Objective-In the deep microenvironments of advanced human atherosclerotic lesions, the intimal fluid becomes acidic.We examined the effect of an acidic extracellular pH on cholesterol removal (efflux) from primary human macrophages. Methods and Results-When cholesterol efflux from acetyl-low-density lipoprotein-loaded macrophages to various cholesterol acceptors was evaluated at pH 7.5, 6.5, or 5.5, the lower the pH the more was cholesterol efflux reduced. The reduction of efflux to lipid-free apolipoprotein A-I was stronger than to high-density lipoprotein 2 or to plasma. Cholesterol efflux to every acceptor was severely compromised also at neutral pH when the macrophages had been loaded with cholesterol at acidic pH, or when both loading and efflux were carried out at acidic pH. Compatible with these observations, the typical upregulation of ABCA1 and ABCG1 mRNA levels in macrophages loaded with cholesterol at neutral pH was rapidly attenuated in acidic medium. The secondary structure of apolipoprotein A-I did not changed over the pH range studied, supporting the notion that the inhibitory effect of acidic pH on cholesterol efflux rather impaired the ability of the foam cells to facilitate ABCA1-mediated cholesterol release. Secretion of apolipoprotein E from the foam cells was fully inhibited when the pH was 5.5, which further reduced cholesterol efflux. Specific cellular transporters preferentially promote efflux of cholesterol from macrophages to different subpopulations of HDL particles. The ABCA1 transporter mediates unidirectional efflux of cholesterol to lipid-free apolipoprotein (apo) A-I and to lipid-poor pre--migrating HDL, 3-5 whereas the ABCG1 transporter facilitates cholesterol efflux to mature ␣-HDL but not to lipid-free apoA-I or small-sized pre--HDL particles. 6,7 Importantly, studies in vitro have evidenced that both transporters become abundantly expressed in cholesterol-loaded macrophages. 8,9 In addition, diffusion-based efflux of cholesterol to mature HDL particles occurs in all types of cells and is facilitated by the scavenger receptor type I (SR-BI), which moderately contributes to cholesterol release from macrophages. 10 Human macrophages can adapt to acidic environments, such as within the core of solid tumors where the extracellular pH may be as low as 5.2. 11 In advanced atherosclerotic lesions, also, the extracellular fluid gradually becomes acidic, and such low pH values have even been suggested as a novel marker of plaque vulnerability. 12 This heterogeneity of pH values well agrees with the general concept of advanced atherosclerotic lesions being "complex" lesions. Acidification of the intimal fluid in advanced atherosclerotic lesions partially depends on redox potential changes, local hypoxia, and on the activation of macrophages that renders them particularly sensitive to hypoxic conditions. 13 Importantly, due to the increased thickness of atherosclerotic lesions, macrophages are subjected to low diffusion of oxygen 14 that stimulates anaerobic glycolysis for cellular ATP ...