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Toribio-Fernández R, Tristão-Pereira C, Carlos Silla-Castro J, Callejas S, Oliva B, Fernandez-Nueda I, Garcia-Lunar I, Perez-Herreras C, María Ordovás J, Martin P, Blanco-Kelly F, Ayuso C, Lara-Pezzi E, Fernandez-Ortiz A, Garcia-Alvarez A, Dopazo A, Sanchez-Cabo F, Ibanez B, Cortes-Canteli M, Fuster V. Apolipoprotein E-ε2 and Resistance to Atherosclerosis in Midlife: The PESA Observational Study. Circ Res 2024; 134:411-424. [PMID: 38258600 DOI: 10.1161/circresaha.123.323921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND APOE is a known genetic contributor to cardiovascular disease, but the differential role APOE alleles play in subclinical atherosclerosis remains unclear. METHODS The PESA (Progression of Early Subclinical Atherosclerosis) is an observational cohort study that recruited 4184 middle-aged asymptomatic individuals to be screened for cardiovascular risk and multiterritorial subclinical atherosclerosis. Participants were APOE-genotyped, and omics data were additionally evaluated. RESULTS In the PESA study, the frequencies for APOE -ε2, -ε3, and -ε4 alleles were 0.060, 0.844, and 0.096, respectively. This study included a subcohort of 3887 participants (45.8±4.3 years of age; 62% males). As expected, APOE-ε4 carriers were at the highest risk for cardiovascular disease and had significantly greater odds of having subclinical atherosclerosis compared with ε3/ε3 carriers, which was mainly explained by their higher levels of low-density lipoprotein (LDL)-cholesterol. In turn, APOE-ε2 carriers were at the lowest risk for cardiovascular disease and had significantly lower odds of having subclinical atherosclerosis in several vascular territories (carotids: 0.62 [95% CI, 0.47-0.81]; P=0.00043; femorals: 0.60 [0.47-0.78]; P=9.96×10-5; coronaries: 0.53 [0.39-0.74]; P=0.00013; and increased PESA score: 0.58 [0.48-0.71]; P=3.16×10-8). This APOE-ε2 atheroprotective effect was mostly independent of the associated lower LDL-cholesterol levels and other cardiovascular risk factors. The protection conferred by the ε2 allele was greater with age (50-54 years: 0.49 [95% CI, 0.32-0.73]; P=0.00045), and normal (<150 mg/dL) levels of triglycerides (0.54 [0.44-0.66]; P=4.70×10-9 versus 0.90 [0.57-1.43]; P=0.67 if ≥150 mg/dL). Omics analysis revealed an enrichment of several canonical pathways associated with anti-inflammatory mechanisms together with the modulation of erythrocyte homeostasis, coagulation, and complement activation in ε2 carriers that might play a relevant role in the ε2's atheroprotective effect. CONCLUSIONS This work sheds light on the role of APOE in cardiovascular disease development with important therapeutic and prevention implications on cardiovascular health, especially in early midlife. REGISTRATION URL: https://www.clinicaltrials.gov: NCT01410318.
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Affiliation(s)
- Raquel Toribio-Fernández
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain (R.T.-F., F.B.-K., C.A., B.I., M.C.-C.)
| | - Catarina Tristão-Pereira
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
| | - Juan Carlos Silla-Castro
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
| | - Sergio Callejas
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
| | - Belen Oliva
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
| | - Irene Fernandez-Nueda
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
| | - Ines Garcia-Lunar
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- Cardiology Department, University Hospital La Moraleja, Madrid, Spain (I.G.-L.)
- CIBER de enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain (I.G.-L., P.M., A.F.-O., A.G.-A., B.I.)
| | | | - José María Ordovás
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- Precision Nutrition and Obesity Research Program, IMDEA Food Institute, CEI UAM+CSI, Madrid, Spain (J.M.O.)
- U.S. Department of Agriculture Human Nutrition Research Center of Aging, Tufts University, MA (J.M.O.)
| | - Pilar Martin
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- CIBER de enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain (I.G.-L., P.M., A.F.-O., A.G.-A., B.I.)
| | - Fiona Blanco-Kelly
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain (R.T.-F., F.B.-K., C.A., B.I., M.C.-C.)
- CIBER de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain (F.B.-K., C.A.)
| | - Carmen Ayuso
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain (R.T.-F., F.B.-K., C.A., B.I., M.C.-C.)
- CIBER de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain (F.B.-K., C.A.)
| | - Enrique Lara-Pezzi
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
| | - Antonio Fernandez-Ortiz
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- CIBER de enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain (I.G.-L., P.M., A.F.-O., A.G.-A., B.I.)
