Dysregulated cellular metabolism in atherosclerosis: mediators and therapeutic opportunities

Accumulating evidence over the past decades has revealed an intricate relationship between dysregulation of cellular metabolism and the progression of atherosclerotic cardiovascular disease. However, an integrated understanding of dysregulated cellular metabolism in atherosclerotic cardiovascular disease and its potential value as a therapeutic target is missing. In this Review, we (1) summarize recent advances concerning the role of metabolic dysregulation during atherosclerosis progression in lesional cells, including endothelial cells, vascular smooth muscle cells, macrophages and T cells; (2) explore the complexity of metabolic cross-talk between these lesional cells; (3) highlight emerging technologies that promise to illuminate unknown aspects of metabolism in atherosclerosis; and (4) suggest strategies for targeting these underexplored metabolic alterations to mitigate atherosclerosis progression and stabilize rupture-prone atheromas with a potential new generation of cardiovascular therapeutics.

Serine synthesis via reversed SHMT2 activity drives glycine depletion and acetaminophen hepatotoxicity in MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects one-third of the global population. Understanding the metabolic pathways involved can provide insights into disease progression and treatment. Untargeted metabolomics of livers from mice with early-stage steatosis uncovered decreased methylated metabolites, suggesting altered one-carbon metabolism. The levels of glycine, a central component of one-carbon metabolism, were lower in mice with hepatic steatosis, consistent with clinical evidence. Stable-isotope tracing demonstrated that increased serine synthesis from glycine via reverse serine hydroxymethyltransferase (SHMT) is the underlying cause for decreased glycine in steatotic livers. Consequently, limited glycine availability in steatotic livers impaired glutathione synthesis under acetaminophen-induced oxidative stress, enhancing acute hepatotoxicity. Glycine supplementation or hepatocyte-specific ablation of the mitochondrial SHMT2 isoform in mice with hepatic steatosis mitigated acetaminophen-induced hepatotoxicity by supporting de novo glutathione synthesis. Thus, early metabolic changes in MASLD that limit glycine availability sensitize mice to xenobiotics even at the reversible stage of this disease.

Spatially Resolved Metabolites in Stable and Unstable Human Atherosclerotic Plaques Identified by Mass Spectrometry Imaging

BACKGROUND

Impairments in carbohydrate, lipid, and amino acid metabolism drive features of plaque instability. However, where these impairments occur within the atheroma remains largely unknown. Therefore, we sought to characterize the spatial distribution of metabolites within stable and unstable atherosclerosis in both the fibrous cap and necrotic core.

METHODS

Atherosclerotic tissue specimens from 9 unmatched individuals were scored based on the Stary classification scale and subdivided into stable and unstable atheromas. After performing mass spectrometry imaging on these samples, we identified over 850 metabolite-related peaks. Using MetaboScape, METASPACE, and Human Metabolome Database, we confidently annotated 170 of these metabolites and found over 60 of these were different between stable and unstable atheromas. We then integrated these results with an RNA-sequencing data set comparing stable and unstable human atherosclerosis.

RESULTS

Upon integrating our mass spectrometry imaging results with the RNA-sequencing data set, we discovered that pathways related to lipid metabolism and long-chain fatty acids were enriched in stable plaques, whereas reactive oxygen species, aromatic amino acid, and tryptophan metabolism were increased in unstable plaques. In addition, acylcarnitines and acylglycines were increased in stable plaques whereas tryptophan metabolites were enriched in unstable plaques. Evaluating spatial differences in stable plaques revealed lactic acid in the necrotic core, whereas pyruvic acid was elevated in the fibrous cap. In unstable plaques, 5-hydroxyindoleacetic acid was enriched in the fibrous cap.

CONCLUSIONS

Our work here represents the first step to defining an atlas of metabolic pathways involved in plaque destabilization in human atherosclerosis. We anticipate this will be a valuable resource and open new avenues of research in cardiovascular disease.

