Mast cells and atherosclerosis

A brief review of the role of mast cells in atherosclerosis. Kindly provided by Guo-Ping Shi, DSc.

Mast cells in atherosclerotic lesions

Mast cells are known primarily as essential effector cells in the elicitation of allergic responses. Their appearance in human atherosclerotic lesions was first recognized by Dr. Paris Constantinides more than half a century ago (Constantinides, 1953).

An increase in the number of mast cells in atherosclerotic lesions with variable focal accumulations was later proposed with the progression of human atherosclerosis. Normally, carotid arteries contain only very few mast cells within the adventitia. However, from the earliest stages of atherosclerosis, mast cells are found in the fatty streak and abundantly in close association with lesion macrophages

At later phases of disease development, mast cells appear at the shoulder regions of fully formed atheroma prone to erosion or rupture, as well as in the lipid cores of advanced plaques (Jeziorska et al., 1997; Cornhill et al., 1990). Similarly, coronary arteries exhibit greater numbers of mast cells in ruptured plaques than in non-ruptured plaques, while the smallest number of mast cells are found in normal arteries (Kaartinen et al., 1998; Laine et al., 1999; Kovanen et al., 1995).

An important feature of mast cells is their ability to release the content of their cytoplasmic granules extracellularly upon activation by stimuli such as IgE, complement components, as well as viral and bacterial pathogens. Activated mast cells secrete large amounts of chemotactic molecules, inflammation activators and soluble granule remnants, including cytokines, chemokines, and mediators such as histamine, tryptase and chymase, which may mediate or modulate atherogenesis (Table 1).

In addition, activated mast cells nonspecifically bind to low-density lipoproteins (LDL), which can be phagocytosed by macrophages to form foam cells, a major cellular component of advanced human atherosclerotic lesions (Metzler and Xu, 1997). Thus, mast cells exhibit a variety of functions that might modulate atherogenesis in vivo.

Mast cells and athersclerosis-associated protease expression

Tryptase and chymase are the most common mast cell specific proteases (Table 1). In addition to degradation of extracellular matrix (ECM) proteins, chymase can generate active angiotensin II, TGF-β​1, IL-1β​, and 31-amino acid endothelin, which are all essential players in atherogenesis (Saarinen et al., 1994; Wang et al., 2001; Mizutani et al., 1991; Kido et al., 1998).

While chymases proteolytically modify LDL into copper oxidized-LDL to promote foam cell formation (Paananen and Kovanen, 1994), tryptases degrade high-density lipoprotein (HDL) and block its function as an acceptor of cellular cholesterol (Lee et al., 2002). These enzymes can also activate latent matrix mettaloproteinases (MMPs) implicated in plaque remodeling and rupture (Johnson et al., 1998).

Increased MMP activities were detected in human carotid atherosclerotic plaques when tissues were treated with a mast cell activator (Lindstedt et al., 1993), whereas chymase and tryptase inhibitors reduced MMP activities by up to 30%. Upon activation, mast cells also release pro-inflammatory TNF-α ​to trigger MMP-9 expression and secretion in macrophages (Kaartinen et al., 1998).

Mast cell-derived basic fibroblast growth factor (bFGF) may act in a similar manner to induce endothelial cell expression of ECM-degrading proteases, which results in a positive correlation between the number of bFGF-positive mast cells and microvessels in human coronary plaques (Lappalainen et al., 2004). 

Interactions between mast cells and vascular cells

Smooth muscle cells (SMCs), endothelial cells (ECs), macrophages, and lymphocytes are probably the major cell types involved in atherogenesis.

Mast cells regulate the behavior of SMCs most likely through their secreted mediators (Figure 1). For example, histamine, bFGF, TGF-β and PAF released from mast cells can activate SMC surface receptors and accelerate their migration and proliferation (Inoue et al., 1996; Toda, 1987).

In contrast, mast cell-derived heparin proteoglycan or heparin glycosaminoglycans inhibit SMC growth efficiently by blocking activation of the extracellular signal-regulated kinases ERK1 and ERK2 (Kazi et al., 2002), and participate in the local regulation of SMC growth in the plaque (Wang & Kovanen, 1999). SMC-derived collagen may help prevent rupture of the atheromatous fibrous caps. However, mast cell-derived chymase inhibits SMC proliferation and collagen synthesis (Wang et al., 2001), thereby reducing plaque stability.

