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Abstract Purpose of Review There is an increasing recognition of the importance of sex in susceptibility, clinical presentation, and outcomes for heart failure. This review focusses on heart failure with reduced ejection fraction (HFrEF), unravelling differences in biology, clinical and demographic features and evidence for diagnostic and therapeutic strategies. This is intended to inform clinicians and researchers regarding state-of-the-art evidence relevant to women, as well as areas of unmet need. Recent Findings Females are well recognised to be under-represented in clinical trials, but there have been some improvements in recent years. Data from the last 5 years reaffirms that women presenting with HFrEF women are older and have more comorbidities like hypertension, diabetes and obesity compared with men and are less likely to have ischaemic heart disease. Non-ischaemic aetiologies are more likely to be the cause of HFrEF in women, and women are more often symptomatic. Whilst mortality is less than in their male counterparts, HFrEF is associated with a bigger impact on quality of life in females. The implications of this for improved prevention, treatment and outcomes are discussed. Summary This review reveals distinct sex differences in HFrEF pathophysiology, types of presentation, morbidity and mortality. In light of this, in order for future research and clinical medicine to be able to manage HFrEF adequately, there must be more representation of women in clinical trials as well as collaboration for the development of sex-specific management guidelines. Future research might also elucidate the biochemical foundation of the sex discrepancy in HFrEF.

Peripheral arterial disease is a growing worldwide problem with a wide spectrum of clinical severity and is projected to consume >$21 billion per year in the United States alone. While vascular researchers have brought several therapies to the clinic in recent years, few of these approaches have leveraged advances in high-throughput discovery screens, novel translational models, or innovative trial designs. In the following review, we discuss recent advances in unbiased genomics and broader omics technology platforms, along with preclinical vascular models designed to enhance our understanding of disease pathobiology and prioritize targets for additional investigation. Furthermore, we summarize novel approaches to clinical studies in subjects with claudication and ischemic ulceration, with an emphasis on streamlining and accelerating bench-to-bedside translation. By providing a framework designed to enhance each aspect of future clinical development programs, we hope to enrich the pipeline of therapies that may prevent loss of life and limb for those with peripheral arterial disease.

Nitric oxide (NO) production by eNOS (endothelial NO synthase) is critical for vascular health. Oxidative stress-induced uncoupling of eNOS leads to decreased NO bioavailability, compounded by increased superoxide generation. FXYD1 (FXYD domain containing ion transport regulator 1), a caveolar protein, protects against oxidative inhibition of the Na + -K + -ATPase. We hypothesized that FXYD1 may afford a similar inhibition of oxidative dysregulation of eNOS, providing a broader protection within caveolae. FXYD1-eNOS colocalization was demonstrated by co-immunoprecipitation in heart protein and by proximity ligation assay in human umbilical vein endothelial cells. The functional nature of this partnership was shown by silencing FXYD1 in human umbilical vein endothelial cells, where 50% decreased NO and 2-fold augmented superoxide was shown. Three-dimensional cocultured cardiac spheroids generated from FXYD1 knockout mice were incapable of acetylcholine-induced NO production. Overexpression of FXYD1 in HEK293 cells revealed a possible mechanism, where FXYD1 protected against redox modification of eNOS cysteines. In vivo, vasodilation in response to increasing doses of bradykinin was impaired in knockout mice, and this was rescued in mice by delivery of FXYD1 protein packaged in exosomes. Bloods vessels extracted from knockout mice exhibited increased oxidative and nitrosative stress with evidence of reduce eNOS phosphorylation. Impaired vascular function and augmented superoxide generation were also evident in diabetic knockout mice. Despite this, blood pressure was similar in wildtype and knockout mice, but after chronic angiotensin II infusion, knockout of FXYD1 was associated with a heightened blood pressure response. FXYD1 protects eNOS from dysregulated redox signaling and is protective against both hypertension and diabetic vascular oxidative stress.

Peripheral arterial disease (PAD) is characterised by accelerated arterial calcification and impairment in angiogenesis. Studies implicate vascular calcification as a contributor to PAD, but the mechanisms remain unclear. We aimed to determine the effect of calcification on ischaemia-driven angiogenesis. Human coronary artery endothelial cells (ECs) were treated with calcification medium (CM: CaCl2 2.7 mM, Na2PO4 2.0 mM) for 24 h and exposed to normoxia (5% CO2) or hypoxia (1.2% O2; 5% CO2 balanced with N2). In normoxia, CM significantly inhibited tubule formation and migration and upregulated calcification markers of ALP, BMP2, and Runx2. CM elevated levels of calcification-protective gene OPG, demonstrating a compensatory mechanism by ECs. CM failed to induce pro-angiogenic regulators VEGFA and HIF-1α in hypoxia and further suppressed the phosphorylation of endothelial nitric oxide synthase (eNOS) that is essential for vascular function. In vivo, osteoprotegerin-deficient mice (OPG−/−), a calcification model, were subjected to hind-limb ischaemia (HLI) surgery. OPG−/− mice displayed elevated serum alkaline phosphatase (ALP) activity compared to wild-type controls. OPG−/− mice experienced striking reductions in blood-flow reperfusion in both 8-week-old and 6-month-old mice post-HLI. This coincided with significant impairment in tissue ischaemia and reduced limb function as assessed by clinical scoring (Tarlov). This study demonstrated for the first time that a pro-calcific environment is detrimental to ischaemia-driven angiogenesis. The degree of calcification in patients with PAD can often be a limiting factor with the use of standard therapies. These highly novel findings require further studies for full elucidation of the mechanisms involved and have implications for the development of therapies to suppress calcification in PAD.

