Extracellular-vesicle containing miRNA-503-5p released by macrophages contributes to atherosclerosis

Endothelial dysfunction, and the differentiation of smooth muscle cells (SMCs) into proliferative, secretory phenotypes, are two major pathophysiological processes in atherosclerosis. SMCs have the potential to recruit macrophages in atherosclerotic plaques, in which macrophages drive inflammatory responses. In this study, we found that microRNA-503-5p (miR-503-5p) was enriched in either extracellular vesicles (EVs), secreted by oxidized low-density lipoprotein-treated macrophages, or the EVs from peripheral blood mononuclear cells of atherosclerosis patients. miR-503-5p was transferred intercellularly from macrophages to the co-cultured human coronary artery endothelial cells (HCAECs) and HCASMCs via EVs, thus reducing the proliferative and angiogenic abilities of HCAECs and accelerating the proliferative and migrating abilities of HCASMCs. Smad family members 1, 2 and 7 were negatively regulated by miR-503-5p in HCAECs and HCASMCs. miR-503-5p was verified as an enhancer of inflammatory cytokines and adhesion molecules released by macrophages, in part via the down-regulation of smad family members 1, 2 and 7. The inhibition of miR-503-5p by lentivirus reduced atherosclerotic lesion formations in the aorta of atherosclerotic mice. Our work demonstrated a miR-503-5p- and EV-mediated mechanism for macrophage communication with HCAECs and HCASMCs in atherosclerosis. miR-503-5p is pro-atherosclerotic stimuli that may be a therapeutic target for atherosclerosis treatment.


INTRODUCTION
Atherosclerosis is a disease caused by lipid-evoked inflammatory responses of vascular walls, orchestrated by the complicated interactions among different types of cells including: endothelial cells (ECs), smooth muscle cells (SMCs) and macrophages [1]. Due to facilitated roles of low endothelial shear stress produced by turbulent blood flow in atherosclerosis formation, ECs could affect atherosclerosis formation via affecting endothelial shear stress [2]. It has been reported that atherosclerosis is initiated by the intimal retention and modification of cholesterol-loaded lipoproteins, followed by the secretions of ECs and SMCs, recruitment of monocytes, and accumulation of inflammatory cells, extracellular matrix and lipids in the tunica intima [3]. Oxidized low-density lipoprotein (ox-LDL) is a well-known risk factor for atherosclerosis progression [4]. Ox-LDL regulates the adherence activity between endothelial cells and monocytes, which recruit monocyte-secreted macrophages into vessel walls and contribute to foam cell formation of macrophages to affect the progression of AGING atherosclerosis [5]. Macrophages, which are scattered around the sites of plaque build-up, play vital roles in the initiation and progression of all atherosclerosis [6]. Thus, it is imperative to further investigate the underlying mechanisms of interactions among macrophages, ECs, and SMCs in atherosclerosis.
Extracellular vesicles (EVs) are lipid-bilayer heterogeneous particles of 20 nm to 2 µm in size, are involved in atherosclerosis-related processes, such as endothelial dysfunction, inflammation of vascular wall, and vascular remodeling [7]. EVs can be transferred between cells and encompass proteins, messenger RNAs (mRNAs), and microRNAs (miRNAs), and they can be secreted from ECs, SMCs, and macrophages to influence the development of atherosclerosis [8]. miRNAs refer to small non-coding RNA molecules, which serve as regulators of protein expression via the degradation of targeted mRNA or the blockade of protein translation [9]. A recent study has demonstrated that miRNAs are able to modulate cellular and molecular processes in the development of atherosclerosis [10]. He et al. have revealed that miR-155 is transferred to human monocytic THP1 cells with EVs as cargos to exert effects on the progression of atherosclerosis [1]. The roles of macrophage-derived EVs carrying miR-503 in atherosclerosis have also been demonstrated in previous evidence [11]. In addition, microarray analysis in the present study has demonstrated that miR-503-5p could target smad7 and smurf1/smurf2. Accumulating evidence has confirmed that miR-503 serves as a regulator in smurf2 expression and the transforming growth factor-β (TGF-β) signaling pathway [12]. TGF-β, induced by inflammatory cells, including macrophages and SMCs, is implicated in atherosclerosis [13,14]. Smad7 is regarded as a downstream suppressive Smad in TGF-β signaling and participates in atherosclerosis by affecting a series of biological processes, including fibrosis and inflammation [15]. However, the roles of macrophage-derived EVs carrying miR-503-5p in atherosclerosis via Smad7-Smurf1/Smurf2-TGF-β axis have not been investigated yet. Therefore, we constructed models with macrophages treated with ox-LDL and ApoE -/mice fed with high-fat diet to explore the specific regulatory mechanism of EVscontaining miR-503-5p from macrophages as a mean to communicate with ECs and SMCs in the biology of atherosclerosis.

