Abstract-In human occluded saphenous vein grafts, we previously demonstrated cytotoxic foam cells, presumably derived from macrophages engulfing platelets. In the present study, we investigated whether platelet phagocytosis occurs in human atherosclerotic plaques, whether this activates macrophages, and whether the platelet constituent, amyloid precursor protein (APP), was involved. Immunohistochemistry documented the presence of APP, -amyloid peptide (A, cleaved from APP), and platelets (CD9), along with inducible NO synthase (iNOS) and cyclooxygenase-2, two markers of macrophage activation, around microvessels in advanced human carotid artery plaques (nϭ18). A colocalized with iNOS-expressing macrophages that were often surrounded by platelets. In vitro, murine J774 and human THP-1 macrophages were incubated with or without washed human platelets. Coincubation of macrophages and platelets led to platelet phagocytosis (electron and confocal microscopy) and formation of lipid-, APP-, and A-containing foam cells. These expressed iNOS mRNA (reverse transcription-polymerase chain reaction) and protein and produced nitrite and tumor necrosis factor-␣ (ELISA). Macrophage pretreatment with 4-(2-aminoethyl)benzenesulfonyl fluoride, a protease inhibitor, reduced APP processing and inhibited NO biosynthesis induced by platelet phagocytosis but not by lipopolysaccharides. Human atherosclerotic plaques and J774 and THP-1 macrophages contained mRNA of the APP-cleaving enzyme -secretase. This is the first demonstration of A, a peptide extensively studied in Alzheimer's disease, in human atherosclerotic plaques. It was present in activated iNOSexpressing perivascular macrophages that had phagocytized platelets. In vitro studies indicate that platelet phagocytosis leads to macrophage activation and suggest that platelet-derived APP is proteolytically processed to A, resulting in iNOS induction. This represents a novel mechanism for macrophage activation in atherosclerosis. T he composition of an atherosclerotic plaque is an important determinant of plaque stability. Unstable ruptureprone plaques are characterized by a thin fibrous cap that contains few smooth muscle cells. 1,2 Several lines of evidence suggest that macrophage activation in the vulnerable shoulder of the plaque could contribute to plaque rupture. 3,4 We have previously postulated the release of factors toxic to smooth muscle cells, possibly NO, from activated macrophages in human atherosclerotic plaques. 5,6 It has been reported that foam cell formation can be induced by platelet phagocytosis. 7-10 Moreover, in human (sub)occluded saphenous vein grafts, the formation of toxic foam cells within mural thrombi is presumably the result of platelet phagocytosis by macrophages. 11 Therefore, we questioned whether in human atherosclerotic plaques platelet phagocytosis evokes macrophage activation and whether proteolytic processing of amyloid precursor protein (APP), present in platelet ␣-granules, 12-15 is involved in this process.To test this hypothesis, we fi...