Atherosclerosis and Lipoproteins |
From the Center for Molecular and Vascular Biology (J.S., D.C., H.R.L.), University of Leuven, Leuven, Belgium, and the Cardiovascular Biology Research Program (F.L.), Oklahoma Medical Research Foundation, Oklahoma City, Okla..
Correspondence to H.R. Lijnen, PhD, Center for Molecular and Vascular Biology, University of Leuven, Campus Gasthuisberg, O & N, Herestraat 49, B-3000 Leuven, Belgium. E-mail roger.lijnen{at}med.kuleuven.ac.be
| Abstract |
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Key Words: matrix metalloproteinases stromelysin-1 apolipoprotein E atherosclerosis aneurysm
| Introduction |
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See p 1389
Thus, several lines of evidence support a role for MMP system components in the development and progression of atherosclerosis. Like most other MMPs, stromelysin-1 (MMP-3) is secreted as a proenzyme; it can be activated by plasmin, and, once activated, it can convert other pro-MMPs, eg, procollagenase and progelatinase B, into their active forms (reviewed in References 16 and 17). Because of its expression in atherosclerotic plaques,8 its broad substrate specificity, and its central role in the activation of other pro-MMPs,1618 we investigated a potential contribution of MMP-3 to the development and progression of atherosclerosis. Therefore, atherosclerosis-susceptible mice deficient in apoE and MMP-3 (ApoE-/-:MMP-3-/-) and apoE-deficient controls (ApoE-/-:MMP-3+/+) were kept on a cholesterol-rich diet for up to 30 weeks. Analysis of the atherosclerotic aortas indicated that MMP-3 contributes to plaque destabilization and aneurysm formation.
| Methods |
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-cellulose, 5% mineral mix, 1% vitamin mix, 1% choline chloride, 0.3% DL-methionine, and 0.13%
-tocopherol). After an overnight fast, the mice were anesthetized by intraperitoneal injection of 60 mg/kg pentobarbital (NembutalTM, Abbott Laboratories). Blood was collected from the vena cava in 1/10 volume EDTA, pH 6.8, and centrifuged at 3000 rpm for 10 minutes; the plasma was stored at -20°C and used for cholesterol determination. The arterial system was perfused with 4% paraformaldehyde in PBS, dissected, rinsed with PBS, and stored in 20% sucrose. After incubation in 4% paraformaldehyde (3 hours for aortas, overnight for the hearts), samples were embedded in ornithine carbamyl transferase (Tissue-Tek, Laborimpex), snap-frozen in precooled 2-methylbutane, and stored at -80°C. Eight-micron-thick sections were made from tissue around the cardiac valves and at 80-µm intervals throughout the aorta. The aortic arch was dissected free of tissue and frozen at -80°C. Gonadal, retroperitoneal, and subcutaneous fat pads were removed and weighed.
All animal experiments were approved by the local ethics committee and were performed in accordance with the guiding principles of the American Physiological Society and the International Society on Thrombosis and Hemostasis.21
Zymographic Analysis
The aortic arch was pulverized by submersion in LN2 and incubated for 1 hour at 4°C with 100 µL extraction buffer (10 mmol/L sodium phosphate buffer, pH 7.2, containing 150 mmol/L NaCl, 1% Triton X-100, 0.1% SDS, 0.5% sodium deoxycholate, and 0.2% sodium azide). After extensive vortexing and centrifugation (13 000 rpm for 5 minutes), the protein concentration of the supernatant was determined (BCA protein assay, Pierce), and equivalent amounts of total protein were subjected to zymography on casein-containing gels without or with addition of 5 µg/mL human plasminogen to the gel.22
Histology and Immunocytochemistry
Eight-micron-thick sections were stained with hematoxylin-eosin, oil red O, Verhoeffvan Giesons, or Sirius red stain under standard conditions. Plaque sizes or stained areas were quantified by computer-assisted image analysis with Quantimed 600 image analysis software (Leica). For each animal, 9 sections were analyzed throughout the thoracic aorta, and data are reported as mean±SD with 5 animals in each group. Statistical analysis was performed by unpaired Students t test.