Expression patterns of miR-503-5p, smad7, smurf1, and smurf2 in plasma-EVs of patients with atherosclerosis
We first collected detailed information of patients with atherosclerosis (recorded in Table 1). Plasma was collected from patients with atherosclerosis and healthy individuals to determine the expression of miR-503-5p, smad/TGF-β signaling pathway molecules (smad7, smurf1, smurf2, and TGF-β1) using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The findings displayed that compared with healthy individuals, the expression of miR-503-5p and TGF-β1 was increased at different degrees in patients with coronary atherosclerosis, cerebral atherosclerosis, peripheral atherosclerosis, combined coronary atherosclerosis and peripheral atherosclerosis, and combined cerebral atherosclerosis with peripheral atherosclerosis, while the expression of smad7, smurf1, and smurf2 was decreased at different degrees (p < 0.05) ( Figure 1A, 1B), which showed a certain linear correlation ( Figure  1C).

Expression pattern of miR-503-5p in macrophage-EVs in the context of atherosclerosis
In order to explore the role of miR-503-5p in macrophage-EVs of atherosclerosis model, PMAinduced THP-1 (100 ng/mL, 24 h) or RAW264.7 cells were treated with ox-LDL (25 µg/mL, 50 µg/mL and 100 µg/mL). Oil red O staining showed an increase in staining intensity in a concentration-dependent manner, suggesting that atherosclerosis models were successfully constructed after treatment with ox-LDL ( Figure 4A). Expression of miR-503-5p (normalized to U6), TGF-β1, smad7, smurf1, and smurf2 (all normalized to GAPDH) in plasma-EVs of healthy individuals (n = 30) and patients with atherosclerosis (n = 53) determined by RT-qPCR. (C) Pearson analyses of miR-503-5p and TGF-β1, smad7, smurf1, or smurf2. Values obtained from three independent experiments in triplicate were analyzed by one-way ANOVA followed by Tukey's post hoc test among three or more groups. *p < 0.05 compared with healthy individuals. Values obtained from three independent experiments in triplicate were analyzed by one-way ANOVA followed by Tukey's post hoc test among three or more groups. *p < 0.05 compared with HCAECs or HCASMCs treated with miR-mimic NC; *p < 0.05 compared with HCAECs or HCASMCs treated with miR-inhibitor NC.

