© 1999 American Heart Association, Inc.
Atherosclerosis and Lipoproteins |
Hyperlipidemia of ApoE2(Arg158-Cys) and ApoE3-Leiden Transgenic Mice Is Modulated Predominantly by LDL Receptor Expression
From the Department of Human Genetics (K.W.v.D., M.P.J.d.W., A.v.d.Z., M.H.H.) and the Departments of Cardiology and Internal Medicine (L.M.H.), Leiden University Medical Center, and TNO Prevention and Health, Gaubius Laboratory (B.J.M.v.V., B.v.t.H., H.v.d.B., L.M.H.), Leiden, The Netherlands.
Correspondence to Dr K. Willems van Dijk, Department of Human Genetics, Leiden University Medical Center, PO Box 9503, 2300 RA Leiden, The Netherlands. E-mail ko{at}ruly46.medfac.leidenuniv.nl
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Abstract |
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Abstract—To investigate the relative roles of the LDL receptor– and non–LDL receptor–mediated pathways in the clearance of apolipoprotein E (apoE) variants in vivo, we have generated apoE2(Arg158-Cys) (apoE2) and apoE3-Leiden transgenic mice deficient for the endogenous mouse Apoe and Ldl receptor genes (Apoe-/-.Ldlr-/- mice). Unexpectedly, on the Apoe-/-.Ldlr-/- background, expression of neither apoE2 nor apoE3-Leiden results in a decrease of the hyperlipidemia. In contrast, serum cholesterol levels are increased by the introduction of apoE2 and apoE3-Leiden in Apoe-/-.Ldlr-/- mice (to 39.1±7.1 and 37.6±7.6 mmol/L, respectively, from 25.9±6.5 mmol/L). In addition, in these transgenic mice, the serum triglyceride levels are substantially increased (to 9.6±7.0 and 5.8±2.8 mmol/L, respectively, from 0.7±0.5 mmol/L), which is associated with a decreased efficiency of in vitro LPL-mediated lipolysis of circulating VLDL. The VLDL-triglyceride secretion rate is not affected by the expression of apoE2 or apoE3-Leiden on the Apoe-/-.Ldlr-/- background. These results indicate that in the absence of the LDL receptor, clearance of triglyceride-rich apoE2 and apoE3-Leiden–containing lipoproteins via alternative hepatic receptors, such as the LDL receptor–related protein (LRP) is inefficient. Although apoE2 and apoE3-Leiden are disturbed in binding to the LDL receptor in vitro, expression of 1 or 2 mouse Ldlr alleles in an apoE2.Apoe-/- or apoE3-Leiden.Apoe-/- background results in a gene dose–dependent decrease of the hyperlipidemia. Furthermore, overexpression of the LDL receptor via adenovirus-mediated gene transfer rescues the hyperlipidemia associated with apoE2 and apoE3-Leiden expression. These data indicate that in apoE2 and apoE3-Leiden transgenic mice, the LDL receptor constitutes the predominant route for clearance of VLDL remnants, carrying even poorly binding apoE variants, and that this pathway is functional despite an apoE-mediated disturbance in VLDL triglyceride lipolysis.