- Hospital Clínico San Carlos, IdISSC, Universidad Complutense, Madrid, Spain (A.F.-O.)
| | - Ana Garcia-Alvarez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- CIBER de enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain (I.G.-L., P.M., A.F.-O., A.G.-A., B.I.)
- Hospital Clínic de Barcelona, IDIBAPS, Universitat de Barcelona, Spain (A.G.-A.)
| | - Ana Dopazo
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
| | - Fatima Sanchez-Cabo
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain (R.T.-F., F.B.-K., C.A., B.I., M.C.-C.)
- CIBER de enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain (I.G.-L., P.M., A.F.-O., A.G.-A., B.I.)
| | - Marta Cortes-Canteli
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain (R.T.-F., F.B.-K., C.A., B.I., M.C.-C.)
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (R.T.-F., C.T.-P., J.C.S.-C., S.C., B.O., I.F.-N., I.G.-L., J.M.O., P.M., E.L.-P., A.F.-O., A.G.-A., A.D., F.S.-C., B.I., M.C.-C., V.F.)
- Icahn School of Medicine at Mount Sinai, New York (V.F.)
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Culleton S, Niu M, Alexander M, McNally JS, Yuan C, Parker D, Baradaran H. Extracranial carotid artery atherosclerotic plaque and APOE polymorphisms: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1155916. [PMID: 38034385 PMCID: PMC10683092 DOI: 10.3389/fcvm.2023.1155916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction Carotid atherosclerotic plaque is an important independent risk factor for stroke. Apolipoprotein E (APOE) influences cholesterol levels and certain isoforms are associated with increased carotid atherosclerosis, though the exact association between APOE and carotid plaque is uncertain. The study aimed to evaluate the association between APOE and carotid plaque. Methods A systematic review was performed to retrieve all studies which examined the association between carotid plaque and APOE. This study was conducted in accordance with the PRISMA guidelines. Independent readers extracted the relevant data from each study including the type of imaging assessment, plaque definition, frequency of APOE E4 carrier status and type of genotyping. Meta-analyses with an assessment of study heterogeneity and publication bias were performed. Results were presented in a forest plot and summarized using a random-effects model. Results After screening 838 studies, 17 studies were included for systematic review. A meta-analysis of 5 published studies showed a significant association between ε4 homozygosity and carotid plaque [odds ratio (OR), 1.53; 95% CI, 1.16, 2.02; p = .003]. Additionally, there was a significant association between patients possessing at least one ε4 allele, heterozygotes or homozygotes, and carotid plaque (OR, 1.25; 95% CI, 1.03, 1.52; p = .03). Lastly, there was no association between ε4 heterozygosity and carotid plaque (OR, 1.08; 95% CI, 0.93, 1.26; p = .30). Conclusion APOE ε4 allele is significantly associated with extracranial carotid atherosclerotic plaque, especially for homozygous individuals.
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Affiliation(s)
- Sinéad Culleton
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake, UT, United States
| | - Mary Niu
- Department of Pediatrics, University of Utah, Salt Lake, UT, United States
| | - Matthew Alexander
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake, UT, United States
| | - J. Scott McNally
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake, UT, United States
| | - Chun Yuan
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake, UT, United States
| | - Dennis Parker
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake, UT, United States
| | - Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake, UT, United States
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Paradela RS, Farias-Itao DS, Leite REP, Pasqualucci CA, Grinberg LT, Naslavsky MS, Zatz M, Nitrini R, Jacob-Filho W, Suemoto CK. Apolipoprotein E ε2 allele is associated with lower risk of carotid artery obstruction in a population-based autopsy study. J Stroke Cerebrovasc Dis 2023; 32:107229. [PMID: 37531722 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 08/04/2023] Open
Abstract
INTRODUCTION Apolipoprotein E (APOE) ε4 allele has been associated with higher carotid atherosclerosis risk, while the APOE-ε2 seems to decrease this risk. Data from autopsy studies, where carotid arteries can be evaluated in their full extension, is scarce. Therefore, we investigated the association between APOE alleles and direct morphometric measurements of carotid atherosclerosis in an autopsy study with an admixed sample. METHODS We measured the intima-media thickness (IMT) and stenosis of the common (CCA) and internal carotid (ICA) arteries. The APOE polymorphisms were determined by real-time polymerase chain reaction. Participants were classified into three groups according to the APOE alleles (ε2, ε3, and ε4). We evaluated the association between APOE groups and carotid atherosclerosis using adjusted regression models and included interaction terms of APOE alleles with age, sex, and race. RESULTS We evaluated 1,850 carotid artery samples from 185 participants (mean age=75±12 years old, 55% female, and 71% White). The APOE-ε2 group (n=17) had a lower carotid obstruction and a lower number of severe stenoses (≥ 70%). Having at least one ε4 allele (n=51) was not associated with carotid atherosclerosis. APOE alleles were also not associated with carotid IMT. Age, sex, and race did not modify these relationships. CONCLUSION APOE-ε2 carriers had a lower percentage of carotid obstruction and less severe stenosis. APOE-ε4 was not related to a higher risk of carotid atherosclerosis in this cross-sectional population-based autopsy study.
