Atherosclerotic plaques consist mostly of smooth muscle cells (SMC), and genes that influence SMC biology can modulate coronary artery disease (CAD) risk. Allelic variation at 15q22.33 has been identified by genome-wide association studies to modify the risk of CAD, and is associated with expression of SMAD3 in SMC, but the mechanism by which this gene modifies CAD risk remains poorly understood. SMC-specific deletion of Smad3 in a murine atherosclerosis model resulted in greater plaque burden, positive remodeling, and increased vascular calcification. Single-cell transcriptomic analyses revealed that loss of Smad3 promoted SMC progeny to take on a chondromyocyte fate. These analyses also identified a unique subset of smooth muscle lineage cells that promote remodeling and recruitment of inflammatory cells. This population was marked by uniquely high Mmp3 and Cxcl12 expression, and increased in number after loss of Smad3, thus contributing to higher-risk plaque features. Further investigation of transcriptional mechanisms by which Smad3 mediates TGFβ effects on SMC gene expression provided evidence that it binds in conjunction with Hox and Sox transcription factors in the regulatory region of genes that regulate aortic remodeling and have been linked to human Mendelian aortic aneurysmal diseases. Together, these data suggest that Smad3 expression in SMC inhibits cell state changes that mediate adverse plaque features, including positive remodeling, monocyte recruitment, and vascular calcification.
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