Atherosclerosis and its major consequence, myocardial infarctions, represent a major cause of morbidity and mortality. Atherosclerosis is a chronic inflammatory process in the intima of most large- and middle-sized arteries.1Frostegard J. Immunity, atherosclerosis and cardiovascular disease.BMC Med. 2013; 11: 117Crossref PubMed Scopus (551) Google Scholar Typical of atherosclerosis is the accumulation of oxidized lipid moieties, mainly from Oxidized Low Density Lipoprotein (OxLDL), in the intima of many arteries. According to the LDL-oxidation hypothesis, OxLDL is involved in the pathogenesis of atherosclerosis and cardiovascular disease (CVD). This was proposed in the 80s, as an extension and development of the concept of LDL being a risk factor.2Steinberg D. Parthasarathy S. Carew T.E. Khoo J.C. Witztum J.L. Beyond cholesterol. Modifications of low-density lipoprotein that increase its atherogenicity [see comments].N Engl J Med. 1989; 320: 915-924PubMed Google Scholar Another major feature of atherosclerosis is the accumulation of dead cells in lesions. Atherosclerosis could therefore be described as a problem of defective clearance since the body normally has strong defence and clearance systems for these types of compounds. It has been known for long time that atherosclerosis is an inflammatory process, where immune competent cells accumulate, initially in the intima of arteries. Cell types believed to be of major importance in atherosclerotic plaques include activated dendritic cells, monocytes/macrophages, and T cells producing mainly proinflammatory cytokines. Also endothelial cells and smooth muscle cells play a role.3Frostegard J. Ulfgren A.K. Nyberg P. Hedin U. Swedenborg J. Andersson U. Hansson G.K. Cytokine expression in advanced human atherosclerotic plaques: dominance of pro-inflammatory (Th1) and macrophage-stimulating cytokines.Atherosclerosis. 1999; 145: 33-43Abstract Full Text Full Text PDF PubMed Scopus (844) Google Scholar One driver of the chronic low grade inflammation in atherosclerosis could be OxLDL which is known to be both immunogenic and proinflammatory under certain circumstances and also toxic for cells4Frostegard J. Nilsson J. Haegerstrand A. Hamsten A. Wigzell H. Gidlund M. Oxidized low density lipoprotein induces differentiation and adhesion of human monocytes and the monocytic cell line U937.Proc Natl Acad Sci U S A. 1990; 87: 904-908Crossref PubMed Google Scholar, but there could be others, including necrotic cells and even infectious agents.1Frostegard J. Immunity, atherosclerosis and cardiovascular disease.BMC Med. 2013; 11: 117Crossref PubMed Scopus (551) Google Scholar During LDL-oxidation several interesting and potentially atherogenic compounds are generated, including lipid related ones malondialdehyde (MDA), phosphorylcholine or phosphocholine (PC), and apoB100-related ones (apoB being the protein in LDL). Oxidation can occur by different non-mutually exclusive mechanisms, including chemical oxidation and enzymatic modification.1Frostegard J. Immunity, atherosclerosis and cardiovascular disease.BMC Med. 2013; 11: 117Crossref PubMed Scopus (551) Google Scholar Antibodies against oxLDL (anti-OxLDL) have been known for a long time, but their role in atherosclerosis is complex. In the early 90s, reports mostly indicated anti-OxLDL as a risk marker for atherosclerosis and its complications, and anti-OxLDL was even demonstrated to be cross-reacting with thrombogenic antiphospholipid antibodies (aPL).5Vaarala O. Alfthan G. Jauhiainen M. Leirisalo-Repo M. Aho K. Palosuo T. Crossreaction between antibodies to oxidised low-density lipoprotein and to cardiolipin in systemic lupus erythematosus.Lancet. 1993; 341: 923-925Abstract PubMed Scopus (373) Google Scholar After that, an association between antibodies and protection in relation to atherosclerosis or CVD was reported for the first time, for anti-OxLDL.6Wu R. de Faire U. Lemne C. Witztum J.L. Frostegard J. Autoantibodies to OxLDL are decreased in individuals with borderline hypertension.Hypertension. 