Figures
Abstract
Background
Atherosclerosis is a complex multifactorial disease and the apolipoprotein E (APOE) polymorphism has been associated to vascular complications of atherosclerosis.
Objectives
To investigate the relationship between the APOE genotypes and advanced peripheral vascular disease.
Materials and methods
258 consecutive patients (201 males and 57 females, mean age 70.83 ± 7.89 years) with severe PVD were enrolled in a 42-months longitudinal study (mean 31.65 ± 21.11 months) for major adverse cardiovascular events. At follow-up genotypes of the APOE polymorphism were investigated in blinded fashion.
Results
As compared with ε3/ε3, in ε4-carriers a significant higher incidence of major adverse cardiovascular events (35.58% vs. 20.79%; p = 0.025) and total peripheral revascularization (22.64% vs. 5.06%; p < 0.001) was observed. Prospective analysis, showed that ε4-carriers have an increased hazard ratio for major adverse cardiovascular events (adjusted HR 1.829, 95% CI 1.017–3.287; p = 0.044) and total peripheral revascularization (adjusted HR = 5.916, 95% CI 2.405–14.554, p <0.001).
Citation: Mastroianno S, Di Stolfo G, Seripa D, Pacilli MA, Paroni G, Coli C, et al. (2017) Role of the APOE polymorphism in carotid and lower limb revascularization: A prospective study from Southern Italy. PLoS ONE 12(3): e0171055. https://doi.org/10.1371/journal.pone.0171055
Editor: Ornit Chiba-Falek, Duke University, UNITED STATES
Received: November 19, 2016; Accepted: January 14, 2017; Published: March 1, 2017
Copyright: © 2017 Mastroianno et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This study was completely supported by “Ministero della Salute”, I.R.C.C.S. Research Program, Ricerca Corrente 2015-2017, Linea n. 2 “Malattie complesse e terapie innovative” and by the “5 x 1000” voluntary contribution.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: 25-OH-Vit D, 25-hydroxy-vitamin D; ACE inhibitors, Angiotensin Converting Enzyme Inhibitors; APOE, apolipoprotein E encoding gene; ARBs, Angiotensin Receptor Blockers; BMI, Body Mass Index; CI, Confidence Interval; CVD, Cardiovascular Disease; eGFR, Estimated Glomerular Filtration Rate; ESR, Erythrocyte Sedimentation Rate; HDL-Ch, High Density Lipoprotein-Cholesterol; HOMAir, Homeostatic Model Assessment—Insulin Resistance; hs-CRP, High Sensitivity—C Reactive Protein; HR, Hazard Ratio; LDL-Ch, Low Density Lipoprotein–Cholesterol; LVEF, Left Ventricle Ejection Fraction; LVMI, Left Ventricular Mass Index; MACE, Major Adverse Cardiovascular Events; NCEP ATP III, Third Report of The National Cholesterol Education Program; PVD, Peripheral Vascular Disease; PWV, Pulse Wave Velocity; SD, Standard Deviation
Introduction
Atherosclerosis and associated cardiovascular diseases (CVD) represent the major cause of death and comorbidities in Western and developing countries [1, 2]. The Global Burden of Disease Study estimated that about 32% of all deaths worldwide in 2013 were caused by CVD, with about 80% of these deaths occurring in low-and middle-income countries [3]. In 2011, CVD still had a significant social burden in the US with annual costs for disease treating estimated about US$320.1 billion [4, 5]. Some manifestations of CVD as stroke, heart attack, limb ischemia, peripheral revascularization or amputation, have a decisive weight on health-related quality of life and disability, for which the long-term care costs tend to exceed health spending [6].
Atherosclerosis recognizes several risk factors, some determined by environment and modifiable, such as diet and smoking, other individual, and some non-modifiable, such as familiar CVD history, age and sex [7, 8]. Furthermore, the most common of these risk factors play a different role on the various arterial districts, such as low density lipoprotein-Cholesterol (LDL-Ch) for coronary heart disease, arterial systemic pressure for stroke, and smoking and systolic blood pressure for carotid and lower limbs disease [9, 10, 11]. In addition, genetic susceptibility in families affected by CVD is an important predisposing factor for atherosclerosis and for the most aggressive forms of vascular disease. In this regard, numerous studies have been conducted to identify susceptibility genes, which may have a predictive role in assessing the aggressiveness of the disease and the individual cardiovascular risk [12, 13]. Among these susceptibility genes, one of the most studied is the polymorphism of apolipoprotein E (APOE) gene [14, 15]. This polymorphism resulted in three most common alleles ε2, ε3, and ε4 and six most common genotypes [16, 17] that have been already related in different way to atherosclerosis and associated CVD [18, 19, 20]. Some epidemiological studies investigated the direct impact of APOE as a risk factor for coronary heart disease while others assessed the impact on cholesterol levels. APOE2 is mainly associated with lower LDL-Ch levels, while APOE4 allele with higher LDL-Ch levels [21, 22, 23]. Clinical studies have suggested a predisposing role for APOE4 in the development of CVD [24, 25, 26]. To date, there is disagreement concerning the APOE role on atherosclerosis involving the carotid and lower limb arteries [27, 28, 29]. Aim of the present study was to investigate in a cohort of patients affected by advanced atherosclerosis, a possible relationship between the APOE genotypes and the progression towards more aggressive forms of the disease, until requiring surgical or endovascular revascularization of peripheral arterial vessels.
