PMC:5767236 / 15658-53174 JSONTXT

{"target":"http://pubannotation.org/docs/sourcedb/PMC/sourceid/5767236","sourcedb":"PMC","sourceid":"5767236","source_url":"https://www.ncbi.nlm.nih.gov/pmc/5767236","text":"Relevance to Cardiovascular Pathologies\nMononuclear phagocytes are becoming increasingly recognized as key cells in the initiation and propagation of cardiac injury and remodeling. This growing body of evidence should prompt cardiovascular researchers to explore new therapeutic targets. Because of their functional and phenotypic versatility, manipulating specific macrophage subsets may spare key and vital cardiovascular functions, such as tissue repair and defense against pathogens, while preventing specific deleterious effects that contribute to adverse cardiac remodeling or atherosclerotic plaque formation.\n\nInfections\n\nChagas Cardiomyopathy\nChagas disease is caused by Trypanosoma cruzi infection and constitutes a major public health problem in Latin America due to its prevalence, morbidity, and mortality. The World Health Organization (WHO) classifies it as a neglected tropical disease, and has recently estimated that 6–7 million people worldwide are infected, and about 7,000 people annually die (35). The cardiomyopathy represents the most frequent and serious complication of Chagas disease, affecting about 30–40% of infected individuals. In consequence, Chagas myocarditis is the most common form of infectious cardiomyopathy worldwide.\nThe clinical course of the disease is divided into acute and chronic phases. During the acute phase, which lasts 2–4 months, the infective trypomastigote form is in the bloodstream and invades target cells, where it replicates as amastigote form. This stage is followed by a life-long chronic phase, in which parasites are cleared from the circulation but persist for years within the myocardium among other target tissues. Nowadays, it is widely accepted that the persistence of parasites in target tissues coupled with an unbalanced immune response is a necessary and sufficient condition for the development of the cardiomyopathy (36–39).\nIn response to the infection, macrophages are one of the main infiltrating leukocytes arriving early to the myocardium (40) and they remain as an important immune cell population in heart explants from patients with severe advanced chronic Chagas disease (41). Interestingly, selective depletion of macrophages causes a significant increment in the number of amastigote nests within cardiomyocytes, suggesting a crucial role for macrophages in the resistance to this infection (42). Even though several anti-parasitic roles of these cells in Chagas disease has been further documented, the functional characterization of resident and infiltrating macrophages in infected myocardium has not been widely studied until very recently. In this sense, we have described the kinetics of macrophage populations during the acute and chronic phase of T. cruzi infection in BALB/c and C57BL/6 cardiac tissue (43, 44). In both mouse strains, macrophages with M1 phenotype (CD45+ F4/80+ CD11b+ CD86+ CD206−) predominate only at short times postinfection [4 days postinfection (dpi)], but then macrophages are rapidly polarized toward M2 phenotype (CD45+ F4/80+ CD11b+ CD86− CD206+), which remains sustained during the acute and chronic phase (90 dpi). The sudden shift in cardiac M1/M2 ratio correlates with the changes in local cytokine milieu. These works evidence that alternatively activated macrophages are the main cardiac cell subset throughout the infection. Alternative macrophages provide protection against overwhelming cardiac inflammation, but they also interfere with the activation of M1 macrophages and its microbicidal function, promoting parasite persistence. The sustained M2 profile is promoted, at least in part, by the action of IL-6 (44).\nIn order to stablish the possible mechanisms by which cardiac M1 macrophages shift toward M2 profile quickly after infection, we focused on purinergic signaling. The ecto-5′-nucleotidase (CD73) enzyme is part of the purinergic system and together with ectonucleoside triphosphate diphosphohydrolase-1 (CD39) metabolize, in a step-wise manner, the extracellular ATP into adenosine (ADO). ADO has a regulating role on macrophage functions associated with M1 profile, such as suppression of chemokines and pro-inflammatory cytokines production, impairment of inducible nitric oxide synthase (iNOS) activity and induction of anti-inflammatory IL-10 production (45). CD73 is the rate-limiting enzyme in the ADO generation and it is expressed by immune and parenchymal cells (46). We showed that pharmacological inhibition of CD73 enzymatic activity with ADO 5′α,β-methylene-diphosphate (APCP) during the early acute phase enhances the number of M1 cardiac macrophages over the M2 subset and increases cardiac levels of NO, IL-6, TNF, and IL-1β in infected BALB/c mice (Figure 3A). These APCP-induced changes result in a concomitant reduction of cardiac parasite load during the acute phase and, as a direct consequence, improve the outcome of chronic cardiomyopathy (43). The study demonstrates that the polarization of cardiac macrophages is strongly influenced by the products of extracellular ATP metabolism and that the manipulation of this pathway could provide new approaches to reduce Chagas heart pathology.