Recombinant apolipoprotein A-IMilano dimer inhibits carotid intimal thickening induced by perivascular manipulation in rabbits

Sepsis and high-density lipoproteins: Pathophysiology and potential new therapeutic targets

In 2020, sepsis has been defined a worldwide health major issue (World Health Organization). Lung, urinary tract and abdominal cavity are the preferred sites of sepsis-linked infection. Research has highlighted that the advancement of sepsis is not only related to the presence of inflammation or microbial or host pattern recognition. Clinicians and researchers now recognized that a severe immunosuppression is also a common feature found in patients with sepsis, increasing the susceptibility to secondary infections. Lipopolysaccharides (LPS) are expressed on the cell surface of Gram-negative, whereas Gram-positive bacteria express peptidoglycan (PGN) and lipoteichoic acid (LTA). The main mechanism by which LPS trigger host innate immune responses is binding to TLR4-MD2 (toll-like receptor4-myeloid differentiation factor 2), whereas, PGN and LTA are exogenous ligands of TLR2. Nucleotide-binding oligomerization domain (NOD)-like receptors are the most well-characterized cytosolic pattern recognition receptors, which bind microbial molecules, endogenous by-products and environmental triggers. It has been demonstrated that high-density lipoproteins (HDL), besides their major role in promoting cholesterol efflux, possess diverse pleiotropic properties, ranging from a modulation of the immune system to anti-inflammatory, anti-apoptotic, and anti-oxidant functions. In addition, HDL are able at i) binding LPS, preventing the activating of TLR4, and ii) inducing the expression of ATF3 (Activating transcription factor 3), a negative regulator of the TLR signalling pathways, contributing at justifying their capacity to hamper infection-based illnesses. Therefore, reconstituted HDL (rHDL), constituted by apolipoprotein A-I/apolipoprotein A-IMilano complexed with phospholipids, may be considered as a new therapeutic tool for the management of sepsis.

Pathophysiology of bone remodelling cycle: Role of immune system and lipids

Osteoporosis is the most common skeletal disease worldwide, characterized by low bone mineral density, resulting in weaker bones, and an increased risk of fragility fractures. The maintenance of bone mass relies on the precise balance between bone synthesis and resorption. The close relationship between the immune and skeletal systems, called "osteoimmunology", was coined to identify these overlapping "scientific worlds", and its function resides in the evaluation of the mutual effects of the skeletal and immune systems at the molecular and cellular levels, in both physiological and pathological states. Lipids play an essential role in skeletal metabolism and bone health. Indeed, bone marrow and its skeletal components demand a dramatic amount of daily energy to control hematopoietic turnover, acquire and maintain bone mass, and actively being involved in whole-body metabolism. Statins, the main therapeutic agents in lowering plasma cholesterol levels, are able to promote osteoblastogenesis and inhibit osteoclastogenesis. This review is meant to provide an updated overview of the pathophysiology of bone remodelling cycle, focusing on the interplay between bone, immune system and lipids. Novel therapeutic strategies for the management of osteoporosis are also discussed.

HDL-replacement therapy: From traditional to emerging clinical applications

The unique and multifaceted properties of high-density lipoproteins (HDL)-ranging from cholesterol efflux to anti-inflammatory, anti-oxidant, and immunomodulatory effects-have prompted their direct use, particularly in cardiovascular ischemic conditions. Recent advances have extended the interest in HDL-based treatments to novel applications, from improving stent biocompatibility, to treatment of heart failure to central nervous system (CNS) disorders. Strategies to harness HDL's therapeutic potential have evolved from the direct use of isolated HDL in animal models to reconstituted HDL (rHDL) in humans. For these latter, the use of isolated apoA-I associated with different phospholipids has been the most frequent approach, also involving apparently beneficial mutants, such as the apo A-I Milano (AIM). From the initial very promising results, particularly with this mutant in coronary patients, later studies have mostly been non-confirmatory, although issues such as possible inadequate dose/response and unexpected immunological properties have come to light. Most recently a study on isolated plasma HDL in coronary patients (AEGIS-II) provided overall negative findings, but a clear fall of major cardiovascular events was recorded when restricting analysis to hypercholesterolemic patients. Emerging approaches, including gene therapy and plant-derived recombinant HDL formulations, hold promise for enhancing the accessibility and efficacy of HDL-based interventions. At this time, an improved approach to heart failure treatment also appears feasible, and a better understanding of the role played by HDL in the CNS may lead to significant improvements in the handling of some dramatic diseases at this level. While challenges persist, the evolving landscape of HDL replacement therapies offers hope for significant progress in addressing both cardiovascular and non-cardiovascular conditions.

Microarray analysis identifies human apoA-IMilano and apoA-II as determinants of the liver gene expression related to lipid and energy metabolism

The phenotype of individuals carrying the apolipoprotein A-IMilano (apoA-IM), the mutant form of human apoA-I (apoA-I), is characterized by very low concentrations of HDL and apoA-I, and hypertriglyceridemia. Paradoxically, these subjects are not found to be at increased risk of premature cardiovascular disease compared to controls. Besides, various in vitro and in vivo studies have demonstrated that apoA-IM possesses greater anti-atherosclerotic activity compared to apoA-I. The molecular mechanisms explaining the apoA-IM carrier's phenotype and the apoA-IM higher efficacy are still not fully elucidated. To investigate such mechanisms, we crossed previously generated apoA-I (A-I k-in) or apoA-IM knock-in mice (A-IM k-in) with transgenic mice expressing human apoA-II but lacking murine apoA-I (hA-II) to generate hA-II/A-I k-in, and hA-II/A-IM k-in, respectively. These genetically modified mice completely reproduced the apoA-IM carrier's phenotype, including hypoalphalipoproteinemia and hypertriglyceridemia. Furthermore, by using the microarray methodology, we investigated the intrinsic differences in hepatic gene expression among these k-in mouse lines. The expression of 871, 1,018, 1129 and 764 genes was significantly altered between 1) hA-II/A-I and hA-II/A-IM k-in; 2) A-IM and hA-II/A-IM k-in; 3) A-I and A-IM; 4) A-I and hA-II/A-I k-in liver samples, respectively. Bioinformatics analysis highlighted that the hepatic expression of two genes, Elovl6 and Gatm, related to fatty acid/lipid and energy metabolism, respectively, is influenced by the presence of the apoA-IM natural variant and/or apoA-II.

Stent-based delivery of AAV2 vectors encoding oxidation-resistant apoA1

In-stent restenosis (ISR) complicates revascularization in the coronary and peripheral arteries. Apolipoprotein A1 (apoA1), the principal protein component of HDL possesses inherent anti-atherosclerotic and anti-restenotic properties. These beneficial traits are lost when wild type apoA1(WT) is subjected to oxidative modifications. We investigated whether local delivery of adeno-associated viral (AAV) vectors expressing oxidation-resistant apoA1(4WF) preserves apoA1 functionality. The efflux of 3H-cholesterol from macrophages to the media conditioned by endogenously produced apoA1(4WF) was 2.1-fold higher than for apoA1(WT) conditioned media in the presence of hypochlorous acid emulating conditions of oxidative stress. The proliferation of apoA1(WT)- and apoA1(4FW)-transduced rat aortic smooth muscle cells (SMC) was inhibited by 66% ± 10% and 65% ± 11%, respectively, in comparison with non-transduced SMC (p < 0.001). Conversely, the proliferation of apoA1(4FW)-transduced, but not apoA1(WT)-transduced rat blood outgrowth endothelial cells (BOEC) was increased 41% ± 5% (p < 0.001). Both apoA1 transduction conditions similarly inhibited basal and TNFα-induced reactive oxygen species in rat aortic endothelial cells (RAEC) and resulted in the reduced rat monocyte attachment to the TNFα-activated endothelium. AAV2-eGFP vectors immobilized reversibly on stainless steel mesh surfaces through the protein G/anti-AAV2 antibody coupling, efficiently transduced cells in culture modeling stent-based delivery. In vivo studies in normal pigs, deploying AAV2 gene delivery stents (GDS) preloaded with AAV2-eGFP in the coronary arteries demonstrated transduction of the stented arteries. However, implantation of GDS formulated with AAV2-apoA1(4WF) failed to prevent in-stent restenosis in the atherosclerotic vasculature of hypercholesterolemic diabetic pigs. It is concluded that stent delivery of AAV2-4WF while feasible, is not effective for mitigation of restenosis in the presence of severe atherosclerotic disease.

