Role of endothelium in sequestration of lipoprotein and firbrinogen in aortic lesions, thrombi, and graft pseudo-intimas

Atherogenesis, Transcytosis, and the Transmural Cholesterol Flux: A Critical Review

The recently described phenomenon of cholesterol-loaded low-density lipoproteins (LDL) entering the arterial wall from the lumen by transcytosis has been accepted as an alternative for the long-held concept that atherogenesis involves only passive LDL movement across an injured or dysfunctional endothelial barrier. This active transport of LDL can now adequately explain why plaques (atheromas) appear under an intact, uninjured endothelium. However, the LDL transcytosis hypothesis is still questionable, mainly because the process serves no clear physiological purpose. Moreover, central components of the putative LDL transcytosis apparatus are shared by the counter process of cholesterol efflux and reverse cholesterol transport (RCT) and therefore can essentially create an energy-wasting futile cycle and paradoxically be pro- and antiatherogenic simultaneously. Hence, by critically reviewing the literature, we wish to put forward an alternative interpretation that, in our opinion, better fits the experimental evidence. We assert that most of the accumulating cholesterol (mainly as LDL) reaches the intima not from the lumen by transcytosis, but from the artery's inner layers: the adventitia and media. We have named this directional cholesterol transport transmural cholesterol flux (TCF). We suggest that excess cholesterol, diffusing from the avascular (i.e., devoid of blood and lymph vessels) media's smooth muscle cells, is cleared by the endothelium through its apical membrane. A plaque is formed when this cholesterol clearance rate lags behind its rate of arrival by TCF.

Correlation Between Hemorheologic Parameters and Carotid Atherosclerosis in Stroke

An evaluation of the hemorheologic parameters and an ultrasonographic study of the extracranial carotid tract were performed on 48 patients, age range: sixty to seventy-five years, affected by acute stroke, 23 of whom had hypertension, while 27 were smokers. None of them was suffering from hyperli pidemia, diabetes mellitus, or symptomatic coronary heart or peripheral artery disease.

The echotomographic analysis, using B-mode real-time echotomography re vealed atherosclerotic lesions in 26 patients. The hemorheologic pattern (hema tocrit, fibrinogen, whole blood filterability, whole blood and plasma viscosity) was determined in all the patients three months after the clinical event.

Statistical analysis of the results indicates a possible link between athero sclerotic lesions of the extracranial carotid tract and age, fibrinogen levels, and whole blood filterability.

Higher fibrinogen levels predict progression of coronary artery calcification in adults with type 1 diabetes

AIM

To determine whether fibrinogen levels predict independently progression of coronary artery calcification (CAC) in adults with type 1 diabetes.

METHODS

Data from a prospective cohort--the Coronary Artery Calcification in Type 1 Diabetes Study--were evaluated. Fibrinogen levels at baseline were separated into quartiles. CAC was measured twice and averaged at baseline and at follow-up 2.4+/-0.4 years later. CAC progressors were defined as participants whose square-root transformed CAC volume increased by >or=2.5 mm3 or development of clinical coronary artery disease during the follow-up period.

RESULTS

Fibrinogen levels were higher in progressors than in non-progressors (276+/-61 mg/dl versus 259+/-61 mg/dl, p=0.0003). CAC progression, adjusted for known cardiovascular risk factors, increased in the highest quartile.

CONCLUSIONS

Higher fibrinogen levels predict CAC progression in type 1 diabetes subjects, independent of standard cardiovascular risk factors.

Inflammation and atherothrombosis

An immune and inflammatory response involving endothelial and smooth muscle cells accompanies the accumulation of lipids and fibrous materials in atheromatous arteries. The inflammatory response involves not only the intrinsic cells of the artery wall, but also circulating leukocytes. Lymphocytes as well as macrophages participate importantly in this disease process. Plaque composition and vulnerability have emerged as more critical determinants of plaque rupture than the degree of lumenal stenosis. Thus, plaque biology has proven more important than gross morphology in determining the clinical consequences of the disease. Rupture of the atherosclerotic plaque, its thrombotic complications, and their sequelae have gained increased recognition as the proximate causes of disability and death due to related syndromes such as acute myocardial infarction. Arterial thromboses occur much more readily in arteries damaged or distorted by the atherosclerotic process. The consequences of a given plaque disruption and subsequent thrombus formation will depend on both "systemic" or fluid phase determinants and local "solid state" factors. The complex heterogeneous structure of thrombi includes fibrin, platelets, erythrocytes, and leukocytes. The local balance of proteases and inhibitors on the fibrin and cell surfaces will determine thrombus stability and persistence. Enhanced understanding of the processes involved in the development and progression of atherosclerosis and its complications will surely provide areas that can be targeted in the treatment of the disease.

