Unstable atherosclerotic plaque and acute coronary syndromes

Acute coronary syndromes (unstable angina pectoris, acute myocardial infarction, sudden cardiac death) participate significantly in cardiovascular and general morbidities and mortalities. Their common pathogenetic mechanism resides in the disturbance of the integrity of atherosclerotic plaque by a fissure, rupture, or ulceration and the origin of unstable atherosclerotic plaque by the formation of thrombi, which together with vasoconstriction, causes a varying degree of the dynamic obstruction of the coronary artery. Thrombogenesis takes place in coincidence with the factors of vascular wall, rheologic, thrombotic (proaggregatory and procoagulatory), and antithrombotic (antiaggregatory and anticoagulatory-fibrinolytic) factors. The formation of unstable atherosclerotic plaque is a critical point of the dissociation of both stable and unstable myocardial ischaemiae. The prevention and therapy of atherosclerosis must be complex, namely antiatherogenic, however most of all endothelium-protective, or cellulo-protective, antilipidogenic and antithrombogenic. They cannot be alternative; one therapy will not substitute another. Regarding the importance of even residual thrombosis and thrombin, new antithrombotic substances are being intensively investigated.     

Biomechanics of atherosclerotic plaque

Atherosclerosis is the leading cause of death in the U.S. In balloon angioplasty, pressure is applied directly to atherosclerotic plaque to reopen the occluded blood vessel. The mechanical behavior of the plaque often determines the outcome of the angioplasty. Little information on the material properties of atherosclerotic plaque is available, yet the properties govern the plaque's behavior. Our discussion of the experimental testing and numerical analysis of plaque is directed toward summarizing the current knowledge of plaque material properties. Atherosclerotic plaque exhibits a wide range of behaviors consistent with the variability in the underlying composition. Overall, plaques exhibit nonlinear and inelastic mechanical behavior, although geometry and material properties are not well known. The histomorphological composition is critical in determining the plaque's mechanical response. Finite element approximations have been used to study the stresses developed in the diseased vessel; however, material properties are a critical component of a finite element analysis: the predictive capabilities depend on how accurately the material is modeled. When more information on plaque behavior is generated through careful and extensive experimental investigations, better models will be constructed to more accurately predict plaque responses. As the biomechanics community learns about plaque mechanics, we can use the knowledge to enhance the reliability of interventional procedures.     

Pathophysiology and inflammatory aspects of plaque rupture

We describe the purification and characterisation of a thioredoxin reductase-like disulphide reductase from the ancient protozoan parasite, Giardia duodenalis. This dimeric flavoprotein contains 1 mol FAD per subunit and had an apparent subunit molecular mass of 35 kDa. The purified enzyme catalysed the NADPH-dependent (Km = 8 microM) reduction of 5,5'-dithio-bis(2-nitrobenzoic acid) to thionitrobenzoate and was unable to utilise NADH as an electron donor. The sulphydryl-active compounds, N-ethylmaleimide, sodium arsenite and Zn2+ ions, strongly inhibited the enzyme suggesting that a thiol component forms part of the active site. Purified enzyme was able to utilise a variety of substrates, including cystine and oxidised glutathione, which suggests that it is a broad-range disulphide reductase, probably accounting for the majority of thiol cycling activity in this organism. While the G. duodenalis enzyme does not require an intermediate electron transport protein, analogous to thioredoxin, for activity, we have identified a candidate carrier protein which enhances DTNB turnover six fold, therefore implying that Giardia contains a thioredoxin-like system. Physical, enzymatic and spectral properties of the G. duodenalis disulphide reductase are also consistent with it being a member of the thioredoxin reductase-class of disulphide reductases. Furthermore, the internal amino acid sequence of a tryptic peptide generated from the purified protein was highly homologous with thioredoxin reductases from other sources. This is the first report of a disulphide reductase to be purified from the anaerobic protozoa and explains the so called "glutathione-induced thiol-reductase activity' previously observed in G. duodenalis.     