Material and methods
Standard protocol approval, registration, and patient consent
This was a longitudinal study of a cardiovascular controlled case-series of patients fulfilling the Declaration of Helsinki [30], the guidelines for Good Clinical Practice [31], and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [32]. The approval of the study was obtained from the local Ethics Committees on human experimentation of "Casa Sollievo della Sofferenza" Hospital, represented by Cardinal Elio Sgreccia, Sister Elisa Cipollone, Dr. Rosa Giuseppa Frazzica, Dr. Giuseppe Fasanella, Professor Antonio Mangiacotti, Dr. Salvatore De Cosmo, Dr. Nicola Giuliani and Dr. Antonio Melchionda. Written informed consent for research was obtained from each patient.
Patient’s recruitment
From November 1st, 2009 to November 30th, 2013 two hundred fifty eight patients (201 males and 57 females, mean age 70.83 ± 7.89 years, range from 45 to 88) consecutively attending the multidisciplinary atherosclerosis outpatient clinic of “Casa Sollievo della Sofferenza” Hospital were enrolled in the study.
Inclusion/exclusion criteria
Inclusion criteria were 1) Caucasian race, 2) written informed consent, and 3) a diagnosis of advanced atherosclerosis defined as carotid occlusion or severe stenosis (reduction of the vessel lumen greater than 50% evaluated with ultrasound) and/or lower limb ischemia II or III stadium Leriche-Fontaine (estimated by treadmill test at 12% inclination and 3.5 km/h speed) as already reported [33]. Exclusion criteria were presence of 1) not critical carotid atheroma, 2) I stadium Leriche-Fontaine (defined as asymptomatic arterial disease), 3) IV stadium Leriche-Fontaine (represented by gangrene of the lower limbs), 4) cancer with an expectation life less than six months, 5) clinical diagnosis of Alzheimer’s disease. A summary of the study design was reported in Fig 1.
Clinical evaluation
Medical status was collected by a structured interview, a clinical evaluation, and a review of records from the patient’s general practitioners. In detail, patients underwent a clinical and laboratory examination for history of cancer, smoking habits, obesity, arterial hypertension, dyslipidemia, type 2 diabetes mellitus, as described in previously [33] and according to criteria of “The Third Report of The National Cholesterol Education Program” (NCEP ATP III) [34]. Lastly, serum concentrations of 25-hydroxy-vitamin D (25-OH-Vit D), erythrocyte sedimentation rate (ESR); homeostatic model assessment-insulin resistance (HOMAir); high sensitivity-C reactive protein (hs-CRP) and fibrinogen were assessed in all patients. Moreover, we assessed by strict analysis of clinical documentation the presence of previous CVD, defining as myocardial infarction, stroke, carotid or lower limb revascularization and myocardial reperfusion procedure.
At enrollment, arterial stiffness was evaluated by non-invasive method of brachial-ankle pulse wave velocity (PWV) and augmentation index using the AngE System (Sonotechnik, Austria, Europe), as already reported [33]. Standard 12-lead electrocardiogram and echocardiogram have been performed for determination of heart rhythms, PR, QRS, QTc intervals, bundle branch block, and for measure left ventricle ejection fraction (LVEF) and ventricular mass, respectively. The estimation of left ventricular mass index (LVMI) was performed dividing left ventricular mass to body surface. Doppler ultrasound examination was used for study course and size of the abdominal aorta, stenosis of carotid, vertebral, subclavian, renal, iliac, femoral, popliteal and tibial arteries. Renal resistance index was calculated at the renal hilum.