\nFigure 3 Role of macrophages in the immune response against Trypanosoma cruzi infection. Macrophages are the main infiltrating cells arriving to the myocardium early after T. cruzi infection. Different mediators can regulate the magnitude and quality of the cardiac immune response by modulating macrophages activation. (A) ATP is released by infected/injured cells and hydrolyzed by two ectoenzymes, CD39 and CD73, to the immunoregulatory metabolite ADO. Pharmacological inhibition of CD73 activity with APCP enhances M1 over M2 macrophage phenotype and increases the local production of TNF, IL-1β, IL-6, and NO and diminished IL-10 levels. (B) IL-6 is a pleiotropic cytokine that contributes to the establishment of cardiac M2 macrophage profile during T. cruzi infection by inducing an anti-inflammatory microenvironment and augmented CD39 expression. Deficiency of IL-6 (IL6KO mice) dysregulates inflammasome activation with a consequent increases in IL1-β-induced NO production. The excessive oxidative stress and exacerbated pro-inflammatory immune response cause the lethal effect observed in infected IL6KO mice. In response to different cardiac injuries, soluble mediators are key players since they drive the immune response and the reestablishment of homeostasis. In this sense, IL-6 cytokine is suddenly and continuously produced by cardiomyocytes and neighboring cells after different pathological stimuli, suggesting that this cytokine is clue for the heart’s intrinsic stress response system. We and others have reported that IL-6-deficient (IL6KO) mice succumb to T. cruzi infection very early during the acute phase (44, 47, 48). By analyzing immune mechanism that could explain the lethal effect observed in the absence of this cytokine, we discovered that IL-6 negatively regulates inflammasome activation and, consequently, IL-1β-induced NO production, and that excessive oxidative stress accounts for the increased mortality of infected IL6KO mice (44). We also found that IL-6 promotes the establishment of M2 cardiac macrophage profile during infection and induces in vivo and in vitro expression of the enzyme CD39 on macrophages, suggesting that IL-6 could promote a shift from an ATP driven pro-inflammatory environment to an anti-inflammatory milieu induced by ADO (44) (Figure 3B). Considering that IL-6 is a therapeutic target in individuals with different inflammatory diseases (49), our results provide the basis for understanding why blocking IL-6 in certain clinical situations does not represent an effective treatment; instead triggering pro-inflammatory adverse events.\nIn agreement with the results obtained with the mouse experimental model, the culture of in vitro-infected peripheral blood mononuclear cells obtained from control human donors with IL-6 blunted T. cruzi-induced nitration of cytotoxic T-cell subpopulation and increased their survival. The nitration of surface proteins on T cells is a consequence of NO and superoxide anion reaction which generates peroxynitrite. Furthermore, the blockade of IL-6 in these cultures with an IL-6 neutralizing antibody increased the frequency of T. cruzi-induced nitration of CD8+ T cells as a consequence of elevated NO production. In line with these results, leukocytes from chronic Chagas patients show increased NO production concomitant with significant tyrosine nitration mainly in CD8+ T cells compared with seronegative patients. Superficial tyrosine nitration on cytotoxic cells is concomitant with impaired effector functions and lower capacity for activation but also it is associated with a significant fall in the number of circulating CD8+ T cells (50). Altogether, the results suggest that CD8+ T cell functionality decreases in the setting of human Chagas disease, but this under-responsiveness could be reverted by the pleiotropic actions of IL-6, which functions as a survival factor for this population and improves its effector functions. Strikingly, the parasite has evolved strategies to counteract IL-6-dependent signaling through the specific cleavage of its receptor, the gp130 chain (51).