DT-109 ameliorates nonalcoholic steatohepatitis in nonhuman primates

Nonalcoholic steatohepatitis (NASH) prevalence is rising with no pharmacotherapy approved. A major hurdle in NASH drug development is the poor translatability of preclinical studies to safe/effective clinical outcomes, and recent failures highlight a need to identify new targetable pathways. Dysregulated glycine metabolism has emerged as a causative factor and therapeutic target in NASH. Here, we report that the tripeptide DT-109 (Gly-Gly-Leu) dose-dependently attenuates steatohepatitis and fibrosis in mice. To enhance the probability of successful translation, we developed a nonhuman primate model that histologically and transcriptionally mimics human NASH. Applying a multiomics approach combining transcriptomics, proteomics, metabolomics, and metagenomics, we found that DT-109 reverses hepatic steatosis and prevents fibrosis progression in nonhuman primates, not only by stimulating fatty acid degradation and glutathione formation, as found in mice, but also by modulating microbial bile acid metabolism. Our studies describe a highly translatable NASH model and highlight the need for clinical evaluation of DT-109.

Fatty liver-mediated glycine restriction impairs glutathione synthesis and causes hypersensitization to acetaminophen

Non-alcoholic fatty liver disease (NAFLD) affects nearly one third of the population worldwide. Understanding metabolic pathways involved can provide insights into disease progression. Untargeted metabolomics of livers from mice with early-stage steatosis indicated a decrease in methylated metabolites suggesting altered one carbon metabolism. The levels of glycine, a central component of one carbon metabolism, were lower in steatotic mice, in line with clinical evidence. Isotope tracing studies demonstrated that increased synthesis of serine from glycine is the underlying cause for glycine limitation in fatty livers. Consequently, the low glycine availability in steatotic livers impaired glutathione (GSH) synthesis under oxidative stress induced by acetaminophen (APAP), enhancing hepatic toxicity. Glycine supplementation mitigated acute liver damage and overall toxicity caused by APAP in fatty livers by supporting de novo GSH synthesis. Thus, early metabolic changes in NAFLD that lead to glycine depletion sensitize mice to xenobiotic toxicity even at a reversible stage of NAFLD.

The interplay between nonalcoholic fatty liver disease and atherosclerotic cardiovascular disease

Therapeutic approaches that lower circulating low-density lipoprotein (LDL)-cholesterol significantly reduced the burden of cardiovascular disease over the last decades. However, the persistent rise in the obesity epidemic is beginning to reverse this decline. Alongside obesity, the incidence of nonalcoholic fatty liver disease (NAFLD) has substantially increased in the last three decades. Currently, approximately one third of world population is affected by NAFLD. Notably, the presence of NAFLD and particularly its more severe form, nonalcoholic steatohepatitis (NASH), serves as an independent risk factor for atherosclerotic cardiovascular disease (ASCVD), thus, raising interest in the relationship between these two diseases. Importantly, ASCVD is the major cause of death in patients with NASH independent of traditional risk factors. Nevertheless, the pathophysiology linking NAFLD/NASH with ASCVD remains poorly understood. While dyslipidemia is a common risk factor underlying both diseases, therapies that lower circulating LDL-cholesterol are largely ineffective against NASH. While there are no approved pharmacological therapies for NASH, some of the most advanced drug candidates exacerbate atherogenic dyslipidemia, raising concerns regarding their adverse cardiovascular consequences. In this review, we address current gaps in our understanding of the mechanisms linking NAFLD/NASH and ASCVD, explore strategies to simultaneously model these diseases, evaluate emerging biomarkers that may be useful to diagnose the presence of both diseases, and discuss investigational approaches and ongoing clinical trials that potentially target both diseases.

Abstract 436: Loss Of Serine Hydroxymethyltransferase 2 In Macrophages Enhances Atherosclerosis While Reducing Macrophage Mitochondrial Respiration

