Cholesterol mobilization and regression of atheroma in cholesterol-fed rabbits induced by large unilamellar vesicles

Effects of withdrawing an atherogenic diet on the atherosclerotic plaque in rabbits

Lifestyle interventions and pharmacotherapy are the most common of non-invasive treatments for atherosclerosis, but the individual effect of diet on plaques remains unclear. The current study aimed to investigate the effect of withdrawing the atherogenic diet on plaque in the aortas of rabbits. Experimental atheroma was induced in 33 rabbits using a 1% high cholesterol diet for 30 days (H-30 d) or 90 days (H-90 d, baseline group). After 90 days of the atherogenic diet, the remaining animals were divided into four groups: A total of 10 rabbits continued to consume the atherogenic diet for 50 days (H-90 d & H-50 d; n=5) or 140 days (H-90 d & H-140 d; n=5). Another 13 rabbits were switched to a chow diet for 50 days (H-90 d & C-50 d; n=7) or 140 days (H-90 d & C-140 d; n=6). A total of 10 age-matched rabbits in the control groups were fed a chow diet for 90 and 230 days, respectively. The en face or cross-sectional plaque areas were determined using oil red O staining and elastic van Gieson staining. Immunohistochemistry analyses were used to assess the macrophages or smooth muscle cell contents. When fed an atherogenic diet for 90 days, the rabbits' abdominal aortas exhibited severe atherosclerotic lesions (the median en face plaque area was 63.6%). After withdrawing the atherogenic diet, the plaque area did not shrink with feeding the chow diet compared with the baseline, but increased to 71.8 or 80.5% after 50 or 140 days, respectively. After removing cholesterol from the diet, the lipids content in the plaques increased during the first 50 days, and then decreased compared with the baseline group. Furthermore, withdrawing the atherogenic diet increased the total collagen content and the percentage of the smooth muscle cells, alleviated macrophage infiltration, decreased the vulnerable index and promoted the cross-linking of collagen. Feeding the rabbits an atherogenic diet followed by removal of cholesterol from the diet did not lead to the regression of established lesions but instead delayed the progression of the lesions and promoted the stabilization of the plaque.

The phenomenon of atherosclerosis reversal and regression: Lessons from animal models

Studies in non-rodent and murine models showed that atherosclerosis can be reversed. Atherosclerosis progression induced by high-fat or cholesterol-rich diet can be reduced and reversed to plaque regression after switching to a normal diet or through administration of lipid-lowering agents. The similar process should exist in humans after implementation of lipid-lowering therapy and as a result of targeting of small rupture-prone plaques that are major contributors for acute atherosclerotic complications. Lowering of low density lipoprotein (LDL) cholesterol and the activation of reverse cholesterol transport lead to a decline in foam cell content, to the depletion of plaque lipid reservoirs, a decrease in lesional macrophage numbers through the activation of macrophage emigration and, probably, apoptosis, dampening plaque inflammation, and the induction of anti-inflammatory macrophages involved in clearance of the necrotic core and plaque healing. By contrast, plaque regression is characterized by opposite events, leading to the retention of atherogenic LDL and oxidized LDL particles in the plaque, an increased flux of monocytes, the immobilization of macrophages in the intimal vascular tissues, and the propagation of intraplaque inflammation. Transfer of various apolipoprotein (apo) genes to spontaneously hypercholesterolemic mice deficient for either apoE or LDL receptor and, especially, the implementation of the transplantation murine model allowed studying molecular mechanisms of atherosclerotic regression, associated with the depletion of atherogenic lipids in the plaque, egress of macrophages and phenotypic switch of macrophages from the proinflammatory M1 to the anti-inflammatory M2.

Therapeutic applications of reconstituted HDL: When structure meets function

Reconstituted forms of HDL (rHDL) are under development for infusion as a therapeutic approach to attenuate atherosclerotic vascular disease and to reduce cardiovascular risk following acute coronary syndrome and ischemic stroke. Currently available rHDL formulations developed for clinical use contain apolipoprotein A-I (apoA-I) and one of the major lipid components of HDL, either phosphatidylcholine or sphingomyelin. Recent data have established that quantitatively minor molecular constituents of HDL particles can strongly influence their anti-atherogenic functionality. Novel rHDL formulations displaying enhanced biological activities, including cellular cholesterol efflux, may therefore offer promising prospects for the development of HDL-based, anti-atherosclerotic therapies. Indeed, recent structural and functional data identify phosphatidylserine as a bioactive component of HDL; the content of phosphatidylserine in HDL particles displays positive correlations with all metrics of their functionality. This review summarizes current knowledge of structure-function relationships in rHDL formulations, with a focus on phosphatidylserine and other negatively-charged phospholipids. Mechanisms potentially underlying the atheroprotective role of these lipids are discussed and their potential for the development of HDL-based therapies highlighted.