In addition, chymase can induce degradation of focal adhesion kinase and fibronectin, which are mediators of SMC survival and adhesion. Mast cell-released pro-inflammatory cytokines such as TNF-α induce SMC protease expression. The appearance of TNF-α mast cells (Kaartinen et al., 1996) together with MMP- or cysteine protease cathespin-positive SMCs and macrophages (Galis et al., 2002; Liu et al., 2004) in rupture-prone areas of human coronary atheroma suggest a regulatory role of mast cell mediators in SMC protease expression and activation.

Dr. Pete Kovanen's group has demonstrated that mast cells store and secrete angiogenic bFGF within neovascularized human coronary plaques (Lappalainen et al., 2004). Activated mast cells containing angiogenic factors preferentially localize around newly formed microvessels in human coronary atheroma (Kaartinen et al., 1996), suggesting that the interaction between mast cells and ECs can be mediated by mast cell-derived angiogenic factors.

Mast cell-derived TNF-α induces the expression of adhesion molecules in ECs (such as ICAM-1, VCAM-1, E-selectin) (Walsh et al., 1991; Meng et al., 1995; Wegner et al., 1990) while the secretion of tryptase from mast cells triggers the release of lymphotactic IL-8 by ECs (Moller et al., 1993; Compton et al., 1998).

T lymphocytes in atherosclerotic lesions can induce the release of inflammatory cytokines and mast cell chemokines. Mast cells are activated in various T cell-mediated inflammatory processes and reside in close physical proximity to T cells.

Indeed, mast cell activation can induce T cell migration, either directly by releasing chemotactic factors or indirectly by inducing the expression of adhesion molecules on ECs (Walsh et al., 1991; Meng et al., 1995; Wegner et al., 1990). Upon activation, mast cells release lyphotactin with preferential chemotactic activity on CD8+ T cells or IL-16, a chemoattractant for CD4T cells (Rumsaeng et al., 1997; Figure 1).

​​​Mast cells also present in antigens to T cells, resulting in their activation in either a MHC class I- or MHC class II-restricted and co-stimulatory molecule-dependent fashion (Malaviya et al., 1996; Mécheri & David, 1997). In addition to T cells, monocytes and neutrophils can also be recruited by mast cells through secretion of chemokines such as MCP-1 and IL-8. Therefore, mast cells are considered to be a central regulator for different cell types in human atherosclerotic lesions.

Proof of concept with animal models

In an apolipoprotein E-deficient (Apoe-/-) mouse model of atherosclerosis, mast cell activation with dinitrophenyl-albumin (DNP) enhanced the size of atherosclerotic lesions in mice by more than 50% (Bot et al., 2007). In contrast, such an increase of atherosclerosis was absent when DNP-treated animals were further treated with the mast cell stabilizer cromolyn.

Consistent with a prior hypothesis (Leskinen et al., 2006), degranulated mast cells or the mast cell components histamine and tryptase promoted macrophage apoptosis. Furthermore, increased atherosclerosis in DNP-treated mice was not due to changes in other immune cells, including neutrophils, monocytes, lymphocytes. Thus, activated mast cells appear to have a specific contribution to atherosclerosis independently of other inflammatory cell types.

We used another conventional low-density lipoprotein receptor-null (Ldlr-/-)​ mouse model for atherosclerosis, and here mast cell-deficient mice directly proved that mast cells play a role atherosclerosis (Sun et al., 2007). Mast cell-deficient mice demonstrated a reduction in atherosclerosis by greater than 50% after consumption of an atherogenic diet for 12 to 26 weeks. The numbers of macrophages, T cells, proliferating cells, and apoptotic cells in lesions were also significantly reduced in mast cell-deficient Ldlr​-/- mice compared to control Ldlr-/- mice.

Using a mast cell reconstitution strategy, we not only restored the atherosclerosis phenotype in mast cell-null mice using wild-type mast cells, but also identified that mast cells contribute to atherosclerosis by releasing pro-inflammatory cytokines IL-6 and IFN-γ to stimulate vascular cell cysteine protease and MMP expression. Both experimental models proved independently the concept that mast cells participate directly in the pathogenesisof atherosclerosis.

Future perspective

The release of mediators from mast cell granules is a common pathological event during allergic responses. Consequently, mast cell stabilization has become the main treatment for patients with allergic symptoms.

Although it is too early to say that atherosclerosis is an allergic disorder, mast cell stabilization does reduce atherosclerosis in Apoe​-/- mice (Bot et al., 2007). Therefore, it is possible that the mast cell stabilizer cromolyn, a widely used anti-allergic medicine, may become a viable therapy for atherosclerosis and other vascular diseases.