Lipoproteins-Nanocarriers as a Promising Approach for Targeting Liver Cancer: Present Status and Application Prospects

The prevalence of liver cancer is increasing over the years and it is the fifth leading cause of mortality worldwide. The intrusive features and burden of low survival rate make it a global health issue in both developing and developed countries. The recommended chemotherapy drugs for patients in the intermediate and advanced stages of various liver cancers yield a low response rate due to the nonspecific nature of drug delivery, thus warranting the search for new therapeutic strategies and potential drug delivery carriers. There are several new drug delivery methods available to ferry the targeted molecules to the specific biological environment. In recent years, the nano assembly of lipoprotein moieties (lipidic nanoparticles) has emerged as a promising and efficiently tailored drug delivery system in liver cancer treatment. This increased precision of nano lipoproteins conjugates in chemotherapeutic targeting offers new avenues for the treatment of liver cancer with high specificity and efficiency. This present review is focused on concisely outlining the knowledge of liver cancer diagnosis, existing treatment strategies, lipoproteins, their preparation, mechanism and their potential application in the treatment of liver cancer.

A Compendium of the Biological Effects of Apolipoprotein A-IMilano

Obesity is a pathologic condition generated by an energy imbalance, that is, excess caloric consumption, leading to weight gain and metabolic disturbances characterized by adipose tissue inflammation and hyperglycemic conditions. In line with these observations, increasing evidence causally links inflammation, or the molecules and networks integral to inflammatory response, to the development of obesity and the complications that emerge from this pathology, such as cardiovascular, neurologic, respiratory, and metabolic illnesses, as well as sepsis and cancer. Not surprisingly, this chronic and abnormal metabolic background leads to constant derangements in innate and adaptive immunity. It is well known that high-density lipoprotein (HDL) possesses anti-inflammatory and antioxidant properties, and various studies have highlighted an emerging role of HDL in modulating immune function. The efficacy of synthetic HDL (sHDL) containing the recombinant form of apoA-IMilano (sHDL-apoA-IM), originating from the observation that carriers of this mutation have low levels of HDL cholesterol without increased atherosclerosis, has been largely proved in diverse animal models of atherosclerosis; however, the therapeutic use of sHDL-apoA-IM still needs clinical validation. One of the main limitations to the use of recombinant proteins in clinical studies lies in the unsustainable purification costs. Unpurified rice-milk-apoA-IM demonstrated anti-inflammatory and antiatherogenic properties in a mouse model, even though administrated by an unconventional way: by oral gavage. Additionally, recent data have uncovered new therapeutic applications for this sHDL-apoA-IM This review provides an overview of all potential application of sHDL-apoA-IM in some inflammatory-based diseases. SIGNIFICANCE STATEMENT: A recent study demonstrated that oral administration of rice-seed protein extracts containing the apoA-IM (i.e., the milk-apoA-IM) reduced atherosclerosis development in a mouse model. Moreover, the rice-milk-apoA-IM preserved both in vitro and in vivo anti-inflammatory properties, as observed when sHDL-apoA-IM was given by intravascular infusion. Besides, various studies suggested that sHDL-apoA-IM could positively affect other inflammatory-based diseases. Together, these data might represent a new starting point for "sHDL-apoA-IM-based therapies" in chronic degenerative disease.

HDL therapy today: from atherosclerosis, to stent compatibility to heart failure

Epidemiologically, high-density lipoprotein (HDL) cholesterol levels have been inversely associated to cardiovascular (CV) events, although a Mendelian Randomisation Study had failed to establish a clear causal role. Numerous atheroprotective mechanisms have been attributed to HDL, the main being the ability to promote cholesterol efflux from arterial walls; anti-inflammatory effects related to HDL ligands such as S1P (sphingosine-1-phosphate), resolvins and others have been recently identified. Experimental studies and early clinical investigations have indicated the potential of HDL to slow progression or induce regression of atherosclerosis. More recently, the availability of different HDL formulations, with different phospholipid moieties, has allowed to test other indications for HDL therapy. Positive reports have come from studies on coronary stent biocompatibility, where the use of HDL from different sources reduced arterial cell proliferation and thrombogenicity. The observation that low HDL-C levels may be associated with an enhanced risk of heart failure (HF) has also suggested that HDL therapy may be applied to this condition. HDL infusions or apoA-I gene transfer were able to reverse heart abnormalities, reduce diastolic resistance and improve cardiac metabolism. HDL therapy may be effective not only in atherosclerosis, but also in other conditions, of relevant impact on human health.Key messagesHigh-density lipoproteins have as a major activity that of removing excess cholesterol from tissues (particularly arteries).Knowledge on the activity of high-density lipoproteins on health have however significantly widened.HDL-therapy may help to improve stent biocompatibility and to reduce peripheral arterial resistance in heart failure.

Lipoproteins for therapeutic delivery: recent advances and future opportunities

The physiological role(s) of mammalian plasma lipoproteins is to transport hydrophobic molecules (primarily cholesterol and triacylglycerols) to their respective destinations. Lipoproteins have also been studied as drug-delivery agents due to their advantageous payload capacity, long residence time in the circulation and biocompatibility. The purpose of this review is to briefly discuss current findings with the focus on each type of formulation's potential for clinical applications. Regarding utilizing lipoprotein type formulation for cancer therapeutics, their potential for tumor-selective delivery is also discussed.

Apo A-I (Apolipoprotein A-I) Vascular Gene Therapy Provides Durable Protection Against Atherosclerosis in Hyperlipidemic Rabbits

OBJECTIVE

Gene therapy that expresses apo A-I (apolipoprotein A-I) from vascular wall cells has promise for preventing and reversing atherosclerosis. Previously, we reported that transduction of carotid artery endothelial cells with a helper-dependent adenoviral (HDAd) vector expressing apo A-I reduced early (4 weeks) fatty streak development in fat-fed rabbits. Here, we tested whether the same HDAd could provide long-term protection against development of more complex lesions.

APPROACH AND RESULTS

Fat-fed rabbits (n=25) underwent bilateral carotid artery gene transfer, with their left and right common carotids randomized to receive either a control vector (HDAdNull) or an apo A-I-expressing vector (HDAdApoAI). Twenty-four additional weeks of high-fat diet yielded complex intimal lesions containing lipid-rich macrophages as well as smooth muscle cells, often in a lesion cap. Twenty-four weeks after gene transfer, high levels of apo A-I mRNA (median ≥250-fold above background) were present in all HDAdApoAI-treated arteries. Compared with paired control HDAdNull-treated arteries in the same rabbit, HDAdApoAI-treated arteries had 30% less median intimal lesion volume (P=0.03), with concomitant reductions (23%-32%) in intimal lipid, macrophage, and smooth muscle cell content (P≤0.05 for all). HDAdApoAI-treated arteries also had decreased intimal inflammatory markers. VCAM-1 (vascular cell adhesion molecule-1)-stained area was reduced by 36% (P=0.03), with trends toward lower expression of ICAM-1 (intercellular adhesion molecule-1), MCP-1 (monocyte chemoattractant protein 1), and TNF-α (tumor necrosis factor-α; 13%-39% less; P=0.06-0.1).

