Case Study “SK”
ApoE-OM3FA Interaction
KIF6
LDL Subclasses
Dmitri Vasin MD
Drew Garcia PA-C
Atherosclerosis Regression Clinic
Bremerton WA, USA
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Doctors Are Not Scientist
• “Some doctors are scientists – just as some
politicians are scientists – but most are not…
[Scientists are] the kind of people who brush their
teeth on only one side of their mouth to see whether
brushing your teeth has any benefit”.
• “In their methods of working [doctors] are more like
jazz musicians than scientists”.
Richard Smith, M.D. Editorial.
BMJ June 14, 2004;328:doi:1136
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Case Study “SK”
• 67 y.o. wm 6’2”, 225 lbs, BMI 29
• Diagnosed with CAD by Nuclear stress test;
small areas of reversible ischemia; normal EF
on ECHO; medical Tx recommended
• Meds: Atorvastatin 80 mg q. hs, Niaspan 1,000
mg q. hs, OM3FA 4 g a day, Perindopril 8 mg
q.d., ASA 325 mg q.hs, Meotprolol XL 50 mg
q.d.
• LDL decreased 80% on Atorvastatin
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Case Study “SK”: ApoE 3/4
On and off 4g/d and then on 1 g Omega-3 FA
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Standard of Care?
• NCEP ATP III lipid panel
guidelines Failed to identify
75% of patients under 55
(n=222) who had first MI
Akosah A. 8th World Congress on Heart Failure. JACC 2003, Vol. 41, No. 9
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Residual Cardiovascular Risk
in Major Statin Trials
Patients Experiencing
Major Coronary Events, %
100
75%
80
75%
73%
69%
62%
62%
60
40
20
0
4S
LIPID
CARE
HPS
WOS
AFCAPS /
TexCAPS
N
4444
9014
4159
20 536
6595
6605
LDL
-36%
-25%
-28%
-29%
-26%
-27%
Secondary
Libby PJ, et al. J Am Coll Cardiol, 2005:46:1225-1228.
High Risk
Primary
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Looking Beyond the Numbers
● Vulnerable blood
 Advanced CVD Profile
plus Apo E
● Vulnerable plaque/artery
 Lp-PLA2
● Vulnerable myocardium
 NT-proBNP
Assessment Directs
Comprehensive Therapy
Naghavi et al. Circulation. 2003;108
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Subclasses Better Predictors of CVD
Biomarker
Cutpoint
TRIG
n
Sensitivity
Patients NOT
Detected by
Biomarker
≥ 150 mg/dL 1,723
39%
61%
HDL-C
≤ 40 mg/dL
1,768
40%
60%
TCHOL
≥ 200 mg/dL 1,015
23%
77%
LDL-C
≥ 130 mg/dL 481
11%
89%
%-HDL 2b
≤ 20 %
3,065
70%
30%
%-LDL IIIa+b
≥ 15%
4,036
92%
8%
30% had TG < 100 mg/dl
8
BHL Internal Study 2006
Inflammation Markers — How to Use?
Inflammation indicates that the process of
arteriographic progression may be occurring
• Key is to treat identified disorders more aggressively
• Test for elevated levels of Lp-PLA2, hs-CRP, and Fibrinogen
Lp-PLA2 – initiation and progression of
atherosclerosis
Blood levels are significantly elevated in advanced
plaque stages
Lp-PLA2 and CRP:
Independent and distinct inflammatory markers
Lp-PLA2
CRP
 Marker of systemic inflammation
 Marker of vascular inflammation
 Produced by liver in response to
inflammatory reactions – acute
phase reactant
 An enzyme produced by
inflammatory cells
 May enhance late stage plaque
progression promoting plaque
instability
 Appears to be involved in the
initiation of the early stage of the
vascular inflammatory process
 Most useful in otherwise healthy
individuals
 Minimal biovariability;
Not affected by other inflammatory
conditions
 A potentially useful tool for the
pharmacological management
of CHD patients
 A specific target for pharmacologic
intervention for the treatment of
CHD
1. Ridker PM, et al, Circulation. 1998
2. Ridker PM, et al. New Engl J Med. 1997
3. Ridker PM, et al, Circ. 2001
4. Carpenter Keri LH, et al. FEBS Lett. 2001
5. Macphee CH, et al. Expert Opin Ther Targets. 2002
6. Packard CH, et al. New Engl J Med. 2000
Lp-PLA2 and CRP:
Independent and distinct inflammatory markers
 Lp-PLA2 is an independent predictor of risk from CRP and should be
ordered in conjunction with CRP as part of comprehensive risk profile in
order to deliver a complete snapshot of the inflammatory process.