Composition- and history-dependent radial compressive behavior of human atherosclerotic plaque

Invasive procedures to revascularize occluded blood vessels rely on the mechanical response of the diseased tissue. Failure rates associated with such procedures show the need for improvement. to understand the associated mechanics, the material properties of atherosclerotic plaque should be known; yet data are scant. The purpose of this study was to investigate the different mechanical responses exhibited by plaques with different compositions, focusing specifically on radial compressive behavior. A custom-built experimental system was developed that was fully computer controlled with a broad range of loading capabilities. A temperature-controlled, physiologic specimen bath allowed testing at 37 degrees C. Monotonically loaded specimens showed that plaque behavior was nonlinear under finite deformations. A multiple cycle protocol, executed in two phases, distinguished three types of mechanical response of different plaques. The differences in behavior were associated with histologic differences in plaque composition, and mechanically characterized by different "repeatability" (the stabilization of the cyclic response) and "recoverability" (the second loading phase retracing the first loading phase behavior). Type 1 behavior was categorized by repeatability and recoverability. Type 2 behavior displayed repeatability but only partial recovery during the second loading phase. Recovery was absent in type 3 behavior. The histologic observations demonstrated that calcified tissue was present only in specimens displaying type 1 behavior. Fibrous tissue and part of a modified media (due to disease) were present in specimens displaying type 2 behavior. An atheroma, along with a relatively thin modified media, was present in specimens displaying type 3 behavior. The differences in the maximum stretches attained at the end of phase I loading, the stretch offset from the first to the 15th cycle of phase I loading, and the hysteresis in the first and 15th cycles of phase I loading distinguished the specimen behaviors with statistical significance. These compression data showed that plaques exhibit composition- and history-dependent nonlinear and inelastic responses under finite deformations.     

Paradoxic decreases in atherosclerotic plaque mass in insulin-treated diabetic patients

This study assessed the impact of diabetes mellitus on atherosclerotic lesion formation. Seventy insulin-treated diabetics, 150 non-insulin-treated diabetics, and 607 nondiabetics with chronic anginal syndromes and de novo native coronary stenoses were studied using (1) angiography, and (2) intravascular ultrasound (reference and lesion arterial, lumen, and plaque areas; area stenosis [reference-lesion/reference lumen area]; remodeling index [reference-lesion lumen area/lesion-reference plaque area]; and slope of the regression line relating lumen area to plaque burden [plaque/arterial area]). Despite being diabetic for longer and having similar lumen compromise, insulin-treated patients had (1) less reference plaque (8.3 +/- 3.4 vs 10.5 +/- 4.5 mm2, p = 0.0015), (2) less stenosis plaque (13.0 +/- 4.9 vs 16.9 mm2, p <0.0001), (3) smaller reference arterial areas (17.1 +/- 5.4 vs 19.7 +/- 6.2 mm2, p = 0.0063), and (4) smaller stenosis arterial areas (15.3 +/- 4.9 vs 19.5 +/- 6.5 mm2, p <0.0001) than non-insulin-treated diabetics. With use of multivariate linear regression analysis, insulin use was an independent (and negative) predictor of reference plaque and arterial areas (p = 0.0308 and p = 0.0179) and stenosis plaque and arterial areas (p = 0.0117 and p = 0.0066). This was also true when normalized for body surface area. The remodeling index showed that insulin treatment resulted in an exaggerated impact of plaque accumulation on lumen compromise. This was confirmed by the slope of the regression line relating lumen area to plaque burden. Patients with a longer duration of diabetes who were treated with insulin for > or = 1 year had (paradoxically) less reference segment and stenosis plaque accumulation. Possible explanations include impaired adaptive remodeling and/or arterial (and plaque) shrinkage.     