\nIn contrast to the antioxidant properties of IL-6, IFN-γ enhances iNOS expression in infected macrophages resulting in the killing of intracellular parasites. Strikingly, IL-17A-stimulated macrophages control replication in a comparable level to IFN-γ treatment (52). The IL-17 stimulation alters the uptake pathway of trypomastigotes promoting phagocytosis over active invasion of macrophages. Phagocytosis of trypomastigotes enhances the number of internalized parasite and prolongs its residency in the endosomal/lisosomal compartment. A recent report demonstrates that IL-17-mediated direct protection of infected macrophages involves the NADPH oxidase activation and ROS production (53). In concordance, mice deficient in IL-23 (IL23p19KO), a potent inducer of IL-17A production, show enhanced parasitemia and a greater susceptibility to acute T. cruzi infection compared with infected WT mice. Moreover, IL-17AKO mice seemed to be even more susceptible to T. cruzi infection than IL23p19KO mice. The fact that the treatment of macrophages with IL-17A plus IFN-γ is more efficient to eliminate the parasite compared with single-cytokine stimulation, might explain the higher mortality ratio in IL23p19KO and IL-17AKO mice even though the Th1 immune response, measured by IFN-γ production and the iNOS expression, is not impaired during the infection in both KO mice (52). Finally, correlation analysis in Chagas disease patients demonstrates that high IL-17 serum levels are associated with better cardiac function (54–56).\nAfter reaching the cytosol in macrophages, T. cruzi is recognized by innate receptor NLRP3, a member of nod-like receptor family (57). Infected mice deficient in IL-1β receptor, ASC, or caspase-1 are defective in NO production and exhibit an enhanced cardiac parasitism and mortality (58). Furthermore, the weak IL-1β production in NLRP3KO macrophages is compensated by an enhanced ROS production that mediates an effective parasite killing, indicating that NLRP3 modulates NADPH oxidase/ROS levels (59). Moreover, these low levels of IL-1β and the partial survival of infected NLRP3KO mice suggest that another Nod-like receptor might be activating inflammasome during infection.\nFollowing cardiac injury, immune cell infiltration and fibroblasts migration trigger tissue remodeling, that is largely dependent on matrix metalloproteinases (MMPs) activity. Immunohistochemistry analysis revealed that vascular wall and infiltrating leukocytes are the cellular source of MMP-2 and MMP-9, which are increased in cardiac tissue during the acute phase of T. cruzi infection. As expected, treatment with MMP inhibitors reduces myocarditis in infected mice (60). In Chagas disease patients, T cells, neutrophils and monocytes are source of MMP-2 and MMP-9. In vitro stimulation with T. cruzi-derived antigens induces higher MMP-2 and MMP-9 expression in monocyte from patients with cardiac clinical forms of Chagas disease compared with those from non-infected patients (61). Recent reports showed a significant positive correlation between the levels of MMP-9, IL-1β and TNF, but a negative correlation between MMP-2 levels and these inflammatory cytokines and a positive correlation with IL-10 expression in serum from chronic Chagas disease patients (61, 62). These results suggest that MMP-9 may be related to inflammation and cardiomyopathy development; meanwhile, MMP-2 would be associated with regulation of chronic inflammatory process. Other study indicated that MMP-2 and MMP-9 levels peaks in plasma from patients clinically asymptomatic with an abnormal ECG (an early indicator of cardiac disease) and progressively augmented in patients with advancing Chagas cardiomyopathy. Although MMPs are strongly associated with several inflammatory diseases, the data suggested that MMP-2 and MMP-9 plasmatic levels could be used as early biomarkers of cardiac disease (63).\nIt is widely accepted that T. cruzi modulate apoptosis of different target cells in order to evade the immune response. In this sense, Freire-de-Lima and coworkers demonstrated that phagocytic removal of apoptotic T lymphocytes by infected-macrophages exacerbate parasite replication by driving its differentiation toward an M2-like phenotype concomitant with TGF-β, IL-10, and PGE2 production (64, 65). TGF-β promotes in macrophages the L-arginine metabolism by arginase to synthesize polyamines which functions as a growth factor for parasites (66). Another work found that blocking apoptosis of CD8+ T cells in cocultures, infected macrophages increase NO levels and M1 features leading to restrict intracellular parasite growth (67). In addition, while coculture of apoptotic neutrophils induce an M2-like phenotype in infected macrophages, live neutrophils via elastase induce M1 macrophages with NO and TNF production that allow to control T. cruzi replication (68). Further studies in human cells are needed to validate these findings.