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Affiliation(s)
| | | | - Renata E P Leite
- Department of Pathology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Carlos A Pasqualucci
- Department of Pathology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Lea T Grinberg
- Department of Pathology, University of Sao Paulo Medical School, Sao Paulo, Brazil; Memory and Aging Center, University of California San Francisco, USA
| | - Michel Satya Naslavsky
- Human Genome and Stem Cell Center, Biosciences Institute, University of São Paulo, São Paulo, Brazil
| | - Mayana Zatz
- Human Genome and Stem Cell Center, Biosciences Institute, University of São Paulo, São Paulo, Brazil
| | - Ricardo Nitrini
- Department of Neurology, University of São Paulo Medical School, Brazil
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Miao G, Zhuo D, Han X, Yao W, Liu C, Liu H, Cao H, Sun Y, Chen Z, Feng T. From degenerative disease to malignant tumors: Insight to the function of ApoE. Biomed Pharmacother 2023; 158:114127. [PMID: 36516696 DOI: 10.1016/j.biopha.2022.114127] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/03/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Apolipoprotein E (ApoE) is a multifunctional protein involved in lipid transport and lipoprotein metabolism, mediating lipid distribution/redistribution in tissues and cells. It can also regulate inflammation and immune function, maintain cytoskeleton stability, and improve neural tissue Function. Due to genetic polymorphisms of ApoE (ε2, ε3, and ε4), its three common structural isoforms (ApoE2, ApoE3, ApoE4) are also associated with the risk of many diseases, especially degenerative diseases, such as vascular degenerative diseases including atherosclerosis (AS), coronary heart disease (CHD), and neurodegenerative disease like Alzheimer's disease (AD). The frequency of the ε4 allele and APOE variants were significantly higher than that of the ε2 and ε3 alleles in the patients with CHD or AD. In recent years, ApoE has frequently appeared in tumor research and become a tumor biomarker gradually. It has been found that ApoE is highly expressed in most solid tumor tissues, such as glioblastoma, gastric cancer, pancreatic ductal cell carcinoma, etc. Studies illustrated that ApoE could regulate the polarization changes of macrophages, participate in the construction of tumor immune microenvironment, regulate tumor inflammation and immune response and play a role in tumor progression, invasion, and metastasis. Of course, many functions of ApoE and its relationship with diseases are still under research. By reviewing the structure and function of ApoE from degeneration diseases to tumor neoplasms, we hope to better understand such a biomarker and further explore the value of ApoE in later studies.
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Affiliation(s)
- Ganggang Miao
- Department of General Surgery, The People's Hospital of Danyang, Affiliated Danyang Hospital of Nantong University, Danyang, Jiangsu, China; Department of General Surgery, The Affiliated Nanjing Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Danping Zhuo
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xue Han
- Department of Clinical Laboratory, the Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Wentao Yao
- Department of Urology, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, Jiangsu, China
| | - Chuan Liu
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, China
| | - Hanyuan Liu
- Department of General Surgery, The Affiliated Nanjing Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hongyong Cao
- Department of General Surgery, The Affiliated Nanjing Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Yangbai Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Zhiqiang Chen
- Department of Nuclear Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China.
| | - Tingting Feng
- Jiangsu Key Laboratory of Infection and Immunity, Institute of Biology and Medical Sciences, Soochow University, Suzhou, China.