Lipid factors and evolution of the atherosclerotic plaque: review of recent trials

A beneficial impact of lipid-lowering therapy on the incidence of coronary artery disease has been demonstrated in several clinical trials. It has been suggested that lipid lowering therapy not only slows the progression of atherosclerotic lesions, but also promotes its regression. Furthermore, reduced levels of circulating cholesterol (total cholesterol as well as LDL fraction) might decrease plaque volume and growth, restore endothelial function and thus reduce vasomotor tone. The obtained increased plaque stability reduces the risk of disruption and subsequent cardiovascular events. Ongoing ultrasonographic and angioscopic studies will provided further insights into the disease itself and its management.     

Characterization of atherosclerotic plaque components by high resolution quantitative MR and US imaging

Dopamine beta-monooxygenase requires copper ions for catalytic activity. The stoichiometry of copper activation has been a matter of discussion, but most of the recent literature agrees on a model with two copper ions per active site. We have now reinvestigated this problem with kinetic experiments at high and low protein levels. The apoenzyme (metal free) is rapidly activated by adding copper. Incremental addition of copper to high levels (up to 10 microM subunits) of enzyme raised the catalytic activity until the stoichiometric relationship between copper and enzyme subunits was 1:1. No increase in activity was observed upon addition of copper in excess of this up to levels of 3 Cu/subunit. Experiments at low protein levels (0.12 microM subunits) revealed that copper activation is described by a hyperbolic, Michaelis-Menten-type curve. This is to be expected for the 1 Cu/subunit model, whereas the 2/1 model predicts sigmoid curves. With an incremental addition of apoenzyme (high level) to a fixed level of copper, a sharp break was again observed at 1 Cu/subunit, and excess apoenzyme showed no evidence of the inhibition predicted by the 2 Cu/subunit model. Steady-state kinetics experiments with variation of the concentrations of copper and the three substrates supported an equilibrium-ordered mechanism, whereby a single activating copper ion is trapped in the active site by the substrates. Treatment of enzyme containing more than 1 Cu/subunit [both the Cu(I) and Cu(II) states were examined] with a chelating column resulted in loss of all copper in excess of 1 Cu/subunit. Reactivation of apoenzyme by vanadyl ions was studied, both as dopamine beta-monooxygenase-catalyzed electron transfer and hydroxylation. The maximal velocity with vanadium was 70% of that with copper, and the activation curve was clearly hyperbolic, again supporting the requirement of only one metal ion per active site. In conclusion, our results support the view that the copper ions bound to dopamine beta-monooxygenase in excess of 1 Cu/subunit are not required for catalysis.     

Proliferative activity in peripheral and coronary atherosclerotic plaque among patients undergoing percutaneous revascularization

We evaluated the proliferative activity of human atherosclerotic lesions associated with active symptoms of ischemia, by assessing the expression of the proliferating cell nuclear antigen (PCNA). We confirmed in vitro that PCNA, an essential component of the DNA synthesis machinery, is selectively expressed in proliferating human vascular smooth muscle cells. 37 atherosclerotic lesions (18 primary and 19 restenotic) retrieved by directional atherectomy from either coronary or peripheral arteries were then studied for the expression of PCNA, using in situ hybridization or immunohistochemistry. Among plaques studied by in situ hybridization, 7 out of 11 primary and 11 out of 11 restenotic lesions contained PCNA-positive cells. The mean rate of proliferation (percent of PCNA-positive cells) was 7.2 +/- 10.8% in primary lesions and 20.6 +/- 18.2% in restenotic lesions (P < 0.05). Among specimens studied by immunohistochemistry, five out of seven primary and eight out of eight restenotic lesions contained proliferating cells. The mean rate of proliferation was again higher in the restenotic (15.2 +/- 13.6%) than primary (3.6 +/- 3.5%) lesions (P < 0.05). Proliferating cells were detected as late as 1 yr after angioplasty. We conclude that cellular proliferation is a feature of atherosclerotic lesions which are associated with symptoms of ischemia, but that it is more prominent in restenosis compared to primary lesions. These findings have implications for therapies aimed at limiting lesion growth, particularly after percutaneous revascularization.     