CONCLUSIONS

In rabbits with severe hyperlipidemia, transduction of vascular endothelial cells with an apo A-I-expressing HDAd yields at least 24 weeks of local apo A-I expression that durably reduces atherosclerotic lesion growth and intimal inflammation.

Acute high-density lipoprotein therapies

PURPOSE OF REVIEW

Increasing interest has focused on the strategies that target the atheroprotective properties of HDL in order to reduce cardiovascular risk. The potential impact of strategies to acutely promote HDL functionality will be reviewed.

RECENT FINDINGS

Population and animal studies suggest that HDLs have a protective impact on atherosclerotic plaque. However, the failure of recent clinical trials of HDL cholesterol-raising agents has raised concerns that this may not be a viable strategy to reduce cardiovascular risk. Increasing attention has highlighted the importance of the functional quality, as opposed to quantity, of HDL with evidence of impaired HDL function in the setting of acute coronary syndromes (ACSs). The finding that infusing HDL in patients with recent acute ischemic events promotes the rapid regression of coronary atherosclerosis suggests a potentially useful strategy for ACS patients, although this remains to be fully established in large clinical outcome trials.

SUMMARY

Infusing HDL has favorable effects on coronary atherosclerosis in ACS patients, suggesting a potentially beneficial therapeutic strategy to acutely promote HDL functionality.

HDL and CER-001 Inverse-Dose Dependent Inhibition of Atherosclerotic Plaque Formation in apoE-/- Mice: Evidence of ABCA1 Down-Regulation

OBJECTIVE

CER-001 is a novel engineered HDL-mimetic comprised of recombinant human apoA-I and charged phospholipids that was designed to mimic the beneficial properties of nascent pre-ß HDL. In this study, we have evaluated the dose-dependent regulation of ABCA1 expression in vitro and in vivo in the presence of CER-001 and native HDL (HDL3).

METHODS AND RESULTS

CER-001 induced cholesterol efflux from J774 macrophages in a dose-dependent manner similar to natural HDL. A strong down-regulation of the ATP-binding cassette A1 (ABCA1) transporter mRNA (- 50%) as well as the ABCA1 membrane protein expression (- 50%) was observed at higher doses of CER-001 and HDL3 compared to non-lipidated apoA-I. In vivo, in an apoE-/- mouse "flow cessation model," in which the left carotid artery was ligatured to induce local inflammation, the inhibition of atherosclerotic plaque burden progression in response to a dose-range of every-other-day CER-001 or HDL in the presence of a high-fat diet for two weeks was assessed. We observed a U-shaped dose-response curve: inhibition of the plaque total cholesterol content increased with increasing doses of CER-001 or HDL3 up to a maximum inhibition (- 51%) at 5 mg/kg; however, as the dose was increased above this threshold, a progressively less pronounced inhibition of progression was observed, reaching a complete absence of inhibition of progression at doses of 20 mg/kg and over. ABCA1 protein expression in the same atherosclerotic plaque was decreased by-45% and-68% at 50 mg/kg for CER-001 and HDL respectively. Conversely, a-12% and 0% decrease in ABCA1 protein expression was observed at the 5 mg/kg dose for CER-001 and HDL respectively.

CONCLUSIONS

These data demonstrate that high doses of HDL and CER-001 are less effective at slowing progression of atherosclerotic plaque in apoE-/- mice compared to lower doses, following a U-shaped dose-response curve. A potential mechanism for this phenomenon is supported by the observation that high doses of HDL and CER-001 induce a rapid and strong down-regulation of ABCA1 both in vitro and in vivo. In conclusion, maximally efficient HDL- or CER-001-mediated cholesterol removal from atherosclerotic plaque is achieved by maximizing macrophage-mediated efflux from the plaque while minimizing dose-dependent down-regulation of ABCA1 expression. These observations may help define the optimal dose of HDL mimetics for testing in clinical trials of atherosclerotic burden regression.

HDL/ApoA-1 infusion and ApoA-1 gene therapy in atherosclerosis

The HDL hypothesis stating that simply raising HDL cholesterol (HDL-C) may produce cardiovascular benefits has been questioned recently based on several randomized clinical trials using CETP inhibitors or niacin to raise HDL-C levels. However, extensive pre-clinical data support the vascular protective effects of administration of exogenous ApoA-1 containing preβ-HDL like particles. Several small proof-of-concept clinical trials using such HDL/ApoA-1 infusion therapy have shown encouraging results but definitive proof of efficacy must await large scale clinical trials. In addition to HDL infusion therapy an alternative way to exploit beneficial cardiovascular effects of HDL/ApoA-1 is to use gene transfer. Preclinical studies have shown evidence of benefit using this approach; however clinical validation is yet lacking. This review summarizes our current knowledge of the aforementioned strategies.

Innovative pharmaceutical interventions in cardiovascular disease: Focusing on the contribution of non-HDL-C/LDL-C-lowering versus HDL-C-raising: A systematic review and meta-analysis of relevant preclinical studies and clinical trials

Non-HDL-cholesterol is well recognised as a primary causal risk factor in cardiovascular disease. However, despite consistent epidemiological evidence for an inverse association between HDL-C and coronary heart disease, clinical trials aimed at raising HDL-C (AIM-HIGH, HPS2-THRIVE, dal-OUTCOMES) failed to meet their primary goals. This systematic review and meta-analysis investigated the effects of established and novel treatment strategies, specifically targeting HDL, on inhibition of atherosclerosis in cholesteryl ester transfer protein-expressing animals, and the prevention of clinical events in randomised controlled trials. Linear regression analyses using data from preclinical studies revealed associations for TC and non-HDL-C and lesion area (R(2)=0.258, P=0.045; R(2)=0.760, P<0.001), but not for HDL-C (R(2)=0.030, P=0.556). In clinical trials, non-fatal myocardial infarction risk was significantly less in the treatment group with pooled odd ratios of 0.87 [0.81; 0.94] for all trials and 0.85 [0.78; 0.93] after excluding some trials due to off-target adverse events, whereas all-cause mortality was not affected (OR 1.05 [0.99-1.10]). Meta-regression analyses revealed a trend towards an association between between-group differences in absolute change from baseline in LDL-C and non-fatal myocardial infarction (P=0.066), whereas no correlation was found for HDL-C (P=0.955). We conclude that the protective role of lowering LDL-C and non-HDL-C is well-established. The contribution of raising HDL-C on inhibition of atherosclerosis and the prevention of cardiovascular disease remains undefined and may be dependent on the mode of action of HDL-C-modification. Nonetheless, treatment strategies aimed at improving HDL function and raising apolipoprotein A-I may be worth exploring.

ApoA-I mimetics

A wealth of evidence indicates that plasma levels of high-density lipoprotein cholesterol (HDL-C) are inversely related to the risk of cardiovascular disease (CVD). Consequently, HDL-C has been considered a target for therapy in order to reduce the residual CVD burden that remains significant, even after application of current state-of-the-art medical interventions. In recent years, however, a number of clinical trials of therapeutic strategies that increase HDL-C levels failed to show the anticipated beneficial effect on CVD outcomes. As a result, attention has begun to shift toward strategies to improve HDL functionality, rather than levels of HDL-C per se. ApoA-I, the major protein component of HDL, is considered to play an important role in many of the antiatherogenic functions of HDL, most notably reverse cholesterol transport (RCT), and several therapies have been developed to mimic apoA-I function, including administration of apoA-I, mutated variants of apoA-I, and apoA-I mimetic peptides. Based on the potential anti-inflammatory effects, apoA-I mimetics hold promise not only as anti-atherosclerotic therapy but also in other therapeutic areas.

