1. HDL Particles and CHD Prevention
Ernst J. Schaefer, MD
Professor & Director, Lipid Metabolism Laboratory and Lipid and Heart Disease Prevention Clinic, Human Nutrition Research Center on Aging
& Tufts University School of Medicine, Boston, MA, Medical Director, Boston Heart Laboratory, Framingham, MA
CRT 2011, Washington DC,
February 28th, 2011

2. Ernst J. Schaefer, MD Advisory Committee Roche Vatera Unilever
Consulting Fees
Merck & Co., Inc. and Company, Inc.
Honoraria
Arisaph Pharmaceuticals

3. Grants/Contracted Research
Abbott Laboratories
DuPont
Resverlogix Corporation
Roche
Ownership Interest (Stocks, Stock Options or Ownership Interest)
Boston Heart Laboratory

4. Disclosures – Past 12 Months
Consultant: Arisaph, Bristol-Myers Squibb, Merck, Roche, Unilever, Vatera
Research Support: Arisaph, DuPont, NIH, Resverlogix, Unilever, USDA
Ownership, Stock, Employment (25%): Boston Heart Laboratory, Framingham, MA
HDL Map, Cholesterol Balance Test, small dense LDL-C, Lp(a), all lipoproteins,

5. - In VA-HIT men were selected
for HDL C < 40 mg/dl and
CHD.
- The male subjects selected had a median BMI of about 30 Kg/m2, and insulin levels that were at the 90th percentile values for control subjects from the Framingham Offspring Study

6. HDL-C as CHD Risk Factor: Framingham Heart Study*
Relative Risk
HDL-C (mg/dl) Men Women
< ** **
 ** **
** p < multivariate analysis (age, systolic blood pressure, total cholesterol or LDL C, smoking and diabetes, 2489 men, 2856 women, years of age, 12 year followup, 383 men and 227 women developed CHD. *Wilson et al., Circulation 97: 1837, 1998.

7. ApoA-I-Containing HDL Subpopulations, ApoA-II is on alpha-2 and alpha-3 HDL, SAA is on alpha 2
Asztalos BF, Roheim PS et al. BBA 1993; 1169:

8. Functions of Different ApoA-I Containing HDL Particles
Interacts with cellular SR-B1 for bidirectional C flux, source of CE for TRL, acceptor of TG from TRL
Interacts with ABCG1 to accept FC
Acceptor of FC and PL from cellular ABCA1, Cleared by Kidney, esp. pre-beta 1 HDL
Asztalos BF, De la Llera-Moya M, Dallal GE, Horvath KV, Schaefer EJ, Rothblat GH. J Lipid Res 2005; 46:

9. Location of Apolipoprotein Particles in HDL – Documentation that ApoA-IV and ApoE are mainly on HDL particles separate from ApoA-I HDL
ApoA-II
ApoA-IV
ApoC-I
ApoC-III
ApoE
Asztalos BF, Schaefer EJ, Horvath KV, Yamashita S, Miller M,
Franceschini G, Calabresi L. J Lipid Res. 2007; 48:

10. Complement regulation
Shotgun Proteomics of HDL: Lipid Metabolism and Inflammatiory Molecules
CETP
LCAT
apoC-I
PLTP
apoC-II
apoM
AGF
SERF2
SERF1
apoC-III
apoF
apoC-IV
apoE
Proteinase inhibitor
Lipid Metabolism
PON3
apoD
SAA4
apoL-1
SAA2
apoA-II
SAA1
Clusterin
apoA-I
AHSG
HRP
SERA1
AMP
ApoA-IV
PON1
KNG1
apoH
Complement regulation C3
Acute-phase response
C4A
C4B
HPX
ORM2
FGA C9
TTR TF
ITIH4
RBP4
VTN
Vaisar T, Heinecke J et al J Clin Invest. 2007;117:

11. Apolipoprotein A-I Immunoblotting in Various Disorders of HDL Metabolism
Control
ApoA-I def.
ABCA1 def.
LCAT def.
LPL def.
HL def.
CETP def.
Schaefer EJ, Santos RD, Asztalos BF. Curr Opin Lipidol 2010;21:

12. HDL-C 1, LDL-C 124, TG 75, ApoA-I 0 mg/dl, CHD 38 yrs Tangier Disease
ApoA-I Deficiency
HDL-C 1, LDL-C 124, TG 75, ApoA-I 0 mg/dl, CHD 38 yrs
Tangier Disease
HDL C 4, LDL C 52, TG 195 mg/dl, ApoA-I 3 mg/dl, CHD 56 yrs
Heterozygous
Familial Hypercholesterolemia, HDL-C 45, LDL-C 375 , TG 110 mg/dl ,
CHD 45 yrs
LCAT Deficiency
HDL-C 8, LDL-C 32, TG 205,
ApoA-I 37 mg/dl, No CHD, Age 50

