Elevated apolipoprotein C3 heightens atherosclerosis risk by mediating arterial accumulation of free cholesterol and local inflammation in diabetes

Cardiovascular outcome trials are being considered for therapeutics that silence apolipoprotein C3 (APOC3) or angiopoietin-like 3 (ANGPTL3) because of their abilities to lower triglyceride-rich lipoproteins (TRLs) and their remnants in individuals with increased cardiovascular disease (CVD) risk1-4. Here we demonstrate that plasma APOC3 predicts CVD events in individuals with diabetes more strongly than in those without diabetes. Accordingly, plasma APOC3 levels are elevated, clearance of TRLs/remnants is slowed, and plasma TRL remnants are increased in two mouse models of diabetes-accelerated atherosclerosis. Silencing mouse APOC3 by a liver-targeted antisense oligonucleotide lowers both cholesterol and triglycerides carried by TRL/remnants and LDL and prevents aortic free cholesterol accumulation in diabetes, while ANGPTL3 silencing reduces triglycerides. Single-cell RNA-sequencing revealed that APOC3 silencing prevents a majority of diabetes-induced pathways in macrophages, endothelial cells, and smooth muscle cells, with inflammation as a major predicted upstream regulator, adding promise to APOC3 as a CVD target in diabetes.