The topographic relationship between MMP-3 or u-PA and macrophages in the atherosclerotic vessel wall was studied by double-immunofluorescence labeling combined with fluorescence microscopy and digital imaging. MMP-3 or u-PA was identified with specific rabbit polyclonal antibodies (custom-made in our laboratory, at a final concentration of 50 µg/mL). Macrophages were detected by using a rat monoclonal anti-mouse Mac-3 antigen (clone M3/84, Pharmingen), and SMCs, with biotinylated mouse anti-human smooth muscle
-actin (clone A14, Sigma Chemical Co). Tissue cryosections, fixed with paraformaldehyde, were quenched with 0.1 mol/L sodium borohydrate in PBS for 15 minutes at room temperature, blocked against nonspecific binding, and incubated overnight at 4°C with cocktails of the primary antibodies. Secondary antibody mixtures of horse anti-mouse IgG coupled to Texas Red and goat anti-rabbit IgG conjugated with FITC were used. The sections were mounted in Vectashield (Vector Laboratories) solution containing 4',6-diamidino-2-phenylindole dihydrochloride (DAPI) as a nuclear counterstain and examined with a Nikon Optiphot microscope equipped with appropriate filters. To correlate the localization of different antigens, images of the same microscopic fields were taken with each filter set (FITC, Texas Red, and DAPI) with a Nikon digital camera and merged by using Adobe Photoshop software.
| Results |
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Five (3 males, 2 females) ApoE-/-:MMP-3+/+ or ApoE-/-:MMP-3-/- mice were kept on the cholesterol-rich diet for 30 weeks. At the time of sacrifice, body weights were not significantly different between both strains (25±3.5 vs 25±1.6 g, mean±SD). Also, the weight of the different fat pads was comparable: 78±4 vs 84±20 g for retroperitoneal, 200±49 vs 180±23 g for subcutaneous, and 260±23 vs 250±63 g for gonadal adipose tissue. The plasma cholesterol levels were also comparable for ApoE-/-:MMP-3+/+ and ApoE-/-:MMP-3-/- mice: 1400±410 vs 1200±410 mg/dL (mean±SEM).
Analysis of Atherosclerotic Aortas
ApoE-/-:MMP-3+/+ as well as ApoE-/-:MMP-3-/- mice developed extensive atherosclerotic lesions throughout the aortic root, as revealed by hematoxylin-eosin (not shown) and oil red O staining (Figures 1a and 1e) of transverse cryosections. In contrast, aortas from ApoE+/+:MMP-3+/+ or ApoE+/+:MMP-3-/- mice, also kept on the cholesterol-rich diet for 30 weeks, did not show significant atherosclerotic plaque (not shown). Computer-assisted image analysis of sections taken at regularly spaced distances (80 µm) throughout the thoracic aorta revealed that the plaque size, defined as the percentage of lumen area outlined by the elastic lamina that contained atherosclerotic plaque, was significantly smaller in ApoE-/-:MMP-3+/+ mice than in ApoE-/-:MMP-3-/- mice (Figure 2).
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Oil red O staining also indicated a higher lipid content of the plaques in ApoE-/-:MMP-3+/+ than in ApoE-/-:MMP-3-/- sections (Figures 1a and 1e). Quantification by image analysis of the lipid content, defined as the percentage of plaque area that was stained with oil red O, confirmed these observations (Figure 3A).
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Staining of fibrillar collagen with Sirius red (Figures 1b and 1f) revealed that the atherosclerotic lesions of ApoE-/-:MMP-3+/+ mice contained significantly less collagen than did those of ApoE-/-:MMP-3-/- mice; the stained area, normalized to plaque size, was 55±0.8% vs 66±2.3% (10 sections throughout the thoracic aorta analyzed per animal; P<0.01, n=5). Verhoeffvan Giesons staining of elastin revealed that the elastic lamina showed more frequent aneurysms in the thoracic and abdominal aortas of ApoE-/-:MMP-3+/+ mice. Aneurysms are characterized by fragmentation of elastic membranes, thinning of the aortic wall, and rupture of elastic membranes across the media (Figures 1c and 1g). This feature is also associated with loss of
-actin SMC staining (Figures 1d and 1h). A normal media with multiple layers of SMCs is shown in an ApoE-/-:MMP-3-/- aorta, whereas SMCs are depleted at the site of media destruction in an ApoE-/-:MMP-3+/+ aorta. Analysis of
150 sections per animal showed aneurysms in 14±2.1% of the ApoE-/-:MMP-3+/+ sections vs only 8.5±1.7% of the ApoE-/-:MMP-3-/- sections (5 animals each, P<0.01).