 Additionally, when both Lp-PLA2 and CRP are elevated to the
highest tertile levels, there is a multiplicative impact on risk.
CRP
Lp-PLA2
+
+
+++
+
+
+++
Plaque Formation
or Progression
+
+
+++
Acute, non-specific
Inflammation
+
+
+++
Stroke
Risk
+
+
++
+++
Important guides in determining intensity of therapy
Case Study “SK”: ApoE 3/4
On and off 4g/d and then on 1 g Omega-3 FA
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Case Study “SK”: ApoE 3/4
On and off 4g/d and then on 1 g Omega-3 FA
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Apo E Genotype Effects on Plasma Lipids
 Apo E3 has “normal” lipid metabolism - no genotype impact
 Apo E2 versus Apo E4 - opposing effects on plasma lipids
● Apo E2 associated with slow conversion of IDL to LDL
 Decreases plasma cholesterol and increases triglycerides
● Apo E4 limits HDL-binding - inhibits normal cholesterol
clearance process (reverse cholesterol transport or RCT)
 Increases total cholesterol, LDL, and TG and decreases HDL
Mamotte C, Sturm M, Foo J, van Bockxmeer F, Taylor R. Am J Physiol 1999 March;276(3 Pt 1):E553-E557
Therapeutic Implications of Apo E
 Interactions between Apo E gene polymorphism, abnormal lipid
profiles, and diet and drug therapy have been documented
 Therapy targeting the lipid abnormalities resulting from the
phenotypic expression of certain Apo E genotypes in response
to environmental “stress” factors can mediate their impact on
CVD
1.
2
3.
4.
5.
6. Wilson PW, Myers RH, Larson MG,
Dallongeville J, Lussier-Cacan S, Davignon
Ordovas JM, Wolf PA, Schaefer EJ.
J Lipid Res 1992 April;33(4):447-54.
JAMA 1994 December 7;272(21):1666-71.
Schaefer EJ, Lamon-Fava S, Johnson S et al.
Arterioscler Thromb 1994 July;14(7):1105-13.
Sing CF, Davignon J.
Am J Hum Genet 1985 March;37(2):268-85.
Stengard JH, Zerba KE, Pekkanen J, Ehnholm C, Nissinen A, Sing CF.
Circulation 1995 January 15;91(2):265-9.
Wang XL, McCredie RM, Wilcken DE.
Arterioscler Thromb Vasc Biol 1995 August;15(8):1030-4.
Apo E Genotype and CVD Risk
Apo E2 Response
Apo E3 Response
Apo E4 Response
Genotype
2/2
2/3
3/3
2/4
3/4
4/4
Population Frequency
1%
10%
62%
2%
20%
5%
CVD Risk
Intermediate
Ann Intern Med 2004 July 20: 141(2): 137-47
Normal
Highest Risk
(  42%)
Apo E Genotype Correlation to Treatment
Response
Apo E2 Response
Apo E3 Response
Apo E4 Response
Genotype
2/2
2/3
3/3
2/4
3/4
4/4
Population Frequency
1%
10%
62%
2%
20%
5%
 LDL
 small dense LDL
 LDL
 small dense LDL
 LDL
 small dense LDL
 LDL
 small dense LDL
 LDL
 small dense LDL
 LDL
 small dense LDL
Moderate Alcohol3
 HDL  LDL
 HDL
 HDL  LDL
Effective Statin
Response
Beneficial
No distinction
Limited
Low Fat Diet1,2
Moderate Fat
1.
2.
