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The inflammable truth of atherosclerosis - Chapter 10: Summary, discussion and clinical implications

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The inflammable truth of atherosclerosis

Verweij, S.L.

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2018

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Verweij, S. L. (2018). The inflammable truth of atherosclerosis.

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ƚŚĞŽǀĞƌĂůůĐŽŶĐĞƉƚŽĨŝŶŇĂŵŵĂƟŽŶĂŶĚs͘ Part I ŽĨƚŚŝƐƚŚĞƐŝƐĚĞĂůƐǁŝƚŚŝŵĂŐŝŶŐŽĨŝŶŇĂŵŵĂƟŽŶĂƚƚŚĞůĞǀĞůŽĨĂƌƚĞƌŝĂůǁĂůů͕ďŽŶĞ ŵĂƌƌŽǁĂŶĚƐƉůĞĞŶ͕ƵƐŝŶŐ18&ͲŇƵŽƌĚĞŽdžLJŐůƵĐŽƐĞƉŽƐŝƚƌŽŶĞŵŝƐƐŝŽŶƚŽŵŽŐƌĂƉŚLJͬĐŽŵƉƵƚĞĚ ƚŽŵŽŐƌĂƉŚLJ;18&Ͳ&'WdͬdͿ͕ŝŶƉĂƟĞŶƚƐĂƚƌŝƐŬĨŽƌŽƌǁŝƚŚŽǀĞƌƚs͘ŚĂƉƚĞƌϮdescribes ĚŝīĞƌĞŶƚ ŵĞƚŚŽĚƐ ƚŽ ƋƵĂŶƟĨLJ ĂƌƚĞƌŝĂů ǁĂůů ŝŶŇĂŵŵĂƟŽŶ ;/͗ ǁŚŽůĞ ĂƌƚĞƌLJ ƵƉƚĂŬĞ ;ƐŚŽǁŶ ĂƐ ƐƚĂŶĚĂƌĚ ƵƉƚĂŬĞ ǀĂůƵĞ ;^hsͿ ĂŶĚ ƚĂƌŐĞƚͲƚŽͲďĂĐŬŐƌŽƵŶĚ ƌĂƟŽ ;dZͿ͖ //͗ ĂĐƟǀĞ ƐĞŐŵĞŶƚ ĂƉƉƌŽĂĐŚͿŝŶƚŚĞĂŽƌƚĂĂŶĚĐĂƌŽƟĚĂƌƚĞƌLJƵƐŝŶŐ18&Ͳ&'Wdͬd͕ŝŶǀĂƌŝŽƵƐƉĂƟĞŶƚŐƌŽƵƉƐ ;ŚĞĂůƚŚLJĐŽŶƚƌŽůƐ͕ƉĂƟĞŶƚƐĂƚƌŝƐŬĨŽƌsĂŶĚƉĂƟĞŶƚƐǁŝƚŚŽǀĞƌƚsͿ͘tŚŽůĞĂƌƚĞƌLJ&' ƵƉƚĂŬĞŝƐŝŶĐƌĞĂƐĞĚŝŶƐƵďũĞĐƚƐĂƚƌŝƐŬĨŽƌĂŶĚǁŝƚŚŽǀĞƌƚsĐŽŵƉĂƌĞĚǁŝƚŚŚĞĂůƚŚLJĐŽŶƚƌŽůƐ ĨŽƌďŽƚŚƚŚĞĂŽƌƚĂĂŶĚĐĂƌŽƟĚĂƌƚĞƌLJ͘/ŶĂĚĚŝƟŽŶƚŚĞǁŚŽůĞĂƌƚĞƌLJ&'ƵƉƚĂŬĞĂƉƉƌŽĂĐŚŚĂƐ ĂŶĞdžĐĞůůĞŶƚƌĞƉƌŽĚƵĐŝďŝůŝƚLJ͘dŚĞĂĐƟǀĞƐĞŐŵĞŶƚĂƉƉƌŽĂĐŚƐŚŽǁƐŽŶůLJĂƐŝŐŶŝĮĐĂŶƚĚŝīĞƌĞŶĐĞ ĨŽƌƚŚĞĐĂƌŽƟĚĂƌƚĞƌLJ͘dŚĞƐĞĚĂƚĂƐƵďƐƚĂŶƟĂƚĞƚŚĂƚǁŚŽůĞĂƌƚĞƌLJ&'ƵƉƚĂŬĞĐĂŶďĞƵƐĞĚ ĂƐĂƌĞůŝĂďůĞǁĂLJƚŽƋƵĂŶƟĨLJĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶ͘ƐŝƚŝƐĚŝĸĐƵůƚƚŽĚĞƚĞƌŵŝŶĞǁŚĂƚ ĞdžƚĞŶƚŽĨ&'ƵƉƚĂŬĞŝŶƚŚĞĂƌƚĞƌŝĂůǁĂůůƌĞƐƵůƚƐŝŶŝŶĐƌĞĂƐĞĚsƌŝƐŬ͕ǁĞƵƐĞĚŽƵƌĚĂƚĂƚŽ ƐĞƚƚŚƌĞƐŚŽůĚƐƌĞĐŽŐŶŝnjŝŶŐůĞǀĞůƐŽĨĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶƚŚĂƚĐŽƌƌĞƐƉŽŶĚƚŽŝŶĐƌĞĂƐĞĚ sƌŝƐŬ͘/ŶƚŚĞĨƵƚƵƌĞ͕ƚŚĞƐĞƚŚƌĞƐŚŽůĚƐĐĂŶďĞƵƐĞĚĂƐŝŶĚŝĐĂƟŽŶŽĨƐŝŐŶŝĮĐĂŶƚĂƌƚĞƌŝĂůǁĂůů ŝŶŇĂŵŵĂƟŽŶŝŶƉĂƟĞŶƚƐǁŚŽƉĂƌƟĐŝƉĂƚĞŝŶƐƚƵĚŝĞƐǁŝƚŚWdͬdĂƐƚŚĞƉƌŝŵĂƌLJŽƵƚĐŽŵĞ͕ ƉƌŽǀŝĚĞĚƚŚĂƚďŽƚŚŝŵĂŐŝŶŐĂŶĚĂŶĂůLJƐŝƐƉƌŽƚŽĐŽůĂƌĞĐŽŵƉĂƌĂďůĞǁŝƚŚƚŚĞƉƌĞƐĞŶƚƐƚƵĚLJ͘ EĞdžƚƚŽƚŚĞƚĞĐŚŶŝĐĂůƉĂƌƚƐŽĨŝŵĂŐŝŶŐŽĨĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶ͕ĐŚĂƉƚĞƌϯĂŶĚϰĂƉƉůLJ ŝŵĂŐŝŶŐŽĨŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJĂĐƟǀŝƚLJŝŶƉĂƟĞŶƚƐǁŝƚŚƐƚĂďůĞĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ;ĐŚĂƉƚĞƌ ϯͿŽƌĨŽůůŽǁŝŶŐĂŶĂĐƵƚĞĐĂƌĚŝŽǀĂƐĐƵůĂƌĞǀĞŶƚ;ĐŚĂƉƚĞƌϰͿ͘/ŶĐŚĂƉƚĞƌϯǁĞŝŶǀĞƐƟŐĂƚĞŵƵůƟͲ ůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJĂĐƟǀŝƚLJŝŶƉĂƟĞŶƚƐǁŝƚŚŬŶŽǁŶs;хϭϮŵŽŶƚŚƐƉŽƐƚŝƐĐŚĞŵŝĐĞǀĞŶƚͿ using 18&Ͳ&'Wdͬd͘tĞƐŚŽǁŝŶĐƌĞĂƐĞĚ18&Ͳ&'ƵƉƚĂŬĞŝŶďŽƚŚƚŚĞĂƌƚĞƌŝĂůǁĂůůĂƐǁĞůů

ĂƐŝŶďŽŶĞŵĂƌƌŽǁĂŶĚƐƉůĞĞŶŝŶsƉĂƟĞŶƚƐĐŽŵƉĂƌĞĚǁŝƚŚŚĞĂůƚŚLJĐŽŶƚƌŽůƐ͘ƐďŽŶĞ ŵĂƌƌŽǁ ĂŶĚ ƐƉůĞĞŶ ĂƌĞ ŝŶǀŽůǀĞĚ ŝŶ ŚĞŵĂƚŽƉŽŝĞƐŝƐ͕ ŝŶĐƌĞĂƐĞĚ18&Ͳ&' ƵƉƚĂŬĞ ƐƵŐŐĞƐƚƐ ŝŶĐƌĞĂƐĞĚƉƌŽůŝĨĞƌĂƟŽŶŽĨŚĞŵĂƚŽƉŽŝĞƟĐƐƚĞŵĂŶĚƉƌŽŐĞŶŝƚŽƌĐĞůůƐ;,^WƐͿ͘/ŶƐƵƉƉŽƌƚ͕Ğdž vivo ǁĞƐŚŽǁƚŚĂƚ,^WƐŽĨƉĂƟĞŶƚƐǁŝƚŚĂƚŚĞƌŽƐĐůĞƌŽƐŝƐŚĂǀĞŝŶĐƌĞĂƐĞĚƉƌŽŐĞŶŝƚŽƌĐĂƉĂĐŝƚLJ ĐŽŵƉĂƌĞĚǁŝƚŚƐƵďũĞĐƚƐǁŝƚŚŽƵƚĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ͘dŚĞƐĞĚĂƚĂƐƵŐŐĞƐƚƚŚĂƚŝŶƉĂƟĞŶƚƐǁŝƚŚ ƐƚĂďůĞĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ͕ŶŽƚŽŶůLJƚŚĞĂƌƚĞƌŝĂůǁĂůů͕ďƵƚĂůƐŽƚŚĞďŽŶĞŵĂƌƌŽǁĂŶĚƐƉůĞĞŶĂƌĞ ŝŶǀŽůǀĞĚ͕ƚŚƵƐƐƵƉƉŽƌƟŶŐĂƐŽĐĂůůĞĚŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJƌĞƐƉŽŶƐĞ͘ ŚĂƉƚĞƌϰĚĞƐĐƌŝďĞƐŝŵĂŐŝŶŐŽĨŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƟŽŶŝŶƉĂƟĞŶƚƐĂŌĞƌĂŶĂĐƵƚĞĐŽƌŽŶĂƌLJ ƐLJŶĚƌŽŵĞ;^Ϳ͕ƵƐŝŶŐ18&ͲWͲϳϭϰĂƐĂWdƚƌĂĐĞƌ͘^ͲƉĂƟĞŶƚƐĂƌĞŚĂůůŵĂƌŬĞĚďLJĂŵƵůƟͲ

