Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Oct 26, 2018; 10(10): 123-126
Published online Oct 26, 2018. doi: 10.4330/wjc.v10.i10.123
T-cells in myocardial infarction: Culprit instigators or mere effectors?
Luca Liberale, Aldo Bonaventura, Fabrizio Montecucco
Luca Liberale, Center for Molecular Cardiology, University of Zürich, Schlieren 8952, Switzerland
Luca Liberale, Aldo Bonaventura, Fabrizio Montecucco, First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa 16132, Italy
Fabrizio Montecucco, IRCCS Ospedale Policlinico San Martino Genoa - Italian Cardiovascular, Network, 16132 Genoa, Italy
ORCID number: Luca Liberale (0000-0003-1472-7975); Aldo Bonaventura (0000-0002-4747-5535); Fabrizio Montecucco (0000-0003-0823-8729).
Author contributions: Liberale L wrote the manuscript; Bonaventura A and Montecucco F revised the draft and gave suggestions for its improvement.
Conflict-of-interest statement: Liberale L, Bonaventura A and Montecucco F declare no conflict of interest related to this publication.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Luca Liberale, MD, Postdoctoral Fellow, Doctor, First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, Genoa 16132, Italy. luca.liberale@uzh.ch
Telephone: +39-10-3537940 Fax: +39-10-3538686
Received: May 29, 2018
Peer-review started: May 29, 2018
First decision: June 14, 2018
Revised: June 20, 2018
Accepted: June 28, 2018
Article in press: June 28, 2018
Published online: October 26, 2018


Immune system activation and dysfunction characterize the early phase of reperfusion after a myocardial infarction (MI). Despite initially neglected, adaptive immunity has been recently showed to play an important role in this setting. In fact, the immune system can recognize sequestered antigens released by the necrotic tissue, initiating a deleterious autoimmune vicious circle leading to worse outcome. In their recent work, Angelini et al shed the light on a new feature of post-MI which involves two “old players” of post-ischemic myocardial injury: CD31 and matrix metalloproteinase (MMP)-9. Specifically, the authors showed that an enhancement of MMP-9 release could determine the cleavage of inhibitory CD31 from CD4+ T-cells surface in patients with Acute Coronary Syndromes (ACS). These findings open the room for new studies investigating the role of MMP9 in other pathological processes associated with a reduction of CD31 functionality, such as plaque instability and rupture. Of interest, in the case of a causative role for CD31 shedding in ACS would be confirmed, there might be a potential role for the administration of CD31 protein or analogue compounds to blunt post-ischemic cardiac inflammation and improve ACS outcome.

Key Words: Matrix metalloproteinase, Lymphocytes, Autoimmunity, Inflammation, Myocardial infarction, Adaptive immunity

Core tip: CD31 and matrix metalloproteinases (MMP)-9 are known mediators that are upregulated during reperfusion after cardiac ischemia. By inhibiting T-cell receptor-dependent lymphocyte activation, the functional CD31 could reduce post-ischemic inflammatory response; while MMP-9 is deeply involved in inflammatory cell recruitment and myocardial remodeling. A recent paper published in European Heart Journal linked these mediators by showing CD31 cleavage to be MMP-9 dependent in patients with acute coronary syndromes (ACS). Whether this process is causative of ACS or rather its effect still needs to be clarified.


