Toll-like receptor 2, hyaluronan, and neutrophils play a key role in plaque erosion: the OPTICO-ACS study

Denitsa Meteva; Ramona Vinci; Claudio Seppelt; Youssef S Abdelwahed; Daniela Pedicino; Gregor Nelles; Carsten Skurk; Arash Haghikia; Ursula Rauch-Kröhnert; Teresa Gerhardt; Elisabeth Straessler; Yingjie Zhao; Felix Golla; Michael Joner; Himanshu Rai; Adelheid Kratzer; Hector Giral Arnal; Giovanna Liuzzo; Jens Klotsche; Filippo Crea; Ulf Landmesser; David M Leistner; Nicolle Kränkel

doi:10.1093/eurheartj/ehad379

Toll-like receptor 2, hyaluronan, and neutrophils play a key role in plaque erosion: the OPTICO-ACS study

Eur Heart J. 2023 Oct 12;44(38):3892-3907. doi: 10.1093/eurheartj/ehad379.

Authors

Denitsa Meteva^{1

2

3}, Ramona Vinci^{4

5}, Claudio Seppelt^{1

2

3

6}, Youssef S Abdelwahed^{1

2

3}, Daniela Pedicino^{4

5}, Gregor Nelles^{1

2}, Carsten Skurk^{1

2

3}, Arash Haghikia^{1

2

3

7}, Ursula Rauch-Kröhnert^{1

2

3}, Teresa Gerhardt^{1

2

3

7}, Elisabeth Straessler^{1

2

3}, Yingjie Zhao^{1

2}, Felix Golla^{1

2}, Michael Joner^{8

9}, Himanshu Rai^{10

11}, Adelheid Kratzer^{1

2

3}, Hector Giral Arnal^{1

2

3}, Giovanna Liuzzo^{4

5}, Jens Klotsche^{2

12}, Filippo Crea^{4

5}, Ulf Landmesser^{1

2

3

7}, David M Leistner^{1

2

3

7

6}, Nicolle Kränkel^{1

2

3}

Affiliations

¹ Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Hindenburgdamm 30, Berlin 12203, Germany.
² Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany.
³ DZHK (German Centre for Cardiovascular Research) partner Site Berlin, Berlin 12203, Germany.
⁴ Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome 00168, Italy.
⁵ Department of Cardiovascular Sciences, IRCCS Fondazione Policlinico Universitario A. Gemelli, Largo Francesco Vito 1, Rome 00168, Italy.
⁶ Department of Cardiology and Angiology, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60598, Germany.
⁷ Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, Berlin 10178, Germany.
⁸ Department of Cardiology and ISAR Research Centre, German Heart Centre Munich, Lazarettstrasse 36, Munich 80636, Germany.
⁹ DZHK (German Centre for Cardiovascular Research) partner Site Munich, Munich 80636, Germany.
¹⁰ Cardiovascular Research Institute Dublin, Mater Private Network, 73 Eccles Street, Dublin D07 YH66, Ireland.
¹¹ School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, 123 St. Stephan's Green, Dublin D02 YN77, Ireland.
¹² German Rheumatism Research Centre (DRFZ) and Institute for Social Medicine, Epidemiology and Health Economy, Charitė University Medicine Berlin, Campus Charite Mitte, Charitėplatz 1, Berlin 10117, Germany.

PMID: 37381760
DOI: 10.1093/eurheartj/ehad379

Abstract

Background and aims: In one-third of patients with acute coronary syndrome (ACS), thrombosis occurs despite an intact fibrous cap (IFC) (IFC-ACS, 'plaque erosion'). Recent studies emphasize neutrophils as the immediate inflammatory response in this pathology, but their exact molecular activation patterns are still poorly understood and may represent future therapeutic targets.

Methods and results: Thirty-two patients with IFC-ACS and matched patients with ACS with ruptured fibrous cap (RFC) (RFC-ACS) from the OPTICO-ACS study were included, and blood samples were collected from the local site of the culprit lesion and the systemic circulation. Neutrophil surface marker expression was quantified by flow cytometry. Neutrophil cytotoxicity towards endothelial cells was examined in an ex vivo co-culture assay. Secretion of active matrix metalloproteinase 9 (MMP9) by neutrophils was evaluated using zymography in supernatants and in plasma samples. Optical coherence tomography (OCT)-embedded thrombi were used for immunofluorescence analysis. Toll-like receptor 2 (TLR2) expression was higher on neutrophils from IFC-ACS than RFC-ACS patients. TLR2 stimulation increased the release of active MMP9 from local IFC-ACS-derived neutrophils, which also aggravated endothelial cell death independently of TLR2. Thrombi of IFC-ACS patients exhibited more hyaluronidase 2 with concomitant increase in local plasma levels of the TLR2 ligand: hyaluronic acid.

Conclusion: The current study provides first in-human evidence for distinct TLR2-mediated neutrophil activation in IFC-ACS, presumably triggered by elevated soluble hyaluronic acid. Together with disturbed flow conditions, neutrophil-released MMP9 might be promoting endothelial cell loss-triggered thrombosis and therefore providing a potential future target for a phenotype-specific secondary therapeutic approach in IFC-ACS.

Keywords: Endothelial cell death; Hyaluronic acid; Matrix metalloproteinase 9; Neutrophils; Plaque erosion; Toll-like receptor 2.

MeSH terms

Acute Coronary Syndrome* / complications
Coronary Angiography
Endothelial Cells / metabolism
Fibrosis
Humans
Hyaluronic Acid
Matrix Metalloproteinase 9
Neutrophils
Plaque, Atherosclerotic* / pathology
Thrombosis* / complications
Toll-Like Receptor 2
Tomography, Optical Coherence / methods

Substances

Hyaluronic Acid
Toll-Like Receptor 2
Matrix Metalloproteinase 9