We have recently demonstrated that cromolyn prevents aortic elastase perfusion-induced abdominal aortic aneurysms (Sun et al., 2007). Based on the data from these different animal models, we anticipate that mast cell stabilizers may have applications for other diseases than just allergies.

Activated mast cells contribute not only to allergic and vascular diseases, but also to multiple sclerosis, rheumotoid arthritis, cancer, and probably many other untested diseases (Leslie, 2007). One important feature of the mast cell-derived mediators listed in Table 1, is their ability to act uniquely in different diseases, i.e. one mediator may be critical to one disease but not another.

For example, mast cell-derived TNF-α is essential in ovalbumin-induced airway hyperresponsiveness in mice (Nakae et al., 2007). However, the same molecule plays a minor role in western diet induced atherosclerosis (Sun et al., 2007) and in elastase perfusion-induced abdominal aortic aneurysms (Sun et al., 2007), as concluded from a TNF-β-deficient (Tnf-/-) mast cell reconstitution protocol in mast cell-deficient mice.

Apparently, mast cell reconstitution in mast cell-deficient mice may become an invaluable approach for examination of individual mast cell mediators in different human disease models in future research.

MediatorsPotential role in atherosclerosisReferences
Pro-inflammatory cytokines: 
​IL-4, IL-5, IL-6, IL-13, IL-18, IFN-γ, TNF-α 
  • Chemotaxis
  • ​Endothelial cell activation
  • Monocyte recruitment
  • Induction of protease expression

Kovanen et al., 1995

Kaartinen et al., 1996

Kobayashi et al., 2000

Huang et al., 2003 

MCP-1, IL-8, RANTES, eotaxin, leukotriene
  • Monocyte recruitment
  • Foam cell formation
Bradding, 1996
Tryptase, chymase, angiotensin converting enzyme (ACE), carboxypeptidase, cathespin G, cysteinyl cathepsins
  • Endothelial cell activation
  • Fibrinogen cleavage
  • Angiotensis II generation
  • Lipoprotein degradation 
  • Tissue/vascular remodeling
  • Protease activation
Saarinen et al., 1994

Lee et al., 2002

Johnson et al., 1998

Ihara et al., 1999

Tsunemi et al., 2002

Doggrell and Wanstall, 2004

Henningsson et al., 2003

Hematopoeitic factors: 

  • Hematopoiesis
  • Foam cell formation
Bradding, 1996
Growth factors: 
  • Angiogensis
  • ​Cellular proliferation
Kovanen et al., 1995

Lappalainen et al., 2004

Inoue et al., 1996
  • Vasodilation
  • ​Endothelial cell activation
Toda, 1987
Heparin proteoglycan
  • Anti-coagulent
  • ​Inhibition of platelet aggregation 
Chondroitin sulfate proteoglycan
  • Lipoprotein binding

Table 1: Selected mediators produced by or released from mast cells.

Figure 1: Participation of mast cells and their mediators in atherosclerosis.


