The influence of acute phase proteins on murine atherosclerosis

Atherosclerosis is a chronic inflammatory reaction that is initiated in response to hyperlipidemia and the retention and modification of lipids within the vascular wall. Chronic inflammatory states lead to steady low-level induction of the acute phase reaction and chronic inflammation is associated with elevated cardiovascular disease and atherosclerosis. The acute phase reaction is mediated by cytokines and results in significant changes in the plasma level of several proteins referred to as acute phase proteins. The liver is a major source of these proteins. Several recent studies in humans have shown that levels of acute phase proteins are modified in patients with established cardiovascular disease or are predictors of future disease. Whether these acute phase proteins are a biomarker of inflammation or have a direct role in the development of atherosclerosis is not clear. Murine models of atherosclerosis have been used to address the role of acute phase proteins in atherosclerosis. Modification of the expression level of these proteins has shown that the individual acute phase proteins are either pro-atherogenic or anti-atherogenic. The absence of an overall trend is perhaps not surprising given the complex nature of the acute phase response.     

Effects of synthetic and biological disease modifying antirheumatic drugs on lipid and lipoprotein parameters in patients with rheumatoid arthritis

BackgroundDyslipidemia in rheumatoid arthritis (RA) patients is frequently observed, and treatment with anti-rheumatic drugs has an impact on lipid profiles. Pathophysiologically, inflammation leads to decreased blood lipids and lipoproteins; RA treatment reduces inflammation and therefore may increase lipids and lipoproteins. Whether the lipid changes with RA treatment confer an increased risk of cardiovascular disease or just reflect their potentially atheroprotective anti-inflammatory effect is currently unclear due to limited and conflicting data.ObjectiveThe aim of this review is to summarize the current knowledge on the effects of synthetic and biological disease modifying antirheumatic drugs for the treatment of RA on lipid and lipoprotein parameters.ResultsRecent studies on methotrexate emphasize its anti-atherogenic effect. Golimumab combined with methotrexate revealed a trend towards an anti-atherogenic potential. The known pro-atherogenic lipid-spectrum alterations caused by tofacitinib can be effectively treated with atorvastatin. Tocilizumab signals a favorable impact on the extent of lipid modifications when combined with methotrexate. Abatacept indicated a trend towards an anti-atherogenic lipid profile demonstrated by favorable effects on HDL-C and on the TC/HDL-C ratio. Rituximab has beneficial effects on HDL-C and ApoA1, as well as on the ApoB/ApoA1 ratio.Clinical implicationsAnti-rheumatic drugs have various effects on lipid parameters, which in part appear pro-atherogenic. However, because many of these lipid changes may well reflect their potentially atheroprotective anti-inflammatory action the cardiovascular impact of these changes remains unclear. Whatsoever, cardiovascular safety trials for antirheumatic drugs would be valuable.     

Cholesteryl ester transfer protein: pharmacological inhibition for the modulation of plasma cholesterol levels and promising target for the prevention of atherosclerosis

Cholesteryl ester transfer protein (CETP) facilitates the exchange of neutral lipids (such as cholesteryl esters and triglycerides) between anti-atherogenic HDL particles and pro-atherogenic VLDL and LDL particles in human plasma. Individuals possessing a genetic deficiency for CETP have higher HDL cholesterol and lower LDL cholesterol and may have a reduced risk for developing cardiovascular disease. Small molecule inhibitors of CETP are being developed that would appear to provide a beneficial change in lipoprotein profile. However, randomized clinical trials are ultimately required to determine whether CETP inhibition will afford a reduction in cardiovascular events.     

IL-1 cytokines in cardiovascular disease: diagnostic, prognostic and therapeutic implications