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10

Discussion ůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJƌĞƐƉŽŶƐĞ͕ĐŽŵƉƌŝƐŝŶŐďŽŶĞŵĂƌƌŽǁĂŶĚƐƉůĞĞŶĂĐƟǀĂƟŽŶ͕ƌĞƐƵůƟŶŐŝŶĂ ƌĞůĞĂƐĞŽĨŵLJĞůŽŝĚĐĞůůƐŝŶƚŽƚŚĞĐŝƌĐƵůĂƟŽŶ͘ůƚŚŽƵŐŚ18&Ͳ&'WdͬdŝƐĂƌĞůŝĂďůĞŝŵĂŐŝŶŐ ƚĞĐŚŶŝƋƵĞ ĨŽƌ ŵĞĂƐƵƌŝŶŐ ĂƌƚĞƌŝĂů ǁĂůů ŝŶŇĂŵŵĂƟŽŶ͕ &' ŝƐ Ă ŐůƵĐŽƐĞ ĂŶĂůŽŐƵĞ ƚŚĞƌĞďLJ ƌĞŇĞĐƟŶŐŶŽŶͲƐƉĞĐŝĮĐŵĞƚĂďŽůŝĐĂĐƟǀŝƚLJŝŶƚŚĞďŽŶĞŵĂƌƌŽǁĂŶĚƐƉůĞĞŶ͘dŚĞƌĞĨŽƌĞ͕ƚƌĂĐĞƌƐ ŵŽƌĞƐƉĞĐŝĮĐĨŽƌŵLJĞůŽŝĚĐĞůůƐĂƌĞƌĞƋƵŝƌĞĚƚŽĨƵƌƚŚĞƌĚĞƚĞƌŵŝŶĞƚŚĞƌŽůĞŽĨƚŚĞƐĞĐĞůůƐŝŶ ƚŚĞŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJƌĞƐƉŽŶƐĞŝŶƉĂƟĞŶƚƐƉŽƐƚͲ^͘18&ͲWͲϳϭϰŝƐĂƚƌĂĐĞƌĨŽƌƚŚĞ ƚƌĂŶƐůŽĐĂƚŽƌƉƌŽƚĞŝŶ;d^WKͿƌĞĐĞƉƚŽƌ͕ǁŚŝĐŚŝƐƉƌĞĚŽŵŝŶĂŶƚůLJĞdžƉƌĞƐƐĞĚŽŶŵLJĞůŽŝĚĐĞůůƐ͘/Ŷ ƚŚĞĂĐƵƚĞƉŚĂƐĞŽĨĂŶ^ǁĞƐŚŽǁŝŶĐƌĞĂƐĞĚŵLJĞůŽŝĚĐĞůůĚĞŶƐŝƚLJŝŶŚĞŵĂƚŽƉŽŝĞƟĐŽƌŐĂŶƐ ;ďŽŶĞ ŵĂƌƌŽǁ ĂŶĚ ƐƉůĞĞŶͿ ĐŽŵƉĂƌĞĚ ǁŝƚŚ ĂŐĞͲ ĂŶĚ ŐĞŶĚĞƌͲŵĂƚĐŚĞĚ ŚĞĂůƚŚLJ ĐŽŶƚƌŽůƐ͕ measured with 18&ͲWͲϳϭϰ Wdͬd͘ &ƵƌƚŚĞƌŵŽƌĞ͕ ƚŚŝƐ ŝŶĐƌĞĂƐĞĚ18&ͲWͲϳϭϰ ƵƉƚĂŬĞ ŝƐ

ĂƐƐŽĐŝĂƚĞĚǁŝƚŚĂŵLJĞůŽŝĚĐĞůůƵůĂƌƌĞƐƉŽŶƐĞƵƐŝŶŐŇŽǁĐLJƚŽŵĞƚƌLJ͕ĐŽŶƐŝƐƟŶŐŽĨŚŝŐŚĞƌŶƵŵďĞƌ ŽĨĐŝƌĐƵůĂƟŶŐ,^WƐĂŶĚĂŶŝŶĐƌĞĂƐĞĚŵŽŶŽĐLJƚĞĐŽƵŶƚǁŝƚŚĂƉƌŽͲŝŶŇĂŵŵĂƚŽƌLJƉŚĞŶŽƚLJƉĞ ŝŶ^ͲƉĂƟĞŶƚƐ͘dŚĞƐĞĚĂƚĂƐƵďƐƚĂŶƟĂƚĞ͚ĂĐƟǀĂƟŽŶ͛ŽĨďŽŶĞŵĂƌƌŽǁĂŶĚƐƉůĞĞŶŝŶƚŚĞĂĐƵƚĞ ƉŚĂƐĞĨŽůůŽǁŝŶŐĂŶ^ŝŶŚƵŵĂŶƐ͕ĐŽŝŶĐŝĚŝŶŐǁŝƚŚĂŶĞŶŚĂŶĐĞĚĐĞůůƵůĂƌƌĞƐƉŽŶƐĞŝŶƉůĂƐŵĂ1. dŚŝƐ ĂƵŐŵĞŶƚĞĚ ŚĞŵĂƚŽƉŽŝĞƟĐ ĂŶĚ ŵLJĞůŽŝĚ ĐĞůůƵůĂƌ ƌĞƐƉŽŶƐĞ ŝƐ ƉƌĞƐĞŶƚ ƵƉ ƚŽ ϯ ŵŽŶƚŚƐ ĂŌĞƌƚŚĞĂĐƵƚĞĞǀĞŶƚ͘/ŶƚĞƌĞƐƟŶŐůLJ͕ŝƚƐĞĞŵƐƚŚĂƚƚŚŝƐƉƌŽůŽŶŐĞĚƌĞƐƉŽŶƐĞŝƐƉƌĞĚŽŵŝŶĂŶƚůLJ ĚƌŝǀĞŶďLJĞdžƚƌĂŵĞĚƵůůĂƌLJŚĞŵĂƚŽƉŽŝĞƐŝƐŝŶƚŚĞƐƉůĞĞŶ͕ƌĞƉƌĞƐĞŶƚĞĚďLJƉĞƌƐŝƐƚĞŶƚĞůĞǀĂƚĞĚ 18&ͲWͲϳϭϰƐƉůĞŶŝĐƵƉƚĂŬĞ͘KǀĞƌĂůů͕ƚŚĞƐĞĚĂƚĂĞdžĞŵƉůŝĨLJƉƌŽůŽŶŐĞĚŚĞŵĂƚŽƉŽŝĞƟĐŽƌŐĂŶ ĂĐƟǀĂƟŽŶĂƐŝŶŝƟĂƚŽƌĨŽƌƚŚĞŽǀĞƌƐƵƉƉůLJŽĨŵLJĞůŽŝĚĐĞůůƐ͘dŚŝƐĂƵŐŵĞŶƚĞĚĐĞůůƵůĂƌŝŶǀĂƐŝŽŶ ŵĂLJŝŶĚƵĐĞŝŶĐƌĞĂƐĞĚƌŝƐŬŽĨƌĞĐƵƌƌĞŶƚĞǀĞŶƚƐďLJƉƌŽƉĂŐĂƟŶŐĂŚLJƉĞƌͲŝŶŇĂŵŵĂƚŽƌLJƌĞĂĐƟŽŶ ŝŶĂƚŚĞƌŽƐĐůĞƌŽƟĐůĞƐŝŽŶƐ͘^ŝŶĐĞ18&ͲWͲϳϭϰƐŚŽǁƐŶŽĞůĞǀĂƚĞĚƵƉƚĂŬĞŝŶƚŚĞďŽŶĞŵĂƌƌŽǁ ϯŵŽŶƚŚƐƉŽƐƚͲĞǀĞŶƚ͕ƚŚĞŝŶĐƌĞĂƐĞĚ18&Ͳ&'ƵƉƚĂŬĞŝŶƐƚĂďůĞĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ;ĂƐĚĞƐĐƌŝďĞĚ ŝŶĐŚĂƉƚĞƌϯͿŵĂLJƌĞƉƌĞƐĞŶƚŵĞƚĂďŽůŝĐĂĐƟǀŝƚLJŽĨ,^WƐŽƌŽƚŚĞƌŝŵŵƵŶĞĐĞůůƐ͕ĚĞƐƉŝƚĞƚŚĞ decline of bone marrow cell numbers.