Macrophages delivered miR-503-5p to HCAECs and HCA-SMCs via EVs
In order to study the mechanism of macrophage-EVs in HCAECs and HCASMCs in vitro, the supernatants of RAW264.7 macrophages treated with ox-LDL and that of the normal control were collected to isolate EVs. A transmission electron microscope (TEM) displayed the structure and diameter of EVs ( Figure 5A) and Nanoparticle tracking analyzer (NTA) revealed diameter and number of EVs ( Figure 5B). Western blot analysis showed the presence of EV marker proteins: Alix, CD63, and CD9 in EVs but the presence of calnexin only in cells ( Figure 5C). We further validated the functional changes of macrophage-EVs co-cultured with HCAECs or HCASMCs, and the specific downstream mechanisms of HCAECs in vitro. HCAECs and HCASMCs were co-cultured with EVs from ox-LDL-treated macrophages and control macrophages, namely ox-LDL-EVs and con-EVs. RT-qPCR indicated that the expressions of miR-503-5p and TGF-β1 were elevated and the expressions of smad7, Smurf1, and smurf2 were decreased in HCAECs and HCASMCs co-cultured with ox-LDL-EVs (p < 0.05) ( Figure 5D). Confocal scanning laser microscopic imaging revealed that EVs were internalized by HCAECs or HCASMCs and distributed around the nucleus ( Figure 5E). Macrophages delivered cy3-miR-503-5p to HCAECs or HCASMCs via EVs (p < 0.05) ( Figure 5F). Western blot analysis presented that TGF-β1 protein levels were elevated and protein levels of smad7, Smurf1, and smurf2 were reduced in HCAECs co-cultured with ox-LDL-EVs and treated with lentivirus-mediated depleted miR-503-5p (p < 0.05) ( Figure 5G). The data above elucidated that macrophages delivered miR-503-5p to HCAECs and HCASMCs via EVs that may affect functions of HCAECs and HCASMCs.

Pro-atherosclerotic role of miR-503-5p in the formation of atherosclerotic plaques
RT-qPCR was lastly adopted to determine the levels of miR-503-5p, smad7, smurf1, smurf2, IL-1β, IL-6, and TNF-α in plasma-EVs, macrophage-EVs, and vascular tissues of ApoE -/mice ( Figure 8A). The results revealed that the expressions of miR-503-5p and TGF-β1 were elevated in plasma-EVs, macrophage-EVs, and vascular tissues of ApoE -/mice, while the expressions of smad7, smurf1, and smurf2 were decreased. Meanwhile, Western blot analysis showed reduced protein levels of smad7 and smurf1/2 in mouse arterial tissues but increased TGFβ protein levels in the vascular tissues of ApoE -/mice (p < 0.05) ( Figure 8B). Oil red O staining showed increased lipid deposition in mouse arterial tissues, which aggravated the progression of atherosclerosis (p < 0.05) ( Figure 8C). To further verify the proatherosclerotic role of miR-503-5p in the formation of atherosclerotic plaques in mice, C57BL/6J WT mice were injected with EVs derived from macrophages with or without ox-LDL treatment, followed by injection with lentivirus expressing anti-miR-503-5p and anti-miR-503-5p NC. Oil red O staining ( Figure  8D) and Western blot analysis ( Figure 8E) demonstrated that depleted levels of miR-503-5p reduced lipid deposition, but increased the expressions of smad7, smurf1, and smurf2 in mouse arterial tissues (p < 0.05). These findings proved that the expression of miR-503-5p was upregulated in atherosclerosis and the inhibition of miR-503-5p could subsequently hinder the progression of atherosclerosis.