Key Words: apolipoprotein E • LDL receptor • LDL receptor–related protein • hypertriglyceridemia • VLDL triglyceride lipolysis
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Introduction |
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Apolipoprotein (apo) E plays a key role in the lipoprotein metabolism by functioning as a ligand for receptor-mediated uptake of chylomicron and VLDL remnants by the liver (for review, see Reference 11 ). Mutations in apoE are associated with familial dysbetalipoproteinemia (FD), which is characterized by elevated levels of chylomicron and VLDL remnants in the serum and premature atherosclerosis (for reviews, see References 2 and 32 3 ). Several variant forms of apoE leading to FD have been described, such as the common apoE2(Arg158-Cys) (apoE2) variant, which is inherited as a recessive trait, and the rare apoE3-Leiden variant, which is inherited as a dominant trait.4
The penetrance and severity of FD associated with the apoE2 and apoE3-Leiden variants is variable,1 4 most likely because of the genetic and environmental heterogeneity of the human population. To investigate the role of these apoE variants in FD in a more homogeneous background, we have previously generated transgenic mice expressing the human apoE2 and apoE3-Leiden variants in the absence of endogenous mouse apoE.5 Both mouse lines display hyperlipidemia, but to a different extent. ApoE2.Apoe-/- mice are much more affected than apoE3-Leiden.Apoe-/- mice. These differences could be partly explained by in vitro binding studies that revealed a severe binding defect of apoE2 and a moderate binding defect of apoE3-Leiden to the LDL receptor.5
In addition to the LDL receptor, the LDL receptor–related protein (LRP) is thought to function as a backup receptor mediating clearance of apoE-containing lipoproteins.6 7 8 This has been demonstrated by the accumulation of chylomicron and VLDL remnants in the serum of LDL receptor–deficient (Ldlr-/-) mice injected with an adenovirus carrying the receptor-associated protein (ad-RAP), a potent inhibitor of LRP-ligand interaction.9 10 Similar observations have been made after liver-specific inactivation of the LRP gene in Ldlr-/- mice by a genetic strategy.11 Inhibition of the LRP by ad-RAP injection in apoE2.Apoe-/- and apoE3-Leiden.Apoe-/- mice resulted in a dramatic increase of the hyperlipidemia.5 These results were interpreted to indicate that both apoE2- and apoE3-Leiden–containing lipoproteins can be cleared via the LRP.
To further investigate the clearance of apoE2- and apoE3-Leiden–containing lipoproteins via non–LDL receptor–mediated pathways, we generated transgenic mice expressing both apoE variants on an Apoe- and LDL receptor–deficient background (apoE2.Apoe-/-.Ldlr-/- and apoE3-Leiden.Apoe-/-.Ldlr-/- mice). These mice were compared with Apoe-/-.Ldlr-/- mice and with apoE2.Apoe-/- and apoE3-Leiden.Apoe-/- mice with varying levels of LDL receptor expression. Our data indicate that despite decreased in vitro binding to the LDL receptor, apoE2 and apoE3-Leiden lipoproteins are cleared predominantly via the LDL receptor in vivo. In addition, compared with LRP-mediated clearance, LDL receptor–mediated clearance seems less sensitive to an apoE2- and apoE3-Leiden–mediated defect in VLDL triglyceride lipolysis.
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Methods |
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Generation and Analysis of Transgenic Mice
Transgenic mice expressing human apoE2(Arg158-Cys) and apoE3-Leiden in the absence of endogenous apoE have been described previously5 (apoE2.Apoe-/- and apoE3-Leiden.Apoe-/- mice). LDL receptor–deficient (Ldlr-/-) mice12 were purchased from the Jackson Laboratory (Bar Harbor, Me). ApoE2.Apoe-/- and apoE3-Leiden.Apoe-/- mice were crossbred with Ldlr-/- mice to obtain transgenic mice that lack both the apoE and LDL receptor gene (apoE2.Apoe-/-.Ldlr-/- and apoE3-Leiden.Apoe-/-.Ldlr-/- mice). The resulting breeding offspring were analyzed for the endogenous Apoe-/- and Ldlr-/- genotype through tail-tip DNA analysis, as described earlier.12 13 The presence of human apoE in serum was determined by sandwich ELISA as described previously.14 For experiments, mice 10 to 20 weeks of age were included. Mice were housed under standard conditions in conventional cages and given free access to food (ie, a standard chow diet) and water. All experiments were performed under protocols approved by the Committee on Animal Experimentation of the Leiden University Medical Center.
Lipid, Lipoprotein, and ApoE Measurements
Mice were fasted from 9 AM to 1 PM, and
150 µL of blood was obtained from each individual mouse through
tail-bleeding. Total serum cholesterol and
triglyceride levels (without measurement of free glycerol)
were measured enzymatically with commercially available kits:
Boehringer Mannheim 236691 and Sigma Chemical Co 337-B. Human
apoE levels were measured by sandwich ELISA as described
previously.14
Lipoprotein fractions were separated by fast protein liquid chromatography (FPLC) using two 25-mL Superose 6B columns in series (Pharmacia). Some 200 µL of pooled serum per group was injected onto the columns and eluted at a constant flow rate of 0.5 mL/min with PBS, pH 7.4. Fractions of 0.5 mL were collected and assayed for total cholesterol and triglyceride levels as described above.