Athero-protective effects of High Density Lipoproteins (HDL): An ODE model of the early stages of atherosclerosis

We present an ODE model which we use to investigate how High Density Lipoproteins (HDL) reduce the inflammatory response in atherosclerosis. HDL causes atherosclerotic plaque stabilisation and regression, and is an important potential marker and prevention target for cardiovascular disease. HDL enables cholesterol efflux from the arterial wall, macrophage and foam cell emigration, and has other athero-protective effects. Our basic inflammatory model is augmented to include several different ways that HDL can act in early atherosclerosis. In each case, the action of HDL is represented via a parameter in the model. The long-term model behaviour is investigated through phase plane analysis and simulations. Our results indicate that only HDL-enabled cholesterol efflux can stabilise the internalised lipid content in the lesion so that it does not continue to grow, but this does not reduce macrophage numbers which is required to stabilise the lesion or prevent rupture. HDL-enabled macrophage emigration guarantees lesion stabilisation by maintaining stable macrophage content.

Molecules that mimic apolipoprotein A-I: potential agents for treating atherosclerosis

Certain amphipathic α-helical peptides can functionally mimic many of the properties of full-length apolipoproteins, thereby offering an approach to modulate high-density lipoprotein (HDL) for combating atherosclerosis. In this Perspective, we summarize the key findings and advances over the past 25 years in the development of peptides that mimic apolipoproteins, especially apolipoprotein A-I (apoA-I). This assemblage of information provides a reasonably clear picture of the state of the art in the apolipoprotein mimetic field, an appreciation of the potential for such agents in pharmacotherapy, and a sense of the opportunities for optimizing the functional properties of HDL.

Tweaking the cholesterol efflux capacity of reconstituted HDL

Mechanisms to increase plasma high-density lipoprotein (HDL) or to promote egress of cholesterol from cholesterol-loaded cells (e.g., foam cells from atherosclerotic lesions) remain an important target to regress heart disease. Reconstituted HDL (rHDL) serves as a valuable vehicle to promote cellular cholesterol efflux in vitro and in vivo. rHDL were prepared with wild type apolipoprotein (apo) A-I and the rare variant, apoA-I Milano (M), and each apolipoprotein was reconstituted with phosphatidylcholine (PC) or sphingomyelin (SM). The four distinct rHDL generated were incubated with CHO cells, J774 macrophages, and BHK cells in cellular cholesterol efflux assays. In each cell type, apoA-I(M) SM-rHDL promoted the greatest cholesterol efflux. In BHK cells, the cholesterol efflux capacities of all four distinct rHDL were greatly enhanced by increased expression of ABCG1. Efflux to PC-containing rHDL was stimulated by transfection of a nonfunctional ABCA1 mutant (W590S), suggesting that binding to ABCA1 represents a competing interaction. This interpretation was confirmed by binding experiments. The data show that cholesterol efflux activity is dependent upon the apoA-I protein employed, as well as the phospholipid constituent of the rHDL. Future studies designed to optimize the efflux capacity of therapeutic rHDL may improve the value of this emerging intervention strategy.

ETC-216 for coronary artery disease

INTRODUCTION

Increasing attention has focused on the role of high-density lipoprotein function as a target for cardiprotection. Apolipoprotein A-I(Milano) (AIM) involves a single amino-acid mutation of the major wild-type protein carried on high-density lipoprotein (HDL) particles. Early evidence of beneficial activities of AIM has stimulated support in its development as a potential therapy to reduce cardiovascular risk.

AREAS COVERED

The importance of HDL as a target and early data supporting the beneficial effects of AIM are reviewed. All clinical studies of AIM found in PubMed are reviewed.

EXPERT OPINION

ETC-216 represents a lipid-deplete form of HDL containing recombinant AIM. While early evidence suggests that administration of ETC-216 promotes rapid regression of coronary atherosclerosis, bringing this compound to clinical practice will require further trials that evaluate its impact on cardiovascular events.

Emerging high-density lipoprotein infusion therapies: fulfilling the promise of epidemiology?

High-density lipoprotein (HDL) plays a key role in reverse cholesterol transport but also activates nitric oxide synthase and stimulates prostacyclin release, enhances endothelial repair, inhibits cell adhesion molecule expression on vascular endothelium and monocyte recruitment into the arterial wall, and exerts antithrombotic effects. In experimental animals, infusions of HDL or apolipoprotein A-1 (apoA-1) halt the progression or induce regression of atherosclerosis, with favorable effects on plaque composition. Remarkably, a benefit is observed after a single infusion. In a pilot study, weekly infusions of ETC-216, a formulation of recombinant apoA-1 Milano, were administered at two doses for 5 weeks to patients beginning within 2 weeks of an acute coronary syndrome (ACS). Among the 47 patients completing the study, percent atheroma volume by intracoronary ultrasound was reduced in the combined active treatment groups but not in the placebo group. In a larger trial, the Effect of rHDL on Atherosclerosis-Safety and efficacy (ERASE), 183 post-ACS patients were randomized to 4 weekly infusions of placebo or one of two doses of CSL-111, which consists of apoA-1 derived from human plasma and combined with soybean phosphatidylcholine. The greater dose was discontinued because of a high incidence of hepatic enzyme elevation. Among the 136 patients with evaluable end point data, percent change in atheroma volume, the primary endpoint, improved significantly in the CSL-111 group but not in the placebo group. The secondary end points of plaque characterization indices and quantitative coronary angiographic changes both improved significantly in the CSL-111 group compared with the group receiving placebo. Taken together, this evidence suggests that infusions of HDL or apoA-1 may reduce events, particularly among patients with ACS.

High-density lipoprotein/apolipoprotein A-I infusion therapy

Strategies to decrease the progression and burden of atherosclerosis by capitalizing on the protective effect of high-density lipoprotein (HDL) and/or apolipoprotein A1 (apoA-I) levels remain active. Although efforts to raise HDL through the administration of oral agents are still being pursued, the disappointing results demonstrated with torcetrapib, an agent that elevated serum HDL and apoA-I levels through the inhibition of cholesterol ester transfer protein, have raised questions regarding this approach. An alternate strategy that consists of short-term infusions of reconstituted HDL or apoA-I is currently under evaluation. Several infusion compounds have been evaluated in clinical trials that utilize cardiovascular imaging technologies and biomarkers to assess potential clinical efficacy. Although these compounds are still in early-stage development, the results of these trials have supported the viability of this line of investigation. This review addresses the potential of HDL and/or apoA-I infusions as a possible therapeutic strategy for the treatment of coronary artery disease.

Emerging HDL-based therapies for atherothrombotic vascular disease

Statin therapy has been a significant advance in the management of dyslipidemia and atherothrombotic cardiovascular disease with a resultant 30% to 40% reduction in cardiovascular events; however, a significant number of events continue to occur in statin-treated patients, including in patients treated with high-dose statins targeted to achieve mean low-density lipoprotein cholesterol levels in the range of 60 to 80 mg/dL. Therefore, development and testing of new therapies that exploit the vascular protective effects of high-density lipoprotein (HDL) constitutes a rational and complementary approach. A number of HDL-based therapies are in various stages of development and testing. It is hoped that one or more of these new HDL-based therapies, if proven effective and safe, will become a part of our armamentarium against vaso-occlusive cardiovascular disease. A paradigm could emerge in which patients recovering from acute coronary syndromes and at high risk of recurrent events could be treated with rapid-acting HDL-based therapy, such as infusions of recombinant HDL or even HDL delipidation, followed by more sustained long-term HDL-based therapies, such as oral agents and perhaps even HDL-based gene therapy.