  • Bot I, de Jager SC, Zernecke A, Lindstedt KA, van Berkel TJ, Weber C and Biessen EA (2007). Perivascular mast cells promote atherogenesis and induce plaque destabilization in apoliprotein E-deficient mice. Circulation 115, 2516–2525.
  • Bradding P (1996). Human mast cell cytokines. Clin. Exp. Allergy 26, 13–19.
  • Compton SJ, Cairns JA, Holgate ST and Walls AF (1998). The role of mast cell tryptase in regulating endothelial cell proliferation, cytokine release, and adhesion molecule expression: tryptase induces expression of mRNA for IL-1 beta and IL-8 and stimulates the selective release of IL-8 from human umbilical vein endothelial cells. J. Immunol. 161, 1939–1946.
  • Constantinides P (1953). Mast cells and susceptibility to experimental atherosclerosis. Science. 117:505–506.
  • Cornhill JF, Herderick EE and Stary HC (1990). Topography of human aortic sudanophilic lesions. Monogr. Atherscler. 15, 13–19.
  • Doggrell SA and Wanstall JC (2004). Vascular chymase: pathophysiological role and therapeutic potential of inhibition. Cardiovasc. Res. 61, 653–662.
  • Henningsson F, Wolters P, Chapman HA, Caughey GH and Pejler G (2003). Mast cell cathespins C and S control levels of carboxypeptidase A and the chymase, mouse mast cell protease 5. Biol. Chem. ​384, 1527–15.
  • Huang M, Pang X, Karalis K and Theoharides TC (2003). Stress-induced interleukin-6 release in mice is mast cell-dependent and more pronounced in Apolipoprotein E knockout mice. Cardiovasc. Res. 59, 241–249.
  • Ihara M, Urata H, Kinoshita A, Suzimiya J, Sasaguri M, Kikuchi M, Ideishi M and Arakawa K (1999). Increased chymase-dependent angiotensin II-forming enzymes, angiotensin converting enzyme and chymase-like enzyme, in the human aneurysmal aorta. Hypertens. Res. 25, 817–822.
  • Inoue Y, King TE Jr, Tinkle SS, Dockstader K and Newman LS (1996). Human mast cell basic fibroblast growth factor in pulmonary fibrotic disorders. Am. J. Pathol. 149, 2097–2054.
  • Jeziorska M, McCollum C and Woolley DE (1997). Mast cell distribution, activation, and phenotype in atherosclerotic lesions of human carotid arteries. J. Pathol. 182, 115–122.
  • Johnson JL, Jackson CL, Angelini GD and George SJ (1998). Activation of matrix-degrading metalloproteinases by mast cell proteases in athersclerotic plaques. Arterioscler. Thromb. Vasc. Biol. 18, 1707–1715.
  • Kaartinen M, Penttila A and Kovanen PT (1996). Mast cells in rupture-prone areas of human coronary atheromas produce and store TNF-alpha. Circulation 94, 2787–2792.
  • Kaartinen M, van der Wal AC, van der Loos CM, Piek JJ, Koch KT, Becker AE and Kovanen PT (1998) Mast cell infiltration in acute coronary syndromes: implications for plaque rupture. J. Am. Coll. Cardiol. 32, 606–612
  • Kazi M, Lundmark K, Religa P, Gouda I, Larm O, Ray A, Swedenborg J and Hedin U (2002). Inhibition of rat smooth muscle cell adhesion and proliferation by non-anticoagulent heparins. J. Cell. Physiol. 193, 365–372.
  • Kido H, Nakano A, Okishima N, Wakabayashi H, Kishi F, Nakaya Y, Yoshizumi M and Tamaki T (1998). Human chymase, an enzyme forming novel bioactive 31-amino acid length endothelins. Biol. Chem. 379, 885–891.
  • Kobayashi H, Ishizuka T and Okayama Y (2000). Human mast cells and basophils as sources of cytokines. Clin. Exp. Allergy. 30, 1205–1212.
  • Kovanen PT, Kaartinen M and Paavonen T (1995). Infiltrates of activated mast cells at the site of coronary atheromatous erosion or rupture in myocardial infarction. Circulation. 92, 1084–1088.
  • Laine P, Kaartinen M, Penttila A, Panula P, Paavonen T and Kovanen PT (1999). Association between myocardial infarction and the mast cells in the adventitia of the infarct-related coronary artery. Circulation. 99, 361–369.
  • Lappalainen H, Laine P, Pentikainen MO, Sajantila A and Kovanen PT (2004). Mast cells in Neovascularized Human Coronary Plaques Store and Secrete Basic Fibroblast Growth Factor, a Potent Angiogenic Mediator. Arterioscler. Thromb. Vasc. Biol. 24, 1880–1885.
  • Lee M, Sommerhoff CP, von Eckardstein A, Zettl F, Fritz H and Kovanen PT (2002). Mast cell tryptase degrades HDL and blocks its function as an acceptor of cellular cholesterol. Arterioscler. Thromb. Vasc. Biol. 22, 2086–2091.
