PATHOGENESIS, RISK FACTORS AND PREVENTION

The pathogenesis What’s new?

of atherosclerosis C Endothelial-derived nitric oxide is critical for maintaining an
Gillian Douglas anti-atherogenic environment in the vessel wall
C Inflammatory cell recruitment is a key determinant in the initi-
Keith M Channon ation and progression of atherosclerosis
C Statin treatment modifies and stabilizes plaques by reducing
cholesterol concentrations, decreasing inflammation and
Abstract
Atherosclerosis is a chronic, inflammatory disease of the arterial wall that improving vascular function
underlies many of the common causes of cardiovascular morbidity and
C Genome-wide association studies are revealing novel disease
mortality, including myocardial infarction (MI), and cerebrovascular and mechanisms and may identify new therapeutic targets for the
peripheral vascular disease. Early pathological descriptions viewed treatment of atherosclerosis
atherosclerosis as an end-stage degenerative process that inevitably
C Modulation of miRNA may provide new therapeutic targets and
resulted in a generalized narrowing of the arterial lumen. However, prog- circulating miRNA may be useful biomarkers for atherosclerosis
ress in our understanding of the pathophysiology and the underlying
cellular and molecular mechanisms has revealed that atherosclerosis is
a dynamic biological process. The identification of key roles for the endo-
Pathogenesis of atherosclerosis
thelium, inflammation and vascular smooth muscle cells (VSMC) in plaque
biology has indicated that the cellular composition and biology of the pla- Atherosclerosis is a disease of large and medium-sized arteries,
que are more relevant to disease progression and complications than characterized by endothelial dysfunction, vascular inflammation
luminal narrowing alone, which offers new opportunities to modify and and the accumulation of modified lipid, inflammatory cells and
treat different aspects of the disease process. cell debris in ‘plaques’ within the vascular wall. Plaques are usu-
Keywords Atherosclerosis; cholesterol; endothelium; inflammation; ally found only at specific sites in the vasculature, such as curva-
nitric oxide tures and bifurcations, characterized by non-laminar (turbulent)
flow and reduced shear stress. In these regions endothelial cells
undergo endoplasmic reticulum stress with decreased atheropro-
tective NO and increased superoxide production. This results in
an increase in endothelial cell turnover, permeability and lipid
The normal vessel wall and endothelial function
accumulation in the sub-endothelial space.1
A normal, healthy artery comprises three layers: Low-density lipoprotein (LDL) is susceptible to modification,
 endothelial cell layer (tunica intima) e a monolayer of particularly by oxidation, resulting in oxidized LDL (oxLDL).
endothelial cells and their basement membrane, which Monocytes entering the plaque proliferate, differentiate into
lines the lumen of all blood vessels macrophages and take up oxLDL to form foam cells that potentiate
 media (tunica media) e concentric layers of vascular the inflammatory response, leading to fatty streak formation e the
smooth muscle cells (VSMC), elastin fibres and extracel- first stage in plaque development. OxLDL is taken up by macro-
lular matrix that control vascular tone phage scavenger receptors that are not down-regulated as the cell
 adventitia (tunica adventitia) e surrounding layer of con- increases cholesterol content. Death of foam cells leads to the
nective tissue, containing micro-vessels (vasa vasorum), formation of a necrotic lipid core within the intima. In response to
and related to perivascular adipose tissue. May be an cytokines and growth factors, some atherosclerotic plaques
important site for inflammation and angiogenesis. accumulate VSMC, which migrate from the media layer, prolif-
Endothelial cells act as an interface and functional link be- erate and synthesize extracellular matrix proteins such as collagen
tween circulating blood and the rest of the vessel wall; alterations and elastin. VSMC migration and proliferation may contribute to
in their phenotype can have dramatic effects on vessel wall luminal narrowing but also to the formation of a strong fibrous
function. Nitric oxide (NO) is one of the most important signal- cap, which maintains plaque stability by isolating the lipid core
ling molecules produced by the endothelium (Figure 1) and has from circulating blood. These factors contribute to the growth and
multiple effects on: stability of the plaque (Figure 2).
 vascular smooth muscle cells e relaxation and inhibition
of proliferation Endothelial dysfunction in atherosclerosis
 platelets e inhibition of activation and aggregation
 inflammation e inhibition of cell adhesion and migration. Endothelial dysfunction occurs at sites where the endothelial cell
layer has been injured (low or non-laminar shear stress) and/or
exposed to metabolic or chemical stress (diabetes mellitus, high
serum cholesterol, effects of cigarette smoke), and is evident before
Gillian Douglas PhD is a Post-Doctoral Research Fellow at the University
the appearance of atherosclerotic plaques. Clinically, endothelial
of Oxford, Oxford, UK. Competing interests: none declared.
dysfunction is measured by abnormalities in endothelial-dependent
Keith M Channon MD FRCP is Professor of Cardiovascular Medicine at the vasodilatation.
University of Oxford and Honorary Consultant Cardiologist at the John Endothelial dysfunction is also associated with increased
Radcliffe Hospital, Oxford, UK. Competing interests: none declared. generation of reactive oxygen species, particularly superoxide.