Eukaryotic elongation factor 2 kinase (eEF2K) is an atypical protein kinase that controls protein synthesis in cells under stress. Although well studied in cancer, less is known about its roles in chronic inflammatory diseases. Here, we examined its regulation of macrophage cholesterol handling in the context of atherosclerosis. eEF2K mRNA expression and protein activity were upregulated in murine bone marrow-derived macrophages (BMDMs) exposed to oxidized low-density lipoprotein cholesterol (oxLDL). When incubated with oxLDL, BMDMs from eEF2K knockout (Eef2k

Background Although the association between dysregulated coagulation and atherosclerosis is well recognized, individual assays have been of minimal value in understanding disease susceptibility. Here we investigated the association of global coagulation profiles with coronary artery disease with consideration of sex differences. Methods and Results The study included patients from the BioHEART‐CT (The BioHEART Study: Assessing Patients With Suspected Cardiovascular Disease for New Disease Markers and Risk Factors) biobank who had computed tomography coronary angiograms scored for coronary artery calcium score (CACS) and Gensini score. The cohort included 206 adult patients who were referred for clinically indicated computed tomography coronary angiography and had a median of 2 major cardiac risk factors; 50% were women and the average age was 62.6 years (±9.9 years). The overall hemostatic potential (OHP) and calibrated automated thrombography generation assays were performed on platelet‐poor plasma. CACS and Gensini score in men were significantly correlated in bivariate analysis with measures from the OHP assay, and regression models predicting disease severity by CACS or Gensini score were improved by adding the OHP assay variables in men but not in women. The calibrated automated thrombography generation assay demonstrated a more hypercoagulable profile in women than in men. The OHP assay showed hypercoagulable profiles in women with hyperlipidemia and men with obesity. Conclusions The OHP assay identified hypercoagulable profiles associated with different risk factors for each sex and was associated with CACS and Gensini score severity in men, emphasizing the associations between increased fibrin generation and reduced fibrinolysis with cardiac risk factors and early atherosclerosis. Registration Information www.anzctr.org.au . Identifier: ACTRN12618001322224.

SUMMARYConverging evidence indicates that extra-embryonic yolk sac is the source of both macrophages and endothelial cells in adult mouse tissues. Prevailing views are that these yolk sac-derived cells are maintained after birth by proliferative self-renewal in their differentiated states. Here we identify clonogenic, self-renewing endothelial-macrophage (EndoMac) progenitor cells in postnatal mouse aorta, heart and lung, that are independent of definitive hematopoiesis and derive from a CX3CR1+ and CSF1R+ yolk sac source. These bipotent progenitors are highly proliferative and vasculogenic, contributing to adventitial neovascularization in the aortic wall and forming perfused blood vessels after adoptive transfer into ischemic tissue. We establish a regulatory role for angiotensin II, which enhances their clonogenic, self-renewal and differentiation properties. Our findings demonstrate that tissue-resident EndoMac progenitors drive local inflammatory and vasculogenic responses by contributing to the renewal and expansion of yolk sac-derived macrophages and endothelial cells postnatally.

Mechanisms involved in the individual susceptibility to atherosclerotic coronary artery disease (CAD) beyond traditional risk factors are poorly understood. Here, we describe the utility of cultured patient-derived endothelial colony-forming cells (ECFCs) in examining novel mechanisms of CAD susceptibility, particularly the role of dysregulated redox signalling. ECFCs were selectively cultured from peripheral blood mononuclear cells from 828 patients from the BioHEART-CT cohort, each with corresponding demographic, clinical and CT coronary angiographic imaging data. Spontaneous growth occurred in 178 (21.5%) patients and was more common in patients with hypertension (OR 1.45 (95% CI 1.03–2.02), p = 0.031), and less likely in patients with obesity (OR 0.62 [95% CI 0.40–0.95], p = 0.027) or obstructive CAD (stenosis &gt, 50%) (OR 0.60 [95% CI 0.38–0.95], p = 0.027). ECFCs from patients with CAD had higher mitochondrial production of superoxide (O2−–MitoSOX assay). The latter was strongly correlated with the severity of CAD as measured by either coronary artery calcium score (R2 = 0.46, p = 0.0051) or Gensini Score (R2 = 0.67, p = 0.0002). Patient-derived ECFCs were successfully cultured in 3D culture pulsatile mini-vessels. Patient-derived ECFCs can provide a novel resource for discovering mechanisms of CAD disease susceptibility, particularly in relation to mitochondrial redox signalling.

Background and Aims. Apolipoprotein A-I (ApoA-I), the main component of high-density lipoprotein (HDL), not only promotes reverse cholesterol transport (RCT) in atherosclerosis but also increases insulin secretion in pancreatic β-cells, suggesting that interventions which raise HDL levels may be beneficial in diabetes-associated cardiovascular disease (CVD). Previously, we showed that TNF-related apoptosis-inducing ligand (TRAIL) deletion in Apolipoprotein Eknockout (Apoe-/-) mice results in diabetes-accelerated atherosclerosis in response to a “Western” diet. Here, we sought to identify whether reconstituted HDL (rHDL) could improve features of diabetes-associated CVD in Trail-/-Apoe-/- mice. Methods and Results. Trail-/-Apoe-/- and Apoe-/- mice on a “Western” diet for 12 weeks received 3 weekly infusions of either PBS (vehicle) or rHDL (containing ApoA-I (20 mg/kg) and 1-palmitoyl-2-linoleoyl phosphatidylcholine). Administration of rHDL reduced total plasma cholesterol, triglyceride, and glucose levels in Trail-/-Apoe-/- but not in Apoe-/- mice, with no change in weight gain observed. rHDL treatment also improved glucose clearance in response to insulin and glucose tolerance tests. Immunohistological analysis of pancreata revealed increased insulin expression/production and a reduction in macrophage infiltration in mice with TRAIL deletion. Furthermore, atherosclerotic plaque size in Trail-/-Apoe-/- mice was significantly reduced associating with increased expression of the M2 macrophage marker CD206, suggesting HDL's involvement in the polarization of macrophages. rHDL also increased vascular mRNA expression of RCT transporters, ABCA1 and ABCG1, in Trail-/-Apoe-/- but not in Apoe-/- mice. Conclusions. rHDL improves features of diabetes-associated atherosclerosis in mice. These findings support the therapeutic potential of rHDL in the treatment of atherosclerosis and associated diabetic complications. More studies are warranted to understand rHDL’s mechanism of action.