Characterization of VLDL
The d<1.006 (g/mL) lipoproteins (VLDL) were isolated
by density-gradient ultracentrifugation. Total and free
cholesterol, triglyceride (without glycerol),
and phospholipid were measured enzymatically with commercially
available kits (Boehringer Mannheim 236691 and 310328, Sigma
Chemical Co 337-B, and Wako Chemicals GmbH 990-54009, respectively).
VLDL protein was determined by the method of Lowry.15
Human apoE levels were measured by sandwich ELISA as described
previously.14
Adenovirus Transfections
The recombinant adenoviral vectors expressing the human LDL
receptor (Ad-LDLR) and the bacterial ß-galactosidase (Ad-LacZ) under
control of the cytomegalovirus promotor were kindly provided by Dr T.
Willnow (University of Texas Southwestern Medical Center, Dallas) and
Dr J. Herz (Max-Delbrueck-Center for Molecular Medicine, Berlin,
Germany).10 The recombinant adenovirus was
propagated and titrated on the Ad5 E1–transformed human embryonic
kidney cell line 911 as described.16 For storage, the
virus was supplemented with mouse serum albumin (0.2%) and
glycerol (10%), and aliquots were flash-frozen in liquid
N2 and stored at -80°C. Routine virus titers
of the stocks varied from 1x1010 to
5x1010 pfu/mL.
For in vivo adenovirus transfection, on day 0, 2.0x109 pfu in a total volume of 200 µL (diluted with PBS) were injected into the tail vein. Blood samples were drawn from the tail vein of fasted mice at 5 days after virus injection.
In Vivo Hepatic VLDL-Triglyceride Production
After a 4-hour fasting period, mice were injected
intravenously with Triton WR1339 (500 mg/kg body
wt)17 with 15% (wt/vol) Triton solution in 0.9% NaCl. At
1, 20, 40, and 60 minutes after injection, blood samples were drawn and
analyzed for triglycerides as described above. The
increase in serum triglycerides was normalized to the
1-minute point. Production of hepatic triglyceride
was calculated from the slope of the curve and expressed as
µmol · h-1 · kg body
wt-1.
Assay of Lipolysis With Lipoprotein Lipase in Solution
The d<1.006 (g/mL) lipoproteins (VLDL) were isolated
by density-gradient ultracentrifugation. Lipolysis
assays were performed at 37°C in a 0.1 mol/L
Tris(hydroxymethyl)-aminomethane (Tris) buffer, pH 8.5,
with bovine lipoprotein lipase (LPL; 0.2 U, Sigma) in the presence of
2% (wt/vol) bovine albumin (essentially free of free fatty
acids [FFAs]). The reaction was stopped by the addition of 50
mmol/L KH2PO4, 0.1% Triton
X-100, pH 6.9, and placed on ice. To obtain a time 0 control, the
reaction was prevented by addition of Triton before the addition of
LPL, and samples were placed on ice. FFAs were measured enzymatically
with a NeFa-C kit (Wako Chemicals GmbH). The rate of FFA release by 0.2
U LPL was linear for 5 minutes as used in this assay. The assay was
performed at a VLDL-triglyceride concentration of 0.14
mmol/L with duplication of FFA determination.
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Results |
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Serum Lipid, ApoE, and Lipoprotein Levels in ApoE Transgenic Apoe-/-.Ldlr-/- Mice
To determine the relative roles of the LDL receptor– versus the non–LDL receptor–mediated pathways in the clearance of apoE variants, apoE2 and apoE3-Leiden transgenic mice were crossbred onto an Apoe-/-.Ldlr-/- background. ApoE2 and apoE3-Leiden mice express their transgenes predominantly in the liver. Both apoE2.Apoe-/-.Ldlr-/- and apoE3-Leiden.Apoe-/-.Ldlr-/- mice are even more severely hyperlipidemic than nontransgenic Apoe-/-.Ldlr-/- mice (Table 1
). Compared with
Apoe-/-.Ldlr-/- mice, the presence of apoE2 and
apoE3-Leiden leads to an aggravation of the
hypercholesterolemia and the appearance of
severe hypertriglyceridemia. Both
apoE2.Apoe-/-.Ldlr-/- and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice have human apoE levels
of >20 mg/dL. As determined by size-separation
chromatography with an FPLC apparatus, the
increase in serum cholesterol and
triglycerides in the
apoE2.Apoe-/-.Ldlr-/- and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice occurred predominantly
in the fractions belonging to the VLDL/IDL size range (Figure 1).