1999; 33: 53-59Crossref PubMed Google Scholar One way of dealing with the complexity of OxLDL and anti-OxLDL is to study antibodies against components of OxLDL or related compounds, which is the topic of the paper entitled “High ImmunoglobulinM Levels to Oxidation-Specific Epitopes Are Associated with Lower Risk of Acute Myocardial Infarction” in this issue of the Journal of Lipid Research, which focuses on oxidation-specific epitopes (OSE). MDA is studied both as a part of MDA-Oxidized LDL and as a peptide mimotope with similar antigenic properties. PC is by itself only a hapten but becomes immunogenic when exposed as in oxLDL or bound to a carrier (here bovine serum albumin. Another component of LDL, apoB100, is also studied as an antigen herein. . All four were lower among patients with acute myocardial infarction (AMI) when controlled for other risk factors, and associations were stronger when high and low percentiles where compared. The present study was carried out in order to investigate the role of these antibodies in MI, and also to simultaneously study these antigens in the same setting, so they could be compared. The study, by far the largest on this topic. consists of a cohort of 4559 patients with acute myocardial infarction (AMI) and 4617 age and sex-matched controls without (AMI) were compared. IgM levels were measured within 24 hours of first AMI. By use of C-statistics it was demonstrated that IgM against OSE significantly adds strength to established risk factors in determining risk of AMI. Importantly, IgM against OSE were specific as a protection marker since total IgM did not give such an association. Both environmental and genetic factors contribute to the continuous production of IgM anti-OSE but details of this need to be more clarified. These antibodies are likely to be pivotal both in protection against infections and in cellular/organ homeostasis including clearance of debris and dead cells. This type of antibodies have previously been reported to be associated with protection, not only against atherosclerosis and its complications, but also against other chronic inflammatory conditions and autoimmune diseases.1Frostegard J. Immunity, atherosclerosis and cardiovascular disease.BMC Med. 2013; 11: 117Crossref PubMed Scopus (551) Google Scholar One limitation of this study is that it only focuses on IgM. Even though IgM against OSE represents 20-30% of the circulating IgM pool in absence of acute infections, other subclasses and isotypes could be of interest. IgG1anti-PC is similar to IgM in association with protection with CVD while IgG2 less so.7Samal S.K. Panda P.K. Vikstrom M. Leander K. de Faire U. Ahuja R. Frostegard J. Antibodies Against Phosphorylcholine Among 60-Year-Olds: Clinical Role and Simulated Interactions.Front Cardiovasc Med. 2022; 9809007Crossref PubMed Scopus (2) Google Scholar Further studies on these are clearly needed. Another limitation is that the study is not prospective, and large studies of incident cases of CVD and the role of these types of antibodies are needed to further establish anti-OSE antibodies as determinants of risk. Animal experiments support a protective role of this type of antibodies. For example, immunization with MDA-modified LDL ameliorated atherosclerosis development in both rabbits8Palinski W. Miller E. Witztum J.L. Immunization of low density lipoprotein (LDL) receptor-deficient rabbits with homologous malondialdehyde-modified LDL reduces atherogenesis.Proc Natl Acad Sci U S A. 1995; 92: 821-825Crossref PubMed Scopus (528) Google Scholar and mice9Freigang S. Horkko S. Miller E. Witztum J.L. Palinski W. Immunization of LDL receptor-deficient mice with homologous malondialdehyde-modified and native LDL reduces progression of atherosclerosis by mechanisms other than induction of high titers of antibodies to oxidative neoepitopes.Arterioscler Thromb Vasc Biol. 1998; 18: 1972-1982Crossref PubMed Google Scholar and immunization with PC decreases atherosclerosis development using active10Caligiuri G. Khallou-Laschet J. Vandaele M. Gaston A.T. Delignat S. Mandet C. Kohler H.V. Kaveri S.V. Nicoletti A. Phosphorylcholine-targeting immunization reduces atherosclerosis.J Am Coll Cardiol. 2007; 50: 540-546Crossref PubMed Scopus (144) Google Scholar or passive11Faria-Neto J.R. Chyu K.Y. Li X. Dimayuga P.C. Ferreira C. Yano J. Cercek B. Shah P.K. Passive immunization with monoclonal IgM antibodies against phosphorylcholine reduces accelerated vein graft atherosclerosis in apolipoprotein E-null mice.Atherosclerosis. 