ůƚŚŽƵŐŚ ƚŚĞ ƌŽůĞ ŽĨ ĐŝƌĐƵůĂƟŶŐ ŵŽŶŽĐLJƚĞƐ ŝŶ ĂƌƚĞƌŝĂů ǁĂůů ŝŶŇĂŵŵĂƟŽŶ ŚĂƐ ďĞĞŶ ĮƌŵůLJ ĞƐƚĂďůŝƐŚĞĚ͕ ŝƚ ŝƐ ŝŵƉŽƌƚĂŶƚ ƚŽ ŝĚĞŶƟĨLJ ƐƉĞĐŝĮĐ ŵŽŶŽĐLJƚĞƐ ǁŚŝĐŚ ĐŽƵůĚ ďĞ ƉĂƌƟĐƵůĂƌůLJ ĂƚŚĞƌŽŐĞŶŝĐ͘dŚĞƌĞĨŽƌĞ͕ƚŚĞƌĞůĂƟŽŶďĞƚǁĞĞŶŵŽŶŽĐLJƚĞƉŚĞŶŽƚLJƉĞ͕ďĂƐĞĚŽŶƚŚĞĞdžƉƌĞƐƐŝŽŶ ŽĨ ƐƵƌĨĂĐĞ ŵĂƌŬĞƌƐ͕ ĂŶĚ ĂƌƚĞƌŝĂů ǁĂůů ŝŶŇĂŵŵĂƟŽŶ ŝŶ ƉĂƟĞŶƚƐ Ăƚ ŝŶĐƌĞĂƐĞĚ s ƌŝƐŬ ŝƐ evaluated in ĐŚĂƉƚĞƌϱ͘sŝĂĂŵƵůƟǀĂƌŝĂƚĞƌĞŐƌĞƐƐŝŽŶĂŶĂůLJƐŝƐǁĞƐŚŽǁƚŚĂƚƚŚĞĞdžƉƌĞƐƐŝŽŶ ŽĨͲĐŚĞŵŽŬŝŶĞƌĞĐĞƉƚŽƌƚLJƉĞϮ;ZϮͿ͕ŝŵƉŽƌƚĂŶƚĨŽƌƚŚĞŵŝŐƌĂƟŽŶŵŽŶŽĐLJƚĞƐŝŶƚŽƚŚĞ ĂƌƚĞƌŝĂůǁĂůů͕ĐŽƌƌĞůĂƚĞƐƚŽĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶ͕ŝŶĚĞƉĞŶĚĞŶƚŽĨŽƚŚĞƌĐĂƌĚŝŽǀĂƐĐƵůĂƌ ƌŝƐŬ ĨĂĐƚŽƌƐ ĂŶĚͬŽƌ ƐƚĂƟŶ ƵƐĞ͘ dŚŝƐ ŝŶĚŝĐĂƚĞƐ ƚŚĂƚ ƚŚĞ ĞdžƉƌĞƐƐŝŽŶ ŽĨ ZϮ ŽŶ ŵŽŶŽĐLJƚĞƐ ĐŽƵůĚ ƉůĂLJ Ă ŵĂũŽƌ ƌŽůĞ ŝŶ ƚŚĞ ĚĞǀĞůŽƉŵĞŶƚ Žƌ ƉƌŽŐƌĞƐƐŝŽŶ ŽĨ ĂƌƚĞƌŝĂů ǁĂůů ŝŶŇĂŵŵĂƟŽŶ͘ dŚĞůĂĐŬŽĨĐŽƌƌĞůĂƟŽŶďĞƚǁĞĞŶŵŽŶŽĐLJƚĞƐƐƵďƐĞƚƐĂŶĚĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶƐƵƉƉŽƌƚƐ ƚŚĞ ĐŽŶĐĞƉƚ ƚŚĂƚ ƚŚĞƌĞŝƐ ĂŶ ĞƐƐĞŶƟĂů ŚĞƚĞƌŽŐĞŶĞŝƚLJŽĨ ĐŚĞŵŽŬŝŶĞ ĞdžƉƌĞƐƐŝŽŶ ǁŝƚŚŝŶ ƚŚĞ ϯ ƉƌĞǀŝŽƵƐůLJ ĚĞĮŶĞĚ ŵŽŶŽĐLJƚĞ ƐƵďƐĞƚƐ ;ĐůĂƐƐŝĐĂůͬŝŶƚĞƌŵĞĚŝĂƚĞͬŶŽŶ ĐůĂƐƐŝĐĂů ŵŽŶŽĐLJƚĞƐͿ͘ dŚĞƌĞĨŽƌĞ͕ƐĞĂƌĐŚŝŶŐĨŽƌƐƉĞĐŝĮĐĂƚŚĞƌŽŐĞŶŝĐŵŽŶŽĐLJƚĞƐŝŶƐƚĞĂĚŽĨĂďƌŽĂĚĂƉƉƌŽĂĐŚĐĂŶ ŝĚĞŶƟĨLJƐĞůĞĐƟǀĞƚĂƌŐĞƚƐĨŽƌsƚŚĞƌĂƉLJ͘

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Part IIŽĨƚŚŝƐƚŚĞƐŝƐĨŽĐƵƐƐĞƐŽŶŵĞĚŝĂƚŽƌƐŽĨƚŚŝƐŝŶŇĂŵŵĂƚŽƌLJƌĞƐƉŽŶƐĞ͘EŽƚŽŶůLJŝƐ>>Ͳ ĐŚŽůĞƐƚĞƌŽů ĂŶ ĂƚŚĞƌŽŐĞŶŝĐ ƉĂƌƟĐůĞ͕ ƌĞŵŶĂŶƚ ĐŚŽůĞƐƚĞƌŽů ŝƐ ĂůƐŽ ͚ĐĂƵƐĂůůLJ͛ ƌĞůĂƚĞĚ ǁŝƚŚ s ;DĞŶĚĞůŝĂŶ ZĂŶĚŽŵŝƐĂƟŽŶ ^ƚƵĚŝĞƐͿ2͘ /Ŷ ƉůĂƐŵĂ͕ ƚƌŝŐůLJĐĞƌŝĚĞͲƌŝĐŚ ůŝƉŽƉƌŽƚĞŝŶƐ ;dZ>͛ƐͿ

ĂƌĞƚƌĂŶƐƉŽƌƚĞĚŝŶs>>ƉĂƌƟĐůĞƐŽƌĐŚLJůŽŵŝĐƌŽŶƐ͘s>>ŽƌĐŚLJůŽŵŝĐƌŽŶƐĐŽŶƚĂŝŶƌĞŵŶĂŶƚ ĐŚŽůĞƐƚĞƌŽů͖ĚĞĮŶĞĚĂƐĂůůƉůĂƐŵĂĐŚŽůĞƐƚĞƌŽůŶŽƚƚƌĂŶƐƉŽƌƚĞĚďLJ,>ĂŶĚ>>ƉĂƌƟĐůĞƐ͘/Ŷ

