PFOA promotes PMAIP1-MCL1 apoptotic vulnerability within a BHLHE41-associated macrophage regulatory architecture in atherosclerosis.

Perfluorooctanoic acid (PFOA), a legacy per- and polyfluoroalkyl substance (PFAS), has been associated with dyslipidemia and adverse cardiovascular phenotypes, yet the plaque-macrophage mechanisms that may connect exposure to lesion biology remain incompletely defined. Here, we integrated human plaque single-cell and spatial transcriptomics, bulk transcriptomic profiles of PFAS-exposed macrophages, cross-cohort regulon validation, human plaque histopathology, ApoE-/- mouse experiments, and targeted perturbation assays to examine how PFOA reshapes plaque-relevant macrophage state features and survival vulnerability. Human plaque analysis operationally defined an ACP5-high oxidized lipid-laden macrophage program that overlaps with previously described TREM2-positive lipid-associated or foam-cell-like macrophages and is enriched in diseased lesions. PFOA and related PFAS induced partial transcriptional convergence toward this lesion program and shifted macrophages toward a PMAIP1-high/MCL1-low apoptotic-vulnerability state. Loss- and gain-of-function assays positioned BHLHE41 as a candidate regulatory and functional buffering node rather than as a proven master regulator. NR1H3 restoration partially improved adaptive lipid-handling readouts, whereas NF-κB/AP-1 interference attenuated propagation of the pro-vulnerability phenotype. Human unstable plaques and PFOA-exposed ApoE-/- mice showed concordant PMAIP1-linked vulnerability features, while Mendelian-randomization and classifier analyses were retained only as boundary-setting support. Together, these data support a mechanism-oriented framework in which PFOA may promote PMAIP1-MCL1 apoptotic vulnerability within a BHLHE41-associated macrophage regulatory architecture in atherosclerosis.