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Ruth Frikke-Schmidt, MD, PhD; Børge G. Nordestgaard, MD, DMSc; Maria C. A. Stene, MSc, PhD; Amar A. Sethi, MD, PhD; Alan T. Remaley, MD, PhD; Peter Schnohr, MD; Peer Grande, MD, DMSc; Anne Tybjærg-Hansen, MD, DMSc

JAMA. 2008;299(21):2524-2532.

Context  Low levels of high-density lipoprotein (HDL) cholesterol are inversely related to cardiovascular risk. Whether this is a causal effect is unclear.

Objective  To determine whether genetically reduced HDL cholesterol due to heterozygosity for 4 loss-of-function mutations in ABCA1 cause increased risk of ischemic heart disease (IHD).

Design, Setting, and Participants  Three studies of white individuals from Copenhagen, Denmark, were used: the Copenhagen City Heart Study (CCHS), a 31-year prospective general population study (n = 9022; 28 heterozygotes); the Copenhagen General Population Study (CGPS), a cross-sectional general population study (n = 31 241; 76 heterozygotes); and the Copenhagen Ischemic Heart Disease Study (CIHDS), a case-control study (n = 16 623; 44 heterozygotes). End points in all 3 studies were recorded during the period of January 1, 1976, through July 9, 2007.

Main Outcome Measures  Levels of HDL cholesterol in the general population, cellular cholesterol efflux, and the association between IHD and HDL cholesterol and genotype.

Results  Heterozygotes vs noncarriers for 4 ABCA1 mutations (P1065S, G1216V, N1800H, R2144X) had HDL cholesterol levels of 41 mg/dL (interquartile range, 31-50 mg/dL) vs 58 mg/dL (interquartile range, 46-73 mg/dL), corresponding to a reduction in HDL cholesterol of 17 mg/dL (P < .001). A 17-mg/dL lower HDL cholesterol level in the CCHS was associated with a multifactorially adjusted hazard ratio for IHD of 1.70 (95% confidence interval [CI], 1.57-1.85). However, for IHD in heterozygotes vs noncarriers, the multifactorially adjusted hazard ratio was 0.67 (95% CI, 0.28-1.61; 1741 IHD events) in the CCHS, the multifactorially adjusted odds ratio was 0.82 (95% CI, 0.34-1.96; 2427 IHD events) in the CGPS, and the multifactorially adjusted odds ratio was 0.86 (95% CI, 0.32-2.32; 2498 IHD cases) in the CIHDS. The corresponding odds ratio for IHD in heterozygotes vs noncarriers for the combined studies (n = 41 961; 6666 cases; 109 heterozygotes) was 0.93 (95% CI, 0.53-1.62).

Conclusion  Lower plasma levels of HDL cholesterol due to heterozygosity for loss-of-function mutations in ABCA1 were not associated with an increased risk of IHD.

Author Affiliations: Department of Clinical Biochemistry, Rigshospitalet (Drs Frikke-Schmidt, Stene, and Tybjærg-Hansen), Department of Cardiology, Rigshospitalet (Dr Grande), Department of Clinical Biochemistry, Herlev Hospital (Dr Nordestgaard), Copenhagen City Heart Study, Bispebjerg Hospital (Drs Nordestgaard, Schnohr, and Tybjærg-Hansen), Copenhagen General Population Study, Herlev Hospital (Drs Frikke-Schmidt, Nordestgaard, and Tybjærg-Hansen), Copenhagen University Hospitals, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; and Lipoprotein Metabolism Section, Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (Drs Sethi and Remaley).

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