DISCUSSION
Atherosclerosis is one of the pathophysiological factors that contribute to acute myocardial infarctions and cerebrovascular accidents and is also the leading cause of cardiovascular deaths worldwide [16]. In recent years, it has been found that EVs-derived miRNAs from macrophages serve as mediators in atherosclerosis [17]. Our study is aimed at exploring the promoting effects of EV-carrying miR-503-5p from macrophages on the proliferation and migration of HCAECs and HCASMCs in atherosclerosis. Taken together, this study reveals that macrophage-derived EVs carrying miR-503-5p can inhibit proliferation, migration, and angiogenic ability of HCAECs, while promoting the proliferation and migration of HCASMCs by downregulating Smad7, smurf1, and smurf2 and elevating TGF-β1, thus aggravating atherosclerosis.
Our results demonstrated that miR-503-5p was enriched in plasma-EVs and macrophage-EVs in atherosclerosis. The aberrant expression of miRNAs has a clearly established role in the process of atherosclerosis [18]. miR-150 is demonstrated to be highly expressed in PMA-induced THP-1 cells in atherosclerosis [19]. Nguyen et al. have indicated that several miRNAs, including miR-503, are abundantly expressed in macrophage-derived EVs in atherosclerosis [17], which is consistent with our findings. Moreover, bioinformatics analysis, in combination with the dual luciferase reporter gene assay validated that miRNA-503-5p could target and negatively regulate smad7, smurf1, and smurf2, being enriched in the TGF-β signaling pathway. The TGF-β signal is dysregulated in the development of atherosclerosis [13]. smad7 expression has been demonstrated to display a reduction in atherosclerosis [15]. Cao et al. have revealed that downregulated levels miR-503 could elevate Smurf2 levels by regulating TGF-β/Smad2 signaling [12]. Also, miR-503 could target smad7 and regulate its expression via TGFβ1 signaling pathway [20], which will be further elucidated through the following serial experiments.
In addition, the data in present study demonstrates that macrophages were able to upregulate miR-503-5p and transfer miR-503-5p to HCAECs and HCASMCs with EVs as cargos. EVs remain small membrane vesicles, including exosomes that are released during the exocytosis of multivesicular bodies, and sprouting from plasma membrane as well [21]. It is also interesting to note that EVs participate in cell-to-cell communication, as they harbor lipids, proteins, mRNAs and miRNAs [7]. Moreover, EVs derived from VECs, VSMCs, and macrophages could transfer multiple molecules to the recipient cells in atherosclerosis [8]. EVs contain many miRNAs that can be delivered to ECs and SMCs to affect the development of cardiovascular diseases [22]. Most importantly, our findings revealed that macrophages could deliver miR-503-5p to HCAECs and HCASMCs to exert promotive effects on the process of atherosclerosis. Based on the in vitro and in Values obtained from three independent experiments in triplicate were analyzed by one-way ANOVA followed by Tukey's post hoc test among three or more groups. * p < 0.05 compared with HCAECs or HCASMCs treated with miR-mimic NC; # p < 0.05 compared with miR-503-5p mimic.
vivo experiments, the present study presented that macrophage-secreted EVs carrying miR-503-5p inhibits proliferation, migration, and angiogenic potentials of HCAECs, while accelerating the proliferation and migration of HCASMCs in atherosclerosis via TGF-β/smad7/smurf1/smurf2 axis. Atherosclerotic plaques are prone to rupture, and angiogenesis is a source of intraplaque hemorrhage [16]. ECs have the ability to transform into smooth musclelike cells in atherosclerosis, and SMCs could differentiate into proliferative, secretory phenotypes and form macrophage/foam cells in atherosclerosis [3]. Hergenreider et al. have confirmed that the protective stimulation of atherosclerosis secretes communicating (normalized to U6), and TGF-β1, smad7, smurf1, and smurf2 (normalized to GAPDH) in plasma-EVs, macrophage-EVs, and arterial tissues of ApoE-/-mice (n = 3) and WT mice (n = 3) determined by RT-qPCR. (B) Protein levels of TGF-β1, smad7, smurf1, and smurf2 (normalized to GAPDH) in plasma-EVs, macrophage-EVs, and arterial tissues of ApoE-/-mice (n = 3) and WT mice (n = 3) determined by Western blot analysis. (C) Lipid deposition in mouse arterial tissues detected by Oil red O staining; Scale bar = 50 µm. (D) EVs derived from macrophages with or without ox-LDL treatment were separately injected into the tail vein of C57BL6 WT mice at dose of 100 µg for each. One week later, EVsinjected mice were injected with lentivirus expressing anti-miR-503-5p and anti-miR-503-5p NC. (E) The lipid plaque of arterial tissues of C57BL/6J WT mice (n = 12) detected by Oil red O staining. (F) Expression of smad7, smurf1, and smurf2 (normalized to GAPDH) in arterial tissues of C57BL/6J WT mice (n = 12) determined by Western blot analysis. Values obtained from three independent experiments in triplicate were analyzed by unpaired t test between two groups and by one-way ANOVA followed by Tukey's post hoc test among three or more groups. * p < 0.05 compared with WT mice or mice injected with EVs derived from macrophages without ox-LDL AGING treatment; # p < 0.05 compared with mice injected with EVs derived from macrophages with ox-LDL treatment followed by lentivirus expressing anti-miR-503-5p NC.
signals between ECs and SMCs through a miRNA-and EVs-mediated mechanism, which provides a potential target for treatment of atherosclerosis [2]. Studies have revealed that THP-1 monocytes-derived miR-150 into ECs via EVs could promote migration and angiogenic ability of ECs and inhibit apoptosis in atherosclerosis [22,23]. A recent study has demonstrated that miR-155 is enriched in ox-LDLinduced ECs-derived EVs and then transferred to THP1 cells, by which EVs could induce inflammatory responses [1]. Upregulated miRNAs in thermogenic macrophage-derived EVs could aggravate the development of atherosclerosis by inhibiting the migration of ECs and enhancing macrophage enrichment in vessel walls [17]. The downregulation of miR-34a could promote viability and inhibit apoptosis of ox-LDL-treated human aortic endothelial cells by upregulating Bcl-2, thus indicating a promising biomarker for atherosclerosis therapy [24]. The proliferation of vascular smooth muscle cells (VSMCs) is involved in the process of atherosclerosis, and elevated expressions of miR-29b induced by ox-LDL could facilitate VSMC migration [25]. Upregulated miR-503 could also promote SMC differentiation by directly targeting smad via TGFβ1 signaling pathways [20]. Herein, it was reasonable to conclude that macrophages delivering miR-503-5p via EVs possessed a great therapeutic potential in atherosclerosis.
In conclusion, we have demonstrated that macrophages can secrete EVs and transmit miR-503-5p into HCAECs and HCASMCs in order to inhibit the proliferative and angiogenic functions of HCAECs, while inhibiting the proliferation and migration of HCASMCs ( Figure 9). Consequently, anti-miR-503-5p was validated to exert an atheroprotective effect in the murine model. Thus, EVs from macrophages with upregulated levels of miR-503-5p may function as a promising new therapeutic target for atherosclerosis. However, the research is still in the preclinical stage, and the investigation on the mechanism of action is still insufficient. Future experiments are needed in order to further explore the intrinsic mechanisms.

