lectin pathways lead to
activation of the key C3 and C5 convertases. Host cells
carry inhibitors and regulators of the pathway to minimize
peripheral damage. Briefly, for classical activation, C1qa
(complement component 1, q subcomponent, A chain) recognizes and binds the Fc portion of antibodies bound to
antigen, commonly on the surface of an invading bacterium. C1q exists as a hexamer that looks like an inverted
umbrella, with a globular head at the tip of each of its
radiating spokes that binds targets. C1q is joined by two
copies each of C1r and C1s to form the C1 complex. C1q
bound to at least two separate Fc regions activates the protease C1r which then cleaves and activates C1s. C1s cleaves
C4 and C2 with resulting C4b and C2a forming a protease
to cleave C3. Cleavage of C3 and C4 exposes an internal,
reactive thioester bond which covalently binds nearby
membrane polysaccharides or proteins, with hydroxyls or
amines, respectively, displacing the sulfur in the bond. In an
acqueous environment such as plasma, the thioester bonds
are merely hydrolyzed, and the components are inactivated.
C3b, now covalently bound to the membrane joins with
C4bC2a to form a C5 convertase with C5b as its product.
C5b then assembles C6, C7, and C8 with insertion of C7
and C8 into the cell membrane followed by assembly of C9
multimers and pore formation. Factors C5b through C9 are
together referred to as the membrane attack complex
(MAC).

mote killing of certain bacteria and viruses by activating the
classical complement cascade much like C1q. In human
epidemiological studies, associations with CAD have been
inconsistent (374, 893, 1110, 1331, 1527). More recently,
MBL was recognized to opsonize apoptotic cells and other
debris and facilitate efferocytosis. MBL can also enhance
macrophage ingestion of oxLDL as can C1q (543). MBL
was found to be atheroprotective in LDLR KO mice (see
TABLE 9). Relevance of MBL for human disease continues
to be debated however (743).
E. HDL Supports Innate Immunity

Although atherosclerotic lesions have been documented in
Egyptian mummies and even hunter gatherers (50, 51,
1787), CAD as a leading cause of death for a large segment
of the population is likely a modern phenomenon. Additionally, CAD generally claims its victims well after procreation, even among strongly predisposed persons. Homozygous FH may be an exception, but a high prevalence of
heterozygous FH persists nonetheless. Most other mammals show little if any atherosclerosis in a natural setting.
Thus little or no evolutionary pressure toward reducing the
development of atherosclerosis is likely to have ever been
exerted. Why then do we have HDL? The inverse association between CAD risk and serum concentrations of
HDL-C or its major structural protein, APOA1 is incontrovertible (420), yet the biological purpose of HDL is manifestly not simply to prevent atherosclerosis.
HDL modulates cellular responses to inflammatory signals

in a general way, since a reduction in membrane cholesterol
concentration mediated by HDL can reduce signaling
through many receptor complexes associated with lipid
rafts including several cytokine receptors (1318). For example, HDL can suppress hematopoeitic stem cell proliferation stimulated by GM-CSF acting through its receptor
(2053), and it normalizes neutrophil activation caused by
ApoE deficiency by mobilization of cholesterol and a decrease in lipid raft formation (1260).
The toxic effects of excess free cholesterol were discussed
above. The cholesterol mobilizing effects of HDL may well
support normal or continuing function of macrophages
which are obliged to engulf great quantities of cholesterol
during efferocytosis of apoptotic and necrotic cells. Such
support may be critical in the setting of infection resolution.
Thus the parallels between the benefits of HDL in atherogenesis may be coincidental to the role of HDL in infection
or other inflammation. HDL has been noted to be particularly important after efferocytosis of previously inflamed
foam cells (742) (possibly because HDL can mobilize oxidized cholesterol), but such cells may arise in the setting of
chronic intracellular infection, as with Mycobacterium tuberculosis (1582), as well as during atherogenesis.
HDL appears to have an effect on common infectious illness
as well. In these studies it is important to note that HDL is
acutely lowered by various cytokines produced in response
to certain illnesses or infections. Thus studies reporting
worse outcomes associated with low HDL in already infected patients (or in those with certain cancers) may provide little insight into potentially causal associations (664).
Nevertheless, some data do suggest benefit with higher
HDL with regard to infectious disease. Mortality from infection was 35% lower in men 85 and older with higher
HDL (128). Risk of nosocomial and surgical infections
were higher in persons with low HDL (251). Risk of noso-
1477
Complement activation downstream of C3 is generally

proatherosclerotic. This was particularly apparent for factor C6 and CD59 (see TABLE 9). CD59 inhibits C9 and
formation of the pore-forming MAC. Lesions in CD59 KO
mice had more macrophages and T-cells, more apoptosis,
larger necrotic cores, decreased fibrous tissue, and much
thinner fibrous caps, all leading to frequent coronary occlusion (in 73% of CD59 KO vs 9% of controls). These CD59
KO mice had decreased overall survival as well. Excess
atherosclerosis was blocked in these mice by an antibody
directed against C5. Furthermore, lesions were significantly
decreased in mice with transgenic overexpression of CD59
primarily in endothelium, an effect also blocked by antibodies against C5 (1985). The protective effects of CD59 were
confirmed by another group (1017), although more equivocal results were reported by others (60, 2052). These animal studies are consistent with an epidemiological study
finding mildly increased risk of cardiovascular events in
those having higher plasma levels of soluble C5b-9 as evidence of an activated complement system (1189). Factors
earlier in the pathway were less strongly or nonsignificantly
associated with risk (479). However, C3 is an acute phase
reactant (1233, 1406), while synthesis of C2, C4, and factor
B are upregulated by IFN- in fibroblasts and macrophages
(960, 1567). Thus plasma levels may reflect inflammation
generally rather than any causal relationship and need to be
interpreted cautiously.
Proteomic analysis of HDL increasingly points to a complex