Analysis of Infiltrating Macrophages
Single immunostaining for Mac-3 indicated the more abundant presence of macrophages in atherosclerotic plaques of ApoE-/-:MMP-3+/+ compared with ApoE-/-:MMP-3-/- aortas (Figures 4e and 4f). Quantification of the Mac-3stained area throughout the thoracic aorta confirmed this observation (Figure 3B). Macrophages appeared to infiltrate more in the ApoE-/-:MMP-3+/+ plaques, whereas they remained closer to the surface in the ApoE-/-:MMP-3-/- plaques. The observed Mac-3 staining pattern corresponded to that seen with oil red O (Figure 1), suggesting that macrophages occur abundantly as foam cells.
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Single immunostaining for MMP-3 revealed very low expression in nonatherosclerotic aortas from ApoE+/+:MMP-3+/+ mice (Figure 4a) but considerable upregulation in atherosclerotic lesions of ApoE-/-:MMP-3+/+ mice (Figure 4c), where it was found predominantly in the plaque shoulders and the fibrous cap, colocalized with macrophages (Figures 4e and 4g). MMP-3 immunostaining was not observed in nonatherosclerotic aortas from ApoE+/+:MMP-3-/- mice (Figure 4b), representing a negative control. The weak staining seen in atherosclerotic plaques of ApoE-/-:MMP-3-/- aortas (Figure 4d) represents background autofluorescence of the tissue. Zymographic analysis of aortic extracts on casein gels confirmed the presence of detectable MMP-3 activity in atherosclerotic tissue from ApoE-/-:MMP-3+/+ but not from ApoE-/-:MMP-3-/- aortas or from nonatherosclerotic ApoE+/+:MMP-3+/+ aortas (data not shown).
Single immunostaining for u-PA revealed very low and comparable expression in nonatherosclerotic aortas from ApoE+/+:MMP-3+/+ and ApoE+/+:MMP-3-/- mice (Figures 5a and 5b). Significantly enhanced expression was observed in atherosclerotic lesions of ApoE-/-:MMP-3+/+ and ApoE-/-:MMP-3-/- aortas, with visibly more intense staining in ApoE-/-:MMP-3+/+ (Figure 5c) than in ApoE-/-:MMP-3-/- (Figure 5d) aortas. u-PA was localized in high amounts in cellular components of the lesion cap and in areas of the necrotic core (Figure 5c), where it colocalized with macrophages (Figures 5e and 5g). A similar topographic pattern, but with less intense staining, was observed in ApoE-/-:MMP-3-/- plaques (Figures 5d, 5f, and 5h).
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Zymographic analysis of aortic extracts on casein gels containing plasminogen confirmed the presence of u-PA activity in atherosclerotic tissues from ApoE-/-:MMP-3+/+ aortas, whereas u-PA was not detected in ApoE-/-:MMP-3-/- aortas (data not shown). Use of an ELISA specific for murine u-PA23 confirmed the presence of detectable u-PA antigen in the aortic extracts of ApoE-/-:MMP-3+/+ mice (5.2±1.7 ng/mg protein, mean±SEM) but not in extracts of ApoE-/-:MMP-3-/-, ApoE+/+:MMP-3+/+, or ApoE+/+:MMP-3-/- aortas (<0.6 ng/mg protein). These data suggest that the u-PA levels in aortic extracts of ApoE-/-:MMP-3-/- mice are below the detection limit of these assays but do not allow us to conclude that u-PA is totally absent (cf weak immunostaining for u-PA in Figure 5d).