All the participants underwent a mean follow-up of 31.65 ± 21.11 months (range 6 to 50 months, mode 42 months). At follow up we have evaluated major adverse cardiovascular events (MACE), defined as myocardial infarction, cerebral ischemia, myocardial and/or peripheral revascularization and cardiovascular death (included all deaths for heart failure, myocardial infarction, stroke, malignant arrhythmias and sudden death). Furthermore, as additional data were recorded all deaths from malignant tumors.
Genetic analysis
Genomic DNA was purified from whole blood by using standard methods [35]. The APOE genotypes were identified in blinded fashion as previously described [36]. The observed genotype frequencies were 10.47% for the ε2/ε3, 68.99% for ε3/ε3, 19.38% for ε3/ε4, and 1.16% for ε4/ε4. No ε2/ε2 or ε2/ε4 genotypes were identified. No differences were observed in respect to the expected Hardy-Weinberg frequencies (p = 0.622). According to these genotype frequencies, the estimated allele frequencies were 5.232 for the ε2 allele, 83.915 for ε3, and 10.853 for the ε4 allele. Agreeing to the APOE genotypes, patients were grouped as ε2 (ε2/ε2 + ε2/ε3), ε3 (ε3/ε3), and ε4 (ε4/ε3 + ε4/ε4) and the ε3 was used as the reference category (wild type).
Statistical analysis
Continuous variables were reported as means ± standard deviation (SD) as well as categorical variables were reported as percentages. Dichotomous variables were compared by using the Pearson's χ2 test. Normal distribution of continuous variables was verified by the Kolmogorov-Smirnov test. Differences in the groups were analyzed using variance analysis (two-tailed unpaired t-test). Hardy-Weinberg equilibrium was tested by χ2test. P values <0.05 were considered statistically significant. Event-free survival in patients were calculated by Kaplan–Meier method and compared by log rank test. For the prospective analysis of cardiovascular events incidence in the groups Cox model were performed to estimate hazard ratio (HR) with 95% confidence interval (95% CI). HR was calculated with adjustment for the common risk factors as BMI, hypertension, diabetes, dislipidemia, smoking, age and gender. SPSS 13.0 software (Chicago, IL, USA) was used for statistical analysis.
Results
Demographic and clinical characteristics of patients at baseline according to the APOE genotypes were reported in Table 1. In respect to ε3, we found ε2-patients significantly more obese (BMI 29.81 ± 2.52 Kg/m2 vs. 28.63 ± 4.13 Kg/m2; p = 0.046), have lower levels of 25-OH-Vit D (10.78 ± 6.45 ng/ml vs. 17.02 ± 14.08 ng/ml; p = 0.001), greater arterial stiffness as PWV (17.00 ± 3.60 m/sec vs. 14.45 ± 4.17 m/sec; p = 0.001), and an increased LVMI (89.69 ± 25.35 gr/m2 vs. 76.52 ± 19.80 gr/m2; p = 0.017). Statistical trend towards a greater waist-hip ratio (0.99 ± 0.06 vs. 0.96 ± 0.06; p = 0.053) and a lower level of LDL-Ch (81.80 ± 48.52 mg/dl vs. 96.28 ± 33.21 mg/dl; p = 0.050) were also observed. Even in respect to ε3, we found ε4-patients significantly less obese (BMI 27.23 ± 3.63 Kg/m2 vs. 28.63 ±4.13 Kg/m2; p = 0.029), and with minor inflammatory indexes as ESR (21.21 ± 13.02 mm/h vs. 26.66 ± 18.52 mm/h; p = 0.026) and hs-CRP (0.42 ± 0.35 mg/dl vs. 0.80 ± 2.69 mg/dl; p = 0.016). Statistical trend towards a minor level of fibrinogen (327.98 ± 68.37 mg/dl vs. 352.26 ± 78.68 mg/dl; p = 0.054) was also observed.
Overall, no differences were observed between comorbidities, smoking habits and concomitant drug treatments of patients at baseline, as reported in Table 2.
Cardiovascular adverse events at follow-up according to APOE genotypes are presented in Table 3. As compared to ε3, in ε4-patients a significant higher incidence of MACE (35.58% vs. 20.79%; p = 0.025), as well as carotid (15.09% vs. 5.06%; p = 0.014) and lower limb (13.21% vs. 1.69%; p < 0.001) revascularizations were observed. Accordingly, an higher incidence of total peripheral revascularizations (defined as carotid plus lower limb revascularizations) in ε4 was observed (22.64% vs. 5.06%; p < 0.001). Notably, an increased cancer-related mortality in ε2-carriers was also observed respect to ε3 (11.11% vs. 2.25%; p = 0.018).
