Patent Publication Number: US-9891234-B2

Title: Biochemical markers for CVD risk assessment

Description:
The present invention relates to assays for detection of biochemical markers valuable for diagnostic purposes in cardiovascular disease and prognosis of disease development, including biochemical markers indicative of the risk of cardiovascular events resulting from atherosclerotic development and plaque instability. 
     Worldwide, cardiovascular disease (CVD) is the leading cause of morbidity and mortality. At present, there are no effective and non-invasive diagnostic methods that allow for diagnosis and classification of patients into different risk-groups and for the diagnosis of low risk patients. Diagnostic and prognostic tools are composed mainly of multivariate analysis of simple markers, such as age, smoking and various lipid and lipoprotein concentrations. 
     CVD covers several clinical syndromes, primarily, angina pectoris, myocardial infarction (coronary thrombosis) and stroke. All of these syndromes are usually the sequelae of complicated atherosclerosis. 
     Atherosclerosis begins with intimal thickening in childhood and progresses to fatty streaks in the intima of arteries—these lesions are characterized as type I and II, respectively. Fatty streaks are the earliest macroscopically visible lesions in the development of atherosclerosis and occur among almost all human beings of all races and societies. In the non-pathogenic state, endothelial cells (EC) resist adhesive interactions with leukocytes. However, the actions of proinflammatory cytokines and accumulated oxidized lipoprotein in the arterial wall during atherogenesis, initiate expression of adhesion molecules, such as intercellular adhesion molecules (ICAM)-1 and vascular cell adhesion molecules (VCAM)-1, on the surface of aortic ECs. This allows for capturing and transmigration of leukocytes through the endothelial surface, into the intimal part of the vessel wall. The development of plaques involves an increasing number of smooth muscle cells (SMC) that undergo displacement and apoptosis, which results in increased matrix turnover. The impaired collagen synthesis can result in a weakened fibrous cap and an atherosclerotic plaque that is more prone to rupture; however, most investigators believe that the actions of a proteolytic enzymes such as matrix metallo-proteases (MMPs) and other proteases importantly contribute to the risk of plaque rupture (Clarkson and Kaplan 509-28). 
     Plaques are divisible into two different types: ‘vulnerable’ and ‘stabilized’ plaques. However, for detailed histological analyses and molecular understanding, a more detailed classification is often used. There are three major stages in development of plaque: initiation, fatty streaks and the complex/advanced plaque (Stary H. C.). 
     Atherosclerotic plaques develop within the intima of arteries, and may be classified depending on their composition and structure. This classification divides lesions into eight types (Stary H. C.):
         I. Macrophages loaded with and enlarged by lipid droplets (macrophage foam cells) are increased in the intima.   II. Macrophage foam cells accumulate in the deep part of the proteoglycan layer along with lipid droplets within the intimal SMC. The layers of foam cells are visible as fatty streaks. In type II lesions monocytes penetrate the endothelial lining by monocyte chemo attractant proteins (mainly MCP-1), which are over expressed in human atheroma. The early types of lesion (type I and II) can start in infancy and do not necessarily lead to plaque rupture. Furthermore, the development of atherosclerosis may end after the formation of type III lesion, and the formation of plaque is not predictable (Stary H. C.).   III. The type III lesion is determined as the intermediate lesion between the fatty streaks (type II) and the atheroma (type IV). These lesions contain pools of extracellular lipid and thereby expand the spaces between the normally closely adjoining SMCs of the deep musculo-elastic layer of the intima. The pools of material may replace proteoglycans and collagen fibres that normally reside here, but this occurs with little impact at this stage of atherogenesis.   IV. The atheroma is the first clinical sign of atherosclerosis. Displacement of SMCs in the intima of arteries by accumulating extracellular pools of lipids and disruption of the intimal architecture is a hallmark of a type IV lesion. The formation of the lipid cores is the end result of this SMC displacement. Formation of a lipid core accounts for the increased wall thickening. The lipid core is a large and well delineated region of the deep intima where the normal structural elements of this part of the arterial wall have been replaced by densely packed foam cell remnants, free lipids droplets, cholesterol crystals and calcium particles. SMCs normally resident in this area are decreased or completely absent at this stage of atherosclerosis progression. Any remnant SMCs become widely dispersed and have developed elongated cell bodies and very often unusually thick basement membranes. At this stage, the development of a layer overlying the lipid core begins. This layer consists of collagen and proteoglycan-rich intercellular matrix, SMCs with and without lipid droplets, macrophages, and foam cells.   V. The response to type IV lesion is the formation of a reparative fibrous tissue matrix, forming a fibrous “cap”. Typically, these lesions will consist of layers of lipid cores and reparative tissue irregularly stacked on top of each other. Events such as hematoma and thrombus formation may additionally complicate these types of lesions. If not fatal, these lesion complications are integrated into the lesion and overgrown by a thin layer of reparative matrix tissue, consisting of collagens and proteoglycans. The content of extracellular matrix proteins collagen and proteoglycans increases in the atherosclerotic plaque during formation of the cap.   VI. The defects of the endothelium such as fissures, erosions, ulcerations, hematoma, thrombus, haemorrhage can if combined lead to more complicated lesion type designated type VI lesion.   VII. The lesion is often referred to as calcified lesion, where more than 50% of the lesion consists of mineral. In addition to calcifications, these lesions contain abundance of reparative fibrous connective tissue. When the SMCs trapped in this undergo apoptosis and disintegrate; their mineralized organelles become a part of the calcification.   VIII. The fibrotic lesion follows the calcific lesion. The fibrotic lesion may consist entirely of collagen and no lipid. (Stary H. C.)       