Plasma lipoproteins support prothrombinase and other procoagulant enzymatic complexes

The prothrombinase complex (factor [F]Xa, FVa, calcium ions, and lipid membrane) converts prothrombin to thrombin (FIIa). To determine whether plasma lipoproteins could provide a physiologically relevant surface, we determined the rates of FIIa production by using purified human coagulation factors, and isolated fasting plasma lipoproteins from healthy donors. In the presence of 5 nmol/L FVa, 5 nmol/L FXa, and 1.4 micromol/L prothrombin, physiological levels of very low density lipoprotein (VLDL) (0.45 to 0.9 mmol/L triglyceride, or 100 to 200 micromol/L phospholipid) yielded rates of 2 to 8 nmol Flla x L(-1) x s(-1) in a donor-dependent manner. Low density lipoprotein (LDL) and high density lipoprotein (HDL) also supported prothrombinase but at much lower rates (< or =1.0 nmol FIIa x L(-1) x s[-1]). For comparison, VLDL at 2 mmol/L triglyceride yielded approximately 50% the activity of 2X10(8) thrombin-activated platelets per milliliter. Although the FIIa production rate was slower on VLDL than on synthetic phosphatidylcholine/phosphatidylsenne vesicles (approximately 50 nmol FIIa x L(-1) x s[-1]), the prothrombin Km values were similar, 0.8 and 0.5 micromol/L, respectively. Extracted VLDL lipids supported rates approaching those of phosphatidylcholine/phosphatidylserine vesicles, indicating the importance of the intact VLDL conformation. However, the presence of VLDL-associated, factor-specific inhibitors was ruled out by titration experiments, suggesting a key role for lipid organization. VLDL also supported FIIa generation in an assay system comprising 0.1 nmol/L FVIIa; 0.55 nmol/L tissue factor; physiological levels of FV, FVIII, FIX, and FX; and prothrombin (3 nmol/L FIIa x L(-1) x s[-1]). These results indicate that isolated human VLDL can support all the components of the extrinsic coagulation pathway, yielding physiologically relevant rates of thrombin generation in a donor-dependent manner. This support is dependent on the intact lipoprotein structure and does not appear to be regulated by specific VLDL-associated inhibitors. Further studies are needed to determine the extent of this activity in vivo.

Fibrinogen and its relations to subclinical extracoronary and coronary atherosclerosis in hypercholesterolemic men

The association between plasma fibrinogen and the presence of carotid, femoral, and aortic plaque (high-resolution B-mode ultrasonography) and coronary calcium deposit (ultrafast computed tomography scanner) was determined in 693 hypercholesterolemic, never-treated men free of previous or current clinical symptoms of cardiovascular disease. The number of subjects with extracoronary disease sites and coronary calcification deposits was significantly higher in the upper than in the lower tertile of fibrinogen. Plasma fibrinogen increased according to the number of diseased sites. The odds ratio of the upper to lower fibrinogen tertile for the presence of arterial lesions was 2.6 (1.7 to 4) for carotid, 2.2 (1.5 to 3.2) for aorta, 2.2 (1.5 to 3.1) for femoral, 1.8 (1.3 to 2.6) for coronary, and 3.6 (2.3 to 6.1) for one of four diseased sites. Adjustment for age, total cholesterol, HDL cholesterol, triglycerides, current smoking, and systolic pressure slightly reduced the association between fibrinogen and atherosclerosis. A synergistic effect between fibrinogen and total cholesterol/ HDL cholesterol (TC/HDL) ratio seemed to be operating on atherosclerosis, because nearly all of the individuals (98%) had a diseased site when fibrinogen and TC/HDL tertiles were the highest. This result suggests that fibrinogen is involved in the subclinical phase of extracoronary and coronary atherosclerosis and may potentiate the atherogenic effect of hyperlipidemia.

Inhibitors of fibrinolysis are elevated in atherosclerotic plaque

The proteins of the fibrinolytic system have been examined in the human normal and atherosclerotic arterial wall by immunohistochemical techniques and by quantitative immunoassay of extracts. The concentration of plasminogen activator inhibitor-1 (PAI-1) increased significantly during the progression from normal vessels to fatty streaks to the developed atherosclerotic plaque. Staining for PAI-1 was strongly positive, particularly in the areas adjacent to the plaque. In these areas, PAI-1 appeared to colocalized with its binding protein vitronectin. Alpha2-antiplasmin (alpha2-AP) was present in the aorta at even higher concentrations than PAI-1; a small but significant increase was seen in some atherosclerotic compared with normal vessel walls. Tissue plasminogen activator (TPA) showed the opposite trend, being lowest in lesions with plaque. Thus, higher concentrations of the two principal inhibitors of fibrinolysis, PAI-1 and alpha2-AP, together with lower levels of TPA, are characteristic of advanced atheromatous lesions. Alteration in the balance of the fibrinolytic system, favoring its inhibition, may predispose to the development or maintenance of atherosclerotic plaque.

