Costimulatory and Coinhibitory Immune Checkpoints in Atherosclerosis: Therapeutic Targets in Atherosclerosis?

The Interplay Between Immunity, Inflammation and Endothelial Dysfunction

The endothelium is pivotal in multiple physiological processes, such as maintaining vascular homeostasis, metabolism, platelet function, and oxidative stress. Emerging evidence in the past decade highlighted the immunomodulatory function of endothelium, serving as a link between innate, adaptive immunity and inflammation. This review examines the regulation of the immune-inflammatory axis by the endothelium, discusses physiological immune functions, and explores pathophysiological processes leading to endothelial dysfunction in various metabolic disturbances, including hyperglycemia, obesity, hypertension, and dyslipidaemia. The final section focuses on the novel, repurposed, and emerging therapeutic targets that address the immune-inflammatory axis in endothelial dysfunction.

Kidney function mediates the effects of four per-and polyfluoroalkyl substances (PFAS) on atherosclerotic cardiovascular disease

BACKGROUND

PFAS pose a significant threat to cardiovascular health and increase the risk of atherosclerotic cardiovascular disease (ASCVD). However, there is limited research evidence regarding the mechanisms by which PFAS affect the risk of ASCVD and the exposure-risk (E-R) relationship. The effect of kidney function in the relationship between PFAS and ASCVD risk has not been adequately validated.

OBJECTIVE

This study aims to explore the mechanisms by which four PFAS (Perfluorooctanoic acid (PFOA), Perfluorooctanesulfonic acid (PFOS), Perfluorohexanesulfonic acid (PFHS), and Perfluorononanoic acid (PFNA)) affect the risk of ASCVD and to verify and discuss the mediating effect of kidney function in this impact.

METHODS

This study utilizes data from 14,607 participants in the NHANES 2005-2018 to conduct a cross-sectional study. Initially, Generalized Linear Model (GLM) and Restricted Cubic Splines models are used to assess the impact of four PFAS on ASCVD risk and the E-R relationship. Subsequently, the Weighted Quantile Sum regression (WQS) model is used to evaluate the relationship between mixed four PFAS exposure and ASCVD risk. Finally, Directed Acyclic Graphs (DAG) and causal mediation models are used to confirm and analyze whether the decline in kidney function mediates the impact of four PFAS on ASCVD risk.

RESULTS

The results from GLM and WQS models indicate that both singular and mixed four PFAS exposures are associated with an increased risk of ASCVD. The E-R curves between four PFAS singular and mixed exposures and ASCVD risk are all characterized by nonlinearity. The results from DAG and causal mediation models clearly indicate that the decline in kidney function plays a significant mediating role in the relationship between four PFAS and ASCVD risk.

CONCLUSION

Exposure levels of four PFAS do not significantly increase the risk of ASCVD unless they reach a certain threshold, and the decline in kidney function exerts a significant mediating effect in the relationship between four PFAS exposure and ASCVD risk.

Current Management of In-Stent Restenosis

In-stent restenosis (ISR) remains the primary cause of target lesion failure following percutaneous coronary intervention (PCI), resulting in 10-year incidences of target lesion revascularization at a rate of approximately 20%. The treatment of ISR is challenging due to its inherent propensity for recurrence and varying susceptibility to available strategies, influenced by a complex interplay between clinical and lesion-specific conditions. Given the multiple mechanisms contributing to the development of ISR, proper identification of the underlying substrate, especially by using intravascular imaging, becomes pivotal as it can indicate distinct therapeutic requirements. Among standalone treatments, drug-coated balloon (DCB) angioplasty and drug-eluting stent (DES) implantation have been the most effective. The main advantage of a DCB-based approach is the avoidance of an additional metallic layer, which may otherwise enhance neointimal hyperplasia, provide the substratum for developing neoatherosclerosis, and expose the patient to a persistently higher risk of coronary ischemic events. On the other hand, target vessel scaffolding by DES implantation confers relevant mechanical advantages over DCB angioplasty, generally resulting in larger luminal gain, while drug elution from the stent surface ensures the inhibition of neointimal hyperplasia. Nevertheless, repeat stenting with DES also implies an additional permanent metallic layer that may reiterate and promote the mechanisms leading to ISR. Against this background, the selection of either DCB or DES on a patient- and lesion-specific basis as well as the implementation of adjuvant treatments, including cutting/scoring balloons, intravascular lithotripsy, and rotational atherectomy, hold the potential to improve the effectiveness of ISR treatment over time. In this review, we comprehensively assessed the available evidence from randomized trials to define contemporary interventional treatment of ISR and provide insights for future directions.