  • Leskinen MJ, Heikkilä​ HM, Speer MY, Hakala JK, Laine M, Kovanen PT and Lindstedt KA (2006). Mast cell chymase induces smooth muscle cell apoptosis by disrupting NF-KappaB-mediated survival signaling. Exp. Cell. Res. 312, 1289–1298.
  • Leslie M (2007). Mast cells show their might. Science. 317, 614–616.
  • Lindstedt KA, Kokkonen JO and Kovanen PT (1993). Inhibition of copper-mediated oxidation of LDL by rat serosal mast cells. A novel cellular protective mechanism involving proteolysis of the substrate under oxidative stress. Arterioscler. Thromb. Vasc. Biol. 18, 1707–1715.
  • Malaviya R, Twesten NJ, Ross EA, Abraham SN and Pfeifer JD (1996). Mast cells process bacterial Ags through a phagocytic route for class I MHC presentation to T cells. J. Immunol. 156:, 490–1496.
  • Mecheri S and David B (1997). Unravelling the mast cell dilemma: culprit or victim of generosity? Immunol. Today. 18, 212–215.
  • Meng H, Tonnesen MG, Marchese MJ, Clark RA, Bahou WF and Gruber BL (1995). Mast cells are potent regulators of endothelial cell adhesion molecule ICAM-1 and VCAM-1 expression. J. Cell Physiol​. 165,  40–53.
  • Metzler B and Xu Q (1997). The role of mast cells in atherosclerosis. Int. Arch. Allergy Immunol. 114, 10–14.
  • Mizutani H, Schechter, Lazurus G, Black RA and Kupper TS (1991). Rapid and specific conversion of precursor interleukin 1 beta (IL-1 beta) to an active IL-1 species by human mast cells chymase. J. Exp. Med. 174, 821–825.
  • Moller A, Lippert U, Lessmann D, Kolde G, Hamann K, Welker P, Schadendorf D, Rosenbach T, Luger T and Czarnetski BM (1993). Human mast cells produce IL-8. J. Immunol. 151, 3261–3266.
  • Nakae S, Ho LH, Yu M, Monteforte R, Iikura M, Suto H and Galli SJ (2007). Mast cell-derived TNF contributes to airway hyperreactivity, inflammation, and TH2 cytokine production in an asthma model in mice. J. Allergy Clin. Immunol. 120, 48–55.
  • Paananen K and Kovanen PT (1994). Proteolysis and fusion of low density lipoprotein particles independently strengthen their binding to exocytosed mast cell granules. J. Biol. Chem​. 269, 2023–2031.
  • Rumsaeng V, Cruikshank WW, Foster B, Prussin C, Kirshenbaum AS, Davis TA, Kornfeld H, Center DM and Metcalfe DD (1997). Human mast cells produce the CD4+ T lymphocyte chemoattractant factor, IL-16. J. Immunol. 159, 2904–2910.
  • Rumsaeng V, Vliaoftis H, Oh CK and Metcalfe DD (1997). Lymphotactin gene expression in mast cells following Fc(epilson) receptor I aggregation: modulation by TGF-beta, IL-4, dexamethasone, and cyclosporin A. J. Immunol. 158, 1353–1360.
  • Saarinen J, Kalkkinen N, Welgus HG and Kovanen PT (1994). Activation of human interstitial procollagenase through direct cleavage of the Leu83-Thr84 bond by mast cell chymase. J. Biol. Chem. 269, 18134–18140.
  • Sun J, Sukhova GK, Wolters PJ, Yang M, Kitamoto S, Libby P, MacFarlene LA, Mallen-St Clair J and Shi GP (2007). Mast cells promote atherosclerosis by releasing proinflammatory cytokines. Nat. Med. 13, 719–724.
  • Sun J, Sukhove GK, Yang M, Wolters PJ, MacFarlene LA, Libby P, Sun C, Zhang Y, Liu J, Ennis T, Knispel R, Xiong W, Thompson RW, Baxter TB and Shi GP (2007). Mast cells modulate the pathogenesis of elastase-induced abdominal aortic aneurysms in mice. J. Clin. Invest.​ 117, 3359–3368.
  • Toda N (1987). Mechanism of histamine actions in human coronary arteries. Circ. Res. 61, 280–286.
  • Walsh LJ, Trinchieri G, Waldorf HA, Whitaker D and Murphy GF (1991). Human dermal mast cells contain and release tumor necrosis factor alpha, which induces endothelial leukocyte adhesion molecule 1. Proc Natl. Acad. Sci. USA. 88, 4220–4224.
  • Wang Y and Kovanen PT (1999). Heparin proteoglycans released from rat serosal mast cells inhibit proliferation of rat aortic smooth muscle cells in culture. Circ. Res. 84, 74–83.
  • Wang Y, Shiota N, Lazurus G, Black RA and Kupper TS (2001). Mast cell chymase inhibits smooth muscle cell growth and collagen expression in vitro: transforming growth factor-beta1-dependent and -independent effects. Arterioscler. Thromb. Vasc. Biol. 21, 1928–1933.
  • Wegner CD, Gundel RH, Reilly P, Haynes N, Letts LG and Rothlein R (1990). Intercellular adhesion molecule-1 (ICAM-1) in the pathogenesis of asthma. Science. 247, 456–459.