Cholesteryl ester transfer protein polymorphisms, statin use, and their impact on cholesterol levels and cardiovascular events

OX-HDL: A Starring Role in Cardiorenal Syndrome and the Effects of Heme Oxygenase-1 Intervention

In this review, we will evaluate how high-density lipoprotein (HDL) and the reverse cholesterol transport (RCT) pathway are critical for proper cardiovascular-renal physiology. We will begin by reviewing the basic concepts of HDL cholesterol synthesis and pathway regulation, followed by cardiorenal syndrome (CRS) pathophysiology. After explaining how the HDL and RCT pathways become dysfunctional through oxidative processes, we will elaborate on the potential role of HDL dysfunction in CRS. We will then present findings on how HDL function and the inducible antioxidant gene heme oxygenase-1 (HO-1) are interconnected and how induction of HO-1 is protective against HDL dysfunction and important for the proper functioning of the cardiovascular-renal system. This will substantiate the proposal of HO-1 as a novel therapeutic target to prevent HDL dysfunction and, consequently, cardiovascular disease, renal dysfunction, and the onset of CRS.

Quantile-specific heritability of high-density lipoproteins with implications for precision medicine

BACKGROUND

We have previously shown that the effect of a high-density lipoprotein (HDL) genetic risk score depends on whether the phenotype (HDL cholesterol) is high or low relative to its distribution (quantile-dependent expressivity).

OBJECTIVE

Evidence for quantile-dependent expressivity was sought using a more inclusive genetic measure (quantile-specific heritability, h²) in a larger population (Framingham cohort).

METHODS

Quantile regression was used to test whether the offspring-parent (β_OP) and full-sib (β_FS) regression slopes increased with the percentiles of the offspring's HDL distribution in 10,650 parent-offspring pairs and 2130 sibships. Quantile-specific heritability was estimated by 2β_OP/(1 + r_spouse) and [(8β_FSr_spouse + 1)^0.5-1]/(2r_spouse), where r_spouse is the spouse correlation.

RESULTS

HDL cholesterol heritability estimated from β_OP increased significantly (P = 4.2 × 10^-5) from the 10^th (h² ± SE: 0.44 ± 0.03), 25^th (0.45 ± 0.03), 50^th (0.47 ± 0.03), and 75^th (0.56 ± 0.04) to the 90^th percentiles (0.65 ± 0.06) of the offspring's age- and sex-adjusted HDL cholesterol distribution. Heritability estimated from β_FS also increased significantly with the percentiles of the offspring's HDL cholesterol (P = .002), apo A1 (P = .006), HDL2 cholesterol (P = .003), and HDL3 cholesterol distribution (P = .02). Consistent with quantile-dependent expressivity, published pharmacologic and nutritional interventions that raised (eg, statin, fibrates, estrogen replacement therapy, efavirenz, and dietary fat) or lowered HDL cholesterol concentrations (tamoxifen, dietary carbohydrate) correspondingly increased and decreased genetic effects.

CONCLUSION

HDL cholesterol heritability increased with increasing percentile of the offspring's HDL distribution. Whereas precision medicine is based on the premise that genetic markers identify patients most likely to benefit from drugs and diet, quantile-dependent expressivity postulates that the strong signals from these genetic markers simply trace the heritability increase with increasing plasma HDL concentrations. Thus, quantile-dependent expressivity provides an alternative interpretation to these genotype-specific effects.

Transcription regulation of NRF1 on StAR reduces testosterone synthesis in hypoxemic murine