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Cardiorespiratory fitness decreases the odds for subclinical carotid plaques in apolipoprotein e4 homozygotes. Sci Rep 2022; 12:19196. [PMID: 36357490 PMCID: PMC9649711 DOI: 10.1038/s41598-022-23075-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
Some studies suggest that being an apolipoprotein e4 (APOE e4) carrier increases the risk of atherosclerosis, and others suggest that cardiorespiratory fitness (CRF) could play a key role in atherosclerotic prevention. Our aim was to analyze the association of APOE e4 with carotid atherosclerosis and the association of CRF with atherosclerosis in APOE e4 carriers. A cross-sectional analysis based on a subsample of 90 participants in the Aragon Workers' Health Study was carried out. Ultrasonography was used to assess the presence of plaques in carotid territory; the submaximal Chester Step Test was used to assess CRF; and behavioral, demographic, anthropometric, and clinical data were obtained by trained personnel during annual medical examinations. APOE e4e4 participants were categorized into Low-CRF (VO2max < 35 mL/kg/min) and High-CRF (VO2max ≥ 35 mL/kg/min) groups. After adjusting for several confounders, compared with APOE e3e3, those participants genotyped as APOE e3e4 and APOE e4e4 showed an OR = 1.60 (95% CI 0.45, 5.71) and OR = 4.29 (95% CI 1.16, 15.91), respectively, for carotid atherosclerosis. Compared to Low-CRF APOE e4e4 carriers, the odds of carotid plaque detection were 0.09 (95% CI 0.008, 0.98) times lower among High-CRF APOE e4e4 carriers. The APOE e4e4 genotype was associated with increased carotid atherosclerosis. However, CRF is a modifiable factor that may be targeted by APOE e4e4 to decrease the elevation of atherosclerotic risk due to this genetic condition.
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Liu M, Sariya S, Khasiyev F, Tosto G, Dueker ND, Cheung YK, Wright CB, Sacco RL, Rundek T, Elkind MS, Gutierrez J. Genetic determinants of intracranial large artery stenosis in the northern Manhattan study. J Neurol Sci 2022; 436:120218. [PMID: 35259553 PMCID: PMC9018518 DOI: 10.1016/j.jns.2022.120218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/01/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intracranial stenosis is one of the most common causes of stroke worldwide. Several single nucleotide polymorphisms have been associated with intracranial atherosclerosis, which is inferred to be the most common underlying cause of intracranial large artery stenosis (ILAS). We previously reviewed known genetic variants related to ILAS in predominantly Asian cohorts, but their prevalence and role in ILAS among western multiethnic populations are uncertain. METHODS We leveraged existing imaging and genetic data from the Northern Manhattan Study, a multiethnic prospective cohort study. Based on literature review, we selected adiponectin Q (ADIPOQ) rs2241767 and rs182052, ring finger protein 213 (RNF213) rs112735431, apolipoprotein E (APOE) rs429358, phosphodiesterase 4D (PDE4D) rs2910829, lipoprotein lipase (LPL) rs320, and aldosterone synthase (CYP11B2) rs1799998 variants as candidates to explore. We defined ILAS as luminal stenosis >50% in any intracranial large artery using time-of-flight magnetic resonance angiography (MRA). RESULTS We included 1109 participants (mean age 70 ± 9 years, 70% Hispanic, 60% women) in this study. ILAS was identified in 81 (7%) NOMAS participants. Logistic regression analyses adjusted for age, sex, principal components, and vascular risk factors showed ILAS prevalence associated with CYP11B2 rs1799998 under the dominant model (OR = 0.56, 95%CI: 0.35-0.89) and LPL rs320 heterozygote genotype (OR = 1.68, 95%CI: 1.05-2.71). The genotype distributions of ADIPOQ rs2241767 and rs182052, APOE rs429358 and CYP11B2 rs1799998 variants were significantly different among non-Hispanic white and Black, and Hispanic groups. When participants were further stratified by race/ethnicity, the estimates were consistent for CYP11B2 rs1799998 across race/ethnic groups but not for LPL rs320. CONCLUSION The CYP11B2 rs1799998 variant may be a protective genetic factor for ILAS across race/ethnic groups, but the risk of ILAS associated with LPL rs320 varies by race/ethnic group. Further functional studies may help elucidate the role that these variants play in the pathophysiology of ILAS.