Prednisolone-containing liposomes accumulate in human atherosclerotic macrophages upon intravenous administration

Drug delivery to atherosclerotic plaques via liposomal nanoparticles may improve therapeutic agents' risk-benefit ratios. Our paper details the first clinical studies of a liposomal nanoparticle encapsulating prednisolone (LN-PLP) in atherosclerosis. First, PLP's liposomal encapsulation improved its pharmacokinetic profile in humans (n=13) as attested by an increased plasma half-life of 63h (LN-PLP 1.5mg/kg). Second, intravenously infused LN-PLP appeared in 75% of the macrophages isolated from iliofemoral plaques of patients (n=14) referred for vascular surgery in a randomized, placebo-controlled trial. LN-PLP treatment did however not reduce arterial wall permeability or inflammation in patients with atherosclerotic disease (n=30), as assessed by multimodal imaging in a subsequent randomized, placebo-controlled study. In conclusion, we successfully delivered a long-circulating nanoparticle to atherosclerotic plaque macrophages in patients, whereas prednisolone accumulation in atherosclerotic lesions had no anti-inflammatory effect. Nonetheless, the present study provides guidance for development and imaging-assisted evaluation of future nanomedicine in atherosclerosis.

FROM THE CLINICAL EDITOR

In this study, the authors undertook the first clinical trial using long-circulating liposomal nanoparticle encapsulating prednisolone in patients with atherosclerosis, based on previous animal studies. Despite little evidence of anti-inflammatory effect, the results have provided a starting point for future development of nanomedicine in cardiovascular diseases.

Has nanomedicine lived up to its promise?

Nanomedicine for diagnosis and treatment of disease, as a discipline has been around for several years, with the first nanotherapeutic product being approved in 1995. Worldwide its importance was recognized with the setting up of several nanomedicine centres in 2004-2006. Many of these centres were set up to accelerate the speed of translation of the research. In this article we review, with a broad brush, the progress made in the last 15 years, and examine whether the translation efforts have been successful, and also evaluate whether such successes have changed the medical landscape. Possible reasons for the relatively long time to commercialization for nanomedicine products are also explored.

Interaction between VLDL and phosphatidylcholine liposomes generates new γ-LpE-like particles

One of the subfractions of HDL involved in reverse cholesterol transport is γ-LpE. It has been assumed that, like preβ-LpAI, it can be generated during the interaction between phosphatidylcholine liposomes and lipoproteins and can contribute to more efficient cholesterol efflux after the introduction of liposomes to plasma. However, there has been no evidence concerning what the sources of these particles in plasma might be. Here, we determined whether the interaction of phosphatidylcholine liposomes with VLDL and the subsequent conversions of particles could be a source of new γ-LpE particles. We found that the interaction between liposomes and VLDL affected its lipid and protein composition. The content of phospholipids increased (~96 %) while the content of free cholesterol and apolipoprotein E decreased in VLDL during the reaction with liposomes (~100 and ~24 %, respectively). New particles which did not contain apolipoprotein B were generated. Heterogeneous HDL-sized populations of particles were generated, containing phospholipids and apolipoprotein E as the sole apolipoprotein, with densities from 1.063 to 1.21 g/ml, either with γ-mobility on agarose gel and Stokes diameters from 8.58 to 22.07 nm or with preβ-mobility and Stokes diameters from 9.9 to 21.08 nm. The obtained results contribute to the understanding of changes in lipoproteins under the influence of phosphatidylcholine liposomes, showing the formation of new (γ-LpE)-like and (preβ-LpE)-like particles, similar in mobility and size to plasma HDL-LpE. These newly generated particles can claim a share of the antiatherogenic effects of liposomes, observed in studies both in vitro and in vivo.

Regression of atherosclerosis: insights from animal and clinical studies

BACKGROUND

Based on studies that date back to the 1920s, regression and stabilization of atherosclerosis in humans has gone from just a dream to one that is achievable. Review of the literature indicates that the successful attempts at regression generally applied robust measures to improve plasma lipoprotein profiles. Examples include extensive lowering of plasma concentrations of atherogenic apolipoprotein B and enhancement of reverse cholesterol transport from atheromata to the liver.