     Cardiovascular events are often the result of plaque rupture, in which inflammation and the release of proteases weaken the shoulder regions of the fibrous cap and allow the fatty materials in the plaque to come into contact with the blood precipitating a mural thrombus (Clarkson and Kaplan). Thinning of the fibrous cap by increased protease activity in the combination with decreased matrix production, is considered a hallmark of plaque instability increasing the risk of rupture. Vulnerability of plaques and their risk of rupture is an area of clinical interest. Definition of a vulnerable plaque (VP) is not standardized, but there is a general agreement stating existence of three histological hallmarks compared to stable plaque: 
     1) A larger lipid core (&gt;40 percent of total lesion). 
     2) A thinner fibrous cap (65-150 micrometers). 
     3) Large amount of acute inflammatory cells. 
     Major criteria for defining VP include: active inflammation (presence of monocytes, macrophages and T cells), thin cap with large lipid core, endothelial denudation with superficial platelet aggregation, fissured plaque, and &gt;90% stenosis of the artery. Other minor criteria include: superficial calcified nodule, intraplaque haemorrhage, endothelial dysfunction, and outward remodelling (Shin, Edelberg, and Hong). 
     Plaque complications, instability and rupture may be inhibited by medical treatment and/or lifestyle modification. In some cases, however, more invasive methods may be needed, i.e. angioplasty or bypass surgery. 
     Presently, diagnostic tools are based on either static image analyses still under development or low-technology methods such as systolic and diastolic blood pressure levels related to the risk of CVD. The field has devoted much attention to the development of multivariate analysis that may better identify patients at high risk. One such model is the SCORE-model (Systematic Coronary Risk Evaluation model). In 1994, with a revision in 2003, The European Atherosclerosis Society, The European Society of Cardiology and The European Society of Hypertension issued a set of recommendations regarding prevention of coronary heart diseases. This guideline is based on several assessment techniques, which have been developed to assess the risk of CVD in asymptomatic subjects, i.e. identification of asymptomatic high-risk patients. The SCORE-model integrates gender, age, smoking, systolic blood pressure and either total cholesterol or the cholesterol/HDL ratio as risk factors (Graham et al.). 
     In order to make a more detailed diagnosis, the SCORE model is not sufficient and imaging techniques are used. Imaging methods are therefore used mostly on patients in the high-risk group or during research. 
     Imaging Techniques 
     Coronary angiography (CAG) is currently the gold standard imaging technique for defining the degree of stenosis. CAG images the lumen of the vessel in two dimensions, but is restricted only to the lumen and not the vessel wall thereby CAG can not distinguish between an artery with a stable plaque and an artery with a vulnerable plaque. CAG is often used to determine whether a patient needs surgery; angioplasty or bypass. In order to determine if a point of luminal narrowing is an advanced plaque, other techniques are needed i.e. intravascular coronary ultrasound (IVUS) or angioscopy. 
     IVUS provides two-dimensional cross-sectional images of the plaque and vessel wall, and is considered as a method good for characterization of vessel wall and morphology and the degree of calcification, but poor for assessing the lipids in the lesion. However, IVUS is invasive and requires expertise and expense: therefore, its use is not wide spread. Angioscopy is another useful method in understanding and identifying atherosclerosis. Angioscopy is a direct visualization of plaque surface and has the capability of detecting colour of plaque and thrombosis. Angioscopy is, however, invasive and technically difficult, and so far it is has not been able to detect the degree of plaque extension. Another imaging technique that currently is receiving much attention is Magnetic Resonance imaging (MRI). MRI is non-invasive and able to identify carotid plaque at high risk of stroke. On the other hand, MRI is not the best technique to image coronary arteries, because of small plaque sizes and location of the coronary arteries. Other imaging techniques are under development, i.e. elastography, thermography and optical coherence tomography (Schaar et al.). 
     The imaging techniques mentioned are all under development and alone, none can identify a vulnerable plaque, but they are useful tools in understanding both the molecular events and plaque turnover prior to rupture. Presently, the only opportunity to diagnose CVD at an early stage is to utilize a range of risk factors for established coronary heart disease, peripheral artery disease and cerebrovascular atherosclerotic disease of the patient in question, as well as close relatives of the patient. 
     Present Biochemical Markers 
     At present, several biochemical markers are known as risk factors for atherosclerosis. Recently much attention has been directed to the measurement of biochemical marker concentrations in serum; both lipids such as total cholesterol, low-density lipoprotein cholesterol (LDL-C) and the high-density lipoprotein cholesterol (HDL-C) and inflammatory markers such as C-Reactive Protein (CRP), Interleukin-6 (IL-6), Interleukin-18 (IL-18), Tumor Necrosis Factor-alpha (TNFα), CD40, CD40 ligand (CD40L) and others. 
     Among lipoprotein markers, there have been at least two noteworthy advances. The size of LDL particles seems to predict the degree of atherosclerosis progression. Increased concentrations of small LDL particles are more related to CVD risk than increased concentrations of large particles (Gardner, Fortmann, and Krauss). 
     The level of HDL-C is strongly related to triglyceride, and high triglyceride level is correlated to a higher risk of CHD. A cohort study by Jeppesen et al. (2003) found high TG/low HDL-C as the strongest risk factors of IHD (ischemic heart disease)(Jeppesen et al.). 
     Lipid profiles are important for evaluation of risk factors, but do not allow understanding and measurement of the molecular events associated with plaque turnover. A number of biochemical markers have been suggested as risk factors for CVD, although not specific product of the disease. These include CRP and Bone natriuretic peptide (BNP) (see Table 1). Table 1 summarizes some of the known markers of CVD. 
     
       
         
           
               
             
               
                 TABLE 1 
               
             
            
               
                   
               
               
                 A selection of present biochemical markers in CVD. 
               
            
           
           
               
               
               
            
               
                 Marker 
                 Type 
                 Description 
               
               
                   
               
               
                 C-reactive protein 
                 Inflammatory 
                 Produced in the liver, 
               
               
                 (CRP) 
                   
                 increases during 
               
               
                   
                   
                 inflammatory states. 
               
               
                 Pregnancy- 
                 Inflammatory 
                 Zinc-binding protein that 
               
               
                 associated plasma 
                   
                 acts as an enzyme, 
               
               
                 protein (PAPP-A) 
                   
                 specifically a 
               
               
                   
                   
                 metallopeptidase. 
               
               
                 Interleukin-6 (IL- 
                 Inflammatory 
                 Elevated level in heart 
               
               
                 6) 
                 cytokine 
                 failure and myocardial 
               
               
                   
                   
                 infarction. 
               
               
                 Inteleukin-8 (IL- 
                 Inflammatory 
                 Elevated in myocardial 
               
               
                 8) 
                 cytokine 
                 infarctions. 
               
               
                 Interleukin-18 
                 Inflammatory 
                 Elevated in myocardial 
               
               
                   
                 cytokine 
                 infarction. 
               
               
                 TNF-α (Tumor 
                 Cytokine 
                 Conc. Elevated in the 
               
               
                 Necrosis Factor) 
                   
                 settings of heart failure. 
               
               
                 MCP-1 
                 Chemokine 
                 Recruits monocytes from 
               
               
                   
                   
                 the blood into early 
               
               
                   
                   
                 atherosclerotic lesion. 
               
               
                 Intercellular 
                 Adhesion molecule 
                 Elevated in myocardial 
               
               
                 adhesion molecule- 
                   
                 infarctions and stroke. 
               
               
                 1 (ICAM-1) 
               
               
                 Vascular cellular 
                 Adhesion molecule 
                 Elevated in myocardial 
               
               
                 adhesion molecule- 
                   
                 infarctions and stroke. 
               
               
                 1 
               
               
                 (VCAM-1) 
               
               
                 Brain natriuretic 
                 Neurohormonal 
                 Produced in atria and 
               
               
                 peptide (BNP) 
                 activity 
                 ventricles of normal 
               
               
                   
                   
                 healthy heart. 
               
               
                 Lipoprotein- 
                 Phospholipase 
                 LDL-associated Lp-PLA 2  has 
               
               
                 associated 
                   
                 proatherogenic effects. 
               
               
                 phospholipase A2 
               
               
                 (Lp-PLA 2 ) 
               
               
                 Creatine 
                 Enzyme 
                 Useful as early detection 
               
               
                 phospokinase (CK- 
                   
                 of myocardial infarction. 
               
               
                 MB) 
               
               
                 Myeloperoxidase 
                 Heme enzyme 
                 Activates metalloproteases 
               
               
                 (MPO) 
                   
                 and promotes 
               
               
                   
                   
                 destabilization of plaque. 
               
               
                 Myoglobulin 
                 Heme protein 
                 Released upon tissue 
               
               
                   
                   
                 necrosis. 
               
               
                 CD40L 
                 Protein 
                 Released in the early 
               
               
                   
                   
                 stages of atherogenesis 
               
               
                   
                   
                 through to plaque rupture. 
               