Drugs affecting plasma fibrinogen levels. Implications for new antithrombotic strategies

Current evidence indicates that plasma fibrinogen is synthesized by the liver; that genetic and environmental factors regulate plasma fibrinogen levels; that interleukin-6 (IL-6) affects the synthesis of plasma fibrinogen by mechanisms involving protein kinase C, and that during the acute-phase response, monocytes generate a variety of monokines including IL-6. Certain drugs and nutrients have been reported to lower plasma fibrinogen levels. The mechanism(s) involved in this effect is poorly understood. However, since most of these substances quantitatively and/or qualitatively affect monocytes, the possibility that these drugs affect plasma fibrinogen levels via these cells should be considered. In addition to fibrinogen, IL-6 also regulates the synthesis of other acute-phase proteins. Especially when combined, major risk factors for atherosclerosis cause vascular injury that triggers inflammatory events. This raises the issue of whether high plasma fibrinogen levels are just the epiphenomenon of as yet unknown events in thrombosis and atherosclerosis. Thus, the issue to be addressed is whether high plasma fibrinogen concentrations should be lowered or should they serve to suggest strong interventions on established risk factors. As for other risk factors, fibrinogen measurements in population-based studies, in parallel with measurements of established risk factors will help define appropriate directions to be followed to gain insight into the issue and define new antithrombotic strategies.

Fibrinogen and silent atherosclerosis in subjects with cardiovascular risk factors

Fibrinogen may play an active role in the development and progression of atherosclerotic plaques. We assessed the association between fibrinogen levels and atherosclerotic plaques over three different arterial sites in an asymptomatic never-treated male population with increased cardiovascular risk. We included 652 men aged 40 to 60 years old with at least one of the following cardiovascular risk factors: cholesterol > 6.2 mmol/L and/or systolic blood pressure > or = 160 mm Hg and/or diastolic blood pressure > or = 95 mm Hg, and/or because they smoked. Carotid and femoral arteries and the abdominal aorta were assessed by using ultrasonographic methods for the presence of plaque, and subjects were categorized according to the presence (or absence) and extent (one versus two or three sites) of plaque. Plasma fibrinogen was measured according to the thrombin-time method of Clauss. While the presence of atherosclerosis was significantly related to age, current smoking, systolic pressure, LDL cholesterol, and fibrinogen levels, the extent of atherosclerosis was related to age and triglyceride and fibrinogen levels. Multiple regression analysis indicated independent associations between fibrinogen and the presence and extent of atherosclerosis. Plaque prevalence was significantly more pronounced with increasing tertile of fibrinogen levels. The odds ratio of the upper to lower fibrinogen tertiles for the presence of plaque was 1.6 (95% confidence interval, 1.4 to 1.8) and 1.4 (95% confidence interval, 1.2 to 1.7) for its extent. Adjustment for other risk factors slightly reduced the association between fibrinogen and atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibrinolysis and atherosclerosis

The link between impaired fibrinolytic function and CHD has been reinforced considerably in the past couple of years. This has been achieved by a combination of epidemiological, clinical, cell biological and molecular biological studies. The molecular mechanisms for the identified associations between more established risk factors for atherosclerotic disease and impaired fibrinolytic function now need to be disentangled to promote the design of specific drugs that may pave the way for intervention. The possibility that some of the observed relations are epiphenomena should also not be disregarded. The concept of genotype-specific differences in the susceptibility of the individual to common metabolic disturbances needs to be examined in greater detail. Basic research on the role of fibrinolysis in atherosclerosis and its thrombotic complications should be given high priority, because the modulation of fibrinolytic function is likely to become an important approach to prevention.

Association of fibrinolytic parameters with early atherosclerosis. The ARIC Study. Atherosclerosis Risk in Communities Study

BACKGROUND

Thrombosis, provoked by a rupture of an atherosclerotic plaque, plays a crucial role in precipitating a coronary heart disease event. Its role at the early stage of atherosclerosis has, however, been unclear, but it has been hypothesized that thrombosis or defective fibrinolysis contributes to the progression of atherosclerotic lesions.

METHODS AND RESULTS

We studied the association of plasminogen activator inhibitor antigen (PAI-1), tissue-type plasminogen activator antigen (TPA), and D-dimer with early atherosclerosis in a cross-sectional case-control study involving 457 pairs chosen from the biracial cohort of the Atherosclerosis Risk in Communities (ARIC) Study. As examined by B-mode ultrasound, patients (cases) had intima-media thickness of carotid arteries above the 90th percentile and control subjects had thickness below the 75th percentile of the ARIC cohort. Persons with a history of heart disease, stroke, or claudication were excluded from the case-control selection. PAI-1, TPA, and D-dimer were higher in patients than in control subjects (P < or = .001, Wilcoxon signed rank statistic). In conditional logistic regression analyses, the odds ratios of carotid atherosclerosis were, for PAI-1, for example, 1.22, 1.54, and 1.60 in the second, third, and fourth quartiles compared with the first quartile (P < .0001, test of linear trend, adjusting for age, systolic blood pressure, total cholesterol, acetylsalicylic acid use, and time of blood draw). Corresponding tests for D-dimer and TPA also showed an increasing trend (P < .0001).