High-density lipoprotein mimetics: focus on synthetic high-density lipoprotein

Epidemiologic studies show an inverse relation between high-density lipoprotein (HDL) cholesterol levels and coronary artery disease, and proof-of-concept experimental studies suggest that HDL and its apolipoproteins, specifically apolipoprotein (apo) A-I , have atheroprotective effects. Atheroprotective effects of HDL are attributed to its ability to remove macrophage cholesterol by stimulating reverse cholesterol transport as well as anti-inflammatory and antioxidant effects. Several different strategies are currently being pursued to exploit the vascular-protective effects of HDL. One such approach involves direct administration of synthetic reconstituted HDL made from linking phospholipid carriers with recombinant mutant apoA-I or plasma-derived wild-type apoA-I.

HDL slowing down endothelial progenitor cells senescence: a novel anti-atherogenic property of HDL

Numerical and functional impairment of circulating endothelial progenitor cells (EPCs) is thought to contribute to endothelial dysfunction and the associated increase in cardiovascular risk. Increased EPCs number and activity are associated with the inhibition of EPCs senescence, which involved activation of telomerase. Telomerase activity can be regulated by phosphatidylinositol-3-kinase/Akt (PI3K/Akt) signaling pathway which also modulates the activity of endothelial nitric oxide synthase (eNOS). Increased oxidative stress induces telomerase inactivity whereas nitric oxide (NO) can reduce oxidative stress, thus activates telomerase. Plasma high-density lipoprotein (HDL) cholesterol levels have an inverse correlation with incidence of ischemic heart disease as well as other atherosclerosis-related ischemic conditions. However, the exact mechanism by which HDL prevents ischemic disease is not fully understood. HDL not only increases NO by activating eNOS through PI3K/Akt signaling pathway, but also directly stimulates EPCs differentiation via PI3K/Akt pathway. Moreover HDL can increase circulating EPCs number and enhances ischemia-induced angiogenesis. On the basis of recent findings, this manuscript proposed a new hypothesis that HDL could against atherosclerotic cardiovascular disease partially through slowing down EPCs senescence by increasing NO and promoting telomerase activity via PI3K/Akt signaling pathway.

Emerging strategies for increasing high-density lipoprotein

High-density lipoprotein cholesterol is a potent and independent epidemiologic risk factor and is a proved antiatherosclerotic agent in animal models of atherosclerosis, acting through the principal mechanisms of accelerating cholesterol efflux and inhibiting oxidation and inflammation. Lifestyle modification increases serum levels by 5% to 15%, whereas niacin, the drug most widely used to increase high-density lipoprotein cholesterol, increases it by 25% to 35% at the highest doses. This review examines the potent methods of increasing high-density lipoprotein and/or enhancing reverse cholesterol transport, including cholesterol ester transfer protein inhibitors, apolipoprotein A-I Milano, D4F, the dual peroxisome proliferator-activated receptor agonists, and rimonabant, that are now in clinical trials. In conclusion, these new agents, used alone or in combination with existing therapies, carry the potential to markedly reduce the incidence of new coronary disease and cardiac events in this decade.

Functionally defective high-density lipoprotein: a new therapeutic target at the crossroads of dyslipidemia, inflammation, and atherosclerosis

High-density lipoproteins (HDL) possess key atheroprotective biological properties, including cellular cholesterol efflux capacity, and anti-oxidative and anti-inflammatory activities. Plasma HDL particles are highly heterogeneous in physicochemical properties, metabolism, and biological activity. Within the circulating HDL particle population, small, dense HDL particles display elevated cellular cholesterol efflux capacity, afford potent protection of atherogenic low-density lipoprotein against oxidative stress and attenuate inflammation. The antiatherogenic properties of HDL can, however be compromised in metabolic diseases associated with accelerated atherosclerosis. Indeed, metabolic syndrome and type 2 diabetes are characterized not only by elevated cardiovascular risk and by low HDL-cholesterol (HDL-C) levels but also by defective HDL function. Functional HDL deficiency is intimately associated with alterations in intravascular HDL metabolism and structure. Indeed, formation of HDL particles with attenuated antiatherogenic activity is mechanistically related to core lipid enrichment in triglycerides and cholesteryl ester depletion, altered apolipoprotein A-I (apoA-I) conformation, replacement of apoA-I by serum amyloid A, and covalent modification of HDL protein components by oxidation and glycation. Deficient HDL function and subnormal HDL-C levels may act synergistically to accelerate atherosclerosis in metabolic disease. Therapeutic normalization of attenuated antiatherogenic HDL function in terms of both particle number and quality of HDL particles is the target of innovative pharmacological approaches to HDL raising, including inhibition of cholesteryl ester transfer protein, enhanced lipidation of apoA-I with nicotinic acid and infusion of reconstituted HDL or apoA-I mimetics. A preferential increase in circulating concentrations of HDL particles possessing normalized antiatherogenic activity is therefore a promising therapeutic strategy for the treatment of common metabolic diseases featuring dyslipidemia, inflammation, and premature atherosclerosis.

Recombinant apolipoprotein A-IMilano for the treatment of cardiovascular diseases

Apolipoprotein A-I(Milano) (apoA-I(M)) is a natural variant of apoA-I characterized by a cysteine for arginine substitution at position 173 of the primary sequence. ApoA-I(M) carriers have much less atherosclerosis than expected from their very low plasma high-density lipoprotein (HDL) cholesterol levels, suggesting that the variant might be protective. Synthetic HDL (sHDL) made with a recombinant form of the dimeric A-I(M) (A-I(M)/A-I(M)) and phospholipids given in single or multiple injections is effective in inducing the regression of atherosclerotic plaques, preventing arterial restenosis, and limiting cardiac dysfunction after ischemia/reperfusion injury. In a phase II trial in patients with acute coronary syndromes, a short-term treatment with A-I(M)/A-I(M) sHDL caused a remarkable reduction of atheroma burden. Although at early stages of drug development, A-I(M)/A-I(M) sHDL holds vast promise for the treatment of a variety of cardiovascular diseases in humans.

Therapeutic use of the high-density lipoprotein protein and peptides

High-density lipoprotein (HDL) therapy is a novel and emerging area of therapeutic development in the cardiovascular field. It attempts to supplement and improve the vascular benefit exerted by other agents that are active on lipid metabolism, for example, hypolipidaemic drugs. Furthermore, it takes advantage of the novel techniques of coronary evaluation. A number of reports have examined the potential therapeutic properties of the synthetic HDLs prepared by complexing recombinant apolipoprotein (apo) A-I(Milano), a variant form of native apoA-I, with phospholipids. The availability of synthetic HDL complexes containing recombinant apoA-I(Milano) has opened up a new era of therapeutic management for coronary disease. HDL formulations of recombinant apoA-I(Milano)-phospholipid complexes have clearly shown rapid regression of a focal carotid atheroma as well as powerful protection from myocardial infarction in a rabbit model. In a pilot study, ETC-216 showed a significant reduction in coronary plaque burden after five weekly treatments, assessed by intravascular ultrasound in patients with acute coronary syndrome. Other therapeutic options of HDL therapy have recently became available.