               
                   
                   
                 Elevated in stroke. 
               
               
                 Troponin T (TnT) 
                 Protein 
                 Tool for risk 
               
               
                   
                   
                 stratification. 
               
               
                 Heart-Type Fatty 
                 Protein 
                 H-FARB is released from 
               
               
                 Acid-binding 
                   
                 the heart immediately 
               
               
                 protein (H-FABP) 
                   
                 after infarction. 
               
               
                 Microalbuminurea 
                 Protein 
                 Marker of vascular 
               
               
                   
                   
                 endothelial dysfunction. 
               
               
                 Low density 
                 Lipoprotein 
                 Transport cholesterol in 
               
               
                 lipoprotein 
                   
                 the blood. 
               
               
                 cholesterol (LDL- 
               
               
                 C) 
               
               
                 High Density 
                 Lipoprotein 
                 Holds antioxidant and 
               
               
                 lipoprotein 
                   
                 antiinflammatory 
               
               
                 cholersterol (HDL- 
                   
                 properties. 
               
               
                 C) 
               
               
                 Triglyceride 
                 Lipid 
               
               
                 PIIINP 
                 Procollagen 
                 Marker of type III 
               
               
                   
                   
                 collagen turnover. 
               
               
                   
               
            
           
         
       
     
     Thus, a range of different biochemical markers have been suggested as markers of cardiovascular events. Wang et al (2006) have measured 10 different biochemical markers in 3200 patients participating in the Framingham study, described in Tabel 1. The conclusion was that the measurement of 10 biochemical markers only contributes moderately to diagnosis over and above standard risk factors. Of the 10 biochemical markers, B-type natriuretic peptide level, C-reactive protein level and the urinary albumin-to-creatinine ratio showed the best correlation between marker and death/cardiovascular events (Wang et al.). 
     Mimecan 
     Recently, a proteoglycan mimecan, also known as osteoglycin (OGN) has been implicated in regulation of collagen fibrillogenesis, artheriogenesis and in regulation of left ventricular mass 12-14 . Mimecan/OGN is part of the small leucin-rich proteoglycans (SLRP). Other members of this family are biglycan, decorin, fibromodulin and lumican. SLRPs comprise many important functions such as regulation of matrix structure, cell cycle and growth actions evoking multiple signaling pathways. The SLRPs modulate cell-matrix interactions and cell function, without participating in structural scaffold of the ECM. 
     The atherosclerotic plaque is continuously remodeling, thereby releasing a range of degradation products of ECM proteins, the so called neoepitopes 15 . These neoepitopes may be specific for the tissue of origin and are therefore interesting when designing novel molecular biochemical markers. The neoepitope based biochemical markers measurable in urine and serum are receiving increased attention for their diagnostic and prognostic potential 16 . 
     Matrix Metalloproteinases (MMP) 
     MMP is a large group of endopeptidases, capable of degrading most components of the ECM. Presently, more than 25 MMPs have been identified. Metallo-proteinases are characterized by an active site containing a metal atom, typically zinc, and are secreted as zymogens. Specific tissue inhibitors, TIMPs, regulate the activity of MMPs. A great variety of MMPs are found in the atherosclerotic plaques. They are most often located in macrophages bordering the fibrous cap, within plaque shoulders in SMC and macrophages and are rarely identified within the fibrous cap (Kunz J.).] 
     MMPs are classified in different groups according to their substrate specificity: Collagenases, which degrade fibrillar collagen, like collagen type I, II, III and V but also proteoglycans; Gelatinases, which degrade proteoglycans, collagen type IV, V, VII and elastin; Stromelysin that is active against proteoglycans and elastin (Rouis M). These three subgroups are of particular interest with regards to matrix remodelling in atherosclerotic plaques. 
     Gelatinases 
     Insoluble elastin is digested by MMP-2 and -9, both belonging to the gelatinase-family of MMPs. MMP-9 has an important role affecting the size and composition of atherosclerotic plaque. In unstable human atherosclerotic plaques and in vulnerable regions of plaques, greater expression and concentration of MMP-9 have been observed. Moreover, MMP-9 is found intracellularly (indicating active synthesis) in coronary plaques more often in patients with unstable angina compared with those with stable angina. Blood MMP-9 level increases in association with coronary atherosclerosis and predicts adverse cardiovascular events (Sundstrom and Vasan). A recent study by Kuzuya et al (2006) indicates that MMP-2 is responsible for accumulation of SMC in the fibrous cap and thereby inducing plaque instability. 
     Stromelysin 
     MMP-3 belongs to the stromelysin proteases and is capable of degrading both elastin and proteoglycans. A study by Yamada et al (2002) indicates that MMP-3 may prove to be a reliable mean of predicting the genetic risk of myocardial infarction in women. 
     Collagenases 
     MMP-1, -8 and -13 have all been identified in atherosclerotic plaques where they degrade proteoglycans and collagen types I and III. 
     MMP-1, -8 and -13 are collagenases, which cleave collagen into two fragments that are further degraded by MMP-2, -3 or -9. 
     MMP-8 is expressed by neutrophils, not commonly found in human atheroma but has been identified in atherosclerotic plaques. MMP-8 may be partly responsible for degradation of the fibrous cap as MMP-8 has a preference for collagen type I (Herman et al), having a three fold greater activity in degradation of collagen I than MMP-1 and 13. This is supported by Turu et al (2006), in this study the content of MMP-8 in the plasma are significantly higher for patients with vulnerable plaques, than patients with stable plaques. 
     MMP-13 has been reported to cleave SLRPS, with high specificity for biglycan. Degradation of biglycan by MMP-13 at a specific cleavage site ( . . . G 177 /V 178 ) has previously been demonstrated by Monfort et al. (2005) and proposed to play a important role in early detection of cartilage degradation in osteoarthritis.) 
     Cathepsins 
     Human cysteine cathepsins consist of 11 members, including cathepsins B, K, L, and S, and are predominantly expressed within the endosomal/lysosomal compartments of cells. Cathepsins are capable of catalysing the hydrolytic breakdown of proteoglycans, collagen and elastin. 
     In abdominal aortic aneurysm (AAA) high levels of cathepsins S, K, and L were found compared to normal aorta. Normal human vascular SMC contain no detectable cathepsin K by immunostaining, but cells within atherosclerotic plaques are clearly positive. Cathepsin K is localized in rupture-prone areas such as the fibrous cap, plaque shoulders and at the actual site of plaque ruptures (Chapman et al). Cathepsin S is found to co-localize with regions of increased elastin breakdown in atherosclerotic plaques, and reduced atherosclerosis is observed in cathepsin S- and K-deficient mice (Liu et al). 
     Both cathepsin L and K degrade several proteoglycans and collagen type I and II, cathepsin K degrades within covalently cross-linked triple helices, while cathepsin L cleaves only in the nonhelical telopeptide regions. Cathepsin K is localized in the fibrous cap and plaque shoulder. Cathepsin K expression in normal arteries is very low. Early human atherosclerotic lesions showed cathepsin K expression in the intimal and medial SMCs. In advanced atherosclerotic plaques, cathepsin K was localized mainly in macrophages and SMCs of the fibrous cap (Lutgens et al). Cathepsin K protein levels were increased in atherosclerotic lesions when compared with normal arteries, whereas cathepsin K mRNA levels were similar in both atherosclerotic and normal arteries. Furthermore, it was shown that cathepsin K mRNA and protein levels were highest in advanced but stable human atherosclerotic plaques compared with early atherosclerotic lesions and lesions containing thrombus (Chapman et al). 
     Cathepsin S is only sparsely expressed in intimal and medial SMCs in early human atherosclerotic lesion and fatty streaks. In advanced human atherosclerotic plaques cathepsin S was localized in macrophages and SMCs of the fibrous cap. EC lining the lumen of the vessel itself and the plaque microvessels also expressed cathepsin S. Furthermore, cathepsin S mRNA and protein levels were increased in human atheroma compared with normal arteries (Lutgens et al). Cathepsin S can degrade proteoglycans, elastin and collagen (Liu et al). 
     Presently, the determination of CVD risk is occurring at a late stage in atherosclerosis progression; a point in which there is a significant risk of fibrous plaque rupture. There is a need for diagnostic or prognostic assays that will provide information regarding atherosclerosis or CVD risk at both earlier stage and late stages. The findings of Katsuda et al (1992) suggest that there are enzymatic mechanisms for removal of collagens from advanced lesions, suggesting indeed a major role of neo-epitopes in arteriosclerosis. 
     The present invention provides a method of bioassay for the quantification of peptide fragments comprising a neo-epitope formed by cleavage of a protein of an atherosclerotic plaque by a proteinase, said method comprising contacting a sample comprising said peptide fragments with an immunological binding partner having specific binding affinity for a said neo-epitope and determining the level of binding of said immunological binding partner to peptide fragments in said sample, wherein said protein is mimecan. 
     The result of said assay may produce an index indicative of the degree of risk in a particular patient of rupture of an atherosclerotic plaque or of the vulnerable status of the atherosclerotic plaques of a patient. 
     Patients having a value for said index above a threshold level may be recommended for further investigation by plaque imaging methods (including those discussed above) or for the prescribing of medication for treatment of atherosclerosis or for surgical treatment of atherosclerosis, and such follow up investigations or treatment may form part of the method of the invention. 
     Said immunological binding partner may have specific binding affinity for peptide fragments comprising a C-terminal neo-epitope or an N-terminal neo-epitope. 
     The immunological binding partner may be one specifically reactive with a C-terminal or N-terminal neo-epitope formed by cleavage of mimecan. 
     An immunological binding partner may be considered to be specifically reactive with a neo-epitope if it is reactive with peptides terminating in the neo-epitope sequence but is not substantially reactive with intact mimecan and is not specifically reactive with peptides in which the neo-epitope terminal sequence is extended by one or more further amino acids. 
     Preferably, the immunological binding partner has specific binding affinity for a peptide fragment which comprises a neo-epitope formed by cleavage of mimecan by one or more proteases giving any one of the following peptide fragments originating from mimecan; 
     
