Published online before print October 19, 2007, doi: 10.1161/ATVBAHA.107.153858
© 2008 American Heart Association, Inc.
Clinical and Population Studies |
Genetic Variation in ABCA1 Predicts Ischemic Heart Disease in the General Population
From the Department of Clinical Biochemistry (R.F.-S., A.T.-H.), Rigshospitalet, Copenhagen University Hospital, University of Copenhagen; the Department of Clinical Biochemistry (B.G.N.), Herlev University Hospital, University of Copenhagen; the Copenhagen City Heart Study (B.G.N., G.B.J., A.T.-H.), Bispebjerg University Hospital, University of Copenhagen; and the Department of Medicine B (R.S.), Hillerød Hospital, Hillerød, Denmark.
Correspondence to Anne Tybjærg-Hansen, MD, DMSc, Chief Physician and Associate Professor, Department of Clinical Biochemistry KB 3011, Section for Molecular Genetics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark. E-mail anne.tybjaerg.hansen{at}rh.regionh.dk
Abstract
Objective— We tested the hypothesis that 6 nonsynonymous single nucleotide polymorphisms (SNPs) in ATP-Binding-Cassette transporter A1 (ABCA1) affect risk of ischemic heart disease (IHD) in the general population.
Methods and Results— We genotyped 9259 individuals from the Danish general population followed for 25 years. Two SNPs (V771M and V825I) were previously associated with increases in HDL-C, 1 (R1587K) with decreased HDL-C, whereas 3 (R219K, I883M and E1172D) did not affect HDL-C levels. Despite this, 5 out of 6 SNPs (V771M, V825I, I883M, E1172D, R1587K) predicted increased risk of IHD. Similar results were obtained in a verification sample with 932 IHD cases versus 7999 controls. A stepwise regression approach identified V771M, I883M, and E1172D as the most important predictors of IHD and additive effects on IHD risk were present for V771M/I883M and I883M/E1172D pairs.
Conclusions— We show that 3 of 6 nonsynonymous SNPs in ABCA1 predict risk of IHD in the general population.
We tested whether nonsynonymous SNPs in ABCA1 affect risk of IHD in the general population. We show that 3 of 6 nonsynonymous SNPs in ABCA1 predict risk of IHD in the general population.
Key Words: atherosclerosis • cardiovascular diseases • genetics • lipids • lipoproteins
Ischemic heart disease (IHD) is the most common cause of death in developed countries,1 and a low level of plasma high-density lipoprotein cholesterol (HDL-C) is a major risk factor for IHD in the general population.2 An important atheroprotective property of the HDL particle is thought to be its key function in reverse cholesterol transport mobilizing cellular cholesterol from arterial wall macrophages to lipid poor plasma apolipoproteins, a transport that is mediated by the transmembrane ATP-Binding-Cassette transporter A1 (ABCA1).3 Mutations in the ABCA1 gene cause rare mendelian HDL deficiency syndromes characterized in the homozygous form by almost complete absence of HDL particles in plasma, but only a modest if any increase in risk of IHD, and in the heterozygous form by half-normal HDL-C levels.4–7 Recently, we and others have shown that both rare and common variants in the ABCA1 gene also contribute to HDL-C levels in the general population.8,9 Whether common genetic variation in ABCA1 predicts risk of IHD in the general population is currently unknown.
This study was performed to test the hypothesis that 6 nonsynonymous single nucleotide polymorphisms (SNPs) in ABCA1 affect risk of IHD in the general population.
Methods
Subjects
General Population Sample
The Copenhagen City Heart Study is a prospective study of the Danish general population initiated in 1976 to 1978 with follow-up examinations in 1981 to 1983 and 1991 to 1994.10,11 Individuals were selected based on the Central Population Register Code to reflect the adult Danish general population aged 20 to 80+ years. In the present study we included 9259 individuals from the 1991 to 1994 examination, whom we genotyped for all nonsynonymous SNPs (R219K, V771M, V825I, I883M, E1172D, R1587K) identified by resequencing ABCA1 in 190 individuals of Danish ancestry.8 Information on diagnosis of IHD (n=1170; World Health Organization; International Classification of Diseases, 8th edition: codes 410 to 414; 10th edition: codes I20-I25) was collected and verified until 31st December 2000 by reviewing all hospital admissions and diagnoses entered in the national Danish Patient Registry, all causes of death entered in the national Danish Causes of Death Registry, and medical records from hospitals and general practitioners. IHD was determined by experienced cardiologists according to the guidelines of the European Society of Cardiology on the basis of previous myocardial infarction or characteristic symptoms of angina pectoris based on location, character and duration of pain, and the relation of pain to exercise.12 A diagnosis of myocardial infarction required the presence of at least 2 of the following criteria: characteristic chest pain, elevated cardiac enzymes, and electrocardiographic changes indicative of myocardial infarction.