array of proteins that are involved in innate immunity and
related functions such as complement factors, proteins related to thrombosis, hemostasis, growth factors, and other
peptides (1479). Many of these proteins are found at levels
of fewer than 1 molecule per HDL particle. A subset of
HDL (found in humans, apes, and Old World monkeys)
which contains both haptoglobin-related protein and
apoL-1 constitutes trypanosome lytic factor 1, an important innate defense against certain trypanosomes (1619).
Besides mobilizing cholesterol, apo A-1 seems to adsorb
and neutralize the inflammatory effects of LPS (748), a
property of HDL that likely has functional anti-inflammatory consequences (1719). The ability of HDL to remove
specific oxidized phospholipids appears to facilitate innate
immune responses in macrophages (357).
PAUL N. HOPKINS
comial respiratory infection was reported to be increased
10-fold in patients with very low HDL (20 mg/dl) (406).
1. Emphasis on the role of HDL in innate immunity
may clarify observations regarding reverse
cholesterol transport
Two studies have recently examined cholesterol efflux capacity of plasma as a predictor of CAD in humans (902,
1038). Both studies utilized plasma from the test subjects
that had been treated to remove APOB-containing lipoproteins. This treated plasma was then diluted (2 4%) and
incubated with macrophages that had been previously
loaded with radiolabeled FC. The FC loading was done in
conditions such that essentially no radiolabeled CE was
formed. In both studies, greater efflux capacity of subject
plasma (the amount of radiolabeled FC transferred from the
macrophages to the diluted plasma) was strongly associated
with reduced risk of CAD in case-control (cross-sectional)
analyses. This efflux capacity of plasma was more closely
associated with CAD than with HDL-C or even APOA1
itself. In addition to HDL-C, the efflux capacity in this assay
was strongly dependent on the presence of precursor HDL
particles, pre--1 HDL, which are the primary cholesterol/
phospholipid acceptors via ABCA1 (395). In the second
study (1038), investigators examined how the radioactive
FC label distributed to different plasma components. Only
30% of the labeled FC was found in HDL particles.
About 45% was associated with APOA1 as either free or
possibly pre- HDL (but not in the HDL density range).
Much of the remainder was bound to albumin, demonstrating a significant nonspecific transfer of cholesterol from the
macrophages. Also in the second study, data were available
for 3-year incidence of new clinical coronary events within
a large angiographic cohort which was followed prospectively. The incidence of new coronary events was paradoxically higher among those with greater plasma efflux capacity (even though cross-sectional analyses in the same group
at baseline and in a separate community case-control group
1478
Prior discussion in this review emphasized the notion of

reverse cholesterol transport as a means to harmonize a
number of otherwise disparate observations such as effects
of LCAT and PLTP on atherogenesis. However, a greater
focus on the role of HDL in its interactions with cells of the
innate immune system, including endothelial cells, might
provide greater clarity. Mobilization of excess free cholesterol should promote survival (allowing more effective and
continuing efferocytosis) and limit the activation of macrophages and probably VSMC. How or where HDL rids itself
of the acquired cholesterol may be of less importance, the
only significance of this unloading step being regeneration
of active cholesterol acceptors and preservation of the number of APOA1-containing particles to carry out their varied
tasks. Such a view would not be discordant with observations on reverse cholesterol transport noted above and may
help explain the negative results to date of intervention
trials using CETP inhibitors (1575). If ongoing trials with
the more effective CETP inhibitors are positive, it may well
be that the benefits are driven by the substantial reduction
in LDL-C seen with these agents (250). Such a view also
reconciles misleading generalizations regarding the lack of
importance of gene variants that affect HDL levels in predicting CAD risk, since these studies were strongly influenced by genes such as CETP and endothelial lipase that
may primarily affect unloading steps (1883). Clearly, certain APOA1 variants are associated with CAD even in population-wide resequencing studies (685), while rare APOA1
variants can cause premature atherosclerotic disease even in
heterozygous form (381, 990).
Reverse cholesterol transport is often considered among the

most important functions of HDL to limit atherogenesis
(401, 1232, 1290). Severe atherosclerosis has long been
associated with a variety of APOA1 mutations (but not all)
that result in APOA1 deficiency in both human and animal
studies (990, 1548, 1657). Mice are clearly protected by
over-expression of APOA1, and there is rapid regression of
atherosclerosis when native or other forms of APOA1 or
various AI mimetics are infused. Later, SR-B1 was recognized to be involved in HDL-mediated cholesterol delivery
to the liver and interactions with other cell types. Severe,
fulminant atherosclerosis and coronary lesions with appearance similar to human disease develop in ApoE-deficient mice lacking the SR-B1 receptor (204). As discussed
below, SR-B1 effects other than selective cholesterol ester
uptake from HDL into hepatocytes may be key to understanding the antiatherogenic effects of SR-B1.
showed an inverse association). Details regarding treatment

of these higher risk subjects after the test plasma was collected were not provided. Subsequent treatment effects in
the angiographic group may well have confounded these
results. However, another interpretation may be that high
plasma levels of pre- HDL frequently reflect the more
rapid generation of these particles in plasma in the face of
high risk elevations in triglycerides and low HDL-C
through the action of CETP and/or PLTP. Indeed, pre-
HDL levels in plasma can reflect multiple competing metabolic effects (e.g., initial generation of APOA1 and precursor
particles, conversion to larger particles both after interaction with ABCA1 and ABCG1 and via the LCAT reaction, regeneration of pre- HDL by CETP- and/or PLTPmediated speciation of triglyceride-enriched spherical
HDL, interactions with hepatic and endothelial lipases, renal loss, and transfer into the interstitial fluid space). Perhaps not surprisingly, in other studies using different methods to directly measure plasma pre- HDL, associations
with CAD ranged from significantly positive to significantly
negative (733, 1221, 1508). Therefore, in some settings,
higher pre- HDL plasma concentrations may manifest an
indirect association with increased CAD risk even though
pre- HDL itself appears to be mechanistically protective.