FINDINGS

Possible mechanisms responsible for lesion shrinkage include decreased retention of atherogenic apolipoprotein B within the arterial wall, efflux of cholesterol and other toxic lipids from plaques, emigration of lesional foam cells out of the arterial wall, and influx of healthy phagocytes that remove necrotic debris as well as other components of the plaque. This review will highlight the role key players such as LXR, HDL and CCR7 have in mediating regression.

CONCLUSION

Although much progress has been made, there are many unanswered questions. There is, therefore, a clear need for preclinical and clinical testing of new agents expected to facilitate atherosclerosis regression with the hope that additional mechanistic insights will allow further progress.

Fat lowers fat: purified phospholipids as emerging therapies for dyslipidemia

Dyslipidemia is a major coronary heart disease (CHD) risk factor. In spite of the proven efficacy of statin drugs in reducing CHD burden, there is still much room for the discovery of novel therapeutic agents to address the considerable residual cardiovascular risk that remains after treatment with currently available medications. In particular, there is an urgent demand for drugs capable of boosting the concentration and/or function of high-density lipoprotein (HDL) and apolipoprotein A-I (apo A-I), thereby promoting reverse cholesterol transport. Phospholipids are naturally occurring fats that play indispensible role in human health via their structural, energy storage, signal transduction and metabolic functions. Supplementation with either purified or mixed preparations of bioactive phospholipids has been reported to ameliorate a range of nutritional and cardiovascular disorders. Moreover, several lines of evidence have supported the efficacy of dietary phospholipids in reducing serum and hepatic contents of cholesterol and triglycerides, while increasing HDL-C and apo A-I levels. These beneficial effects of phospholipids could be attributed to their ability in reducing intestinal cholesterol absorption, enhancing biliary cholesterol excretion and modulating the expression and activity of transcriptional factors and enzymes that are involved in lipoprotein metabolism. Given their extreme safety and biocompatibility, dietary supplementation with phospholipid preparations, in particular phosphatidylinositol, appears as a novel and effective strategy that could be used as an alternative or adjunctive therapy to the current medications. The present review outlines the in-vitro, in-vivo and clinical findings on the anti-dyslipidemic effects of three most abundant phospholipids in the human body and diet namely phosphatidylcholine, phosphatidylethanolamine and phosphatidylinositol.

Perspectives and opportunities for nanomedicine in the management of atherosclerosis

The use of nanotechnology for medical purposes--nanomedicine--has grown exponentially over the past few decades. This is exemplified by the US Food and Drug Administration's approval of several nanotherapies for various conditions, as well as the funding of nanomedical programmes worldwide. Although originally the domain of anticancer therapy, recent advances have illustrated the considerable potential of nanomedicine in the diagnosis and treatment of atherosclerosis. This Review elaborates on nanoparticle-targeting concepts in atherosclerotic disease, provides an overview of the use of nanomedicine in atherosclerosis, and discusses potential future applications and clinical benefits.

Synthetic dimyristoylphosphatidylcholine liposomes assimilating into high-density lipoprotein promote regression of atherosclerotic lesions in cholesterol-fed rabbits

We have reported recently that enrichment of high-density lipoprotein (HDL) with phosphatidylcholine (PC) liposomes is effective in solubilizing cholesterol from isolated human atherosclerotic plaques. In the present study, we investigated the in vivo effect of enrichment of HDL with PC on regression of diet-induced atherosclerosis in rabbits. As part of the study, a preliminary in vitro study on blood collected from the cholesterol-fed rabbits was performed to assess the capacity of the HDL density ( d > 1.063 g/mL) plasma fraction from cholesterol-fed rabbits to assimilate multilamellar liposomes of synthetic dimyristoylphosphatidylcholine (DMPC). This was compared with the capacities of egg- and soy-PC liposomes to be assimilated into the HDL density plasma fraction. The capacity of the HDL density fraction to absorb PC from DMPC liposomes (11.5 mg/mL) was more than 10 times greater than egg or soy liposomes. Therefore, DMPC liposomes were chosen to infuse into cholesterol-fed rabbits. Cholesterol-fed rabbits infused weekly with DMPC liposomes (300 mg/kg body weight) for five weeks had significantly decreased aortic cholesterol contents ( P < 0.05) compared with saline-infused cholesterol-fed controls. Atherosclerotic plaque volume, as measured by a type of new magnetic resonance imaging analysis, also decreased significantly ( P < 0.05) after DMPC treatment. The present findings suggest that the enrichment of HDL with PC via intravenous infusion of synthetic DMPC liposomes could be a potential therapeutic approach for atherosclerotic plaque regression.