ĐŚĂƉƚĞƌϲ we show increased 18&Ͳ&'ƵƉƚĂŬĞŝŶƚŚĞĂƌƚĞƌŝĂůǁĂůůŝŶƉĂƟĞŶƚƐǁŝƚŚĞůĞǀĂƚĞĚ

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Discussion ŝŶ ƚŚĞƐĞ ŝŶĚŝǀŝĚƵĂůƐ͘ dŚĞƐĞ ĚĂƚĂ ŝŶĚŝĐĂƚĞ ƚŚĂƚ ĞůĞǀĂƚĞĚ >Ɖ;ĂͿ ĂĐĐĞůĞƌĂƚĞƐ ƉƌŽŐƌĞƐƐŝŽŶ ŽĨ ĂƚŚĞƌŽƐĐůĞƌŽƐŝƐŝŶŝŶĚŝǀŝĚƵĂůƐǁŝƚŚĂĨĂŵŝůLJŚŝƐƚŽƌLJŽĨƉƌĞŵĂƚƵƌĞĂƚŚĞƌŽƐĐůĞƌŽƟĐs͕ƚŚĞƌĞďLJ ĐŽŶƚƌŝďƵƟŶŐƚŽƚŚĞŝƌŝŶĐƌĞĂƐĞĚsƌŝƐŬ͘>Ɖ;ĂͿŝƐƚŚĞŵĂŝŶĐĂƌƌŝĞƌŽĨŽdžŝĚŝnjĞĚƉŚŽƐƉŚŽůŝƉŝĚƐ ĂŶĚ ƚŚĞƌĞďLJ >Ɖ;ĂͿ ŚĂƐ ĂŶ ŝŶŇĂŵŵĂƚŽƌLJ ĞīĞĐƚ ĂƐ ǁĞůů5͘ KƵƌ ĚĂƚĂ ĞdžĞŵƉůŝĨLJ ƚŚĂƚ ďĞƐŝĚĞƐ Ă ƉƌŽͲŝŶŇĂŵŵĂƚŽƌLJ ĞīĞĐƚ ŽĨ ĂƚŚĞƌŽŐĞŶŝĐ ƉĂƌƟĐůĞƐ͕ ƚŚĞƐĞ ƉĂƌƟĐůĞƐ ĐĂŶ ĂůƐŽ ŚĂǀĞ Ă ĚŝƌĞĐƚ ĂƚŚĞƌŽŐĞŶŝĐ ĞīĞĐƚ ĂŶĚ ƚŚĞƌĞďLJ ĂĐĐĞůĞƌĂƟŶŐ ĂƚŚĞƌŽƐĐůĞƌŽƟĐ ďƵƌĚĞŶ ŝƚƐĞůĨ ŝŶƐƚĞĂĚ ŽĨ ŽŶůLJ ƉƌŽŵŽƟŶŐƉůĂƋƵĞǀƵůŶĞƌĂďŝůŝƚLJ͘ EŽƚ ŽŶůLJ ůŝƉŝĚƐ ĂƌĞ ŵĞĚŝĂƚŽƌƐ ŽĨ ĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ͕ ĂůƐŽ ŽƚŚĞƌ ŶŽŶͲůŝƉŝĚ ĚƌŝǀĞŶ ĚŝƐĞĂƐĞƐ ĂƌĞ ƌŝƐŬ ĨĂĐƚŽƌƐ ĨŽƌ s͘ WĂƟĞŶƚƐ ǁŝƚŚ ĐŚƌŽŶŝĐ ŬŝĚŶĞLJ ĚŝƐĞĂƐĞ ŚĂǀĞ ĂŶ ŝŶĐƌĞĂƐĞĚ s ƌŝƐŬ͘ &ŽůůŽǁŝŶŐ ŽƵƌ ĮŶĚŝŶŐƐ ƚŚĂƚ ŝŶŇĂŵŵĂƚŽƌLJ ĂĐƟǀĂƟŽŶ ŝƐ Ă ƉŝǀŽƚĂů ƉƌŽĐĞƐƐ ĐŽŶƚƌŝďƵƟŶŐ ƚŽ ĂĐĐĞůĞƌĂƚĞĚ ĂƚŚĞƌŽŐĞŶĞƐŝƐ ŝŶ ĚLJƐůŝƉŝĚĞŵŝĐ ĐŽŶĚŝƟŽŶƐ͕ ǁĞ ƐƵďƐĞƋƵĞŶƚůLJ ƐĞƚ ŽƵƚ ƚŽ ĞǀĂůƵĂƚĞǁŚĞƚŚĞƌĂŶĚƚŽǁŚĂƚĞdžƚĞŶƚĂŶŝŶĐƌĞĂƐĞĚŝŶŇĂŵŵĂƚŽƌLJƐƚĂƚĞĐŽƵůĚďĞĚĞƚĞĐƚĞĚ ŝŶƉĂƟĞŶƚƐǁŝƚŚĐŚƌŽŶŝĐŬŝĚŶĞLJĚŝƐĞĂƐĞ͘/ŶĐŚĂƉƚĞƌϴ͕ǁĞƐŚŽǁƚŚĂƚƉĂƟĞŶƚƐǁŝƚŚĐŚƌŽŶŝĐ ŬŝĚŶĞLJ ĚŝƐĞĂƐĞ ŚĂǀĞ ĐůĞĂƌůLJ ĞůĞǀĂƚĞĚ ĂƌƚĞƌŝĂů ǁĂůů ŝŶŇĂŵŵĂƟŽŶ͕ ŵĞĂƐƵƌĞĚ ǁŝƚŚ18&Ͳ&' Wdͬd͕ĐŽŵƉĂƌĞĚǁŝƚŚŚĞĂůƚŚLJĐŽŶƚƌŽůƐ͘ZĞŶĂůĨƵŶĐƟŽŶ͕ƵƌĞĂĂŶĚƐLJƐƚŽůŝĐďůŽŽĚƉƌĞƐƐƵƌĞ ĂƌĞ ŝŶĚĞƉĞŶĚĞŶƚ ƉƌĞĚŝĐƚŽƌƐ ŽĨ ƚŚŝƐ ŝŶŇĂŵŵĂƚŽƌLJ ĂĐƟǀŝƚLJ͘ &ƵƌƚŚĞƌŵŽƌĞ͕ ǁĞ ƐŚŽǁ ƚŚĂƚ ŝŶ ĂĚĚŝƟŽŶƚŽůŽĐĂůƉůĂƋƵĞŝŶŇĂŵŵĂƟŽŶĂůƐŽƚŚĞƉůĂƐŵĂĐŽŵƉĂƌƚŵĞŶƚŝƐŝŶǀŽůǀĞĚ͕ƐŚŽǁŝŶŐ ŵŽƌĞ ƉƌŽͲŝŶŇĂŵŵĂƚŽƌLJ ŵŽŶŽĐLJƚĞƐ ĂŶĚ Ă ĐŽŶĐŽŵŝƚĂŶƚ ŝŶĐƌĞĂƐĞ ŽĨ ƚƌĂŶƐͲĞŶĚŽƚŚĞůŝĂů ŵŝŐƌĂƟŽŶ ŽĨ ƚŚĞƐĞ ŵŽŶŽĐLJƚĞƐ͘ dŚĞƐĞ ĚĂƚĂ ƐƵƉƉŽƌƚ ƚŚĞ ŚLJƉŽƚŚĞƐŝƐ ƚŚĂƚ ŝŶŇĂŵŵĂƟŽŶ ŝŶ ƉĂƟĞŶƚƐ ǁŝƚŚ ĐŚƌŽŶŝĐ ŬŝĚŶĞLJ ĚŝƐĞĂƐĞ ŵĂLJ ĐŽŶƚƌŝďƵƚĞ ƚŽ ĂĐĐĞůĞƌĂƚĞĚ ĂƚŚĞƌŽŐĞŶĞƐŝƐ͘ EŽƚ ŽŶůLJ ƉĂƟĞŶƚƐ ǁŝƚŚ ĐŚƌŽŶŝĐ ŬŝĚŶĞLJ ĚŝƐĞĂƐĞ ĂƌĞ ŵĂƌŬĞĚ ďLJ ĂŶ ŝŶĐƌĞĂƐĞĚ s ƌŝƐŬ͕ ďƵƚ ĂůƐŽ ƉĂƟĞŶƚƐ ǁŝƚŚ ĐŚƌŽŶŝĐ ŝŶŇĂŵŵĂƚŽƌLJ ĚŝƐĞĂƐĞƐ͕ ƐƵĐŚ ĂƐ ƉĞƌŝƉŚĞƌĂů ƐƉŽŶĚLJůŽĂƌƚŚƌŝƟƐ ;Ɖ^ƉͿ͕ĂƌĞĐŚĂƌĂĐƚĞƌŝnjĞĚďLJĂŶĞůĞǀĂƚĞĚsƌŝƐŬ6͘dŚŝƐŚĂƐĂůƐŽďĞĞŶ;ƉĂƌƚůLJͿĂƩƌŝďƵƚĞĚ ƚŽ ƚŚĞ ĐŚƌŽŶŝĐ ŝŶŇĂŵŵĂƚŽƌLJ ƐƚĂƚĞ ŝŶ ƚŚĞƐĞ ƉĂƟĞŶƚƐ͕ ƐƵƉƉŽƌƚĞĚ ďLJ ŝŶĐƌĞĂƐĞĚ ĂƌƚĞƌŝĂů ǁĂůů ŝŶŇĂŵŵĂƟŽŶ7͘Ɛ/>ͲϭϳŚĂƐƌĞĐĞŶƚůLJďĞĞŶĚĞƐĐƌŝďĞĚĂƐĂŶŝŵƉŽƌƚĂŶƚŵĞĚŝĂƚŽƌŝŶĚŝƐĞĂƐĞ ĂĐƟǀŝƚLJŽĨƉ^Ɖ͕/>ͲϭϳďůŽĐŬĂĚĞ͕ƵƐŝŶŐƐĞĐƵŬŝŶƵŵĂď͕ŚĂƐďĞĞŶŝŶƚƌŽĚƵĐĞĚĂƐĂŶĞīĞĐƟǀĞ ĂŶƟͲŝŶŇĂŵŵĂƚŽƌLJƚŚĞƌĂƉLJŝŶƚŚĞƐĞƉĂƟĞŶƚƐ͘,ŽǁĞǀĞƌ͕ƚŚĞƌŽůĞŽĨ/>ͲϭϳŽŶĂƚŚĞƌŽŐĞŶĞƐŝƐͬ ĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶŝƐƵŶŬŶŽǁŶ͘ŚĂƉƚĞƌϵĚĞƐĐƌŝďĞƐƚŚĞĞīĞĐƚŽĨƐĞĐƵŬŝŶƵŵĂďŽŶ ĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶŝŶƉ^ƉƉĂƟĞŶƚƐ͘tĞĚŝƐƉůĂLJƚŚĂƚƚƌĞĂƚŵĞŶƚǁŝƚŚƐĞĐƵŬŝŶƵŵĂď ŝŶƉ^ƉƉĂƟĞŶƚƐĚƵƌŝŶŐϭϮǁĞĞŬƐƚĞŶĚƐƚŽůŽǁĞƌĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶ͕ĞƐƉĞĐŝĂůůLJŝŶ ƉĂƟĞŶƚƐǁŝƚŚĂŐŽŽĚĐůŝŶŝĐĂůƌĞƐƉŽŶƐĞŽŶƉ^ƉĚŝƐĞĂƐĞĂĐƟǀŝƚLJ͘dŚŝƐƐƚƵĚLJƐŚŽǁƐƚŚĂƚŶŽƚ ŽŶůLJůŝƉŝĚͲůŽǁĞƌŝŶŐƐƚƌĂƚĞŐŝĞƐ͕ďƵƚĂůƐŽĂŶƟͲŝŶŇĂŵŵĂƚŽƌLJƚƌĞĂƚŵĞŶƚ͕ĐĂŶƌĞĚƵĐĞĂƌƚĞƌŝĂůǁĂůů ŝŶŇĂŵŵĂƟŽŶ͘