Introduction: Bioavailability of nitric oxide (NO) is often compromised in early atherosclerosis, driving disease onset. This is usually due to dysfunctional endothelial nitric oxide synthase (eNOS). We have found that the transmembrane protein, FXYD1, is highly concentrated in the caveolae sub-cellular region and is closely associated with eNOS. Our preliminary data suggest that FXYD1 protects eNOS from redox-dependent inactivation. So, we hypothesise that FXYD1 may protect against atherosclerosis. Hypothesis: We aimed to test the role of FXYD1 in a murine model of atherosclerosis Methods: We produced a novel mutant mouse line by cross-breeding FXYD1 heterozygote (FXYD1 +/- ) and apolipoprotein E knock out (ApoE -/- ) mice. FXYD1 -/- /ApoE -/- and FXYD1 +/+ /ApoE -/- littermates were fed a high fat/high cholesterol diet from 6-8 weeks of age for 16 weeks. At sacrifice, blood was taken, and plasma was separated for analysis of cholesterol and pro-inflammatory cytokines using ELISA. The thoracic aorta was isolated and formalin-fixed to assess atherosclerotic plaque development using oil red O stain. Immunoblotting for eNOS expression was performed in heart lysates. Results: Plasma total cholesterol was significantly increased in FXYD1-/-/ApoE-/- female mice (n = 14 compared to FXYD1+/+/ApoE-/- mice (n = 21; p Conclusions: FXYD1-/- atherosclerotic female mice have higher circulating lipids and pro-inflammatory cytokines, but this does not appear to alter plaque development in the short term. Ongoing studies will determine the effect on plaque stability and role of FXYD1 in lipidomics. FXYD1 appears to have an anti-inflammatory role and may also be involved in cholesterol metabolism or handling. This could provide a novel therapeutic angle for females.

Micro-RNAs (miRs) are small non-coding RNAs that alter the expression of multiple mRNA targets. Although they participate in physiological processes, dysregulation of their expression is implicated in various diseases. We investigated whether miRs could be involved in the regulation of FXYD1 expression, a sub-unit of the Na+/K+-ATPase pump, that we previously described as both cardio- and vasculoprotective, under oxidative stress conditions. Using in silico analysis, we identified 3 potential miRs that could target FXYD1 mRNA: miR-3178, miR-3960 and miR-6770-3p. Using a FXYD1-3’UTR-luciferase reporter assay, we found that the overexpression of miR-6770-3p in HEK293T cells resulted in the largest reduction in luciferase activity, showing a strong targeting of FXYD1 mRNA. A mutation of the binding site in the 3’UTR of FXYD1 restored luciferase activity, confirming the binding site of miR-6770-3p. Mir-6770-3p is a novel miR that currently has no known function. MiR-6770-3p is the minor strand of its 5p/3p miR duplex in both the human endothelial cell (EC) line, EA.hy.926, and human dermal microvascular (HMVECs). Its overexpression dramatically increased endothelial tube formation in a Matrigel angiogenesis assay (>4 fold change vs. control transfection, p

Background and aims Clinical trials have demonstrated reductions in major adverse cardiovascular events with purified high-dose eicosapentaenoic acid (EPA), independent of effects on lipids. We aimed to investigate whether omega-3 fatty acids reduce vascular inflammation, a critical mediator of atherosclerosis, and hypothesised that EPA is superior to docosahexaenoic acid (DHA). Methods In a double-blind randomised controlled trial and cell-culture study, 40 healthy volunteers were supplemented with 4 g daily of either EPA, DHA, fish oil (2:1 EPA:DHA), or placebo for 30 days. Serum was incubated with TNF-stimulated human umbilical vein endothelial cells (HUVECs), and markers of acute vascular inflammation (AVI) were measured. The effects of EPA, DHA (600 mg/kg/day), olive oil, or no treatment were also measured in preclinical models of [1] AVI using a periarterial collar (C57Bl/6J; n = 40 mice) and [2] atherosclerosis where ApoE−/− mice (n = 40) were fed a 16-week atherogenic diet. Results EPA supplementation reduced expression of C–C motif chemokine ligand 2 (CCL2) by 25% compared to placebo (p = 0.03). In the AVI model, EPA reduced vascular expression of VCAM1 by 43% (p = 0.02) and CCL2 by 41% (p = 0.03). Significant inverse correlations were observed between EPA levels and vascular expression of VCAM1 (r = −0.56, p = 0.001) and CCL2 (r = −0.56, p = 0.001). In ApoE−/- mice, EPA reduced aortic expression of Il1b by 44% (p = 0.04) and Tnf by 49% (p = 0.04), with similar inverse correlations between EPA levels and both Il1b (r = −0.63, p = 0.009) and Tnf (r = −0.50, p = 0.04). Conclusions Supplementation with EPA, more so than DHA, ameliorates acute and chronic vascular inflammation, providing a rationale for the cardiovascular benefit observed with high dose omega-3 fatty acid administration.

This study demonstrates the therapeutic potential for right-sided heart failure of a novel inhibitor of the P2X7 receptor (P2X7R). Inflammatory signaling and right ventricular function were improved in a mouse model of pulmonary fibrosis with secondary pulmonary hypertension when treated with this inhibitor. Importantly, survival was also improved, suggesting that this inhibitor, and other P2X7R antagonists, could be uniquely effective in right ventricle (RV)-targeted therapy in pulmonary hypertension. This addresses a major limitation of current treatment options, where the significant improvements in pulmonary pressures ultimately do not prevent mortality due to RV failure.

Systemic hypertension, characterized by elevated blood pressure ≥140/90 mm Hg, is a major modifiable risk factor for cardiovascular disease. Hypertension also associates with non-alcoholic fatty liver disease (NAFLD), which is becoming common due to a modern diet and lifestyle. The aim of the present study was to examine whether a high-fat "Western" diet had effects on hypertension and associated NAFLD. Normotensive Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHR) were placed on a normal chow or high-fat diet for 8 weeks; blood pressure was measured fortnightly and body weight recorded weekly. As expected, SHR had elevated blood pressure compared to WKY. Diet did not influence blood pressure. Compared to SHR, WKY rats gained more weight, associating with increased white adipose tissue weight. Normotensive rats also had higher plasma cholesterol and triglycerides in response to a "Western" diet, with no changes in plasma glucose levels. Neither strain developed atherosclerosis. Interestingly, high-fat diet-fed SHR had increased liver weight, associating with a significant level of hepatic lipid accumulation not observed in WKY. Further, they exhibited hepatocellular ballooning and increased hepatic inflammation, indicative of steatohepatitis. These findings suggest that a high-fat "Western" diet promotes features of NAFLD in SHR, but not WKY rats. Importantly, the high-fat diet had no effect on blood pressure.