Events-free survivals associated to the APOE status were presented in Fig 2. As compared with ε3, ε4-patients showed a significantly lower MACE-free survival (p = 0.040, Fig 2A), and lower total peripheral revascularizations-free survival (p < 0.001, Fig 2B). No statistically significant difference was observed between free survival curves from total deaths (Fig 2C).
A) Major adverse cardiac events (MACE), B) Total peripheral revascularizations, C) Total deaths.
Prospective analysis (Table 4), showed that ε4-carriers, in respect to ε3, have a higher risk of MACE (adjusted HR 1.829, 95% CI 1.017–3.287; p = 0.044), and total peripheral revascularizations (adjusted HR = 5.916, 95% CI 2.405–14.554; p < 0.001) as resulted from the single revascularization item of carotid (adjusted HR = 3.550, 95% CI 1.291–9.765; p = 0.014) and lower limb (adjusted HR = 9.607, 95% CI 2.405–14.554; p = 0.002).
Discussion
The present study analyzed the association of the APOE polymorphism with the incidence of cardiovascular events and death occurred in a short-term follow-up study of a cohort of 258 patients affected by advanced atherosclerosis. Our results showed that the ε4 allele seems to be risk factor for MACE, and in particular for total peripheral revascularizations in these patients.
Notably, our study focuses on a very-high risk elderly population, affected by known peripheral atherosclerosis with large prevalence of previous major cardiovascular events (stroke, myocardial infarct, peripheral and cardiac revascularization) and presenting traditional risk factors already managed by a tailored treatment approach. Most part of previous studies analyzed several genes in population affected by mild atherosclerosis, thus enrolling patients at not very-high cardiovascular risk [25, 37].
The other part of these studies are represented by large epidemiological studies with medium-term follow up [38]. More recently, the SMART study analyzed APOE relation with PVD in a wide sample of patients aged 56.7 ± 12.4 years (72% of subjects with manifest CVD and 28% with only risk factors), showing incidence of more cardiovascular events and peripheral revascularizations in ε2/ε2 subgroup; otherwise, this relation was partially explained by different non-HDL-Ch and inhomogeneity in previous events, not present in our population [28].
The present study is a small, single-center study with a short follow-up. Nevertheless the population is homogeneous and well defined for clinical and therapeutic characteristic. Accordingly, in this condition we have found an increased incidence of MACE in ε4-carriers, and in particular a significant incidence of lower limb and carotid revascularizations in this group. The present study finds no association between the polymorphism and all-cause mortality as a previous study on Italian diabetic patients [39].
Although some studies have shown increased risk of myocardial revascularization and adverse events after coronary artery bypass in ε4-carriers [19, 40], in our population we did not replicate this finding; at least a selection bias could be represented by abovementioned selection criteria.
In the evaluated population, we found a significant increase of cancer mortality in the ε2-patients; this finding has not been declared as the object of the study; nevertheless, this result, partially corroborated by scientific literature [41, 42], yet still controversial at some meta-analysis [43, 44], remains of interest for further studies. Our study follows an observational prospective approach, therefore we can only infer association link, more than causal relationship; however this limit is common to many previous researches. A longer follow up and the enlargement of patient number could provide a better understanding on the role of APOE in patients affected by advanced atherosclerosis.
In several multiethnic studies, APOE polymorphism did not have a strong correlation with BMI [12, 45]; once again our study, according to research on ethnically homogeneous populations in Croatia [46], showed higher BMI in ε2-carriers compared to reference group. Furthermore, we found lower BMI in ε4-carriers. These differences, within ethnically homogeneous populations, could be explained by the action of adjacent genes, segregating in linkage disequilibrium with APOE allele [47, 48].
Previous study of Huebbe et al. shows higher vitamin D levels in mice and humans ε4-carriers [49]; otherwise our data show significant lower level 25-OH-Vit D in ε2-patients. Since lower level of 25-OH-Vit D are associated to artery calcification [50], this could explain the relationship between dissimilar calcified atherosclerosis in ε2, ε4 and ε3-carriers. Of great interest, a different at atherosclerosis process based on various grade of atheroma and wall vessels calcification could determine a plaque stabilization, as suggested by Nandalur [51], inducing a slower disease progression in ε2 than in ε4-carriers.
Evaluation of PWV showed that ε2-carriers have greater arterial stiffness, expression of vessel calcifications burden [52]. Instead of the study presented by Alvim [53], our results could be determined by ethnic homogeneity of our population; at same time, in our cohort, the PWV shows a correlation with ventricular mass indexed in ε2-patients, expression of organ damage, yet the evaluation of arterial stiffness was not able to stratify the cardiovascular risk in the setting of advanced atherosclerosis during follow-up (data not showed).