Effect of lipid-modifying therapies on the functional quality of high-density lipoproteins: implications for drug development

BACKGROUND

Increasing interest has focused on the development of therapeutic strategies to promote the biological activity of high-density lipoproteins (HDL) to achieve more effective prevention of cardiovascular disease. The highly publicized failure of raising HDL cholesterol with the cholesteryl ester transfer protein inhibitor, torcetrapib, has fueled immense discussion with regard to the potential impact of lipid modifying therapies on the functional quality of HDL particles.

OBJECTIVE/METHOD

To review the literature that has investigated the role of HDL functionality in protection against cardiovascular disease.

CONCLUSION

It remains to be unequivocally demonstrated that therapies that directly target HDL are cardioprotective in humans. Increasing attention on the functional quality of HDL will be essentinal for developing new biomarkers and medical therapies.

HDL-replacement therapy: mechanism of action, types of agents and potential clinical indications

HDL-replacement therapy is a promising new treatment strategy involving the acute administration of HDL to rapidly stabilize patients at imminent risk for developing a myocardial infarction, such as those with acute coronary syndrome. This review will first focus on the anti-atherogenic mechanisms for HDL, such as the stimulation of the reverse cholesterol transport pathway, and then discuss the other potential beneficial biological effects of HDL on atherosclerosis. The various types of HDL-replacement therapies that are being investigated and developed will be reviewed and ongoing clinical trials and other possible clinical indications for HDL-replacement therapy besides the prevention of myocardial infarction will also be described. Finally, HDL-replacement therapy will be put into perspective by summarizing the current gaps in our knowledge of HDL metabolism and identifying challenges for future research in this area.

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.

Is raising HDL a futile strategy for atheroprotection?

The dramatic failure of clinical trials evaluating the cholesterol ester transfer protein inhibitor torcetrapib has led to considerable doubt about the value of raising high-density lipoprotein cholesterol (HDL-C) as a treatment for cardiovascular disease. These results have underscored the intricacy of HDL metabolism, with functional quality perhaps being a more important consideration than the circulating quantity of HDL. As a result, HDL-based therapeutics that maintain or enhance HDL functionality warrant closer investigation. In this article, we review the complexity of HDL metabolism, discuss clinical-trial data for HDL-raising agents, including possible reasons for the failure of torcetrapib, and consider the potential for future HDL-based therapies.

The effect of large unilamellar vesicles on vascular function in patients with coronary atherosclerosis

OBJECTIVE

To evaluate the effect of large unilamellar vesicles (LUVs) infusion on endothelial function. Low-density lipoprotein (LDL) lowering, particularly with statins, results in rapid attenuation of endothelial dysfunction and decreases cardiovascular events. Unique methods of removing cholesterol from the vessel wall are being developed. The effect of LUVs on endothelial function has not been evaluated in humans.

METHOD

75 subjects (mean age 61+/-10 years) with established vascular disease were randomized to receive either 2g, 8 g or matching placebo of LUVs as a weekly intravenous bolus infusion for 4 consecutive weeks. Brachial artery flow-mediated dilation (FMD) and nitroglycerin-mediated dilation was measured at baseline and 1 week after the last infusion. The primary study outcome was the change from baseline in FMD in the active therapy groups combined. Predefined secondary end-points included nitroglycerin-mediated dilation and safety.

RESULTS

Active therapy (combined 2g+8 g treatment groups, n=49) did not result in a change in FMD, but did improve nitroglycerin dilation (p<0.05). However, a beneficial effect on both FMD (10.2+/-5.7% vs. 11.8+/-5.5%) and nitroglycerin-mediated dilation (18.1+/-9.3% vs. 21.2+/-8.7%, both p<0.05) was seen in the 2-g group. Infusion of the 8-g dose resulted in significantly higher levels of unesterified cholesterol compared with the other groups during the study period (p<0.01).

CONCLUSION

The current study demonstrated no overall effect of LUVs on FMD, however nitroglycerin-mediated dilation was improved. Further studies are required to clarify if there is a dose-dependent effect of this therapy and what its role is in subjects with atherosclerosis.