Interleukins (ILs) are key mediators in the chronic vascular inflammatory response underlying several aspects of cardiovascular disease. Due to their powerful pro-inflammatory potential, and the fact that they are highly expressed by almost all cell types actively implicated in atherosclerosis, members of the IL-1 cytokine family were the first to be investigated in the field of vessel wall inflammation. The IL-1 family is comprised of five proteins that share considerable sequence homology: IL-1alpha, IL-1beta, IL-1 receptor antagonist (IL-1Ra), IL-18 (also known as IFNgamma-inducing factor), and the newly discovered ligand of the ST2L receptor, IL-33. Expression of IL-1s and their receptors has been demonstrated in atheromatous tissue, and serum levels of IL-1-cytokines have been correlated with various aspects of cardiovascular disease and their outcome. In vitro studies have confirmed pro-atherogenic properties of IL-1alpha, IL-1beta and IL-18 such as, up-regulation of endothelial adhesion molecules, the activation of macrophages and smooth muscle cell proliferation. In contrast with this, IL-1Ra, a natural antagonist of IL-1, possesses anti-inflammatory properties, mainly through the endogenous inhibition of IL-1 signaling. IL-33 was identified as a functional ligand of the, till recently, orphan receptor, ST2L. IL-33/ST2L signaling has been reported as a mechanically activated, cardioprotective paracrine system triggered by myocardial overload. As the roles of individual members of the IL-1 family are being revealed, novel therapies aimed at the modulation of interleukin function in several aspects of cardiovascular disease, are being proposed. Several approaches have produced promising results. However, none of these approaches has yet been applied in clinical practice.     

Lipoprotein lipase and atherosclerosis

Lipoprotein lipase (LPL) is a rate-limiting enzyme that hydrolyzes circulating triglyceride-rich lipoprotein such as very low density lipoproteins and chylomicrons. A decrease in LPL activity is associated with an increase in plasma triglycerides (TG) and decrease in high density lipoprotein (HDL) cholesterol. The increase in plasma TG and decrease in HDL cholesterol are risk factors of coronary heart disease. However, whether LPL directly or indirectly promotes or protects against atherosclerosis remains unclear as two contrary views exist in this regard: one where LPL promotes atherosclerosis and one where LPL protects against atherosclerosis. Many studies have been carried out to investigate whether LPL is an anti-atherogenic or atherogenic enzyme by using animals with genetic defects or with an excess of this enzyme. From these studies, much evidence has been acquired showing that LPL is an anti-atherogenic enzyme. We hypothesized that elevating LPL activity would cause a reduction of plasma TG and increase in HDL cholesterol, resulting in protection against the development of atherosclerosis. To test this hypothesis, we studied the effects of the LPL activator NO-1886 in animals. NO-1886 has been shown to increase LPL mRNA in adipose tissue and myocardium, and increase LPL activity in adipose tissue, myocardium and skeletal muscle, resulting in an elevation of postheparin plasma LPL activity and LPL mass in rats. NO-1886 has also been shown to decrease plasma TG levels accompanied by a concomitant rise in HDL cholesterol. Long-term administration of NO-1886 to rats and rabbits with experimental atherosclerosis inhibited the development of atherosclerotic lesions in coronary arteries and aortae. The results of multiple regression analysis in these studies suggest that the increase in plasma HDL cholesterol and the decrease in TG protect against atherosclerosis. We have determined in our studies that the atherogenic lipid profile is changed to an anti-atherogenic lipid profile by increasing LPL activity, resulting in protection against the development of atherosclerosis. Therefore, we believe that high activity of LPL is anti-atherogenic, whereas a low activity of LPL is atherogenic.     

Oxidative modification of lipoproteins: mechanisms, role in inflammation and potential clinical applications in cardiovascular disease

Abnormalities of lipid metabolism often lead to pathologic lipid accumulation in the vessel wall, oxidative and chronic inflammatory sequelae and the formation of atherosclerotic lesions, ultimately leading to clinical events. Oxidation of lipoproteins, and in particular low density lipoprotein (LDL), is a seminal even that mediates many pro-atherogenic and pro-inflammatory pathways. Many in vivo mechanisms exist to oxidize LDL, including transition metals such as divalent iron cations, heme, as well as a number of different enzyme systems, such as lipoxygenases, myeloperoxidase, NADPH oxidases, and nitric oxide synthases. Oxidized LDL is taken up in an unregulated fashion. By macrophages leading to foam cell formation, ultimately generating a potent pro-inflammatory milieu. Minimally modified LDL also induces proinflammatory effects in macrophages, including cytoskeletal rearrangements and macropinocytosis, generation of reactive oxygen species, survival of foam cells, reduced phagocytic capacity toward apoptotic cells, and expression of inflammatory genes, many of these effects mediated through toll-like receptor-4. Using the scientific knowledge gained from understanding these pathways, antibodies binding well-defined oxidation-specific epitopes have been generated and are being used in translational clinical applications. In particular, assays measuring oxidized phospholipids on apolipoprotein B-100 particles (OxPL/apoB) predict the presence and progression of femoral, carotid and coronary artery disease and predict new cardiovascular events independent of established risk factors. Human oxidation-specific antibodies have also been successfully used to image the extent and regression of experimental atherosclerotic lesions using nuclear and magnetic resonance imaging approaches. If validated and translated to humans, this imaging approach may provide a means to non-invasively detect, quantitate and monitor extent of atherosclerosis and potentially image high risk plaques. Further understanding of the role of oxidation of lipoproteins may allow more rational targeted diagnostic and therapeutic modalities in clinical applications.     