Patients With IHD
A second population comprised 992 consecutive patients from the greater Copenhagen area referred for coronary angiography to Copenhagen University Hospital, during the period from 1991 through 1993. Of these, 948 (26% women) had documented IHD based on characteristic symptoms of angina pectoris,12 plus at least 1 of the following: 
70% stenosis of at least 1 coronary artery or 50% stenosis of the left main coronary artery on coronary angiography (n=767), a previous myocardial infarction (n=494), or a positive exercise electrocardiography test.
Studies were approved by institutional review boards and Danish ethical committees: Nos. 100.2039/91, Copenhagen and Frederiksberg committee, and KA 93125, Copenhagen County committee, and conducted according to the Declaration of Helsinki. Informed consent was obtained from participants. Roughly 99% were white and of Danish descent.
Study Designs
Prospective Study
A prospective study was conducted using IHD as end point. The cohort was participants in The Copenhagen City Heart Study who attended the 1991 to 1994 examination, and for whom combined genotypes for all 6 nonsynonymous SNPs (R219K, V771M, V825I, I883M, E1172D, R1587K) were available as well as all clinical and biochemical data (n=9028 out of n=9259; Table 1). All end points were recorded in the follow-up period 1976 to 2000. Follow-up time was 25 years (172 525 person-years). Individuals diagnosed with IHD before entry into the study (n=63) were excluded, leaving 1107 incident IHD cases (n=455 women and n=652 men), and a total of 8965 individuals for all further analyses. Follow-up was 100% complete. Please see http://atvb.ahajournals.org Data Supplements, Expanded Methods for description of risk factors.
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Case–Control Study (Verification Sample)
To retest whether SNP genotype was associated with risk of IHD in an independent sample, a case–control study was conducted. The cases were consecutive patients referred for coronary angiography at Copenhagen University Hospital in 1991 through 1994 with documented IHD (see above), and for whom genotypes for all 6 nonsynonymous SNPs were available as well as all clinical and biochemical data (n=932 out of n=948). Patients with IHD (n=245 women and n=687 men) were compared with unmatched controls from the general population without IHD (n=4598 women and n=3401 men).
SNP Genotyping
The ABI PRISM 7900HT Sequence Detection System (Applied Biosystem Inc) was used to genotype for all 6 nonsynonymous SNPs (R219K, V771M, V825I, I883M, E1172D, R1587K) identified by resequencing ABCA1 in 190 individuals, as previously described.8
Biochemical Analyses
Colorimetric and turbidimetric assays (Hitachi autoanalyzer) were used to measure plasma levels of total cholesterol, HDL-C, triglycerides, and apolipoproteins B and -AI (all Boehringer Mannheim GmbH).
Statistical Analyses
We used the statistical software package Stata (STATA Corp). Two-sided probability values <0.05 were considered significant. Pearson 
2 test, t test, and Mann–Whitney U test were used for 2-group comparisons. Kaplan–Meier curves and log-rank tests evaluated the cumulative incidence of IHD as a function of SNP genotypes. With the use of left truncation (or delayed entry), Cox proportional hazards regression models with age as time scale estimated HRs for IHD.13 Covariates were dichotomized (smoking, diabetes, hypertension), or tertilized (body mass index, HDL-C and low-density lipoprotein cholesterol [LDL-C]), and incorporated into the regression models. A stepwise backward Cox regression model was used to select the best set of SNPs for prediction of IHD. To account for Type I error, a verification strategy was applied in an independent case-control study. Logistic regression was used for the verification study. For expanded Statistical Analyses please see Data Supplements, Expanded Methods.
Results
Characteristics of Individuals in the Prospective Study
The general population cohort (The Copenhagen City Heart Study) experienced 1107 incident IHD events during 25 years of follow-up and 172 525 person-years. All risk factors were increased in individuals who later developed IHD compared with those without IHD (Table 1, all probability values <0.05).
Allele Frequencies
Minor allele frequencies in the general population for the 6 nonsynonymous SNPs previously identified by resequencing the entire ABCA1 gene in 190 individuals of Danish descent were: 0.26 (R219K), 0.03 (V771M), 0.03 (E1172D), 0.06 (V825I), 0.12 (I883M), and 0.24 (R1587K).8 Similar allele frequencies have been reported for other White populations.14 Please see Data Supplements, Expanded Results for description of Hardy-Weinberg equilibrium.
Linkage Disequilibrium and Haplotypes
Figure 1 illustrates the pairwise linkage disequilibrium (LD) pattern among the six nonsynomymous SNPs in ABCA1, with D' above and r2 below the diagonal. A strong positive D' was present for R219K/V771M, M825I/I883M, and E1172D/R1587K (D'>0.9), whereas a strong negative D' was present for R219K/V825I, V771M/V825I, and V771M/I883M (D'<–0.9). The r2 for the V825/I883M pair was 0.44 whereas the remaining SNP pairs had r2 <0.10 (Figure 1). Haplotypes are described in the Data Supplements, Expanded Results and Table III.