Acute Coronary Syndromes (ACS)-including unstable angina and myocardial infarction (MI) are the most detrimental atherosclerosis-related complications being the leading causes of mortality worldwide and a considerable source of morbidity[1]. Although outstanding leap forwards of primary and secondary prevention measures, the issue of the residual risk for ischemic complication is still unsolved[2]. Also, it is now well-recognized that after a prompt reperfusion, as it is the case of vast majority of patients suffering from MI, the ischemic hearts need to face an additional damage directly induced by the re-establishment of blood flow itself[3]. The role of innate immunity in the determination of both residual risk and ischemia/reperfusion injury has been studied from decades and is now better established[4-6]. The adaptive immune system (i.e., T-cells and B-cells) have only recently come into focus. Indeed, lymphocytes’ ability to react only against specific non-self-antigens, as opposed to the reactivity against non-specific danger signal showed by innate immunity, excluded these mediators from the list of “guilty” parties for a long time. Only recently, the recognition of a role for the release of sequestered antigens from the necrotic tissue in the progressive diversification of autoreactive lymphocytes (i.e., epitope spreading) shed the light on the potential involvement of adaptive auto-reactivity in the determination of post-MI outcome[7]. After an ACS, the necrotic heart tissue releases several danger-associated molecular patterns (DAMPs) together with cardiac intracellular proteins[8,9]. In this highly inflamed micro-environment, cardiac antigens can be recognized by autoreactive lymphocyte clones and trigger autoimmunity processes. Afterward, the same immune-mediated tissue injury supplies the amount of autoantigens necessary to maintain the auto-reactivity thus sustaining the dysfunctional immune cardiac process[9]. This editorial refers to the outstanding research article entitled “matrix metalloproteinases-9 might affect adaptive immunity in non-ST segment elevation ACS by increasing CD31 cleavage on CD4+ cells”, recently published by Angelini et al[10] in European Heart Journal.


Although several studies have implicated T-cells in the pathophysiology of ACS, the knowledge about their specific role is still elusive. Considering the heterogeneity of T-cell subsets and the quickly evolving local and systemic environment after ACS, a tight regulation of rapidly changing T-cell phenotypes with regulator or effector functions is likely[11]. Experimental evidence highlights infiltrating T-cells as effector lymphocytes which have been antigen-restricted and primed in the heart-draining lymph nodes. Of interest, after ACS, particular subsets of pro-inflammatory CD28- CD4+ and Th17 lymphocytes are released in the blood stream and produce large amounts of interferon-γ and IL-17: Detrimental cytokines with known ability to increase cardiomyocyte death, fibroblast proliferation and pro-fibrotic gene expression[12-14]. Not only detrimental T-cells with effector functions are increased after ACS but they also display dysfunctional features. Indeed, they overexpress CD40 ligand in this way being more easily activated by antigen presenting cells[15]. Furthermore, a direct cytotoxic effect of infiltrating autoreactive CD8+ T-lymphocytes with specificity towards cardiac myosin has been described[16]. To further potentiate the detrimental role of T lymphocytes in the setting of MI, the raise of pro-inflammatory lymphocyte subsets is accompanied by a reciprocal reduction in CD4+CD25+Foxp3+ regulatory T-lymphocytes with a beneficial cardiac protective role[17].


Post-transcriptional CD31 modifications showed capacity to affect normal T-lymphocyte function. Indeed, CD31 (also known as platelet endothelial cell adhesion molecule-1) was shown to regulate T lymphocyte activity through the inhibition of T cell receptor (TCR) signalling[18]. Of interest, CD31 extracellular domain is shed from the lymphocyte surface during ACS and this contributes to the over activation of adaptive immunity[19]. In their recent article, Angelini et al[10] added one more piece to this puzzle by showing matrix metalloproteinase (MMP)-9 to be involved in CD31 cleavage in lymphocytes from ACS patients. Firstly, they confirm CD31 shedding to be a specific feature of lymphocytes in ACS, as compared to samples from healthy subjects but also patients with stable angina (SA). Then, the authors demonstrated in vitro that down-regulation of the functional CD31 domain in ACS is associated with TCR activation and is led by post-transcriptional mechanisms since post-stimulation levels of CD31 mRNA were similar in ACS and SA cells. Finally, after observing CD31 to be a possible substrate for MMP-9 by using an dedicated software predicting novel substrates and their cleavage sites, the authors show lymphocytes from ACS patients to produce higher enzyme levels after stimulation and CD31 active domain to be preserved by MMP-9 inhibition. Based on these results, the authors propose a new sequence of events that might characterize ACS onset in which the increased release of MMP-9 causes CD31 cleavage, thus affecting TCR-dependent T-cell activation and causing T-cell hyperactivity[10].


