Residual immunological risk identified by single cell multi-omics is associated with poor outcomes in patients with coronary artery disease

H. Horstmann (Freiburg im Breisgau)¹, N. Anto Michel (Freiburg im Breisgau)², C. Losert (München )³, S. T. Abogunloko (Freiburg im Breisgau)⁴, A. Peikert (Graz)⁵, S. Hansen (Freiburg im Breisgau)⁶, M. C. Gissler (Freiburg im Breisgau)⁴, T. Marchini (Freiburg im Breisgau)⁴, I. Hilgendorf (Freiburg im Breisgau)⁴, T. Gerhardt (Berlin)⁷, H. Winkels (Köln)⁸, K. Stark (München)⁹, M. Heinig (Neuherberg)¹⁰, D. Westermann (Freiburg im Breisgau)², W. März (Mannheim)¹¹, A. Zirlik (Graz)⁵, D. Wolf (Freiburg im Breisgau)^4
1Universitäts-Herzzentrum Freiburg - Bad Krozingen Klinik für Kardiologie und Angiologie I Freiburg im Breisgau, Deutschland; ²Universitäts-Herzzentrum Freiburg - Bad Krozingen Innere Medizin III, Kardiologie und Angiologie Freiburg im Breisgau, Deutschland; ³Institute of Computational Biology Helmholtz Zentrum München München , Deutschland; ⁴Universitäts-Herzzentrum Freiburg - Bad Krozingen Klinik für Kardiologie und Angiologie Freiburg im Breisgau, Deutschland; ⁵LKH-Univ. Klinikum Graz - Universitätsklinik für Innere Medizin Klinische Abteilung für Kardiologie Graz, Österreich; ⁶Universitäts-Herzzentrum Freiburg - Bad Krozingen Cardiology and Angiology Freiburg im Breisgau, Deutschland; ⁷Charité - Universitätsmedizin Berlin CC 11: Med. Klinik für Kardiologie Berlin, Deutschland; ⁸Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ⁹LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ¹⁰Helmholtz Zentrum München, Deutsches Forschungszentrum für Gesundheit und Umwelt (GmbH) Neuherberg, Deutschland; ¹¹SYNLAB Holding Deutschland GmbH SYNLAB Akademie Mannheim, Deutschland

Background and Aims: While inflammation and (auto-)immunity are known modifiers of atherosclerosis, immunological predictors of cardiovascular risk beyond the established inflammatory markers, high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) remain unknown. This proof-of-concept study aimed to detect novel transcriptional signals that specifically identify patients at an increased immunological risk.
Methods: We performed a nested case-control study within the Ludwigshafen Risk and Cardiovascular Health (LURIC) cohort, a single-center prospective study of 3,316 patients undergoing coronary angiography. A total of 44 individuals with and without angiographically confirmed coronary artery disease (CAD) were selected for transcriptomic and proteomic profiling. Peripheral blood mononuclear cells were analyzed using flow cytometry, single-cell and bulk RNA sequencing. Multi-omics Factor Analysis (MOFA) was applied to identify shared transcriptional programs associated with CAD and all-cause mortality, with a median follow-up period of 18 years.
Results: Unsupervised analysis revealed transcriptional signatures associated with activation, memory formation, proliferation, and immunoreceptor signaling in adaptive immune cells, which were linked to CAD presence and predicted poor long-term survival. These immune-related programs were not captured by established inflammatory markers, accounted for a substantial proportion of the residual risk, and outperformed hsCRP and IL-6 in terms of C-statistics.
Conclusion: Transcriptomic profiling of blood immune cells reveals distinct adaptive immune signatures associated with CAD and long-term mortality. These findings support the causality of autoimmunity in atherosclerosis progression in a subpopulation of patients with CAD and propose the use of immune transcriptomics as a powerful tool for risk stratification.
Keywords: Atherosclerosis, Leukocytes, scRNA-seq, Transcriptome, Prediction, Immunity