Rapid regression of atherosclerosis: insights from the clinical and experimental literature

Looking back at animal and clinical studies published since the 1920s, the notion of rapid regression and stabilization of atherosclerosis in humans has evolved from a fanciful goal to one that might be achievable pharmacologically, even for advanced plaques. Our review of this literature indicates that successful regression of atherosclerosis generally requires robust measures to improve plasma lipoprotein profiles. Examples of such measures include extensive lowering of plasma concentrations of atherogenic apolipoprotein B (apoB)-lipoproteins and enhancement of 'reverse' lipid transport from atheromata into the liver, either alone or in combination. Possible mechanisms responsible for lesion shrinkage include decreased retention of apoB-lipoproteins within the arterial wall, efflux of cholesterol and other toxic lipids from plaques, emigration of foam cells out of the arterial wall, and influx of healthy phagocytes that remove necrotic debris and other components of the plaque. Unfortunately, the clinical agents currently available cause less dramatic changes in plasma lipoprotein levels, and, thereby, fail to stop most cardiovascular events. Hence, there is a clear need for testing of new agents expected to facilitate atherosclerosis regression. Additional mechanistic insights will allow further progress.

New targets of high-density lipoprotein therapy

PURPOSE OF REVIEW

Increasing attention has focused on the development of therapeutic strategies to promote the biologic activity of HDL particles, which possess a number of functional properties that contribute to their role in cardioprotection. Currently available therapies raise levels of HDL-cholesterol by relatively modest amounts. This review describes experimental strategies that promote HDL activity.

RECENT FINDINGS

The functional quality of HDL may be more important than the absolute level of HDL-cholesterol found in the systemic circulation. This is supported by the observation that small rises in HDL-cholesterol with current therapies is associated with clinical benefit. This has major implications for the development of new therapies. A number of therapeutic strategies have been developed that promote reverse cholesterol transport, inhibit inflammatory events in the vessel wall, and modify remodeling of HDL particles within the systemic circulation.

SUMMARY

A number of emerging therapies appear to promote the biologic activity of HDL. These agents can be administered as acute infusions in the setting of acute ischemic syndromes or as oral therapy for chronic prevention of cardiovascular disease.

LDL-cholesterol lowering or HDL-cholesterol raising for cardiovascular prevention

A number of reports have indicated that both lowering low density lipoprotein (LDL)-cholesterol and raising high density lipoprotein (HDL)-cholesterol can result in significant cardiovascular benefit, both in terms of reduction of events and also, to a variable extent, of atheromatous lesions. LDL and HDL have opposite roles in body cholesterol regulation and, in theory, both reduced deposition (LDL reduction) and increased removal (raised HDL) can improve vascular disease. A number of reports over the last 30 years have attempted to quantitate with cholesterol balance/turnover studies, the correlations between LDL and HDL levels and body cholesterol pool sizes. More recently, these studies have evaluated the effects of LDL or HDL changes on cholesterol elimination. Data have, at times, been fully consistent with theoretical expectations, whereas at others they have not. Evaluation of these, at times, historical data provides, however, an important clue to the understanding of current results with different medications for the management of lipoprotein disorders.

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.

Lipoprotein Retention—and Clues for Atheroma Regression

Subendothelial retention of apoB-lipoproteins is the key initiating event in atherosclerosis, provoking a cascade of pathogenic responses. Dissection of the molecular participants provides fresh insight into how this major killer might be reversed. Efflux of harmful lipids derived from retained lipoproteins may be crucial in promoting beneficial remodeling of lesions.

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.

Phosphatidylinositol promotes cholesterol transport and excretion

Administration of phosphatidylinositol (PI) to New Zealand White rabbits increases HDL negative charge and stimulates reverse cholesterol transport. Intravenously administered PI (10 mg/kg) associated almost exclusively with the HDL fraction in rabbits. PI promoted an increase in the hepatic uptake of plasma free cholesterol (FC) and a 21-fold increase in the biliary secretion of plasma-derived cholesterol. PI also increased cholesterol excretion into the feces by 2.5-fold. PI directly affects cellular cholesterol metabolism. In cholesterol-loaded macrophages, PI stimulated cholesterol mass efflux to lipid-poor reconstituted HDL. PI was about half as effective as cAMP at stimulating efflux, and the effects of cAMP and PI were additive. In cultured HepG2 cells, PI-enriched HDL also enhanced FC uptake from HDL by 3-fold and decreased cellular cholesterol synthesis and esterification. PI enrichment had no effect on the selective uptake of cholesterol esters or on the internalization of HDL particles. PI-dependent metabolic events were efficiently blocked by inhibitors of protein kinase C and the inositol signaling cascade. The data suggest that HDL-PI acts via cell surface ATP binding cassette transporters and signaling pathways to regulate both cellular and intravascular cholesterol homeostasis.