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CLINICAL IMPLICATIONS

/ŵĂŐŝŶŐ͗ĨƌŽŵůŽĐĂůƉůĂƋƵĞŝŶŇĂŵŵĂƟŽŶƚŽŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJĂĐƟǀŝƚLJŝŶĂƚŚĞƌŽͲ ƐĐůĞƌŽƐŝƐ ƐƚŚĞŝŶŇĂŵŵĂƟŽŶͲŚLJƉŽƚŚĞƐŝƐŝŶĂƚŚĞƌŽƐĐůĞƌŽƐŝƐďĞĐĂŵĞŵŽƌĞŝŵƉŽƌƚĂŶƚ͕WdͬdŝŵĂŐŝŶŐ ǁĂƐƵƐĞĚƉƌĞĚŽŵŝŶĂŶƚůLJĨŽƌŵĞĂƐƵƌŝŶŐŝŶŇĂŵŵĂƚŽƌLJĂĐƟǀŝƚLJŝŶƚŚĞůŽĐĂůƉůĂƋƵĞ͘/ŶƚŚŝƐƚŚĞƐŝƐ͕ WdͬdŝŵĂŐŝŶŐŝƐƵƐĞĚĂƐŝŶƐƚƌƵŵĞŶƚƚŽƐŚŽǁŝŶŇĂŵŵĂƚŽƌLJĂĐƟǀŝƚLJďŽƚŚŝŶƚŚĞĂƌƚĞƌŝĂůǁĂůůĂƐ ǁĞůůĂƐŝŶďŽŶĞŵĂƌƌŽǁĂŶĚƐƉůĞĞŶ͕ŝŶďŽƚŚƐƚĂďůĞĂƚŚĞƌŽƐĐůĞƌŽƐŝƐĂŶĚĂĐƵƚĞĞǀĞŶƚƐ͕ƐƵƉƉŽƌƟŶŐ ƚŚĞŶŽƟŽŶƚŚĂƚĂƚŚĞƌŽƐĐůĞƌŽƐŝƐƐŚŽƵůĚďĞƌĞŐĂƌĚĞĚĂƐĂŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJĚŝƐĞĂƐĞ͘ 18&Ͳ&'WdͬdŝƐĂǀĂůŝĚĂƚĞĚŵĞƚŚŽĚƚŽŵĞĂƐƵƌĞŝŶŇĂŵŵĂƚŽƌLJĂĐƟǀŝƚLJŝŶƚŚĞĂƌƚĞƌŝĂůǁĂůů8. ,ŽǁĞǀĞƌ͕18&Ͳ&'ƌĞŇĞĐƚƐŵĞƚĂďŽůŝĐĂĐƟǀŝƚLJŽŶůLJ͕ƐŽŝƚŝƐŶŽƚƐƉĞĐŝĮĐĨŽƌŝŶŇĂŵŵĂƚŽƌLJĐĞůůƐ ŝŶďŽŶĞŵĂƌƌŽǁĂŶĚƐƉůĞĞŶ͘&ƵƌƚŚĞƌŵŽƌĞ͕18&Ͳ&'ŝƐĂůƐŽŶŽƚƚŚĞďĞƐƚƚƌĂĐĞƌĨŽƌŵĞĂƐƵƌŝŶŐ ŝŶŇĂŵŵĂƚŽƌLJĂĐƟǀŝƚLJŝŶƚŚĞĐŽƌŽŶĂƌLJĂƌƚĞƌŝĞƐ͕ĂƐƚŚĞƌĞŝƐĂŚŝŐŚďĂĐŬŐƌŽƵŶĚ18&Ͳ&'ƵƉƚĂŬĞ ŝŶ ƚŚĞ ŚĞĂƌƚ͘ dŚĞƌĞĨŽƌĞ͕ ŶĞǁ Wd ƚƌĂĐĞƌƐ ĂƌĞ ƌĞƋƵŝƌĞĚ ƚŽ ĂƐƐĞƐƐ ŝŶŇĂŵŵĂƚŽƌLJ ĂĐƟǀŝƚLJ ;ĞƐƉĞĐŝĂůůLJƚŽĂƐƐĞƐƐƚŚĞƉƌĞƐĞŶĐĞŽĨŵLJĞůŽŝĚĐĞůůƐͿŝŶĂƚŚĞƌŽŐĞŶĞƐŝƐĂƚǁŚŽůĞďŽĚLJůĞǀĞů͘ ƐƵƐĞĚŝŶƚŚŝƐƚŚĞƐŝƐ͕18&ͲWͲϳϭϰ͕ƚƌĂĐĞƌĨŽƌƚŚĞd^WKƌĞĐĞƉƚŽƌ͕ŝƐĂŶĂůƚĞƌŶĂƟǀĞWdƚƌĂĐĞƌ͕ ƌĞŇĞĐƟŶŐƚŚĞŶƵŵďĞƌŽĨŵLJĞůŽŝĚĐĞůůƐŝŶƟƐƐƵĞƐ͘,ŽǁĞǀĞƌ͕ĂƐƚŚĞd^WKƌĞĐĞƉƚŽƌŝƐŶŽƌŵĂůůLJ ĞdžƉƌĞƐƐĞĚŝŶƐĞǀĞƌĂůŚƵŵĂŶƟƐƐƵĞƐ͕ǁĞƐŚŽǁƚŚĂƚƚŚĞƌĞŝƐƐŝŐŶŝĮĐĂŶƚŶŽŶͲƐƉĞĐŝĮĐďŝŶĚŝŶŐŽĨ 18&ͲWͲϳϭϰŝŶĨŽƌĞdžĂŵƉůĞƚŚĞŚĞĂƌƚĂŶĚĂƌƚĞƌŝĂůǁĂůů͕ůŝŵŝƟŶŐƚŚĞƵƐĞŽĨƚŚĞd^WKƌĞĐĞƉƚŽƌ ĂƐƚĂƌŐĞƚĨŽƌǁŚŽůĞďŽĚLJ͛ŝŶŇĂŵŵĂƟŽŶ͛ŝŵĂŐŝŶŐ͘dŚĞƌĞĨŽƌĞ͕ƚŚĞƐĞĂƌĐŚĨŽƌŽƉƟŵĂů͕ƐƉĞĐŝĮĐ ŝŵĂŐŝŶŐƚƌĂĐĞƌƐĨŽƌĚĞƚĞĐƟŽŶŽĨŝŶŇĂŵŵĂƚŽƌLJĂĐƟǀŝƚLJŝŶƚŚĞĞŶƟƌĞŚƵŵĂŶďŽĚLJƐŚŽƵůĚďĞ ĐŽŶƟŶƵĞĚ͘ŶĞǁƉƌŽŵŝƐŝŶŐWdƚƌĂĐĞƌƚĂƌŐĞƟŶŐŵĂĐƌŽƉŚĂŐĞƐŝƐ68'ĂͲKddd͕ďŝŶĚŝŶŐ ƚŽƚŚĞƵƉƌĞŐƵůĂƚĞĚƐŽŵĂƚŽƐƚĂƟŶƌĞĐĞƉƚŽƌͲϮŽŶĂĐƟǀĂƚĞĚŵĂĐƌŽƉŚĂŐĞƐ͕ǁŚŝĐŚŚĂƐƌĞĐĞŶƚůLJ ďĞĞŶǀĂůŝĚĂƚĞĚĨŽƌƋƵĂŶƟĨLJŝŶŐĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶ9. Whether this tracer is suitable

ƚŽ ŝĚĞŶƟĨLJ ŵLJĞůŽŝĚ ĐĞůůƐ ĚƵƌŝŶŐ ǁŚŽůĞ ďŽĚLJ ŝŵĂŐŝŶŐ ŶĞĞĚƐ ĨƵƌƚŚĞƌ ǀĂůŝĚĂƟŽŶ͘ ŶŽƚŚĞƌ ŝŶƚĞƌĞƐƟŶŐƚƌĂĐĞƌƚŽƐĞůĞĐƟǀĞůLJĞǀĂůƵĂƚĞĐĞůůƉƌŽůŝĨĞƌĂƟŽŶŝƐϯ͛ͲĚĞŽdžLJͲϯ͛Ͳ;18&ͿͲŇƵŽƌƚŚLJŵŝĚŝŶĞ ;18&Ͳ&>dͿ͕ĂƚŚLJŵŝĚŝŶĞĂŶĂůŽŐƵĞ10. Ɛ ǁĞ ĐĂŶ ĨŽƌ ŶŽǁ ŽŶůLJ ŵĞĂƐƵƌĞ ƉůĂƋƵĞ ŝŶŇĂŵŵĂƟŽŶ ƵƐŝŶŐ Wdͬd͕ ŝƚ ƐĞĞŵƐ ƚŚĂƚ Wd ƚĞĐŚŶŝƋƵĞƐ ƚŽ ĂĚĞƋƵĂƚĞůLJ ĞǀĂůƵĂƚĞ ƉůĂƋƵĞ ďƵƌĚĞŶ ;ŝ͘Ğ͘ ƉůĂƋƵĞ ĐŽŵƉŽƐŝƟŽŶͿ ĂƌĞ ŵŝƐƐŝŶŐ͘ dŚĞƌĞĨŽƌĞ͕ WdͲDZ/ ŵĂLJ ďĞ ƚŚĞ ŶĞǁ ŝŵĂŐŝŶŐ ƚĞĐŚŶŝƋƵĞ ĨŽƌ ƚŚĞ ĨƵƚƵƌĞ͕ ŐĞŶĞƌĂƟŶŐ ďŽƚŚ ŝŶĨŽƌŵĂƟŽŶ ĂďŽƵƚ ƉůĂƋƵĞ ĐŽŵƉŽƐŝƟŽŶ ĂŶĚ ŝŶŇĂŵŵĂƚŽƌLJ ĂĐƟǀŝƚLJ ŽĨ ƚŚĞ ƉůĂƋƵĞ ƐŝŵƵůƚĂŶĞŽƵƐůLJ11. &ƌŽŵĂƌƚĞƌŝĂůǁĂůůƚŽƉůĂƐŵĂĐŽŵƉĂƌƚŵĞŶƚĂŶĚŚĞŵĂƚŽƉŽŝĞƟĐŽƌŐĂŶƐ ƐĂƚŚĞƌŽƐĐůĞƌŽƐŝƐŝƐĂůŝƉŝĚͲĚƌŝǀĞŶŝŶŇĂŵŵĂƚŽƌLJĚŝƐĞĂƐĞ͕ůŝƉŝĚƐĂƌĞĞƐƐĞŶƟĂůŝŶĂƚŚĞƌŽŐĞŶĞƐŝƐ͘ /ƚŚĂƐůŽŶŐďĞĞŶƚŚŽƵŐŚƚƚŚĂƚ>>ͲĐŚŽůĞƐƚĞƌŽůŝŶĚƵĐĞƐĂƉƌŽͲŝŶŇĂŵŵĂƚŽƌLJƌĞƐƉŽŶƐĞŝŶƚŚĞ ĂƌƚĞƌŝĂůǁĂůů͕ĂƩƌĂĐƟŶŐŵŽŶŽĐLJƚĞƐ͕ĂŶĚƚŚƵƐĞdžĂĐĞƌďĂƟŶŐĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ͘,ŽǁĞǀĞƌ͕ƚŚŝƐŝƐ