Besides stimulation of cholesterol efflux from macrophages,
endothelial, and other cells, HDL mediates a number of
additional protective effects. In various in vitro studies,
HDL is known to protect cultured endothelial cells from
apoptosis induced by oxLDL, TGRL, TNF-, and activated
complement. HDL stimulates NO production by eNOS and
increases PGI2 production through COX-2. HDL suppresses expression of VCAM-1, ICAM-1, and E-selectin by
endothelial cells with decreased monocyte adherence, as
well as reducing other signs of endothelial activation after
exposure to oxLDL or cytokines (1315). HDL may also
inhibit monocyte activation after interacting with T-cells
(1338).
2. ABCA1 is a signaling hub as well as a cholesterol
and phospholipid transporter
About 80% of plasma HDL is thought to be produced by

the liver with the remainder released from intestine (219,
1795). In both these tissues, ABCA1 plays a critical role in
ultimate release of HDL particles from the organ. Unlike
apo-B-containing TGRL which are released essentially intact from hepatocytes or enterocytes, HDL is released as a
precursor followed immediately by binding of lipid-poor
APOA1 to the extracellular (and/or possibly the intravesicular) surface of ABCA1. Without this interaction and
obtaining phospholipid and FC through the action of
ABCA1, released APOA1 is rapidly cleared by the kidneys,
and HDL levels are exceedingly low (as in Tangier disease).
Not only does ABCA1-induced lipid transfer stabilize
APOA1, but the interaction of APOA1 with ABCA1 stabilizes ABCA1. In the absence of APOA1, ABCA1 undergoes
rapid proteolysis and degradation by calpain which recognizes a proline-glutamate-serine-threonine rich (PEST) sequence in one of the cytosolic loops of ABCA1. PEST members Thr1286 and Thr1305 are constitutively phosphorylated, allowing recognition by calpain. However, binding of
APOA1 leads to dephosphorylation of these threonines and
stabilization of ABCA1 (1149). Without APOA1, ABCA1
half-life in the plasma membrane of macrophages was under 1 h (1149), while in intestinal cells the half-life was 10 h,
presumably due to constant exposure to actively synthesized and secreted APOA1 (525).
Transcription of ABCA1 and ABCG1 is mediated by LXR/

RXR heterodimers as noted previously. ApoE appears to
upregulate ABCA1 expression, supporting cholesterol efflux through an additional pathway besides direct cholesterol binding by ApoE itself (2095). Inflammatory stimuli
that activate NF-B, such as TNF-, inhibit transcription
and increase proteolysis of ABCA1 (525), providing an explanation for reduced HDL levels in conditions such as
Crohns disease, rheumatoid arthritis, and certain cancers.
Surprisingly, activation of PKC which accompanies
APOA1 binding to ABCA1 binding through generation of
DAG also promotes ABCA1 transcription through Sp1 and
LXR/RXR interactions (2087). Possibly related are observations that ceramide increases expression of ABCA1 by an
unknown mechanism (879). Transport of ABCA1 to the
plasma membrane is facilitated by palmitoylation of
ABCA1 in the ER (879). Additionally, APOA1 binding may
promote direct binding of Cdc42 to ABCA1, facilitating
transport of ABCA1 from trans-Golgi to the cell membrane
(1065). As an example of another protein interaction,
ABCA1 forms a complex with phagocytosis regulating proteins syntaxin 13 and flotillin. Syntaxin 13 helps stabilize
ABCA1 while ABCA1 can promote macrophage efferocytosis (107, 526, 2039).
Some of the anti-inflammatory signaling initiated by
ABCA1-APOA1 interactions is undoubtedly a result of reduced cholesterol content and fewer lipid rafts of the
plasma membrane as noted above. Exactly how ABCA1
facilitates lipid transfer to HDL is still a matter of debate.
According to one model, binding of lipid-free (or nearly
lipid-free) APOA1 to ABCA1 (probably as a homotetramer
or higher order oligomer) is thought to cause ABCA1 to
actively transfer phospholipids to the outer cell membrane
leaflet, causing the membrane to bulge outward (exovesiculation). This seems to occur in PC-enriched areas of the
1479
In addition to its role as a cholesterol/phospholipid transporter, ABCA1 supports a remarkable array of anti-inflammatory intracellular signaling when bound by APOA1
(1349). In BMT experiments, lack of macrophage ABCA1
increased atherosclerosis in LDLR-deficient mice (1849).
Overexpression of ABCA1 on endothelium led to both a
reduction in atherosclerosis and an increase in HDL in
C57Bl/6 mice fed an atherogenic Paigen diet (1838). A brief
summary of the control of ABCA1 expression and antiinflammatory signaling mediated by ABCA1-APOA1 interaction follows.
APOA1 binding to ABCA1 led to ABCA1 stabilization by

additional mechanisms. Calcium influx is also triggered by
APOA1 binding to ABCA1 by an apparently unknown
mechanism (885). Calmodulin is activated and binds to
ABCA1 blocking calpain-mediated degradation (885). The
increased calcium together with DAG produced by reactions triggered by lipid mobilization (see below) result in
activating PKC. In turn, PKC phosphorylates ABCA1 at
serine/threonine residues near the PEST sequence which inhibits proteolysis of ABCA1, resulting in increased protein
expression in cell membranes (1558, 2087). Finally,
APOA1 binding to ABCA1 leads to binding of PDZ-RhoGEF and leukemia-associated Rho GEF (LARG) to the PDZ
domain of ABCA1, activating RhoA which, in some way,
acutely inhibits rapid degradation of ABCA1. Although activation of RhoA acutely protects ABCA1 from degradation, chronic RhoA activation decreases PPAR and LXR
induction of ABCA1 while prolonged inhibition of RhoA
promotes ABCA1 transcription (1342).
PAUL N. HOPKINS
membrane away from cholesterol-enriched lipid rafts. The
exovesiculated domain is pinched off and surrounded by
APOA1 with the formation of nascent, PC-rich, cholesterol-poor HDL disks with two to four APOA1 molecules/disk
(814, 1869). These PC-rich discs are particularly good acceptors of free cholesterol (FC), which is transferred to the
nascent disks by diffusion from nearby lipid rafts. In other
models, transfer of PC and FC to HDL occurs together and
involves initial binding of APOA1 to a low-capacity binding
site on or near ABCA1, followed by activation of JAK2, and
transfer of the APOA1 to a high-capacity binding site followed by PC and FC loading (1065). Active ABCA1 is able
to transfer cholesterol to other apoproteins with amphipathic alpha helices, including most apoproteins carried by
HDL as well as ApoE (1065). Paradoxically, early cholesterol enrichment of the ER seems to promote ABCA1 ubiquitination and degradation (512), and cell membraine cholesterol enrichment impairs APOA1 binding to the highcapacity binding site on ABCA1 (814), phenomena that
could both promote foam cell formation.
As the newly formed HDL disks adsorb cholesterol from