Slowed progression or elimination of atherosclerosis by low-frequency electrical impulses

BACKGROUND

In our previous investigations we showed that electrical impulses (EI) can prevent the development of atherosclerosis if they began simultaneously with high cholesterol diet (HCD) or in the early stages of atherosclerosis (after three weeks of HCD only). In this investigation we demonstrated the slow progression or elimination of atherosclerosis by low-frequency EI in case of moderate atherosclerosis (after eight weeks of HCD).

METHODS

Series I rabbits (control group) were fed HCD for eight weeks. Series II rabbits were fed HCD for eight weeks and were then switched to normal diet for eight weeks (no EI). Series III rabbits were fed HCD for eight weeks and then switched to a normal diet with simultaneous EI (applied near the abdominal aorta) for eight weeks (3 V, 30 single impulses per minute, 24 hours/day). After euthanization, the level of atherosclerosis, percentage of surface area involved in the atherosclerosis process, and an atherosclerosis score were calculated in the aortic arch, thoracic and abdominal aorta.

RESULTS

Statistically significant differences were seen in the level of atherosclerosis in the abdominal aorta between series III animals (0.4 +/- 0.2) and the other two groups: 1.5 +/- 0.4 in series I (HCD only), 1.2 +/- 0.3 in series II (HCD then normal diet). Gross examination of the surface also revealed statistically significant differences (p < 0.05) in the percentage of atherosclerosis between the control series I (30.1 +/- 4.1%) and series II (21.3 +/- 3.6%), compared with series III (5.5 +/- 5.4%). In addition, the atherosclerosis score was also significantly different: 45.8 +/- 3.9 in series I, 25.2 +/- 6.9 in series II, and 2.2 +/- 2.0 in series III (p < 0.05).

CONCLUSION

Our study showed that, when applied near the abdominal aorta, low-frequency electrical impulses decrease atherosclerotic deposition in the abdominal aorta.

High-dose recombinant apolipoprotein A-I(milano) mobilizes tissue cholesterol and rapidly reduces plaque lipid and macrophage content in apolipoprotein e-deficient mice. Potential implications for acute plaque stabilization

BACKGROUND

Repeated doses of recombinant apolipoprotein A-I(Milano) phospholipid complex (apoA-I(m)) reduce atherosclerosis and favorably change plaque composition in rabbits and mice. In this study, we tested whether a single high dose of recombinant apoA-I(m) could rapidly mobilize tissue cholesterol and reduce plaque lipid and macrophage content in apoE-deficient mice.

METHODS AND RESULTS

High cholesterol-fed, 26-week-old apoE-deficient mice received a single intravenous injection of saline (n=16), 1080 mg/kg dipalmitoylphosphatidylcholine (DPPC; n=14), or 400 mg/kg of recombinant apoA-I(m) complexed with DPPC (1:2.7 weight ratio; n=18). Blood was sampled before and 1 and 48 hours after injection, and aortic root plaques were evaluated for lipid content and macrophage content after oil-red O and immunostaining, respectively. One hour after injection, the plasma cholesterol efflux-promoting capacity was nearly 2-fold higher in recombinant apoA-I(m)-treated mice compared with saline and DPPC-treated mice (P<0.01). Compared with baseline values, serum free cholesterol, an index of tissue cholesterol mobilization, increased 1.6-fold by 1 hour after recombinant apoA-I(m) injection, and it remained significantly elevated at 48 hours (P<0.01). Mice receiving recombinant apoA-I(m) had 40% to 50% lower lipid content (P<0.01) and 29% to 36% lower macrophage content (P<0.05) in their plaques compared with the saline- and DPPC-treated mice, respectively.

CONCLUSIONS

A single high dose of recombinant apoA-I(m) rapidly mobilizes tissue cholesterol and reduces plaque lipid and macrophage content in apoE-deficient mice. These findings suggest that this strategy could rapidly change plaque composition toward a more stable phenotype.