Coronary artery calcification (CAC) was once thought to be a passive, degenerative, and quiescent development of disease. However, it has now been shown to be an active process associated with atherosclerosis that is stimulated by inflammatory pathways. Calcification forms within the intimal and medial layers of the vessel wall by way of mechanisms similar to bone development. A variety of imaging modalities have been used to identify and characterize CAC, from early microcalcifications to well-developed fibroatheromas that have calcified. There are sex and race differences in prevalence and development of CAC, and medical therapies such as statin and warfarin use exhibit pro-calcific effects on the vessel wall. Effective medical treatment of CAC has yet to be established; therefore a greater understanding of the factors that induce calcification is needed to develop appropriate therapeutic strategies.

Cholesteryl ester transfer protein (CETP) facilitates movement of esterified cholesterol between high-density lipoproteins (HDLs) and apolipoprotein B-containing lipoproteins. By virtue of their ability to raise HDL cholesterol and lower low-density lipoprotein cholesterol, pharmacological inhibitors of CETP have received considerable attention as potential new agents in cardiovascular prevention. While early studies of CETP inhibitors have demonstrated a lack of clinical efficacy and potential toxicity, development of the potent CETP inhibitor, anacetrapib, has moved forward, with emerging evidence suggesting a role in reducing cardiovascular events. The experience with anacetrapib and its potential for use in clinical practice are reviewed here.

The clinical reality of residual risk despite statin (HMG-CoA reductase inhibitor) therapy and emergence of statin intolerance support the need to develop additional lipid-lowering strategies. Proprotein convertase subtilisin kexin type 9 (PCSK9) has received considerable attention by virtue of genetic and clinical studies that have revealed its pivotal role in the regulation of cholesterol homeostasis. Monoclonal antibodies have been developed targeting PCSK9, which have been demonstrated to produce profound low-density lipoprotein cholesterol (LDL-C) lowering when provided as monotherapy or in combination with statins. With the reports that the PCSK9 inhibitor evolocumab has a favorable impact on both plaque progression and cardiovascular outcomes, these findings begin to translate the benefits of PCSK9 inhibition from lipids to the vessel wall and ultimately to clinical outcomes. The clinical implications for the use of these agents are reviewed in this article.

Background: Although high-density lipoprotein (HDL) has atheroprotective properties, the association of HDL functionality with coronary plaques remains unclear. Methods: We investigated the association between HDL-mediated cholesterol efflux capacity (CEC) and coronary lipid burden in 74 patients who underwent near-infrared spectroscopy (NIRS) imaging for acute coronary syndrome (ACS) or stable ischemic symptoms. We measured baseline HDL-mediated CEC, distinguishing the specific pathways, and stratified patients according to their median CEC values. Coronary lipid burden was assessed as lipid core burden index (LCBI) using NIRS at baseline (n=74) and on serial imaging (n=47). Results: Patients with baseline ATP-binding cassette transporter G1 (ABCG1)-mediated CEC > median had a greater baseline LCBI {74 [20, 128] vs . 32 [5, 66]; P=0.04} or change in LCBI {−30 [−89, 0] vs . −3 [−16, 0]; P=0.048}. In addition to a negative association between baseline LCBI and change in LCBI (standardized β=−0.31; P=0.02), multivariable analysis demonstrated a significant interaction effect between clinical presentation of coronary artery disease (CAD) and baseline ABCG1-mediated CEC on change in LCBI (P=0.003), indicating that baseline ABCG1-mediated CEC was inversely associated with change in LCBI in patients with ACS (standardized β=−0.79, P=0.003), but not in those with stable ischemic symptoms (P=0.52). Conclusions: In this study, ABCG1-mediated CEC, but not ATP-binding cassette transporter A1 and scavenger receptor B type I, was associated with regression of coronary artery lipid content, especially in patients with high-risk phenotype. Further studies are required to determine the roles of ABCG1 pathway in the development coronary plaques.

Diabetic vascular complications are characterized by impaired angiogenic responses to ischemia, resulting in delayed healing following tissue injury. MicroRNAs (miRNAs), small non-coding RNAs that target gene expression, regulate angiogenesis in a time-dependent manner. Using a miRNA array approach, we discovered that miR-181c was regulated by angiogenic stimuli but had no previous reported role in diabetes. We sought to elucidate the role of miR-181c in diabetes-impaired angiogenesis. We found that miR-181c was inhibited in endothelial cells (ECs) exposed to hypoxia but were, conversely, elevated in high glucose. To assess the importance of miR-181c in angiogenesis, ECs were transfected with mimics or antimiRs to mimic or suppress miR-181c activity respectively. Cells with increased miR-181c activity had a reduced capacity to form tubules and lower VEGFA protein levels. Conversely, suppression of miR-181c activity augmented tubule formation and VEGFA expression. This suggests that miR-181c plays an inhibitory role in angiogenesis, at least in part, through VEGFA regulation. In vivo, miR-181c was temporally tracked following ischemic induction in the hindlimb. Early post-ischemia, when angiogenesis is important, diabetic mice had elevated miR-181c levels compared to nondiabetic controls. However, at later timepoints, miR-181c levels dropped to levels similar to nondiabetic mice. This indicates that miR-181c suppression may be critical to facilitate early responses to ischemia. Diabetic mice were injected with antimiR-181c or antimiR-Neg to determine if miR-181c knockdown rescues diabetes-impaired angiogenesis. Inhibition of miR-181c completely rescued diabetes-impaired blood flow reperfusion, restoring it back to that of nondiabetic levels. Taken together, this study has identified that miR-181c plays a key role in the regulation of angiogenesis in ischemia and in diabetes. This highlights a potential new therapeutic approach for the treatment of diabetic vascular complications. Disclosure E. Solly: None. S.T. Hourigan: None. J. Mulangala: None. P.J. Psaltis: None. B. Di Bartolo: None. M. Ng: None. S. Nicholls: Consultant; Self; Amgen Inc., AstraZeneca, Boehringer Ingelheim International GmbH, Cerenis, CSL Behring, Eli Lilly and Company, Merck Sharp & Dohme Corp., Novo Nordisk Inc., Omthera, Pfizer Inc., Resverlogix Corp., Roche Pharma, Sanofi, Takeda Pharmaceutical Company Limited. Research Support; Self; Amgen Inc., AstraZeneca, Athernova, Cerenis, Eli Lilly and Company, InfraReDx, Novartis Pharmaceuticals Corporation, Resverlogix Corp., Sanofi. C. Bursill: None. J.T.M. Tan: None. Funding Diabetes Australia