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Risk of IHD
Prospective Study
The cumulative incidence of IHD as a function of age was increased for V771M (GA+AA versus GG, borderline P=0.06), V825I (GA+AA versus GG; P=0.02), I883M (AG+GG versus AA, P=0.01), E1172D (GC+CC versus GG, P=0.03), and for R1587K (AA versus GG, borderline P=0.06), but not for R219K (Figure 2). The age adjusted hazard ratios (HRs) for IHD were: V771M (GA+AA versus GG) 1.2 (95% confidence interval [CI] 1.0 to 1.5), V825I (GA+AA versus GG) 1.2 (1.0 to 1.5), I883M (AG+GG versus AA) 1.2 (1.0 to 1.4), E1172D (GC+CC versus GG) 1.3 (1.0 to 1.6) and R1587K (AA versus GG) 1.2 (1.0 to 1.6), respectively (Table 2). Adjusting for HDL-C or for LDL-C, smoking, diabetes, hypertension, and body mass index did not alter these HRs substantially. There was evidence for a statistically significant interaction between gender and V771M (P=0.04) in the prediction of IHD, whereas the remaining 5 SNPs did not interact with gender (all probability values >0.52). Please see all gender specific cumulative incidence plots and HRs in the Data Supplements, Figure I and Table I.
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Case–Control Study (Verification Sample)
The significant effects in the prospective study were retested in an independent case-control study comprising 932 cases with IHD and 7999 controls without IHD. The age-adjusted odds ratios (ORs) were: V771M (GA+AA versus GG) 1.2 (0.9 to 1.5), V825I (GA+AA versus GG) 1.2 (0.9 to 1.4), I883M (AG+GG versus AA) 1.2 (1.0 to 1.4), E1172D (GC+CC versus GG) 1.1 (0.8 to 1.4), and R1587K (GA versus GG) 1.2 (1.0 to 1.4). Please see the Data Supplements, Table II for frequencies and gender specific results.
Stepwise Regression Approach
To determine which ABCA1 SNPs were independent predictors and not caused by LD among SNPs, a stepwise Cox regression approach was performed. The final prediction model included the 3 noncorrelated SNPs, V771M, I883M, and E1172D (HRs: V771M, 1.2 [1.0 to 1.6]; I883M, 1.2 [1.0 to 1.4]; E1172D, 1.2 [1.0 to 1.6]). Performing gender specific stepwise regression, V771M and I883M were the best predictors in women (HRs: V771M, 1.6 [1.2 to 2.3]; I883M, 1.3 [1.1 to 1.6]), whereas I883M and E1172D were best in men (HRs: I883M, 1.1 (1.0 to 1.4); E1172D, 1.3 (1.0 to 1.7). Using standard statistical tests, there was no evidence for interactions among pairs of the 3 SNPs identified from the stepwise regression approach (all probability values >0.21). However, because additive effects of these significant SNPs might have clinical relevance, the pairwise combinations of these 3 SNPs are shown and described in the Data Supplements, Expanded Results and Figure II.
ABCA1 SNPs and HDL-C Levels
In genders combined, V771M and V825I were associated with increases in HDL-C of 0.04 and 0.05 mmol/L, respectively (Figure 3, upper panel). R1587K was associated with a decrease in HDL-C of 0.03 mmol/L (P<0.005), whereas R219K, I883M, and E1172D were not associated with changes in HDL-C levels (Figure 3, upper panel). Gender specific effects are shown in middle and lower panels of Figure 3.
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0.005.Discussion
The principal finding of this study is that common genetic variation in ABCA1, a well-known HDL gene, predicts risk of IHD in the general population. Although most SNPs had significant effects on plasma HDL-C levels, the association between ABCA1 SNPs and risk of IHD was not related to their association with HDL-C.
Mechanistically, the results are highly plausible. ABCA1 is a transmembrane protein of key importance for reverse cholesterol transport,3 a major pathway for removing excess cholesterol from peripheral tissues back to the liver. When cholesterol accumulates in the arterial wall atherosclerosis develops and may eventually lead to IHD and possibly to early death. ABCA1 in macrophages within the arterial wall facilitates removal of cholesterol and is likely to have antiatherogenic effects. Therefore, genetic variation in ABCA1 could influence the speed by which atherosclerosis develops, and thus the risk of IHD, exactly as was observed in the present study.