7-Hydroperoxycholesterol and its products in oxidized low density lipoprotein and human atherosclerotic plaque

7-Hydroperoxycholesterols (7OOHs) are intermediates in cholesterol oxidation and potential cytotoxins. A normal-phase HPLC method with UV (205 nm) detection was developed that could resolve 7 alpha OOH, 7 beta OOH, 7-ketocholesterol (7K), and the epimeric 7-hydroxycholesterols (7OHs). 7OOH formation was investigated when LDL was exposed to four different oxidizing systems: Cu2+; Ham's F-10; mouse peritoneal macrophages in Ham's F-10; and a metal-independent peroxyl-radical generating system (AAPH). With all four oxidizing systems, 7OOH (both free and esterified, mostly as the beta-isomer) was the major oxysterol formed at early times, with 7K dominating at later stages (> or = 24 h) in Cu-oxLDL. When LDL was oxidized in the presence of cells there was transfer of free oxysterols from LDL to the cells. Negligible 7OOH, but significant amounts of 7OH, accumulated in the cells suggesting efficient cellular reduction of 7OOH. Lipid extracts from eight plaque samples obtained from patients undergoing carotid endarterectomy were analyzed. Only trace amounts of 7OOH (< 0.02% of total cholesterol) could be detected using this normal-phase HPLC method with UV detection or with a more sensitive reverse-phase method utilizing chemiluminescence detection. 7K was the major 7-oxygenated sterol detected, at least 20-fold in excess of that calculated for 7OOH, followed by 7 beta OH and 7 alpha OH. The trace concentrations of 7OOH in plaque indicate its lability in biological/cellular systems and may signify the ability of cells in the artery wall to metabolize it further.     

Regression of severe atherosclerotic plaque in patients with mild elevation of LDL cholesterol

BACKGROUND: Intensive risk factor reduction in patients with dyslipidemias and coronary atherosclerosis has been shown to result in alterations in coronary artery morphology and reduced clinical events. However, the impact of such interventions in populations with relatively normal levels of low-density lipoproteins (LDL) is unclear. METHODS: To test the hypothesis that intensive risk factor reduction results in angiographic regression in patients with only mildly elevated levels of LDL, 14 patients with angiographically proven coronary atherosclerosis were entered into the University of California Davis Coronary Artery Disease Regression Program and intensively treated with pharmacologic and nonpharmacologic interventions for 2 years. Quantitative angiography was performed prior to and after 2 years of therapy to determine changes in coronary artery diameter. RESULTS: As a result of this program, dietary fat intake was reduced by 58% and LDL fell from 120 +/- 7 mg/dL to 104 +/- 6 mg/dL (p = 0.05). The average diameter of the measured arterial locations (including all 53 stenoses and 292 nondiscrete regions) on study entry was 2.74 +/- 0.05 mm. After 24 months, there was a net increase in arterial diameter (regression) of +0.05 +/- 0.04 mm to 2.81 +/- 0.05 mm (p = 0.01). While there was no significant change in the average diameter of discrete stenoses, all 8 lesions > or = 50% initial diameter narrowing regressed, with a mean diameter change of + 0.2 mm. Conversely, only 1 of 8 mild lesions < or = 20% regressed, while 4 progressed. Intermediate lesions (20% to 50%, n = 37) had balanced progression and regression. CONCLUSIONS: When examined as a continuous variable, there was a significant linear correlation between initial lesion severity (% stenosis) and the extent of regression (mm). Therefore, risk factor reduction (dietary therapy, exercise, psycho-social counseling, and lipid lowering therapy) in patients with only mild dyslipidemia results in angiographic regression of more severe lesions (> 50% initial stenosis), but does not prevent progression of mild lesions (< 20%). These findings demonstrate that intensive risk factor reduction in patients with only mild elevation of lipids beneficially influences the morphology of the most severe lesions.     

