Rheum Dis Clin N Am 31 (2005) 355 – 362

Inflammation and Accelerated Atherosclerosis:

Basic Mechanisms
Andrea Doria, MDa, Yaniv Sherer, MDb, Pier L. Meroni, MDc,
Yehuda Shoenfeld, MDb,*
a
Division of Rheumatology, Department of Medical and Surgical Science, University of Padua,
Via Guistiniani 2, 35128 Padua, Italy
b
Department of Medicine B, Sackler Faculty of Medicine, Center for Autoimmune Diseases,
Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer 52621, Israel
c
Allergy and Clinical Immunology Unit, Department of Internal Medicine,
IRCCS Istituto Auxologico Italiano, University of Milan, Via G. Spagoletto 32, 10249 Milan, Italy

The last decade was characterized by a revolution achieved in the therapy of

many of the autoimmune rheumatic diseases (AIRDs), leading to decreased
morbidity and mortality. The dramatic change was caused by the more efficient
use of existing therapies or the use of novel biological agents including anti-
cytokine monoclonal antibodies, fusion molecules, and peptides having neu-
tralizing and immunomodulatory effects. These approaches enabled reduction in
the doses of corticosteroids and immunosuppressants used, drugs associated with
major and severe adverse effects. With these changes, novel factors have emerged
determining the prognosis of AIRD. One of those factors is the accelerated
atherosclerosis (AS) recorded in almost all AIRDs (ie, systemic lupus erythe-
matosus [SLE], rheumatoid arthritis, Sjogren’s syndrome, systemic sclerosis, and
vasculitis). Another aspect unraveled during the previous decade is the autoim-
mune nature of AS [1–4].
Atherosclerosis is a multifactorial process that commences as early as child-
hood but usually clinically manifests itself later in life. Atherosclerosis in-
creasingly is considered to be an immune-mediated process of the vascular

* Corresponding author.
E-mail address: shoenfel@post.tau.ac.il (Y. Shoenfeld).

0889-857X/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.rdc.2005.01.006 rheumatic.theclinics.com
356 doria et al

system. The presence of macrophages and activated lymphocytes within athero-

sclerotic plaques supports the concept of AS as an immuno-mediated inflam-
matory disorder [5]. Inflammation can be implicated in AS by means of different
mechanisms, such as secondary to autoimmunity, infectious diseases and general
inflammatory state. This article summarizes knowledge of the pathogenic mecha-
nisms in AIRD as risk factors for accelerated AS.

Immune cellular components in atherosclerosis

Cells of the immune system can be found within AS plaques, suggesting

that they have a role in the atherogenic process. Their migration and activation
within the plaques can be secondary to various stimuli such as infectious agents.
These cells probably aggravate AS, as CD4+ and CD8+ T-cell depletion reduced
fatty streak formation in C57BL/6 mice [6]. In addition, following crossing of
ApoE knockout mice with immunodeficient scid/scid mice, the offspring had a
73% reduction in aortic fatty streak lesions compared with the immunocompetent
apoE mice. Moreover, when CD4+ T cells were transferred from the immuno-
competent to the immunodeficient mice, they increased lesion area in the latter
by 164% [7]. Associated findings were infiltration of the transferred T cells into
the atherosclerotic lesions.
It is not surprising therefore that similar to autoimmune diseases, the cellu-
lar components within atherosclerotic plaques secrete various cytokines includ-
ing interleukin (IL)-1, IL-2, IL-6, IL-8, IL-12, IL-10, tumor necrosis factor
alpha (TNF-a), interferon gamma (INF-g), and platelet-derived growth factor
(PDGF) [4].
A cellular immune response specifically directed against heat shock pro-
teins (HSPs), oxidized low-density lipoproteins (ox-LDL) and b2-glycoprotein-I
(b2GPI) has been reported, suggesting a direct involvement of these molecules in
the atherosclerotic process [1–3].
b2GPI is the main target antigen recognized by antiphospholipid antibodies
(aPLs) frequently present in AIRD patients. It can be found in human athero-
sclerotic lesions obtained from carotid endarterectomies and expressed abun-
dantly within the subendothelial regions and the intimal–medial border of human
atherosclerotic plaques and colocalizing with CD4+ lymphocytes [8]. Upon
transfer of lymphocytes obtained from b2GPI-immunized LDL receptor-deficient
mice into syngeneic mice, the recipients exhibited larger fatty streaks compared
with mice that received lymphocytes from control mice. T-cell depletion, how-
ever, failed to induce this effect [9]. Therefore, T cells specific for b2GPI are
capable of increasing AS, suggesting that b2GPI is a target autoantigen in AS.
This study demonstrates that T cells reacting with a specific autoantigen
can aggravate AS. There are probably many more such cell lines reacting with
specific antigens that can modulate AS, either by aggravating or decreasing its
extent (pro- or antiatherogenic) [10].
 inflammation & accelerated as: basic mechanisms 357