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Pitchika A, Markus MRP, Schipf S, Teumer A, Van der Auwera S, Nauck M, Dörr M, Felix S, Grabe HJ, Völzke H, Ittermann T. Effects of Apolipoprotein E polymorphism on carotid intima-media thickness, incident myocardial infarction and incident stroke. Sci Rep 2022; 12:5142. [PMID: 35332187 PMCID: PMC8948289 DOI: 10.1038/s41598-022-09129-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/09/2022] [Indexed: 11/09/2022] Open
Abstract
The Apolipoprotein E (APOE) gene polymorphism (rs429358 and rs7412) shows a well-established association with lipid profiles, but its effect on cardiovascular disease is still conflicting. Therefore, we examined the association of different APOE alleles with common carotid artery intima-media thickness (CCA-IMT), carotid plaques, incident myocardial infarction (MI) and stroke. We analyzed data from 3327 participants aged 20-79 years of the population-based Study of Health in Pomerania (SHIP) from Northeast Germany with a median follow-up time of 14.5 years. Linear, logistic, and Cox-regression models were used to assess the associations of the APOE polymorphism with CCA-IMT, carotid plaques, incident MI and stroke, respectively. In our study, the APOE E2 allele was associated with lower CCA-IMT at baseline compared to E3 homozygotes (β: - 0.02 [95% CI - 0.04, - 0.004]). Over the follow-up, 244 MI events and 218 stroke events were observed. APOE E2 and E4 allele were not associated with incident MI (E2 HR: 1.06 [95% CI 0.68, 1.66]; E4 HR: 1.03 [95% CI 0.73, 1.45]) and incident stroke (E2 HR: 0.79 [95% CI 0.48, 1.30]; E4 HR: 0.96 [95% CI 0.66, 1.38]) in any of the models adjusting for potential confounders. However, the positive association between CCA-IMT and incident MI was more pronounced in E2 carriers than E3 homozygotes. Thus, our study suggests that while APOE E2 allele may predispose individuals to lower CCA-IMT, E2 carriers may be more prone to MI than E3 homozygotes as the CCA-IMT increases. APOE E4 allele had no effect on CCA-IMT, plaques, MI or stroke.
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Affiliation(s)
- Anitha Pitchika
- Institute for Community Medicine, University Medicine Greifswald, SHIP/Clinical-Epidemiological Research, Walther Rathenau Str. 48, 17475, Greifswald, Germany.
| | - Marcello Ricardo Paulista Markus
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,German Center for Cardiovascular Research (DZHK E.V.), Partner site Greifswald, Greifswald, Germany.,DZD (German Center for Diabetes Research), Site Greifswald, Greifswald, Germany
| | - Sabine Schipf
- Institute for Community Medicine, University Medicine Greifswald, SHIP/Clinical-Epidemiological Research, Walther Rathenau Str. 48, 17475, Greifswald, Germany.,Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Alexander Teumer
- Institute for Community Medicine, University Medicine Greifswald, SHIP/Clinical-Epidemiological Research, Walther Rathenau Str. 48, 17475, Greifswald, Germany.,German Center for Cardiovascular Research (DZHK E.V.), Partner site Greifswald, Greifswald, Germany
| | - Sandra Van der Auwera
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Greifswald, Germany
| | - Matthias Nauck
- German Center for Cardiovascular Research (DZHK E.V.), Partner site Greifswald, Greifswald, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Marcus Dörr
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,German Center for Cardiovascular Research (DZHK E.V.), Partner site Greifswald, Greifswald, Germany
| | - Stephan Felix
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,German Center for Cardiovascular Research (DZHK E.V.), Partner site Greifswald, Greifswald, Germany
| | - Hans-Jörgen Grabe
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Greifswald, Germany
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, SHIP/Clinical-Epidemiological Research, Walther Rathenau Str. 48, 17475, Greifswald, Germany.,German Center for Cardiovascular Research (DZHK E.V.), Partner site Greifswald, Greifswald, Germany.,DZD (German Center for Diabetes Research), Site Greifswald, Greifswald, Germany
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, SHIP/Clinical-Epidemiological Research, Walther Rathenau Str. 48, 17475, Greifswald, Germany
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8
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Abstract
PURPOSE OF REVIEW The functions, genetic variations and impact of apolipoprotein E on lipoprotein metabolism in general are placed in the context of clinical practice dealing with moderate dyslipidaemia as well as dysbetalipoproteinemia, a highly atherogenic disorder and lipoprotein glomerulopathy. RECENT FINDINGS Additional variants of apolipoprotein E and participation of apolipoprotein E in inflammation are of interest. The mostly favourable effects of apolipoprotein E2 as well as the atherogenic nature of apolipoproteinE4, which has an association with cognitive impairment, are confirmed. The contribution of remnant lipoproteins of triglyceride-rich lipoproteins, of which dysbetalipoproteinemia represents an extreme, is explored in atherosclerosis. Mimetic peptides may present new therapeutic approaches. Apolipoprotein E is an important determinant of the lipid profile and cardiovascular health in the population at large and can precipitate dysbetalipoproteinemia and glomerulopathy. Awareness of apolipoprotein E polymorphisms should improve medical care.