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LDL Receptor Expression in ApoE Transgenic Mice
We have previously reported the generation and analysis of
apoE2 and apoE3-Leiden transgenic mice on an
Apoe-/-.Ldlr+/+ background.5 These
mice have a significantly less pronounced
hyperlipidemia than apoE2 and apoE3-Leiden transgenic
mice on an Apoe-/-.Ldlr-/- background (Table 1
).
Interestingly, apoE2.Apoe-/- and
apoE3-Leiden.Apoe-/- mice heterozygous for LDL receptor
deficiency (Ldlr-/+) have serum lipid levels that are
intermediate between complete absence or presence of the LDL receptor
(Table 1). Apparently, the murine LDL receptor is capable of
mediating clearance of VLDL carrying apoE variants that bind poorly in
in vitro assays.5
To further demonstrate the capacity of the LDL receptor to mediate
clearance of apoE2 and apoE3-Leiden, the human LDL receptor was
overexpressed in apoE2 and apoE3-Leiden transgenic mice by
adenovirus-mediated gene transfer. Injection of
2x109 pfu of Ad-LDLR in Apoe-/-
mice does not affect serum cholesterol levels, whereas a
similar dose of Ad-LDLR in Ldlr-/- mice reduces the serum
cholesterol levels to that of a wild-type mouse. In
apoE2.Apoe-/- and apoE3-Leiden.Apoe-/- mice,
injection of 2x109 pfu of Ad-LDLR results in a
reduction of serum cholesterol of >70% and >50%,
respectively, compared with injection of
2x109 pfu of Ad-LacZ. The reduction in serum
triglyceride and apoE levels shows a similar trend (Table 2). As illustrated by size separation
chromatography, the reduction in serum lipids in
apoE2.Apoe-/- and apoE3-Leiden.Apoe-/-
mice occurs across the whole spectrum of VLDL-, IDL-, and LDL-sized
particles (Figure 2).
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Characterization of the d<1.006 Lipoproteins From
ApoE Transgenic Apoe-/-.Ldlr-/- Mice
The composition of the d<1.006 lipoproteins (VLDL) was
determined to further characterize the hyperlipidemia
associated with apoE2 and apoE3-Leiden expression in the absence of the
LDL receptor. Sets of pooled serum from Ldlr-deficient mice
that express endogenous mouse Apoe, no
Apoe, apoE2, and apoE3-Leiden were fractionated by density
ultracentrifugation. The lipid and apoE content of the
various VLDL particles is shown in Table 3. The total cholesterol and
triglyceride levels in the apoE transgenic VLDL are
significantly increased compared with non–apoE transgenic VLDL.
Concomitant with the increased apolar lipid content (free
cholesterol and triglycerides) of the apoE2 and
apoE3-Leiden VLDL and thus an expected size increase, the surface
resident phospholipid levels are elevated. A significant fraction
(20%) of the total VLDL protein consists of apoE.
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Analysis of the Disturbance in
Triglyceride Metabolism in ApoE Transgenic
Apoe-/-.Ldlr-/- Mice
The concomitant increase in serum triglyceride and
apoE levels in the apoE2 and apoE3-Leiden transgenic mice is indicative
of an apoE-mediated defect in the triglyceride
metabolism (Table 1). This was further supported by
a strong positive correlation between the serum apoE and
triglyceride levels and not the serum apoE and
cholesterol levels in the individual
apoE2.Apoe-/-.Ldlr-/- and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice (data not shown).
The pronounced hypertriglyceridemia in the
apoE transgenic Apoe-/-.Ldlr-/- mice compared with
the nontransgenic Apoe-/-.Ldlr-/- mice could be
explained by an apoE-induced increase in VLDL-triglyceride
production and/or a decrease in the efficiency of
triglyceride lipolysis.
To determine whether apoE expression affects
VLDL-triglyceride production,
Apoe-/-.Ldlr-/-,
apoE2.Apoe-/-.Ldlr-/-, and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice were injected with
Triton WR1339, and the serum triglyceride increase was
determined. As evident from Table 4,
differences in the VLDL-triglyceride secretion rate cannot
explain the observed hypertriglyceridemia
in the apoE transgenic mice on the Apoe-/-.Ldlr-/-
background.