\nSimilar to others cardiac pathologies, cardiomyocyte apoptosis seems to be determinant of Chagas disease progression. In this sense, it was found that infection induces apoptosis of cardiomyocytes (69, 70). In contrast, several reports demonstrated that T. cruzi induces anti-apoptotic effect on cardiac cell (51, 71–75). Indeed, it is plausible to think that cardiac cell exposure to pro-inflammatory milieu may precondition the heart tissue to protect cardiomyocytes from a massive apoptosis (76). This hypothesis is clinically supported by experiments performed by Metzger et al. The authors described that apoptotic cells are increased in the myocardium from Chagas disease patients with severe heart failure. However, the apoptotic cells are not cardiomyocytes, and the majority of TUNEL+ cells are also CD68+ (human macrophage marker) (77), similar results also being observed by other researchers (78). Related to this, an intense Bcl-2 expression is induced in cardiomyocytes during the acute phase of the experimental infection, likely establishing a higher threshold to apoptosis in this cell type (73).\nAlthough enthusiastic researchers have suggested the therapeutic use of apoptosis inhibitors as an attractive choice for adjuvant therapy during the chronic phase (79), the effects of apoptosis modulation on the outcome of chronic cardiomyopathy requires further studies.\n\nViral Myocarditis\nThe cardiotropic viruses that cause myocarditis in humans include enteroviruses, adenoviruses, influenza viruses, cytomegaloviruses, parvoviruses, and herpes viruses. Although most of these viruses commonly cause only mild upper respiratory or gastrointestinal complications in most individuals, a few infected people develop cardiac clinical symptoms (80). The enteroviral coxsackievirus B group type 3 (CVB3), adenoviruses parvovirus B19, and human herpes virus 6 are frequently observed in myocarditis biopsies. The most common viral myocarditis is caused by CVB3 infection. It affects about 5–20% of world population, and yet lacks efficient treatments. Although acute viral myocarditis is self-limiting in most individuals, in others develop chronic myocarditis, progressive cardiac fibrosis, dilated cardiomyopathy, heart failure, and even death (81–83). Strong clinical and experimental evidence has demonstrated that two main mechanisms are involved in pathogenesis of CVB3-induced myocarditis, first a direct viral injury to cardiac cells during the acute stage of infection and second, the excessive pro-inflammatory immune response against CVB3 which can subsequently evolve to a chronic autoimmune cardiac pathology in some susceptible patients (80).\nMonocytes/macrophages represent one of the major infiltrating inflammatory cells in CVB3-induced myocarditis. It was reported that cardiac CCL2 levels are significantly enhanced at 1 dpi and peak at 4 dpi and hence closely involved in CVB3-induced myocarditis initiation, by attracting monocytes. CCL2 incidence in viral myocarditis was even more evident after blocking CCL2 activity in vivo, since those infected mice exhibit reduced myocardial cell infiltration, decreased serum CK-MB levels and increased host survival (82).\nOther study showed that in vivo CVB3 infection also triggers the production of galectin-3 (a β-galactoside binding lectin) in cardiac macrophages during acute and chronic phases. Abrogation of galectin-3 expression or its pharmacological inhibition does not affect viral titers but reduce acute myocarditis and chronic fibrosis, suggesting a critical role of galectin 3-producing macrophages in the induction of fibrosis subsequent to CVB3 infection.\nStudies in experimental murine infection with CVB3 have been widely employed as a model of human enteroviral infection and they have significantly contributed to the understanding of the immunological mechanisms underlying acute and chronic viral inflammatory heart disease. Strikingly, male, but not female, mice infected with CVB3 present a severe myocarditis with a pathological process resembling human disease. Although similar viral infection titers have been detected in patients of both genders, the estimated incidence of myocarditis in men is twofold increase or more than in women (84, 85).\nExperimental approaches assessing the differential susceptibility against CVB3 infection between male and female mice have greatly contributed to the knowledge of the etiopathological mechanisms of this viral myocarditis. During the early acute infection, cardiac tissue from male and female mice presents high levels of IFN-γ and IL-4, respectively. Consistently, male cardiac macrophages express M1 markers; meanwhile, female cardiac macrophages polarize toward M2 phenotype (86, 87). Employing adoptive transfer experiments of in vitro IFN-γ-induced M1 macrophages, the authors demonstrated this pro-inflammatory subset is responsible for myocardial inflammation and damage after CVB3 infection (86).