Atherosclerosis is characterized by inflammation and proliferation of vascular cells. The intracellular bacterium Chlamydia (Chlamydophila) pneumoniae uses blood monocytes [peripheral blood mononuclear cells (PBMCs)] for dissemination, has been found to persist in atherosclerotic lesions, and has been implicated in atherogenesis by small GTPase activation and T lymphocyte recruitment. Infection of human coronary artery smooth muscle cells with C. pneumoniae significantly induced mRNA and protein for the angiogenic transcription factor Egr-1, resulting in enhanced coronary artery smooth muscle cell proliferation, which was reduced by transfection with small interfering RNA duplexes targeted at Egr-1 mRNA. These effects required viable chlamydiae and depended on p44͞42 mitogen-activated protein kinase activity but not on the p38 mitogen-activated protein kinase pathway. Postinfectious Egr-1 mRNA up-regulation in arterial vessels was confirmed ex vivo in a rat aortic ring model of focal vascular chlamydial infection. An in vivo model based on the injection of C. pneumoniae-infected PBMCs into mice confirmed Egr-1 mRNA up-regulation within 24 h of endovascular infection. Arterial injury from repeated direct chlamydial infections and cell-to-cell contact with C. pneumoniae-infected PBMCs might represent a chronic focus of proliferative activity linked to the media proliferation seen in advanced atherosclerosis. Overall, chlamydial infection induces a proliferative phenotype in vascular cells via transcription factor Egr-1 activation in vitro, ex vivo, and in vivo.atherosclerosis ͉ cell proliferation T he comprehension of the pathogenesis of atherosclerosis has changed fundamentally. Models suggesting atherogenesis as a static accumulation of lipid-loaded macrophages and adherent thrombocytes were expanded by a more dynamic view of the mechanisms involved (1). Inflammation and proliferation of vascular smooth muscle cells were established as the central pathomechanisms (2), suggesting that injurious stimuli other than the known risk factors may initiate and trigger atherosclerosis. Epidemiological studies indicated that persistent infectious agents like Chlamydia (Chlamydophila) pneumoniae or herpesviruses might be involved in perpetuating coronary artery disease. Although diagnostic assays have produced controversial results on its frequency in vascular infection, C. pneumoniae remains the only replicative pathogen that has been recovered from atherosclerotic lesions, where it seems to be deposited by infected circulating blood monocytes (3-6). Vascular C. pneumoniae infection has recently been linked to the inflammatory and procoagulatory component of atherosclerosis by demonstrating small GTPase-mediated NF-B activation (7). Chlamydial heat-shock protein (8) and a soluble factor derived from infected endothelial cells are known to trigger smooth muscle cell proliferation (9). The molecular mechanisms leading to postinfectious proliferation of vascular cells, however, are unknown, although the entry into and the pro...