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9
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Apolipoprotein E Gene Polymorphism, Glycated Hemoglobin, and Peripheral Arterial Disease Risk in Chinese Type 2 Diabetic Patients. DISEASE MARKERS 2021; 2020:6040525. [PMID: 32211081 PMCID: PMC7085830 DOI: 10.1155/2020/6040525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/27/2019] [Accepted: 01/16/2020] [Indexed: 11/17/2022]
Abstract
Background The apolipoprotein E (ApoE) gene polymorphism has been found to influence plasma lipid concentration, and its correlation with peripheral arterial disease (PAD) has been investigated. However, it is unclear whether ApoE is associated with PAD in Chinese type 2 diabetes mellitus (T2DM) patients. Therefore, our study is aimed at investigating the relationship between the ApoE gene polymorphism and PAD in Chinese T2DM patients. Methods A total of 192 T2DM patients were divided into two groups: T2DM and T2DM with PAD. The clinical and biochemical parameters were obtained. Polymerase chain reaction was used to identify the genotypes of ApoE. The multivariable logistic regression analysis was used to identify the possible risk factor for PAD. Results There were no significant differences in the genotype and allele frequencies of ApoE between the T2DM and T2DM with PAD groups. However, the T2DM with PAD group tended to have more ε4/ε4/ Conclusions These results demonstrated that there was no evidence of a relationship between ApoE and PAD.
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10
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Czeck MA, Northrop EF, Evanoff NG, Dengel DR, Rudser KD, Kelly AS, Ryder JR. Relationship of Apolipoproteins with Subclinical Cardiovascular Risk in Youth. J Pediatr 2020; 227:199-203.e1. [PMID: 32795477 PMCID: PMC7686115 DOI: 10.1016/j.jpeds.2020.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine the association of apolipoproteins with arterial stiffness and carotid artery structure in children and adolescents. STUDY DESIGN A total of 338 children and adolescents (178 female) with a mean age 13.0 ± 2.8 years were examined. Apolipoproteins (AI, AII, B100, CII, CIII, and E) were measured via human apolipoprotein magnetic bead panel. Applanation tonometry determined pulse wave velocity and ultrasound imaging measured carotid intima-media thickness. Dual X-ray absorptiometry measured total body fat percent. Linear regression models were adjusted for Tanner stage, sex, and race with further adjustments for body fat percent. Linear regression models also examined the interaction between Tanner stage and apolipoproteins. RESULTS There was a significant positive association between pulse wave velocity and apolipoproteins: AI (0.015 m/s/10 μg/mL [CI 0.005-0.026], P = .003), AII (0.036 m/s/10 μg/mL [0.017-0.056], P < .001), B100 (0.009 m/s/10 μg/mL [0.002-0.016], P = .012), E (0.158 m/s/10 μg/mL [0.080-0.235], P < .001), and CIII:CII (0.033/μg/mL [0.014-0.052], P < .001). After we added body fat percent to the models, pulse wave velocity (PWV) remained positively associated with greater levels of apolipoproteins: AI, AII, B100, E, and CIII:CII. Both with and without the adjustment for body fat percent, there were no significant associations between any apolipoprotein and carotid intima-media thickness. There were no significant interactions between Tanner stage and apolipoproteins. CONCLUSIONS These findings suggest that greater levels of apolipoprotein AII, E, and CIII:CII are associated with increased arterial stiffness in children and adolescents, both with and without adjusting for percent body fat. These specific apolipoproteins may be useful as biomarkers of cardiovascular risk.
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Affiliation(s)
- Madeline A Czeck
- School of Kinesiology, University of Minnesota, Minneapolis, MN.