       
         
           
               
               
               
            
               
                   
                 DFADIPNLR 
                 SEQ ID NO 1 
               
               
                   
                   
               
               
                   
                 TGNLIEDIEDGTFSK 
                 SEQ ID NO 2 
               
               
                   
                   
               
               
                   
                 LDFTGNLIEDIEDGTFSK 
                 SEQ ID NO 3 
               
               
                   
                   
               
               
                   
                 LEGNPIVLGK 
                 SEQ ID NO 4 
               
               
                   
                   
               
               
                   
                 RLDFTGNLIEDIEDGT 
                 SEQ ID NO 5 
               
               
                   
                   
               
               
                   
                 RLDFTGNLIEDIEDGTFSK 
                 SEQ ID NO 6 
               
               
                   
                   
               
               
                   
                 RLEGNPIVLGK 
                 SEQ ID NO 7 
               
               
                   
                   
               
               
                   
                 DFTGNLIEDIEDGTFSK 
                 SEQ ID NO 8 
               
               
                   
                   
               
               
                   
                 DHNALESVPLNLPESLR 
                 SEQ ID NO 9 
               
               
                   
                   
               
               
                   
                 DIDAVPPLPK 
                 SEQ ID NO 10 
               
               
                   
                   
               
               
                   
                 FTGNLIEDIEDGTFSK 
                 SEQ ID NO 11 
               
               
                   
                   
               
               
                   
                 GNLIEDIEDGTFSK 
                 SEQ ID NO 12 
               
            
           
         
       
     
     Suitable immunological binding partners may therefore be specifically reactive with any of the following sequences consisting of six amino acids (or more) at the N terminal of a peptide: 
                                DFADIP . . .   SEQ ID NO 13                       TGNLIE . . .   SEQ ID NO 14                       LDFTGN . . .   SEQ ID NO 15                       RLDFTG . . .   SEQ ID NO 16                       RLEGNP . . .   SEQ ID NO 17                       DFTGNL . . .   SEQ ID NO 18                       DHNALE . . .   SEQ ID NO 19                       DIDAVP . . .   SEQ ID NO 20                       FTGNLI . . .   SEQ ID NO 21                       GNLIED . . .   SEQ ID NO 22            
or with any of the following sequences consisting of six amino acids (or more) at the C-terminal of a peptide:
 
     
       
         
           
               
               
               
            
               
                   
                 . . . DIPNLR 
                 SEQ ID NO 23 
               
               
                   
                   
               
               
                   
                 . . . DGTFSK 
                 SEQ ID NO 24 
               
               
                   
                   
               
               
                   
                 . . . PIVLGK 
                 SEQ ID NO 25 
               
               
                   
                   
               
               
                   
                 . . . DIEDGT 
                 SEQ ID NO 26 
               
            
           
         
       