Despite significant advancements in therapeutics and intervention, cardiovascular diseases remain the leading cause of death worldwide. Atherosclerosis, the accumulation of lipid-laden plaques in large arteries, is the underlying cause of most cardiovascular diseases. While the role of lipids is well-established in atherosclerotic cardiovascular disease, the contribution of amino acids is becoming increasingly recognized. Indeed, lower circulating glycine is consistently reported in patients with cardiovascular diseases. The mitochondrial serine hydroxymethyltransferase (SHMT2) is responsible for the bulk of glycine biosynthesis in most cell types. SHMT2 catalyzes the formation of glycine from serine and drives one-carbon metabolism necessary for mitochondrial protein translation. SHMT2 is critical in development since global knockout mice are nonviable. Previous studies showed patients with significant coronary artery disease exhibit a reduced glycine:serine ratio compared with healthy individuals. We discovered LPS-treated macrophages similarly attenuated glycine:serine concomitant with reduced SHMT2 expression. Moreover, we found SHMT2 is highly expressed in plaque-associated macrophages in both human and mouse atherosclerotic plaques. We hypothesized that SHMT2 regulates macrophage inflammatory phenotype in atherosclerosis through alterations in mitochondrial function. Deletion of SHMT2 reduced mitochondrial respiration while enhancing glycolysis similar to LPS-treated macrophages. In addition, SHMT2 deletion augmented oxidized-LDL accumulation in macrophages. To determine whether macrophage-expressed SHMT2 contributes to atherosclerosis, we applied CRISPR/Cas9 and Cre-lox recombination system to generate myeloid-specific SHMT2 knockout ( Shmt2 MKO ) mice. We further crossed Shmt2 MKO mice with Apoe knockout ( Apoe -/- ) mice to study atherosclerosis following Western diet feeding. Compared to littermate controls ( Shmt2 fl / Apoe -/- ), Shmt2 MKO / Apoe -/- mice had significantly enhanced plaque area. Our findings, representing the first investigation of conditional SHMT2 knockout mice, suggest a novel immunometabolic role for SHMT2 in macrophages in atherosclerosis.

Induction of glutathione biosynthesis by glycine-based treatment mitigates atherosclerosis

Lower circulating levels of glycine are consistently reported in association with cardiovascular disease (CVD), but the causative role and therapeutic potential of glycine in atherosclerosis, the underlying cause of most CVDs, remain to be established. Here, following the identification of reduced circulating glycine in patients with significant coronary artery disease (sCAD), we investigated a causative role of glycine in atherosclerosis by modulating glycine availability in atheroprone mice. We further evaluated the atheroprotective potential of DT-109, a recently identified glycine-based compound with dual lipid/glucose-lowering properties. Glycine deficiency enhanced, while glycine supplementation attenuated, atherosclerosis development in apolipoprotein E-deficient (Apoe^−/−) mice. DT-109 treatment showed the most significant atheroprotective effects and lowered atherosclerosis in the whole aortic tree and aortic sinus concomitant with reduced superoxide. In Apoe^−/− mice with established atherosclerosis, DT-109 treatment significantly reduced atherosclerosis and aortic superoxide independent of lipid-lowering effects. Targeted metabolomics and kinetics studies revealed that DT-109 induces glutathione formation in mononuclear cells. In bone marrow-derived macrophages (BMDMs), glycine and DT-109 attenuated superoxide formation induced by glycine deficiency. This was abolished in BMDMs from glutamate-cysteine ligase modifier subunit-deficient (Gclm^−/-) mice in which glutathione biosynthesis is impaired. Metabolic flux and carbon tracing experiments revealed that glycine deficiency inhibits glutathione formation in BMDMs while glycine-based treatment induces de novo glutathione biosynthesis. Through a combination of studies in patients with CAD, in vivo studies using atherosclerotic mice and in vitro studies using macrophages, we demonstrated a causative role of glycine in atherosclerosis and identified glycine-based treatment as an approach to mitigate atherosclerosis through antioxidant effects mediated by induction of glutathione biosynthesis.

EphA2 stimulates VCAM-1 expression through calcium-dependent NFAT1 activity

Endothelial cell activation by proinflammatory stimuli drives leukocyte recruitment through enhanced expression of counter-receptors such as vascular cell adhesion molecule-1 (VCAM-1). We previously demonstrated that activation of the receptor tyrosine kinase EphA2 with its ligand ephrin-A1 induces VCAM-1 expression. Here, we sought to characterize the proinflammatory signaling pathways involved. Analysis of over-represented transcription factors in ephrin-A1-induced genes identified multiple potential transcriptional regulators, including the Rel family members nuclear factor-κB (NF-κB/p65) and nuclear factor of activated T-cells (NFAT). While ephrin-A1 failed to induce endothelial NF-κB activation, NF-κB inhibitors prevented ephrin-A1-induced VCAM-1 expression, suggesting basal NF-κB activity is required. In contrast, ephrin-A1 induced a robust EphA2-dependent increase in NFAT activation, and mutation of the NF-κB/NFAT-binding sites in the VCAM-1 promoter blunted ephrin-A1-induced promoter activity. NFAT activation classically occurs through calcium-dependent calcineurin activation, and inhibiting NFAT signaling with calcineurin inhibitors (cyclosporine A, FK506) or direct NFAT inhibitors (A-285222) was sufficient to block ephrin-A1-induced VCAM-1 expression. Consistent with robust NFAT activation, ephrin-A1-induced an EphA2-dependent calcium influx in endothelial cells that was required for ephrin-A1-induced NFAT activation and VCAM-1 expression. This work provides the first data showing EphA2-dependent calcium influx and NFAT activation and identifies NFAT as a novel EphA2-dependent proinflammatory pathway in endothelial activation.