lipid rafts, they appear to remove some SM at the same
time. The lipid transporter ABCG1, which preferentially
interacts with large spherical HDL, transfers SM to HDL
more effectively than ABCA1 (924). Consistent with this
observation, large HDL particles are greatly enriched in SM
compared with small HDL (936). By whatever means,
APOA1 interacting with ABCA1 and/or ABCG1 results in
reduced membrane SM content. A reduction in SM can
promote net transfer of phosphocholine from phosphatidylcholine to ceramide to replace the sphingomyelin, resulting in an increase in membrane DAG (2010). This fully
reversible reaction is catalyzed in the plasma membrane by
SMS2 (sphingomyelin synthase 2, also known as SGMS2)
(779, 1735). SMS1, a counterpart to SMS2, is found primarily in the Golgi. The ability to extract phosphocholine
from either PC or SM and transfer it reversibly to ceramide
or DAG is thought to establish an equilibrium of these lipids
in the membrane. Furthermore, such activity could provide
a dynamic balance between the pro-apoptotic effects of ceramide and the cytokine-associated, mitotic effects of DAG
(1735). Thus a relative deficit of SM after HDL interaction
1480
From the above paragraph, SMS2 might reasonably be expected to be protective. However, net results from alterating SMS2 activity appear to depend on cell status. It should
be noted that the activity ascribed to SMS2 has been described in the literature as belonging to a putative PC-PLC,
which is inhibited by the compound D609 (13). In some
models, inhibition of SMS2 with D609 increased ceramide
and resulted in impaired proliferation and increased apoptosis (13). In contrast, overexpressing SMS1 and/or SMS2
together with TNF- treatment in Chinese hamster ovary
cells or LPS treatment in macrophages led to increased apoptosis in cells while siRNA knockdown of SMS1/2 protected against apoptosis (427). In these models, SMS1/2
seemed to increase membrane SM with increased lipid raft
formation and greater TNFR1 and TLR4 activity. Overexpression of SMS1/2 also suppressed HDL-mediated cholesterol efflux in this study. More recently, administration of
D609 to ApoE-null mice was reported to arrest progression
of atherosclerosis and resulted in a more stable plaque phenotype (2077). The investigators further found that SMS2
activity appeared to be required for expression of the proinflammatory LOX-1 receptor in endothelial cells and that
D609 treatment decreased endothelial expression of
VCAM-1, ICAM-1, and MCP-1. In another study, adenoviral delivery of SMS2 to ApoE KO mice increased atherosclerosis substantially but also increased non-HDL lipid levels and decreased HDL, confounding the interpretation of
direct SMS2 effects (1914). Effects of these manipulations
on SM in lipoproteins should also be examined since APOBcontaining lipoproteins that have more SM are more subject
to aggregation upon treatment with sphingomyelinase.
As noted above, the calcium influx triggered by APOA1
binding to ABCA1 promotes calmodulin binding to ABCA1
and helps prevent calpain-mediated degradation. In addition, calmodulin activation also promotes JAK2 activation
in some manner that requires calcineurin (885). JAK2 apparently binds ABCA1 directly and its activation is required
for normal lipid transfer activity to APOA1 and HDL
(1065). Activation of JAK2 by APOA1 binding to ABCA1
also results in STAT3 binding to ABCA1 and STAT3 activation. JAK2/STAT3 signaling is strongly anti-inflammatory in endothelial cells and macrophages. Recently, STAT3
was shown to induce production of tristetraprolin (TTP), a
specific inhibitor of several inflammatory cytokines including TNF- and IL-1. TTP acts by binding the 3= end of the
Sphingomyelin (SM) is also transferred to HDL in its interaction with various cells. In artificial membranes, SM is said
to promote lipidation of reconstituted HDL or APOA1
(412, 564). One might postulate that this is due to SMmediated sequestration of membrane cholesterol into the
discrete, cholesterol-enriched lipid rafts, domains which remain separate from the PC-enriched areas where ABCA1
seems to partition itself. SM seems uniquely suited to this
task due to its saturated fatty acid tails which effectively
interact with cholesterol while the large, highly charged
head allows effective interaction with the aqueous environment.
with the membrane might lead to net transfer of phosphocholine from PC to ceramide, thereby regenerating SM and
decreasing ceramide but with a net result of increased DAG.
Such a reaction, together with increased calcium entry into
the cytoplasm, occurs after APOA1 binding to ABCA1, the
resulting DAG leading to activation of PKC and stabilization of ABCA1 (as noted above). An inhibitor of SMS2 (and
SMS1) decreased PKC activation and also impaired cholesterol transfer to APOA1 (831, 2010).

mRNA of these cytokines and causing destabilization and
degradation. Phosphorylation of TTP by p38 causes its inactivation, but APOA1 binding to ABCA1 is also reported
to inhibit p38 (2038).
ABCA1 appears to be coupled in some way to Gs subunits
which activate adenylate cyclase upon APOA1 binding
(694). Subsequent PKA activation leads to ABCA1 phosphorylation and increased transport activity. This property
was recently utilized to examine efflux of cholesterol to
APOB-deficient serum with or without incubation of free
cholesterol-loaded macrophages with a cAMP analog
(1038). Active PKA may cause release of cholesterol as microparticles by an unknown mechanism which is greatly
facilitated by ABCA1 (455, 1099, 2088). Increasing intracellular cAMP by pharmacological means appears to increase APOA1-mediated cholesterol removal from macrophages and may even increases plasma HDL-C levels
(2087).
3. Role of SR-B1 in HDL signaling
Whole-body SR-B1 KO in mice increased HDL-C and atherosclerosis substantially while liver-specific KO resulted in
similar effects on HDL-C but lesser effects on atherosclerosis (1523). However, bone marrow-derived cells (353,
1848) and endothelium deficient in SR-B1 each contribute
to excess atherosclerosis without affecting serum lipid levels
(1523). Macrophage-specific knockout of SR-B1 had a
lesser effect on atherosclerosis, suggesting that HDL interactions with SR-B1 on other cells may be more important
(1913, 2081). An altered ratio of plasma unesterified to
total cholesterol in SR-B1 deficiency leads to platelet activation and may contribute to the atherosclerosis (772).
These studies suggest reverse cholesterol transport is not the
only means whereby SR-B1 affects atherogenesis.
PDZ domain-containing protein 1 (PDZK1, where PDZ