| | - Elise F Northrop
- Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | - Nicholas G Evanoff
- School of Kinesiology, University of Minnesota, Minneapolis, MN; Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, MN
| | - Donald R Dengel
- School of Kinesiology, University of Minnesota, Minneapolis, MN; Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, MN
| | - Kyle D Rudser
- Division of Biostatistics, University of Minnesota, Minneapolis, MN; Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, MN
| | - Aaron S Kelly
- Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, MN; Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Justin R Ryder
- Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, MN; Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
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11
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Brewin JN, Smith AE, Cook R, Tewari S, Brent J, Wilkinson S, Brousse V, Inusa B, Menzel S, Rees DC. Genetic Analysis of Patients With Sickle Cell Anemia and Stroke Before 4 Years of Age Suggest an Important Role for Apoliprotein E. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2020; 13:531-540. [PMID: 32924542 DOI: 10.1161/circgen.120.003025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Ischemic stroke is a devastating complication affecting children with sickle cell anemia. Genetic factors are likely to be important in determining the risk of stroke but are poorly defined. METHODS We have studied a cohort of 19 children who had an overt ischemic stroke before 4 years of age. We predicted genetic determinants of stroke would be more prominent in this group. We performed whole exome sequencing on this cohort and applied 2 hypotheses to our variant filtering. First, we looked for strong, potentially mono- or oligogenic variants for ischemic stroke, and second, we considered that more common polygenic variants will be enriched in our cohort. Candidate variants emerging from both strategies were validated in a cohort of 283 patients with sickle cell anemia and known pediatric cerebrovascular outcomes. We used principal component analysis in this cohort to control for relatedness and population substructure. RESULTS Our primary finding was that the Apoliprotein E genotypes ε2/ε4 and ε4/ ε4, defined by the interplay of rs7412 and rs429358, were associated with increased stroke risk, with an odds ratio of 4.35 ([95% CI, 1.85-10.0] P=0.0011) for ischemic stroke in the validation cohort. We also found that rs2297518 in NOS (NO synthase) 2 (odds ratio, 2.25 [95% CI, 1.21-4.19]; P=0.014) and rs2230123 in signal transducer and activator of transcription (odds ratio, 2.60 [95% CI, 1.30-5.20]; P=0.009) both had increased odds ratios for ischemic stroke, although these two variants were below the threshold for statistical significance after correction for multiple testing. CONCLUSIONS These data identify new loci for future functional investigations into cerebrovascular disease in sickle cell anemia. Based on African population reference allele frequencies, the Apoliprotein E genotypes would be present in about 10% of children with sickle cell anemia and represent a genetic risk factor that is potentially modifiable by both dietary and pharmaceutical manipulation of its dyslipidemic effects.
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Affiliation(s)
- John N Brewin
- King's College London, United Kingdom (J.N.B., R.C., S.T., B.I., S.M., D.C.R.)
- King's College Hospital NHS Foundation Trust, London, United Kingdom (J.N.B., A.E.S., S.T., D.C.R.)
- Royal Wolverhampton NHS Trust, United Kingdom (J.B.)
| | - Alexander E Smith
- King's College Hospital NHS Foundation Trust, London, United Kingdom (J.N.B., A.E.S., S.T., D.C.R.)
| | - Riley Cook
- King's College London, United Kingdom (J.N.B., R.C., S.T., B.I., S.M., D.C.R.)
| | - Sanjay Tewari
- King's College London, United Kingdom (J.N.B., R.C., S.T., B.I., S.M., D.C.R.)
- King's College Hospital NHS Foundation Trust, London, United Kingdom (J.N.B., A.E.S., S.T., D.C.R.)
| | | | - Sarah Wilkinson
- Lewisham and Greenwich NHS Trust, London, United Kingdom (S.W.)
| | | | - Baba Inusa
- King's College London, United Kingdom (J.N.B., R.C., S.T., B.I., S.M., D.C.R.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (B.I.)
| | - Stephan Menzel
- King's College London, United Kingdom (J.N.B., R.C., S.T., B.I., S.M., D.C.R.)
| | - David C Rees
- King's College London, United Kingdom (J.N.B., R.C., S.T., B.I., S.M., D.C.R.)
- King's College Hospital NHS Foundation Trust, London, United Kingdom (J.N.B., A.E.S., S.T., D.C.R.)
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12
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Pereira LC, Nascimento JCR, Rêgo JMC, Canuto KM, Crespo-Lopez ME, Alvarez-Leite JI, Baysan A, Oriá RB. Apolipoprotein E, periodontal disease and the risk for atherosclerosis: a review. Arch Oral Biol 2018; 98:204-212. [PMID: 30503976 DOI: 10.1016/j.archoralbio.2018.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/25/2018] [Accepted: 11/10/2018] [Indexed: 12/26/2022]
Abstract
The association between cardiovascular and periodontal diseases is characterized by chronic inflammatory processes, with a high prevalence worldwide and complex genetic-environment interactions. Although apolipoprotein E4 (ApoE4), one of the isoforms coded by a polymorphic APOE gene, has been widely recognized as a risk factor for cardiovascular diseases and as an immunoinflammatory factor, less is known regarding how ApoE4 affects atherosclerosis in periodontitis patients. The aim of this review was to investigate the potential underlying mechanisms related to APOE4 that could increase the risk of periodontal disease and, ultimately, of atherosclerosis. There have only been a few studies addressing apoE polymorphisms in patients with chronic periodontitis. To date, no studies have been performed that have assessed how ApoE4 affects atherosclerotic disease in chronic periodontitis patients. Although clinical studies are warranted, experimental studies have consistently documented the presence of periodontal pathogens, which are usually found in the oral cavity and saliva, in the atherosclerotic plaques of ApoE-deficient mice. In addition, in this review, the potential role of the APOE4 allele as an example of antagonistic pleiotropy during human evolution and its relation to oral health is discussed.