Ethics statement
The Ethics Committee of the Affiliated Hospital of North Sichuan Medical College approved the study protocol. Informed written consent was obtained from each patient prior to the study. Animals were treated in strict accordance with the Guide for the Care and Use of Laboratory animals published by the US National Institutes of Health (NIH). Extensive efforts were made to minimize the number of animals used in the experiments and their suffering.

Dual luciferase reporter gene assay
Dual luciferase reporter gene assay was performed to identify whether smad7, smurf1, and smurf2 were direct target genes of miR-503-5p. The 3'UTR gene fragments of smad7, smurf1, and Smurf2 were artificially synthesized and subsequently introduced into pGL3control vectors (Promega, Madison, WI, USA) using XhoI and NheI restriction endonuclease sites. Mutation sites of complementary sequences of seed sequences were designed based on smad7, Smurf1 and Smurf2 WT plasmids. The verified pGL3-WT or pGL3-MUT of smad7, smurf1, smurf2 were co-transfected with miR-503-5p mimic and mimic NC into HEK293 cells from Shanghai Institute of Biochemistry and Cell Biology, Chinese Academy of Sciences (Shanghai, China). Dual Luciferase Reporter Assay System kit (Promega, USA) was employed to detect the luciferase activity on the TD-20/20 Luminometer (E5311, Promega, USA).

RNA isolation and quantitation
Total RNA was extracted from macrophage-EVs and plasma-EVs using TRIzol (15596026, Thermo Fisher, MA, USA). Next, the extracted total RNA was reversetranscribed into cDNA according to the instructions of the Reverse transcription Kit (Takara Bio Inc., Otsu, Shiga, Japan). RT-qPCR was carried out with a mixture of 2 µL reverse transcription reagent, 10 uL TB Green Premix Ex Taq II (Takara, Shiga, Japan), and 10 µM primer reactions were run on a LightCycler 480 (Roche). U6 was used as the internal reference for miR-503-5p in cells, and cel-miR-39 as the external reference for miR-503-5p in EVs. The expression ratio of the target gene between the experimental and control groups was calculated using the 2 -ΔΔCt method. Primers are listed in Table 2.