stands for the original recognition of a shared structure in 3
proteins, PSD-95, DlgA, and ZO-1) is an adapter or scaffolding protein which binds to the cytosolic side of SR-B1
and interacts with a number of other membrane-associated
proteins to properly locate it in the cell membrane (in some
cells) and mediate intracellular signaling. PDZK1 is highly
expressed in liver, intestine, and kidney, and in humans, in
adrenal, ovary, and testis as well (1523). It is not expressed
in macrophages (1752). In hepatocytes, PDZK1 deficiency
leads to 95% reduction in SR-B1 expression, but no effect
on macrophage SR-B1 expression and little effect in endothelial cells was seen. Nevertheless, PDZK1 is required in
endothelial cells for APOA1-induced signaling. Thus, in
endothelial cells, APOA1 binding to SR-B1 leads to Srcdependent activation of type 1A PI3K isoforms. Src also
seems to mediate activation of Rac and ERK1/2 (1523).
PDZK1 is required for Src activation by HDL. Indeed,
PDZK1 KO completely blocked HDL-mediated increases
in eNOS and promotion of endothelial repair after injury
(2113). Increased atherosclerosis was reported for PDZK1
KO in ApoE null mice fed a western diet and led to coronary
occlusion when these mice were fed a Paigen-type diet
(2034).
The COOH terminus transmembrane segment of SR-B1
contains a conserved glutamine that was recently shown to
serve as a membrane cholesterol sensor. In cells expressing
normal SR-B1, depletion of cholesterol by either cyclodextran or HDL caused Src-dependent phosphorylation and
activation of eNOS. Converting the conserved glutamine to
alanine in the SR-B1 COOH terminus cytoplasmic membrane domain prevented the HDL-induced activation of
eNOS. This occurred without affecting the binding of
PDZK1 to the SR-B1 COOH terminus. Furthermore, reverse cholesterol transport from HDL to hepatocytes and
bile was not affected (1522). The significance for atherosclerosis of this membrane cholesterol sensing function of
SR-B1 awaits further studies.
4. HDL and S1P signaling
Several of the atheroprotective effects of HDL on endothelial cells and probably macrophages appear to be mediated
not only by apo A-1 but also by lipid components carried in
HDL, particularly sphingosine-1-phosphate (S1P) and related lysosphingolipids binding to specific receptors (partic-
1481
Binding of HDL APOA1 to the SR-B1 receptor results in

selective uptake of cholesterol ester (that is, without holoparticle degradation) from HDL into hepatocytes and steroidogenic adrenal cells (7). HDL released after interaction
with hepatic SR-B1 is thought to be more capable of eliciting efflux from cholesterol-loaded cells. In human macrophages, SR-B1 can mediate net transfer of cholesterol to
HDL but apparently in mouse, little if any cholesterol efflux
from macrophages occurs via SR-B1 (1523, 1874). Macrophages from human subjects heterozygous for a variant of
SR-B1 (P297S) that impaired HDL binding displayed decreased transfer of CE to HDL. In addition, SR-B1-deficient
mouse hepatocytes transfected with the abnormal human
variant showed impaired uptake of cholesterol from HDL.
Finally, increased platelet activation and decreased glucocorticoid production were demonstrated in heterozygous
humans, together with a 50% increase in serum HDL-C (to
70 mg/dl) (1874).
Another illustration of anti-atherosclerotic effects realized

by HDL without cholesterol transport was recently reported. Vein grafts transplanted to the carotid arteries of
ApoE-deficient mice were greatly protected from atherosclerosis when a gel containing HDL was applied to the
adventitial side of the transplanted vein. The treatment was
strongly anti-inflammatory, promoted recruitment of true
endothelial colony forming cells with increased VEGF signaling, and was dependent on the presence of SR-B1 (518).
PAUL N. HOPKINS
ularly S1PR1) (1338, 1888, 1953). HDL carries over 50%
of the S1P in plasma (77, 78).
Of potentially great interest is the relatively neglected apolipoprotein, apoM, found on only 5% of HDL particles
(as well as some non-HDL lipoproteins). ApoM apparently
mediates virtually all S1P removal from cells and loading
onto HDL, as well as subsequent receptor interaction (322,
323). ApoM also seems to be required for normal regeneration of pre- HDL, possibly by interacting with PLTP
or hepatic lipase (HL) (321). Overexpression of apoM
was reported to decrease atherosclerosis progression in
hyperlipidemic mice (321, 1970), but effects of knockout
on atherosclerosis have apparently not been examined
(see TABLE 8).
Binding of APOA1 to SR-B1 not only leads to selective CE

uptake in hepatocytes and SR-B1 mediated signaling in endothelial cells but also brings the HDL particle into the
proximity of S1PR1 receptors. Injection of mice with an
agonist of the S1PR1 receptor or incubation of isolated
aorta with S1P ex vivo blocks TNF-induced monocyte adhesion through upregulation of PKB signaling, increased
eNOS activity, and possibly inhibition of JNK (172). Indeed, activation of the S1PR1 recapitulates a number of the
protective features of prolonged exposure to laminar flow
(see FIGURE 7). These effects appear to be mediated by
PI3K, Akt/PKB, Erk1/2, and Rac1 activation with resulting increased barrier integrity, increased NO production,
suppression of inflammatory responses, promotion of cellular antioxidants, and increased cell survival. PI3K can
also signal to p38 MAPK which, through CREB, can induce
COX-2 and support increased PGI2 synthesis (1888).
There are five known S1P receptors, S1PR1 through S1PR5
(also abbreviated S1P15). These are GPCR with the potential to be coupled to a variety of heterotrimeric G proteins.
They have diverse and frequently opposing functions
(1338). S1PR1 is primarily coupled to Gi. Gi subunits
activate PI3K with subsequent activation of PKB/Akt and
eNOS. The subunits of Gi can also stimulate PLC to
1482
In VSMC, S1PR1 and S1PR3 seem to promote proliferation