Analysis of lipid levels in enrolled patients has not showed significant differences regarding to the APOE polymorphism, as already receiving optimal statin treatment for secondary prevention. The known complex association between apolipoprotein E and lipid levels justifies the genetically determined risk of developing CVD. Moreover, numerous scientific evidence showed that apolipoprotein E plays a pleiotropic effect beyond dyslipidemia; in particular, at the level of atherosclerotic plaque the expression of apolipoprotein E by macrophages might have an important role in the determination of plaque instability not only attributable to the progression of the degree of stenosis [54, 55].
Literature showed that atherosclerosis is an inflammatory disease within the arterial wall, responsible for several important events such as coronary and peripheral vascular disease [56]. In the studied population, ESR and hs-CRP do not correlate with aggressiveness of disease observed in ε4-carriers. It could be due to patient’s characteristics, affected by already severe atherosclerosis at enrollment, or to an independent and important role played by the gene.
In our population, APOE4 provide further cardiovascular prognostic stratification; this finding implies a huge role of APOE polymorphism for better shaping individual additional residual risk stratification. Although recent analysis are not conclusive in cardiovascular event prediction by using genetic risk score [38], in the future, this could lead to an improved clinical decision making by more aggressive treatment of those subjects at greatest genetic risk, economizing treatment for those at less risk, and therefore translating pharmacogenetics and individualized medicine in finer health system cost-effectiveness [57].
Conclusions
In our cohort of patients at very high-risk of cardiovascular events the APOE4 may be used for a further prognostic stratification for MACE and peripheral revascularization, adding more information useful for individual residual risk determination. Prospectively, this finding would improve pharmacogenetics, leading to the "best marriage" between individualized medicine and health system cost-effectiveness. Clearly APOE polymorphisms represent just a brick in the Great Wall of atherosclerosis building, yet still having a definite weight in the physiopathology of this complex disease.
Acknowledgments
The authors thank Mr. Giovanni Fiore, Leading Nurse at Cardiology Outpatient Clinic of “Casa Sollievo della Sofferenza” Hospital, Italy, for his kind and brilliant professional job.
The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Author Contributions
- Conceptualization: SM GDS DS MAP GDL CC.
- Data curation: SM GDS DS MAP GDL CC Cd’A GP MU CG.
- Formal analysis: SM GDS DS MAP GDL CC Cd’A GP.
- Funding acquisition: SM GDS DS AG AR.
- Investigation: SM GDS DS MAP GDL CC Cd’A GP.
- Methodology: SM GDS DS MAP GDL CC Cd’A GP.
- Project administration: SM GDS DS MAP GDL CC DRP AG AR.
- Resources: SM GDS DS MAP GDL CC Cd’A GP MU CG DRP AG AR.
- Software: SM GDS MAP.
- Supervision: SM GDS DS MAP GDL DRP AG AR.
- Validation: SM GDS DS MAP GDL CC DRP AG AR.
- Visualization: SM GDS DS MAP GDL CC Cd’A GP MU CG DRP AG AR.
- Writing – original draft: SM GDS DS.
- Writing – review & editing: SM GDS DS MAP GDL CC.
References
- 1. Bhatnagar P, Wickramasinghe K, Wilkins E, Townsend N. Trends in the epidemiology of cardiovascular disease in the UK. Heart. 2016 Dec 15. 102(24): 1945–1952. pmid:27550425
- 2. Ingaramo RA. Obesity, Diabetes, and Other Cardiovascular Risk Factors in Native Populations of South America. Curr Hypertens Rep. 2016 Jan 1. 18.