Abstract 621: Vascular Smooth Muscle EphA2 Signaling Regulates Fibrillar Adhesion Formation to Drive Fibronectin Deposition

During atherosclerosis, synthetic vascular smooth muscle cells drive development of the fibrous cap through extracellular matrix deposition. Deposition of the provisional matrix protein fibronectin appears to critically regulate fibrous cap development by promoting smooth muscle recruitment and by providing a critical scaffold for assembly of fibrillar collagens. We previously showed that deletion of the receptor tyrosine kinase EphA2 in ApoE knockout mice attenuated plaque size and progression, characterized by a reduction of both smooth muscle content and fibrosis, and we further demonstrated that EphA2 depletion attenuates smooth muscle fibronectin deposition in vitro. Despite this, the mechanisms by which EphA2 regulates smooth muscle matrix deposition remains unknown. Fibronectin fibrillogenesis involves both the formation of α5β1 integrin-rich fibrillar adhesions and contractility-dependent fibronectin unfolding. We now show EphA2 localizes to integrin adhesions and appears to regulate matrix deposition through multiple mechanisms. Knockdown of EphA2 reduces the formation of fibrillar adhesions characterized by a loss of α5β1 integrins and tensin, whereas EphA2 overexpression is sufficient to induce fibrillar adhesion formation in contractile smooth muscle cells. In addition, vascular smooth muscle cells show diminished collagen gel contraction following EphA2 knockdown, and EphA2 depletion significantly reduces smooth muscle myosin light chain phosphorylation, suggesting that EphA2 expression is required to generate the contractive forces required for matrix remodeling in synthetic smooth muscle cells. Together these data identify a novel role for EphA2 in the regulation of smooth muscle matrix deposition through effects on both integrin adhesion structure and cytoskeletal contractility.

Abstract 088: Fibronectin Promotes EphA2 Expression through RGD Integrin Signaling in Vascular Smooth Muscle Cells

Vascular smooth muscle cells undergo a phenotypic shift to a “synthetic” phenotype during atherosclerosis characterized by downregulation of contractile markers and augmented proliferation, migration, and deposition of extracellular matrix. While absent in contractile, medial vascular smooth muscle, the receptor tyrosine kinase EphA2 is detectable in vascular smooth muscle within the plaque and in synthetic vascular smooth muscle cells in vitro , and deletion of EphA2 in ApoE knockout mice attenuates plaque size and progression characterized by a loss of smooth muscle and fibrous tissue content. However, the mechanisms driving EphA2 expression in vascular smooth muscle remains unknown. Both serum treatment and plating on provisional extracellular matrix proteins (e.g. fibronectin) are sufficient to induce EphA2 protein expression and transcriptional activation of the EphA2 promoter. While multiple factors in serum could contribute to EphA2 expression, treating vascular smooth muscle cells with individual growth factors (PDGF, FGF, EGF) or insulin failed to recapitulate the increase in EphA2 expression. However, depleting fibronectin from the serum significantly attenuated expression of EphA2, suggesting fibronectin may critically regulate smooth muscle EphA2 expression. This reduction in serum-induced EphA2 expression upon fibronectin depletion was further enhanced by siRNA knockdown of smooth muscle fibronectin expression, suggesting that both serum fibronectin and smooth muscle-derived fibronectin contribute to the enhanced EphA2 expression. Fibronectin binds to a distinct subset of RGD-binding integrins, and blocking fibronectin-integrin interactions or inhibiting specific fibronectin-binding integrins both attenuate EphA2 expression. Together these data identify a novel role for fibronectin-dependent integrin signaling in the induction of smooth muscle EphA2 expression during phenotypic transition.