Several studies have reported associations between V825I/I883M and increased plasma HDL-C levels8,15,16 and associations between R1587K and a decreased HDL-C or apoAI.8,14,17 For in silico prediction of ABCA1 SNPs please see the Data Supplements Expanded Results. The rare allele of the R219K SNP has previously been reported to be associated with decreased14,17 or increased risk of coronary heart disease.18 The present largest prospective results as well as a recent case–control study did not find any association with atherosclerosis susceptibility.19 In support of I883M and E1172D as 2 of the 3 most important ABCA1 SNPs for IHD prediction, a previous study of 2028 White men found increased frequencies in cases compared with controls, and also detected increased risk of future IHD events associated with the 1172D allele.18
The pairwise LD structure of the SNPs is important for the interpretation of the association results. Because the effects on IHD are modest and concern almost all SNPs, one might suspect that this is attributable to LD. Where D' is useful in detecting recombination and haplotype structure of the gene, r2 describes how closely correlated the genotype is between a pair of SNPs and is thus a useful statistic for determining whether an effect associated with one SNP could be detected by genotyping a second SNP.20 In general, the present ABCA1 SNPs are weakly correlated and do not serve as good genotype markers for each other (all r2 <0.8). There seem, however, to be several smaller relatively nonrecombinant regions as illustrated by the high D' for several of the SNP pairs, either positive (the 2 rare alleles segregate together) or negative (the rare allele at one SNP segregates together with the common allele at the second SNP). The fact that the stepwise regression approach identified the V771M, I883M, and E1172D SNPs, which have very weak association between rare alleles (low r2 or negative D'), as important for the final IHD prediction model, supports that the observed findings for these 3 SNPs are not caused by LD. However, the single site result on IHD risk for V825I is most likely attributable to LD with I883M, and the findings for R1587K are most likely attributable to LD with E1172D, the latter also supported by the haplotype analysis presented in the Data Supplements, Table III and Expanded Results.
In the present study, risk of IHD predicted by SNPs in ABCA1 was independent of plasma HDL-C levels: SNPs predicting increased risk were associated with either increases or decreases in HDL-C, or no effect on HDL-C. In most cases the risk associated with genetic variation in ABCA1 was not explained by the inverse relationship between HDL-C and risk of IHD, as observed for other important genes in reverse cholesterol transport, cholesteryl ester transfer protein,21,22 and hepatic lipase.23,24 This is in good agreement with experimental studies, because several observations favor antiatherosclerotic effects of ABCA1 beyond plasma HDL-C levels: (1) In mice, macrophage specific deficiency of ABCA1 had a minimal effect on reducing plasma HDL-C levels, but resulted in significantly increased atherosclerosis.25,26 Thus, macrophage ABCA1 appears to contribute little to bulk lipidation of HDL and therefore to plasma HDL-C levels,27 but seems to be important in the prevention of atherosclerotic lesion development locally in the arterial wall.25 (2) Macrophage ABCA1 appears to possess antiinflammatory properties28 mediating engulfment of apoptotic cells by macrophages.29,30 (3) Platelet ABCA1 might be involved in the modulation and suppression of platelet activation.31 (4) ABCA1 mediates efflux of cellular phospholipids and cholesterol to lipid-poor apolipoproteins, such as apoAI and apoE, but in contrast to ABCG1 and ABCG4, it interacts poorly with HDL-2 and HDL-3 particles that constitute the bulk of plasma HDL.32 (5) Tangier disease (homozygosity or compound heterozygosity for mutations in ABCA1) is associated with extremely low levels of HDL-C, but despite this with only moderate increases in risk of IHD.4 This is only partly explained by the low levels of LDL-C in some of these patients, and might suggest that risk of IHD attributable to ABCA1 mutations may not, or may only partly, be reflected in HDL-C levels in these individuals as well. (6) We have recently shown that a common mutation (frequency 0.4%) in ABCA1, K776N, predicted a 2- to 3-fold increase in risk in the general population independent of HDL-C levels.33 (7) Finally, in the present study adjustments for HDL-C levels did not substantially alter the risk estimates, supporting that ABCA1 has effects on risk of IHD independent of HDL-C levels. Taken together, these results suggest that mutations in ABCA1 may have proatherosclerotic effects independent of HDL-C levels.
Conclusion
We show that 3 of 6 nonsynonymous SNPs in ABCA1 predict risk of IHD in the general population.
Acknowledgments
We thank Mette Refstrup for her persistent attention to the details of the large-scale genotyping. We also thank the subjects who participated in the study.
Sources of Funding
This work was supported by The Danish Heart Foundation, The Danish Medical Research Council, Ingeborg, and Leo Dannin’s Grant, the Research Fund at Rigshospitalet, Copenhagen University Hospital, and a Specific Targeted Research Project grant from the European Union, Sixth Framework Programme Priority [FP-2005-LIFESCIHEALTH-6], contract # 037631.
Disclosures
None.
Footnotes
Original received February 27, 2007; final version accepted October 4, 2007.
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