- 3. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015 Jan 10. 385(9963): 117–71. pmid:25530442
- 4. McQueen RB, Ghushchyan V, Olufade T, Sheehan JJ, Nair KV, Saseen JJ. Incremental increases in economic burden parallels cardiometabolic risk factors in the US. Diabetes Metab Syndr Obes. 2016 Aug 2. 9: 233–41. pmid:27536152
- 5. Nicholson G, Gandra SR, Halbert RJ, Richhariya A, Nordyke RJ. Patient-level costs of major cardiovascular conditions: a review of the international literature. Clinicoecon Outcomes Res. 2016 Sep 21. 8: 495–506. pmid:27703385
- 6. Writing Group Members, Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation. 2016 Jan 26. 133(4): e38–360. pmid:26673558
- 7. Emerging Risk Factors Collaboration, Di Angelantonio E, Kaptoge S, Wormser D, Willeit P, Butterworth AS, et al. Association of Cardiometabolic Multimorbidity With Mortality. JAMA. 2015 Jul 7. 314(1): 52–60. pmid:26151266
- 8. Weijmans M, van der Graaf Y, de Borst GJ, Nathoe HM, Algra A, Visseren FL, SMART study. Parental history and the risk of subsequent vascular events in patients with clinically manifest vascular disease: the effects of sex of the parent and vascular disease location. Atherosclerosis. 2014 May. 234(1): 129–35. pmid:24650753
- 9. Stoekenbroek RM, Boekholdt SM, Luben R, Hovingh GK, Zwinderman AH, Wareham NJ, et al. Heterogeneous impact of classic atherosclerotic risk factors on different arterial territories: the EPIC-Norfolk prospective population study. Eur Heart J. 2016 Mar 14. 37(11): 880–9. pmid:26681771
- 10. Rosenson RS, Brewer HB Jr, Ansell BJ, Barter P, Chapman MJ, Heinecke JW, et al. Dysfunctional HDL and atherosclerotic cardiovascular disease. Nat Rev Cardiol. 2016 Jan. 13(1): 48–60. pmid:26323267
- 11. Behrouz R, Powers CJ. Epidemiology of classical risk factors in stroke patients in the Middle East. Eur J Neurol. 2016 Feb. 23(2): 262–9. pmid:26041584
- 12. Teixeira AA, Marrocos MS, Quinto BM, Dalboni MA, Rodrigues CJ, Carmona Sde M, et al. Diversity of apolipoprotein E genetic polymorphism significance on cardiovascular risk is determined by the presence of metabolic syndrome among hypertensive patients. Lipids Health Dis. 2014 Nov 20. 13(174).
- 13. Lusis AJ. Genetics of atherosclerosis. Trends Genet. 2012 Jun. 28(6): 267–75. pmid:22480919
- 14. Marrocos MS, Teixeira AA, Quinto BM, Carmona Sde M, Kuniyoshi M, Rodrigues CJ, et al. Apolipoprotein E polymorphism modulation of asymmetric dimethylarginine in hypertensive patients is determined by renal function. Lipids Health Dis. 2016 Jan 20. 15:14. pmid:26790728
- 15. Mahley RW. Apolipoprotein E: from cardiovascular disease to neurodegenerative disorders. J Mol Med (Berl). 2016 Jul. 94(7): 739–46.
- 16. Seripa D, Matera MG, Daniele A, Bizzarro A, Rinaldi M, Gravina C, et al. The missing ApoE allele. Ann Hum Genet. 2007 Jul. 71(Pt4): 496–500.
- 17. Seripa D, D'Onofrio G, Panza F, Cascavilla L, Masullo C, Pilotto A. The genetics of the human APOE polymorphism. Rejuvenation Res. 2011 Oct. 14(5): 491–500. pmid:21958003
- 18. Gustavsson J, Mehlig K, Leander K, Strandhagen E, Björck L, Thelle DS, et al. Interaction of apolipoprotein E genotype with smoking and physical inactivity on coronary heart disease risk in men and women. Atherosclerosis. 2012 Feb. 220(2): 486–92. pmid:22071360
- 19. Bennet AM, Di Angelantonio E, Ye Z, Wensley F, Dahlin A, Ahlbom A, et al. Association of apolipoprotein E genotypes with lipid levels and coronary risk. JAMA. 2007 Sep 19. 298(11): 1300–11. pmid:17878422
- 20. Saidi S, Slamia LB, Ammou SB, Mahjoub T, Almawi WY. Association of apolipoprotein E gene polymorphism with ischemic stroke involving large-vessel disease and its relation to serum lipid levels. J Stroke Cerebrovasc Dis. 2007 Jul-Aug. 16(4): 160–6. pmid:17689412
- 21. Vaisi-Raygani A, Rahimi Z, Nomani H, Tavilani H, Pourmotabbed T. The presence of apolipoprotein epsilon4 and epsilon2 alleles augments the risk of coronary artery disease in type 2 diabetic patients. Clin Biochem. 2007 Oct. 40(15): 1150–6. pmid:17689519