CONCLUSIONS

The findings support the hypothesis that thrombosis and fibrinolysis play a role at the early stage of the atherosclerotic process.

Hemostatic abnormalities in acute myocardial infarction as detected by specific blood markers

In order to elucidate the mechanism of thrombus formation in acute myocardial infarction (AMI), coagulation and fibrinolytic and inhibitory proteins were systemically examined in 12 patients with AMI and 29 normal subjects. Activities of factor XII, II and V and concentration of high molecular weight kininogen and Factor II were significantly lower in AMI patients than in normal control subjects. Factor XI activity was also increased in AMI patients as compared with normal controls. Von Willebrand Factor and fibrinogen levels were increased in patients with AMI. Plasma D-dimer concentration was also significantly higher in AMI patients than in controls. Activation of the intrinsic pathway, thrombin generation, fibrin formation and fibrin degradation may be present in patients with AMI just after the onset of coronary thrombus formation.

Atherogenesis and fibrinogen: historical perspective and current status

A review of 117 research publications describes a deficiency in fatty acid transport into intracellular oxidative energy metabolism which causes increased fibrinogen synthesis and turnover into fibrin. The increased production of fibrin, coupled with depressed activation of plasminogen, increases the fibrin/plasmin ratio causing thrombosis-induced atherogenesis. This discovery unifies the two schools of atherogenesis based on blood lipid or fibrin deposition theories.

Fibrinogen mediates leukocyte adhesion to vascular endothelium through an ICAM-1-dependent pathway

Leukocyte traffic in immune-inflammatory responses requires regulated adhesion of leukocyte subsets to vascular endothelium. We show that fibrinogen or normal human plasma enhances by 2- to 5-fold the adhesion of cells of myeloid and lymphoid lineage to endothelium. This mechanism is mediated by fibrinogen binding to complementary membrane receptors on leukocytes and endothelial cells. Using an affinity chromatography purification strategy, genetically engineered transfectants, and direct binding studies to the isolated recombinant protein, we identified a novel hematopoietic fibrinogen receptor participating in this adhesion pathway as intercellular adhesion molecule 1 (ICAM-1). Accordingly, a new model can be proposed, in which fibrinogen binding to a variety of vascular cell receptors mediates a specific pathway of cell to cell adhesion by bridging together leukocytes and endothelial cells.

Coagulation factors and lipid composition of the blood in treated and untreated hypertensive patients

The cardiovascular risk factors blood pressure, overweight, hyperlipidaemia and several coagulation parameters were studied in a group of 54 otherwise healthy patients with essential hypertension of moderate severity. Of the 54 hypertensive patients, 43 were treated with anti-hypertensive drugs and 11 were not. The patients included in this study who were treated with anti-hypertensive drugs were still hypertensive in spite of their treatment. Lipoprotein levels and coagulation parameters did not differ between the untreated and treated hypertensive patients. Substantial percentages of patients were found to have hypertriglyceridaemia (46%), elevated LDL-cholesterol (28%) and elevated lipoprotein(a) concentrations (43%). Coagulation factors F VIIIc, fibrin monomer and factor VII in males were significantly elevated in comparison with a healthy reference group. These data are compatible with a moderate activation of the coagulation system. Correlations were established between systolic blood pressure and serum cholesterol (r = 0.43, p = 0.003), LDL-cholesterol (r = 0.34, p = 0.02) and triglycerides (r = 0.35, p = 0.01); Quetelet-index with fibrinogen (r = 0.37, p = 0.02) and thrombin-antithrombin III (r = 0.30, p = 0.04); and triglycerides with F VIIc (r = 0.34, p = 0.03) and fibrin monomer (r = 0.29, p = 0.04) respectively. These data link hypertension and hyperlipidaemia with increased coagulation activity and may contribute to our understanding of why these two cardiovascular risk factors accelerate atherogenesis.

Time course of 125I-labeled LDL accumulation in the healing, balloon-deendothelialized rabbit aorta

We previously showed by qualitative en face autoradiography that after 24 hours of circulation, 125I-labeled low density lipoprotein (LDL) injected in tracer amounts accumulated focally at the edges of regenerating endothelial islands in the balloon catheter-deendothelialized aorta of the normocholesterolemic rabbit. In the present study with the same animal model, we have used quantitative autoradiography to examine 125I-LDL accumulation in the healing aorta as a function of LDL circulation time from 2.5 to 40 hours. The results demonstrated that 125I-LDL accumulation in the healing aorta occurred in two kinetically and biochemically distinct compartments, one of which was in equilibrium with plasma and one of which sequestered LDL. LDL accumulation in the still-deendothelialized aorta (DEA) was diffuse and only moderately intense on autoradiography. It peaked 4 hours after injection; over the following 36 hours the disappearance of 125I-LDL from DEA paralleled the disappearance of 125I-LDL from plasma. In contrast, accumulation of 125I-LDL at the edges of regenerating endothelial islands was focal and intense. LDL accumulation in this compartment also peaked 4 hours after injection but remained elevated even at 40 hours, despite falling plasma levels of LDL. At 24 hours, edge LDL accumulation per unit area was more than five times greater than DEA accumulation. The data indicate that LDL accumulation in specific compartments of the functionally modified arterial wall occurs independently of either acute or chronic hypercholesterolemia. The contrast between labile LDL accumulation in DEA and persistent accumulation at the edges of healing aortic islands indicates that LDL accumulation in the two areas must involve different processes within the arterial wall itself.