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Affiliation(s)
- L C Pereira
- Laboratory of the Biology of Tissue Healing, Ontogeny and Nutrition, Department of Morphology and Institute of Biomedicine, School of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - J C R Nascimento
- Laboratory of the Biology of Tissue Healing, Ontogeny and Nutrition, Department of Morphology and Institute of Biomedicine, School of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - J M C Rêgo
- Laboratory of the Biology of Tissue Healing, Ontogeny and Nutrition, Department of Morphology and Institute of Biomedicine, School of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - K M Canuto
- Laboratory of the Biology of Tissue Healing, Ontogeny and Nutrition, Department of Morphology and Institute of Biomedicine, School of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - M E Crespo-Lopez
- Laboratory of Molecular Pharmacology, Institute of Biological Sciences, Federal University of Para, Belém, PA, Brazil
| | - J I Alvarez-Leite
- Institute of Biological Sciences, Department of Biochemistry and Immunology, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - A Baysan
- Institute of Dentistry, Barts and the London, School of Medicine and Dentistry, Queen Mary University, London, UK
| | - R B Oriá
- Laboratory of the Biology of Tissue Healing, Ontogeny and Nutrition, Department of Morphology and Institute of Biomedicine, School of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil.
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13
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Oviedo DC, Lezcano H, Perez AR, Villarreal AE, Carreira MB, Isaza B, Wesley L, Grajales SA, Fernandez S, Frank A, Britton GB. Vascular biomarkers and ApoE4 expression in mild cognitive impairment and Alzheimer's disease. AIMS Neurosci 2018; 5:148-161. [PMID: 32341958 PMCID: PMC7181887 DOI: 10.3934/neuroscience.2018.2.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
Vascular pathology and genetic markers such as apolipoprotein E allele ε4 (ApoE ε4) are risk factors for the progression from mild cognitive impairment (MCI) to Alzheimer's disease (AD). In Panama, a high prevalence of vascular risk factors and an increase in the aging population, generate the need to investigate biomarkers using specific, sensitive, non-invasive and cost-efficient methods that could be used in primary care. The main objective of this study was to explore the association between vascular biomarkers such as intima-media thickness (IMT) and stenosis, ApoΕ ε4 and cognitive function in a sample of older adults, including healthy controls (n = 41), MCI (n = 33), and AD (n = 12). A descriptive and cross-sectional study was conducted. Participants were part of the Panama Aging Research Initiative (PARI), the first prospective study in aging in Panama. Assessments included a neuropsychological battery, ApoΕ ε4 genotyping and a Doppler ultrasound of the left carotid artery to examine the presence of vascular risk factors. Neuropsychological tests were combined to form six cognitive domains: Global cognition, language, visuospatial abilities, learning and memory, attention and executive functions. Multivariable analyses (using age, education, and ApoE ε4 expression as covariates) were conducted. Participants with increased IMT showed poorer performance in memory and those with carotid stenosis showed poorer performance in language, visuospatial abilities and attention, independent of age, education or ApoΕ ε4 expression. The results support the use of vascular markers in cognitive assessments of aged individuals.
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Affiliation(s)
- Diana C Oviedo
- Universidad Católica Santa María La Antigua (USMA), Panamá
| | | | - Ambar R Perez
- Universidad Católica Santa María La Antigua (USMA), Panamá.,Centro de Neurociencias y Unidad de Investigación Clínica, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panamá
| | - Alcibiades E Villarreal
- Centro de Neurociencias y Unidad de Investigación Clínica, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panamá
| | - Maria B Carreira
- Centro de Neurociencias y Unidad de Investigación Clínica, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panamá
| | - Baltasar Isaza
- Servicio de Radiología, Complejo Hospitalario Arnulfo Arias Madrid, Caja del Seguro Social, Panamá
| | - Lavinia Wesley
- Servicio de Radiología, Complejo Hospitalario Arnulfo Arias Madrid, Caja del Seguro Social, Panamá
| | - Shantal A Grajales
- Centro de Neurociencias y Unidad de Investigación Clínica, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panamá
| | - Sara Fernandez
- Departmento de Psicología Básica II (Procesos Cognitivos), Facultad de Psicología, Universidad Complutense de Madrid, Madrid, España
| | - Ana Frank
- Servicio de Neurología, Hospital Universitario La Paz, Madrid, España
| | - Gabrielle B Britton
- Centro de Neurociencias y Unidad de Investigación Clínica, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panamá
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