The cellular origins of vasa vasorum are ill-defined and may involve circulating or local progenitor cells. We previously discovered that murine aortic adventitia contains Sca-1+CD45+ progenitors that produce macrophages. Here we investigated whether they are also vasculogenic. In aortas of C57BL/6 mice, Sca-1+CD45+ cells were localised to adventitia and lacked surface expression of endothelial markers (ApoE−/− aortas. Although Sca-1+CD45+ cells from C57BL/6 aorta did not express CD31, they formed CD31+ colonies in endothelial differentiation media and produced interconnecting vascular-like cords in Matrigel that contained both endothelial cells and a small population of macrophages, which were located at branch points. Transfer of aortic Sca-1+CD45+ cells generated endothelial cells and neovessels de novo in a hindlimb model of ischaemia and resulted in a 50% increase in perfusion compared to cell-free control. Similarly, their injection into the carotid adventitia of ApoE−/− mice produced donor-derived adventitial and peri-adventitial microvessels after atherogenic diet, suggestive of newly formed vasa vasorum. These findings show that beyond its content of macrophage progenitors, adventitial Sca-1+CD45+ cells are also vasculogenic and may be a source of vasa vasorum during atherogenesis.

High-density lipoproteins (HDL) have received considerable interest as a target for the development of novel anti-atherosclerotic agents beyond conventional approaches to lipid lowering. While a number of approaches have focused on modifying remodeling and expression pathways implicated in the regulation of HDL levels, an additional approach involves simply infusions of delipidated HDL. Several groups have advanced HDL infusions to clinical development with intriguing signs suggesting potentially favorable impacts at the level of the artery wall. The findings of early studies of infusional HDL therapies will be reviewed.

Pharmacologic interventions are commonly used to treat patients with cardiovascular disease, and some may have important effects on vascular calcification. In this chapter we briefly review imaging of vascular calcification and then discuss the known effects of commonly used cardiovascular risk reduction medications such as statins on the process of vascular calcification. The pattern and content of plaque calcium is likely due to the degree of responsiveness to intensive risk factor modification. Lipid-lowering therapies such as statins seem to not only reduce lipid content in the arterial wall but also the degree of plaque calcification, with the suggestion that these changes result in more clinically stable disease.

Recent clinical trial evidence has demonstrated a reduction in major adverse cardiovascular events with high-dose eicosapentaenoic acid (EPA), independent of effects on lipids, suggesting an alternative mechanism. We hypothesized that EPA reduces vascular inflammation, a critical mediator of

Considerable evidence from preclinical and population studies suggests that HDLs (high-density lipoproteins) possess atheroprotective properties. Reports from HDL infusion studies in animals and early clinical imaging trials reported evidence of plaque regression. These findings have stimulated further interest in developing new agents targeting HDL. However, the results of more recent imaging studies in the setting of high-intensity statin use have been disappointing. As the concept of plaque changes with HDL therapeutics evolves and imaging technology to evaluate these effects advances, there will become increasing opportunity to determine the effects of HDL agents on atherosclerotic plaque (Graphic Abstract).

Background: Peripheral arterial disease (PAD) is characterised by accelerated arterial calcification and impairment in angiogenesis, both of which can influence cardiovascular clinical outcomes. Studies implicate calcification as a driver of PAD, however, the mechanisms by which calcification modulates angiogenesis remain poorly understood. This study assessed the effect of high calcium on angiogenesis both in vitro and in vivo . Methods: Human Coronary Artery Endothelial Cells (EC) were cultured and treated with calcification medium (CM) (CaCl 2 2.7mM, Na 2 PO 4 2.0mM) for 24 h. Angiogenic assays of proliferation, migration and tubulogenesis were conducted, and immunoblotting assessed angiogenic regulatory proteins. In vivo studies employed a calcification model with 8-12-week-old male OPG -/- and wildtype (C57BL6/J, control) mice which underwent hind-limb ischaemia (HLI) surgery. Blood flow reperfusion was assessed by Laser Doppler Perfusion Imaging (LDPI). Calcium assay assessed calcium levels in blood serum of the C57BL6/J and OPG -/- mice. Results: CM significantly reduced EC tubulogenesis and viability (34% and 58% p-/- mice at days 6 (0.03±0.01 vs 0.32±0.05 p Conclusion: This is the first demonstration that high-levels of calcium impair ischaemia-driven angiogenesis in vivo and cause inflammation in ECs that suppresses tubule formation in vitro , despite upregulation of key angiogenic regulators VEGFA and HIF-1α. These findings have implications for the development of therapies that can suppress calcification in PAD.

Background: Vascular calcification (VC), alongside atherogenic lipoprotein profiles, have been correlated with poor cardiovascular outcome, however there is a paucity of literature exploring the relationship between the two regarding VC progression. We therefore aim to examine the roles of lipoprotein species and their oxidised forms on both medial and intimal VC. Methods: Human aortic smooth muscle cells (HAoSMC) were pre-treated with 200 μg/ml high (HDL), low (LDL) and very low (VLDL) density lipoproteins for 24 hours before treating cells with a calcification medium (CM; Ca 2.7mM, PO 4 2.0 mM). Cells were harvested using an alizarin red (ARS) calcification assay, or at various time points for qPCR analysis. In parallel, in vivo studies using apolipoprotein E knock-out mice were fed an atherogenic diet for 40 weeks and received reconstituted HDL (rHDL) infusions containing apoA-I (20mg/kg) and 1-palmitoyl-2-linoleoyl phosphatidylcholine during the final 4 weeks of the study. Tissues were harvested and stained for plaque assessment (H&E) and calcium deposits (ARS). Results: Pre-treatment of HAoSMC with rHDL inhibited calcification (43.9%, p Conclusions: This study is the first to demonstrate the effects of lipoproteins on VC in vitro and the effects of rHDL on in vivo VC. Somewhat in accordance to the roles of lipoproteins in atherosclerosis, HDL and ox-VLDL show a reduction of calcification, where-as ox-LDL enhances calcification of HAoSMC.