Immune humoral components in atherosclerosis

Several autoantibodies are associated with AS and its manifestations in

people. Animals provide good models for studying the effect of these autoanti-
bodies on AS. Active immunization of LDL receptor-deficient mice with anti-
cardiolipin antibodies (aCLs: the hallmark of antiphospholipid syndrome [APS],
an autoimmune procoagulant syndrome that affects many SLE patients) resulted
in development of high titers of mouse aCL and increased AS compared with
controls [11]. Immunization of mice with b2GPI resulted in pronounced cellular
and humoral response to b2GPI, with high titers of anti-b2GPI antibodies con-
comitant with larger atherosclerotic lesions that contained abundant CD4+ cells
[12,13].
ox-LDL is the type of LDL that is more likely to undergo uptake by
macrophages, which turn into the foam cells characterizing the atherosclerotic
lesions. Anti-ox-LDL antibodies are present in patients with AS and AIRD and
in healthy individuals [14].
In multivariate analyses, anti–ox-LDL autoantibodies discriminated better
between patients with peripheral vascular disease and control subjects than
did any of the different lipoprotein analyses. There was also a tendency for
higher autoantibody levels in patients with more extensive atherosclerotic le-
sions [15].
The autoantibodies to ox-LDL were investigated in several AIRD groups,
including patients with systemic sclerosis [16,17] systemic vasculitides [14,18],
and SLE [17,18]. The antibody levels were higher in each of those patient groups
than in normals. There was a correlation between the total level of immuno-
globulins and the level of antibodies against ox-LDL, while no correlation was
demonstrated between the levels of the total immunoglobulin and the levels
of antibodies to unrelated antigens (Epstein Barr virus and purified protein
derivative). This finding suggests that the increasing total immunoglobulin
levels in SLE patients are selective for some specific antibodies including auto-
antibodies against ox-LDL [17,18].
Although in people these autoantibodies are associated with manifestations
and extent of AS in most studies, immunization with ox-LDL in animal models
was followed by induction of anti-ox-LDL antibodies but surprisingly with
suppression rather than aggravation of early atherogenesis [19]. These results
support the presence of different types of anti–ox-LDL antibodies, some of which
might be protective against AS [20]. This also may be true regarding aCL, as
in a recent study, those antibodies that cross-react with native and ox-LDL suc-
ceeded in decreasing rather than aggravating the extent of AS [21].
These discrepancies may be explained by the presence of several types
of autoantibodies that are measured together, namely protective and patho-
genic autoantibodies [20]. It is possible that upon immunization with ox-LDL,
the immune system acts by producing anti–ox-LDL antibodies, which help
to clear the high levels of ox-LDL, thus being protective. On the other hand,
upon oxidation of LDL, other autoantibodies directed toward other parts of
358 doria et al

the ox-LDL particle are produced, and these aid in uptake of ox-LDL by
macrophages, turning them into foam cells within the atherosclerotic plaque
(ie, pathogenic).

Endothelium as an additional key player in atherosclerosis

Two main pathogenic hypotheses have been suggested to explain the athero-
sclerotic plaque formation: the injury hypothesis and the lipid hypothesis [22].
In both cases, endothelium has been suggested to play a pivotal role in all the
phases of the atherosclerotic process, given its ability to regulate vessel tone and
interfere with inflammatory processes and coagulation [23].
In the early and intermediate stages, endothelial cells (ECs) activated by
ox-LDL or other triggers up-regulate adhesion molecules, thereby favoring
monocyte adhesion and transmigration. At the same time, EC perturbation leads
to proinflammatory cytokine (chemokine) secretion, which activates monocytes
and ultimately facilitates the foam cell formation [22]. When activated, ECs
express class II major histocompatibility complex (MHC) molecules and might
serve as nonprofessional antigen presenting cells (APCd) [24]. In this way, they
might cooperate with the professional APC of the vascular-associated lymphoid
tissue in mounting the adaptive immune responses to endogenous (eg, ox-LDL,
HSP, or b2GPI) or exogenous (infectious antigens) molecules that have been
proposed as playing a role in the early phases of the atherosclerotic process [1–3].
Endothelium activation appears also to be important in favoring fibroblast
and smooth muscle cell proliferation and migration through the secretion of
growth factors in the intermediate steps of plaque formation [22]. The same
growth factors and the pro-inflammatory cytokines (and chemokines) themselves
cooperate in macrophage activation with the consequent secretion of metal-
loproteases able to increase the matrix turnover and eventually lead to plaque
instability [22].
The final event that produces the clinical cardiovascular manifestations is the
plaque rupture and subsequent thrombus formation (atherothrombosis). Interest-
ingly, EC are involved largely in hemostasis and, once perturbed, they display
a procoagulant phenotype [23]. The up-regulation of tissue factor (TF) expression
and the impairment of the fibrinolytic system in perturbed ECs have been
suggested to play major roles in favoring the thrombus formation on the ruptured
plaques [22].
On the other hand, in AIRD, endothelium itself is also a target for several
circulating immune mediators that might induce a cell perturbation potentially
able to facilitate the atherosclerotic process.
Complement (C) activation by circulating immune complexes or by other
mechanisms might induce endothelial damage by activated products of the
C cascade or even the cell membrane insertion of the membrane attack complex
(MAC). The latter phenomenon was reported to result in the release of an array
 inflammation & accelerated as: basic mechanisms 359