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Please cite this article in press as: Douglas G, Channon KM, The pathogenesis of atherosclerosis, Medicine (2014), http://dx.doi.org/10.1016/
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 PATHOGENESIS, RISK FACTORS AND PREVENTION

LDL, low-density lipoprotein; NO, nitric oxide; VCAM, vascular cell adhesion molecule.

Figure 1

NO reacts rapidly with superoxide radicals to form peroxynitrite accumulation and atherosclerosis. Once differentiated into mac-
(ONOO ), which has damaging effects on proteins and lipids and rophages, monocytes produce pro-inflammatory cytokines and
also removes NO from the blood vessel wall before it can bind to take up oxLDL, leading to foam cell formation and plaque pro-
soluble guanylate cyclase. Although it is well recognized that gression as previously described. It used to be thought that, once
superoxide has an important role as a signalling molecule in present, macrophages could not leave the plaque and that pla-
normal vascular function, excess production is highly patholog- ques could only progress and not regress, but it is now estab-
ical and linked to the progression of atherosclerosis.1 Other lished that macrophages can leave the plaque in response to
contributors to reduced NO production include deficiency of chemo-attractant signals such as CCR7. In addition, macro-
essential co-factors for eNOS function (e.g. tetrahydrobiopterin) phages can offload cholesterol to circulating acceptors such as
and reduced availability of the substrate L-arginine. high-density lipoprotein (HDL) via reverse cholesterol transport,
thereby decreasing lipid accumulation within the plaque.3
Inflammation and atherosclerosis
T cells
Monocytes and macrophages T cells are a subset of lymphocytes found in the adventitia of
Monocytes are produced in the bone marrow and circulate in the healthy non-diseased arteries, which play a central role in cell-
blood. Resident monocytes are also found in healthy arteries, mediated immunity. T cells have been found to also play a role
where they patrol healthy tissue for sites of inflammation.2 In in mature plaques. T-helper (Th) 1 cells secrete a number of in-
response to oxLDL, local tissue produces chemokines that direct flammatory pro-atherogenic cytokines (e.g. interferon-g and
monocytes to areas of inflammation where they differentiate into tumour necrosis factor [TNF]), whereas regulatory T cells (Treg),
macrophages and proliferate, further increasing monocyte which secrete IL-10 and transforming growth factor (TGF)-b and
recruitment. In genetically altered mice, inhibition of chemokine are essential for controlling or dampening immune responses,
receptors results in almost complete prevention of macrophage are beneficial. Adoptive transfer of Treg cells to ApoE-/- mice

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Please cite this article in press as: Douglas G, Channon KM, The pathogenesis of atherosclerosis, Medicine (2014), http://dx.doi.org/10.1016/
j.mpmed.2014.06.011
 PATHOGENESIS, RISK FACTORS AND PREVENTION