and migration (as after acute experimental balloon injury)
while S1PR2 is generally inhibitory. Furthermore, the relative proportion of these receptors is modulated during injury repair. G12/13 (which may be stimulated by all 5 S1P
receptors but primarily in S1PR25) is coupled to Rho activation with promotion of vasoconstriction (for VSMC) or
disruption of barriers when expressed at high levels (in endothelial cells).
S1PR2 was shown to be highly proatherogenic, particularly
in macrophages (see TABLE 7) (1640). In macrophages,
S1PR2 activated cAMP/PKA signaling which inhibits motility and may prevent egress from plaques (S1PR1 may
have opposite effects). S1PR2 also promotes TLR4 expression and stimulated macrophage production of IL-1 and
IL-18 (1640). In another study, S1PR3 KO led to increased
VSMC proliferation and migration (898). Gq is coupled to
S1PR2 and -3 and primarily activates PLC and calcium
signaling, and hence, vasoconstriction. Thus S1P can promote vasoconstriction or relaxation depending on the balance of S1P receptors and their associated G proteins. In
addition, S1P strongly supports angiogenesis through complex signaling and modulation of S1P receptors.
Interestingly, some of the opposing effects of S1P may be
controlled by concentration. Thus high levels of S1P (over 1
M as may occur in the vicinity of aggregated platelets),
acting primarily through S1PR3, may stimulate endothelial
activation, Weibel-Palade body exocytosis, and adhesion
molecule expresion. In contrast, low levels of S1P (1100
nM), acting through S1PR1, may have virtually the opposite effects (1338). In addition to concentration-dependent
effects, some of the anti-inflammatory signaling of S1P appears dependent on simultaneous APOA1-mediated stimulation of ABCA1 and SR-B1 (910, 1541).
5. Antioxidant effects of HDL
Spherical HDL can protect endothelial cells and promote
NO production by removal of various oxysterols, including
Production of S1P occurs in response to cytokines that utilize TRAF2 and TRAF6 in their downstream signaling.
TRAF2 binds and activates sphingosine kinase 1 (SPHK1).
The S1P produced was shown to be a cofactor required for
TRAF2 (and probably TRAF6) to function as a E3 ubiquitin ligase (1665). The S1P produced by these reactions then
seems to be transported, in part, to HDL by apo M. Thus
S1P has the unusual distinction of supporting proinflammatory signaling directly as an intracellular cofactor (and
when bound to certain of its GPCR) while directing antiinflammatory signaling when presented to S1PR1 by HDL.
This duality may help explain the reported strong positive
association between CAD and the ratio of non-HDL-bound
S1P to HDL-bound S1P (1543).
release IP3 with subsequent calcium signaling, which might

have the potential for proinflammatory signaling but may
be at a lower level in S1PR1 receptor signaling. The adapter
-arrestin binds to the receptor with subsequent Src activation, tyrosine phosphorylation, Grb2-Sos binding, and Ras
GTP exchange. The ERK pathway is then activated with
generally anti-inflammatory, antioxidant, and survival effects in endothelial cells. While PI3K and Src can activate
Rac1 and Cdc42 in VSMC and leukocytes to promote migration (indeed S1PR1 is required for leukocyte egress from
the thymus), in confluent endothelial cells, PI3K and Rac1
primarily promote increased cell-cell adhesion and barrier
integrity (1665). The Rac GEF P-Rex1 seems to interact
directly with the S1PR1 GPCR and may mediate Rac1 activation in response to S1P (987).

the spontaneous oxidation product 7-ketocholesterol, by
way of the ABCG1 transporter (1763, 1771). HDL also
removes 7-ketocholesterol from macrophages and thereby
decreases apoptosis in an ABCG1-dependent fashion
(1769). Oxidized sterol was found to accumulate when
mice were fed a western-type diet. It has been pointed out
that AGCG1 may primarily move cholesterol and oxysterols to the inner leaflet of intracellular endosomes and that
a variety of molecules other than HDL can serve as the
cholesterol acceptor (1762). Nevertheless, HDL helps prevent LDL oxidation or detoxifies oxidized phospholipids in
LDL through the HDL-associated enzyme PON1. PON1
KO mice express increased atherosclerosis, while overexpression of PON1, PON3, or the entire human PON1,
PON2, PON3 cluster was protective (1607, 1620). These
findings contrast with the much more variable outcomes
associated with more mild effects on PON1 caused by common human variants (1656). Finally, HDL also binds and
inactivates LPS, reducing endotoxin activation through
TLR4 (1259).
The molecular biology and related signaling of the pathways presented in this section have been the topic of numerous recent reviews. This is particularly true of thrombosis
and angiogenesis pathways. For this reason, these topics
will be presented in a relatively abbreviated format with a
few orienting comments as they relate specifically to atherogenesis.
A. Matrix Metalloproteinases and

Cathepsins
Matrix metalloproteinase (MMP) enzymes and cathepsins
are generally thought of as powerful extracellular matrix
degrading enzymes that cause plaque instability. Virtually
all migrating cells must secrete some array of digestive enzymes to move through the extracellular matrix. Nevertheless, MMP functions differ considerably from one to another. A relatively complete series of genetic manipulation
studies have now been completed (summarized in TABLE
10). As it turns out, some MMPs (particularly normal levels
of MMP-2 and -9) seem to promote plaque stability by
promoting VSMC migration and cap formation. In contrast, MMP-12, (and to a lesser extent 13 and 14) and high
levels of activated MMP-9 promote inflammation and
plaque instability (1295). Tissue inhibitor of metalloproteinases 2 (TIMP2) and TIMP3 inhibited macrophage migration while all the cathepsins tested appeared to support
macrophage migration and activation. Thus cathepsin
deletion or TIMP2/3 overexpression were protective (see
TABLE 10).
Thrombosis followed by thrombus organization clearly