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10

ŝƐĐƵƐƐŝŽŶ ŶŽƚƚŚĞŽŶůLJƚƌƵƚŚ͗ůŝƉŝĚƐĂƌĞŶŽƚŽŶůLJŝŵƉŽƌƚĂŶƚĨŽƌŝŶŇĂŵŵĂƟŽŶŝŶƚŚĞĂƌƚĞƌŝĂůǁĂůů͕ďƵƚĂůƐŽ ĂīĞĐƚŝŶŇĂŵŵĂƚŽƌLJĐĞůůƐŝŶƚŚĞĐŝƌĐƵůĂƟŽŶĂŶĚĂīĞĐƚƉƌŽŐĞŶŝƚŽƌĐĞůůƐŝŶƚŚĞďŽŶĞŵĂƌƌŽǁ͘ /ƚŝƐƐŚŽǁŶƚŚĂƚƉĂƟĞŶƚƐǁŝƚŚĨĂŵŝůŝĂůŚLJƉĞƌĐŚŽůĞƐƚĞƌŽůĞŵŝĂŚĂǀĞŵŽƌĞƉƌŽͲŝŶŇĂŵŵĂƚŽƌLJ ŵŽŶŽĐLJƚĞƐŝŶƚŚĞĐŝƌĐƵůĂƟŽŶǁŝƚŚĂŚŝŐŚĞƌĞdžƉƌĞƐƐŝŽŶŽĨZϮĂŶĚĂĐŽŶĐŽŵŝƚĂŶƚŚŝŐŚĞƌ ƚƌĂŶƐͲĞŶĚŽƚŚĞůŝĂů ŵŝŐƌĂƟŽŶ ƌĂƚĞ ŽĨ ƚŚĞƐĞ ŵŽŶŽĐLJƚĞƐ ĐŽŵƉĂƌĞĚ ǁŝƚŚ ŚĞĂůƚŚLJ ĐŽŶƚƌŽůƐ12. >ŽǁĞƌŝŶŐ>>ͲĐŚŽůĞƐƚĞƌŽůƵƐŝŶŐW^<ϵƚƌĞĂƚŵĞŶƚƌĞƐƵůƚĞĚŝŶĂĚĞĐƌĞĂƐĞŽĨZϮĞdžƉƌĞƐƐŝŽŶ ĂŶĚ Ă ĚĞĐƌĞĂƐĞ ŽĨ ƚƌĂŶƐͲĞŶĚŽƚŚĞůŝĂů ŵŝŐƌĂƟŽŶ ƌĂƚĞ ŽĨ ƚŚĞƐĞ ĐĞůůƐ12͘ >ŝƉŝĚƐ ŶŽƚ ŽŶůLJ ĂīĞĐƚ ŝŶŇĂŵŵĂƚŽƌLJ ĐĞůůƐ ŝŶ ƚŚĞ ƉůĂƐŵĂ ĐŽŵƉĂƌƚŵĞŶƚ͕ ďƵƚ ƚŚĞ ĐƵƌƌĞŶƚ ŚLJƉŽƚŚĞƐŝƐ ŝƐ ƚŚĂƚ ůŝƉŝĚƐ ĂůƐŽĂīĞĐƚƉƌŽŐĞŶŝƚŽƌĐĞůůƐŝŶŚĞŵĂƚŽƉŽŝĞƟĐŽƌŐĂŶƐ13͘ŚŝŐŚĐŝƌĐƵůĂƟŶŐŵŽŶŽĐLJƚĞĐŽƵŶƚŝƐ ĂƐƐŽĐŝĂƚĞĚǁŝƚŚs͕ƐƵŐŐĞƐƟŶŐƚŚĂƚůŝƉŝĚƐĐĂŶŝŶŇƵĞŶĐĞƚŚĞƉƌŽĚƵĐƟŽŶŽĨŝŶŇĂŵŵĂƚŽƌLJ ĐĞůůƐ ŝŶ ƚŚĞ ďŽŶĞ ŵĂƌƌŽǁ ĂŶĚ ƐƉůĞĞŶ ďLJ ŝŶĚƵĐŝŶŐ ,^W ƉƌŽůŝĨĞƌĂƟŽŶ14͘ ^Ž͕ ƚŚĞ ĨŽĐƵƐ ŝƐ ƐǁŝƚĐŚĞĚĨƌŽŵůŝƉŝĚƐŝŶĚƵĐŝŶŐŝŶŇĂŵŵĂƟŽŶŝŶƚŚĞĂƌƚĞƌŝĂůǁĂůůŽŶůLJƚŽĂŵƵůƟͲůĞǀĞůƐLJƐƚĞŵŝĐ ŝŶŇĂŵŵĂƚŽƌLJƌĞƐƉŽŶƐĞ͕ŝŶǀŽůǀŝŶŐďŽƚŚŵŽŶŽĐLJƚĞƐŝŶƚŚĞƉůĂƐŵĂĐŽŵƉĂƌƚŵĞŶƚĂŶĚ,^WƐ ŝŶƚŚĞŚĞŵĂƚŽƉŽŝĞƟĐŽƌŐĂŶƐ͕ĂƐƐŚŽǁŶŝŶĮŐƵƌĞϭ͘

1. Bone marrow and spleen

2. Plasma compartment 3. Arterial wall &ŝŐƵƌĞϭ͘KǀĞƌǀŝĞǁŽĨƚŚĞŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJƌĞƐƉŽŶƐĞŝŶĂƚŚĞƌŽŐĞŶĞƐŝƐ͘&ŝƌƐƚ͕ĚLJƐƌĞŐƵůĂƟŽŶŽĨŚĞŵĂƚŽƉŽŝĞƟĐ ŽƌŐĂŶƐ;ϭͿ ;ďŽŶĞ ŵĂƌƌŽǁ ĂŶĚ ƐƉůĞĞŶͿ ůĞĂĚƐ ƚŽ ĂŶ ŝŶĐƌĞĂƐĞ ŽĨ ;ƉƌŽͲŝŶŇĂŵŵĂƚŽƌLJͿ ŵŽŶŽĐLJƚĞƐ ŝŶ ƚŚĞ ƉůĂƐŵĂ ĐŽŵƉĂƌƚŵĞŶƚ;ϮͿ͕ƚŚĞƐĞŵŽŶŽĐLJƚĞƐŵŝŐƌĂƚĞŝŶƚŽƚŚĞĂƌƚĞƌŝĂůǁĂůů;ϯͿ͕ŝŶĚƵĐŝŶŐĂƌƚĞƌŝĂůǁĂůůŝŶŇĂŵŵĂƟŽŶ͘ DŽƌĞ ŽĨ ŝŶƚĞƌĞƐƚ ŝƐ ƚŚĞ ŵĞĐŚĂŶŝƐŵ ďĞŚŝŶĚ ƚŚŝƐ ŵƵůƟͲůĞǀĞů ŝŶŇĂŵŵĂƚŽƌLJ ƌĞƐƉŽŶƐĞ͘ /ƚ ŝƐ ĂůƌĞĂĚLJ ƐŚŽǁŶ ƚŚĂƚ ĐŝƌĐƵůĂƟŶŐ ŵŽŶŽĐLJƚĞƐ ŝŶ s ƉĂƟĞŶƚƐ ŚĂǀĞ Ă ŵĞŵŽƌLJ͘ dŚŝƐ ŵĞŵŽƌLJ ĐĂŶ ŬĞĞƉ ƚŚĞŵ ŝŶ Ă ƉƌŽͲŝŶŇĂŵŵĂƚŽƌLJ ƐƚĂƚĞ͕ ǁŚŝĐŚ ŝƐ ŬŶŽǁŶ ĂƐ ͚ƚƌĂŝŶĞĚ ŝŵŵƵŶŝƚLJ͛15. ,ŝƐƚŽŶĞŵŽĚŝĮĐĂƟŽŶŽƌŵĞƚŚLJůĂƟŽŶĐĂŶďĞĐĂƵƐĞĚďLJŽdžŝĚŝnjĞĚĐŚŽůĞƐƚĞƌŽůĂŶĚ>Ɖ;ĂͿ͕ƚŚŝƐ ƉŚĞŶŽŵĞŶŽŶ ŝƐ ŬŶŽǁŶ ĂƐ ĞƉŝŐĞŶĞƟĐ ƌĞƉƌŽŐƌĂŵŵŝŶŐ͕ ŝŶĚƵĐŝŶŐ ƚŚĞ ͚ƚƌĂŝŶĞĚ ŝŵŵƵŶŝƚLJ͛16. ,ŽǁĞǀĞƌŝƚŝƐƵŶĐůĞĂƌǁŚĂƚƚŚĞĚƵƌĂƟŽŶŽĨŵŽŶŽĐLJƚĞůŝƉŝĚĞdžƉŽƐƵƌĞƐŚŽƵůĚďĞƚŽƉƌŽǀŽŬĞ ĞƉŝŐĞŶĞƟĐĐŚĂŶŐĞƐĂŶĚǁŚĞƚŚĞƌƚŚĞƐĞĐŚĂŶŐĞƐĐĂŶďĞƌĞǀĞƌƐĞĚďLJůŝƉŝĚůŽǁĞƌŝŶŐƚŚĞƌĂƉLJ͘