2006; 189: 83-90Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar immunization. There are also several underlying mechanisms which could explain how these antibodies could be protective, with the three most important appearing to be an anti-inflammatory effect, inhibition of OxLDL uptake in macrophages in the artery wall leading to foam cell formation, and increased clearance of dead cells.1Frostegard J. Immunity, atherosclerosis and cardiovascular disease.BMC Med. 2013; 11: 117Crossref PubMed Scopus (551) Google Scholar There are interesting similarities, but also differences between these OSEs. All are danger-associated molecular patterns (DAMPs), signaling to different defense systems in the body that the compound to which they are exposed needs to be neutralized and/or removed. PC, though, is not only a DAMP, but also a pathogen associated molecular pattern (PAMP). To the best of my knowledge, neither MDA or apoB100 play an important role if any, as PAMPs. PC is exposed as a PAMP on many bacteria, including the polysaccharide capsule of Streptococcus pneumoniae. PC is also an important antigen in other microorganisms such as nematodes and parasites. Heritability is relatively high for antibodies against OSE in general, (67%)12Rao F. Schork A.J. Maihofer A.X. Nievergelt C.M. Marcovina S.M. Miller E.R. Witztum J.L. O'Connor D.T. Tsimikas S. Heritability of Biomarkers of Oxidized Lipoproteins: Twin Pair Study.Arterioscler Thromb Vasc Biol. 2015; 35: 1704-1711Crossref PubMed Scopus (37) Google Scholar while lower for anti-PC (we reported 40%)13Rahman I. Atout R. Pedersen N.L. de Faire U. Frostegard J. Ninio E. Bennet A.M. Magnusson P.K. Genetic and environmental regulation of inflammatory CVD biomarkers Lp-PLA2 and IgM anti-PC.Atherosclerosis. 2011; 218: 117-122Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar which may reflect a substantial influence by pathogens and/or the microbiome on anti-PC levels. This makes PC a potentially even more interesting vaccine candidate to increase protection against atherosclerosis and its complications since we are already immunized “naturally” by such external and microbial antigens. An example of natural immunization is observed in brown bears (Ursus arctos), which during hibernation show no signs of atherosclerosis in spite of uremia, immobilization, and very high cholesterol levels – all strong risk factors. They have much higher anti-PC levels during the winter than in summer. This is not the case for anti-MDA. As MDA is only a DAMP, not a PAMP, this increase in anti-PC levels may be caused by the bears´ behavior, exposure to PC-bearing antigens and consumption pattern during the preparation for hibernation, including being exposed to PAMPs.14Samal S.K. Frobert O. Kindberg J. Stenvinkel P. Frostegard J. Potential natural immunization against atherosclerosis in hibernating bears.Sci Rep. 2021; 1112120Crossref PubMed Scopus (9) Google Scholar Similarly, IgM anti-PC levels are much higher among individuals from Papua New Guinea, living a life as hunters, gatherers and horticulturalists and with little signs of CVD as compared to age and sex-matched Swedes.15Frostegard J. Tao W. Georgiades A. Rastam L. Lindblad U. Lindeberg S. Atheroprotective natural anti-phosphorylcholine antibodies of IgM subclass are decreased in Swedish controls as compared to non-westernized individuals from New Guinea.Nutr Metab (Lond). 2007; 4: 7Crossref PubMed Scopus (46) Google Scholar In line with this reasoning, humans are born with substantial amounts of IgM anti-MDA, while anti-PC is almost non-detectable at birth and thus requires contact with the external world to develop.16Thiagarajan D. Lundstrom S.L. Pershagen G. Almqvist C. Andolf E. Hedman A. Berg O. Oparina N. Frostegard J. Antibodies against Phosphorylcholine and Malondialdehyde during the First Two Years of Life.J Immunol. 2020; 205: 2109-2116Crossref PubMed Scopus (5) Google Scholar Furthermore IgM anti-PC is not germ line encoded with dominating clone as TI5 in mice, instead humans mount somatically mutated antibodies against PC using a broad variety of Ig genes.17Fiskesund R. Steen J. Amara K. Murray F. Szwajda A. Liu A. Douagi I. Malmstrom V. Frostegard J. Naturally occurring human phosphorylcholine antibodies are predominantly products of affinity-matured B cells in the adult.J Immunol. 2014; 192: 4551-4559Crossref PubMed Scopus (35) Google Scholar Interestingly, women have higher levels of these antibodies than men in all studies I am aware of. This is interesting given that women get CVD some years later in life, than men, which would support the notion of a protective role. The cause of womens´ higher levels of this type of antibodies is interesting per se and could have different causes, which are not well described. Taken together, this interesting study adds strength to the notion that increasing antibody levels against OSE, through active and even passive immunization, could ameliorate atherosclerosis and decrease the risk of complications of atheroslerosis like MI as in the present paper, but also stroke and other chronic inflammatory conditions.