cap of extracellular matrix and VSMC and does not encroach on

Optical coherence tomography the lumen diameter. Plaque growth may be associated with
(OCT) of a normal human expansion of vessel diameter (so called ‘positive re-modelling’),
coronary artery, with an so that the lumen is not significantly narrowed and the lesion
unoccluded remains asymptomatic. Conversely, the plaque may re-model
L lumen (L) and minimal
thickening of the artery wall without change in the external arterial diameter to cause nar-
(W). The imaging wire is seen rowing of the lumen (‘negative re-modelling’) and tissue
W within the vessel lumen. ischaemia (e.g. chronic stable angina). Regardless of effects on
the lumen, these plaques remain stable as long as the endothe-
An example of an lium and fibrous cap are intact, isolating the thrombogenic lipid
atherosclerotic coronary artery. core from the circulating blood.
P A large lipid-rich plaque (P) is A plaque may become unstable as a result of rapid changes in
observed, partially occluding cellular composition and structure. Unstable plaques have a large
L the lumen (L) in addition to
lipid core, and a thin fibrous cap that contains a high ratio of
increasing arterial wall (W)
W thickness. macrophages to VSMC and reduced collagen content. These
characteristics result in mechanical weakness of the cap, partic-
ularly at the shoulder regions, which are exposed to high me-
chanical strain. Such factors combined with endothelial erosion
Example of an atherosclerotic cause plaque instability.
R coronary artery that has Endothelial erosion and/or weakening of the fibrous cap are
recently ruptured (R)/had a mediated via:
L thrombotic event. The presence
 increased secretion of pro-inflammatory cytokines and
of an intra-coronary thrombus
can be observed within the synthesis of procoagulant molecules (e.g. tissue factor)
lumen of the vessel.  production by endothelial and inflammatory cells and VSMC
of matrix metalloproteinases, which degrade collagen in the
fibrous cap and endothelial cell basement membrane
Figure 2  VSMC apoptosis.
Plaque erosion or rupture allows blood to come into contact
with its highly thrombogenic core, leading to platelet aggregation
decreased the Th1-cell response and significantly reduced lesions.
and thrombus formation. Rapid expansion of the plaque with
The role of Th17 and Th 2 cells is still controversial.4
subsequent thrombus formation and distal micro-embolism re-
sults in an acute coronary syndrome. Expansion and propagation
Cellular basis of plaque stability
of luminal thrombus may result in abrupt occlusion, causing MI.
The atherosclerotic plaque is not a static, fixed lesion but a dynamic However, if coronary occlusion does not occur, or if flow is
milieu in which the behaviour of different cell types (Table 1) may restored (e.g. by antiplatelet or thrombolytic drugs), the plaque
have rapid and dramatic consequences for the resulting clinical may re-stabilize over time. Endogenous fibrinolytic mechanisms
syndromes. remodel luminal thrombus, and new VSMC migrate and prolif-
At any one time, most atherosclerotic plaques are quiescent erate to repair the fibrous cap. The plaque may become larger as
and asymptomatic. The plaque is contained beneath a fibrous a result of these (often recurrent) episodes of instability, or may

Cell types in atherosclerosis

Normal role Role in atherosclerosis

Endothelial cells Signal transduction Loss of normal function facilitates smooth muscle cell
migration and thrombosis
Production of mediators of vascular homoeostasis Activation mediates inflammatory cell recruitment
(e.g. nitric oxide, prostaglandin I2)
Smooth muscle cells Vessel contractility Form fibrous cap, synthesis of extracellular matrix, stabilize
lesion
Responsible for re-stenosis
Monocytes/macrophages Secrete cytokines and growth factors Migrate into core of plaque
Form foam cells after scavenging modified lipids
Secrete matrix-digesting enzymes that destabilize plaque
Platelets Mediate thrombosis at sites of vascular injury Cause thrombosis and embolization at sites of plaque
erosion/rupture