\nIt is important to highlight that IL-10 has a protective role during virus-induced cardiac fibrotic process by inhibiting fibroblast collagen synthesis (85, 88). As counterpoint, male infected mice exhibit a reduced frequency of cardiac monocytic-myeloid-derived suppressor cell (MDSC) subset and regulatory T cells, which negatively correlates with the severity of cardiac fibrosis induced by CVB3 infection. Although it was reported that myocardial infiltrating immune cells have a different cell composition in both mouse genders, how this difference affects macrophage functions and the development of CVB3-induced myocarditis needs further studies. In this sense, infiltrating NK cells could have a role in the physiopathology of the disease. Kinetic studies of myocardial infiltrate revealed that NK cells arrive together with macrophages and the synergistic action of sex hormones and CVB3 infection contribute to NK cells differential cytokine production (87).\nOn the other hand, it was reported that CVB3 can efficiently induce endoplasmic reticulum (ER) stress in infected cardiomyocytes and, in turn, stressed myocardial cells transfer the ER stress to macrophages via some unknown soluble molecules and facilitate the pro-inflammatory phenotype. In concordance, an in vivo pharmacological treatment with ER stress inhibitor induces a substantial reduction of pro-inflammatory cytokines in macrophages, diminishes CK-MB serum levels, relieves myocardial inflammation and improves cardiac functions. Moreover, adoptive transfer experiments of ER stress-inhibited macrophages into infected mice also alleviate viral-myocarditis together with an increase in mice survival, confirming the pathological role of ER stressed macrophages in CVB3-induced myocarditis (89). Other work showed that CVB3 infection in cardiac cells induces ROS production and alters potassium efflux, triggering NLRP3 inflammasome activation in infected cardiomyocytes (90). Therefore, all these studies indicate that the cardiac environment that shape macrophages polarization has a key role in the outcome of CVB3-induced heart disease.\n\nBacterial Infections\nMononuclear phagocytic cells are essential in cardiac immunity to several myocarditis-related to bacterial infections. Lyme disease is a long-term infection caused by Borrelia burgdorferi spirochetes. Its most severe complications are myocarditis and inflammatory arthritis of the lower bearing joints. An important difference between arthritis and myocarditis is the distribution of phagocytes within the lesions; while polymorphonuclear leukocytes are more prevalent in the joint, macrophages are the predominant infiltrating cells in infected hearts (91). The severity of Lyme myocarditis is controlled by CD11c integrin, because CD11cKO mice caused increased cardiac MCP-1 production and consequently, increased macrophage infiltration. The loss of this integrin generates an impaired macrophage immune response leading to an aggravated Lyme disease (92). Similarly, in absence of CCR2, the receptor that induces monocyte recruitment to the site of infection, resistant CCR2KO mice had augmented bacterial heart burden compared with WT counterpart (C57BL/6) suggesting a reduced clearance of the bacteria. In contrast, deficiency of CCR2 in sensitive mice strain CCR2KO (C3H) produced severe inflammation with increased presence of polymorphonuclear cells but decreased B. burgdorferi burden in comparison with WT (C3H/HeJ) mice. The less efficient spirochete clearance from hearts of WT C3H mice compared with CCR2KO C3H mice suggests an impaired recruitment or function of macrophages in C3H mice, which may contribute to the susceptibility of this animal strain to B. burgdorferi infection (93). Nevertheless, there were no differences in cardiac macrophage polarization of C3H sensitive strain, with similar number of M1 and M2 subtype macrophages at the peak of inflammation (94).\nRegarding cytokine production, there are several reports showing that IFN-γ is a key cytokine that modulates the immune response to B. burgdorferi, particularly the macrophage activation and functions. Sabino and coworkers proposed that IFN-γ influence the composition of cardiac leukocyte infiltrates. They found that B. burgdorferi and IFN-γ synergistically enhance the secretion of mononuclear cell chemoattractants such as CXCL9 and CXCL10, decrease those for neutrophils (CXCL1 and CXCL2), and, in consequence, this modifies the nature of the cellular infiltration (95). Additionally, the production of IFN-γ by iNKT cells enhance the bacterial recognition and activation of macrophages as evidenced by augmented TNF and IL-6 production, leading to an increased phagocytic activity (91). Importantly, IFN-γ is produced in lesions of Lyme patient myocarditis and its levels positively correlate with the severity of the pathology.