Changes in lipoprotein-Associated phospholipase A2 activity predict coronary events and partly account for the treatment effect of pravastatin: results from the Long-Term Intervention with Pravastatin in Ischemic Disease study

Harvey D White, John Simes, Ralph A H Stewart, Stefan Blankenberg, Elizabeth H Barnes, Ian C Marschner, Peter Thompson, Malcolm West, Tanja Zeller, David M Colquhoun, Paul Nestel, Anthony C Keech, David R Sullivan, David Hunt, Andrew Tonkin, LIPID Study Investigators, Harvey D White, John Simes, Ralph A H Stewart, Stefan Blankenberg, Elizabeth H Barnes, Ian C Marschner, Peter Thompson, Malcolm West, Tanja Zeller, David M Colquhoun, Paul Nestel, Anthony C Keech, David R Sullivan, David Hunt, Andrew Tonkin, LIPID Study Investigators

Abstract

Background: Lipoprotein-associated phospholipase A2 (Lp-PLA2) levels are associated with coronary heart disease (CHD) in healthy individuals and in patients who have had ischemic events.

Methods and results: The Long-term Intervention with Pravastatin in Ischemic Disease (LIPID) study randomized 9014 patients with cholesterol levels of 4.0 to 7.0 mmol/L to placebo or pravastatin 3 to 36 months after myocardial infarction or unstable angina and showed a reduction in CHD and total mortality. We assessed the value of baseline and change in Lp-PLA2 activity to predict outcomes over a 6-year follow-up, the effect of pravastatin on Lp-PLA2 levels, and whether pravastatin treatment effect was related to Lp-PLA2 activity change. Lp-PLA2 was measured at randomization and 1 year, and levels were grouped as quartiles. The prespecified end point was CHD death or nonfatal myocardial infarction. Baseline Lp-PLA2 activity was positively associated with CHD events (P < 0.001) but not after adjustment for 23 baseline factors (P = 0.66). In 6518 patients who were event free at 1 year, change in Lp-PLA2 was a significant independent predictor of subsequent CHD events after adjustment for these risk factors, including LDL cholesterol and LDL cholesterol changes (P < 0.001). Pravastatin reduced Lp-PLA2 by 16% compared with placebo (P < 0.001). After adjustment for Lp-PLA2 change, the pravastatin treatment effect was reduced from 23% to 10% (P = 0.26), with 59% of the treatment effect accounted for by changes in Lp-PLA2. Similar reductions in treatment effect were seen after adjustment for LDL cholesterol change.

Conclusion: Reduction in Lp-PLA2 activity during the first year was a highly significant predictor of CHD events, independent of change in LDL cholesterol, and may account for over half of the benefits of pravastatin in the LIPID study.

Keywords: LIPID; Lp‐PLA2; biomarkers; pravastatin.

Figures

Figure 1.
Figure 1.
Consort diagram for patient flow.
Figure 2.
Figure 2.
Distribution of lipoprotein‐associated phospholipase A2 (Lp‐PLA2) activity levels. Baseline Lp‐PLA2 activity by sex, P<0.0001.
Figure 3.
Figure 3.
Baseline Lp‐PLA2 activity and prediction of CVD events. HR and 95% CI are adjusted for baseline variables: treatment, sex, stroke, diabetes, smoking, hypertension, total cholesterol, apolipoprotein B and A1, HDL‐C, age, nature of prior ACS, timing of coronary revascularization, SBP, atrial fibrillation, eGFR, BMI, dyspnea class, angina grade, WBC, peripheral vascular disease, triglycerides, fasting glucose and aspirin at baseline. ACS indicates acute coronary syndromes; BMI, body mass index; CHD, coronary heart disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; HDL‐C, HDL cholesterol; HR, hazard ratio; Lp‐PLA2, lipoprotein‐associated phospholipase A2; MI, myocardial infarction; SBP, systolic blood pressure; WBC, white blood cell count.
Figure 4.
Figure 4.
Distribution of lipoprotein‐associated phospholipase A2 (Lp‐PLA2) activity levels. Lp‐PLA2 activity at 1 year by randomized treatment, P<0.001.
Figure 5.
Figure 5.
Distribution of lipoprotein‐associated phospholipase A2 (Lp‐PLA2) activity levels. Change in Lp‐PLA2 activity from baseline to 1 year by randomized treatment, P<0.001.
Figure 6.
Figure 6.
Lp‐PLA2 activity vs LDL‐C at baseline. LDL‐C indicates LDL cholesterol; Lp‐PLA2, lipoprotein‐associated phospholipase A2.
Figure 7.
Figure 7.
Change in Lp‐PLA2 activity vs change in LDL‐C. LDL‐C indicates LDL cholesterol; Lp‐PLA2, lipoprotein‐associated phospholipase A2.
Figure 8.
Figure 8.
Quartiles of change in Lp‐PLA2 activity and prediction of CVD events. HR and 95% CI are adjusted for baseline variables: treatment, sex, stroke, diabetes, smoking, hypertension, total cholesterol, apolipoprotein B and A1, HDL‐C, age, nature of prior ACS, timing of coronary revascularization, SBP, atrial fibrillation, eGFR, BMI, dyspnea class, angina grade, WBC, peripheral vascular disease, triglycerides, fasting glucose, aspirin at baseline and change in LDL. ACS indicates acute coronary syndromes; BMI, body mass index; CHD, coronary heart disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; HDL‐C, HDL cholesterol; HR, hazard ratio; Lp‐PLA2, lipoprotein‐associated phospholipase A2; MI, myocardial infarction; SBP, systolic blood pressure; WBC, white blood cell count.
Figure 9.
Figure 9.
Effect of pravastatin on events after adjustment for changes in Lp‐PLA2 activity and LDL cholesterol (LDL‐C). Baseline and change in LDL‐C and Lp‐PLA2 activity are expressed as continuous variables. CHD indicates coronary heart disease; CVD, cardiovascular disease; HR, hazard ratio; Lp‐PLA2, lipoprotein‐associated phospholipase A2; MI, myocardial infarction; RRR, relative risk reduction.

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