Table 1

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 PATHOGENESIS, RISK FACTORS AND PREVENTION

Clinical consequences of plaque instability, rupture and remodelling

Stable Unstable Acute coronary Myocardial
Effort angina syndrome infarction

Rupture/
Stable Thrombosis
erosion
Fixed stenosis

Remodelling
Partial occlusion with
Total occlusion
distal embolization

Repair

Figure 3

remain unchanged in size. Alternatively, re-modelling may modifiable risk factors, in particular lifestyle changes, the control
expand the external diameter of the vessel, ‘compensating’ for of associated diseases such as hypertension and diabetes and the
the size of the plaque and maintaining luminal area (Figure 3). lowering of serum lipid concentrations.
New imaging techniques, such as optical coherence tomography
Lipid concentrations
(OCT), allow detailed evaluation of coronary artery plaque
Large-scale studies show that increased LDL cholesterol con-
characteristics and composition in vivo (Figure 2). The ability to
centrations are highly correlated with cardiovascular risk and
image features of high-risk plaques and monitor plaque pro-
that lowering of circulating LDL cholesterol with lipid-lowering
gression may open the way to the identification of high-risk
drugs decreases cardiovascular events. In contrast to LDL
unstable plaques in vivo, the prediction of atherosclerosis
cholesterol an inverse relationship between HDL cholesterol and
events, monitoring and the targeting of therapeutic interventions.
cardiovascular disease have been established in epidemiological
studies. Acute infusion of HDL cholesterol has been shown to
Modifying atherosclerosis
promote monocyte efflux from plaques.5 However, recent clinical
There are multiple modifiable and non-modifiable risk factors for studies have not supported this beneficial role; HPS2-THRIVE,
atherosclerosis (Table 2). Current therapies are aimed at the which increased circulating HDL cholesterol concentrations by

Modifiable and non-modifiable risk factors for atherosclerosis

Risk factor Effect on atherosclerosis

Non-modifiable
Advanced age Ageing is associated with cardiovascular changes including vascular stiffening, calcification, increased
endothelial dysfunction and increased blood pressure
Gender Males have a higher risk than pre-menopausal females but female risk increases after menopause.
Oestrogen is cardioprotective and blood pressure is lower in women than in age-matched men.
Heredity For example, genetic alterations resulting in hyperlipidaemia and/or hypertension. New, large genome-wide
association studies have identified many genes with small but potentially new effects on atherosclerosis
susceptibility
Modifiable
Dyslipidaemia Excess LDL accumulation in the intima augments atherosclerosis development
Hypertension Altered shear stress leading to endothelial cell dysfunction, increased endothelial cell permeability and
endothelial cell activation, resulting in increased inflammatory cell recruitment.
Diabetes mellitus Associated with endothelial cell dysfunction and increased modification of LDL
Tobacco smoking Increase reactive oxygen species production, increased modified LDL, endothelial dysfunction
Obesity and lack of exercise Augmentation of dyslipidaemia, hypertension and insulin resistance