Soy, isoflavones and atherosclerosis

Consumption of soy protein is associated with a lower risk of cardiovascular disease in man, and reduced atherosclerosis in a variety of experimental animals. Although a portion of the cardiovascular protective effects appears to be due to reductions in plasma lipoprotein concentration, in most people the magnitude of this effect is relatively small. In many, but not all studies using animal models, the reduction in atherosclerosis is in part independent of changes in plasma lipids and lipoproteins. This implies that there may be a direct effect on the arterial wall of one or more of the components in soyprotein that reduces susceptibility to atherosclerosis. The most actively studied components of soy protein that may be responsible for these anti-atherogenic effects are the isoflavones and various protein factions. Extraction of isoflavones and other alcohol-soluble components from soy protein lowers, but does not eliminate its ability to reduce atherosclerosis. Surprisingly, in most studies, adding back the isoflavone-rich alcohol extract to the previously extracted soy protein, or to another protein, does not restore its lipoprotein lowering or anti-atherogenic properties. This implies that alcohol extraction either destroys an active component of soy, alters the structural integrity of the soy proteins, or disassociates a required isoflavone-soy protein complex. Understanding the mechanism of this effect is an important goal for future research. Likewise, the sites of action on the arterial wall, and the mechanisms by which various soy components act to reduce atherosclerosis are just now being studied. The recent demonstration that expression of estrogen receptor alpha is required for atheroprotection by soy protein provides important new mechanistic insight. Other properties of soy, including antioxidant, anti-inflammatory and potentially antithrombogenic properties need to be explored more mechanistically before the full potential of dietary soy protein for the protection from cardiovascular disease will be known.     

Platelet-derived chemokines in atherogenesis: what's new?

Over the past decade, platelets have been demonstrated to have various functions beyond their role in hemostasis. Platelets possess a rich repertoire of chemokines that are stored in their alpha granules and can be released upon activation. The pro-atherogenic effects of activated platelets are most likely mediated by release of these pro-inflammatory mediators that promote recruitment, activation or differentiation of other cell types including endothelial cells and leukocytes. These effects have been excellently reviewed in the past by various authors. The current review will therefore focus on novel findings. A specific focus will be put on CXCL4, on which a lot of new data have been published since 2008. Thus, the effects of CXCL4 on macrophage differentiation have been studied in detail revealing that CXCL4 induces a specific macrophage phenotype. Furthermore, novel data on CXCL4L1, a protein similar to CXCL4 that is probably transcribed from a duplication of the PF4 gene coding for CXCL4, will be discussed. A very interesting study has recently demonstrated that the inhibition of heterophilic chemokine interactions using a specifically designed small molecule can inhibit atherogenesis in Apoe-/- mice, thereby demonstrating the clinical potential of tackling platelet chemokines as therapeutic targets in atherosclerosis. Finally, novel data on CXCL1 and CCL5 will be discussed. Overall, while our understanding of the role of platelet chemokines in atherogenesis has significantly improved over the past years, it seems that there may still be many buried treasures in this field that could improve disease prevention or lead to novel clinical therapies.     

Dietary small molecules and large-scale gene expression studies: an experimental approach for understanding their beneficial effects on the development of malignant and non-malignant proliferative diseases

Epidemiological studies have repeatedly demonstrated a correlation between nutrition, development and the severity of malignant and non-malignant proliferative diseases such as cancer and atherosclerosis. Therefore, the prevention of chronic proliferative diseases through dietary intervention is currently receiving considerable attention. Until now, much of the research is being focused on the cellular and molecular action mechanisms of dietary small molecules explaining their beneficial effects. Dietary chemicals may affect gene expression in several human diseases. However, significant progress has been made and several molecular action mechanisms have been proposed. Alteration of genetical pathways by nutrition, also called "Nutrigenomics", may offer a new approach for understanding the beneficial effects of dietary compounds on the development of severe polygenic diseases, such as cardiovascular disease, diabetes and hypertension. This review focuses on the nutritional genomics of dietary chemicals with a special emphasis on catechins. Catechins belong to the flavonoid family, which are polyphenolic compounds available in foods of plant origin. Several epidemiological studies have reported that consumption of flavonoids, and especially catechins might function as chemopreventive agents against cancer and cardiovascular diseases.     

