This document summarizes a presentation given by Dr. M. John Chapman on HDL-C (high-density lipoprotein cholesterol). It discusses the structure and composition of HDL particles, their role in reverse cholesterol transport from tissues to the liver, and functions such as promoting cholesterol efflux from cells. While HDL-C level is commonly used clinically, Dr. Chapman questions whether it accurately reflects HDL functionality in protecting against cardiovascular disease. The document presents evidence that HDL's ability to efflux cholesterol from macrophages better predicts atherosclerosis and coronary artery disease than HDL-C level alone.

1. M. John Chapman BSc, Ph.D., D.Sc., FESC
Past-President, European Atherosclerosis Society
Research Professor, University of Pierre and Marie Curie
Director Emeritus,
Dyslipidemia and Atherosclerosis Research,
INSERM UMR1166
Pitié-Salpetriere University Hospital,
Paris, France
17eme Journee d’Endocrinologie, Metabolisme
& Nutrition, Hopital de la Pitie-Salpetriere 2014
Le HDL-C :
Ou en est-on aujourd’hui ?:

2. Inflammatio
n
-
macrophages
- T
lymphocytes
- mast cells
Lipid-
rich
core
Thin-cap atherosclerotic plaque
The rupture-prone or high-risk plaque = Killer #1high-risk plaque = Killer #1
Courtesy: Erling FalkCourtesy: Erling Falk
Thin cap

3. Atherosclerotic Plaque Development:
From Healthy Vessel to Clinical CVD
Genetic/GenomicGenetic/Genomic
DeterminantsDeterminants
EnvironmentalEnvironmental
ModifiersModifiers
Healthy
Vascular
State
Traditional
Risk Factors
Novel Risk
Factors
SubclinicalSubclinical
AtherosclerosisAtherosclerosis
ClinicalClinical
CardiovascularCardiovascular
DiseaseDisease

4. The Emerging Risk Factors Collaboration. JAMA 2009;302:1993-2000
Coronary Heart Disease and HDL-C
0.80.8
1.01.0
1.51.5
2.02.0
2.52.5
3.03.0
3.53.5
HazardRatio
4040 6060 8080
HDL-C (mg/dL)
N = 302,430
3030 5050 7070

5. www.escardio.org/guidelines
ESC/EAS Guidelines for the management
of dyslipidaemias
The Task Force for the management of dyslipidaemias of the
European Society of Cardiology (ESC) and the European
Atherosclerosis Society (EAS)
Developed with the special contribution of: European Association for Cardiovascular
Prevention & Rehabilitation†
Authors/Task Force Members: Željko Reiner* (ESC Chairperson) (Croatia)
Alberico L. Catapano* (EAS Chairperson)* (Italy), Guy De Backer (Belgium),
Ian Graham (Ireland), Marja-Riitta Taskinen (Finland), Olov Wiklund (Sweden),
Stefan Agewall (Norway), Eduardo Alegria (Spain), M. John Chapman (France),
Paul Durrington (UK), Serap Erdine (Turkey), Julian Halcox (UK), Richard Hobbs
(UK), John Kjekshus (Norway), Pasquale Perrone Filardi (Italy), Gabriele Riccardi
(Italy), Robert F. Storey (UK), David Wood (UK).
European Heart Journal 2011;32 (14):1769–1818
Atherosclerosis 2011 Jul;217(1):3-46

6. www.escardio.org/guidelines
SCORE charts with HDL-C
for use in high risk regions: HDL-C= 1.4 mmol/L (56
mg/dL)
4
6
9
12
5
7
10
14
6
8
11
15
7
9
13
18
8
11
15
20
3
4
6
8
3
5
7
9
4
6
8
11
5
6
9
13
6
8
11
15
2
3
4
5
2
3
4
6
3
4
5
7
3
4
6
8
4
5
7
10
0
0
1
1
0
1
1
1
0
1
1
1
1
1
1
2
1
1
1
2
1
2
2
3
1
2
3
4
2
2
3
5
2
3
4
5
2
3
5
6
4 5 6 7 8
Smokers
6
8
10
13
6
8
11
14
7
9
12
15
8
10
13
17
9
11
14
18
3
4
5
6
3
4
5
7
3
4
6
7
4
5
6
8
4
5
7
9
2
2
3
4
2
2
3
4
2
2
3
4
2
3
4
5
2
3
4
5
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
0
1
1
1
1
1
1
1
1
1
2
1
1
1
2
1
1
2
2
1
1
2
2
4 5 6 7 8
Women
Total Cholesterol (mmol/L)
Age
65
60
55
50
40
Men
Non-smokers Smokers
7
11
15
21
9
12
17
23
10
14
19
26
11
16
22
29
13
18
25
34
5
7
10
14
6
8
12
16
7
10
14
19
8
11
16
22
10
13
18
25
3
5
6
9
4
5
8
11
5
6
9
12
6
8
11
15
7
9
13
17
1
1
1
2
1
1
1
2
1
1
2
2
1
1
2
3
1
2
2
3
2
3
4
6
2
3
5
7
3
4
6
8
4
5
7
10
4
6
8
11
4 5 6 7 8
Non-smokers
180
160
140
120
180
160
140
120
180
160
140
120
180
160
140
120
180
160
140
120
3
4
5
7
3
4
5
7
3
4
6
8
4
5
6
8
4
6
7
9
1
2
2
3
1
2
2
3
2
2
3
4
2
2
3
4
2
3
3
4
1
1
1
2
1
1
1
2
1
1
2
2
1
1
2
2
1
1
2
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
1
1
0
1
1
1
0
1
1
1
1
1
1
1
4 5 6 7 8
Systolicbloodpressure(mmHg)
European Heart Journal 2011;32 (14):1769–1818
Atherosclerosis 2011 Jul;217(1):3-46