High-density lipoproteins (HDLs) have presented an attractive target for development of new therapies for cardiovascular prevention on the basis of epidemiology and preclinical studies demonstrating their protective properties. Development of HDL mimetics provides an opportunity to administer functional HDL. However, clinical trials have produced variable results, with no evidence to date that they reduce cardiovascular events. This article reviews development programs of HDL mimetics.

High-density lipoproteins augment hypoxia-induced angiogenesis by inducing the key angiogenic vascular endothelial growth factor A (VEGFA) and total protein levels of its receptor 2 (VEGFR2). The activation/phosphorylation of VEGFR2 is critical for mediating downstream, angiogenic signaling events. This study aimed to determine whether reconstituted high-density lipoprotein (rHDL) activates VEGFR2 phosphorylation and the downstream signaling events and the importance of VEGFR2 in the proangiogenic effects of rHDL in hypoxia. In vitro, rHDL increased VEGFR2 activation and enhanced phosphorylation of downstream, angiogenic signaling proteins ERK1/2 and p38 MAPK in hypoxia. Incubation with a VEGFR2-neutralizing antibody attenuated rHDL-induced phosphorylation of VEGFR2, ERK1/2, p38 MAPK, and tubule formation. In a murine model of ischemia-driven neovascularization, rHDL infusions enhanced blood perfusion and augmented capillary and arteriolar density. Infusion of a VEGFR2-neutralizing antibody ablated those proangiogenic effects of rHDL. Circulating Sca1+/CXCR4+ angiogenic progenitor cell levels, important for neovascularization in response to ischemia, were higher in rHDL-infused mice 3 d after ischemic induction, but that did not occur in mice that also received the VEGFR2-neutralizing antibody. In summary, VEGFR2 has a key role in the proangiogenic effects of rHDL in hypoxia/ischemia. These findings have therapeutic implications for angiogenic diseases associated with an impaired response to tissue ischemia.-Cannizzo, C. M., Adonopulos, A. A., Solly, E. L., Ridiandries, A., Vanags, L. Z., Mulangala, J., Yuen, S. C. G., Tsatralis, T., Henriquez, R., Robertson, S., Nicholls, S. J., Di Bartolo, B. A., Ng, M. K. C., Lam, Y. T., Bursill, C. A., Tan, J. T. M. VEGFR2 is activated by high-density lipoproteins and plays a key role in the proangiogenic action of HDL in ischemia.

Background: Insulin regulates glucose homeostasis but can also promote vascular smooth muscle (VSMC) proliferation, important in atherogenesis. Recently, we showed that tumor necrosis factor‐related apoptosis‐inducing ligand (TRAIL) stimulates intimal thickening via accelerated growth of VSMCs. The aim of the present study was to determine whether insulin‐induced effects on VSMCs occur via TRAIL. Methods: Expression of TRAIL and TRAIL receptor in response to insulin and glucose was determined by polymerase chain reaction. Transcriptional activity was assessed using wild‐type and site‐specific mutations of the TRAIL promoter. Chromatin immunoprecipitation studies were performed. VSMC proliferation and apoptosis was measured. Results: Insulin and glucose exposure to VSMC for 24 h stimulated TRAIL mRNA expression. This was also evident at the transcriptional level. Both insulin‐ and glucose‐inducible TRAIL transcriptional activity was blocked by dominant‐negative specificity protein‐1 (Sp1) overexpression. There are five functional Sp1‐binding elements (Sp1‐1, Sp1‐2, Sp‐5/6 and Sp1‐7) on the TRAIL promoter. Insulin required the Sp1‐1 and Sp1‐2 sites, but glucose needed all Sp1‐binding sites to induce transcription. Furthermore, insulin (but not glucose) was able to promote VSMC proliferation over time, associated with increased decoy receptor‐2 (DcR2) expression. In contrast, chronic 5‐day exposure of VSMC to 1 µg/mL insulin repressed TRAIL and DcR2 expression, and reduced Sp1 enrichment on the TRAIL promoter. This was associated with increased cell death. Conclusions: The findings of the present study provide a new mechanistic insight into how TRAIL is regulated by insulin. This may have significant implications at different stages of diabetes‐associated cardiovascular disease. Thus, TRAIL may offer a novel therapeutic solution to combat insulin‐induced vascular pathologies.

The cellular origins of vasa vasorum are ill-defined and may involve circulating or local progenitor cells. We previously discovered that murine aortic adventitia contains Sca-1+CD45+ progenitors that produce macrophages. Here we investigated whether they are also vasculogenic. In aortas of C57BL/6 mice, Sca-1+CD45+ cells were localised to adventitia and lacked surface expression of endothelial markers (

Background: Peripheral artery disease (PAD) is a progressive occlusive disease of the arteries and a vascular complication in diabetes. Vascular calcification (VC) is implicated as a potential driver of PAD, and although the exact mechanisms are unclear, the site and location of calcification within the arterial wall contributes greatly. Long considered a passive process, VC is now recognised as a tightly regulated active process balancing the promotion and inhibition of calcification in the arterial wall. There is little evidence however, to demonstrate the effect of calcification on endothelial cell angiogenesis. This study sought to investigate the effects of calcium as a known inducer of calcification on in vitro angiogenesis. Methods: Human Coronary Artery Endothelial Cells were cultured and treated with increasing calcium concentrations (CaCl 2 2.45-3.3 mM) for 24h. Proliferation, migration and tubule formation assays were conducted and real-time PCR assessed angiogenic and osteogenic genes. Alkaline phosphotase (ALP) activity was measured in supernatants following treatment. Results: High concentrations of calcium reduced cell proliferation with a corresponding increase in ALP production suggesting release of osteogenic stimuli adversely affects cell viability. Mid-range concentrations of calcium induced a significant increase in cell migration (1.0 vs 2.4±0.3, p500 fold), and fibroblast growth factor-2 (>150 fold). This increase corresponded with a decrease (1.0 vs 15.02±4.24; p Conclusion: This is the first demonstration investigating the effects of calcium on endothelial cell angiogenesis. These findings suggest that calcium can directly affect genes involved in regulating angiogenesis, and could therefore provide an opportunity to develop potential treatments.