Macrophage-associated lipin-1 enzymatic activity contributes to modified low-density lipoprotein-induced pro-inflammatory signaling and atherosclerosis

Macrophage proinflammatory responses induced by modified low-density lipoproteins (modLDL) contribute to atherosclerotic progression. How modLDL causes macrophages to become proinflammatory is still enigmatic. Macrophage foam cell formation induced by modLDL requires glycerolipid synthesis. Lipin-1, a key enzyme in the glycerolipid synthesis pathway, contributes to modLDL-elicited macrophage proinflammatory responses in vitro. The objective of this study was to determine if macrophage-associated lipin-1 contributes to atherogenesis and to assess its role in modLDL-mediated signaling in macrophages. We developed mice lacking lipin-1 in myeloid-derived cells and used adeno-associated viral vector 8 expressing the gain-of-function mutation of mouse proprotein convertase subtilisin/kexin type 9 (AAV8-PCSK9) to induce hypercholesterolemia and plaque formation. Mice lacking myeloid-associated lipin-1 had reduced atherosclerotic burden compared to control mice despite similar plasma lipid levels. Stimulation of bone marrow-derived macrophages with modLDL activated a persistent PKCα/βII-ERK1/2-cJun signaling cascade that contributed to macrophage proinflammatory responses that was dependent on lipin-1 enzymatic activity. Our data demonstrate that macrophage-associated lipin-1 is atherogenic, likely through persistent activation of a PKCα/βII-ERK1/2-cJun signaling cascade that contributes to foam cell proinflammatory responses. Taken together these results suggest modLDL-induced foam cell formation and modLDL-induced macrophage proinflammatory responses are not independent consequences of modLDL stimulation, but rather are both directly influenced by enhanced lipid synthesis.

Macrophage-Associated Lipin-1 Enzymatic Activity Contributes to Modified Low-Density Lipoprotein-Induced Proinflammatory Signaling and Atherosclerosis

OBJECTIVE

Macrophage proinflammatory responses induced by modified low-density lipoproteins (modLDL) contribute to atherosclerotic progression. How modLDL causes macrophages to become proinflammatory is still enigmatic. Macrophage foam cell formation induced by modLDL requires glycerolipid synthesis. Lipin-1, a key enzyme in the glycerolipid synthesis pathway, contributes to modLDL-elicited macrophage proinflammatory responses in vitro. The objective of this study was to determine whether macrophage-associated lipin-1 contributes to atherogenesis and to assess its role in modLDL-mediated signaling in macrophages.

APPROACH AND RESULTS

We developed mice lacking lipin-1 in myeloid-derived cells and used adeno-associated viral vector 8 expressing the gain-of-function mutation of mouse proprotein convertase subtilisin/kexin type 9 (adeno-associated viral vector 8-proprotein convertase subtilisin/kexin type 9) to induce hypercholesterolemia and plaque formation. Mice lacking myeloid-associated lipin-1 had reduced atherosclerotic burden compared with control mice despite similar plasma lipid levels. Stimulation of bone marrow-derived macrophages with modLDL activated a persistent protein kinase Cα/βII-extracellular receptor kinase1/2-jun proto-oncogene signaling cascade that contributed to macrophage proinflammatory responses that was dependent on lipin-1 enzymatic activity.

CONCLUSIONS

Our data demonstrate that macrophage-associated lipin-1 is atherogenic, likely through persistent activation of a protein kinase Cα/βII-extracellular receptor kinase1/2-jun proto-oncogene signaling cascade that contributes to foam cell proinflammatory responses. Taken together, these results suggest that modLDL-induced foam cell formation and modLDL-induced macrophage proinflammatory responses are not independent consequences of modLDL stimulation but rather are both directly influenced by enhanced lipid synthesis.

EphA2 Expression Regulates Inflammation and Fibroproliferative Remodeling in Atherosclerosis

BACKGROUND

Atherosclerotic plaque formation results from chronic inflammation and fibroproliferative remodeling in the vascular wall. We previously demonstrated that both human and mouse atherosclerotic plaques show elevated expression of EphA2, a guidance molecule involved in cell-cell interactions and tumorigenesis.

METHODS

Here, we assessed the role of EphA2 in atherosclerosis by deleting EphA2 in a mouse model of atherosclerosis (Apoe^-/-) and by assessing EphA2 function in multiple vascular cell culture models. After 8 to 16 weeks on a Western diet, male and female mice were assessed for atherosclerotic burden in the large vessels, and plasma lipid levels were analyzed.