Angelini et al[10] added knowledge to the field of dysfunctional adaptive immunity in ACS. At the same time, they raise new appealing questions. In particular, CD31 is known to mediate also endothelial-endothelial interactions, thus allowing the constitution of the continuous and protective intimal cell monolayer[20]. Now, further investigations are advisable to assess whether the inflammation-induced overproduction of MMP-9[21] could reduce these interactions and potentially contribute to endothelial erosion and plaque instability. Under this point of view, CD31 was previously described to target macrophage activation, as well as cytokine and chemokine release within atherosclerotic plaques and aneurysmal peri-aorta[22]. Also, it would be of interest to show CD31 modifications in lymphocytes to take act before ACS onset. In general, this is a very common weakness of studies focused on cellular phenotype during ACS due to the requirement of intact cells for fluorescent-activated sorting which does not allow sample storage before the dosage. Animal studies could help in assessing this causal connection.

Given the fact that CD31 protein or analog molecules are already available[23], answering these questions could point out CD31 replacement as a potential therapeutic approach to blunt inflammation and modulate tissue damage in acute cardiovascular diseases (such as MI and stroke) that are characterized by an impaired adaptive immunity.


Manuscript source: Invited manuscript

Specialty type: Cardiac and cardiovascular systems

Country of origin: Italy

Peer-review report classification

Grade A (Excellent): 0

Grade B (Very good): B, B, B

Grade C (Good): 0

Grade D (Fair): D

Grade E (Poor): 0

P- Reviewer: Aksu T, Altarabsheh SE, Dai X, Iacoviello M S- Editor: Ji FF L- Editor: A E- Editor: Wu YXJ

