Potent lipoprotein(a) lowering following apolipoprotein(a) antisense treatment reduces the pro-inflammatory activation of circulating monocytes in patients with elevated lipoprotein(a)

Lotte C A Stiekema, Koen H M Prange, Renate M Hoogeveen, Simone L Verweij, Jeffrey Kroon, Johan G Schnitzler, Kim E Dzobo, Arjen J Cupido, Sotirios Tsimikas, Erik S G Stroes, Menno P J de Winther, Mahnoush Bahjat, Lotte C A Stiekema, Koen H M Prange, Renate M Hoogeveen, Simone L Verweij, Jeffrey Kroon, Johan G Schnitzler, Kim E Dzobo, Arjen J Cupido, Sotirios Tsimikas, Erik S G Stroes, Menno P J de Winther, Mahnoush Bahjat

Abstract

Aims: Elevated lipoprotein(a) [Lp(a)] is strongly associated with an increased cardiovascular disease (CVD) risk. We previously reported that pro-inflammatory activation of circulating monocytes is a potential mechanism by which Lp(a) mediates CVD. Since potent Lp(a)-lowering therapies are emerging, it is of interest whether patients with elevated Lp(a) experience beneficial anti-inflammatory effects following large reductions in Lp(a).

Methods and results: Using transcriptome analysis, we show that circulating monocytes of healthy individuals with elevated Lp(a), as well as CVD patients with increased Lp(a) levels, both have a pro-inflammatory gene expression profile. The effect of Lp(a)-lowering on gene expression and function of monocytes was addressed in two local sub-studies, including 14 CVD patients with elevated Lp(a) who received apolipoprotein(a) [apo(a)] antisense (AKCEA-APO(a)-LRx) (NCT03070782), as well as 18 patients with elevated Lp(a) who received proprotein convertase subtilisin/kexin type 9 antibody (PCSK9ab) treatment (NCT02729025). AKCEA-APO(a)-LRx lowered Lp(a) by 47% and reduced the pro-inflammatory gene expression in monocytes of CVD patients with elevated Lp(a), which coincided with a functional reduction in transendothelial migration capacity of monocytes ex vivo (-17%, P < 0.001). In contrast, PCSK9ab treatment lowered Lp(a) by 16% and did not alter transcriptome nor functional properties of monocytes, despite an additional reduction of 65% in low-density lipoprotein cholesterol (LDL-C).

Conclusion: Potent Lp(a)-lowering following AKCEA-APO(a)-LRx, but not modest Lp(a)-lowering combined with LDL-C reduction following PCSK9ab treatment, reduced the pro-inflammatory state of circulating monocytes in patients with elevated Lp(a). These ex vivo data support a beneficial effect of large Lp(a) reductions in patients with elevated Lp(a).

Keywords: Apo(a)-antisense; Inflammation; Lipoprotein(a); Monocytes; PCSK9ab; Transcriptomics.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Inflammatory gene expression in circulating monocytes of healthy individuals with elevated Lp(a) and cardiovascular disease patients with elevated Lp(a). (A) Volcano plot showing the difference in gene expression between healthy individuals with normal Lp(a) vs. healthy individuals with elevated Lp(a). (B) Canonical and Hallmark pathway analysis of top 1000 up-regulated genes. Dark red bars indicate inflammatory pathways. Blue dotted line at P = 0.05. (C) Volcano plot showing the difference in gene expression between healthy individuals with normal Lp(a) vs. cardiovascular disease patients with elevated Lp(a). (D) Canonical and Hallmark pathway analysis of top 1000 up-regulated genes. Dark red bars indicate inflammatory pathways. Blue dotted line at P = 0.05.
Figure 2
Figure 2
Potent, but not modest, Lp(a)-lowering reduces inflammatory gene expression in circulating monocytes. (A) Volcano plot showing the difference in gene expression between cardiovascular disease patients before AKCEA-APO(a)-LRx treatment vs. cardiovascular disease patients after AKCEA-APO(a)-LRx treatment. (B) Canonical and Hallmark pathway analysis of top 1000 down-regulated genes. Dark blue bars indicate inflammatory pathways. Red dotted line at P = 0.05. (C) Gene set enrichment analysis enrichment plots of interferon alpha/beta (up), interferon gamma (middle), and TLR pathway (bottom). Left: cardiovascular disease patients before AKCEA-APO(a)-LRx (red) vs. healthy individuals with normal Lp(a) (green). Right: cardiovascular disease patients before AKCEA-APO(a)-LRx (red) vs. after AKCEA-APO(a)-LRx (orange). (D) Boxplot and heatmap showing average expression of the top 15 most expressed genes in cardiovascular disease patients before AKCEA-APO(a)-LRx vs. healthy individuals with normal Lp(a) for the interferon alpha/beta signalling, gamma signalling, and TLR pathways. Column colours: green, healthy individuals with normal Lp(a), red, cardiovascular disease patients before AKCEA-APO(a)-LRx treatment, orange: cardiovascular disease patients after AKCEA-APO(a)-LRx treatment. (E) Volcano plot showing the difference in gene expression between patients before PCSK9ab treatment vs. patients after PCSK9ab treatment.
Figure 3
Figure 3
Potent, but not modest, Lp(a)-lowering reduces inflammatory receptor expression, with a concomitant functional improvement. (A) Flow cytometry results of inflammatory markers on circulating monocytes before and after AKCEA-APO(a)-LRx treatment, expressed as delta Median Fluorescence Intensity (MFI). Data are represented as mean ± standard deviation. (B) Percentage trans-endothelial migrated CD14+ monocytes before and after AKCEA-APO(a)-LRx treatment. Data are represented as mean ± standard deviation. (C) Correlation between absolute reduction in Lp(a) and percent reduction in trans-endothelial migration. (D) Flow cytometry results of inflammatory markers on circulating monocytes before and after PCSK9ab treatment, expressed as delta MFI. Data are represented as mean ± standard deviation. (E) Percentage trans-endothelial migrated CD14+ monocytes before and after PCSK9ab treatment. Data are represented as mean ± standard deviation and were analysed by Wilcoxon signed rank test (P-values < 0.05 were considered statistically significant).
Take home figure
Take home figure
Unbiased whole-genome RNA sequencing and functional analyses of circulating monocytes of individuals with elevated Lp(a) show a strong pro-inflammatory and pro-migratory profile. Only potent Lp(a) reduction demonstrated a profound reduction in the reported pro-inflammatory and pro-migratory profile, as opposed to modest Lp(a) reduction, indicating the promising potential of potent Lp(a)-lowering strategies in reducing cardiovascular risk.
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/7308540/bin/ehaa171f4.jpg

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Source: PubMed

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