Factors influencing the accumulation in fibrous plaques of lipid derived from low density lipoprotein. I. Relation between fibrin and immobilization of apo B-containing lipoprotein

The lipid that accumulates in some fibrous atherosclerotic lesions appears to be derived from plasma low density lipoprotein (LDL). An early stage in lipid accumulation may be immobilization of a fraction of the LDL, and this is released by incubation with proteolytic enzymes, of which the most effective is the fibrinolytic enzyme, plasmin. We have examined the relationship between release of fibrin degradation products (FDP) and LDL in controlled plasmin incubations of 42 samples of normal intima and atherosclerotic lesions from aortas of 10 patients. In three patients (group 1) no LDL was released from any of the 11 tissue samples although they comprised lesions as well as normal intima. In 2 more patients (group 2) LDL was consistently low. However, in 5 patients (group 3) substantial amounts of LDL were released from all 21 tissue samples, and there was a significant correlation between the amounts of FDP and LDL (P less than 0.001). In spite of this correlation there were marked differences in the ratio FDP/LDL, but analysis by SDS-polyacrylamide gel electrophoresis and immuno blotting of the FDP released showed no consistent pattern related to LDL binding. Although the ratio FDP/LDL showed a 4-fold range, in 6 lesions subjected to successive 2-h incubations with plasmin the ratio within each lesion remained constant, supporting the concept that fibrin and LDL are linked.

Factors influencing the accumulation in fibrous plaques of lipid derived from low density lipoprotein. II. Preferential immobilization of lipoprotein (a) (Lp(a))

The extracellular lipid that accumulates in fibrous atherosclerotic lesions appears to be derived directly from plasma low density lipoprotein (LDL). One factor that may influence the lipid deposition is immobilization of part of the LDL in lesions, and an immobilized fraction can be released by incubation with the fibrinolytic enzyme, plasmin, suggesting that it is associated with fibrin. The lipoprotein variant Lp(a) is associated with increased risk of arterial disease, and its characteristic apoprotein, apo(a), is structurally related to plasminogen, suggesting that it might bind to the plasminogen binding sites on fibrin. In this study we have compared blood Lp(a) and the soluble and plasmin-releasable Lp(a) in 45 samples of normal intima and different types of lesion. Levels of soluble and plasmin-releasable Lp(a) were dependent on both blood level and type of tissue sample. Although the amount of soluble LDL was 5-20 times higher than Lp(a) in intima, the amounts released by plasmin were similar, and Lp(a) appears to account for most of the apo B-containing lipoprotein that is immobilized in lesions.

Disorders of the hemostatic system and the risk of the development of thrombotic and cardiovascular diseases: limitations of laboratory diagnosis

The relationship between hemostatic abnormalities and thrombotic and cardiovascular diseases is summarized. All known congenital and acquired abnormalities in the biochemistry of hemostasis are related to thrombotic and cardiovascular diseases in the way that would be expected on the basis of theories about the role of balances between coagulation and fibrinolysis and between activating and inhibiting factors. Notwithstanding the consistency between theory and observed abnormalities, a causal relationship between biochemical abnormality and clinical symptoms has been proved only in a limited number of situations, and it is possible that certain abnormalities only (or also) mark pathologic events. The limitations of laboratory diagnosis of hemostatic disorders in relation to hemostasis as a local process are discussed. It is proposed that more attention be paid to methods of evaluating the local aspects, for example, methods that assess reaction products in the circulation and that can provide an averaged message of the local phenomena. In addition, such methods can provide information about the dynamic balances in the hemostatic system, whereas historically more attention has been paid to the static balances in the potential of hemostatic processes.

Measuring plasma fibrinogen to predict stroke and myocardial infarction

Epidemiological observations indicate that high plasma fibrinogen levels are strongly correlated with the frequency of two major thrombotic complications of atherosclerosis, stroke and myocardial infarction. Thrombosis is increasingly recognized as a central mechanism in stroke and myocardial infarction, and fibrinogen is involved in events thought to play a major role in thrombosis. Therefore, elucidation of the relationship between fibrinogen and thrombosis may strengthen the predictive value of this protein and suggest new treatment to prevent stroke and myocardial infarction. The current data relating fibrinogen to thrombosis are not easy to reconcile with the available epidemiological observations. In addition, advances in understanding the atherogenic potential of several risk factors for coronary heart disease have used information on the measurement of the risk factors in population-based studies. Thus, measuring plasma fibrinogen to predict stroke and myocardial infarction may be important in gaining insight into the thrombogenic potential of this protein and in inspiring new strategies against the thrombotic complications of atherosclerosis.