Plasma delipidation process induces rapid regression of atherosclerosis and mobilisation of adipose tissue

Cholesterol is a major component of atherosclerotic plaques. Cholesterol accumulation within the arterial intima and atherosclerotic plaques is determined by the difference of cellular cholesterol synthesis and/or influx from apo B-containing lipoproteins and cholesterol efflux. In humans, apo A-1 Milano infusion has led to rapid regression of atherosclerosis in coronary arteries. We hypothesised that a multifunctional plasma delipidation process (PDP) would lead to rapid regression of experimental atherosclerosis and probably impact on adipose tissue lipids. In hyperlipidemic animals, the plasma concentrations of cholesterol, triglyceride and phospholipid were, respectively, 6-, 157-, and 18-fold higher than control animals, which consequently resulted in atherosclerosis. PDP consisted of delipidation of plasma with a mixture of butanol-diisopropyl ether (DIPE). PDP removed considerably more lipid from the hyperlipidemic animals than in normolipidemic animals. PDP treatment of hyperlipidemic animals markedly reduced intensity of lipid staining materials in the arterial wall and led to dramatic reduction of lipid in the adipose tissue. Five PDP treatments increased apolipoprotein A1 concentrations in all animals. Biochemical and hematological parameters were unaffected during PDP treatment. These results show that five PDP treatments led to marked reduction in avian atherosclerosis and removal of lipid from adipose tissue. PDP is a highly effective method for rapid regression of atherosclerosis.

Genetic determinants of low high-density lipoprotein cholesterol

PURPOSE OF REVIEW

High-density lipoprotein cholesterol (HDL-C) has been well established as an inverse predictor of coronary heart disease (CHD), and in recent years, investigations have focused on the genetic regulation of high-density lipoprotein. Although numerous candidate genes contribute to the low HDL-C phenotype, their impact on CHD is heterogeneous, reflecting diverse gene-gene interactions and gene-environmental relationships. This review summarizes recent data involving HDL regulatory genes and their role in atherothrombosis.

RECENT FINDINGS

The primary genetic determinants associated with relative HDL-C deficiency states are the ATP binding cassette protein, ABCA1; apolipoprotein (APO) A1; and lecithin cholesteryl acyl transferase. Other potentially important candidates invoked in low HDL-C syndromes in humans include APOC3, lipoprotein lipase, sphingomyelin phosphodiesterase 1, and glucocerebrosidase. Molecular variation in ABCAI and APOAI and, in selected cases, lecithin cholesteryl acyl transferase deficiency have been associated with increased CHD, whereas two notable variants, APOAIMilano and APOAIParis, are associated with reduced risk.

SUMMARY

Low HDL-C syndromes have generally been correlated with an increased risk of CHD. However, single-gene abnormalities responsible for HDL-C deficiency states may have variable effects on atherothrombotic risk.

Therapeutic approaches to raising plasma HDL-cholesterol levels

Epidemiologic data from the Framingham and Prospective Cardiovascular Munster studies, demonstrating an inverse correlation between the plasma concentration of HDLs and the incidence of cardiovascular disease, have driven research to explore precisely how HDLs confer this cardioprotective effect. HDLs are anti-inflammatory, antithrombogenic and have vasoactive effects, as well as being efficient cholesterol acceptors enabling the removal of cholesterol from peripheral tissues, all functions that are likely to protect the vasculature. The first part of this article will review the clinical evidence in support of the pleiotropic effects of HDLs, along with laboratory-based investigations of the molecular mechanisms of action. As the evidence of clinical benefits of raising plasma HDL concentration has increased, so has the number of strategies currently being considered to achieve this goal. The second part of this article will review three current strategies: infusion of HDL-like products, comparing physicopharmacologic characteristics of the two commercial products currently under trial; the use of fibrates to raise plasma HDLs (although fibrates primarily reduce triglyceride levels, certain derivatives are able to induce significant increases in plasma HDLs); and the use of drugs that inhibit cholesterol ester transfer protein (these drugs increase plasma HDL concentration either alone or as an adjunct therapy with statins). The clinical efficacy and mechanism of action of fibrates and inhibitors of cholesterol ester transfer protein will be reviewed.

Rapid reversal of endothelial dysfunction in hypercholesterolemic apolipoprotein E-null mice by recombinant apolipoprotein A-IMilano-phospholipid complex

OBJECTIVES

In this study, we examined whether a reconstituted high-density lipoprotein (HDL) utilizing recombinant apolipoprotein A-I(Milano) (apo A-I(M))/phospholipid complex (PC) could restore normal endothelial function in hypercholesterolemic apolipoprotein (apo) E-null mice.

BACKGROUND

We have previously shown antiatherosclerotic and vasculoprotective effects of recombinant apo A-I(M).

METHODS

A perfused vessel preparation was used to examine vascular responses in control wild-type, untreated, and treated apo E-null mice. Aortic tissue cholesterol content and platelet aggregation were also measured.

RESULTS

Endothelium-dependent vasodilator responses to acetycholine were significantly inhibited in untreated apo E-null mice compared with control wild-type mice (p < 0.001). Treatment of the mice for five weeks with once every-other-day intravenous bolus injections of apo A-I(M)/PC restored endothelium-dependent dilation in a dose-dependent manner (p < 0.01 at 80 mg/kg dose). The improvement in endothelial function was associated with a reduction in aortic cholesterol content and reduced platelet aggregability and occurred despite severe and persistent hypercholesterolemia. Neither treatment with free protein nor phospholipid carrier alone produced any significant effects. We performed additional experiments in vitro in isolated rabbit carotid arteries to compare the effects on lysophosphatidylcholine (LPC)-induced endothelial dysfunction. Treatment with apo A-I(M)/PC prevented impairment of endothelium-dependent vasodilator responses to acetylcholine to a greater degree than either wild-type apo A-I or plasma-derived HDL.

CONCLUSIONS

Our results indicate a rapid improvement in endothelial dysfunction with recombinant apo A-I(M)/PC that is associated with mobilization of tissue cholesterol. Taken together with previously established antiatherosclerotic and antithrombotic effects, these findings suggest significant vasculoprotective effects with apo A-I(M)/PC therapy.

Apolipoprotein A-I(Milano): current perspectives

PURPOSE OF REVIEW

Strategies to increase HDL are among the major targets of clinical research in atherosclerosis prevention. The mutant apolipoprotein A-I(Milano) has been associated with a reduced incidence of coronary disease in carriers. Furthermore, recombinant apolipoprotein A-I(Milano) has displayed remarkable atheroprotective activities and the possibility of directly reducing the burden of atherosclerosis in experimental models. This review is aimed at providing an update on the experimental studies in which apolipoprotein A-I(Milano), produced as a recombinant protein, has displayed important effects in the treatment of vascular diseases.

RECENT FINDINGS

In the past year, two reports have appeared, indicating that a single-dose administration of recombinant apolipoprotein A-I(Milano) dimers formulated into liposomes can reduce atheromas in models such as the apolipoprotein E-deficient mice and a rabbit model of carotid focal lesion, in which a direct 90 min infusion of the product reduced atheroma up to 30%. This finding was associated with an increase in HDL free cholesterol and the permanence of the recombinant product in the lesion for over 72 h.

SUMMARY

Recombinant apolipoprotein A-I(Milano), formulated as synthetic HDL with phospholipids, appears to exert a direct removing effect on arterial cholesterol. This is well evident in experimental animals and, more recently in clinical findings, as indicated by a dramatic increase in HDL free cholesterol after the infusion of different doses of the agent. As the product appears to be well tolerated and non-immunogenic, ongoing phase II studies in patients are being awaited with interest to obtain a 'proof of principle' for 'HDL therapy'.