\nConsidering innate receptors, it was reported that mice deficient in the intracellular adapter molecule myeloid differentiation antigen 88 (MyD88KO), which is required for several TLR-induced inflammatory responses had 250-fold higher pathogen burden than WT mice. In agreement, in vitro experiment confirmed that MyD88KO macrophages phagocytize spirochetes but degrade them more slowly than WT macrophages (96). In accordance, Hawley et al. demonstrated that CR3KO-mediated spirochete internalization requires the participation of CD14 molecule as an accessory receptor and showed that CR3/CD14-mediated phagocytosis generates a pro-inflammatory macrophage phenotype in response to bacterial invasion (97). On the other hand, several reports demonstrate key roles for the intracellular innate receptor Nod2. In B. burgdorferi infection context, Nod2-deficient mice resulted in increased myocarditis compared with control mice. Although Nod2 induces inflammatory milieu in in vitro models of B. burgdorferi infection, BMDM upon a prolonged stimulation of Nod2 no longer respond in the same manner. Indeed, prolonged exposure to the Nod2 ligand results in suppression of pro-inflammatory responses. The authors theorize that the dual role of Nod2 signaling in the inflammatory response may be associated with the chronicity of the infection (98). In the same way, Zlotnikov et al. revealed that a high fat diet-induced obesity (DIO) in a murine model of Lyme disease was associated with systemic suppression of innate immune response. The hearts of DIO-infected mice presented significantly elevated inflammation and increased bacterial burden due to an impaired bacterial uptake and pro-inflammatory cytokine production by macrophages and this effect became more pronounced as infection progressed (99). All these data together substantiate the importance of macrophages in the immune response against this pathogen, but also the dual role that they can play in order to control the infection or perpetuate the inflammation state.\nOther bacterial infection in which macrophages play a key role on disease outcome is poststreptococcal myocarditis. Streptococcus pneumoniae is capable of invading the heart soon after the development of bacteremia. The pneumococcus is the responsible of the community-acquired pneumonia and sometimes it may worsen by producing the invasive pneumococcal disease that injures the heart. Macrophages have been postulated as inducers of heart-reactive T cells due to their capacity to transfer the inflammatory lesions into normal recipient mice when they are pulsed with group A streptococcus extract (SAE) resulting in an increased serum CK levels, an enzyme that is released in the bloodstream after inflammatory cardiac muscle injury. SAE pulsed macrophages may present to T cells an antigenic determinant characteristic to rheumatogenic streptococci that cross-reacts with a normal component of the heart tissue (100). In accordance, group A streptococcal M proteins had the ability to stimulate human PBMC to proliferate and induce cytotoxic T cells against cultured human heart cells (101). The results suggest a critical role for monocytes/macrophages as antigen-presenting cells in the outcome of heart damage after infection.\nMore recent studies have proposed that S. pneumoniae forms discrete pneumococcus-filled micro lesions in the myocardium during invasive pneumococcal disease (102) generating direct tissue damage. The pneumococci within cardiac micro lesions produce pneumolysin, a cholesterol-dependent pore-forming toxin, which kills cardiomyocytes and macrophages due to pneumolysin-induced necroptosis. This precludes the generation of an effective immune response and perpetuates cardiac damage (103). These reports bring to light that macrophages are crucial for innate immune response to bacterial infections and that the alteration of their functions can alter the outcome of the disease.