Vitamin E levels in human atherosclerotic plaque: the influence of risk factors

Recent studies suggest that vitamin E may be an important preventative factor in the development and progression of atherosclerosis. In order to more clearly define the role of vitamin E in atherosclerosis, we measured vitamin E, conjugated diens, and lipid flurochromes, as well as cholesterol, triglycerides and phospholipid in arterial and venous tissue of 83 patients. Serum cholesterol and triglyceride levels were significantly higher (P < 0.05) in patients with aortic occlusive (AIOD) and aneurysmal (AAA) disease than in control organ donors (OD). Tissue cholesterol concentrations were significantly elevated in AAA tissue when compared to OD and tissue from patients with peripheral occlusive disease (POD). Tissue from patients with AIOD contained greater concentrations of phospholipid (PL) than were measured in patients with POD and in OD. Vitamin E concentrations were highest in POD tissue and approximately 3.0, 2.0, and 1.6 fold greater than OD, AIOD and AAA tissue respectively. Diene conjugates and lipid flurochromes, measures of early and intermediate products of lipid peroxidation, were markedly elevated in all diseased arterial tissue compared to controls. There were no significant differences in tissue or serum lipid levels between saphenous vein (SVBG) and diseased vein grafts (DVG). However, conjugated diene concentrations were elevated in DVG compared to SVBG. Vitamin E levels were significantly elevated in diseased arterial and venous tissue (AIOD, AAA, POD, DVG) removed from patients with diabetes (P = 0.013) and hypertension (P = 0.049) compared to those without these risk factors. Diabetes was the only risk factor associated with significantly increased (P = 0.005) levels of vitamin E when only data from atherosclerotic arterial tissue (AAA, POD, AIOD) were analyzed. These preliminary data provide additional evidence of altered vitamin E metabolism and free radical processes in the tissues of patients with various manifestations of atherosclerosis.     

Correlation of thoracic aortic atherosclerotic plaque detected by multiplane transesophageal echocardiography and cardiovascular risk factors

This study of 416 patients identified age, male gender, smoking, diabetes, hypertension, and hypercholesterolemia as independent predictors of thoracic aortic atherosclerotic plaque. Age, smoking, hypercholesterolemia, hypertension, and diabetes were predictors of the severity and extent of thoracic aortic atherosclerosis.     

Medial elastic structure alterations in atherosclerotic arteries in minipigs: plaque proximity and arterial site specificity

Using a model of atherosclerosis in minipigs, we analyzed changes in elastic structure within the medial sections of the abdominal aorta and left interventricular coronary artery both in the vicinity of and distal to atheromatous plaques. Twenty-four animals, divided into three groups, were fed either a control diet or a hypercholesterolemic and hyperhomocysteinic atherogenic diet, alone or in association with an antihypertensor, namely isosorbide dinitrate (Risordan). The atherogenic diet, administered for a period of four months, induced in the minipig advanced noncalcified atherosclerotic lesions that were histologically similar to those found in humans. A morphodensitometric analysis of the medial elastic structures was carried out on images obtained from specifically stained transverse arterial sections examined under a light microscope. The volume density of the elastic structures was diminished in the arterial media of the atherosclerotic animals due to opening and widening of the fenestrae in the elastic laminate and increased communication between the interlamellar spaces. Whereas this elastolytic process was uniform and independent of the proximity of atheromatous plaques in the left interventricular coronary artery, it was intensified in the vicinity of the plaques in the abdominal aorta. Overall elastolytic activity was increased in the walls of atheromatous artery in both arterial sites, and metalloproteinases were implied in this increase of activity. We previously reported that treatment with isosorbide dinitrate significantly reduced the moderate systolic hypertension and the increase in transparietal stress observed in the abdominal aorta of atheromatous animals. We report here that isosorbide dinitrate prevented the atherogenic-diet-induced deterioration of the elastic structure in these arteries; complete inhibition of changes to the elastic laminae was evident in areas remote from plaque formation, but only partial inhibition in the vicinity of such plaques. It did not, however, prevent structural damage in the left interventricular coronary artery or modify the increase in parietal elastolytic activity in either of the two arteries. This suggests that damage to the elastic structure in atheromatous arteries is dependent not only on overall elastolytic activity but also on localized factors, possibly related to parietal stresses, affected by the presence of atheromatous plaques.