     
     Further cleavage sites defining neo-epitopes that may be assayed in a similar manner can be identified by exposing mimecan to any of the enzymes described herein and isolating and sequencing peptides thereby produced. 
     Optionally, said immunological binding partner has specific binding affinity for the sequence EDIEDGTFSK [SEQ ID NO 28] at the C terminal of a peptide or has specific binding affinity for the sequence TGNLIEDIED [SEQ ID NO 30] at the N terminal of a peptide. 
     Assays for more than one of the peptides described above may be conducted separately and their results combined or more than one of the peptides described above may be measured together. 
     The result of an assay according to the invention may be combined with one or more other measured biomarkers to form a composite index of diagnostic or prognostic value. 
     The term ‘immunological binding partner’ as used herein includes polyclonal and monoclonal antibodies and also specific binding fragments of antibodies such as Fab or F(ab′) 2 . Thus, said immunological binding partner may be a monoclonal antibody or a fragment of a monoclonal antibody having specific binding affinity. 
     The term ‘protein’ used herein includes lipoproteins and proteoglycans and other protein-(non-protein) naturally occurring conjugates. 
     Generally, all previously known immunoassay formats can be used in accordance with this invention including heterogeneous and homogeneous formats, sandwich assays, competition assays, enzyme linked assays, radio-immune assays and the like. Thus, optionally, said method is conducted as a competition immunoassay in which said immunological binding partner and a competition agent are incubated in the presence of said sample and the competition agent competes with the peptide fragments in the sample to bind to the immunological binding partner. 
     Said competition agent may be a synthetic peptide or a purified native peptide formed by cleavage of mimecan. 
     Alternatively, said method is conducted as a sandwich immunoassay in which said immunological binding partner and a further immunological binding partner having specific binding affinity for a peptide sequence contained in peptide fragments bound by said immunological binding partner are incubated in the presence of said sample and both bind together to said peptide fragments in the sample. Suitably, in such a format, a first antibody binds the sequence EDIEDGTFSK and a second antibody binds the sequence TGNLIEDIED [SEQ ID NO 30]. 
     One suitable method could be a competition immunoassay using monoclonal antibodies or antibody binding fragments binding to neo-epitopes of fragments of mimecan. Appropriately selected synthetic peptides coated onto the solid surface of a microtitre plate could compete with the sample for binding to the monoclonal antibodies or binding fragments. Alternatively, purified, native fragments from one or more of these proteins carrying the neo-epitope recognised by the monoclonal antibody or binding fragment could be used on the solid surface. Yet another alternative is to immobilise the monoclonal antibody or binding fragment on the solid surface and then co-incubate the sample with a synthetic peptide appropriately linked to a signal molecule, e.g. horseradish peroxidase or biotin. The sample may be a sample of urine, serum, blood, plasma or other, e.g. atherosclerotic plaque biopsy. 
     In certain preferred methods, the sample is a patient derived sample, and the method further comprises comparing the determined level of said binding of said peptide fragments with values characteristic of (a) comparable healthy individuals and/or (b) a pathological atherosclerotic condition and optionally associating a higher level of the measured peptide (normally indicated by a higher level of binding) with a more severe degree of a said condition. 
     An aspect of the present invention relates to the development of monoclonal antibodies recognising neo-epitopes as described above. This can be achieved by immunising mice with synthetic peptides originating from the amino acid sequence of mimecan (including the sequences listed above or sequences terminating therein), fusing the spleen-cells from selected mice to myeloma cells, and testing the monoclonal antibodies for binding to neo-epitopes on relevant synthetic peptides. Specificity for neo-epitopes can be ensured by requiring reactivity with a synthetic peptide and a lack of reactivity with either a C-terminal prolongated form of the immunising peptide (for a C-terminal neo-epitope) or an N-terminal prolongated form of the immunising peptide (for an N-terminal neo-epitope). Antibodies for neo-epitopes may also be evaluated to establish a lack of binding capacity to the intact protein. Alternatively, specificity for a neo-epitope can be ensured by requiring the reactivity of the antibody to be negatively dependent on the presence of biotin or other functional groups covalently linked to one of the terminal amino acids. 
     The invention includes an immunological binding partner which is specifically immunoreactive with a neo-epitope formed by cleavage of mimecan by a protease at an end-site in any one of the partial sequences set out above, and may be for instance a monoclonal antibody or a binding fragment thereof. 
     The invention includes a cell line producing a monoclonal antibody against a C-terminal or N-terminal neo-epitope formed by cleavage of mimecan at the end-sites of sequences in any one of the partial sequences set out above. 
     The invention further provides a peptide comprising a C-terminal or N-terminal neo-epitope formed by cleavage of mimecan in any one of the partial sequences set out above. Such a peptide may be conjugated as a hapten to a carrier for producing an immune response to said peptide, or immobilised to a solid surface or conjugated to a detectable marker for use in an immunoassay. 
     The invention further comprises an isolated nucleic acid molecule coding for a peptide comprising a C-terminal or N-terminal neo-epitope formed by cleavage of mimecan in any one of the partial sequences set out above. 
     The invention further comprises a vector comprising a nucleic acid sequence comprising an expression signal and a coding sequence which codes for the expression of a peptide comprising a C-terminal or N-terminal neo-epitope formed by cleavage of mimecan in any one of the partial sequences set out above and further includes a host cell transformed with such a vector and expressing a said peptide. 
     Yet another aspect of the invention relates to kits, which can be used conveniently for carrying out the methods described above. 
     Such kits may include (1) a microtitre plate coated with synthetic peptide carrying the sequence of the neo-epitope; (2) a monoclonal antibody or antibody binding fragment of the invention reactive with said synthetic peptide; and (3) a labelled anti-mouse IgG immunoglobulin. Alternatively, such kits may include (1) a microtitre plate coated with purified native protein fragments; (2) a monoclonal antibody recognising a neo-epitope on fragments of any one of said proteins, and reactive with said purified fragments; and (3) a labelled anti-mouse IgG immunoglobulin. Alternatively, such kits may include (1) a microtitre plate coated with streptavidin; (2) a synthetic peptide linked to biotin, said synthetic peptide carrying the sequence of a neo-epitope; (3) a monoclonal antibody recognising a neo-epitope on said protein fragments and reactive with said synthetic peptide; and (4) a labelled anti-mouse IgG immunoglobulin. Yet another alternative could be kits including (1) a microtitre plate coated with streptavidin; (2) a synthetic peptide linked to biotin, said peptide carrying the sequence of a neo-epitope; (3) a monoclonal antibody recognising a neo-epitope on said protein fragments (and reactive with said synthetic peptide) and conjugated to horseradish peroxidase. Yet another alternative could be a kit including (1) a microtitre plate coated (directly or indirectly) with a monoclonal antibody or a fragment thereof, said antibody recognising a neo-epitope on said protein fragment; (2) a HRP labelled synthetic peptide carrying the sequence of a neo-epitope. Or alternatively, a kit including (1) a microtitre plate coated (directly or indirectly) with a monoclonal antibody or a fragment thereof, said antibody recognising a neo-epitope on said protein fragment; (2) a biotin-labelled synthetic peptide carrying the sequence of a neo-epitope; (3) HRP-labelled streptavidin. 
     Thus, the invention includes an immunoassay kit comprising an immunological binding partner as described herein, and a competition agent which binds said immunological binding partner, and optionally one or more of a wash reagent, a buffer, a stopping reagent, an enzyme label, an enzyme label substrate, calibration standards, an anti-mouse antibody and instructions for conducting a said immunoassay. 
     The assays described herein are useful in the diagnosis of atherosclerotic disease in patients. In addition, the tests are useful for the assessment of disease progression, and the monitoring of response to therapy. The immunological binding partners of the invention may also be used in immunostaining to show the presence or location of cleavage products of any atherosclerotic plaque protein described herein. 
    
    
     
       The invention will be further explained and illustrated with reference to the accompanying drawings, in which: 
         FIG. 1  shows and example of a 4-parametric fitted standard curve with peptide concentrations of 0, 3.125, 6.25, 12.5, 25, 50, 100 and 200 ng/ml obtained in Example 1. 
         FIG. 2  shows competitive ELISA test results obtained in Example 1. 
         FIGS. 3A-3C  A and B show plasma levels of MMCN-151 in control (ctrl) and ApoE-KO mice, at baseline (BL), after 10 weeks and after 20 weeks of feeding either standard chow ( FIG. 3A ) or high fat diet ( FIG. 3B ) obtained in Example 1. In  FIG. 3C  control and ApoE-KO mice fed a normal diet are compared at 20 weeks. 
         FIG. 4 , results obtained in Example 1 showing the effect of diet on circulating levels of MMCN-151 neoepitope after 20 weeks of feeding. Here, we compare effect of normal diet (ND) with high-fat diet (HFD) in control (ctrl) and apolipoproteinE knockout (ApoE KO) mice plasma. 
         FIGS. 5A-5B  show correlation between plasma cholesterol of control mice fed HFD and their plasma levels of mimecan fragments ( FIG. 5A ) and plasma cholesterol of ApoE KO mice fed HFD and the levels of mimecan fragments ( FIG. 5B ). 
         FIG. 6  shows plasma levels of mimecan fragments in human patients characterised by high Ca 2+  levels and controls. 
         FIG. 7  shows results from a sandwich ELISA described below. 
     