Identification and distribution of fibrinogen, fibrin, and fibrin(ogen) degradation products in atherosclerosis. Use of monoclonal antibodies

Samples of normal and atherosclerotic vessels obtained from vascular and cardiothoracic surgery were examined for the distribution of fibrinogen/fibrin I, fibrin II, and fibrin(ogen) degradation products (Fragment D/DD) by using recently characterized monoclonal antibodies that recognize and distinguish the three molecular forms (MAbs 18C6, T2G1, and GC4, respectively) with the ABC-immunoperoxidase technique. In normal aortas, little fibrinogen/fibrin I or fibrin II was present and no fibrin(ogen) degradation products could be detected. In early lesions and in fibrous plaques, fibrinogen/fibrin I and fibrin II were distributed in long threads and surrounding vessel wall cells and macrophages. Fibrin(ogen) degradation products were not seen in early lesions. In fibrous and advanced plaques, fibrinogen/fibrin I, fibrin II, and fibrin(ogen) degradation products were detected in areas of loose connective tissue, in thrombus, and around cholesterol crystals. The results of this study suggest that increased fibrin formation and degradation may be associated with progression of atherosclerotic disease. The observed distribution of the different molecular forms of fibrinogen also suggests the possibility that the cells present in the lesions actively participate in the fibrinogen-to-fibrin transition within the vessel wall.

Imaging human atherosclerosis with 99mTc-labeled low density lipoproteins

The feasibility of localizing human atherosclerotic plaques by gamma scintillation camera external imaging with technetium-99m-labeled low density lipoproteins (99mTc-LDL) was tested in 17 patients who had atherosclerosis. Imaging demonstrated focal accumulation of radiolabel consistent with 99mTc-LDL sequestration by plaques in the carotid, iliac, or femoral vessels of four patients 8 to 21 hours after intravenous injection of the radiopharmaceutical. Focal accumulation of 99mTc-LDL also appeared in the location of coronary lesions in four patients, but this accumulation could not be distinguished with certainty from residual blood pool radioactivity. When carotid endarterectomy specimens from six patients who received 99mTc-LDL 1 day before endarterectomy were examined, the specimens had focal accumulations of radiolabel, with two to four times greater radioactivity in some regions of each specimen than in others; this occurred whether or not the lesions were detected on the gamma camera images. Lesion composition may have determined whether accumulation was quantitatively sufficient to produce an external image. Histologically, the imaged carotid specimen had abundant foam cells and macrophages and poorly organized intramural blood consistent with a plaque hemorrhage; in contrast, nonimaged endarterectomy specimens were mature, fibrocalcific plaques. We conclude that: 1) 99mTc-LDL did accumulate in human atherosclerotic plaques; 2) in some patients, the accumulation of 99mTc-LDL was sufficient for detection by gamma camera imaging; 3) the amount of LDL that accumulated appeared to depend on lesion composition; and 4) the design of new radiopharmaceuticals with reduced residual blood pool activity relative to plaque accumulation should lead to improved external imaging of atherosclerosis.

Residualizing and non-residualizing analogues of low-density lipoprotein as iodine-123 radiopharmaceuticals for imaging LDL catabolism

Low-density lipoprotein (LDL) labeled via direct iodination or via the radioiodinated residualizing moiety tyramine-cellobiose (TC) were compared in rabbits as potential 123I radiopharmaceuticals for imaging sites of LDL catabolism. The tissue deposition of 131I-TC-LDL after 24 h as determined by dissection was in the major catabolic organs (liver, adrenals, spleen), and its plasma clearance was slower in rabbits with dietary hypercholesterolemia than in normals. 131I-LDL was unsuitable as a metabolic tracer due to redistribution of catabolites and/or loss of the label before protein degradation, which resulted in little accumulation of radioactivity in catabolic organs and high thyroid uptake. The plasma clearance half-time was similar (ca 22 h) for the two compounds in normal rabbits, but was increased to about 36 h for 131I-TC-LDL and decreased to approximately 9 h for 131I-LDL in hypercholesterolemic animals. The were similar with dynamic imaging of control and hypercholesterolemic rabbits using 123I-labeled analogues. 123I-TC-LDL rapidly localized in the liver, with low thyroid accumulation of radioactivity. The hepatic uptake of 123I-LDL was about half that of 123I-TC-LDL, and thyroid sequestration of radioactivity was significant for 123I-LDL but not 123I-TC-LDL. These data suggest that whereas the residualizing 123I-TC-LDL has a pharmacokinetic profile representative of lipoprotein metabolism, the biodistribution of the activity from injected 123I-LDL is complicated by processes other than protein degradation. The results are discussed with regard to nuclear medicine applications in evaluating lipoprotein catabolism in man.