plays a role in the progression of advanced, complex
plaques, resulting in demonstrable saltatory progression of
obstructive lesions (233, 1136). However, genetic predisposition to venous thrombosis does not necessarily translate to
a predilection to atherosclerosis or a measurable increased
risk of MI or other acute coronary events. Arterial thrombi
are rich in platelets and poor in fibrin while in venous
thrombi, platelets are sparse, fibrin predominates, and the
clots are friable and prone to large emboli. Well-recognized
risk factors for the two conditions are also different. In
human studies, genetic factors that clearly increased risk of
VTE only slightly increased risk for MI (2032). Similarly,
carrying an allele for a bleeding disorder may only slightly
decrease risk for MI, if at all (1628, 1667, 1668, 1820).
Despite these caveats, a number of new animal models of
thrombosis-related genes present promising new avenues
for research into this late stage of atherogenesis (see TABLE
10) (183).
At later stages of atherogenesis, ANG II action to increase
PAI-I may become important. In ApoE KO mice, the longacting angiotensin receptor blocker azilsartan decreased
PAI-1 expression and increased VSMC in plaques, suggestive of greater stability (548). However, whole body PAI-1
KO had no effect on atherosclerosis overall (see TABLE 10
under vaso-vasorum and angiogenesis related).
Prothrombotic vWF was found to be proatherogenic in
mouse models while ADAMTS13 which proteolyzed vWF
into small fragments was protective. Tissue factor (TF), the
main instigator of clotting, had mixed effects on atherosclerosis, factor V was proatherogenic, while tissue factor pathway inhibitor (TFPI) appeared protective. TFPI blocks the
active TF-VIIa complex when activated by active factor X.
These and other clotting factors are reviewed in TABLE 10.
Among the most promising late-stage animal models are
those that relate to thrombin activation, signaling, and inhibition (183). Thrombin (activated coagulation factor II)
has multiple proinflammatory effects on endothelium as
well as other cells and stimulates activation of NOX enzymes and ROS production. Thrombin may directly promote VSMC migration and proliferation through proteaseactivated receptor 1 (PAR1) on VSMC or by increasing
PDGF release from endothelial cells (184). Thrombin deficiency was reported to decrease atherosclerosis in animal
models (see TABLE 10). Thrombomodulin (TM), expressed
on the luminal surface on endothelial cells, binds and inhibits thrombin activation. ApoE KO mice that expressed a
defective TM had more than twofold increase in spontaneous atherosclerosis. Carotid cuff placement in these mice
greatly increased plaque size, leading to frequent plaque
rupture and hemorrhage. Marked reduction in plaque size
was reported when mice were treated with the thrombin
1483
XI. FURTHER PLAQUE DESTABILIZATION

AND PRECIPITATION OF THROMBOSIS
B. Thrombosis and Atherosclerosis
PAUL N. HOPKINS
(1135). These findings provide new impetus for controlling
weight gain and other factors that may increase deposition
of coronary perivascular fat, recently shown to be strongly
associated with atherosclerotic plaques in humans (1114,
1161, 1750).
C. Vaso-vasorum
XII. PERSPECTIVES
When the thickness of the intima increases beyond just 0.5

mm, hypoxia induces ingrowth of vaso-vasorum (934). In
recent years there has been growing appreciation for the
potentially major destabilizing effects of these leaky, friable
vessels. Postcapillary venules of vaso-vasorum are much
more reactive to inflammatory signals than arterial endothelium and were recently shown to harbor 100 times more
firmly attached leukocytes than the arterial luminal side
(485). Such inflammation is further supported by the lymphoid tissue that can develop in the adventitia, supported
by VSMC activation as previously noted. Others have identified adventitial entry through vaso-vasorum as a major
source of plaque macrophages (1206). Furthermore, vasovasorum invading lipid-rich plaques remains highly permeable due to constant exposure to inflammatory factors.
Rather than sudden hemorrhage, vaso-vasorum constantly
leaks red blood cells into plaques leading to plentiful red cell
markers in unstable plaques despite relatively few recognizable red blood cells. In these large, lipid-rich, inflammed
lesions, red cell membranes appear to contribute majorly to
free cholesterol which may greatly exacerbate formation of
toxic cholesterol crystals in lesional phagocytes. In addition, red blood cells are a source of strongly pro-oxidant
heme iron which is thought to favor inflammation and lesion progression when exposed to already inflammed, M1type macrophages. Such a scenario may ominously favor
progression of lesions for some time even after plasma lipoprotein levels are reduced.
As the field of molecular biology and signaling matures and

physiologically meaningful pathways emerge, we take satisfaction in recognizing the elegance of many of these systems and seeing opportunities for new interventions. While
lengthy, this review is but an introduction, lacking, for example, any but the most cursory mention of negative regulation of many of the presented pathways (which have generally not been the focus of the molecular interventions
conducted thus far).
Gene manipulation of factors which control the neovascularization of atherosclerotic plaques demonstrate that proliferation of vaso vasorum substantially aggravates the
growth of advanced plaques. Some investigators had hypothesized that treatment of mice to promote angiogenesis
(as with G-CSF and GM-CSF) would limit atherosclerosis
but were surprised to find the opposite (691). Details of a
number of such interventions are presented in TABLE 10.
Finally, perivascular fat has been suspected to promote increased vascular inflammation from the outside in (1455).
In a remarkable series of investigations, transplanting
perivascular fat around a carotid vessel was shown to markedly increase intimal proliferation after wire injury, enhance adventitial inflammation, stimulate angiogenesis of
new vaso-vasorum, and markedly promote localized atherosclerosis in LDLR KO mice. Furthermore, perivascular
fat was much more proinflammatory than fat from other
sources and showed greatly increased release of TNF-,
MCP-1 (CCL2), and MIP-1 (CCL3) upon high-fat feeding
1484
Recently, yet another level of control has been recognized in