    
    
     EXAMPLE 1 
     In Vitro Cleavage 
     Recombinant mouse mimecan (cat. No. 2949-MC-050, R&amp;D Systems, DK) was cleaved with activated MMP-12 (cat.no.ab54058, Abcam, UK). To facilitate MMP-12 cleavage of mimecan, 1 mg/mL mimecan was filtered to remove proteins below 10.000 kDa (Microcon Ultracel YM-10, cat. no. 42407, Millipore, Billerica, Mass., USA). Protease cleavage was performed by mixing 100 μg mimecan and 1 μg of enzyme (MMP-12) in MMP buffer (100 mM Tris-HCl, 100 mM NaCl, 10 mM CaCl2, 2 mM Zn acetate, pH 8.0). As a control, 100 μg of mimecan was mixed with MMP buffer only. The mimecan cleavages were incubated for 24 hrs at 37° C. All cleavages were terminated using EDTA. Finally the cleavage was verified by visualization using the SilverXpress® Silver Staining Kit (cat. no. LC6100, Invitrogen, Carlsbad, Calif., USA) according to the manufacturer&#39;s instructions. 
     Peptide Identification 
     Peptide fragments in the in vitro cleaved samples were identified using matrix-assisted laser desorption time of flight mass spectrometry (MALDI-TOF MS) and liquid chromatography coupled to electro spray ionization (ESI) tandem mass spectrometry (LC-MS/MS). MALDI-TOF samples were purified using C18 zip-tips (cat.no.ZTC18SO24, Millipore, Billerica, Mass., USA) according to specifications and 0.1 μg of material was eluted onto a MTP 384 ground steel target plate (Bruker-Daltonics, Bremen, Germany). MALDI tandem mass spectra were recorded on a Bruker ultraflex MALDI-TOF/TOF mass spectrometer (Bruker-Daltonics, Bremen, Germany) in positive ion reflector mode. Mass spectra were externally calibrated in the m/z range of 800-4000 using peptides generated by tryptic digestion of bovine β-lactoglobulin. The m/z software “Flexanalysis” (Bruker-Daltonics, Bremen, Germany) was used to analyze spectra. LCMS samples were ultra-filtrated to remove proteins above 10 kDa, the pH was adjusted to 2.0 using formic acid, and a 4 μL sample was analyzed by LC-MS/MS. LC was performed on a nanoACQUITY UPLC BEH C18 column (Waters, Milford, Mass., USA) using a formic acid/acetonitrile gradient. MS and MS/MS were performed on a Synapt High Definition Mass Spectrometry quadruple time of flight MS (QUAD-TOF; Waters, Milford, Mass., USA), with acquisition range of 350-1600 m/z in MS and 50-2000 m/z, in MS/MS. The software “ProteinLynx Global SERVER (PLGS)” (Waters, Milford, Mass., USA) was used to analyze spectra and generate peak lists. To identify peptides, MS and MS/MS data was searched against mimecan (FASTA) protein database using the Mascot 2.2 (Matrix Science, Boston, Mass., USA) software with either the MALDI-TOF/TOF or ESI-QUAD-TOF settings. 
     EXAMPLE 2 
     Selection of Peptide for Immunizations 
     The first six amino acids of each free end of the sequences identified by MS were regarded as neo-epitopes generated by the protease in question. All obtained protease-generated sequences were analyzed for homology and distance to other cleavage sites and then blasted for homology using the NPS@: network protein sequence analysis. 
     Reagents and Peptides 
     All reagents were standard high-quality chemicals from companies such as Merck and Sigma Aldrich. The synthetic peptides used for monoclonal antibody production and validation were: (a) immunogenic peptide: Ovalbumin-GGC-EDIEDGTFSK (OVA)-SEQ ID NO 27, (b) screening peptide EDIEDGTFSK-SEQ ID NO 28, (c) de-selection peptide EDIEDGTFSK L -SEQ ID NO 29 which has been elongated with one amino acid in the C-terminus were purchased from Chinese Peptide Company, Beijing, China. Peptide conjugation reagents were produced by Pierce (Thermofisher, Denmark). 
     Buffers Used for the ELISAs 
     Buffer used for dissolving the coating peptide was composed of the following: 40 mM NaHPO 4 , 12H20, 7 mM KH PO 4 , 137 mM NaCl, 2.7 mM KCl, 25 mM EDTA, 0.1% TWEEN 20, a non-ionic detergent, 1% BSA, 10% sorbitol, pH 7. 
     Buffer containing following chemicals was used for incubation of serum/plasma assay: 100 mM TRIZMA, 0.05% TWEEN 20, 0.1% BSA, 0.36% Bronidox L5, pH 7.4. For washing steps, we used a buffer composed of: 25 mM TRIZMA, 50 mM NaCl, 0.036% Bronidox L5, 0.1% TWEEN 20, and reaction stopping buffer composed of 0.1% H 2 SO 4 . 
     ELISA-plates used for the assay development were Streptavidin-coated from Roche cat.: 11940279. All ELISA plates were analysed with the ELISA reader from Molecular Devices, SpectraMax M, (CA, USA). 
     Development of an ELISA 
     Methods for monoclonal antibody development are previously described (Barascuk et al. C3). Briefly, 4-6-week-old Balb/C mice were immunized subcutaneously with 200 μl emulsified antigen and 50 μg MMCN-151 (EDIEDGTFSK) as Ovalbumin-GGC-EDIEDGTFSK. Consecutive immunizations were performed at 2-week intervals in Freund&#39;s incomplete adjuvant, until stable sera titre levels were reached, and the mice were bled from the 2nd immunization on. At each bleeding, the serum titre was detected and the mouse with highest antiserum titre was selected for fusion. The selected mouse was rested for 1 month followed by intravenous boosting with 50 μg MMCN-151 in 100 μl 0.9% Sodium Chloride solution 3 days before isolation of the spleen for cell fusion. 
     Fusion 
     The fusion procedure previously described 26  was followed with SP2/0 as myeloma cells. The fusion cells were cloned in 35-mm cell culture dishes by the semi-solid medium method and the dishes were incubated in a CO 2 -incubator. Next, clones were plated into sixteen 96-well microtiter plates and left for three days, followed by screening of culture supernatants. 
     Antibody Screening 
     Supernatants were screened in a competitive ELISA setting. Peptide EDIEDGTFSK was used as the selection peptide and the EDIEDGTFSK L  as the elongated peptide. Cell lines specific to selection peptide and without cross-reactivity to the elongated peptide were selected and the antibodies were purified. 
     MMCN-151 ELISA Methodology 
     In preliminary experiments, we optimized the reagents, their concentrations and the incubation periods by performing several checkerboard analyses. The MMCN-151 ELISA was developed as follows: A 96-well ELISA plate pre-coated with streptavidin was further coated with 1.25 ng/ml of the synthetic peptide Biotin-EDIEDGTFSK dissolved in PBS-TBE buffer at 20° C. for 30 min by constant shaking at 300 rpm. The plate was washed five times in washing buffer and 20 μl of sample was added, followed by 100 μl of peroxidase conjugated anti-human mAb-MMCN-151 solution (30 ng/ml). The plate was incubated for 1 h at 20° C. in 100 mM Tris-BT buffer during which time it was shaken at 300 rpm. 
     The plate was again washed five times followed by addition of 100 μl tetramethylbenzinidine (TMB) (Kem-En-Tec cat.4380H). The plate was incubated for 15 min in darkness and shaken at 300 rpm. In order to cease the reaction, 100 μl of stopping solution (95-97% H2SO4, Merck Cat. No.: 1.00731) was added and the plate was analysed in the ELISA reader at 450 nm with 650 nm as the reference. 
     Standards 
     A standard curve was performed by serial dilution of MMCN-151 (EDIEDGTFSK). Standard concentrations were 0, 0.3125, 6.25, 12.5, 25, 50, 100, 200 ng/ml. 