- 22. Gultom LC, Sjarif DR, Sudoyo HA, Mansyur M, Hadinegoro SR, Immanuel S, et al. The role of apolipoprotein E polymorphism in improving dyslipidemia in obese adolescents following physical exercise and National Cholesterol Education Program Step II intervent. J Pediatr Endocrinol Metab. 2015 May. 28(5–6): 597–603. pmid:25870958
- 23. Phillips MC. Apolipoprotein E isoforms and lipoprotein metabolism. IUBMB Life.2014 Sep. 66(9): 616–23. pmid:25328986
- 24. El-Lebedy D, Raslan HM, Mohammed AM. Apolipoprotein E gene polymorphism and risk of type 2 diabetes and cardiovascular disease. Cardiovasc Diabetol. 2016 Jan 22. 15:12. pmid:26800892
- 25. Chaudhary R, Likidlilid A, Peerapatdit T, Tresukosol D, Srisuma S, Ratanamaneechat S, et al. Apolipoprotein E gene polymorphism: effects on plasma lipids and risk of type 2 diabetes and coronary artery disease. Cardiovasc Diabetol. 2012 Apr 23. 11:36. pmid:22520940
- 26. Xu H, Li H, Liu J, Zhu D, Wang Z, Chen A, et al. Meta-analysis of apolipoprotein E gene polymorphism and susceptibility of myocardial infarction. PLoS One. 2014 Aug 11. 9(8): e104608. pmid:25111308
- 27. Volcik KA, Barkley RA, Hutchinson RG, Mosley TH, Heiss G, Sharrett AR, et al. Apolipoprotein E polymorphisms predict low density lipoprotein cholesterol levels and carotid artery wall thickness but not incident coronary heart disease in 12,491 ARIC study. Am J Epidemiol. 2006 Aug 15. 164(4): 342–8. pmid:16760224
- 28. Koopal C, Geerlings MI, Muller M, de Borst GJ, Algra A, van der Graaf Y, et al. The relation between apolipoprotein E (APOE) genotype and peripheral artery disease in patients at high risk for cardiovascular disease. Atherosclerosis. 2016 Mar. 246: 187–92. pmid:26800308
- 29. Elosua R, Ordovas JM, Cupples LA, Fox CS, Polak JF, Wolf PA, et al. Association of APOE genotype with carotid atherosclerosis in men and women: the Framingham Heart Study. J Lipid Res. 2004 Oct. 45(10): 1868–75. pmid:15258198
- 30.
World Medical Association, WMA. http://www.wma.net/en/30publications/10policies/b3.
- 31.
European Medicines Agency, EMA. http://www.ema.europa.eu/ema/index.jsp?curl=pages/regulation/general/general_content_000072.jsp&mid=WC0b01ac05800268ad.
- 32.
STROBE Statement, The Strengthening the Reporting of Observational Studies in Epidemiology. http://strobe-statement.org/index.php?id=available-checklists.
- 33. Di Stolfo G, Mastroianno S, Potenza DR, De Luca G, d'Arienzo C, Pacilli MA, et al. Serum uric acid as a prognostic marker in the setting of advanced vascular disease: a prospective study in the elderly. J Geriatr Cardiol. 2015 Sep. 12(5): 515–20. pmid:26512243
- 34. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001 MAy 16. 285(19): 2486–97. pmid:11368702
- 35. Miller SA, Dykes DD, Polesky HF. A simple salting out procedure for extracting DNA from human nucleated cells. Nucleic Acids Res. 1988 Feb 11. 16(3): 1215. pmid:3344216
- 36. Seripa D, Signori E, Gravina C, Matera MG, Rinaldi M, Fazio VM. Simple and effective determination of apolipoprotein E genotypes by positive/negative polymerase chain reaction products. Diagn Mol Pathol. 2006 Sep. 15(3): 180–5. pmid:16932075
- 37. Hillen T, Nieczaj R, Münzberg H, Schaub R, Borchelt M, Steinhagen-Thiessen E. Carotid atherosclerosis, vascular risk profile and mortality in a population-based sample of functionally healthy elderly subjects: the Berlin ageing study. J Intern Med. 2000 Jun. 247(6): 679–88. pmid:10886490
- 38. Weijmans M, de Bakker PI, van der Graaf Y, Asselbergs FW, Algra A, Jan de Borst G, et al. Incremental value of a genetic risk score for the prediction of new vascular events in patients with clinically manifest vascular disease. Atherosclerosis. 2015 Apr. 239(2): 451–8. pmid:25687271