Male chronic obstructive pulmonary disease (COPD) and sleep apnea patients are associated with serum testosterone level decline because of hypoxemia, resulting in male sexual dysfunction and lower reproductive capacity. Although testosterone replacement therapy used in clinic achieves good results, the side effects indicates that understanding the mechanism followed with targeted treatments are more meaningful. The known mechanism of Hypoxia-inducible factor-1 (HIF-1) mediated steroidogenic acute regulatory protein (StAR) repression did not well explain the reason of hypoxia induced testosterone decline. Our primary results indicated Nuclear respiratory factor 1(NRF1) might be participate in StAR transcription regulation. The study aims to identify the mechanism of the regulation of StAR by NRF1, providing an explanation for the decrease of testosterone induced by hypoxemia. Testosterone level and StAR were determined in COPD model rats, sleep apnea model mice and hypoxia rats (10%O₂). Results indicated NRF1, StAR and testosterone decreased in testis and ovary and increased in adrenal. Regulation of NRF1 expression under normoxia or hypoxia induced synchronous changes of both StAR and testosterone, indicating the decrease of NRF1 induced StAR repression in hypoxemia were the main cause of serum testosterone decline. The results were confirmed by dual-luciferase reporter assays, regulation of NRF1 synchronously altered the transcriptional activity of StAR. By ChIP, EMSA supershift, NRF1 was found to bind to the Star promoter region. Mutation assays identified two NRF1-binding sites on mouse Star promoter. These findings indicated that NRF1 positivly regulated Star transcription through directly binding to the Star promoter at -1445/-1422 and -44/-19.

Meta-analysis of genome-wide association studies of HDL cholesterol response to statins

BACKGROUND

In addition to lowering low density lipoprotein cholesterol (LDL-C), statin therapy also raises high density lipoprotein cholesterol (HDL-C) levels. Inter-individual variation in HDL-C response to statins may be partially explained by genetic variation.

METHODS AND RESULTS

We performed a meta-analysis of genome-wide association studies (GWAS) to identify variants with an effect on statin-induced high density lipoprotein cholesterol (HDL-C) changes. The 123 most promising signals with p<1×10-4 from the 16 769 statin-treated participants in the first analysis stage were followed up in an independent group of 10 951 statin-treated individuals, providing a total sample size of 27 720 individuals. The only associations of genome-wide significance (p<5×10-8) were between minor alleles at the CETP locus and greater HDL-C response to statin treatment.

CONCLUSIONS

Based on results from this study that included a relatively large sample size, we suggest that CETP may be the only detectable locus with common genetic variants that influence HDL-C response to statins substantially in individuals of European descent. Although CETP is known to be associated with HDL-C, we provide evidence that this pharmacogenetic effect is independent of its association with baseline HDL-C levels.

Pharmacogenetics of Lipid-Lowering Agents: Precision or Indecision Medicine?

Lipid-lowering medications, particularly statins, have been a popular target for pharmacogenetic studies. A handful of genes have shown promise for predicting response to therapy from the perspective of lipid lowering, as well as myopathy. A number of genes have been implicated and have biological plausibility based on their involvement with the pharmacokinetics or pharmacodynamics of statins or other lipid-lowering medications. The level of confidence and replication of these findings varies, although several associations are likely true. Novel classes of lipid-lowering therapy have opened up new possibilities in the treatment of severe inherited forms of dyslipidemia, making the identification of such mutations an important pharmacogenetic predictor of failure of standard therapy, with potential response to novel therapy. Advances in next-generation sequencing technology bring the application of pharmacogenetics even closer to routine clinical practice.

Seventeen years of statin pharmacogenetics: a systematic review

AIM

We evaluated the evidence of pharmacogenetic associations with statins in a systematic review.

METHODS

Two separate outcomes were considered of interest: modification of low-density lipoprotein cholesterol (LDL-C) response and modification of risk for cardiovascular events.

RESULTS

In candidate gene studies, 141 loci were claimed to be associated with LDL-C response. Only 5% of these associations were positively replicated. In addition, six genome-wide association studies of LDL-C response identified common SNPs in APOE, LPA, SLCO1B1, SORT1 and ABCG2 at genome-wide significance. None of the investigated SNPs consistently affected the risk reduction for cardiovascular events.

CONCLUSION

Only five genetic loci were consistently associated with LDL-C response. However, as effect sizes are modest, there is no evidence for the value of genetic testing in clinical practice.

Regulation of cholesteryl ester transfer protein expression by upstream polymorphisms: reduced expression associated with rs247616

BACKGROUND

Cholesteryl ester transfer protein (CETP) is involved in reverse cholesterol transport by exchanging cholesteryl esters for triglycerides between high-density lipoprotein and low-density lipoprotein particles, effectively decreasing high-density lipoprotein cholesterol levels. Variants within a large haplotype block upstream of CETP (rs247616, rs173539) have been shown to be significantly associated with reduced expression; however, the underlying mechanism has not been identified.