\n\nSterile Inflammation\nAlthough inflammation is the process in which components of the innate immune system respond to an injury or infection, inflammatory response can also be triggered in absence of infection by a process known as sterile inflammation. This type of inflammation is implicated in the development of a variety of clinical conditions such as atherosclerosis, cardiac injury, neurodegenerative and metabolic disorders. Unlike microbial-induced inflammation, sterile inflammation is activated by endogenous danger-associated molecular patterns (DAMPs) released as a consequence of cellular injury and/or inflammation, such as oxidized low-density lipoprotein (oxLDL), oxidized phospholipids (oxPLs), amyloid β or uric-acid crystals (104, 105). This sterile inflammatory response induces recruitment of neutrophils and monocytes leading to production of pro-inflammatory cytokines and chemokines, mainly IL-18 and IL-1β in a caspase-1-dependent manner. As mentioned above, monocytes subsets (classical, intermediate, and non-classical) extensively participate in the response to infectious disease; however, their role in sterile inflammation in cardiac ischemia-reperfusion injury and atherosclerosis is still not well understood. Myocardial ischemia-reperfusion injury is a condition that involved cardiomyocytes death affecting contractibility and loss of heart function as a result of a vascular occlusion and loss of tissue irrigation. While different pathways contributed to limit the damage, the inflammatory response in the ischemic heart can be detrimental (106).\nThe knowledge gained on the origin of resident cardiac macrophages has greatly improved the therapeutic potential of macrophage manipulation in the context of sterile inflammation. Considering that adult mammalian heart contains two macrophage pools which include: Ly6Clow MHC-IIlow and MHC-IIhigh (CCR2−) representing embryonically established macrophages and the second pool and much less abundant derived from blood Ly6Chigh CCR2+ monocytes. Altered homeostasis induced by transient depletion (chemically) of monocytes and macrophages population in heart shown proliferation of CCR2− resident macrophages and recruitment of Ly6Chigh CCR2+ monocytes from blood to contribute to tissue macrophages repopulation (107). Thus, after myocardial injury and knowing that NLRP3 inflammasome activation impair tissue regeneration, blockage of CCR2 abolishes ischemic damage. This concept suggests that blockage of CCR2+ monocytes influx or recruitment during cardiac ischemia-reperfusion will be protective, while a strategy of depletion of resident macrophages (CCR2−) abolished that protection. In the same way, Marchetti et al. applied a pharmacological inhibitory strategy for NLRP3 inflammasome in a mouse model of myocardial injury. They found that in acute myocardial infarction (MI) with reperfusion and in a model of non-ischemic injury induced with doxorubicin, the inhibition of NLRP3 inflammasome cause a significantly reduction of infarct size and preserved systolic function (108).\nThe understanding of circulating monocytes and cardiac macrophage biology under physiology and disease condition may help discover new mechanisms to target specific subset population of macrophage that impact in cardiac cytoprotective pathways.\n\nAtherosclerosis\nAtherosclerosis is the result of lipid accumulation and chronic inflammation in the arterial wall where macrophage plays a central role in the development and progression of plaque formation (Figure 4). Thus, transmigration of monocytes into the subendothelial space, lipid uptake (oxLDL) and foam cell differentiation are key step in atherogenesis. The maintenance of a healthy endothelium regulates the precise balance in vascular homeostasis between vasoconstriction and vasodilation, trombogenesis and fibrinolysis, cellular migration and proliferation (109). Disturbance of normal vascular physiology is characterized by endothelial activation, which may be caused by infection or by cardiovascular risk factor such as hyperlipidemia (pathophysiologic). Thus, pro-inflammatory mediators (IL-1β, TNF, and MCP-1) induce a deleterious effect on NO bioavailability increasing ROS which stimulate the expression of endothelial adhesion molecules (VCAM-1, ICAM-1) to favor the passage of monocytes to the subendothelium and promoting their differentiation into macrophages (110).