Clonal Haematopoiesis of Indeterminate Potential and Mortality in Coronary Artery Disease

M. von Scheidt (München)¹, S. S. Adkar (Stanford)², J. Krefting (München)³, G. Hoermann (München)⁴, M. Meggendorfer, (München)⁴, S. Bauer (München)¹, S. Mitchell (Stanford)², I. Pugach (München)⁵, C. Friess (München)¹, A. Ma (New York)⁶, H. Ke (New York)⁶, S. Steigerwald (Martinsried)⁷, M. Wahle (Martinsried)⁸, T. Keßler (München)¹, M. Schwab (München)¹, F. Voll (München)¹, M. Mokry (Utrecht)⁹, C. Sofokleous (Utrecht)⁹, K. C. Palm (Utrecht)⁹, D. Bongiovanni (Augsburg)¹⁰, J. Fleig (München)¹¹, L. Oldenbuettel (München)⁵, Z. Chen (München)¹, J. S. Hecker (München)¹², F. Bassermann (München)¹², L. Maegdefessel (München)¹³, M. Graw (München)¹⁴, A. Ruusalepp (Tartu)¹⁵, I. Hilgendorf (Freiburg im Breisgau)¹⁶, F. Leuschner (Heidelberg)¹⁷, H. Sager (München)¹, J. B. Heimlich (Nashville)¹⁸, W. Koenig (München)¹, S. Cremer (Frankfurt am Main)¹⁹, D. Leistner (Frankfurt am Main)¹⁹, W. Abplanalp (Frankfurt am Main)²⁰, S. Dimmeler (Frankfurt am Main)²¹, A. M. Zeiher (Frankfurt am Main)²², S. W. van der Laan (Utrecht)²³, G. Pasterkamp (Utrecht)²⁴, C. Braun (München)²⁵, S. Jaiswal (Stanford)²⁶, J. C. Kovacic (Darlinghurst)²⁷, W. Kern (München)¹¹, C. Haferlach (München)¹¹, M. Mann (Martinsried)²⁸, S. Cassese (München)²⁹, A. Kastrati (München)¹, T. Haferlach (München)¹¹, N. J. Leeper (Stanford)³⁰, J. L. M. Björkegren (Stockholm)³¹, H. Schunkert (München)^1
1Deutsches Herzzentrum München Klinik für Herz- und Kreislauferkrankungen München, Deutschland; ²Division of Vascular Surgery Department of Surgery Stanford, USA; ³Deutsches Herzzentrum München Klink für Herzkreislauferkrankungen München, Deutschland; ⁴MLL Munich Leukemia Laboratory München, Deutschland; ⁵Deutsches Herzzentrum München, TUM Universitätsklinikum München, Deutschland; ⁶New York, USA; ⁷Max-Plack-Institut für Biochemie Proteomics und Signaltransduktion Martinsried, Deutschland; ⁸Martinsried, Deutschland; ⁹Central Diagnostics Laboratory, University Medical Center Utrecht Utrecht, Niederlande; ¹⁰Universitätsklinikum Augsburg I. Medizinische Klinik Augsburg, Deutschland; ¹¹München, Deutschland; ¹²Department of Medicine III, TUM Klinikum Rechts der Isar München, Deutschland; ¹³Klinikum rechts der Isar der Technischen Universität München Klinik für Vaskuläre und Endovaskuläre Chirurgie München, Deutschland; ¹⁴Ludwig-Maximilians-Universität Institut für Rechtsmedizin München, Deutschland; ¹⁵Tartu, Estland; ¹⁶Universitäts-Herzzentrum Freiburg - Bad Krozingen Klinik für Kardiologie und Angiologie Freiburg im Breisgau, Deutschland; ¹⁷Universitätsklinikum Heidelberg Klinik für Innere Med. III, Kardiologie, Angiologie u. Pneumologie Heidelberg, Deutschland; ¹⁸Department of Medicine, Vanderbilt University Medical Center Nashville, USA; ¹⁹Universitätsklinikum Frankfurt Med. Klinik III - Kardiologie, Angiologie Frankfurt am Main, Deutschland; ²⁰Universitätsklinikum Frankfurt Zentrum für Molekulare Medizin, Institut für Kardiovaskuläre Regeneration Frankfurt am Main, Deutschland; ²¹Goethe Universität Frankfurt am Main Zentrum für Molekulare Medizin, Institut für Kardiovaskuläre Regeneration Frankfurt am Main, Deutschland; ²²Goethe Universität Frankfurt am Main Institute of Cardiovascular Regeneration Frankfurt am Main, Deutschland; ²³PhD Laboratory of Experimental Cardiology Department of Cardiology Utrecht, Deutschland; ²⁴University Medical Center Utrecht Department of Experimental Cardiology Utrecht, Niederlande; ²⁵Institute of Legal Medicine München, Deutschland; ²⁶Stanford, USA; ²⁷Darlinghurst, Australien; ²⁸Max-Planck-Institut für Biochemie Martinsried, Deutschland; ²⁹Deutsches Herzzentrum München München, Deutschland; ³⁰Stanford University School of Medicine Division of Vascular Surgery Stanford, USA; ³¹Department of Medicine, Huddinge, Karolinska Institutet, Karolinska Universitetssjukhuset Stockholm, Schweden

Background and Aims: Clonal haematopoiesis of indeterminate potential (CHIP) has been associated with cardiovascular risk, but its prognostic relevance and mechanistic role in coronary artery disease (CAD) remains incompletely understood. This study investigated the association between CHIP and all-cause mortality in CAD and explored the cellular and molecular mechanisms, focusing on TET2 mutations.

Methods: Targeted deep sequencing of 13 CHIP driver genes in 8,612 patients with angiographically confirmed CAD was performed. Clonal haematopoiesis of indeterminate potential carriers (variant allele frequency ≥2%) were propensity-score matched 1:1 to non-carriers. Mortality was assessed over 3 years. Mechanistic insights were derived from post-mortem high- sensitivity plaque proteomics (MISSION), RNA sequencing from carotid plaques (Athero-Express), monocyte-derived macrophage transcriptomes (STARNET), and CRISPR/Cas9-generated TET2+/− macrophages in vitro.

Results: Clonal haematopoiesis of indeterminate potential was associated with increased 3-year mortality (hazard ratio 1.39, 95% conf idence interval 1.16–1.65, P < 0.001) in 2,389 matched pairs. Mutations in TET2, ASXL1, DNMT3A, JAK2, PPM1D, SF3B1, SRSF2, and U2AF1 individually conferred higher mortality risk. In human plaques, CHIP mutations were found in lesional macrophages. TET2 CHIP carriers showed increased necrotic core size, inflammation, and reduced plaque stability. Multi-omics profiling revealed up-regulation of lipid metabolism and inflammatory pathways. TET2+/− macrophages exhibited increased LDLR expression and lipid uptake, linked to enhanced chromatin accessibility at the LDLR promoter. These findings were confirmed in carotid plaques, which showed increased LDLR and inflammasome-related gene expression in TET2 CHIP carriers.

Conclusions: Clonal haematopoiesis of indeterminate potential is a predictor of mortality in CAD patients. TET2 mutations promote a pro-atherogenic macrophage phenotype via LDLR up-regulation and inflammatory activation, linking epigenetic dysregulation to adverse outcomes in CAD.