- 39. Boemi M, Sirolla C, Testa R, Gregorio F, Brandoni G, Fumelli P, et al. Apolipoprotein E polymorphisms and mortality in Italian type 2 diabetic patients. Eur J Clin Invest. 2003 Apr. 33(4): 296–300. pmid:12662159
- 40. Eifert S, Rasch A, Beiras-Fernandez A, Nollert G, Reichart B, Lohse P. Gene polymorphisms in APOE, NOS3, and LIPC genes may be risk factors for cardiac adverse events after primary CABG. J Cardiothorac Surg. 2009 Aug 19. 4:46. pmid:19691831
- 41. Katan MB. Apolipoprotein E isoforms, serum cholesterol, and cancer. 1986. Int J Epidemiol. 2004 Feb. 33(1): 9. pmid:15075136
- 42. Kang R, Li P, Wang T, Li X, Wei Z, Zhang Z, et al. Apolipoprotein E epsilon 2 allele and low serum cholesterol as risk factors for gastric cancer in a Chinese Han population. Sci Rep. 2016 Jan 28. 6:19930. pmid:26817942
- 43. Anand R, Prakash SS, Veeramanikandan R, Kirubakaran R. Association between apolipoprotein E genotype and cancer susceptibility: a meta-analysis. J Cancer Res Clin Oncol. 2014 Jul. 140(7): 1075–85. pmid:24706182
- 44. Liu YL, Zhang HM, Pan HM, Bao YH, Xue J, Wang TC, et al. The relationship between apolipoprotein E gene ε2/ε3/ε4 polymorphism and breast cancer risk: a systematic review and meta-analysis. Onco Targets Ther. 2016 Mar 7. 9: 1241–9. pmid:27022282
- 45. Rahilly-Tierney CR, Arnett DK, North KE, Pankow JS, Hunt SC, Ellison RC, et al. Apolipoprotein ε4 polymorphism does not modify the association between body mass index and high-density lipoprotein cholesterol: a cross-sectional cohort study. Lipids Health Dis. 2011 Sep 23. 10:167. pmid:21939561
- 46. Zeljko HM, Škarić-Jurić T, Narančić NS, Tomas Ž, Barešić A, Salihović MP, et al. E2 allele of the apolipoprotein E gene polymorphism is predictive for obesity status in Roma minority population of Croatia. Lipids Health Dis. 2011 Jan 18. 10:9. pmid:21244662
- 47. Seripa D, Bizzarro A, Pilotto A, Palmieri O, Panza F, D'Onofrio G, et al. TOMM40, APOE, and APOC1 in primary progressive aphasia and frontotemporal dementia. J Alzheimers Dis. 2012. 31(4): 731–40. pmid:22710912
- 48. Long JR, Liu PY, Liu YJ, Lu Y, Xiong DH, Elze L, et al. APOE and TGF-beta1 genes are associated with obesity phenotypes. J Med Genet. 2003 Dec. 40(12): 918–24. pmid:14684691
- 49. Huebbe P, Nebel A, Siegert S, Moehring J, Boesch-Saadatmandi C, Most E, et al. APOE ε4 is associated with higher vitamin D levels in targeted replacement mice and humans. FASEB J. 2011 Sep. 25(9): 3262–70. pmid:21659554
- 50. de Boer IH, Kestenbaum B, Shoben AB, Michos ED, Sarnak MJ, Siscovick DS. 25-hydroxyvitamin D levels inversely associate with risk for developing coronary artery calcification. J Am Soc Nephrol. 2009 Aug. 20(8): 1805–12. pmid:19443637
- 51. Nandalur KR, Baskurt E, Hagspiel KD, Phillips CD, Kramer CM. Calcified carotid atherosclerotic plaque is associated less with ischemic symptoms than is noncalcified plaque on MDCT. AJR Am J Roentgenol. 2005 Jan. 184(1): 295–8. pmid:15615991
- 52. Cecelja M, Chowienczyk P. Role of arterial stiffness in cardiovascular disease. JRSM Cardiovasc Dis. 2012 Jul 31. 1(4). pii: cvd.2012.012016.
- 53. Alvim RO, Freitas SR, Ferreira NE, Santos PC, Cunha RS, Mill JG, et al. APOE polymorphism is associated with lipid profile, but not with arterial stiffness in the general population. Lipids Health Dis. 2010 Nov 8. 9:128. pmid:21059196
- 54. Lorkowski S, Cullen P. Genetics and molecular biology: apolipoprotein E—from plasma lipids to plaque stability. Curr Opin Lipidol. 2002 Dec. 13(6): 689–92. pmid:12441893
- 55. Davignon J. Apolipoprotein E and atherosclerosis: beyond lipid effect. Arterioscler Thromb Vasc Biol. 2005 Feb. 25(2): 267–9. pmid:15681305
- 56. Taleb S. Inflammation in atherosclerosis. Arch Cardiovasc Dis. 2016 Dec. 109(12): 708–715. pmid:27595467
- 57. Smith JD, Topol EJ. Identification of atherosclerosis-modifying genes: pathogenic insights and therapeutic potential. Expert Rev Cardiovasc Ther. 2006 Sep. 4(5): 703–9. pmid:17081092