13. ApoA-I-Containing HDL Subpopulation Profiles of a Control and a CHD Patient
ApoA-I-Containing HDL Subpopulation Profiles of a Control (a) a CHD Patient (b), and a Schematic Diagram of 2D Gel System Based on Size (Vertical) and Charge (Horizontal) for HDL Particle Seperation – CHD Patients Have Decreases in Large Alpha 1 and Alpha 2 HDL and Increases in Pre-Beta 1 HDL. These particle patterns are significantly superior to HDL-C in predicting future CHD events in both the Framingham Offspring
Study and the Veterans Affairs HDL Intervention Trial.
Asztalos et al. Arterioscler Thromb Vasc Biol. 2003;23: ; 2004; 24: , 2005; 25: , HATS Trial, Framingham Offspring Study, and the Veterans Affairs HDL Intervention Trial

14. 17 mg/dl - 39%* 40 mg/dl - 9% 38 mg/dl + 29%* 12 mg/dl + 16%*
Differences in HDL Particles in Male CHD Cases vs Controls in the Framingham Offspring Study
Apo A-I Concentration % Difference
Controls (n=1277) Cases (n=169)
17 mg/dl %*
(16% of total)
40 mg/dl %
(37% of total)
38 mg/dl %*
(36% of total)
12 mg/dl %*
(11% of total)
“For each 1 mg/dl apoA-I increase in alpha 1 HDL there is a 26% reduction in CHD risk
Asztalos BF, et al Arterioscler Thromb Vasc Biol 2004; 24:

15. 9.1 mg/dl - 12%** 31.9 mg/dl - 7% 40.5 mg/dl + 3%* 12.1mg/dl + 9%*
HDL Particles and Recurrent CHD Events in VA HIT (1097 without vs 398 with recurrent events)
Apo A-I Concentration % Difference
Recurrent Dis.
9.1 mg/dl %**
(54% of normal)
31.9 mg/dl %
(80% of normal)
40.5 mg/dl %*
(107% of normal)
12.1mg/dl %*
(100% of normal)
“In CHD patients with low HDL, those with lower alpha 1 HDL on trial were
significantly more likely to have recurrent events.”
Asztalos BF, et al Arterioscler Thromb Vasc Biol 2005; 25:

16. + 12%* + 24%* + 4% + 13* -7% - 6% - 40%* - 39%*
Effects of Atorvastatin 80 mg/dl vs. Rosuvastatin 40 mg/dl on HDL Particles vs Baseline in STELLAR (n=306)
Atorvastatin Rosuvastatin
+ 12%* %*
+ 4% *
-7% %
- 40%* %*
Asztalos BF, LeMaulf F, Dallal GE, Stein E, Jones PH, Horvath KV, McTaggert F, Schaefer EJ. Am J Cardiol 2007; 99:

17. 9 mg/dl + 115%* 30 mg/dl + 27% 45 mg/dl - 17%* 15 mg/dl - 39%*
Effects of Simvastatin/Niacin on HDL Particles in CHD Cases in HATS (n=123)
Apo A-I Concentration % Difference
9 mg/dl %*
30 mg/dl %
45 mg/dl %*
15 mg/dl %*
“The increase in apoA-I in large alpha 1 HDL was significantly related (p<0.01) to
lack of progression or regression of coronary artery stenosis. If alpha 1 HDL apoA-I is increased to > 20 mg, there was net regression, provided LDL C < 80 mg/dl”
Asztalos BF, Batista M, Horvath KV, Cox CE, Dallal GE, Morse JS, Brown GB, Schaefer EJ. Arterioscler Thromb Vasc Biol 2003;23:

18. Conclusions from Studies on Statins, and Niacin
Statins inhibit cholesterol production, resulting in enhanced fractional clearance of apoB-48 and apoB-100 containing lipoproteins by 40-50%, (secondarily decreasing CETP activity 40%). Statins have little effects on HDL apoA-I production or clearance, but remodel HDL particles by enhancing the conversion of small pre-beta 1 HDL to large alpha 1 HDL.
Lamon-Fava S. Diffenderfer MR, Barrett PH, Buchsbaum A, Matthan NR, Lichtenstein AH, Dolnikowski GG, Horvath K, Asztalos BF, Zago V, Schaefer EJ.. J Lipid Res 2007; 48:
Niacin enhances the clearance of apoB in triglyceride-rich lipoproteins and increases HDL apoA-I production. This latter effect may occur because of upregulation of ABCA1 and increased cellular cholesterol efflux. Therefore the statin/niacin combination is ideal for promoting regression of atherosclerosis. More studies needed to confirm this.
Lamon-Fava S, Diffenderfer MR, Barrett PHR, Buchsbaum A, Nyaku M, Horvath K, Asztalos BF, Otokozawa S, Ai M, Matthan NR, Lichtenstein AH, Dolnikowski GG, Schaefer EJ. Arterioscler Thromb Vasc Biol 2008; 28:

19. Niacin Update
We have shown in humans that niacin increases HDL apoA-I synthesis and doubles adiponectin levels Lamon-Fava S et al ATVB 2008; 28:1672-8
We have recent data in hamsters that niacin and niacin analogs increase mRNA for ABCA1 (+100%) and apoA-I (+40%) in liver and adiponectin (+100%) in fat tissue. O’Connor et al unpublished observations
Rubic T et al reported that niacin treatment increases ABCA1 gene expression in macrophages and hepatocytes. Biochem Pharm 2004;67:411-9
3. Siripurkpong P et al reported that niacin treatment increases ABCA1 and apoA-I mRNA levels in HepG2 cells. J Nutr Biochem 2009;20:261-8
Wu ZH et al reported that niacin treatment increased PPAR gamma, LXR-alpha, and ABCA1 gene expression in 3T3-L1 adipocytes. Pharmacology 2009;84:282-7

20. Effects of CETP Inhibition
- Marked Increase in HDL Particle Size (150% increase in alpha 1 HDL), and HDL CE Levels, associated with increases in apoA-I and apoA-II due to delayed clearance, no effect on fecal sterol excretion with torcetrapib, may be increased with dalcetrapib - Marked decrease in TRL CE levels associated with decreased production of apoB-48, and enhanced clearance of TRL apoB-100, and apoE. - Modest decreases in LDL, with decreased LDL CE, larger LDL particles, and slightly enhanced LDL apoB-100 clearance
Brousseau ME, Schaefer EJ et al. N Engl J Med 2004; 350:
Brousseau ME et al. Arterioscler Thromb Vasc Biol 2005;25:

21. Dalcetrapib Torcetrapib Anacetrapib
“All 3 CETP inhibitors bind tightly to form a complex between CETP and HDL . Anacetrapib and torcetrapib have similar potency, and dalcetrapib is considerably less potent.”
Ranelletta et al J Lipid Res ;51:
Dalcetrapib
Torcetrapib
Anacetrapib

22. Effects of Diet and Weight Loss
As compared to an average US diet, an NCEP step II diet (low in cholesterol and saturated fat) decreases LDL C and apoB-100 due to enhanced clearance, and decreases HDL apoA-I due to decreased production (this latter effect may be compensatory, and those who cannot compensate may well be a higher CHD risk)
Gastric bypass surgery in morbidly obese subjects markedly lowers body weight and fat, LDL-C, and insulin levels, and increases HDL cholesterol and large alpha 1 HDL (+177%). Changes of fasting plasma insulin concentrations were positively correlated with those of LCAT mass (P = 0.043) and inversely with changes of alpha-1 (P = 0.03) and alpha-2 HDL levels (all p<0.05), indicative of a strong link between insulin resistance and HDL particle metabolism. CETP activity change linked to increase in large alpha 1 HDL
Velez-Carrasco W, Lichtenstein AH, Welty FK, Li Z, Lamon-Fava S, Dolnikowski GG, Schaefer EJ. Arterioscler Thromb Vasc Biol 1999;19:
Asztalos BF, Swarbrick MM, Schaefer EJ, Dallal GE, Horvath KV, Stanhope KL, Austrheim-Smith I, Wolfe BM, Ali M, Havel PJ. J Lipid Res. 2010; 51:

23. Effects of Gastric Bypass on HDL Particles – 1 Year
Baseline Value After 1 Year
ApoA-I mg/dl % Change %*
(32% of control) %*
(70% of control) %
(86% of control) %
(104% of control) %
(115% of control)
*p<0.01, related to 83% decrease in CETP activity, but not mass, HDL C increased from 34 to 45 mg/dl .
Asztalos BF, Swarbrick MM, Schaefer EJ, Dallal GE, Horvath KV, Stanhope KL, Austrheim-Smith I, Wolfe BM, Ali M, Havel PJ. J Lipid Res. 2010; 51:

24. ApoA-II

26. Thank You