The n e w e ng l a n d j o u r na l of m e dic i n e
clinical implications of basic research
The Monocyte in Atherosclerosis — Should I Stay
or Should I Go Now?
Robert E. Gerszten, M.D., and Andrew M. Tager, M.D.
Generations of evolutionary pressure have honed
a human immune system that is well poised to
combat infectious challenges. However, the very
same system can turn against us when it is acti-
vated by certain noxious stimuli, as is the case
with cholesterol-laden meals triggering athero-
sclerosis.
Monocytes are recruited to arterial walls that
are inflamed by the subendothelial accumula-
tion of apolipoprotein B–containing lipoproteins,
where they transform into macrophages. These
macrophages then take up cholesterol to give
rise to foam cells, which drive the progression
of atherosclerotic lesions. As macrophages con-
tinue to ingest and process lipids, they may ulti-
mately contribute to the development of vulner-
able plaques through the formation of a necrotic
core and thinning of the fibrous cap. The rupture
of vulnerable plaques appears to be responsible
for most acute atherothrombotic myocardial in-
farctions, and macrophages are prominently
found at sites of plaque rupture in the throm-
bosed coronary arteries of patients with acute
myocardial infarction. A recent study by van Gils
and colleagues underscores both the atherogenic
role of macrophage accumulation in the vessel
wall and the therapeutic potential of preventing
the accumulation of these cells.1
The first investigations into the molecular
mechanisms of atherosclerosis focused on the
signals responsible for monocyte recruitment to
the walls of inflamed arteries. This migration
occurs in response to chemokines — molecular
directional cues that are elaborated by endothe-
lial cells overlying retained lipids in early athero-
sclerosis. The chemokine CCL2 contributes to
this process, interacting with its receptor, CCR2,
which is expressed on circulating monocytes
(Fig. 1). Mice that are deficient in either CCL2
or its receptor are resistant to the development of
atherosclerosis,2,3 and this interaction has been
1734 n engl j med 366;18
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the object of considerable attention as a poten-
tial target for new pharmacologic therapies.
Although early work emphasized the signals
guiding leukocytes to tissues, it has become in-
creasingly apparent that leukocyte exit from tis-
sues is also a highly regulated process — and
one that might be amenable to therapeutic ma-
nipulation. For example, the egress of lympho-
cytes from lymphoid tissues is induced by a lipid
chemoattractant called sphingosine 1-phosphate.
Inhibition of this pathway by the drug fingoli-
mod results in peripheral lymphopenia because
of lymphocyte sequestration in lymph nodes.
This mechanism is thought to contribute to the
efficacy of fingolimod in patients with multiple
sclerosis, for which it has recently been approved.
Recent investigations have suggested that macro-
phage exit from inflamed vessel walls is also
directed by chemoattractants distinct from those
that promote monocyte entry and that failure of
this process resulting from hypercholesterole-
mia makes an important contribution to chronic
inflammation and plaque progression in athero-
sclerosis. Transplantation of atherosclerotic aor-
tic arches from animals with hypercholesterole-
mia to animals with normal cholesterol levels
results in plaque regression in the transferred
vascular tissues, and cell-tracking studies have
shown macrophage egress from lesions in the
transferred vessels after their exposure to normal
cholesterol levels. Subsequent studies have shown
that macrophage exit from atherosclerotic lesions
is directed by two other chemokines, CCL19 and
CCL21, interacting with their receptor, CCR7,
on macrophages.4 In animal models, drugs that
activate the nuclear receptor LXR promote
monocyte egress from inflamed vessels at least
in part by up-regulating macrophage expression
of CCR7.5
The study by van Gils and colleagues adds to
our understanding of the ins and outs of mono-
nejm.org may 3, 2012
 clinical implications of basic research

Circulating Inflamed
monocytes CCR2 coronary
artery

CCL2

Adhesion Lumen

Endothelial
cells
Monocyte
Inflammatory Intima
chemokines Migration
Nascent
atherosclerotic Chemokines
plaque CCR7 CCL19 and
Smooth- CCL21
muscle cells
Differentiation

Macrophage Enhances
macrophage
Unc5b
egress
Media
Netrin-1

Genetic deletion
of netrin-1

Adventitia

Figure 1. Macrophage Movements and the Atherosclerotic Plaque.

Monocyte adhesion and early accumulation in the nascent atherosclerotic plaque are triggered by inflammatory che-
mokines (such as CCL2) activating CCR2 on circulating monocytes. Monocytes differentiate into macrophages, which
become engorged with cholesterol and transform into C O Lfoam cells. Macrophages may be released from the athero-
OR FIGURE

sclerotic plaque, probably into the surrounding adventitia.