\nFigure 4 Role of macrophages in the pathogenesis of atherosclerosis. Disturbance of normal vascular physiology is characterized by endothelial activation which stimulates the expression of endothelial adhesion molecules (VCAM-1, ICAM-1) to favor the passage of inflammatory monocytes to the subendothelium. Modified LDL and other DAMPS are recognized by pattern-recognition receptors such as CD36 (scavenger receptor-B) in infiltrating macrophages. Thus, these innate cells are transformed into lipid-laden foam cells in the vasculature intima. The activation of NF-κB in response to ox-LDL induce the secretion of inflammatory cytokines (IL-1β, TNF), NO, MCP-1, and macrophage-derived matrix metalloproteinases (MMPs) that degrade the extracellular matrix generating a maladaptative inflammatory response and contribute to plaque formation. In atherosclerosis, circulating low-density lipoprotein (LDL) molecules undergoes modifications mainly oxidation, acetylation and glycation that alter the normal metabolism of lipoprotein to promote cytotoxic damage on endothelial cells and macrophages. There is a broad spectrum of mediators that induce LDL oxidation from enzymatic (lipoxygenase and cyclooxygenase) to non-enzymatic reactions (free radicals and oxidants). Some of these reactions have differential selectivity for LDL components as occur with ROS that oxidize predominantly the lipid portion of LDL or the neutrophil myeloperoxidase that oxidize the protein portion (Apo B) of LDL by action of hypochlorous acid byproducts (111, 112).\nIn this inflammatory milieu, other biomolecules, in addition to LDL, such as lipids and proteins are target of oxidation and nitration reactions generating new species that may affect the fate of the plaque development and limit or exacerbate the inflammatory state. Thus, nitro-fatty acids (NO2-FAs) are the product of the reaction of unsaturated fatty acids and nitrogen-derived species (NO and nitrites) (113). Administration of NO2-FA in a mice model of atherosclerosis (ApoEKO) exhibited anti-inflammatory and protective actions, decelerating the development of the atheroma plaque, affecting oxLDL uptake and foam cell formation in macrophages (114).\nModified LDLs are recognized and internalized in macrophages by pattern-recognition receptor (PRR) which includes scavenger receptor (SR) and toll-like receptor (TLR). SRs bind diverse ligands and contribute to the clearance of foreign or modified particles. Regarding to macrophage cholesterol metabolism, CD36 (SR-B) and SR-A1 mediate internalization of oxLDL and transform these cells into cholesterol-laden foam cells in the vasculature intima. Exploration in experimental models evidenced that CD36-deficient macrophages exhibited a reduced uptake of oxLDL; further study in ApoE/CD36 double mutant mice described the reduction of the size of atherosclerotic plaque (115, 116). These results emphasized the role of CD36 as a pro-atherogenic receptor in the vasculature and cardiovascular disease. However, discrepancy on CD36 implication as pro- or anti-atherogenic has been raised by other studies in which described advanced atherogenesis in LDLR/CD36 double mutant mice or less macrophage accumulation but increased aortic lesions in ApoE/CD36 double KO (117). The inconsistency of this result may be in part explained by the different experimental model and animal background employed. Besides the discrepancy on CD36 function in atheroma plaque formation the binding of oxLDL stimulates pro-inflammatory signaling pathways (NF-κB) in macrophage contributing to maintain the chronic inflammatory state generated during the onset of atherosclerosis disease.\nIn atherosclerosis, the recognition of the subsets of recruited monocytes that differentiate into macrophages in the atheroma plaque may be relevant to design new strategies to treat pathological inflammatory process. During the development of atheroma plaque, the recruitment of monocytes are drawn from the Ly6Chigh circulating subset (precursor of M1 macrophages) but after treatment and control of hyperlipidemia a rapid reduction of plaque inflammation and regression was exhibited, characterized by decrease number of macrophages and the relative increase in markers of M2 macrophages state. Rahman et al. described in a model of aortic arch transplantation that plaque regression is characterized by recruitment of Ly6Chigh circulating monocytes and the posterior polarization to M2 phenotype (118). This result is contrary to the prevailing paradigm about M2 macrophages recruitment in plaque regression and the authors promote the strategy of M2 macrophage accumulation in atherosclerotic lesions to stimulate plaque regression. Consistent results were obtained in mice treated with IL-13 and IL-4 (promote M2 polarization) which describe protective effects in plaque progression in mice (119).\nSumming up, the data obtained clearly illustrate the clue role that mononuclear phagocytic cells play in the development of the atherosclerotic pathology, further molecular mechanisms involved in plaque formation are described in the next chapter.\n","divisions":[{"label":"Title","span":{"begin":0,"end":39}},{"label":"Section","span":{"begin":618,"end":27977}},{"label":"Title","span":{"begin":618,"end":628}},{"label":"Section","span":{"begin":630,"end":15598}},{"label":"Title","span":{"begin":630,"end":651}},{"label":"Figure 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