Isolation and characterization of macrophage-EVs
The EVs were isolated by ultracentrifugation. Briefly, macrophages were cultured with conditioned medium (DMEM + 10% EV-depleted serum or RPMI 1640 + 10% EV-depleted medium) for 48 h and then were centrifuged at 500 × g for 15 min, 2000 × g for 15 min, and at 10,000 × g for 20 min. The macrophages were finally filtered through 0.22 µm filter two times, followed by ultracentrifugation at 110, 000 ×g for 70 min.
NTA was used to measure the number and diameter of EVs. The 20 μg EVs were dissolved in 1 mL PBS and whirled for 1 min to maintain homogeneity. A AGING NanoSight NTA (Malvern Panalytical, UK) system was subsequently used to analyze EV distribution.
The fresh EV samples (20 μL) were loaded on the carboncoated copper electron microscopy grids for 2 min with under the guidance of a TEM, and labeled with phosphotungstic acid solution (12501-23-4, Sigma-Aldrich, USA) or negative staining for 5 min. The grids were washed with PBS three times to remove the remaining phosphotungstic acid solution, and semi-dried with filter paper. The images were observed under the Hitachi H7650 TEM (80KV, Hitachi, Tokyo, Japan).

CCK-8 assays
HCAECs and HCASMCs were seeded into 96-well plates at a density of 3000 cells/well (100 μL), with or without extracted macrophage-EVs at a concentration of 10 μg/mL, 20 μg/mL, and 40 μg/m. The first detection was conducted at 12 th h or 24 th h. Each well was added with 10 mL CCK-8 reagent (DOJINDO, CK04), and the plates were placed in the cell incubator and incubated for 2 h. The absorbance value of each well was measured on a microplate reader at 450 nm [27].

Flow cytometric analysis
The Annexin V-APC apoptosis detection kit (Ebioscience, Thermo Fisher, USA) was employed to detect cell apoptosis. In brief, after transfection for 48 h, cells were collected and detached with trypsin without ethylenediaminetetracetic acid (EDTA). Cells were centrifuged and re-suspended in 200 μL binding buffer after being washed with PBS two times. The cells were later added with 10 μL fluorescein isothiocyanate (FITC)-Annexin V and 5 μL propidium iodide (PI) and mixed without light exposure at room temperature for 15 min, followed by incubation with 300 μL binding buffer. A flow cytometer (FACScan; BD Biosciences, Franklin Lakes, NJ, USA) with CellQuest software (BD Biosciences, USA) was utilized to detect apoptosis at the excitation wavelength of 488 nm and the emission wavelength of more than 630 nm.

Transwell migration assays
Cell suspension was incubated with the serum-free medium, which was added into the apical chamber containing 3 × 10 4 cells/100 ul (3422, Corning). The basolateral chamber was added with 700 uL 10% FBS/medium with or without 20 μg/ml EVs, either derived from untreated or ox-LDL-treated macrophages. The chamber was cultured in an incubator for 12-16 h (smooth muscle cells usually left to incubate for 12 h, while endothelial cells generally for 16 h). The basolateral chamber was then fixed in 95% ethanol for 30 min, and the cells were stained with 4 g/L crystal violet (Sigma-Aldrich, USA) for 30 min under the microscope.

Scratch test
The scratches were made on HCAECs and HCASMCs using a 20-200 μL pipette and were left to incubate in the serum-free medium with or without 20 ug/ml EVs, either derived from untreated or ox-LDL-treated macrophages. The cells were photographed at 0 h, and further cultured in an incubator for 24 h. Finally, the migration of cells was analyzed following photograph.

Matrigel-based angiogenesis assays in vitro
A total of 3 × 10 4 serum-free medium-incubated HCAECs were seeded in 96-well plates coated with Matrigel (50 ul/well, 356234, Corning) with or without 20 μg/ml EVs, either derived from untreated or ox-LDL-treated macrophages. After 8 h, vessel-like tubes formed in cells were photographed and observed and analyzed using Image J.