Diet2
Am J Clin Nutr 2003; 77: 1098-111
J Nutr 2004 134: 2517-2522
3.
a) Am J Clin Nutr 2001 Apr; 73 (4): 736-45 b) Obes Res 2003 Oct; 11
(10) 1200-6 c) Atherosclerosis 2004 Mar: 173 (1); 79-87 d) J Neural
Trans 2003 Apr: 110 (4) : 401-11 e) Proc Nutri Soc 2004 (65) 5-10
f)
Art Thromb Vasc Biol 2002: AMy 1: 22 (5) 824-31
Apo E Genotype Correlation to Treatment
Response
Apo E2 Response
Apo E3 Response
Apo E4 Response
Genotype
2/2
2/3
3/3
2/4
3/4
4/4
Population Frequency
1%
10%
62%
2%
20%
5%
 LDL
 LDL
 LDL
 TG
 small dense LDL
 HDL
 TG
 small dense LDL
 HDL
 TG
 small dense LDL
 HDL  LDL
Plant Sterols3
 LDL
 Apo B
 LDL
 Apo B
 LDL
 Apo B
Soy Protein4
 Apo B
 Apo B
 Apo B
Soluble Fiber1
Fish
1.
2.
3.
4.
Oil2
a) Am J Clin Nutr 1997 Sep; 66 (3): 584-90 b) Metabolism 1993 (42): 585-93
Arterioscler Thromb Vasc Biol 2000 Aug; 20 (8): 1990 -7
Nutrition 2002 Jul-Aug: 18 (7-8): 561-5
Nutr Metab Cardiovasc Dis 2000 Dec: 10 (6): 315-22
Apo E Genotype Response
Treatment Summary
Apo E
Genotype
Apo E2
Apo E4
Treatment
Surrogate Markers
Response
 Statin
  LDL
 Beneficial
 Moderate Alcohol
  LDL /  HDL
 Beneficial
 Low Fat Diet
  Small Dense LDL / limited  LDL
 Not Recommended
 Statin

Limited  LDL
 Limited
 Moderate Alcohol

 LDL /  HDL
 Not Recommended
 Low Fat Diet

 LDL /  TG /  small dense LDL
 Beneficial
 Increases
 decreases
Therapeutic Implications of Apo E
 When managed with treatment algorithms based on the routine CVD
analytes supported by consensus guidelines (without Apo E genotype),
a significant percentage of patients will be:
● sub-optimally treated
● managed in a limited way with a “one diet, standard drug therapy regimen
fits all” approach
 Conditions for which an Apo E genotype is applicable to make
treatment decisions to reduce progression of vascular disease in
patients with known hyperlipidemia and/or vascular disease include:
● Pharmaceutical recommendation
● Diet Recommendation
● Alcohol recommendation
Apo E Genotype and CVD Management
Heterogeneity of gene-environment interaction
Heterogeneity of therapeutic response to “accepted” treatments
Establish Apo E genotyping as an important adjunct to an aggressive,
targeted, and effective cardiovascular disease management program
…..allowing personalization of:
● Pharmaceutical Recommendation
● Diet Recommendation
● Alcohol Recommendation
Apo E ¾ Implications for “SK”
• A LOT of exercise
• Low (really low) fat diet, including avoidance
of OM3FA, unless indicated for non-lipid
effects
• Imperative target to lose waist size/weight to
optimal
• Avoidance of alcohol
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Case Study “SK”: Apo E 3/4
LDL gels On 4g/d and 1 g/d ofOmega-3 FA
4g/d OM3FA
Off OM3FA
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Case Study “SK”: Apo E 3/4
LDL gels On 4g/d and 1 g/d ofOmega-3 FA
4g/d OM3FA
Off OM3FA
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Off OM3FA
4g/d OM3FA
Case Study “SK”: Apo E ¾
HDL gels On 4g/d and 1 g/d of Omega-3 FA
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Case Study “SK”: ApoE 3/4
On 4g/d, 1 g/d and 1+g/d of Omega-3 FA
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Case Study “SK”: ApoE 3/4
On 4g/d, 1 g/d and 1+g/d of Omega-3 FA
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Case Study “SK”
Summary of OM3FA and Apo E interactions
• LDL (total and subclasses) trended parallel with dose
of OM3FA, with high dose of OM3FA associated with
NEGATIVE changes
• HDL (total and especially subclasses) trended
reciprocal to dose of OM3FA, with higher dose
associated with NEGATIVE changes
• OM3FA are used in SK for its non-lipid effects, i.e. to
decrease in CV mortality (GISSI, GISSI-HF trials)
