Otvos JD, Collins D, Freedman DS, Shalaurova I, Schaefer EJ, McNamara J, Bloomfield HE, Robins SJ

1. LDL and HDL Particle Subclasses Predict Coronary Events and are Favorably Changed by Gemfibrozil Therapy in the Veterans Affairs HDL Intervention Trial (VA-HIT) Otvos JD, Collins D, Freedman DS, Shalaurova I, Schaefer EJ, McNamara J, Bloomfield HE, Robins SJ Circulation 2006;113:1556-63

2. VA-HIT Background Purpose: Randomized, double-blind trial to determine if increasing low HDL-C will decrease CHD events Subjects: 2531 men with CHD, low HDL-C (31.5 mg/dL), and low LDL-C (111 mg/dL) Therapy: The fibric acid, gemfibrozil (1.2 g/d) vs. placebo

3. VA-HIT Background Principal Results: Gemfibrozil treatment resulted in a 22% decrease in nonfatal MI + CHD death 31% decrease in stroke No increase in adverse events N Engl J Med 1999; 341:410-418 Circulation 2001; 103:2828-2833

4. VA-HIT Background Principal Results: Gemfibrozil induced a 6% increase in HDL-C, 31% decrease in triglycerides, and no change in LDL-C Only HDL-C was a significant independent predictor of CHD events among on-trial lipid/apolipoprotein variables However, changes in levels of HDL-C and other lipids could account for <25% of the drug benefit JAMA 2001; 285: 1585-91

5. VA-HIT Background Unresolved: Is some of thebenefit of gemfibrozil due to favorable changes in lipoprotein particle subclass levels or size distributions that are not reflected by conventional lipid or apolipoprotein measurements?

6. Study Design • Nested case-control design • - 364 men with nonfatal MI or CHD death during 5-year • follow-up • - 697 age-matched controls • Lipids / lipoproteins measured at baseline and on-trial • - Lipids / apolipoproteins by standard chemical methods • - LDL and HDL particle subclass concentrations by NMR • All data analysis performed at VA Medical Center Cooperative Studies Program Coordinating Center

7. V6 V5 V4 V3 V2 V1 IDL L3 L2 L1 H5 H4 H3 H2 H1 Subclass Particle Concentrations (nmol/L, mol/L) Weighted Ave VLDL, LDL, HDL Particle Sizes (nm) NMR LipoProfile Large VLDL Medium VLDL Small VLDL IDL Large LDL Small LDL Large HDL Med HDL Small HDL

8. Gemfibrozil Treatment Effects Circulation 2006;113:1556-63

9. Lipids/Apolipoproteins as Predictors of CHD Events * ** Adjusted for treatment, age, diabetes, hypertension, smoking, and BMI *p<0.05 **p<0.01 ***p<0.001 Circulation 2006;113:1556-63

10. NMR Lipoprotein Particle Measures as Predictors of CHD Events ** *** *** ** ** *** * Adjusted for treatment, age, diabetes, hypertension, smoking, and BMI *p<0.05 **p<0.01 ***p<0.001 Circulation 2006;113:1556-63

11. Lipoprotein Particles as Multivariable Predictors of CHD Events *** *** *** *** *** *** **p<0.01; ***p<0.001 All NMR parameters were included in the same regression model, adjusted for treatment, age, diabetes, hypertension, smoking, and BMI Circulation 2006;113:1556-63

12. Residual Risk of CHD Events in Gemfibrozil Group by Achieved Levels of LDL and HDL Particle Number in VA-HIT Adjusted for age, diabetes, hypertension, smoking, and BMI 2002 AHA Scientific Sessions

13. Risk of CHD Events According to Quartile of Lipid/Lipoprotein Ratios Relative Risk P values for trend p=0.009 p=0.27 p=0.37 Circulation 2006;113:1556-63

14. Conclusion In this nested case-control sub-study of VA-HIT, NMR-measured HDL and LDL particle numbers were significant independent predictors of incident CHD events, whereas levels of HDL and LDL cholesterol (or apolipoproteins A-1 and B) were not. Circulation 2006;113:1556-63

15. Gemfibrozil Treatment Effects in VA-HIT Large LDL-P 36* Small HDL-P 21* HDL-P HDL-C 10* LDL-C 6* Mean Percent Change 3 -5* LDL-P -15 -20* Large HDL-P Small LDL-P * p<0.001 Circulation 2006;113:1556-63

16. Alternative Measures of LDL as Predictors of CHD Events in VA-HIT p<0.001 Odds Ratio per 1-SD Increment of on-trial value p=0.17 p=0.25 p=0.31 LDL-C Non-HDL-C ApoB LDL-P Adjusted for treatment, age, hypertension, smoking, BMI, and diabetes Circulation 2006;113:1556-63

17. Alternative Measures of HDL as Predictors of CHD Events in VA-HIT p<0.001 Odds Ratio per 1-SD Decrement of on-trial value p=0.18 p=0.42 HDL-C ApoA-1 HDL-P Adjusted for treatment, age, hypertension, smoking, BMI, and diabetes Circulation 2006;113:1556-63

18. Alternative Measures of LDL and HDL as Predictors of CHD Events in VA-HIT LDL HDL p<0.001 p<0.001 Odds Ratio per 1-SD Increment Odds Ratio per 1-SD Decrement LDL-C Non-HDL-C ApoB LDL-P HDL-C ApoA-1 HDL-P Adjusted for treatment, age, hypertension, smoking, BMI, and diabetes Circulation 2006;113:1556-63

19. LDL Subclasses as Predictors of CHD Events in VA-HIT p<0.001 p=0.02 p=0.03 Odds Ratio per 1-SD Increment of on-trial values p=0.35 LDL-P IDL-P Large LDL-P Small LDL-P Adjusted for treatment, age, hypertension, smoking, BMI, and diabetes Circulation 2006;113:1556-63

20. HDL Subclasses as Predictors of CHD Events in VA-HIT p<0.001 p<0.001 Odds Ratio per 1-SD Decrement of on-trial value p=0.37 p=0.52 HDL-P Large HDL-P Medium HDL-P Small HDL-P Adjusted for treatment, age, hypertension, smoking, BMI, and diabetes Circulation 2006;113:1556-63

21. On-Trial LDL and HDL Subclasses as Multivariate Predictors of CHD Events in VA-HIT p=0.001 p=0.002 p=0.11 Odds Ratio per 1-SD Increment p=0.30 p=0.02 p<0.001 IDL-P Large LDL-P Small LDL-P Large HDL-P Medium HDL-P Small HDL-P All subclasses in 1 model, adjusted for treatment, age, hypertension, smoking, BMI, and diabetes Circulation 2006;113:1556-63