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To investigate whether increased amounts of apoE2 and apoE3-Leiden have
an effect on the efficiency of VLDL lipolysis, VLDL from
Ldlr-/- mice carrying normal amounts of
endogenous mouse Apoe and VLDL from
apoE2.Apoe-/-.Ldlr-/- and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice carrying excess
human apoE variants (Table 3) were subjected to lipolysis by
bovine LPL in solution. Both apoE2 and apoE3-Leiden VLDL is lipolyzed
at <20% of the efficiency of VLDL containing endogenous
mouse apoE (Table 4).
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Discussion |
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In this article, we demonstrate that compared with Apoe-/-.Ldlr-/- mice, expression of apoE2 and apoE3-Leiden on an Apoe-/-.Ldlr-/- background does not result in a reduction of the hyperlipidemia. On the contrary, both serum cholesterol and triglyceride levels are dramatically increased in apoE2.Apoe-/-.Ldlr-/- mice and apoE3-Leiden.Apoe-/-.Ldlr-/- mice (Table 1
). The hypertriglyceridemia can be
explained by a poor efficiency of lipolysis of the apoE-rich VLDL
particles (Table 4). Because expression of the apoE variants on
the Apoe-/-.Ldlr-/- background does not affect the
hepatic VLDL-triglyceride secretion rate (Table 4),
we conclude that the increase in
hypercholesterolemia is due to dysfunctional
VLDL clearance via a backup receptor pathway such as the LRP. Despite
decreased in vitro binding of apoE2 and apoE3-Leiden VLDL to the LDL
receptor5 and impaired triglyceride
lipolysis, increasing the expression of the LDL receptor in both
apoE2.Apoe-/-.Ldlr-/- and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice by breeding or by
Ad-LDLR injection results in a gene dose–dependent decrease of the
hyperlipidemia (Tables 1 and 2).
Increased LDL receptor expression in apoE3-Leiden mice results in a
much more efficient reduction of serum cholesterol level
than in apoE2 mice (Tables 1 and 2). Only excess LDL
receptor expression after adenovirus-mediated gene transfer results in
a nearly complete rescue of the hyperlipidemia in
apoE2.Apoe-/- mice. This is in agreement with the poor in
vitro LDL receptor binding capacity of apoE2 compared with
apoE3-Leiden5 and, moreover, sustains our conclusion
that the LDL receptor is the predominant pathway for lipoprotein
clearance in apoE2 and apoE3-Leiden transgenic mice.
In vivo, LRP-mediated clearance is thought to occur after enrichment of
the remnant lipoproteins with apoE in the space of Disse, the so-called
secretion-recapture process.18 19 20 21 Our data clearly
indicate that LRP-mediated clearance of lipoproteins from the
circulation of apoE2.Apoe-/-.Ldlr-/- and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice is disturbed, despite
high levels of apoE on the VLDL particles (Table 3).
Explanations for disturbed LRP-mediated clearance include defective
lipoprotein binding caused by the apoE variants and/or the lipid
composition of the particles. We and others have recently demonstrated
in mice that excess apoE3, the most common apoE variant in humans, on
VLDL particles also leads to inhibition of
VLDL-triglyceride lipolysis and a disturbed clearance via
the LRP.22 23 The present observations
demonstrate that the triglyceride-rich VLDL from
apoE2.Apoe-/-.Ldlr-/- and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice is poorly
cleared via the LRP. We conclude from the combined data that the high
triglyceride content of the VLDL particles is one of the
factors contributing to defective LRP-mediated clearance in the
apoE2.Apoe-/-.Ldlr-/- and
apoE3-Leiden.Apoe-/-.Ldlr-/- mice.
Disturbance of VLDL-triglyceride lipolysis by variant forms of human apoE has been reported previously.24 25 26 However, this negative effect on triglyceride lipolysis may be partly apoE isotype independent, because wild-type apoE3 can also decrease the efficiency of triglyceride lipolysis when present at high levels on the VLDL.23 27 28 29 30 On the basis of our experiments, we cannot distinguish quantitative effects from qualitative effects of apoE2 and apoE3-Leiden on the efficiency of triglyceride lipolysis. It has recently been described that increased levels of mouse apoE in the serum of Apoe-/-.Ldlr-/- mice do not result in hypertriglyceridemia.31 This indicates that increased human and mouse apoE levels may have distinct effects on the efficiency of triglyceride lipolysis.