| Discussion |
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It was previously shown that a u-PA or a tissue-type plasminogen activator deficiency in mice did not alter the size or the predilection site of early fatty streaks and more advanced plaques. However, u-PA deficiency protected against aneurysm formation. It was suggested that u-PAgenerated plasmin causes activation of macrophage-secreted pro-MMPs, resulting in the degradation of elastin and fibrillar collagen.13 In the present study, the role of stromelysin-1 (MMP-3) in this phenomenon was investigated by using mice with a combined deficiency of apoE and MMP-3 (ApoE-/-:MMP-3-/-) kept on a cholesterol-rich diet. All mice used in this study were of the same genetic background. Pronounced differences in atherosclerotic lesion formation have indeed been reported in mice with different genetic backgrounds.3335
This study revealed a potential dual effect of MMP-3. Whereas the cholesterol-rich diet caused extensive atherosclerotic plaque formation in both ApoE-/-:MMP-3+/+ and ApoE-/-:MMP-3-/- mice, the size of the plaques throughout the thoracic aorta was significantly smaller in wild-type mice for MMP-3. Immunostaining confirmed enhanced expression of MMP-3 in atherosclerotic versus nonatherosclerotic aortas of ApoE-/-:MMP-3+/+ mice and showed its colocalization with macrophages, whereas zymography with aortic extracts confirmed MMP-3 activity. Macrophages were more abundant and infiltrated in the plaques of ApoE-/-:MMP-3+/+ than of ApoE-/-:MMP-3-/- mice; enhanced oil red O staining and colocalization with macrophages suggest that foam cells are predominant. Furthermore, enhanced expression of u-PA, colocalizing with macrophages, was observed in atherosclerotic MMP-3 wild-type aortas. In vitro studies with cultured macrophages have previously revealed that in the presence of plasminogen, wild-type but not u-PAdeficient macrophages can activate secreted pro-MMP-3.13 Our data are thus compatible with the hypothesis that enhanced expression of u-PA by macrophages contributes to the activation of macrophage-secreted pro-MMP-3, most likely by plasmin generation. Active MMP-3 may then contribute to plaque destabilization by degrading matrix components. Thus, we speculate that reduced u-PA secretion and plasmin generation in MMP-3-/- compared with MMP-3+/+ atherosclerotic plaques may affect migration and accumulation of macrophages; reduced matrix degradation in the absence of MMP-3 could in turn contribute to impaired infiltration of macrophages into the lesions. Interestingly, it has been reported that the presence of a genetic variant of the human MMP-3 promoter, resulting in reduced gene expression, is associated with accelerated progression of atherosclerotic lesions.36 On the other hand, aortic aneurysm formation was significantly more frequent in ApoE-/-:MMP-3+/+ than in ApoE-/-:MMP-3-/- aortas. Elastin fibers were eroded, fragmented, and eventually completely degraded. At the site of media destruction, loss of
-actinstained SMCs was also observed.
Taken together, our findings indicate that MMP-3 on the one hand contributes to plaque destabilization, possibly by degrading matrix components, and on the other hand, promotes aneurysm formation by degrading the elastic lamina. It remains to be shown whether and which other MMPs may play a role in these phenomena. Recently, Pyo et al37 provided direct genetic evidence that MMP-9, which can be activated by MMP-3, plays an essential role in a mouse model of nonatherosclerotic aneurysm formation. The biological effects observed in this study may thus be mediated by MMP-3 activity directly, by activation of other pro-MMPs, or even by other (proteolytic) systems. It has been reported previously that eg, progelatinase B and procollagenase, can be activated by MMP-3 (cf References 16 and 17).
| Acknowledgments |
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Received March 20, 2001; accepted May 24, 2001.
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M. Torzewski, P. Suriyaphol, K. Paprotka, L. Spath, V. Ochsenhirt, A. Schmitt, S.-R. Han, M. Husmann, V. B. Gerl, S. Bhakdi, et al. Enzymatic Modification of Low-Density Lipoprotein in the Arterial Wall: A New Role for Plasmin and Matrix Metalloproteinases in Atherogenesis Arterioscler Thromb Vasc Biol, November 1, 2004; 24(11): 2130 - 2136. [Abstract] [Full Text] [PDF] |
