Macrophages heterogeneity in atherosclerosis – implications for therapy

•  Introduction •  Current concepts in monocyte heterogeneity •  Pro‐atherogenic role of plaque macrophages •  Anti‐atherogenic role of plaque macrophages •  Macrophage heterogeneity and in vitro classification •  Macrophage heterogeneity within atherosclerotic plaques •  Macrophage heterogeneity in obesity and    obesity‐associated disorders •  Macrophage modulation by pathogens and tumours •  Pharmacological modulation of macrophage function •  Macrophages as a target to non‐invasively image vulnerable plaques •  SummaryAtherosclerosis is a chronic inflammatory disease occurring within the artery wall and is an underlying cause of cardiovascular complications, including myocardial infarction, stroke and peripheral vascular disease. Its pathogenesis involves many immune cell types with a well accepted role for monocyte/macrophages. Cholesterol‐loaded macrophages are a characteristic feature of plaques and are major players in all stages of plaque development. As well as modulating lipid metabolism, macrophages secrete inflammatory cytokines, chemokines and reactive oxygen and nitrogen species that drive pathogenesis. They also produce proteases and tissue factor that contribute to plaque rupture and thrombosis. Macrophages are however heterogeneous cells and when appropriately activated, they phagocytose cytotoxic lipoproteins, clear apoptotic bodies, secrete anti‐inflammatory cytokines and synthesize matrix repair proteins that stabilize vulnerable plaques. Pharmacological modulation of macrophage activity therefore represents a potential therapeutic strategy for atherosclerosis. The aim of this review is to provide an overview of the current understanding of the different macrophage subsets and their monocyte precursors, and, the implications of these subsets for atherosclerosis. This will present a foundation for highlighting novel opportunities to exploit the heterogeneity of macrophages as important diagnostic and therapeutic targets for atherosclerosis and its associated diseases.