Involvement of transcription factors in plasma HDL protection against TNF-alpha-induced vascular cell adhesion molecule-1 expression

Plasma HDL has been reported to protect against the initial development of inflammatory atherosclerosis. Although cellular and molecular mechanisms of this HDL protection are not fully understood, they may involve prevention of the endothelial trafficking of circulating leukocytes via its down-regulation of inflammatory genes. To test this hypothesis, HDL inhibition of monocyte adherence to the endothelium and of the expression of vascular cell adhesion molecule-1 (VCAM-1) and its transcriptional regulatory mechanism were elucidated in human umbilical vein endothelial cells (HUVECs) stimulated by pro-inflammatory TNF-alpha. Plasma HDL (1mg/ml apo A1) markedly prevented the monocyte adhesion to TNF-alpha-activated HUVECs with blunting the increased expression levels of VCAM-1 protein and its mRNA at a maximal TNF-alpha stimulation. Electrophoretic mobility shift assay showed that in the activated HUVECs HDL substantially inhibited DNA binding activities of transcription factors of nuclear factor-kappaB (NF-kappaB) and activator protein-1 (AP-1) that have binding sites in the promoter region of the VCAM-1 gene. In addition, immunocytochemical staining analysis confirmed that HDL inhibited TNF-alpha-induced VCAM-1 expression via reduced nuclear translocation of NF-kappaB. These results suggest that HDL down-regulates the expression of VCAM-1 gene in TNF-alpha-activated HUVECs at transcriptional levels via blunted translocation and transactivation of NF-kappaB and AP-1 transcription factors. Plasma HDL may block the initial atherosclerotic process via inhibited monocyte adhesion to the endothelium, which is independent of modulating the cholesterol reverse transport of plasma HDL.

HDL therapy for the acute treatment of atherosclerosis

Although pharmacologic intervention to treat atherosclerosis originally focused on lowering LDL-cholesterol levels as a therapeutic target, a number of intervention trials have also highlighted the powerful effect of elevating HDL-cholesterol levels to reduce cardiovascular morbidity and mortality. Although the mechanism(s) by which HDL beneficially alters the atherosclerotic disease process is (are) still unknown, it is presumed that high levels of HDL facilitate the efflux of cholesterol from the arterial wall, thereby enhancing the transport of cholesterol and other lipids from arteries back to the liver for biliary excretion as fecal sterols and bile acids. It has therefore been hypothesized that through a rapid facilitation of HDL mediated cholesterol efflux from arteries by infusion of synthetic apolipoprotein A-I (apoA-I)/phospholipid (A-I/PL) complexes, HDL therapy could have an acute therapeutic application to treat cardiovascular disease at the site of action, namely the vulnerable, unstable atherosclerotic plaque. Single high dose infusions and repeated injections of lower doses of apoA-I variants or mimetics complexed to phospholipids have produced remarkable effects on the progression and regression of atherosclerosis in animal models. The positive results of these preclinical experiments have compelled researchers to perform exploratory studies in human subjects in which reconstituted HDL and synthetic A-I/PL complexes are infused through a peripheral vein. These clinical studies are testing the hypothesis and the potential use of synthetic HDL as a new treatment modality for acute coronary syndromes. Given that there is an unmet medical need for new and more effective therapies to elevate HDL-cholesterol levels and improve HDL function, a historical review, update and discussion of the preclinical and clinical studies which support the use of HDL therapy for reducing cardiovascular morbidity and mortality is warranted.

Lack of inhibitory effect of HDL on TNFalpha-induced adhesion molecule expression in human aortic endothelial cells

Monocyte adhesion to and transmigration across the endothelium are initiating steps in atherogenesis. Cytokine-induced adhesion molecule expression in human umbilical vein endothelial cells (HUVEC) has been reported to be inhibited by either native HDL or reconstituted discoidal HDL (rHDL). In the present study we investigated these putative anti-atherosclerotic effects of HDL and rHDL in a more physiologically relevant cell type, i.e. human aortic endothelial cells (HAEC). HDL isolated by ultracentrifugation from eleven healthy subjects or rHDL made with apoA-I and either 1-palmitoyl-2-oleyl-sn-glycero-3-phosphocholine, 1-palmitoyl-2-linoleoyl-sn-glycero-3-phosphocholine (PLPC), or 1,2-dimyristoyl-sn-glycero-3-phosphocholine was incubated for 16 h with HAEC prior to stimulation with tumor necrosis factor-alpha (TNFalpha, 100 U/ml). Expression of E-selectin, vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1) was measured by cell ELISA and Northern blot analysis. HDL (0.25, 0.5, 1.0 and 2.0 mgprotein/ml) failed to significantly inhibit TNFalpha-induced mRNA and protein expression of all three adhesion molecules. Furthermore, of the three rHDL preparations (16 micromol/l apoA-I) only that containing the polyunsaturated PLPC significantly reduced TNFalpha-induced VCAM-1 expression (by 29.9+/-9.1%). These data contrast with previously reported results using plasma HDL and HUVEC, and show that human HDL and rHDL, except for PLPC-rHDL, are ineffective inhibitors of TNFalpha-induced adhesion molecule expression in HAEC. The ability of polyunsaturated phospholipids in HDL to affect endothelial activation remains to be further investigated.

Marked neointimal lipoprotein lipase increase in distinct models of proclivity to atherosclerosis: a feature independent of endothelial layer integrity

Lipoprotein lipase (LPL) in the arterial wall has been proposed to enhance the retention of apoB-containing lipoproteins, an early event in atherosclerosis. As the neointima is considered the primary site of lipid accumulation in atherogenesis, the arterial expression and location of LPL was investigated in distinct experimental models of neointimal formation in normolipidemic rabbits and rats. Neointima elicited by balloon aortic denudation or raised beneath an anatomically intact endothelial layer by placing a silastic collar around the common carotid artery, both showed a striking LPL immunostaining that mostly co-localized with neointimal smooth muscle cells. Besides, increased LPL protein and mRNA in deendothelialized aortas was demonstrated by Western and Northern blot analysis, respectively, suggesting an enhanced expression of LPL in injured arteries. It was concluded that LPL is increased in neointima developed in either denuded vessels or arteries with a preserved endothelium, a finding which suggests that LPL abundance may be an attribute of the neointima, whatever the stimulus that promotes its formation. On the basis of former evidence concerning the role of LPL in lipid retention, this study provides a possible explanation for the injury-induced vessel susceptibility to atherosclerosis, and the particular proneness of the neointimal layer to lipid accretion.

Recombinant lipoproteins: lipoprotein-like lipid particles for drug targeting

Lipoproteins are endogenous particles that transport lipids through the blood to various cell types, where they are recognised and taken up via specific receptors. These particles are, therefore, excellent candidates for the targeted delivery of drugs to various tissues. For example, the remnant receptor and the asialoglycoprotein receptor (ASGPr), which are uniquely localised on hepatocytes, recognise chylomicrons and lactosylated high density lipopoteins (HDL), respectively. In addition, tumour cells of various origins overexpress the low density lipoprotein (LDL) receptor that recognises apolipoprotein E (apoE) on small triglyceride-rich particles and apoB-100 on LDL. Being endogenous, lipoproteins are biodegradable, do not trigger immune reactions, and are not recognised by the reticuloendothelial system (RES). However, their endogenous nature also hampers large-scale pharmaceutical application. In the past two decades, various research groups have successfully synthesised recombinant lipoproteins from commercially available natural and synthetic lipids and serum-derived or recombinant apolipoproteins, which closely mimic the metabolic behaviour of their native counterparts in animal models as well as humans. In this paper, we will summarise the studies that led to the development of these recombinant lipoproteins, and we will address the possibility of using these lipidic particles to selectively deliver a wide range of lipophilic, amphiphilic, and polyanionic compounds to hepatocytes and tumour cells. In addition, the intrinsic therapeutic activities of recombinant chylomicrons and HDL in sepsis and atherosclerosis will be discussed.