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Y. Fukumoto, J.-o Deguchi, P. Libby, E. Rabkin-Aikawa, Y. Sakata, M. T. Chin, C. C. Hill, P. R. Lawler, N. Varo, F. J. Schoen, et al. Genetically Determined Resistance to Collagenase Action Augments Interstitial Collagen Accumulation in Atherosclerotic Plaques Circulation, October 5, 2004; 110(14): 1953 - 1959. [Abstract] [Full Text] [PDF] |
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L. J. McCawley, H. C. Crawford, L. E. King Jr., J. Mudgett, and L. M. Matrisian A Protective Role for Matrix Metalloproteinase-3 in Squamous Cell Carcinoma Cancer Res., October 1, 2004; 64(19): 6965 - 6972. [Abstract] [Full Text] [PDF] |
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E. Kaschina, M. Stoll, M. Sommerfeld, U. M. Steckelings, R. Kreutz, and T. Unger Genetic kininogen deficiency contributes to aortic aneurysm formation but not to atherosclerosis Physiol Genomics, September 16, 2004; 19(1): 41 - 49. [Abstract] [Full Text] [PDF] |
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B.A. Kelly, B.C. Bond, and L. Poston Aortic adaptation to pregnancy: elevated expression of matrix metalloproteinases-2 and -3 in rat gestation Mol. Hum. Reprod., May 1, 2004; 10(5): 331 - 337. [Abstract] [Full Text] [PDF] |
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A. Luttun, E. Lutgens, A. Manderveld, K. Maris, D. Collen, P. Carmeliet, and L. Moons Loss of Matrix Metalloproteinase-9 or Matrix Metalloproteinase-12 Protects Apolipoprotein E-Deficient Mice Against Atherosclerotic Media Destruction but Differentially Affects Plaque Growth Circulation, March 23, 2004; 109(11): 1408 - 1414. [Abstract] [Full Text] [PDF] |
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A. Daugherty and L. A. Cassis Mouse Models of Abdominal Aortic Aneurysms Arterioscler Thromb Vasc Biol, March 1, 2004; 24(3): 429 - 434. [Abstract] [Full Text] |
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C. Whatling, W. McPheat, and E. Hurt-Camejo Matrix Management: Assigning Different Roles for MMP-2 and MMP-9 in Vascular Remodeling Arterioscler Thromb Vasc Biol, January 1, 2004; 24(1): 10 - 11. [Full Text] [PDF] |
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E. Lutgens, R.-J. van Suylen, B. C. Faber, M. J. Gijbels, P. M. Eurlings, A.-P. Bijnens, K. B. Cleutjens, S. Heeneman, and M. J.A.P. Daemen Atherosclerotic Plaque Rupture: Local or Systemic Process? Arterioscler Thromb Vasc Biol, December 1, 2003; 23(12): 2123 - 2130. [Abstract] [Full Text] [PDF] |
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W. Shi, M. D. Brown, X. Wang, J. Wong, D. F. Kallmes, A. H. Matsumoto, G. A. Helm, T. A. Drake, and A. J. Lusis Genetic Backgrounds but Not Sizes of Atherosclerotic Lesions Determine Medial Destruction in the Aortic Root of Apolipoprotein E-Deficient Mice Arterioscler Thromb Vasc Biol, October 1, 2003; 23(10): 1901 - 1906. [Abstract] [Full Text] [PDF] |
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C. B Jones, D. C Sane, and D. M Herrington Matrix metalloproteinases: A review of their structure and role in acute coronary syndrome Cardiovasc Res, October 1, 2003; 59(4): 812 - 823. [Abstract] [Full Text] [PDF] |
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E. H. Sage, M. Reed, S. E. Funk, T. Truong, M. Steadele, P. Puolakkainen, D. H. Maurice, and J. A. Bassuk Cleavage of the Matricellular Protein SPARC by Matrix Metalloproteinase 3 Produces Polypeptides That Influence Angiogenesis J. Biol. Chem., September 26, 2003; 278(39): 37849 - 37857. [Abstract] [Full Text] [PDF] |
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Y. Agmon, B. K. Khandheria, I. Meissner, G. L. Schwartz, J. D. Sicks, A. J. Fought, W. M. O'Fallon, D. O. Wiebers, and A. J. Tajik Is aortic dilatation an atherosclerosis-related process?: Clinical, laboratory, and transesophageal echocardiographiccorrelates of thoracic aortic dimensions in the populationwith implications for thoracic aortic aneurysm formation J. Am. Coll. Cardiol., September 17, 2003; 42(6): 1076 - 1083. [Abstract] [Full Text] [PDF] |
