Abstract
Atherosclerotic cardiovascular disease (ASCVD) is a chronic inflammatory disease of the arterial walls and is characterized by the accumulation of lipoproteins that are insufficiently cleared by phagocytes. Following the initiation of atherosclerosis, the pathological progression is accelerated by engagement of the adaptive immune system. Atherosclerosis triggers the breakdown of tolerance to self-components. This loss of tolerance is reflected in defective expression of immune checkpoint molecules, dysfunctional antigen presentation, and aberrations in T cell populations — most notably in regulatory T (Treg) cells — and in the production of autoantibodies. The breakdown of tolerance to self-proteins that is observed in ASCVD may be linked to the conversion of Treg cells to ‘exTreg’ cells because many Treg cells in ASCVD express T cell receptors that are specific for self-epitopes. Alternatively, or in addition, breakdown of tolerance may trigger the activation of naive T cells, resulting in the clonal expansion of T cell populations with pro-inflammatory and cytotoxic effector phenotypes. In this Perspective, we review the evidence that atherosclerosis is associated with a breakdown of tolerance to self-antigens, discuss possible immunological mechanisms and identify knowledge gaps to map out future research. Rational approaches aimed at re-establishing immune tolerance may become game changers in treating ASCVD and in preventing its downstream sequelae, which include heart attacks and strokes.
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A.K. and P.R. researched data for the article. All authors contributed substantially to discussion of the content. K.L. and A.K. wrote most of the article and P.R. wrote much of the box text. All authors reviewed and/or edited the manuscript before submission.
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K.L. is a co-founder of Atherovax, a biotech company developing a tolerogenic vaccine for atherosclerosis. The other authors declare no competing interests.
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Khan, A., Roy, P. & Ley, K. Breaking tolerance: the autoimmune aspect of atherosclerosis. Nat Rev Immunol (2024). https://doi.org/10.1038/s41577-024-01010-y
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DOI: https://doi.org/10.1038/s41577-024-01010-y
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