METHODS

We analyzed the linkage structure of our top candidate single-nucleotide polymorphism (SNP), rs247616, and assessed each SNP of the haplotype block for potential interactions with transcription factor binding sites. We then used a reporter gene assay to assess the effect of three SNPs (rs247616, rs173539, and rs1723150) on expression in vitro.

RESULTS

Several variants in the upstream haplotype, including rs247616, rs173539, and rs1723150, disrupt or generate transcription factor binding sites. In reporter gene assays, rs247616 and rs173539 were found to significantly affected expression in HepG2 cells, whereas rs17231506 had no effect. rs247616 decreased expression by 1.7-fold (P<0.0001), whereas rs173539 increased expression by 2.2-fold (P=0.0006).

CONCLUSION

SNPs rs247616 and rs173539 are in high linkage disequilibrium (R=0.96, D'=1.00) and have the potential to regulate CETP expression. Although opposing effects suggest that regulation of CETP expression could vary between tissues, the minor allele of rs247616 and SNPs in high linkage with it were found to be associated with reduced expression across all tissues.

CETP inhibitors and cardiovascular disease: Time to think again

Inhibition of cholesteryl ester transfer protein (CETP) lowers plasma low-density lipoprotein cholesterol concentration and raises high-density lipoprotein (HDL) cholesterol, suggesting it might prevent cardiovascular disease (CVD). From the outset, however, the concept has been controversial owing to uncertainty about its effects on HDL function and reverse cholesterol transport (RCT). Although there has long been good evidence that CETP inhibition reduces atherosclerosis in rabbits, the first information on CETP as a CVD risk factor in a prospectively followed cohort was not published until after the first Phase 3 trial of a CETP inhibitor had begun. The worrying finding that CVD incidence was related inversely to plasma CETP has since been reproduced in each of five further prospective cohort studies. Similar results were obtained in subjects on or off statin therapy, for first and second CVD events, and for mortality as well as CVD morbidity. Additionally, two recent studies have found alleles of the CETP gene that lower hepatic CETP secretion to be associated with an increased risk of myocardial infarction. Meanwhile, CETP gene transfer in mice was found to increase RCT from peripheral macrophages in vivo, and human plasma with high CETP activity was shown to have a greater capacity to remove cholesterol from cultured cells than plasma with low activity. This mounting evidence for a protective function of CETP has been given remarkably little attention, and indeed was not mentioned in several recent reviews.  It appears to show that CETP inhibition does not test the HDL hypothesis as originally hoped, and raises a pressing ethical issue regarding two Phase 3 trials of inhibitors, involving more than forty thousand subjects, which are currently in progress. As the weight of evidence now clearly supports an adverse effect of CETP inhibition on CVD, an urgent review is needed to determine if these trials should be discontinued.

Genetic variants affecting alternative splicing of human cholesteryl ester transfer protein

Cholesteryl ester transfer protein (CETP) plays an important role in reverse cholesterol transport, with decreased CETP activity increasing HDL levels. Formation of an alternative splice form lacking exon 9 (Δ9-CETP) has been associated with two single nucleotide polymorphisms (SNPs) in high linkage disequilibrium with each other, namely rs9930761 T>C located in intron 8 in a putative splicing branch site and rs5883 C>T in a possible exonic splicing enhancer (ESE) site in exon 9. To assess the relative effect of rs9930761 and rs5883 on splicing, mini-gene constructs spanning CETP exons 8 to 10, carrying all four possible allele combinations, were transfected into HEK293 and HepG2 cells. The minor T allele of rs5883 enhanced splicing significantly in both cell lines whereas the minor C allele of rs9930761 did not. In combination, the two alleles did not yield greater splicing than the rs5883 T allele alone in HepG2 cells. These results indicate that the genetic effect on CETP splicing is largely attributable to rs5883. We also confirm that Δ9-CETP protein is expressed in the liver but fails to circulate in the blood.