Acyl-CoA:cholesterol acyltransferase 1 (Acat1) converts cellular cholesterol to cholesteryl esters and is considered a drug target for treating atherosclerosis. However, in mouse models for atherosclerosis, global Acat1 knockout (Acat1 caused much fewer leukocytes to appear at the activated endothelium. Studies in inflammatory (Ly6C hi -positive) monocytes and in cultured macrophages showed that inhibiting ACAT1 by gene knockout or by pharmacological inhibition caused a significant decrease in integrin  1 (CD29) expression in activated monocytes/macrophages. The sparse presence of lesion macrophages without Acat1 can therefore, in part, be attributed to decreased interaction between inflammatory monocytes/macrophages lacking Acat1 and the activated endothelium. We conclude that targeting ACAT1 in a myeloid cell lineage suppresses atherosclerosis progression while avoiding many of the undesirable side effects caused by global Acat1 inhibition.In the early stages of atherogenesis, chronic inflammation increases the adherence of monocytes to activated endothelial cells of the artery, causing more monocytes to infiltrate the subendothelial space and transform into macrophages. In sustained hypercholesterolemia, resident macrophages continue to devour denatured lipoproteins, converting excess cholesterol to cholesteryl esters, and cause the cholesterol-loaded cells to become foamy. The cholesterol esterification process is carried out by acyl-coenzyme A:cholesterol acyltransferases (ACATs), 5 also known as sterol O-acyltransferases. There are two ACAT genes, Acat1 (1) and Acat2 (2-4). Most tissues, including macrophages, express ACAT1 as the major isoenzyme and express ACAT2 as the minor isoenzyme (5). For many years, targeting ACAT1 to reduce foam cell formation has been considered as a strategy to treat atherosclerosis. Pharmacological studies in mouse models have shown that partial inhibition of both ACAT1 and ACAT2 (6, 7) or of ACAT1 only (8) reduces foam cell content in plaques and is beneficial in reducing atherosclerosis without much toxicity. In human trials, the ACAT inhibitors avasimibe and pactimibe (a second generation of avasimibe) were tested as supplements to statin (the potent HMG-CoA reductase inhibitor). However, neither drug showed efficacy in reducing plaque volume. These trials were inconclusive, likely because of the fact that avasimibe activates the expression of hepatic CYP3A4, which metabolizes various drugs, including statin. Co-administering avasimibe with statin might have neutralized the beneficial effects of statin. In addition, these trials did not examine whether ACAT inhibitors stabilized plaques. Mouse genetic studies were employed as an independent approach to evaluate the effect of ACAT1 inhibition in atherosclerosis. The results showed that, in hyperlipidemic mouse models, global Acat1 KO (Acat1 Ϫ/Ϫ ) or transplant study using bone marrow cells from Acat1 Ϫ/Ϫ mice did not prevent lesion development. In addition, global Acat1 Ϫ/Ϫ caused several additional undesirable phenotypes, i...