     Samples for Testing Native Reactivity of the Antibodies 
     During assay development and validation serum from healthy adult subjects of different age and gender were used. Serum samples are obtained from young healthy volunteers 23-50 years of age. The positive control used in the assays was the material obtained from in vitro cleavage of mimecan with purified human MMP-9 and MMP-12. We also tested serum samples from different species including mouse, rat, rabbit, monkey, pig to determine the level of interspecies cross reactivity. 
     Technical Evaluation of the ELISA 
     All ELISA&#39;s were developed according to the internal standard operating procedures. We addressed the following requirements: 
     Intra-assay precision and accuracy: 10 independent runs on 10 different plates have been performed on the test samples, which consisted of human serum. 
     Inter-assay precision and accuracy: This was determined by 10 independent assay runs of each validation sample on 10 different plates. 
     Lower Limit of Detection (LLD): In an analytical run, 40 determinations were made of the lowest standard (the zero standards). This was repeated three times. At each plate LLD was estimated as the following: LLD=mean-3×St.Dev. The LLD concentration was calculated using the 4-parametric-fit equation to generate the average LLD concentration. 
     Recovery: Four different samples covering more than 50% of the standard curve, from all dilutions, were back-calculated from diluted to undiluted to samples in order to estimate the recovery percentage. 
     Animal Samples 
     20 ApoE KO and 20 wild type C57 BL/6 male mice aged 10 weeks from Taconic, Europe A/S (Lille Skensved, Denmark) were fed either standard maintenance diet Altromin (product ID: 1320, Brogaarden, Denmark) or D12492 High fat diet containing 60% fat (Brogaarden, Denmark), ad libitum. Ethics guidelines for experimental investigations in animals were followed and the protocol was approved by the local Experimentation Ethics Committee—“Dyreforsogstilsynet”. The study also conforms to the “Guide for care and use of laboratory animals published by US National Institute of Health. When mice were aged 10 (baseline), 20 and 30 weeks, plasma samples were collected by blood sampling using retro orbital puncture or, in the case of sacrifice, at weeks 20 or 30, by syringe aspiration from the jugular vein (around 1 ml). Heparinized (lithium heparin) blood was centrifuged, and plasma frozen at −20° C. until assayed. Plasma cholesterol was measured by enzymatic assays using an analyser from Molecular Devices, SpectraMax M, (CA, USA). 
     Densitometry 
     Densitometry measurements were performed using UN-SCAN-IT Version 6.1 from Silk Scientific, according to the manufacturer&#39;s guidelines. 
     Histology Image Analysis 
     Histology sections of mouse aorta were stained with Alcian blue and were analysed using Visiopharm software Version 3.2.8.0 (Hørsholm, Denmark). Visiopharm application allowed for quantification of specific tissue areas containing positive staining. Images were acquired using Pixelink PL-A623C microscope digital camera. 
     Statistical Analysis 
     For assay validation, optical density was fitted against analyte concentration applying a four-parameter logistic regression to the calibration curve. Average, standard deviations, percentage coefficient of variation (% CV), and differences from theoretical values were calculated for all standards and samples. Quantitative data were analysed using GraphPad Prism 5 (GraphPad Software, San Diego, Calif., USA). Significant differences between means were determined using the Student&#39;s two-tailed unpaired t-test, not assuming Gaussian distribution. Correlations between serum MMCN-151 values and the rest of the variables studied were analysed with Pearson&#39;s two-tailed test. Data was expressed as mean±standard error of the mean and differences were considered significant at a p level of 0.05 or lower. 
     Results 
     ELISA Technical Specifications 
     The antibody with best native reactivity, affinity and stability in the assay was chosen from the antibody-producing clones generated after the fusion of spleen- and myeloma cells. The clone chosen for antibody purification and the subsequent development of the ELISA was NB206-15B6-F8, raised against MMCN-151 antigen. 
     Standard Curve and Recovery 
     A typical standard curve is presented in  FIG. 1 , showing chosen standards and the 4-parametric fit equation for determination of sample concentration, based on peptide concentrations of 0, 3.125, 6.25, 12.5, 25, 50, 100 and 200 ng/ml. 
     Determination of the linearity or recovery by dilution in different samples resulted in following. The average determined recoveries back-calculated from samples diluted 1:1, 1:2, 1:4, 1:8 and 1:16 to undiluted sample were close to 100% and within the recommended ±10% (data not shown). 
     In order to ensure that the antibody produced is specific towards the neoepitope of mimecan and is not cross-reacting to either elongated peptide or whole mimecan, we tested the assay reactivity of MMP-12 cleaved mimecan compared to uncleaved mimecan and elongated peptide.  FIG. 2  shows the results of the competitive ELISA test of MMCN-151 antibody reaction towards free peptide, elongated peptide, mimecan cleaved with MMP12 and intact mimecan. The x-axis is representative of the concentrations of free and elongated peptide. Concentrations of samples containing mimecan and mimecan cleaved with MMP12 are 43 ug/ml as the highest concentration followed by 2-fold dilutions of samples. As shown by  FIG. 2 , the MMCN-151 antibody is specific towards the synthetic free peptide(EDIEDGTFSK), resulting in the inhibition of signal from approximately 2.0 OD (450-650) to 0.5. Similar results are seen for in vitro cleaved mimecan by MMP12, where the signal inhibition follows the synthetic peptide curve. Moreover, there seems to be no inhibition of the signal in the sample containing the synthetic peptide elongated with one amino-acid EDIEDGTFSK L ). Very weak competition is seen with intact mimecan at the highest concentration. 
     The lowest limit of detection (LLD) is defined as the lowest analyte concentration that can be quantitatively determined with suitable accuracy was 0.5 ng/ml in the assay. 
     Precision-Intra-Assay Variability and Inter-Assay Variability 
     Intra-assay variability, calculated as the average % coefficient of variation (% CV) from the readings of 10 replicates of four human serum samples and one rat serum sample. For the four human serum samples with an average concentration of MMCN-151 of 5 ng/ml, the average intra-assay variability was 1.3%. Rat serum sample had an average MMCN-151 concentration of 13 ng/ml with an average intra-assay variability of 1.1%. 
     Inter-assay mean % CVs were determined from the same sets of samples as the intra-assay and standards but on 10 different plates on 10 different days. The average inter-assay variability, between the highest and lowest levels detected, was 10.2%. 
     Plasma MMCN-151 Values Reflect Early Atherosclerosis in ApoE KO Mice. 