Reversal of chronic obstructive pulmonary disease-associated weight loss : are there pharmacological treatment options?

Poor nutritional status is associated with an increased incidence of morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD). While a number of factors have been shown to produce tissue catabolism, no single mechanism has been clearly identified as a primary cause for weight loss in patients with severe COPD. Without a clear understanding of the aetiology of weight loss, therapeutic strategies to reverse this process have historically been unsuccessful. A review of recent studies allows consideration of a model of mechanisms of weight loss. This model includes multiple pathways that may be activated singly or simultaneously to cause loss of weight, specifically lean body mass. These include energy imbalances, elevated levels of cytokines, tissue hypoxia and the effects of cocorticosteroid therapy. To date, interventional studies that have looked at newer pharmacotherapies such as growth hormone and anabolic steroids in patients with COPD who are losing weight have not demonstrated reversal of weight loss or improvement in nutritional status. Currently, early identification of patients at risk for weight loss and aggressive nutritional supplementation coupled with an exercise programme has demonstrated the greatest benefit. However, with increasing understanding of the mechanisms that may be implicated, new targets for therapies are being identified. Of particular research interest are molecules such as leukotrienes, hormones, tumour necrosis factor-alpha and acute-phase proteins, which are noted to be elevated in some patients with COPD-associated weight loss. Currently, inhibitors to some of these inflammatory substances are used therapeutically in other chronic illnesses such as rheumatoid arthritis and cancer cachexia. Future research may investigate their usefulness in COPD and direct new therapies that target the processes contributing to weight loss in these patients.     

Statin treatment and progression of atherosclerotic plaque burden

Atherosclerosis is a progressive systemic disorder that, in the initial stages, is often asymptomatic. The measurement of atherosclerotic burden using imaging techniques enables the clinical benefits of lipid-modifying therapies to be assessed in early atherosclerosis and facilitates more rapid evaluation of interventions in clinical trials compared with the measurement of clinical outcome.The effect of HMG-CoA reductase inhibitors, commonly referred to as 'statins', on disease progression has been assessed in a number of imaging studies both in patients with established coronary heart disease (CHD) and in those with subclinical atherosclerosis. Statins slow plaque progression and, in early atherosclerosis, they have been demonstrated to promote regression of atherosclerotic lesions. The benefits of statin therapy on soft atherosclerotic plaques that are still developing support the use of vascular measures to detect subclinical atherosclerosis, and the subsequent early intervention with statin therapy. Moreover, given that the effects of statins on atherosclerosis progression are evident even in normocholesterolaemic patients at increased risk of developing CHD, early intervention with statin therapy may be effective in preventing CHD, irrespective of lipid level.     

Anti-oxidant therapy: does it have a role in the treatment of human disease?

Free radical oxidative stress has been implicated in the pathogenesis of a variety of human diseases. Natural anti-oxidant defences have also been found to be defective in many of the same diseases. Many researchers have concluded that, if the imbalance between the oxidative stresses and anti-oxidant defence can be corrected by supplementing natural anti-oxidant defences, it may be possible to prevent or retard disease progression. Potential anti-oxidant therapies include natural anti-oxidant enzymes and vitamins or synthetic agents with anti-oxidant activity. Diseases where anti-oxidant therapy may be beneficial can be divided into those involving acute intervention, such as reperfusion injury or inflammation, and those involving chronic preventative therapy, such as atherosclerosis, carcinogenesis and diabetic vascular disease. The pharmaceutical considerations are different in each case. The principles guiding the development, use and assessment of anti-oxidant therapies are discussed in this review.     