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S. Beyzade, S. Zhang, Y.-k. Wong, I. N. M. Day, P. Eriksson, and S. Ye Influences of matrix metalloproteinase-3 gene variation on extent of coronary atherosclerosis and risk of myocardial infarction J. Am. Coll. Cardiol., June 18, 2003; 41(12): 2130 - 2137. [Abstract] [Full Text] [PDF] |
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T. L. Medley, B. A. Kingwell, C. D. Gatzka, P. Pillay, and T. J. Cole Matrix Metalloproteinase-3 Genotype Contributes to Age-Related Aortic Stiffening Through Modulation of Gene and Protein Expression Circ. Res., June 13, 2003; 92(11): 1254 - 1261. [Abstract] [Full Text] [PDF] |
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M. W. Manning, L. A. Cassis, and A. Daugherty Differential Effects of Doxycycline, a Broad-Spectrum Matrix Metalloproteinase Inhibitor, on Angiotensin II-Induced Atherosclerosis and Abdominal Aortic Aneurysms Arterioscler Thromb Vasc Biol, March 1, 2003; 23(3): 483 - 488. [Abstract] [Full Text] [PDF] |
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D. Li, L. Liu, H. Chen, T. Sawamura, S. Ranganathan, and J. L. Mehta LOX-1 Mediates Oxidized Low-Density Lipoprotein-Induced Expression of Matrix Metalloproteinases in Human Coronary Artery Endothelial Cells Circulation, February 4, 2003; 107(4): 612 - 617. [Abstract] [Full Text] [PDF] |
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V. Lemaitre, P. D. Soloway, and J. D'Armiento Increased Medial Degradation With Pseudo-Aneurysm Formation in Apolipoprotein E-Knockout Mice Deficient in Tissue Inhibitor of Metalloproteinases-1 Circulation, January 21, 2003; 107(2): 333 - 338. [Abstract] [Full Text] [PDF] |
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W. Palinski and C. Napoli Unraveling Pleiotropic Effects of Statins on Plaque Rupture Arterioscler Thromb Vasc Biol, November 1, 2002; 22(11): 1745 - 1750. [Full Text] [PDF] |
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V. Fontaine, M.-P. Jacob, X. Houard, P. Rossignol, D. Plissonnier, E. Angles-Cano, and J.-B. Michel Involvement of the Mural Thrombus as a Site of Protease Release and Activation in Human Aortic Aneurysms Am. J. Pathol., November 1, 2002; 161(5): 1701 - 1710. [Abstract] [Full Text] [PDF] |
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A. Cho and M. A. Reidy Matrix Metalloproteinase-9 Is Necessary for the Regulation of Smooth Muscle Cell Replication and Migration After Arterial Injury Circ. Res., November 1, 2002; 91(9): 845 - 851. [Abstract] [Full Text] [PDF] |
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N. Lamblin, C. Bauters, X. Hermant, J.-M. Lablanche, N. Helbecque, and P. Amouyel Polymorphisms in the promoter regions of MMP-2, MMP-3, MMP-9 and MMP-12 genes as determinants of aneurysmal coronary artery disease J. Am. Coll. Cardiol., July 3, 2002; 40(1): 43 - 48. [Abstract] [Full Text] [PDF] |
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M. P. Bendeck Matrix Metalloproteinases: Are They Antiatherogenic but Proaneurysmal? Circ. Res., May 3, 2002; 90(8): 836 - 837. [Full Text] [PDF] |
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J. Silence, D. Collen, and H.R. Lijnen Reduced Atherosclerotic Plaque but Enhanced Aneurysm Formation in Mice With Inactivation of the Tissue Inhibitor of Metalloproteinase-1 (TIMP-1) Gene Circ. Res., May 3, 2002; 90(8): 897 - 903. [Abstract] [Full Text] [PDF] |
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A. J. Chase, M. Bond, M. F. Crook, and A. C. Newby Role of Nuclear Factor-{kappa}B Activation in Metalloproteinase-1, -3, and -9 Secretion by Human Macrophages In Vitro and Rabbit Foam Cells Produced In Vivo Arterioscler Thromb Vasc Biol, May 1, 2002; 22(5): 765 - 771. [Abstract] [Full Text] [PDF] |
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J.-B. Michel Contrasting Outcomes of Atheroma Evolution: Intimal Accumulation Versus Medial Destruction Arterioscler Thromb Vasc Biol, September 1, 2001; 21(9): 1389 - 1392. [Full Text] [PDF] |
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J. Silence, D. Collen, and H.R. Lijnen Reduced Atherosclerotic Plaque but Enhanced Aneurysm Formation in Mice With Inactivation of the Tissue Inhibitor of Metalloproteinase-1 (TIMP-1) Gene Circ. Res., May 3, 2002; 90(8): 897 - 903. [Abstract] [Full Text] [PDF] |
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