1.  Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation. 2018;137:e67-e492.  [PubMed]  [DOI]
2.  Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315-2381.  [PubMed]  [DOI]
3.  Yellon DM, Hausenloy DJ. Myocardial reperfusion injury. N Engl J Med. 2007;357:1121-1135.  [PubMed]  [DOI]
4.  Carbone F, Liberale L, Bonaventura A, Cea M, Montecucco F. Targeting Inflammation in Primary Cardiovascular Prevention. Curr Pharm Des. 2016;22:5662-5675.  [PubMed]  [DOI]
5.  Montecucco F, Liberale L, Bonaventura A, Vecchiè A, Dallegri F, Carbone F. The Role of Inflammation in Cardiovascular Outcome. Curr Atheroscler Rep. 2017;19:11.  [PubMed]  [DOI]
6.  Bonaventura A, Liberale L, Vecchié A, Casula M, Carbone F, Dallegri F, Montecucco F. Update on Inflammatory Biomarkers and Treatments in Ischemic Stroke. Int J Mol Sci. 2016;17:pii: E1967.  [PubMed]  [DOI]
7.  Vanderlugt CL, Miller SD. Epitope spreading in immune-mediated diseases: implications for immunotherapy. Nat Rev Immunol. 2002;2:85-95.  [PubMed]  [DOI]
8.  Lv H, Lipes MA. Role of impaired central tolerance to α-myosin in inflammatory heart disease. Trends Cardiovasc Med. 2012;22:113-117.  [PubMed]  [DOI]
9.  Liao YH, Cheng X. Autoimmunity in myocardial infarction. Int J Cardiol. 2006;112:21-26.  [PubMed]  [DOI]
10.  Angelini G, Flego D, Vinci R, Pedicino D, Trotta F, Ruggio A, Piemontese GP, Galante D, Ponzo M, Biasucci LM. Matrix metalloproteinase-9 might affect adaptive immunity in non-ST segment elevation acute coronary syndromes by increasing CD31 cleavage on CD4+ T-cells. Eur Heart J. 2018;39:1089-1097.  [PubMed]  [DOI]
11.  Bluestone JA, Mackay CR, O’Shea JJ, Stockinger B. The functional plasticity of T cell subsets. Nat Rev Immunol. 2009;9:811-816.  [PubMed]  [DOI]
12.  Yan X, Shichita T, Katsumata Y, Matsuhashi T, Ito H, Ito K, Anzai A, Endo J, Tamura Y, Kimura K. Deleterious effect of the IL-23/IL-17A axis and γδT cells on left ventricular remodeling after myocardial infarction. J Am Heart Assoc. 2012;1:e004408.  [PubMed]  [DOI]
13.  Liuzzo G, Biasucci LM, Trotta G, Brugaletta S, Pinnelli M, Digianuario G, Rizzello V, Rebuzzi AG, Rumi C, Maseri A. Unusual CD4+CD28null T lymphocytes and recurrence of acute coronary events. J Am Coll Cardiol. 2007;50:1450-1458.  [PubMed]  [DOI]
14.  Liuzzo G, Kopecky SL, Frye RL, O’Fallon WM, Maseri A, Goronzy JJ, Weyand CM. Perturbation of the T-cell repertoire in patients with unstable angina. Circulation. 1999;100:2135-2139.  [PubMed]  [DOI]
15.  Aukrust P, Müller F, Ueland T, Berget T, Aaser E, Brunsvig A, Solum NO, Forfang K, Frøland SS, Gullestad L. Enhanced levels of soluble and membrane-bound CD40 ligand in patients with unstable angina. Possible reflection of T lymphocyte and platelet involvement in the pathogenesis of acute coronary syndromes. Circulation. 1999;100:614-620.  [PubMed]  [DOI]
16.  Huber SA, Graveline D, Born WK, O’Brien RL. Cytokine production by Vgamma(+)-T-cell subsets is an important factor determining CD4(+)-Th-cell phenotype and susceptibility of BALB/c mice to coxsackievirus B3-induced myocarditis. J Virol. 2001;75:5860-5869.  [PubMed]  [DOI]
17.  Han SF, Liu P, Zhang W, Bu L, Shen M, Li H, Fan YH, Cheng K, Cheng HX, Li CX. The opposite-direction modulation of CD4+CD25+ Tregs and T helper 1 cells in acute coronary syndromes. Clin Immunol. 2007;124:90-97.  [PubMed]  [DOI]
18.  Clement M, Fornasa G, Guedj K, Ben Mkaddem S, Gaston AT, Khallou-Laschet J, Morvan M, Nicoletti A, Caligiuri G. CD31 is a key coinhibitory receptor in the development of immunogenic dendritic cells. Proc Natl Acad Sci USA. 2014;111:E1101-E1110.  [PubMed]  [DOI]
19.  Flego D, Severino A, Trotta F, Previtero M, Ucci S, Zara C, Pedicino D, Massaro G, Biasucci LM, Liuzzo G. Altered CD31 expression and activity in helper T cells of acute coronary syndrome patients. Basic Res Cardiol. 2014;109:448.  [PubMed]  [DOI]
20.  Lertkiatmongkol P, Liao D, Mei H, Hu Y, Newman PJ. Endothelial functions of platelet/endothelial cell adhesion molecule-1 (CD31). Curr Opin Hematol. 2016;23:253-259.  [PubMed]  [DOI]
21.  Papazafiropoulou A, Tentolouris N. Matrix metalloproteinases and cardiovascular diseases. Hippokratia. 2009;13:76-82.  [PubMed]  [DOI]
22.  Fornasa G, Clement M, Groyer E, Gaston AT, Khallou-Laschet J, Morvan M, Guedj K, Kaveri SV, Tedgui A, Michel JB. A CD31-derived peptide prevents angiotensin II-induced atherosclerosis progression and aneurysm formation. Cardiovasc Res. 2012;94:30-37.  [PubMed]  [DOI]
23.  Groyer E, Nicoletti A, Ait-Oufella H, Khallou-Laschet J, Varthaman A, Gaston AT, Thaunat O, Kaveri SV, Blatny R, Stockinger H. Atheroprotective effect of CD31 receptor globulin through enrichment of circulating regulatory T-cells. J Am Coll Cardiol. 2007;50:344-350.  [PubMed]  [DOI]