Effect of up-regulating individual steps in the reverse cholesterol transport pathway on reverse cholesterol transport in normolipidemic mice

Cholesterol acquired by extrahepatic tissues (from de novo synthesis or lipoproteins) is returned to the liver for excretion in a process called reverse cholesterol transport (RCT). We undertook studies to determine if RCT could be enhanced by up-regulating individual steps in the RCT pathway. Overexpression of 7alpha-hydroxylase, Scavenger receptor B1, lecithin:cholesterol acyltransferase (LCAT), or apoA-I in the liver did not stimulate cholesterol efflux from any extrahepatic tissue. In contrast, infusion of apoA-I.phospholipid complexes (rHDL) that resemble nascent HDL markedly stimulated cholesterol efflux from tissues into plasma. Cholesterol effluxed to rHDL was initially unesterified but by 24 h this cholesterol was largely esterified and had shifted to normal HDL (in mice lacking cholesteryl ester transfer protein) or to apoB containing lipoproteins (in cholesteryl ester transfer protein transgenic mice). Most of the cholesterol effluxed into plasma in response to rHDL came from the liver. However, an even greater proportion of effluxed cholesterol was cleared by the liver resulting in a transient increase in liver cholesterol concentrations. Fecal sterol excretion was not increased by rHDL. Thus, although rHDL stimulated cholesterol efflux from most tissues and increased net cholesterol movement from extrahepatic tissues to the liver, cholesterol flux through the entire RCT pathway was not increased.

Does therapeutic intervention achieve slowing of progression or bona fide regression of atherosclerotic lesions?

-This review focuses on the regression of atherosclerosis in humans and experimental animals. It highlights the difficulties to determine unequivocally whether with a given therapeutic intervention, such as diet, drugs, or apheresis, the progression of lesions was curtailed or bona fide regression of atherosclerotic lesions was achieved. It seems appropriate to mention that 2 very different ways to measure regression were used in experimental animals and in humans. Regression in animals was determined mainly in the aorta or coronary arteries isolated at post mortem, and the criteria used were degree of sudanophilia and/or aortic wall thickness and cellular composition or cholesterol content. In humans, the evaluation of regression relied mainly on quantitative coronary angiography. The literature of the past decade is reviewed selectively but not exhaustively, and in some instances, a brief historical overview is given.

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.

Rapid restoration of normal endothelial functions in genetically hyperlipidemic mice by a synthetic mediator of reverse lipid transport

Endothelial dysfunction is a major pathophysiological consequence of hypercholesterolemia and other conditions. We examined whether a synthetic mediator of lipid transport from peripheral tissues to the liver (ie, the "reverse" pathway) could restore normal endothelial function in vivo. Using assays of macrovascular and microvascular function, we found that genetically hypercholesterolemic apolipoprotein E knockout mice exhibited key endothelial impairments. Treatment of the mice for 1 week with daily intravenous bolus injections of large "empty" phospholipid vesicles, which accelerate the reverse pathway in vivo, restored endothelium-dependent relaxation, leukocyte adherence, and endothelial expression of vascular cell adhesion molecule-1 to normal or nearly normal levels. These changes occurred despite the long-standing hyperlipidemia of the animals and the persistence of high serum concentrations of cholesterol-rich atherogenic lipoproteins during the treatment. Our results indicate that dysfunctional macrovascular and microvascular endothelium in apolipoprotein E knockout mice can recover relatively quickly in vivo and that accelerated reverse lipid transport may be a useful therapy.

Lack of regression of atherosclerotic lesions in phytosterol-treated apo E-deficient mice

We evaluated the effects of a phytosterol mixture (FCP-3PI) on the regression of atherosclerotic lesions in male apo E-deficient mice. Atherosclerosis was induced in fifteen mice by a "Western-type" diet containing 9% (w/w) fat and 0.15% (w/w) cholesterol over a period of 18 weeks (Induction phase). Then, two mice were used to evaluate the development of atherosclerosis, and the rest was divided into the control (n=6) and treated (n=7) groups. The control group was fed mouse chow (4.5% w/w fat) and the treated group fed the same chow supplemented with 2% (w/w) FCP-3PI for an additional 25 weeks (Regression phase). The mice developed severe hypercholesterolemia and advanced atherosclerotic lesions over the induction phase. During the first 6 weeks of regression phase, plasma cholesterol concentrations decreased at a similar rate (35%) in both groups of control and phytosterol-treated mice. Although evidence of lesion regression was not observed in either group of mice, the treated group had slightly smaller lesion size than the controls. During the induction phase, each mouse developed atherosclerotic lesions averaging 0.025 mm2 per week. However, during the regression phase, this was decreased to approximately one fifth and one third in the treated and control groups, respectively. Thus, compared to the end of the induction phase, the control group had a 40% increase in the lesion size, while this increase was only 28% in the treated animals. In conclusion, our previous findings along with a small decrease in the atherosclerotic lesion size observed in the treated group in the present study suggest that FCP-3PI treatment may slow the development of atherosclerotic lesions in apo E-deficient mice; however, a longer regression period may yield a greater benefit.