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&ƵƌƚŚĞƌŵŽƌĞ͕ĂƐŵŽŶŽĐLJƚĞƐĂŶĚŵĂĐƌŽƉŚĂŐĞƐŚĂǀĞĂůŝĨĞͲƟŵĞŽĨŚŽƵƌƐƚŽĚĂLJƐ͕ĞƉŝŐĞŶĞƟĐ ƌĞƉƌŽŐƌĂŵŵŝŶŐ ŽĨ ƚŚĞ ƉƌŽŐĞŶŝƚŽƌ ĐĞůůƐ ;,^WƐͿ ŵŝŐŚƚ ƐŚŽǁ ƉŽƚĞŶƟĂů͘ hŶƌĂǀĞůůŝŶŐ ƚŚĞ ŵĞĐŚĂŶŝƐŵƐďĞŚŝŶĚƚŚĞŵƵůƟͲůĞǀĞůƉƌŽͲŝŶŇĂŵŵĂƚŽƌLJƌĞƐƉŽŶƐĞŝŶsƉĂƟĞŶƚƐĐĂŶƉĂǀĞƚŚĞ ǁĂLJĨŽƌŶĞǁƚŚĞƌĂƉĞƵƟĐŽƉƟŽŶƐƚĂƌŐĞƟŶŐĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ͘ůƐŽZEƐĞƋƵĞŶĐŝŶŐ͕ƉƌŽƚĞŽŵŝĐƐ ĂŶĚůŝƉŝĚŽŵŝĐƐĐŽƵůĚďĞǀĂůƵĂďůĞƚĞĐŚŶŝƋƵĞƐƚŽĞdžƉůŽƌĞƚŚĞŝŶŇĂŵŵĂƚŽƌLJƉĂƚŚǁĂLJƐŝŶŵŽƌĞ depth. &ƌŽŵŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƟŽŶƚŽƚŚĞƌĂƉĞƵƟĐƚĂƌŐĞƚƐ /Ŷ ƚŚĞ ůĂƐƚ LJĞĂƌƐ ƚŚĞ ŝŶŇĂŵŵĂƟŽŶͲŚLJƉŽƚŚĞƐŝƐ ŝŶ ĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ ďĞĐĂŵĞ ŝŶĐƌĞĂƐŝŶŐůLJ ŝŵƉŽƌƚĂŶƚ͘,ŽǁĞǀĞƌ͕ƚŚĞƌĞǁĂƐŶŽĞǀŝĚĞŶĐĞƚŚĂƚďĞƐŝĚĞĐŚŽůĞƐƚĞƌŽůůŽǁĞƌŝŶŐƚƌĞĂƚŵĞŶƚĂŶƟͲ ŝŶŇĂŵŵĂƚŽƌLJƚŚĞƌĂƉŝĞƐĐŽƵůĚĂůƐŽďĞĞīĞĐƟǀĞƚŽůŽǁĞƌsƌŝƐŬ17͘ZĞĐĞŶƚůLJƚŚĞEdK^ ƚƌŝĂůƐŚŽǁĞĚĨŽƌƚŚĞĮƌƐƚƟŵĞƚŚĂƚŝŶŇĂŵŵĂƟŽŶƌĞĂůůLJŵĂƩĞƌƐŝŶĂƚŚĞƌŽƐĐůĞƌŽƐŝƐ18͕ƐŚŽǁŝŶŐ Ă ƌĞĚƵĐƟŽŶ ŽĨ ŵĂũŽƌ ĂĚǀĞƌƐĞ ĐĂƌĚŝĂĐ ĞǀĞŶƚƐ ŝŶ s ƉĂƟĞŶƚƐ ƚƌĞĂƚĞĚ ǁŝƚŚ ĐĂŶĂŬŝŶƵŵĂď͘ dŚĞƐĞ ĚĂƚĂ ƉĂǀĞ ƚŚĞ ǁĂLJ ĨŽƌ ĨƵƌƚŚĞƌ ƐƚƵĚŝĞƐ ǁŝƚŚ ĂŶƟͲŝŶŇĂŵŵĂƚŽƌLJ ƚŚĞƌĂƉŝĞƐ ŝŶ s ƉĂƟĞŶƚƐ͘ƵƌƌĞŶƚůLJ͕ŽƚŚĞƌƚƌŝĂůƐǁŝƚŚƐLJƐƚĞŵŝĐĂŶƟͲŝŶŇĂŵŵĂƚŽƌLJƚŚĞƌĂƉŝĞƐŝŶƉĂƟĞŶƚƐǁŝƚŚ s ĂƌĞŽŶŐŽŝŶŐ͕ĨŽƌĞdžĂŵƉůĞƚŚĞ/ZdƚƌŝĂů͗ϳϬϬϬƉĂƟĞŶƚƐǁŝƚŚ ƐƚĂďůĞs ƚƌĞĂƚĞĚǁŝƚŚ ŵĞƚŚŽƚƌĞdžĂƚĞŽƌƉůĂĐĞďŽ19͘,ŽǁĞǀĞƌ͕ĂƐĂƚŚĞƌŽƐĐůĞƌŽƐŝƐŝƐĂŵƵůƟͲůĞǀĞůŝŶŇĂŵŵĂƚŽƌLJĚŝƐĞĂƐĞ͕ ƚŚĞƌĞĂƌĞŵŽƌĞŝŶŇĂŵŵĂƚŽƌLJƉĂƚŚǁĂLJƐĂƚĚŝīĞƌĞŶƚůĞǀĞůƐƐƵŝƚĂďůĞƚŽďĞĐŽŵĞĂŶĞǁƚĂƌŐĞƚ ĨŽƌsƚŚĞƌĂƉLJ͘dŚĞƌĞĨŽƌĞ͕ŶŽƚŽŶůLJĐLJƚŽŬŝŶĞƐĂƌĞƉŽƚĞŶƟĂůƚĂƌŐĞƚƐĨŽƌŶĞǁƚƌĞĂƚŵĞŶƚƐ;Ğ͘Ő͘ EdK^ƚƌŝĂůͿ͕ďƵƚĂůƐŽĐĞůůƵůĂƌͲƚĂƌŐĞƚĞĚƚŚĞƌĂƉŝĞƐĐŽƵůĚďĞƚŚĞĨƵƚƵƌĞ͘ƐŵLJĞůŽŝĚĐĞůůƐĂƌĞ ƚŚĞŵŽƐƚĂďƵŶĚĂŶƚĐĞůůƐŝŶĂƚŚĞƌŽƐĐůĞƌŽƟĐƉůĂƋƵĞƐ͕ƚŚĞƐĞĐĞůůƐĐŽƵůĚďĞĂƉŽƚĞŶƟĂůƚĂƌŐĞƚ ǀŝĂ/ͿƚĂƌŐĞƟŶŐƚŚĞŝŶŇƵdžŽĨŵŽŶŽĐLJƚĞƐŝŶƚŽƚŚĞƉůĂƋƵĞ͕//ͿƚĂƌŐĞƟŶŐƚŚĞƌĞůĞĂƐĞŽĨŵLJĞůŽŝĚ ĐĞůůƐ ĨƌŽŵ ďŽŶĞ ŵĂƌƌŽǁ ĂŶĚͬŽƌ ƐƉůĞĞŶ͘ ŽƚŚ ƉĂƚŚǁĂLJƐ ĂƌĞ ƌĞŐƵůĂƚĞĚ ďLJ͕ ĂŵŽŶŐ ŽƚŚĞƌƐ͕ ZϮĞdžƉƌĞƐƐŝŽŶ͘dŚĞƌĞďLJ͕ZϮͲŝŶŚŝďŝƟŽŶŵŝŐŚƚďĞĂƉŽƚĞŶƟĂůƚŚĞƌĂƉLJĨŽƌĂƚŚĞƌŽƐĐůĞƌŽƟĐ ĚŝƐĞĂƐĞ͖ŚŽǁĞǀĞƌůĂƌŐĞĐůŝŶŝĐĂůƚƌŝĂůƐĂƌĞŶĞĞĚĞĚƚŽŝŶǀĞƐƟŐĂƚĞZϮĂƐƚĂƌŐĞƚ͘&ƵƌƚŚĞƌŵŽƌĞ͕ ŝŶŚŝďŝƟŶŐ ƚŚĞ ƐLJŵƉĂƚŚĞƟĐ ŶĞƌǀŽƵƐ ƐLJƐƚĞŵ ǀŝĂ ďĞƚĂ ďůŽĐŬĞƌƐ ĐŽƵůĚ ƌĞĚƵĐĞ ďŽŶĞ ŵĂƌƌŽǁ ĂĐƟǀĂƟŽŶŝŶƚŚĞĂĐƵƚĞƉŚĂƐĞĂŌĞƌĂŶĞǀĞŶƚ͕ƚŚĞƌĞďLJƌĞĚƵĐŝŶŐůĞƵŬŽĐLJƚĞĞdžĐĞƐƐ20. Another ĐĞůůƵůĂƌ ƚĂƌŐĞƚ ĐŽƵůĚ ďĞ ĞŶĚŽƚŚĞůŝĂů ĐĞůůƐ͘ &ƌŽŵ ƚŚĞ ĮĞůĚ ŽĨ ƚƵŵŽƌ ďŝŽůŽŐLJ ǁĞ ŬŶŽǁ ƚŚĂƚ ƚĂƌŐĞƟŶŐ ŝŶĚƵĐŝďůĞ ŐůLJĐŽůLJƐŝƐ ŝŶ ƚŚĞ ĞŶĚŽƚŚĞůŝƵŵ ůĞĂĚƐ ƚŽ Ă ŵŽƌĞ ƋƵŝĞƐĐĞŶƚ ǀĞƐƐĞů ǁĂůů and therefore less vascular growth21͘dŚŝƐŝŵƉůŝĞƐƚŚĂƚƚĂƌŐĞƟŶŐŝŶĚƵĐŝďůĞŐůLJĐŽůLJƐŝƐŝŶƚŚĞ