Non-alcoholic fatty liver disease (NAFLD) incorporates steatosis, non-alcoholic steato-hepatitis (NASH) and liver cirrhosis, associating with diabetes and cardiovascular disease (CVD). TNF-related apoptosis-inducing ligand (TRAIL) is protective of CVD. We aimed to determine whether TRAIL protects against insulin resistance, NAFLD and vascular injury. Twelve-week high fat diet (HFD)-fed Trail−/− mice had increased plasma cholesterol, insulin and glucose compared to wildtype. Insulin tolerance was impaired with TRAIL-deletion, with reduced p-Akt, GLUT4 expression and glucose uptake in skeletal muscle. Hepatic triglyceride content, inflammation and fibrosis were increased with TRAIL-deletion, with elevated expression of genes regulating lipogenesis and gluconeogenesis. Moreover, Trail−/− mice exhibited reduced aortic vasorelaxation, impaired insulin signaling, and >20-fold increased mRNA expression for IL-1β, IL-6, and TNF-α. In vitro, palmitate treatment of hepatocytes increased lipid accumulation, inflammation and fibrosis, with TRAIL mRNA significantly reduced. TRAIL administration inhibited palmitate-induced hepatocyte lipid uptake. Finally, patients with NASH had significantly reduced plasma TRAIL compared to control, simple steatosis or obese individuals. These findings suggest that TRAIL protects against insulin resistance, NAFLD and vascular inflammation. Increasing TRAIL levels may be an attractive therapeutic strategy, to reduce features of diabetes, as well as liver and vascular injury, so commonly observed in individuals with NAFLD.

Acute vascular inflammation (AVI) plays an important role in atherogenesis. Omega-3 fatty acids (O3FA) have anti-inflammatory properties, yet their effects on AVI remain poorly understood. With the recent report that O3FAs reduce cardiovascular (CV) events in high-risk patients with

TNF-related apoptosis-inducing ligand (TRAIL) is protective in cardiovascular disease and diabetes; whether it regulates insulin resistance and inflammation in the vessel wall is unknown. Wildtype and Trail -/- mice were placed on a high fat diet (HFD) for 12 w. Plasma chemistries were assessed; glucose and insulin tolerance tests performed. Histological GLUT4 expression in skeletal muscle was assessed. Aortic inflammatory marker expression and downstream insulin signaling was also measured; myography was performed. In response to a HFD for 12 w, wildtype mice had increased aortic IL-1beta, MCP-1, IL-6, TNF-alpha and TRAIL mRNA, with reduced circulating TRAIL levels. Compared to 12 w HFD-fed wildtype mice, Trail -/- mice had significantly increased plasma glucose, insulin, and cholesterol levels. Insulin intolerance was worse with TRAIL deletion, with reduced GLUT4 expression and glucose uptake in skeletal muscle. In response to insulin, Trail -/- aortas displayed impaired vasorelaxation and reduced aortic p-Akt expression. Importantly, aortic insulin resistance was associated with > 20-fold increased aortic mRNA expression for IL-1beta, IL-6, and TNF-alpha. We show that TRAIL protects against insulin resistance and type-2 diabetes, in part by regulating downstream insulin signals and inflammation in the vessel wall. These findings suggest that TRAIL may offer a novel therapeutic solution to combat inflammation and insulin resistance in diabetic vascular diseases.

Mimetic peptides of apolipoprotein A-I (apoA-I) present a new strategy for promoting the biological activity of high density lipoproteins (HDL). This study aimed to compare the anti-inflammatory effects of ETC-642, a new apoA-I mimetic peptide, with discoidal reconstituted HDL (rHDL).New Zealand White rabbits (n=42) received daily infusions of saline, rHDL or discoidal complexes of an amphipathic peptide, ETC-642 (1-30 mg/kg), prior to insertion of non-occlusive carotid collars. Human coronary artery endothelial cells (HCAECs) were pre-incubated with ETC-642 or rHDL before TNF-α stimulation. Monocyte adhesion was investigated by pre-incubating HCAECs with rHDL or ETC-642, stimulating with TNF-α and incubating with THP-1 monocytes.Infusion of ETC-642 resulted in dose-dependent reductions of collar-induced expression of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) in the artery wall (p0.05). Pre-incubation of HCAECs with ETC-642 and rHDL reduced TNF-α-induced THP-1 monocyte adhesion (p0.01). Furthermore, ETC-642 and rHDL treatment reduced TNF-α induced mRNA levels of inflammatory markers VCAM-1, fractalkine, MCP-1 and the p65 subunit of NF-κB (p0.05).These studies demonstrate that ETC-642 exhibits anti-inflammatory properties that are comparable to apoA-I both in vivo and in vitro and that these effects are mediated via the NF-κB signaling pathway.