Contact hypersensitivity: a simple model for the characterization of disease-site targeting by liposomes

A murine model of delayed-type hypersensitivity (DTH) is characterized with respect to liposome accumulation at a site of inflammation. Mice were sensitized by painting the abdominal region with a solution of 2,4-dinitrofluorobenzene (DNFB) and inflammation was induced 5 days later by challenging the ear with a dilute solution of DNFB. The inflammatory response was readily monitored by measuring ear thickness (edema) and radiolabeled leukocyte infiltration. Maximum ear swelling and cellular infiltration occurred 24 h after the epicutaneous challenge with the ear returning to normal size after approximately 72 h. We demonstrate that large unilamellar vesicles (LUV) accumulate at the site of inflammation to a level more than 20-fold higher than that measured in the untreated ear. Vesicle delivery to the ear correlated with increased vascular leakage resulting from endothelium remodeling in response to DNFB challenge, and was not a consequence of increased local tissue blood volume. Extravasation occurred only during the first 24 h after ear challenge; after this time the permeability of the endothelium to vesicles returned to normal. We further showed that LUV with a diameter of 120 nm exhibit maximum levels of accumulation, that a polyethylene glycol surface coating does not increase delivery, and that the process can be inhibited by the application of topical corticosteroids at the time of induction. These data and the inflammation model are discussed with respect to developing lipid-based drug delivery vehicles designed to accumulate at inflammatory disease sites.

Lamellar lipoproteins uniquely contribute to hyperlipidemia in mice doubly deficient in apolipoprotein E and hepatic lipase

Remnants of triglyceride-rich lipoproteins containing apolipoprotein (apo) B-48 accumulate in apo E-deficient mice, causing pronounced hypercholesterolemia. Mice doubly deficient in apo E and hepatic lipase have more pronounced hypercholesterolemia, even though remnants do not accumulate appreciably in mice deficient in hepatic lipase alone. Here we show that the doubly deficient mice manifest a unique lamellar hyperlipoproteinemia, characterized by vesicular particles 600 A-1,300 A in diameter. As seen by negative-staining electron microscopy, these lipoproteins also contain an electron-lucent region adjacent to the vesicle wall, similar to the core of typical lipoproteins. Correlative chemical analysis indicates that the vesicle wall is composed of a 1:1 molar mixture of cholesterol and phospholipids, whereas the electron-lucent region appears to be composed of cholesteryl esters (about 12% of the particle mass). Like the spherical lipoproteins of doubly deficient mice, the vesicular particles contain apo B-48, but they are particularly rich in apo A-IV. We propose that cholesteryl esters are removed from spherical lipoproteins of these mice by scavenger receptor B1, leaving behind polar lipid-rich particles that fuse to form vesicular lipoproteins. Hepatic lipase may prevent such vesicular lipoproteins from accumulating in apo E-deficient mice by hydrolyzing phosphatidyl choline as scavenger receptor B1 removes the cholesteryl esters and by gradual endocytosis of lipoproteins bound to hepatic lipase on the surface of hepatocytes.

Structural and metabolic consequences of liposome-lipoprotein interactions

The two major proposed uses for liposomes, i.e., drug delivery and mobilization of peripheral deposits of cholesterol, each impose requirements and restrictions on liposomal structure, particularly as it affects interactions with lipoproteins. This chapter focuses on the role of lipoproteins and apolipoproteins in (1) disrupting membrane structure and causing the leakage of liposomal contents by inducing disc formation and (2) marking liposomes for whole-particle uptake by receptors involved in lipoprotein metabolism. Control of membrane stability and whole-particle half-life can be achieved by several strategies, such as membrane stiffening, shielding the membrane surface, and increasing the dose or predosing with "empty" liposomes. The rationales and applicabilities of these strategies are discussed in the contexts of liposomes as drug delivery vehicles and as antiatherogenic particles. Directions for further basic and applied research are also presented.