ĞŶĚŽƚŚĞůŝƵŵĐŽƵůĚďĞĂƉŽƚĞŶƟĂůƚĂƌŐĞƚŝŶƚŚĞĐŽŶƚĞdžƚŽĨƌĞĚƵĐŝŶŐĂƚŚĞƌŽƐĐůĞƌŽƐŝƐĂƐǁĞůů͕ ďLJƚŚĞƌĞĚƵĐƟŽŶŝŶŵŽŶŽĐLJƚĞĂĚŚĞƐŝŽŶƌĞĐĞƉƚŽƌĞdžƉƌĞƐƐŝŽŶŽŶƚŚĞǀĞƐƐĞůǁĂůů͘>ĂƐƚůLJ͕ŝĨŝƚ ŝƐ ƉŽƐƐŝďůĞ ƚŽ ŶĞƵƚƌĂůŝnjĞ ĞƉŝŐĞŶĞƟĐ ĐŚĂŶŐĞƐ͕ ƚŚŝƐ ĂƉƉƌŽĂĐŚ ŵŝŐŚƚ ƐŚŽǁ ƉƌŽŵŝƐĞ͘ ĞƐƉŝƚĞ ƚŚĞŬŶŽǁůĞĚŐĞƚŚĂƚŝŶŇĂŵŵĂƟŽŶƌĞĂůůLJŵĂƩĞƌƐŝŶs͕ŵŽƌĞƌĞƐĞĂƌĐŚŝƐƐƟůůŶĞĐĞƐƐĂƌLJƚŽ ĮŶĚŶĞǁƉŽƚĞŶƟĂůƚĂƌŐĞƚƐŽĨƚŚĞŝŶŇĂŵŵĂƚŽƌLJƉĂƚŚǁĂLJƐĂŶĚƚŽƐŚŽǁƚŚĂƚƚĂƌŐĞƟŶŐƚŚĞƐĞ ƉĂƚŚǁĂLJƐǁŝůůůĞĂĚƚŽĂƌĞĚƵĐƟŽŶŽĨs͘

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Discussion ŽŶĐůƵƐŝŽŶ dŚŝƐƚŚĞƐŝƐĚĞŵŽŶƐƚƌĂƚĞƐƚŚĂƚĂƚŚĞƌŽŐĞŶĞƐŝƐŝƐĂƐLJƐƚĞŵŝĐŝŶŇĂŵŵĂƚŽƌLJƉƌŽĐĞƐƐŝŶĐůƵĚŝŶŐ ƚŚĞŚĞŵĂƚŽƉŽŝĞƟĐŽƌŐĂŶƐ͕ƚŚĞƉůĂƐŵĂĐŽŵƉĂƌƚŵĞŶƚĂŶĚƚŚĞĂƌƚĞƌŝĂůǁĂůů͘ƐŵĂdžŝŵĂů>>Ͳ ĐŚŽůĞƐƚĞƌŽůůŽǁĞƌŝŶŐƚŚĞƌĂƉLJŝƐĂĐŚŝĞǀĞĚǁŝƚŚƐƚĂƟŶƐĂŶĚW^<ϵŝŶŚŝďŝƚŽƌƐ͕ƌĞĚƵĐƟŽŶŽĨƚŚĞ ƌĞƐŝĚƵĂů ĂƚŚĞƌŽƐĐůĞƌŽƟĐ ŝŶŇĂŵŵĂƟŽŶ ǁŝƚŚ ĂŶƟͲŝŶŇĂŵŵĂƚŽƌLJ ƚŚĞƌĂƉŝĞƐ ĂƌĞ ĞƐƐĞŶƟĂů ďƵƚ ĂƌĞĨŽƌŶŽǁůĂƌŐĞůLJůĂĐŬŝŶŐ͘/ŶĂĚĚŝƟŽŶŝƚŝƐŝŵƉŽƌƚĂŶƚƚŽŝĚĞŶƟĨLJŝŶĚŝǀŝĚƵĂůƉĂƟĞŶƚƐǁŝƚŚĂ ŚŝŐŚƌĞƐŝĚƵĂůŝŶŇĂŵŵĂƚŽƌLJƌŝƐŬĂŶĚƚŚƵƐƉĂƟĞŶƚƐǁŚŽŵŽƐƚůŝŬĞůLJďĞŶĞĮƚŵŽƐƚĨƌŽŵĂŶƟͲ ŝŶŇĂŵŵĂƚŽƌLJƚŚĞƌĂƉLJ͘

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ϭϰ͘ dĂůůZ͕zǀĂŶĐŚĂƌǀĞƚ>͘ŚŽůĞƐƚĞƌŽů͕ŝŶŇĂŵŵĂ-ƟŽŶĂŶĚŝŶŶĂƚĞŝŵŵƵŶŝƚLJ͘Nat Rev Immunol. ϮϬϭϱ͖ϭϱ͗ϭϬϰͲϭϭϲ͘

ϭϱ͘ ĞŬŬĞƌŝŶŐ^͕:ŽŽƐƚĞŶ>͕ǀĂŶĚĞƌDĞĞƌ:tĞƚ Ăů͘dŚĞĞƉŝŐĞŶĞƟĐŵĞŵŽƌLJŽĨŵŽŶŽĐLJƚĞƐĂŶĚ macrophages as a novel drug target in athero-sclerosis. ůŝŶdŚĞƌ͘ϮϬϭϱ͖ϯϳ;ϰͿ͗ϵϭϰͲϵϮϯ͘

ϭϲ͘ ,ŽŽŐĞǀĞĞŶZD͕EĂŚƌĞŶĚŽƌĨD͕ZŝŬƐĞŶEWĞƚ Ăů͘DŽŶŽĐLJƚĞĂŶĚŚĂĞŵĂƚŽƉŽŝĞƟĐƉƌŽŐĞŶŝƚŽƌ reprogramming as common mechanism un- ĚĞƌůLJŝŶŐĐŚƌŽŶŝĐŝŶŇĂŵŵĂƚŽƌLJĂŶĚĐĂƌĚŝŽǀĂƐ-cular diseases. Eur Heart J. 2017.

ϭϳ͘ ,ĂŶƐƐŽŶ'<͘/ŶŇĂŵŵĂƟŽŶĂŶĚƚŚĞƌŽƐĐůĞ-ƌŽƐŝƐͲdŚĞŶĚŽĨĂŽŶƚƌŽǀĞƌƐLJ͘ŝƌĐƵůĂƟŽŶ͘ ϮϬϭϳ͖ϭϯϲ͗ϭϴϳϱͲϭϴϳϳ ϭϴ͘ ZŝĚŬĞƌWD͕ǀĞƌĞƩD͕dŚƵƌĞŶdĞƚĂů͘ ŶƟŝŶŇĂŵŵĂƚŽƌLJdŚĞƌĂƉLJǁŝƚŚĂŶĂŬŝŶƵŵĂď ĨŽƌƚŚĞƌŽƐĐůĞƌŽƟĐŝƐĞĂƐĞ͘N Engl J Med. ϮϬϭϳ͖ϯϳϳ;ϭϮͿ͗ϭϭϭϵͲϭϭϯϭ͘ ϭϵ͘ ǀĞƌĞƩD͕WƌĂĚŚĂŶ͕^ŽůŽŵŽŶ,ĞƚĂů͘ ZĂƟŽŶĂůĞĂŶĚĚĞƐŝŐŶŽĨƚŚĞĂƌĚŝŽǀĂƐĐƵůĂƌ /ŶŇĂŵŵĂƟŽŶZĞĚƵĐƟŽŶdƌŝĂů͗ƚĞƐƚŽĨƚŚĞ ŝŶŇĂŵŵĂƚŽƌLJŚLJƉŽƚŚĞƐŝƐŽĨĂƚŚĞƌŽƚŚƌŽŵďŽ-sis. Am Heart J. ϮϬϭϯ͖ϭϲϲ͗ϭϵϵͲϮϬϳ͘ ϮϬ͘ ĂŶŶŽŶW͕ƌĂƵŶǁĂůĚ͕DĐĂďĞ,ĞƚĂů͘

Intensive versus moderate lipid lowering with ƐƚĂƟŶƐĂŌĞƌĂĐƵƚĞĐŽƌŽŶĂƌLJƐLJŶĚƌŽŵĞƐ͘N

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10

Discussion Ϯϭ͘ ^ƚĂƉŽƌW͕tĂŶŐy͕'ŽǀĞŝĂ:ĞƚĂů͘ŶŐŝŽŐĞŶĞƐŝƐ ƌĞǀŝƐŝƚĞĚͲƌŽůĞĂŶĚƚŚĞƌĂƉĞƵƟĐƉŽƚĞŶƟĂůŽĨ ƚĂƌŐĞƟŶŐĞŶĚŽƚŚĞůŝĂůŵĞƚĂďŽůŝƐŵ͘J Cell Sci. ϮϬϭϰ͖ϭϮϳ͗ϰϯϯϭͲϰϯϰϭ͘

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