Diabetes Mellitus-Associated Atherosclerosis

While diabetes mellitus is most often associated with hypertension, dyslipidemia, and obesity, these factors do not fully account for the increased burden of cardiovascular disease in patients with the disease. This strengthens the need for comprehensive studies investigating the underlying mechanisms mediating diabetic cardiovascular disease and, more specifically, diabetes-associated atherosclerosis. In addition to the recognized metabolic abnormalities associated with diabetes mellitus, upregulation of putative pathological pathways such as advanced glycation end products, the renin-angiotensin system, oxidative stress, and increased expression of growth factors and cytokines have been shown to play a causal role in atherosclerotic plaque formation and may explain the increased risk of macrovascular complications. This review discusses the methods used to assess the development of atherosclerosis in the clinic as well as addressing novel biomarkers of atherosclerosis, such as low-density lipoprotein receptor-1. Experimental models of diabetes-associated atherosclerosis are discussed, such as the streptozocin-induced diabetic apolipoprotein E knockout mouse. Results of major clinical trials with inhibitors of putative atherosclerotic pathways are presented. Other topics covered include the role of HMG-CoA reductase inhibitors and fibric acid derivatives with respect to their lipid-altering ability, as well as their emerging pleiotropic anti-atherogenic actions; the effect of inhibiting the renin-angiotensin system by either ACE inhibition or angiotensin II receptor antagonism; the effect of glycemic control and, in particular, the promising role of thiazolidinediones with respect to their direct anti-atherogenic actions; and newly emerging mediators of diabetes-associated atherosclerosis, such as advanced glycation end products, vascular endothelial growth factor and platelet-derived growth factor. Overall, this review aims to highlight the observation that various pathways, both independently and in concert, appear to contribute toward the pathology of diabetes-associated atherosclerosis. Furthermore, it reflects the need for combination therapy to combat this disease.     

Glucose lowering and anti-atherogenic effects of incretin-based therapies: GLP-1 analogues and DPP-4-inhibitors

Background: Type 2 diabetes is a chronic, progressive disease with a multi-faceted pathophysiology. Beyond the known defects of insulin resistance and β-cell insufficiency, derangement of incretin hormones normally produced from the gut wall in response to food intake play an important role. In recent years, the ‘incretin-based’ therapies (IBTs) have been developed to address hyperglycemia through either mimicking the action of the endogenous incretin glucagon-like polypeptide (GLP-1) (GLP-1 receptor agonists) or by inhibiting the activity of the enzyme that degrades GLP-1 (the dipeptyl peptidase-4 inhibitors). Objective: We reviewed available evidence on the glucose lowering and anti-atherogenic effects of IBT. Results: In addition to their glucose-lowering and weight-neutral or weight-reducing actions, IBT decrease systolic blood pressure and improve fasting and postprandial lipid parameters by reducing total-cholesterol, low-density lipoprotein-cholesterol and triglycerides concentrations, and increasing high-density lipoprotein-cholesterol values. Reduced high-sensitivity C-reactive protein levels and improved endothelial dysfunction have been reported too. Conclusions: IBT have several beneficial effects on cardiovascular risk factors and, for this reason, it has been recently suggested to extend the use of these drugs in diabetic patients with cardiovascular complications. Yet, the long-term effects of IBT on subclinical or clinical atherosclerosis remain to be established by future studies.     

Cytokines as drug targets

Cytokines (interleukins, chemokines, and some growth factors) play an important role in cancer, metabolic disorders, autoimmune disorders and inflammatory diseases, such as rheumatoid arthritis, asthma, Crohn's disease, psoriasis, multiple sclerosis and asthma. Cytokine-based drugs and anticytokine therapies are an increasingly important class of drugs in the treatment and management of many diseases. Interferons are being used to treat viral diseases and cancers. Anti-tissue necrosis factor therapies, such as Enbrel (etanercept; Immunex Corp) and Remicade (infliximab; Centocor) have demonstrated clinical efficacy in rheumatoid arthritis and Crohn's disease. In addition, thalidomide (Celgene) is being used to treat erythema nodosum in leprosy, cancers (multiple myeloma and colon cancer) and autoimmune diseases. This conference focused on new developments in basic research, drug discovery and clinical development of cytokine-based drugs.     

Augmented atherogenesis in ApoE-null mice co-exposed to polychlorinated biphenyls and 2,3,7,8-tetrachlorodibenzo-p-dioxin

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) and polychlorinated biphenyls (PCBs) are persistent organic pollutants found as complex mixtures in the environment throughout the world. Therefore, humans are ubiquitously and simultaneously exposed to TCDD and PCBs. TCDD and PCBs alone have been linked to atherosclerosis. However, the effects of interactions or synergism between TCDD and PCBs on atherogenesis are unknown. We investigated the possible enhanced atherogenesis by co-exposure to TCDD and PCBs and the potential mechanism(s) involved in this enhancement. Male ApoE^−/− mice were exposed to TCDD (15 μg/kg) and Aroclor1254 (55 mg/kg, a representative mixture of PCBs) alone or in combination by intraperitoneal injection four times over six weeks of duration. Our results showed that mice exposed to TCDD alone, but not Aroclor1254 alone, developed atherosclerotic lesions. Moreover, we found that atherosclerotic disease was exacerbated to the greatest extent in mice co-exposed to TCDD and Aroclor1254. The enhanced lesions correlated with several pro-atherogenic changes, including a marked increase in the accumulation of the platelet-derived chemokine PF4, and the expression of the proinflammatory cytokine MCP-1 and the critical immunity gene-RIG-I. Our data demonstrated that co-exposure to TCDD and Aroclor1254 markedly enhanced atherogenesis in ApoE^−/− mice. Significantly, our observations suggest that combined exposure to TCDD and PCBs may be a greater cardiovascular health risk than previously anticipated from individual studies.     