Table 2

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 PATHOGENESIS, RISK FACTORS AND PREVENTION

the administration of niacin, showed no benefit from raised HDL associated with the disease. GWAS studies identify genetic loci,
cholesterol.6 Genome-wide association studies (GWAS) have marked by the SNPs, which can be used to identify biological
also failed to find an association between genetic variants of HDL pathways associated with the disease. Forty-six genetic loci have
and coronary disease.7 The absolute concentration of HDL been reliably shown to contain common genetic variants that
cholesterol may be less important than the HDL subtype (small confer susceptibility to coronary artery disease (CAD).10 Inter-
vs. large) and the functionality of HDL particles, (e.g. ability to estingly, a high proportion of these do not associate with known
mediate reverse cholesterol transport). CAD risk factors (such as lipid concentrations), nor do they
contain genes known to have a role in atherosclerosis. Hence these
The effects of statins loci may indicate novel disease mechanisms that could identify
Statins inhibit hydroxymethylglutaryl-CoA reductase (HMG-CoA new therapeutic targets for the treatment of atherosclerosis.
reductase), the rate-limiting enzyme in cholesterol biosynthesis,
resulting in increased cholesterol uptake (principally in the MicroRNA
form of LDL particles). Their role in the treatment of hyper- MicroRNA (miRNA) is a single-stranded RNA molecule, targeted
cholesterolaemia, particularly in patients with, or at risk of, to the 3’ and 5’ untranslated regions (utr) of mRNA, which
coronary artery disease, is well established. Several large ran- regulate gene expression at the post-transcriptional level. miRNA
domized controlled trials, including 4S, WOSCOPS, CARE LIPID variants control the function of endothelial cells (miR-126 and -31
and the Heart Protection Study (HPS) show that lowering total control expression of adhesion molecules), VSMC (miR-29 targets
cholesterol by 25e30%, even in patients without severely MMP2 and mediates VSMC migration) and macrophages (miR-
elevated serum concentrations, has a significant beneficial effect 33, inhibition decreases plaque macrophage content), as well as
on cardiovascular events and total mortality multiple studies cholesterol metabolism (miR-122 regulates serum lipid concen-
have shown that high-dose statins not only decrease progression tration), thereby regulating atherosclerosis. Targeting miRNA
but also cause regression of plaque. expression may provide the basis for novel therapeutic targets for
Regression of atherosclerotic plaques was first noted in animal atherosclerosis. In addition, circulating miRNA variants may
studies in which animals were switched from a high-fat to a low- prove good biomarkers of atherosclerosis and different miRNA
fat diet, resulting in decreased plaque size. Multiple studies in the profiles may indicate different stages of atherosclerosis.11 A
coronary, carotid and thoracic aorta have shown plaque regres-
sion with a 40% reduction in LDL cholesterol after an average
REFERENCES
duration of 19.7 months’ treatment with high-dose statins.8
1 Sima A, Stancu C, Simionescu M. Vascular endothelium in athero-
Studies using higher doses of more potent statins that lower
sclerosis. Cell Tissue Res 2009; 335: 191e203.
LDL cholesterol by 50% show further clinical benefits over lower-
2 Auffray C, Fogg D, Garfa M, et al. Monitoring of blood vessels and
dose regimens (e.g. PROVE-IT, TNT). High-dose statin therapy in
tissues by a population of monocytes with patrolling behavior.
acute coronary syndromes confers a significant reduction in early
Science 2007; 317: 666e70.
risk (e.g. MIRACLE, PROVE-IT). These and other observations
3 Moore KJ, Sheedy FJ, Fisher EA. Macrophages in atherosclerosis: a
have stimulated considerable interest in the ability of statins to
dynamic balance. Nat Rev Immunol 2013; 13: 709e21.
modify the biology of atherosclerosis beyond reduction of serum
4 Tse K, Tse H, Sidney J, Sette A, Ley K. T cells in atherosclerosis. Int
cholesterol alone and before physical plaque regression. These
Immunol 2013; 25: 615e22.
pleiotropic effects include reduced vascular inflammation
5 Rosenson RS, Brewer HB, Davidson WS, et al. Cholesterol efflux and
(reduction in serum C-reactive protein), improved endothelial
atheroprotection: advancing the concept of reverse cholesterol
cell function (increased eNOS and endothelial cell repair), sta-
transport. Circulation 2012; 125: 1905e19.
bilization of plaque (decreased inflammatory cell recruitment and
6 Group H-TC. HPS2-THRIVE randomized placebo-controlled trial in 25
activation, reduced matrix-degrading enzymes, and increased
673 high-risk patients of ER niacin/laropiprant: trial design,
VSMC and collagen) and inhibition of platelet aggregation.9
pre-specified muscle and liver outcomes, and reasons for stopping
The HMG-CoA reductase pathway is present in many different
study treatment. Eur Heart J 2013; 34: 1279e91.
cell types and regulates production of lipid-modified proteins
7 Global Lipids Genetics C. Discovery and refinement of loci associated
(e.g. prenylation) through production of mevalonate. These
with lipid levels. Nat Genet 2013; 45: 1274e83.
proteins (e.g. Rho GTPases) are important signalling molecules
8 Noyes AM, Thompson PD. A systematic review of the time course of
in a wide range of important cellular processes. The effect of
atherosclerotic plaque regression. Atherosclerosis 2014; 234: 75e84.
statins on both cholesterol synthesis and protein modification in
9 Sadowitz B, Maier KG, Gahtan V. Basic science review: statin therapy-
diverse cell types may explain the beneficial ‘non-lipid-lowering’
part I: the pleiotropic effects of statins in cardiovascular disease.
effects of statins.
Vasc Endovascular Surg 2010; 44: 241e51.
10 Consortium CADDeloukas P, Kanoni S, Willenborg C, Farrall M,
Future therapies
Assimes TL, et al. Large-scale association analysis identifies new risk
New candidate genes loci for coronary artery disease. Nat Genet 2013; 45: 25e33.
GWAS studies examine common genetic variants (usually single 11 Madrigal-Matute J, Rotllan N, Aranda JF, Fernandez-Hernando C.
nucleotide polymorphisms [SNPs]) to establish if the variant is MicroRNAs and atherosclerosis. Curr Atheroscler Rep 2013; 15: 322.

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Please cite this article in press as: Douglas G, Channon KM, The pathogenesis of atherosclerosis, Medicine (2014), http://dx.doi.org/10.1016/
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