miRNA (micro RNA). One reviewer likened these 700
known small transcripts to conductors of the orchestra
(735). After transcription from nongenic regions and introns, followed by processing in the nucleus by removal of
the 5cap and poly-A tail, pre-miRNA are transported out
of the nucleus and further processed, finally ending up in the
RNA-induced silencing complex (RISC) where they bind to
the 3 end of many mRNA, leading either to transcriptional
repression or complete mRNA degradation. Because a
given miRNA can bind many different mRNA molecules,
and a particular mRNA can bind multiple different
miRNA, the potential for control and its complexity escalates rapidly. More than two dozen miRNA species have
been documented to affect vascular function (735). One of
these, miR-21, is upregulated in endothelial cells by prolonged laminar flow and silences PTEN expression (1934).
This decrease in PTEN due to miR-21 expression resulted in
enhanced PKB and eNOS activity and increased NO production. Recently, HDL was shown to be capable of transporting and delivering miRNA, resulting in functional effects, with relevance to atherosclerosis awaiting further
study (1877). Furthermore, endothelial cells exposed to
laminar flow were shown to release miRNA-containing microvesicles which could penetrate and direct VSMC quiescence as manifest by a more contractile phenotype (752).
miR-126, secreted by endothelial cells and found in endothelial-derived microvesicles, suppresses endothelial
VCAM-1 expression (723) while disturbed flow increased
miR-92a which blocked KLF2 and KLF4 (2006). miR-217
and miR-34a block SIRT1, miR-221/222 block eNOS,
miR-27b blocks thrombospondin-1, and so on (2006).
Many more findings regarding miRNA are likely forthcoming, but models directly demonstrating an effect on atherosclerosis from miRNA manipulation have apparently not
yet been reported.
Despite our incomplete understanding, new innovations in
treating and preventing atherosclerotic cardiovascular dis-
inhibitor dabigatran (181). Similar results were reported

with another thrombin inhibitor, melagatran (117, 746).
Several other genes that affect clotting or platelet activity
are also reviewed in TABLE 10.

ease will likely come from continued creative efforts to understand and intervene in the pathways presented above.
That being said, vigorous application of proven interventions to control standard risk factors remains the cornerstone for prevention at this time and finds ample justification in the literature reviewed here (particularly for lipids,
blood pressure, and weight control to prevent diabetes).
Indeed, experimental atherosclerosis rarely occurs without
substantial hyperlipidemia and regression generally occurs
with normalization of serum lipids.
In choosing targets for intervention, the importance of balance must always be kept in mind, particularly for longterm use in asymptomatic populations. Reduction of inflammation, such as by increasing Treg (perhaps with vitamin D supplementation), or by targeted inhibition of
TNF-, PKC, NOX2, or other interventions must be balanced against risk of immunodeficiency (even if subtle), a
judgement that will ultimately require large clinical trials.
Direct TNF- inhibition appears to benefit patients with
autoimmune disease, but further understanding of why
there is a gradual increase in TNF signaling with age accompanied by a general deficit of cellular antioxidant defenses
would perhaps lead to even greater benefits. Pharmacological inhibition of the apoptosis-promoting actions of various signaling molecules (such as p66Shc or JNK) needs to
be weighed against a potential increased risk of cancer.
Increasing the strongly cytoprotective signaling of PKB paradoxically seems to decrease longevity. Bolstering natural
cellular antioxidant defenses seems worth pursuing, recog-
Redundancy, compensatory networks, and the usually mild

effects of common variants will make the discovery of new
atherosclerosis genes difficult by GWAS or similar statistical approaches in human populations. Nevertheless, inherent limitations are being partly overcome by ever-increasing
sample sizes utilized in these studies and application of
newer resequencing methodologies. However, the fundamental limitations of human gene discovery have not impeded the explosion in our understanding of molecular
pathways mediating atherogenesis nor need they hinder future translation into clinical applications. Indeed, based on
the rich store of knowledge already gleaned, that future
looks bright indeed.
ACKNOWLEDGMENTS
Address for reprint requests and other correspondence:
P. N. Hopkins, Cardiovascular Genetics, Dept. of Internal
Medicine, Univ. of Utah, 420 Chipeta Way, Rm. 1160, Salt
Lake City, UT (e-mail: paul.hopkins@utah.edu).
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared
by the author.
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Molecular Biology of Atherosclerosis

Paul N. Hopkins
Physiol Rev 93:1317-1542, 2013. doi:10.1152/physrev.00004.2012

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Physiol Rev 93: 13171542, 2013

MOLECULAR BIOLOGY OF ATHEROSCLEROSIS

atherosclerosis. Because the field is now so extensive, an

0031-9333/13 Copyright 2013 the American Physiological Society

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Among the strongest effects on atherosclerosis in animal

CCR2-/- in apo E -/300

CCR2+/- in apo E -/CCR2+/+ in apo E -/p = 0.003

Gene dose effect

Weeks on atherogenic diet

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Networks may also broaden the functionality achievable by

Mean lesion area

sheds little or no light on function (e.g., Keap1 is Kelch-like,

MOLECULAR BIOLOGY OF ATHEROSCLEROSIS

II. OVERVIEW OF ATHEROGENESIS

In this scheme, major risk factors frequently act at more

Physiol Rev VOL 93 JULY 2013 www.prv.org

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While fascinating, genomic or proteomic approaches will

agnosis of cancer (499). The associated risks for such events

The measure of atherosclerosis generally utilized for this

III. FUNDAMENTAL SIGNALING

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Promotion proceeds as retained and modified lipoproteins

size the value of these models in providing general insights

MOLECULAR BIOLOGY OF ATHEROSCLEROSIS

A surprisingly large number of signaling pathways occur on or

An exception to the frequently anti-atherogenic effects of RTK

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A. Receptor Tyrosine Kinases

Ras PI3K P IRS1/2

Peripheral actin assembly

p53, LKB1, p66Shc

CCND1, claudin 5, NF-B, eNOS

PKB, Bcl-XL, VEGF, p53

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MOLECULAR BIOLOGY OF ATHEROSCLEROSIS

Insulin-signaling, Akt/PKB, and related pathways

INSR/ BMT into

ESMIRO (endothelial-specific INSR knockout) effect may be due

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The INS2 (insulin 2) Akita mutation (Cys96Tyr) causes misfolding

Atherosclerosis difference in aortic root given. Whole body

Physiol Rev VOL 93 JULY 2013 www.prv.org

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MOLECULAR BIOLOGY OF ATHEROSCLEROSIS

Disturbed flow and oxLDL can lead to activation of PKC,

Grb2/ is embryolethal. Grb2 is an adapter protein that

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In JNK2 KO, macrophage SR-A was not phosphorylated and

NF-B signaling including activation by TNF-

TACE (TNF cleavage enzyme)/ADAM17 cleaves TNF, TNFR1,

Physiol Rev VOL 93 JULY 2013 www.prv.org