The role of the LRP in lipoprotein clearance has recently been investigated by liver-specific ablation of LRP expression.11 On an Ldlr-/- background, absence of the LRP from the liver results in the accumulation of lipoproteins in the VLDL and IDL/LDL size range. On a wild-type Ldlr+/+ background, absence of the LRP from the liver does not result in the accumulation of lipoproteins in the circulation but does result in a compensatory upregulation of the endogenous LDL receptor gene and protein. These data provide direct evidence for a role of the LRP in lipoprotein clearance but also emphasize the relative importance of the LDL receptor for lipoprotein clearance, which is in line with our present conclusions.
The conditional LRP knockout experiments have also provided novel insight into the effects of adenovirus-mediated overexpression of RAP, a potent inhibitor of the LRP.9 Injection of Ad-RAP in Ldlr-/- mice results in a much more dramatic accumulation of VLDL-size lipoproteins10 than with Ldlr-/- mice lacking the LRP exclusively from the liver.11 Apparently, overexpression of RAP not only inhibits lipoprotein interaction with the LRP but also interferes with additional steps in the metabolism of VLDL-size lipoproteins. We have previously demonstrated that adenovirus-mediated overexpression of RAP in apoE2.Apoe-/- and apoE3-Leiden.Apoe-/- mice results in a dramatically increased hyperlipidemia.5 Given the recent information on the effects of RAP on lipoprotein metabolism, we cannot exclude the possibility that part of this observed phenotype is due to additional disturbances of lipoprotein metabolism.
Huang et al32 generated apoE2 transgenic mice expressing various plasma levels of apoE2 (3 to 60 mg/dL) in the presence of endogenous mouse apoE (apoE2.Apoe+/+ mice). In moderately expressing apoE2.Apoe+/+ mice (10 to 30 mg/dL human apoE2), absence of one or both LDL receptor alleles resulted in a LDL receptor gene dose–dependent hyperlipidemia,33 similar to what we observe. Surprisingly, in low-expressing apoE2.Apoe+/+ mice (2 to 10 mg/dL human apoE2), absence of the LDL receptor was found to result in hypolipidemia.26 These authors concluded from their data that these phenotypes can be explained by the combined effects of both defective LDL receptor–mediated clearance and an apoE2-mediated disturbance of triglyceride lipolysis, which is fully in line with our present conclusions.
The apoE2.Apoe+/+ mice used to generate the
apoE2.Apoe-/-.Ldlr-/- mice in the present
study5 express levels of apoE similar to those of the
low-expressing mice used by Huang et al.26 However, in
contrast to the mice used by Huang et al, our low-expressing
apoE2.Apoe-/-.Ldlr-/- mice are severely
hyperlipidemic compared with both Ldlr-/-
mice and even Apoe-/-.Ldlr-/- mice (Table 1). The
apparent discrepancy in the plasma cholesterol and
triglyceride levels of apoE2 mice on the
Apoe+/+.Ldlr-/-26 versus the
Apoe-/-.Ldlr-/- background (this study) must be due to
the apparent beneficial effects of mouse apoE on clearance and
lipolysis.
It has been reported that humans heterozygous for LDL receptor deficiency have increased hyperlipidemia in the presence of 1 or 2 apoE2 alleles.34 35 These observations in the human agree with the present data on the relative importance of the LDL receptor for the clearance of lipoproteins containing even poorly binding apoE variants in the mouse. Thus, individual variation in the level of LDL receptor expression could play an important role in the expression of hyperlipidemia even in individuals expressing mutant forms of apoE that bind poorly to the LDL receptor.
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Acknowledgments |
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This research was supported by the Netherlands Heart Foundation (projects M93.001 and 96.178) and the Netherlands Foundation of Scientific Research (project 900-504-092). Financial contribution of the specific RTD Program of the European Commission (BIOMED-2, BMH4-CT96-0898) is gratefully acknowledged. Dr Hofker is an Established Investigator of the Netherlands Heart Foundation. We gratefully acknowledge the technical assistance of V.E.H. Dahlmans.
Received August 3, 1998; accepted May 19, 1999.
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