Genetic and cultural inheritance of plasma fibrinogen concentration

Genetic and cultural heritability of plasma fibrinogen concentration was estimated by path analysis with environmental indices in 85 families identified by means of probands with early myocardial infarction and in 85 families randomly selected from the general population. A substantial proportion of the variance of the plasma fibrinogen level, 51%, was accounted for by genetic heritability, whereas the cultural heritability was negligible. No intergenerational differences were indicated in genetic or cultural heritability. The combined effect of obesity and smoking was found to explain 3% of the variance of the plasma fibrinogen level. The demonstration of such substantial genetic control further supports the view that plasma fibrinogen is a primary risk factor for CHD rather than a reflection of the severity of manifest disease.

Role of endothelial cells and their products in the modification of low-density lipoproteins

A majority of the LDL preparations from various donors could be modified by incubation with endothelial cells from human arteries, veins and microvessels. These alterations comprise changes in electrophoretic mobility, buoyant density and lipid composition of LDL, the generation of thiobarbituric acid reactive substances in the medium, and a decrease in primary amino groups of LDL. Furthermore, the association of endothelial cell proteins with LDL was demonstrated by [35S]methionine incorporation and trichloroacetic acid precipitation of reisolated endothelial cell-modified LDL. After SDS-polyacrylamide gel electrophoresis of the reisolated modified LDL particles, radioactivity was mainly found at a molecular mass of 48 kDa and at one or two bands with a molecular mass of more than 100 kDa. The 48 kDa protein was identified as a latent plasminogen activator inhibitor. Cell viability was necessary for the cell-mediated LDL modification, which indicates that endothelial cells are actively involved in this process. The Ca2+ ionophore A23187 and monensin did not influence LDL modification. LDL modification was markedly inhibited by antioxidants. It was not prevented by cyclooxygenase and lipoxygenase inhibitors, which indicates that non-enzymatic lipid peroxidation is involved. Transition metal- (copper-) induced lipid peroxidation results in similar physiochemical alterations of the LDL particle as found with endothelial cells; it is prevented by the presence of superoxide dismutase. In contrast, endothelial cell LDL modification was not influenced by superoxide dismutase. Catalase or singlet oxygen and hydroxyl radical scavengers also did not affect it. We suggest that yet unidentified radicals or lipid peroxides are generated in the cells or on the cell membrane and that these reactive molecule(s) will react with LDL after leaving the cell. HDL and lipoprotein-depleted serum prevented LDL modification markedly, and to a larger extent than that by copper ions. We speculate that LDL modification by endothelial cells will only occur under those conditions in which the balance between the generation of reactive oxygen molecules and the cellular protection against these reactive species is disturbed.

Activation of coagulation releases endothelial cell mitogens

Recent studies have indicated that endothelial cell function includes elaboration of growth factors and regulation of coagulation. In this paper we demonstrate that activated coagulation Factor X (Factor Xa), a product of the coagulation mechanism generated before thrombin, induces enhanced release of endothelial cell mitogens, linking these two functions. Mitogenic activity generated by cultured bovine aortic endothelial cells in response to Factor Xa included platelet-derived growth-factor-like molecules based on a radioreceptor assay. Effective induction of mitogens by Factor Xa required the integrity of the enzyme's active center and the presence of the gamma-carboxyglutamic acid-containing domain of the molecule. Factor Xa-induced release of mitogens from endothelium occurred in serum-free medium and was not altered by hirudin or antibody to Factor V, indicating that it was a direct effect of Factor Xa and was not mediated by thrombin. Elaboration of mitogenic activity required only brief contact between Factor Xa and endothelium, and occurred in a time-dependent manner. Generation of enhanced mitogenic activity in response to Factor Xa was unaffected by the presence of actinomycin D and was not associated with increased hybridization of RNA from treated cells to a v-sis probe. Release of mitogenic activity was dependent on the dose of Factor Xa, being half-maximal at 0.5 nM and reaching a maximum by 5 nM. Radioligand binding studies demonstrated a class of endothelial cell sites half-maximally occupied at a Factor Xa concentration of 0.8 nM. The close correspondence between the parameters of Factor Xa-induced mitogen release and Factor Xa binding suggests these sites may be related. When Factor X was activated on the endothelial cell surface by Factors IXa and VIII, the Factor Xa formed resulted in the induction of enhanced release of mitogenic activity. These data suggest a mechanism by which the coagulation system can locally regulate endothelial cell function and vessel wall biology before thrombin-induced release of growth factors from platelets.

