The central role of arterial retention of cholesterol-rich apolipoprotein-B-containing lipoproteins in the pathogenesis of atherosclerosis: a triumph of simplicity

• Published in: Current opinion in lipidology Vol. 27; no. 5; pp. 473 - 483
• Main Authors: Borén, Jan, Williams, Kevin Jon
• Format: Journal Article
• Language: English
• Published: England Wolters Kluwer Health, Inc. All rights reserved 01-10-2016
• Subjects: Animals; apolipoprotein-B; Apolipoproteins B - chemistry; Apolipoproteins B - metabolism; Arteries - metabolism; atherogenic lipoproteins; atherosclerosis; Atherosclerosis - etiology; Atherosclerosis - metabolism; Biochemistry & Molecular Biology; cardiovascular events; Cardiovascular System & Cardiology; Cholesterol - metabolism; Clinical Medicine; e-deficient mice; Endocrinology & Metabolism; extracellular-matrix; Humans; Klinisk medicin; low-density-lipoprotein; Mendelian randomization studies; metabolic syndrome; promotes atherosclerosis; prospective randomized controlled trials; Protein Aggregates; proteoglycan; proteoglycan-binding-site; Risk Factors; smooth-muscle-cells; subendothelial retention
• ISSN: 0957-9672; 1473-6535
• DOI: 10.1097/MOL.0000000000000330

Today, it is no longer a hypothesis, but an established fact, that increased plasma concentrations of cholesterol-rich apolipoprotein-B (apoB)-containing lipoproteins are causatively linked to atherosclerotic cardiovascular disease (ASCVD) and that lowering plasma LDL concentrations reduces cardiovascular events in humans. Here, we review evidence behind this assertion, with an emphasis on recent studies supporting the 'response-to-retention' model - namely, that the key initiating event in atherogenesis is the retention, or trapping, of cholesterol-rich apoB-containing lipoproteins within the arterial wall.
New clinical trials have shown that ezetimibe and anti-PCSK9 antibodies - both nonstatins - lower ASCVD events, and they do so to the same extent as would be expected from comparable plasma LDL lowering by a statin. These studies demonstrate beyond any doubt the causal role of apoB-containing lipoproteins in atherogenesis. In addition, recent laboratory experimentation and human Mendelian randomization studies have revealed novel information about the critical role of apoB-containing lipoproteins in atherogenesis. New information has also emerged on mechanisms for the accumulation in plasma of harmful cholesterol-rich and triglyceride-rich apoB-containing remnant lipoproteins in states of overnutrition. Like LDL, these harmful cholesterol-rich and triglyceride-rich apoB-containing remnant lipoprotein remnants become retained and modified within the arterial wall, causing atherosclerosis.
LDL and other cholesterol-rich, apoB-containing lipoproteins, once they become retained and modified within the arterial wall, cause atherosclerosis. This simple, robust pathophysiologic understanding may finally allow us to eradicate ASCVD, the leading killer in the world.