C57BL6 WT and ApoE -/mice
A total of 12 C57BL6 WT and 12 ApoE -/male mice (aged 6-8 weeks and weighing 18-24 g) were purchased from the Laboratory Animal Center of Peking University, and fed in specific-pathogen-free environment in the Laboratory Animal Center of Affiliated Hospital of North Sichuan Medical College. All mice were euthanized by cervical dislocation after anesthesia induction. The blood vessels of mice were collected with sodium citrate anticoagulant tubes. The EVs were extracted according to the abovementioned methods. The plasma-EVs and EVs derived from mouse bone marrow derived macrophages were extracted. Mice were given a high-fat diet (21% crude fat, 0.15% cholesterol, and 19.5% casein) for 12 weeks [28].

Lentivirus transduction in vivo
The plasmids, anti-miR-503-5p and anti-miR-503-5p NC, (Exiqon, Vedbaek, Denmark) (each 16 μg) and two envelope plasmids, PSPAX2 (12 μg) and PMD2G (4.8 μg), were co-transfected into HEK293T cells using Lipofectamine 3000 (at#L3000015, Invitrogen) according to the instructions provided by manufacturer. Forty-eight hours later, the supernatant was concentrated using a Centricon Plus-70 filter (UFC910096, Millipore, USA). Lentivirus at titer of 10 8 TU/mL was used in the experiment. EVs derived from macrophages with or without ox-LDL treatment were separately injected into the tail vein of C57BL6 WT mice at dose of 100 μg for each. One week later, EV-treated mice were injected with lentivirus expressing anti-miR-503-5p and anti-miR-503-5p NC for once a week. After the mice were fed with high-fat diet for 12 weeks, they were euthanized by cervical dislocation for Oil red O staining and Western blot analysis.

Oil red O staining
The mouse aorta was subject to Oil red O staining as previously described [28].

Sample collection
The study consisted of 53 patients (29 males and 24 females) with atherosclerosis who were hospitalized in the Department of Cardiology and Department of Neurology in the Affiliated Hospital of North Sichuan Medical College from July 2018 to December 2018. Another 30 healthy individuals (17 males and 13 females) were also enrolled in this study. The inclusion criteria were as follows: a, patients with coronary atherosclerosis diagnosed by coronary angiography, b, patients with brain atherosclerosis diagnosed by CT Scanning; c, patients with peripheral atherosclerosis (carotid atherosclerosis, lower extremity atherosclerosis) diagnosed by ultrasonography. The exclusion criteria were as follows: patients with rheumatic heart disease, acute myocardial infarction, recent history of trauma surgery, medication history of oral contraceptives, folic acid, and vitamin B, renal insufficiency, blood urea nitrogen > 7.11 mmol/L, creatinine > 106 mmol/L, heart failure, various bleeding diseases or a proclivity for bleeding, poor blood pressure control [systolic pressure ≥ 160 mm Hg(1 mm Hg = 0.133 kPa) or diastolic pressure ≥ 100 mm Hg], poor heart rate control (heart rate ≥ 90 times/min), limb infection, thrombophlebitis, severe varicosities, deep vein thrombosis, severe valvular disease, congenital heart disease, aortic aneurysm, artery dissection, coronary artery fistula, coronary aneurysm, or arrhythmia with possible interference of ECG gating function of equipment. EVs were obtained by gradient centrifugation from 5-10 mL whole blood samples, which were collected from patients and healthy individuals, and placed into sodium citrate anticoagulant tubes.

Statistical analysis
Data conforming to normal distribution were expressed as mean ± standard deviation. Unpaired t test was performed for statistical comparison between two groups and one-way analysis of variance (ANOVA) with Tukey's post hoc test for statistical comparisons among multiple groups. The relationship between the two indicators was analyzed by Pearson Correlation Analysis. Statistical significance was set at a level of p < 0.05 and analyzed using SPSS 24.0 software (IBM Corp. Armonk, NY, USA).