Focus on HDL: a new treatment paradigm for athero-thrombotic vascular disease

Atherosclerotic vascular disease is the leading cause of mortality and morbidity in much of the Western world. Although advances in lifestyle and risk factor modification, pharmacotherapy, endovascular interventions and surgery have considerably improved clinical outcome, 40 - 50% of adverse cardiovascular events continue to occur despite current strategies. A number of new targets for therapeutic exploitation are currently being investigated that include, among others, apolipoprotein A-I, the major structural component of high density lipoprotein (HDL) particle. The strong negative relationship between HDL-cholesterol levels and coronary heart disease in epidemiological studies, as well as data from experimental models suggest that HDL-based therapies could be an important new paradigm for prevention, treatment and reversal of atherosclerotic vascular disease.

Current, new and future treatments in dyslipidaemia and atherosclerosis

The new therapeutic options available to clinicians treating dyslipidaemia in the last decade have enabled effective treatment for many patients. The development of the HMG-CoA reductase inhibitors (statins) have been a major advance in that they possess multiple pharmacological effects (pleiotropic effects) resulting in potent reductions of low density lipoproteins (LDL) and prevention of the atherosclerotic process. More recently, the newer fibric acid derivatives have also reduced LDL to levels comparable to those achieved with statins, have reduced triglycerides, and gemfibrozil has been shown to increase high density lipoprotein (HDL) levels. Nicotinic acid has been made tolerable with sustained-release formulations, and is still considered an excellent choice in elevating HDL cholesterol and is potentially effective in reducing lipoprotein(a) [Lp(a)] levels, an emerging risk factor for coronary heart disease (CHD). Furthermore, recent studies have reported positive lipid-lowering effects from estrogen and/or progestogen in postmenopausal women but there are still conflicting reports on the use of these agents in dyslipidaemia and in females at risk for CHD. In addition to lowering lipid levels, these antihyperlipidaemic agents may have directly or indirectly targeted thrombogenic, fibrinolytic and atherosclerotic processes which may have been unaccounted for in their overall success in clinical trials. Although LDL cholesterol is still the major target for therapy, it is likely that over the next several years other lipid/lipoprotein and nonlipid parameters will become more generally accepted targets for specific therapeutic interventions. Some important emerging lipid/lipoprotein parameters that have been associated with CHD include elevated triglyceride, oxidised LDL cholesterol and Lp(a) levels, and low HDL levels. The nonlipid parameters include elevated homocysteine and fibrinogen, and decreased endothelial-derived nitric oxide production. Among the new investigational agents are inhibitors of squalene synthetase, acylCoA: cholesterol acyltransferase, cholesteryl ester transfer protein, monocyte-macrophages and LDL cholesterol oxidation. Future applications may include thyromimetic therapy, cholesterol vaccination, somatic gene therapy, and recombinant proteins, in particular, apolipoproteins A-I and E. Non-LDL-related targets such as peroxisome proliferator-activating receptors, matrix metalloproteinases and scavenger receptor class B type I may also have clinical significance in the treatment of atherosclerosis in the near future. Before lipid-lowering therapy, dietary and lifestyle modification is and should be the first therapeutic intervention in the management of dyslipidaemia. Although current recommendations from the US and Europe are slightly different, adherence to these recommendations is essential to lower the risk of atherosclerotic vascular disease, more specifically CHD. New guidelines that are expected in the near future will encompass global opinions from the expert scientific community addressing the issue of target LDL goal (aggressive versus moderate lowering) and the application of therapy for newer emerging CHD risk factors.

Apolipoprotein A-I, cyclodextrins and liposomes as potential drugs for the reversal of atherosclerosis. A review

Several studies have revealed that high-density lipoprotein (HDL) is the most reliable predictor for susceptibility to cardiovascular disease. Since apolipoprotein A-I (apoA-I) is the major protein of HDL, it is worthwhile evaluating the potential of this protein to reduce the lipid burden of lesions observed in the clinic. Indeed, apoA-I is used extensively in cell culture to induce cholesterol efflux. However, while there is a large body of data emanating from in-vitro and cell-culture studies with apoA-I, little animal data and scant clinical trials examining the potential of this apolipoprotein to induce cholesterol (and other lipid) efflux exists. Importantly, the effects of oxysterols, such as 7-ketocholesterol (7KC), on cholesterol and other lipid efflux by apoA-I needs to be investigated in any attempt to utilise apoA-I as an agent to stimulate efflux of lipids. Lessons may be learnt from studies with other lipid acceptors such as cyclodextrins and phospholipid vesicles (PLVs, liposomes), by combination with other effluxing agents, by remodelling the protein structure of the apolipoprotein, or by altering the composition of the lipoprotein intended for administration in-vivo. Akin to any other drug, the usage of this apolipoprotein in a therapeutic context has to follow the traditional sequence of events, namely an evaluation of the biodistribution, safety and dose-response of the protein in animal trials in advance of clinical trials. Mass production of the apolipoprotein is now a simple process due to the advent of recombinant DNA technology. This review also considers the potential of cyclodextrins and PLVs for use in inducing reverse cholesterol transport in-vivo. Finally, the potential of cyclodextrins as delivery agents for nucleic acid-based constructs such as oligonucleotides and plasmids is discussed.

Apolipoprotein A-I, phospholipid vesicles, and cyclodextrins as potential anti-atherosclerotic drugs: delivery, pharmacokinetics, and efficacy

High-density lipoprotein (HDL) is a reliable predictor for susceptibility to cardiovascular disease. Since apolipoprotein A-I (apoA-I) is the major protein of HDL, it is worthwhile to evaluate the potential of this protein to reduce the lipid burden of lesions observed in the clinic. While a large body of data emanates from in vitro and cell culture studies with apoA-I, few animal and lesser clinical trials examining the potential of this apolipoprotein to induce cholesterol (and other lipid) efflux exist. Lessons may be learned from studies with other lipid acceptors such as phospholipid vesicles (PLVs, liposomes) and cyclodextrins (CDs). Additionally, the combination of apoA-I with other effluxing agents, alteration of the composition of the lipoprotein, or a remodeling of the protein structure of the apolipoprotein to be administered in vivo may result in increased efficacy. The usage of this apolipoprotein in a therapeutic context has to follow the conventional sequence of events: an evaluation of the biodistribution, safety, and dose-response of the protein in animal trials before clinical trials. The review also considers the potential of cyclodextrins and PLVs to induce reverse cholesterol transport in vivo and discusses the potential of CDs as delivery agents for genetic constructs, such as plasmids and oligonucleotides.

High-density lipoprotein: multipotent effects on cells of the vasculature

The epidemiological evidence showing a strong inverse correlation between the level of plasma high-density lipoprotein (HDL) and the incidence of heart disease suggests that HDL has a protective effect against cardiovascular disease. The mechanism of this protective effect has been the raison d'etre for much research. The ability of HDL to mediate cholesterol efflux from peripheral tissues has been used to explain the cardioprotective effect of HDL. However, there is little direct evidence to suggest that in subjects with low plasma levels of HDL the rate of cholesterol efflux from peripheral tissues is significantly reduced. This observation suggested that HDL may be mediating its protective effect through other mechanisms. This review provides an account of the burgeoning evidence that HDL has many effects on cellular processes, in addition to the effects on cholesterol efflux, and will illustrate the multipotency of this lipoprotein.