Draft 2 Such egress is stimulated by the action of the chemokines
4/11/2012
Author 1 have identified netrin-1 (which activates the receptor Unc5b)
Gerszten–cibr1114526
CCL19 and CCL21 on CCR7. Van Gils and colleagues
Fig # 1
as an inhibitor of macrophage egress. They Title
found that genetic
The Monocyte in deletion of this stop sign enhances macrophage
egress from atherosclerotic plaques, thus limiting disease progression.
Atherosclerosis - Should I Stay
or Should I Go Now?
DE Phimister
ME Prince
Artist Williams
cytes in atherosclerotic lesions by identifying a surface
AUTHOR PLEASE NOTE: of target cells. Investigators recently made
Figure has been redrawn and type has been reset

blockade of macrophage exit from inflamed ves- the surprising observation that netrin-1 is robust-
Please check carefully

sel walls in atherosclerosis. This group took ly expressed by activated macrophages. Building
clues from the developing nervous system, in on this observation, van Gils and colleagues
which certain neurons can be attracted and found that netrin-1 inhibits monocyte migration
then subsequently repulsed during the complex that would otherwise be directed by atheroscle-
orchestration of cell movement required for cor- rosis-associated chemokines such as CCL2. This
rect axonal path finding. One particular neuro- led them to hypothesize that netrin-1 is the stop
nal guidance molecule, netrin-1, oddly enough signal that blocks macrophage egress from in-
serves as both a stop and a go signal, depend- flamed vessel walls in the presence of hypercho-
ing on the expression of its receptors on the lesterolemia. This failure of normal macrophage

n engl j med 366;18 nejm.org may 3, 2012 1735

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 clinical implications of basic research

exit mechanisms would then lead to chronic
vessel-wall inflammation and plaque progression.
In support of this hypothesis, the investiga-
tors found that netrin-1 and one of its receptors,
Unc5b, were robustly expressed in atherosclerotic
plaques and that expression of these molecules
was increased by cholesterol loading in both hu-
man and mouse macrophages. Furthermore, ab-
rogation of netrin-1 in macrophages induced
their emigration from atherosclerotic lesions de-
spite ongoing hypercholesterolemia, markedly
diminishing atherosclerosis. The mechanisms by
which netrin-1 stuns the lesional monocyte re-
main poorly understood. Van Gils et al. obtained
additional clues to suggest that netrin-1 inter-
feres with a signaling pathway involving the
protein Rac1, a key modulator of the actin cyto-
skeleton, the arrangement of which governs cell
motility.
Thus, van Gils and colleagues have identified
a mechanism for the blockade of macrophage
exit produced by hypercholesterolemia and in so
doing have identified a new potential therapeu-
tic target for atherosclerosis. Strategies to exploit
this observation clinically are likely to be com-
plicated, since the signals need to be delivered
with a substantial amount of precision to move
cells where one wants them to go. To therapeu-
tically manipulate cell migration, one may need
to engineer the precise location of directional
signals, as well as the magnitude of their ex-
pression. This point is underscored by results of
another study in which investigators found that
intravenous viral delivery of netrin-1 to mice with
hypercholesterolemia resulted in less atheroscle-
rosis, presumably by increasing netrin-1 expres-
sion on endothelial cells and thus snaring mono-
cytes before they reach the nascent plaque.6
Netrin-1 thus may have a differential influence
on inflammation, depending on the site of its
expression.
That said, the work by van Gils and colleagues
highlights the therapeutic opportunities that
may ensue from a better understanding of the
mechanisms of monocyte egress. Interventions
that directly encourage macrophage egress from
plaques — to show these unwanted visitors the
door — could synergize with cholesterol-lowering
therapies to more effectively and rapidly cause
regression of established atherosclerosis.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
From Massachusetts General Hospital and Harvard Medical
School — both in Boston.
1. van Gils JM, Derby MC, Fernandes LR, et al. The neuroim-
mune guidance cue netrin-1 promotes atherosclerosis by inhib-
iting the emigration of macrophages from plaques. Nat Immu-
nol 2012;13:136-43.
2. Boring L, Gosling J, Cleary M, Charo I. Decreased lesion
formation in CCR2−/− mice reveals a role for chemokines in the
initiation of atherosclerosis. Nature 1998;394:894-7.
3. Gu L, Okada Y, Clinton SK, et al. Absence of monocyte chemo-
attractant protein-1 reduces atherosclerosis in low density lipo-
protein receptor-deficient mice. Mol Cell 1998;2:275-81.
4. Trogan E, Feig JE, Dogan S, et al. Gene expression changes
in foam cells and the role of chemokine receptor CCR7 during
atherosclerosis regression in ApoE-deficient mice. Proc Natl
Acad Sci U S A 2006;103:3781-6.
5. Feig JE, Pineda-Torra I, Sanson M, et al. LXR promotes the
maximal egress of monocyte-derived cells from mouse aortic
plaques during atherosclerosis regression. J Clin Invest 2010;
120:4415-24.
6. Khan JA, Cao M, Kang BY, Liu Y, Mehta JL, Hermonat PL.
Systemic human Netrin-1 gene delivery by adeno-associated virus
type 8 alters leukocyte accumulation and atherogenesis in vivo.
Gene Ther 2011;18:437-44.
Copyright © 2012 Massachusetts Medical Society.

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Copyright © 2012 Massachusetts Medical Society. All rights reserved.