Porphyromonas gingivalis mediated periodontal disease and atherosclerosis: disparate diseases with commonalities in pathogenesis through TLRs

Toll-like receptors (TLRs) are a group of pathogen-associated molecular pattern receptors, which play an important role in innate immune signaling in response to microbial infection. It has been demonstrated that TLRs are differentially up regulated in response to microbial infection and chronic inflammatory diseases such as atherosclerosis. Furthermore hyperlipidemic mice deficient in TLR2, TLR4, and MyD88 signaling exhibit diminished inflammatory responses and decreased atherosclerosis. Accumulating evidence has implicated specific infectious agents including the periodontal disease pathogen Porphyromonas gingivalis in the progression of atherosclerosis. Evidence in humans suggesting that periodontal infection predisposes to atherosclerosis is derived from studies demonstrating that the periodontal pathogen P. gingivalis resides in the wall of atherosclerotic vessels and seroepidemiological studies demonstrating an association between pathogen-specific IgG antibodies and atherosclerosis. We have established that the inflammatory signaling pathways that P. gingivalis utilizes is dependent on the cell type and this specificity clearly influences innate immune signaling in the context of local and distant chronic inflammation induced by this pathogen. We have demonstrated that P. gingivalis requires TLR2 to induce oral inflammatory bone lose in mice. Furthermore, we have demonstrated that P. gingivalis infection accelerates atherosclerosis in hyperlipidemic mice with an associated increase in expression of TLR2 and TLR4 in atherosclerotic lesions. Our recent work with P. gingivalis has demonstrated the effectiveness of specific intervention strategies (immunization) in the prevention of pathogen-accelerated atherosclerosis. Improved understanding of the mechanisms driving infection, and chronic inflammation during atherosclerosis may ultimately provide new targets for therapy.     

Effects of atorvastatin on the different phases of atherogenesis

Molecular differences among the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) give rise to some important differences in their properties, including their anti-atherogenic and anti-inflammatory actions (among the so-called pleiotropic effects) - differences that may help to account for variation in clinical efficacy and safety among the available drugs of this class. The question of whether the clinical benefit of statins such as atorvastatin in reducing cardiovascular events in individuals with elevated cholesterol levels results from direct anti-atherogenic effects in addition to cholesterol-lowering-dependent effects cannot be conclusively answered at present. However, the available evidence suggests that these actions should be considered further, especially in some clinical situations such as acute coronary syndrome where an anti-inflammatory effect could conceivably have a greater role. In the case of atorvastatin, various direct anti-atherogenic effects have been demonstrated. These effects include modification of endothelial dysfunction, inflammatory processes and lipid oxidation, and a possible direct effect on the composition of atheromatous plaques, which together may have a positive influence on the development of atherosclerosis and its subsequent progression (e.g. on the reduction of carotid intima media thickness and regression of atheromas noted in studies with intensive atorvastatin therapy [80 mg/day]). In terms of its effects on endothelial function, improvements in flow-mediated endothelium-dependent vasodilatation have been observed as early as 2 weeks after starting atorvastatin treatment. This effect does not appear to be quantitatively correlated with lowering of low-density lipoprotein-cholesterol (LDL-C) as greater improvements in endothelial function versus ezetimibe/simvastatin have been noted with atorvastatin despite comparable reductions in LDL-C. Atorvastatin has also been shown to reduce levels of the inflammatory marker C-reactive protein; in comparative studies, this effect proved to be superior to that of simvastatin or pravastatin and equivalent to that of rosuvastatin. In other studies, atorvastatin has been found to inhibit the in vitro oxidation of LDL - an effect that appears to be due mainly its active hydroxy metabolite - and to reduce various oxidative stress markers in hypercholesterolaemic patients. In addition, there is evidence that atorvastatin is able to modify the composition of atherosclerotic plaques and their inflammatory status via a series of effects, mostly involving tissue factors.