RESULTS

Despite enhanced weight gain and plasma lipid levels compared with Apoe^-/- controls, EphA2^-/-Apoe^-/- knockout mice show diminished atherosclerotic plaque formation, characterized by reduced proinflammatory gene expression and plaque macrophage content. Although plaque macrophages express EphA2, EphA2 deletion does not affect macrophage phenotype, inflammatory responses, and lipid uptake, and bone marrow chimeras suggest that hematopoietic EphA2 deletion does not affect plaque formation. In contrast, endothelial EphA2 knockdown significantly reduces monocyte firm adhesion under flow. In addition, EphA2^-/-Apoe^-/- mice show reduced progression to advanced atherosclerotic plaques with diminished smooth muscle and collagen content. Consistent with this phenotype, EphA2 shows enhanced expression after smooth muscle transition to a synthetic phenotype, and EphA2 depletion reduces smooth muscle proliferation, mitogenic signaling, and extracellular matrix deposition both in atherosclerotic plaques and in vascular smooth muscle cells in culture.

CONCLUSIONS

Together, these data identify a novel role for EphA2 in atherosclerosis, regulating both plaque inflammation and progression to advanced atherosclerotic lesions. Cell culture studies suggest that endothelial EphA2 contributes to atherosclerotic inflammation by promoting monocyte firm adhesion, whereas smooth muscle EphA2 expression may regulate the progression to advanced atherosclerosis by regulating smooth muscle proliferation and extracellular matrix deposition.

Abstract 213: Deletion of Epha2 Reduces Fibroproliferative Remodeling in Atherosclerosis and Vascular Smooth Muscle

Advanced atherosclerosis involves the recruitment of vascular smooth muscle cells, leading to smooth muscle-mediated fibroproliferative remodeling and plaque stiffening. We previously demonstrated the neuronal guidance receptor EphA2 shows enhanced expression in murine and human atherosclerosis, and EphA2 deletion in atherosclerosis-prone ApoE knockout mice attenuates lesion formation and endothelial cell activation in models of atherosclerosis. We now demonstrate deletion of EphA2 attenuates plaque progression to advanced stages associated with diminished smooth muscle content. While contractile smooth muscle cells show minimal EphA2 expression in vitro and in vivo , transition to the synthetic phenotype results in enhanced EphA2 expression and luciferase reporter activity in vitro and in atherosclerotic lesions. Furthermore, forced expression of EphA2 in quiescent smooth muscle cells is sufficient to suppress contractile smooth muscle markers, suggesting a role for EphA2 in smooth muscle phenotypic switch. Depletion of EphA2 results in significant reductions in proliferation within atherosclerotic plaques and in smooth muscle cells with associated reductions in serum-induced ERK and Akt signaling. Conversely, overexpression of EphA2 enhances smooth muscle proliferation in vitro , suggesting EphA2 is sufficient to drive proliferation. EphA2-deficient mice show reductions in plaque fibrosis and matrix remodeling. Consistent with this, depletion of EphA2 in vascular smooth muscle cells exhibit a significant reduction in matrix deposition. Together these data suggest a role for EphA2 in smooth muscle-mediated fibroproliferative remodeling, representing the first link between EphA2 signaling and smooth muscle function in atherosclerosis.

Abstract 446: EphA2 Regulates Vascular Smooth Muscle Fibroproliferative Remodeling in Atherosclerosis

Eph receptors, the largest mammalian subfamily of receptor tyrosine kinases, regulate inflammation and tissue remodeling. The EphA2 receptor shows enhanced expression in atherosclerosis, and deletion of EphA2 in atherosclerosis-prone ApoE knockout mice attenuates lesion formation. We now show that EphA2 knockout mice exhibit reduced late stage plaque progression associated with diminished smooth muscle content. While EphA2 is absent in quiescent vascular smooth muscle cells in vitro and in vivo , dedifferentiation to a synthetic phenotype significantly upregulates EphA2 expression. Deletion of EphA2, a known oncogene, reduces markers of proliferation in atherosclerotic plaques, and EphA2 knockdown similarly reduces vascular smooth muscle proliferation in culture with associated reductions in serum-induced ERK and Akt signaling. In addition to proliferation, EphA2 knockout mice show significantly reduced collagen content in their atherosclerotic plaques, and EphA2 knockdown reduces smooth muscle matrix deposition in vitro . Together these data suggest a potential role for EphA2 in smooth-muscle driven vascular fibroproliferative remodeling, representing the first link between EphA2 signaling and smooth muscle function.