SummaryPlaque rupture underlies most myocardial infarctions. Plaques vulnerable to rupture have thin fibrous caps, an excess of macrophages over vascular smooth muscle cells, large lipid cores, and depletion of collagen and other matrix proteins form the cap and lipid core. Production of matrix metalloproteinases from macrophages is prominent in human plaques, and studies in genetically modified mice imply a causative role for metalloproKeywords Atherosclerosis, atherothrombosis, extracellular matrix, inflammation, matrix metalloproteinases teinases in plaque vulnerability. Recent in-vitro studies on human monocyte-derived macrophages and on foam-cell macrophages generated in vivo suggest the existence of several macrophage phenotypes with distinct patterns of metalloproteinase expression. These phenotypes could play differing roles in cap, core and aneurysm formation. There are more than 200,000 cases of myocardial infarction (MI) in the UK alone each year, and almost half this number of patients dies (http//:www.heartsats.org). MI results from coronary thrombosis at the site of an atherosclerotic plaque caused either by detachment of a large patch of surface endothelial cells or, more often, from rupture of the plaque cap. The characteristic features of ruptured plaques are: a thin fibrous cap; a higher ratio of macrophages to vascular smooth muscle cells (VSMCs) in the cap; less collagen, the main strength-giving component, in the cap; and a large, lipid-rich, collagen-poor necrotic core (1). The implication is that production of extracellular proteases from inflammatory cells degrades collagen and leads to mechanical weakness of the cap, particularly in the shoulder regions, which suffer high strain when the core is large and flexible (2). Intact plaques with the features of ruptured plaques listed above are believed vulnerable to subsequent rupture (vulnerable plaques), and patients with such plaques are thought vulnerable to MI (vulnerable patients). If so, pharmacological agents that reverse the features of vulnerable plaque will prevent MIs. So far this concept appears to hold true at least for statin drugs, which reduce the incidence of MI in clinical trials (3) and have biological effects such as inhibiting macrophage activation and protease production. Statins also reduce systemic and local plaque inflammation (4), the size of the lipid-rich necrotic core measured by magnetic resonance imaging (5), and the frequency of high-strain regions of the plaque cap measured by palpography in man (6). The present hope is to identify additional, maybe even more effective treatments to reverse plaque vulnerability and thereby prevent MIs.
Role of matrix metalloproteinases (MMPs) in plaque vulnerabilityLoss of collagen and other extracellular matrix (ECM) components occurs in the highly-inflamed regions of plaque cap thereby reducing tensile strength; it also occurs in the lipid core, which promotes transfer of hydrodynamic forces during the cardiac cycle to the high-strain, shoulder regions of the plaque. For thi...