of growth factors and cytokines that induces proliferation, inflammation, and

thrombus formation in the vascular walls [25]. These events might cooperate
in all the different steps of the atherosclerotic process. C deposition has been
reported in the atherosclerotic lesions recently, raising its potential role in the
plaque formation [26].
Antiendothelial cell antibodies (AECAs) reacting with yet unknown EC
membrane constituents have been described in sera from different AIRD [27].
In most cases, AECAs were shown to induce a proinflammatory and a
procoagulant phenotype in EC monolayers in vitro [27]. It is useful to speculate
on the potential role of these autoantibodies in perturbing the endothelium, thus
favoring the occurrence of the accelerated AS reported in AIRD. In accordance
with such a hypothesis is the demonstration of AECA in primary AS or in
patients displaying conditions at risk for AS [28–30].
Besides the pure antiendothelial antibodies, other autoantibodies have been
reported to react with ECd because of their ability to recognize their own antigens
planted on the EC membranes. This is the case for the anti-dsDNA antibodies that
can react with DNA-histone complexes adhering on EC membranes through
electric charge interactions [27,31]. The binding of anti-dsDNA antibodies to
their own antigens adhered on the cell membranes has been shown to induce EC
activation in vitro [27,31]. A similar effect has been described when aPL is
incubated with human EC monolayers in vitro. Antiphospholipid antibodies
react with plasma PL-binding proteins; among them the most important one is
represented by b2GPI. b2GPI was found to be expressed on ECs obtained from
different anatomical localizations in in vitro and in vivo studies. The binding of
the autoantibodies to adhered b2GPI has been suggested to induce a cell signaling
that ends with the expression of an endothelial proinflammatory and procoagulant
phenotype. Interestingly, such an effect was reported in in vivo experimental
models also, suggesting that it might be one of the actual pathogenic mechanisms
for the thrombophilic state associated with the persistent presence of aPL [32].
Antiphospholipid antibodies frequently are detected in AIRD and might con-
tribute to the plaque formation through their endothelial proinflammatory effect
and to the athero-thrombosis, owing to their procoagulant ability.
Moreover, most AIRDs are characterized by a chronic systemic inflammatory
state with elevated plasma levels of proinflammatory cytokines and chemokines.
As reported in patients with primary AS, a chronic inflammatory state is
suggested to represent a risk factor for plaque formation and a condition that
favors its instability and rupture [33]. Being in close contact with the blood and
expressing specific cell membrane receptors, the endothelium represents one of
the most available cell targets for the circulating cytokines. The final result is
a further EC perturbation.
In line with the endothelium perturbation mediated by several circulating
immune mediators is the demonstration of an impaired endothelium-dependent
vasodilation in AIRD patients [34]. Such impairment is related to the reduction
in vasodilator bioavailability (mainly nitric oxide), and it has been associated
with the propensity of an individual to develop atherosclerotic disease [34].
360 doria et al

Immunomodulation of atherosclerosis

Several experimental studies emphasize that immunomodulation can affect AS

and thus provide hope for the development of similar therapies for people. These
options recently have been summarized [35]. Among them, several approaches
have been shown to be effective: treatment with antibodies against CD40 ligand
[36], induction of oral tolerance to autoantigens associated with AS [37], ma-
nipulation of the cytokine network in AS (upregulating the antiatherogenic cyto-
kines and blockade of proatherogenic cytokines), and gene therapy [35]. There is
also evidence for the use of statins and intravenous immunoglobulin (IVIg) as
therapeutic tools to immunomodulate the atherosclerotic process [38,39].
Statins, beyond their ability to reduce serum cholesterol levels, display clear
anti-inflammatory and immunomodulatory effects by reducing monocyte adhe-
sion to EC and endothelial secretion of cytokines and MHC class II expression
[38,40].
Intravenous immunoglobulins have many immunoregulatory and anti-
inflammatory properties and have shown the ability to reduce plaque develop-
ment in a model of murine AS [41]. Looking at mechanisms specifically relevant
in AS, it has been reported that IVIgs contain anti-idiotypic activity against anti–
ox-LDL antibodies [42], and they are able to reduce metaloproteinase-9 (MMP-9)
activity [39]; moreover IVIgs include a subset of natural antiendothelial
antibodies that, opposite to pathologic AECA, directly modulate endothelial
function, reducing proinflammatory and prothrombotic properties of resting EC
and inhibiting cytokine and metalloprotease secretion by EC activated with
proinflammatory stimuli [43]. Finally IVIgs reduce cytokine secretion and the
membrane expression of adhesion molecules on EC stimulated with TNF-a and
ox-LDL, and inhibit one of the pathways of internalization of ox-LDL in EC [44].

Summary

The studies described in this article support a role for immunologic–inflammatory

mechanisms in the pathogenesis of atherosclerosis. This immunologic–inflammatory
state is evident in many autoimmune diseases, but also in the general population
lacking an overt autoimmune disease. The ability to immunomodulate atheroscle-
rosis (currently only experimental) should lead to future research into the
mechanisms and treatment of atherosclerosis, the leading cause of death in the
Western world.

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