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KIF6 Trp719Arg and CHD
● Up to 50% increased risk of CHD in carriers of a common KIF6 variant
– KIF6 719Arg is the risk variant
– ~60% of Caucasians carry one or two risk variant of the gene
– KIF6 encodes a kinesin, a molecular motor protein
● Statin therapy can provide substantial and significant benefit in carriers
KIF6 Trp719Arg and CHD
● Up to 50% increased risk of CHD in carriers of a common KIF6 variant
– KIF6 719Arg is the risk variant
– ~60% of Caucasians carry one or two risk variant of the gene
– KIF6 encodes a kinesin, a molecular motor protein
● Statin therapy can provide substantial and significant benefit in carriers
Previous Genetic Studies of KIF6 719Arg
Risk of CHD in 5 Prospective Studies
Placebo arm of CARE
Patients with prior MI
Placebo arm of WOSCOPS
Patients with LDL-C >178mg/dL
CHS
Men and women of ≥65 years old
ARIC
Middle-aged Americans
WHS
Initially healthy middle-aged women
0.5
1
1.5
2
2.5
Adjusted Risk Ratios
● Carriers of the KIF6 719Arg variant (60% of Caucasians) are at greater
risk of coronary events compared with noncarriers
● More than 49,000 participants
WHS: Shiffman et al. J Am Coll Cardiol 2008; 51:444
ARIC: Bare et al. Genet Med. 2007; 10:682
CHS: Shiffman et al. Arterioscler Thromb Vasc Biol. 2008; 1:173
CHD Event Reduction by Pravastatin
According to KIF6 719Arg Carrier Status
WOSCOPS
CARE
All
Carriers Non-carriers
All
Carriers Non-carriers
0
Absolute Risk 2
Reduction (%)
4
6
8
3.5%
4.9%* 1.4%
P = 0.005
3.5%
5.5%*
0.1%
P < 0.0001
● Carriers of the 719Arg risk allele received significant benefit from pravastatin
therapy
● In WOSCOPS, risk reduction was significantly greater in carriers than in
noncarriers (Pinteraction = 0.003)
CHD death or major CHD events (%)
Coronary Events According to KIF6 719Arg Carrier Status
in PROSPER Patients with Prior Vascular Disease
Noncarriers
719Arg Carriers
Placebo
20
20
HR=0.66
15
P=0.002
10
P=0.64
HR=0.94
15
10
5
Pravastatin
0
5
0
0
6
12
18
24
30
36
0
6
Months of follow up
12
18
24
30
36
Months of follow up
Fatal or nonfatal CHD
● Among patients with prior vascular disease, carriers of KIF6 719Arg risk allele received
substantial and significant reduction of coronary events, whereas noncarriers did not
– 34% relative risk reduction in carriers
● Among patients without prior vascular disease, no significant event reduction
38
LDL-C Lowering by Pravastatin Therapy
LDL Cholesterol (mmol/L)
In the Elderly with Prior Vascular Disease
PROSPER Study
Placebo
4.0
3.0
2.0
1.0
KIF6 Carriers
Pravastatin
Noncarriers
Baseline 3
6
12 24 36
Months of follow-up
● In PROSPER, substantial and significant difference in reduction of events between
carriers and noncarriers was observed despite similar reduction of LDL-C levels
● A similar observation was made in PROVE IT–TIMI 22
● An indication of the pleiotropic effect of statins among 719Arg carriers
39
Statin Intensity and CHD Event Reduction
According to KIF6 719Arg Carrier Status
Death or major CV events
PROVE IT—TIMI22
●
40
30
20
10
KIF6 Carriers
40
Pravastatin
p≤0.001
Atorvastatin
30
20
10
Noncarriers
Pravastatin
Inclusion
 Hospit
 Total c
Atorvastatin  Stabili
P=1.0
Major Exc
0
0

Co
-mo
0
3
6
9
12
15
18
21
24
27
30
0
3
6
9
12
15
18
21
24
27
30
Months of follow-up
Months of follow-up  Curren
 Need f
 CABG
KIF6 carriers received greater benefit from 80mg atorvastatin,
 Liver d
compared with 40mg pravastatin, than did noncarriers
 Strong
● NNT for atorvastatin vs pravastatin:
– 10 for KIF6 carriers
– 125 for noncarriers
LDL-C Lowering by Statin Therapy
Similar Reduction in KIF6 Carriers and Noncarriers
PROVE IT
Pravastatin
120
LDL (mg/dL)
100