     Plasma MMCN-151 levels were measured in ApoE KO mice and in the C57bl6 controls at baseline, and at 10 and 20 weeks of feeding of either normal chow or high fat diet HFD, results are shown in  FIGS. 3A-3B  respectively. The effect of diet in ApoE KO mice was compared with ctrl mice at 20 weeks was compared in  FIG. 3C . 
     The results of the one way ANOVA were significant (p&lt;0.0001) both in control diet group and in HFD group; In particular, MMCN-151 values were significantly higher in ApoE-KO mice on HFD at both 10 and 20 weeks of feeding 12.1 ng/mL, p&lt;0.001 and 18.2 ng/mL, p&lt;0.001 respectively compared to the control mice on HFD with 5.7 ng/mL, p&lt;0.001 and 10.4 ng/mL. 
     The effect of HFD on the levels of circulating MMCN-151 are significantly increased (p=0.002) in ApoE-KO mice compared to controls after 20 weeks of feeding. There was no effect on the levels of MMCN-151 in animals consuming control diet, see  FIG. 3C . 
     Plasma Cholesterol Levels in Control and ApoE KO Mice. 
       FIG. 4  shows cholesterol levels measured in mice plasma at baseline and after 20 weeks of feeding normal diet (ND) or high fat diet (HFD) in either control mice (ctrl) or in ApoE-KO mice. A significantly higher level of cholesterol was identified in control mice when comparing baseline and 20 week time point for mice fed HFD (p&lt;0.001), but not for mice fed ND. In the case of ApoE KO animals, there is as expected a significant increase in cholesterol after 20 weeks of feeding compared to baseline on both normal (p=0.001) and on HFD (p=0.001). Furthermore, there is a significant difference in cholesterol levels between ApoE KO and control mice at baseline and in both diet groups (p&lt;0.001). 
     We also investigated the lineal relationship between plasma MMCN-151 values and total cholesterol in control mice after 20 weeks of HFD (r=0.48; p=0.276) ApoE-KO animals (r=0.04; p=0.931).  FIGS. 5A-5B  show linear correlation between plasma cholesterol of control mice fed HFD and their plasma levels of MMCN-151 and plasma cholesterol of ApoE KO mice fed HFD and the levels of MMCN-151, respectively. 
     Plasma MMCN-151 is Increased in Patients with Arterial Calcifications. 
     Further insight on the suitability of MMCN-151 as a surrogate indicator of pathological changes in the cardiovascular tissue was obtained by measuring plasma levels of MMCN-151 in patients diagnosed with high coronary calcium deposition in the cardiovascular system. We compared these plasma levels of MMCN-151 with plasma levels of age-matched controls with no diagnosed deposition of coronary calcium,  FIG. 6 . 
     The above work shows that there was significant increase in MMCN-151 in patients with coronary calcium depositions compared to their age-matched controls. Apart from the coronary calcium depositions, these two groups of patients seem similar, with no significant difference in plasma cholesterol levels, blood pressure or triglycerides. 
     In conclusion, we have developed technically robust competitive assay using a specific monoclonal antibody for the detection in human, rat and mouse serum and plasma of MMCN-151, a fragment of mimecan derived from MMP-9 and 12 degradation. We demonstrated that MMCN-151 was significantly elevated in ApoE KO mice fed high fat diet for 20 weeks in comparison with control mice. Additionally, we have shown that human plasma samples from patients diagnosed with extensive coronary calcium depositions was significantly elevated compared to age-matched controls. We have established the principle that neo-epitope containing fragments of mimecan provide valuable biomarkers for CVD and for atherosclerotic plaque calcification. 
     EXAMPLE 3 
     Sandwich ELISA Assay 
     A sandwich ELISA assay for mimecan has been developed as follows: a catcher antibody is directed towards the neo-epitope sequence   generated by in vitro cleavage of mimecan by MMP9 and MMP12 and a tracer HRP-labelled antibody is directed towards the partially overlapping sequence  151 ‘TGNLIEDIED’ 160 . The ELISA procedure was as follows: a 96-well streptavidin pre-coated plate is coated with 1 μg/mL of the biotinylated catcher antibody, dissolved in 25 mM PBS-BTB buffer and incubated for 1 hour at 20° C. Calibrators were prepared by 2-fold dilution of a human serum sample with elevated concentration of the antigens (MIM2, mimecan fragments). 20 μL of the calibrator or sample were added to appropriate wells, followed by 100 μL of 25 mM PBS-BTB buffer and incubation for 1 hour at 20° C. 100 μl of 1 μg/ml HRP-conjugated tracer antibody was added to the well and incubated for 1 hour at 20° C. Finally, 100 μL tetramethyl benzidine (TMB) (Kem-En-Tec cat.438OH, Taastrup, Denmark) developer was added, and the plate was incubated for 15 minutes at 20° C. in the dark. All the above incubation steps included shaking at 300 rpm. After each incubation step the plate was washed five times in washing buffer (20 mM Tris, 50 mM NaCl, pH 7.2). The TMB reaction was stopped by adding 100 μL of stopping solution (1% HCl) and measured at 450 nm with 650 nm as the reference. A standard calibration curve was plotted using a 4-parametric mathematical fit model with a starting concentration of 500 ng/mL for the calibrator following a 2-fold dilution and the last standard was a zero standard. 
     This assay was used to measure CVD plasma samples obtained through an academic collaboration. The group of patients included abdominal aortic aneurism patients (AAA) (n=6, 3f, 3m, average age=69,16±18,36, average BMI=27±4,33), atherosclerosis patients (n=40, 13f, 27m, average age=69,25±10,18, BMI=27,63±7,17), peripheral vascular disease patients (PVD) (n=22, 8f, 14m, average age=68,33±9,94, BMI=30,84±5,00) and control patients formed by surgical patients not affected by CVD (n=25, 14f, 11m, average age=54,57±18,46, BMI=31,19±7,9). 
     The results are shown in  FIG. 7 . The data show a significantly higher presence of the investigated mimecan fragment (MIM2) in plasma of patients with abdominal aortic aneurism (AAA). Three of the plasma samples from patients with AAA had MIM2 values far above the measuring range and were therefore not included in the figure. In addition, plasma samples from atherosclerotic patients were elevated compared to controls. No difference was observed in peripheral vascular disease (PVD) patients compared to controls. These data show the potential of this mimecan fragment assessed in a sandwich assay as a non-invasive marker of cardiovascular diseases and indicate that mimecan remodeling is an important event in the pathogenesis of CVD, leading to the release of mimecan fragments into circulation. 
     In this specification, unless expressly otherwise indicated, the word ‘or’ is used in the sense of an operator that returns a true value when either or both of the stated conditions is met, as opposed to the operator ‘exclusive or’ which requires that only one of the conditions is met. The word ‘comprising’ is used in the sense of ‘including’ rather than in to mean ‘consisting of’. All prior teachings acknowledged above are hereby incorporated by reference. 
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