Background Tumor necrosis factor–related apoptosis‐inducing ligand ( TRAIL ) has the ability to inhibit angiogenesis by inducing endothelial cell death, as well as being able to promote pro‐angiogenic activity in vitro. These seemingly opposite effects make its role in ischemic disease unclear. Using Trail −/− and wildtype mice, we sought to determine the role of TRAIL in angiogenesis and neovascularization following hindlimb ischemia. Methods and Results Reduced vascularization assessed by real‐time 3‐dimensional Vevo ultrasound imaging and CD 31 staining was evident in Trail −/− mice after ischemia, and associated with reduced capillary formation and increased apoptosis. Notably, adenoviral TRAIL administration significantly improved limb perfusion, capillary density, and vascular smooth‐muscle cell content in both Trail −/− and wildtype mice. Fibroblast growth factor‐2, a potent angiogenic factor, increased TRAIL expression in human microvascular endothelial cell‐1, with fibroblast growth factor‐2‐mediated proliferation, migration, and tubule formation inhibited with TRAIL si RNA . Both fibroblast growth factor‐2 and TRAIL significantly increased NADPH oxidase 4 ( NOX 4) expression. TRAIL ‐inducible angiogenic activity in vitro was inhibited with si RNA s targeting NOX 4, and consistent with this, NOX 4 mRNA was reduced in 3‐day ischemic hindlimbs of Trail −/− mice. Furthermore, TRAIL ‐induced proliferation, migration, and tubule formation was blocked by scavenging H 2 O 2 , or by inhibiting nitric oxide synthase activity. Importantly, TRAIL ‐inducible endothelial nitric oxide synthase phosphorylation at Ser‐1177 and intracellular human microvascular endothelial cell‐1 cell nitric oxide levels were NOX 4 dependent. Conclusions This is the first report demonstrating that TRAIL can promote angiogenesis following hindlimb ischemia in vivo. The angiogenic effect of TRAIL on human microvascular endothelial cell‐1 cells is downstream of fibroblast growth factor‐2, involving NOX 4 and nitric oxide signaling. These data have significant therapeutic implications, such that TRAIL may improve the angiogenic response to ischemia and increase perfusion recovery in patients with cardiovascular disease and diabetes.

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.

Increasing attention has focused on efforts to promote the biological activities of high-density lipoproteins (HDL) in order to reduce cardiovascular risk. Targeting apolipoprotein A-I (apoA-I), the major protein carried on HDL particles, represents an attractive approach to promoting HDL by virtue of its ability to increase endogenous synthesis of functional HDL particles. A number of pharmacological strategies that target apoA-I, including upregulation of its production with the bromodomain and extraterminal (BET) protein inhibitor RVX-208, development of short peptide sequences that mimic its action, and administration as a component of reconstituted HDL particles, have undergone clinical development. The impact of these approaches on cardiovascular biomarkers will be reviewed.

Background and Aims: Atherosclerosis is characterized by the infiltration and accumulation of monocytes in the arterial wall, combined with elevated plasma low density lipoprotein (LDL) and triglycerides, and low levels of high density lipoprotein (HDL). Apolipoprotein A-I (apoA-I), the main HDL apolipoprotein, is not only athero-protective but can also increase insulin secretion from pancreatic β-cells. Our laboratory recently demonstrated that in response to a ‘western’ diet TNF-related apoptosis-inducing ligand (TRAIL)-deficiency accelerated plaque development in ApoE-/- mice, and promoted features of diabetes typical to those observed in humans. We sought to determine whether reconstituted HDL (rHDL) could improve TRAIL-dependent disease. Methods and Results: TRAIL-/-ApoE-/- and ApoE-/- mice on a ‘western’ diet for 12 w received 3 weekly infusions of either PBS (vehicle) or rHDL (20 mg/kg apoA-I, 1-palmitoyl-2-linoleoyl phosphatidylcholine) in the final 2 weeks of feeding prior to euthanasia. While no change in weight gain was observed, administration of rHDL significantly reduced plasma cholesterol, triglyceride and glucose levels, and improved glucose clearance and insulin sensitivity in TRAIL-/-ApoE-/- mice. Notably, rHDL treatment significantly attenuated atherosclerotic plaque size in brachiocephalic arteries of TRAIL-/-ApoE-/-, but not in ApoE-/- mice. rHDL-treated TRAIL-deficient mice also displayed elevated aortic mRNA expression of the ATP-binding cassette (ABC) transporters ABCA1 and ABCG1. This was associated with significantly increased expression of the pan macrophage marker F4/80 and the M2 marker CD206, suggesting that the rHDL stimulated polarization towards an M2 phenotype. Immunohistological analysis of the rHDL-treated TRAIL-/-ApoE-/- pancreata revealed increased insulin expression and reduced macrophage infiltration relative to ApoE-/- pancreata. Conclusions: This is the first demonstration of rHDL improving atherosclerosis and rescuing features of diabetes which are dependent on TRAIL. Understanding how rHDL may be beneficial in TRAIL-dependent disease could identify new strategies in the treatment of atherosclerosis and associated diabetic complications.

Insulin regulates glucose homeostasis but can also promote vascular smooth muscle (VSMC) proliferation, important in atherogenesis. Recently, we showed that tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) stimulates intimal thickening via accelerated growth of VSMCs. The aim of the present study was to determine whether insulin-induced effects on VSMCs occur via TRAIL.Expression of TRAIL and TRAIL receptor in response to insulin and glucose was determined by polymerase chain reaction. Transcriptional activity was assessed using wild-type and site-specific mutations of the TRAIL promoter. Chromatin immunoprecipitation studies were performed. VSMC proliferation and apoptosis was measured.Insulin and glucose exposure to VSMC for 24 h stimulated TRAIL mRNA expression. This was also evident at the transcriptional level. Both insulin- and glucose-inducible TRAIL transcriptional activity was blocked by dominant-negative specificity protein-1 (Sp1) overexpression. There are five functional Sp1-binding elements (Sp1-1, Sp1-2, Sp-5/6 and Sp1-7) on the TRAIL promoter. Insulin required the Sp1-1 and Sp1-2 sites, but glucose needed all Sp1-binding sites to induce transcription. Furthermore, insulin (but not glucose) was able to promote VSMC proliferation over time, associated with increased decoy receptor-2 (DcR2) expression. In contrast, chronic 5-day exposure of VSMC to 1 µg/mL insulin repressed TRAIL and DcR2 expression, and reduced Sp1 enrichment on the TRAIL promoter. This was associated with increased cell death.The findings of the present study provide a new mechanistic insight into how TRAIL is regulated by insulin. This may have significant implications at different stages of diabetes-associated cardiovascular disease. Thus, TRAIL may offer a novel therapeutic solution to combat insulin-induced vascular pathologies.