Objective-Oxysterols such as 7-ketocholesterol (7-KC) are important mediators of cell death in atherosclerosis. Therefore, in vitro studies of human smooth muscle cell (SMC) death in response to 7-KC were undertaken to investigate the potential mechanisms. Methods and Results-Human aortic SMCs treated with 7-KC showed enhanced immunoreactivity for the oxidative stress marker 4-hydroxy-2-nonenal and upregulated several stress genes (70-kDa heat shock protein 1, heme oxygenase 1, and growth arrest and DNA damage-inducible protein 153) at the mRNA but not at the protein level. 7-KC-treated SMCs rapidly underwent cell death as determined by neutral red, counting of adherent cells, and depolarization of the mitochondrial inner membrane. Cell death was associated with upregulation of ubiquitin mRNA and ubiquitination of cellular proteins. Inhibition of the proteasome by lactacystin potentiated considerably the toxicity of 7-KC. Transmission electron microscopy revealed formation of myelin figures, extensive vacuolization, and depletion of organelles. Formation of autophagosomes was suggested by labeling cells with LysoTracker and monitoring processing of microtubule-associated protein 1 light chain 3 (LC3). Analogous to our in vitro studies, human atherosclerotic plaques showed signs of ubiquitination in SMCs. Key Words: 7-ketocholesterol Ⅲ ubiquitination Ⅲ smooth muscle cells Ⅲ myelin figures Ⅲ LC3 Ⅲ autophagy Ⅲ atherosclerosis C ell death is a major event in the progression of atherosclerosis. Indeed, a large body of evidence suggests that apoptosis or type I programmed cell death 1 frequently occurs in advanced human plaques (1% to 2% TUNEL-positive nuclei). 2-5 However, results from electron microscopy studies showed that the majority of dying cells have an ultrastructure typical of cells undergoing "accidental" cell death or oncosis 6 (type III programmed cell death). 1 Furthermore, it is important to note that there are multiple pathways leading to cell death. Cells sometimes die with a morphology that is intermediate between apoptosis and oncosis (eg, aponecrosis and paraptosis), or they undergo cell death with a less clear morphology or mechanism such as lysosome-mediated cell death or autophagy (type II programmed cell death). 1 It is presently unknown whether cells in human atherosclerotic plaques die by mechanisms distinct from apoptosis or oncosis, as shown recently for myocytes in failing human hearts. 7,8 Oxidative processes, particularly oxidation of low-density lipoprotein (LDL), are thought to play a pivotal role in atherogenesis. 9 Oxidized LDL (oxLDL) exerts its proatherogenic effects in several ways, including stimulation of inflammatory responses, foam cell formation, and induction of cell death. 9 The mechanism of oxLDL-induced cell death is unclear, as oncosis and apoptosis have been reported, 10 and largely depends on the oxidation degree, exposure time, and concentration of oxLDL. 3 In macrophages, oxLDL induces mitochondrial dysfunction and lysosomal damage, 11,12 indicating that oxLDL upt...