KIF6 Carriers
Noncarriers
80
60
Atorvastatin
40
20
Baseline 30 Days
4 Mo
8 Mo
16 Mo
Time of Visit
● Similar reduction of LDL-C levels in carriers and noncarriers
● However, event reduction was significantly greater in carriers
KIF6 Variant: Carriers and Noncarriers
Carriers
● Carriers of the deleterious gene variant might benefit from aggressive
treatment of modifiable CHD risk factors
Noncarriers
● The absence of significant benefit from intensive statin therapy in
noncarriers does not preclude the possibility that a portion
of noncarriers do benefit from statin therapy
● But it does suggest that noncarriers may be treated with standard statin
therapy and also with other lipid-modifying drugs or by strategies that
target other risk factors such as hypertension, diabetes, or smoking
KIF6 719Arg Variant and CHD
Summary
● Associated with risk of CHD in 5 prospective studies
– ARIC, WHS, CHS, CARE, and WOSCOPS
● Carriers at up to 50% higher risk
● Risk estimate unchanged after adjustment for traditional risk factors
● 60% of Caucasians carry the risk allele
● Carriers received significant event reduction from statin therapy
– Standard-dose pravastatin vs placebo
– High-dose atorvastatin vs standard-dose pravastatin
Our Take*
Primary Prevention and KIF6
●Age <70
– KIF6 AA or AT:
maximal dose potent
statin (Atorva 80 or
Rosuva 20-40)
– KIF6 TT: non-stain
therapy (Niacin,
Fibrate, Resin,
Omega3 FA), statin as
3rd or 4th line therapy
●Age >70
● Regardless of KIF6
status:
– non-stain therapy
(Niacin, Fibrate, Resin,
Omega3 FA), statin as
3rd or 4th line therapy
*Represents current position of Atherosclerosis Regression Clinic
*May or may not reflect position of Celera and/or contributing authors
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Our Take*
Secondary Prevention and KIF6
●KIF6 AA or AT
– maximal dose potent
statin (Atorva 80 or
Rosuva 20-40)
– non-stain therapy
(Niacin, Fibrate, Resin,
Omega3 FA**)
●KIF6 TT
– non-stain therapy
(Niacin, Fibrate, Resin,
Omega3 FA**)
– statin as 3rd or 4th line
therapy: Pravastatin
20-40 mg QHS
*Represents current position of Atherosclerosis Regression Clinic ;May or may not
reflect position of Celera and/or contributing authors
**Limit to 1g qd for ApoE ¾ or 4/4 genotype
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Risks of Not Using Berkeley
● May miss a lipid disorder or other risk biomarker
● Can’t target intervention or degree of aggressiveness, i.e.;
 1,000 mg of niacin or 1,500 mg, 2,000 mg…?
 10 mg/d of statin or 40 mg?
 Combination drug therapy (statin / niacin / fenofibrate) ?
 Aggressiveness of goal setting?
 When is it imperative to initiate medication (rather than lose weight)?
● Can’t monitor patient responsiveness to treatment and
determine whether to continue to optimize treatment
 You need greater discrimination to determine if the treatment
plan is effective
 Monitoring Apo B, LDL IIIa+b, LDL IVb, and HDL2b are key to
monitoring the patient’s progress
Case Study “SK”
Summary
• Multiple risk factors were still present despite “optimal”
ATP III panel
• OM3FA were clearly associated with adverse changes in
LDL and HDL subclasses, as expected with Apo E ¾
genotype
• Even small dose (1 g/d) of OM3FA was associated with
adverse lipid effects
• ApoE genotyping can help in individualizing lipid lowering
therapy choices (as well as diet, EtOH, and exercise
recommendations)
• KIF6 genotyping allowed to optimize statin brand/dose
recommendations
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Final Comment
“If you aren’t confused, you don’t
know what’s going on.”
Jack Welsh
Former CEO General Electric
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48