Fibrinolysis and plasminogen concentration in aortic intima in relation to death following myocardial infarction

In samples of human aortic intima fibrin/fibrinogen degradation products (FDP) were assayed by isoelectric focussing/immunoelectrophoresis as a possible measure of endogenous fibrinolysis, and plasminogen concentration was assayed by rocket immunoelectrophoresis as a possible marker for fibrinolytic potential. No consistent differences were found between normal intima and different types of atherosclerotic lesion, but there was marked variation between patients, and multiple samples from the same aorta showed similar levels. There was no significant correlation with age, sex, or time after death. Low concentrations of FDP and failure to recover measureable amounts of plasminogen from intima were highly associated with death in patients who had suffered a recent myocardial infarction. In aortas from which 3 or more samples of intima and lesions were obtained (n = 16), no FDP were found in 3 (total of 12 samples); all of these were from patients who died following myocardial infarction. Low levels were present in the 4th patient with myocardial infarction. No plasminogen was found in 10 of 11 aortas from patients dying after myocardial infarction (total of 46 samples with no plasminogen), but it was present in 10 of 17 aortas from patients dying of other causes (X2 = 7.6, P less than 0.01). Where both were assayed, FDP were not found in any samples which did not contain plasminogen. Low levels of FDP and absence of plasminogen were associated with increased involvement with atherosclerosis. There was no relation between intimal and serum plasminogen levels, and prothrombin and low density lipoprotein were present in all samples from which no plasminogen was recovered. The results indicate that in some patients, particularly those dying after myocardial infarction, there is decreased fibrinolysis and fibrinolytic potential in the arterial intima, and this may result in increased intimal accumulation of fibrin.

Surface determinants of low density lipoprotein uptake by endothelial cells

The surface sialic acid content of aortic endothelial cells in vitro was substantially lower in sparse cultures than at confluence. Binding of LDL to endothelial cells did not change at different culture densities and was unaffected by brief pretreatment with neuraminidase to partially remove surface sialic acid residues. In contrast, internalization of LDL declined by a factor of 3 between low density cell cultures and confluent monolayers; neuraminidase pretreatment increased LDL uptake and the effect was most marked (greater than 10-fold) at confluence. Pretreatment with cationised ferritin, which removed most of the surface sialic acid residues as well as glycosaminoglycans, increased LDL internalization by up to 20-fold, again with most effect on confluent monolayers. Thus LDL uptake is inversely correlated with sialic acid content. We conclude that changes in the surface density of sialic acid (and possibly other charged) residues significantly modulate endothelial LDL uptake, and suggest that focal increases in LDL accumulation during atherogenesis may be related to alterations in endothelial endocytic properties at sites of increased cell turnover or damage.

Repair in arterial tissue. Demonstration of fibrinogen/fibrin in the normal and healing rabbit thoracic aorta by the indirect immunoperoxidase technique

The results of immunoperoxidase staining for fibrinogen/fibrin in ethanol- and formaldehyde-fixed, normal and healing arterial tissue are presented. Fibrinogen/fibrin was not observed in the normal aortic wall. The thoracic aorta damaged by a balloon catheter contained fibrinogen/fibrin in all layers of the wall. In the healing aortic wall there was a strong positive reaction in neo-intima, whereas the reaction in media was weak or absent. The staining reaction for fibrinogen/fibrin in formaldehyde-fixed neo-intima covered with aortic smooth muscle cells was strong and almost independent of proteolytic digestion, while such treatment increased the staining intensity for fibrinogen/fibrin in neo-intima covered with endothelium. Our results indicate that an extracellular matrix of fibrin and fibronectin may play a role in migration and proliferation of aortic smooth muscle cells.

Haemostatic factors associated with ischaemic heart disease in men aged 45 to 64 years. The Speedwell study

In the Speedwell study set up to examine primarily the relation of plasma lipids and ischaemic heart disease in men aged 45 to 64 years drawn randomly from the practices of 16 general practitioners, various haemostatic factors which may contribute both to thrombogenesis and atherogenesis were measured. Fibrinogen measured nephelometrically and plasma viscosity were positively associated with the prevalence of ischaemic heart disease. Antithrombin III was negatively associated with the prevalence of ischaemic heart disease. These associations were statistically significant at the 1% level of probability. Fibrinogen measured by a clotting method and the heparin neutralising activity of platelet poor plasma had negative and positive associations with ischaemic heart disease, respectively, but neither association achieved statistical significance. Because of the interrelation of these variables and also age, a multiple logistic regression analysis was undertaken separately for the two measures of fibrinogen. The negative association of "clottable' fibrinogen and the positive association of plasma viscosity with the prevalence of ischaemic heart disease were confirmed and both were statistically significant at the 5% level of probability. Apart from age the independent association of the other variables with ischaemic heart disease did not achieve statistical significance. Fibrinogen measured by both methods had positive and statistically significant associations with serum total cholesterol, but no associations with serum total triglycerides, smoking, or alcohol consumption. "Clottable' fibrinogen had an inverse and statistically insignificant association with serum high density lipoprotein cholesterol. The observed associations support the concept of the involvement of some haemostatic factors in the aetiology of ischaemic heart disease, and these associations are now being examined more critically in a longitudinal study.