7. www.escardio.org/guidelines
SCORE charts with HDL-C
for use in high risk regions: HDL-C= 0.8 mmol/L (32
mg/dL)
6
8
11
16
7
9
13
18
8
11
15
21
9
13
18
24
11
15
21
28
4
6
8
11
5
7
9
13
6
8
11
15
7
9
13
18
8
11
15
21
3
4
5
7
3
4
6
9
4
5
7
10
5
6
9
12
6
8
11
15
0
1
1
1
1
1
1
2
1
1
1
2
1
1
2
2
1
1
2
3
2
2
3
5
2
3
4
5
2
3
5
7
3
4
6
8
4
5
7
9
4 5 6 7 8
Smokers
10
13
17
22
11
14
19
24
12
16
20
26
14
18
22
28
15
19
25
31
5
6
8
11
5
7
9
12
6
8
10
13
7
9
11
14
7
10
12
16
3
4
5
6
3
4
5
7
3
4
6
8
4
5
6
8
4
6
7
9
0
0
1
1
0
1
1
1
0
1
1
1
1
1
1
1
1
1
1
1
1
2
2
3
1
2
2
3
2
2
3
3
2
2
3
4
2
3
3
4
4 5 6 7 8
Women
Total Cholesterol (mmol/L)
Age
65
60
55
50
40
Men
Non-smokers Smokers
10
14
19
26
12
16
22
30
14
19
25
34
16
22
29
39
19
26
34
45
7
10
14
19
8
12
16
22
10
14
19
25
12
16
22
30
14
19
26
35
5
7
9
13
6
8
11
15
7
9
13
18
8
11
15
21
10
14
19
25
1
1
2
2
1
1
2
3
1
2
2
3
1
2
3
3
2
2
3
5
3
4
6
8
4
5
7
10
4
6
8
12
5
7
10
14
6
9
12
17
4 5 6 7 8
Non-smokers
180
160
140
120
180
160
140
120
180
160
140
120
180
160
140
120
180
160
140
120
5
7
9
11
6
7
9
12
6
8
10
13
7
9
12
15
8
10
13
16
2
3
4
5
3
3
4
6
3
4
5
6
3
4
6
7
4
5
6
8
1
2
2
3
2
2
3
3
2
2
3
4
2
2
3
4
2
3
4
5
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
0
1
1
1
1
1
1
1
1
1
2
1
1
1
2
1
1
2
2
1
1
2
2
4 5 6 7 8
Systolicbloodpressure(mmHg)
European Heart Journal 2011;32 (14):1769–1818
Atherosclerosis 2011 Jul;217(1):3-46

8. What is HDL-C ?

9. NY-160626.038/020131YlsjoLS1
HDLHDL2a2aHDLHDL2b2b HDLHDL3c3cHDLHDL3b3bHDLHDL3a3a
PARTICLE SIZEPARTICLE SIZE
APOLIPOPROTEIN COMPOSITIONAPOLIPOPROTEIN COMPOSITION
DiscoidalDiscoidal
apoA-I HDLapoA-I HDL apoA-I/A-II HDLapoA-I/A-II HDL
Lipid-poor apoA-ILipid-poor apoA-I
HDL-C
= Sum of cholesterol content in all plasma
HDL particle subpopulations

10. What are the building blocks
of HDL particle structure ?

11. Lipid-free
apoAI
The
HDL
Building
Block

12. Plasma HDL subpopulations :
symmetrical cage-like structure with 4 apoAI copies per
particle
Huang et al, Nature Struct Mol Biol, 2011

13. Correlational network of proteins in HDL subfractions
Davidson et al, ATVB 2009

14. Kumpula et al. (2008) Chem Phys Lipids 155: 57-62
Molecular models of plasma HDL
% Chemical
Composition
HDL2 HDL3
PL 30 24
FC 3 1
CE 27 23
TG 4 2
PRN 34 51
6 nm
ApoAI

15. HDL Lipids = HDL Lipidome
Ceramides
Sphingolipids
Glycosphingolipids
Phospholipids
Di- and Triacylglycerols
Cholesteryl esters
Modified lipids (oxidized, glycated)
Lysolipids
Free fatty acids

16. Lipidomics technology
Analytical platform = Liquid chromatography, electrospray
ionisation triple quadrapole mass spectrometer
(LC ESI-MS/MS)
Lipid extraction
• 10µL plasma
• Single phase CHCl3/MeOH
Lipid Quantification
• Stable isotope dilution
• Multiple reaction monitoring

17. Camont et al, ATVB 2013

18. HDL in 2014
Lipidome
CVD
protection
HDL
Functionality
Proteome

19. What is the origin of
HDL-C ?

20. Courtesy of
Dr H.B. Brewer

21. Kontush A, Chapman MJ, Nature CPCM 2008
Lipids
60%
Protein40%
Protein
45%
Lipids
55%
Lipids
35%
HDL3a
Heterogeneity and Intravascular Metabolism of HDL particles
HDL2b
HDL3c
HDL3b
HDL2a
Pre-β-HDL
FC, PL
ABCA1
HDL3
Lipid-free A-I
HDL2
FC, CE
PLTP
HL
EL
Hepatocyte
A-I
LCAT
LCAT
Peripheral
cell
SR-BI
CE
FC
FC
CE
Intestine
ABCG1
FC, PL
HDL-R LDL-R
VLDL
IDL
LDL
CETP
CE
CE
FC, CE
TG
TG

22. What are the major
physiological, clinically-
relevant functions of HDL ?

23. 23
23
Cholesterol efflux from cells to HDL particles
Extracellular space Cell membrane
FC
FC
FC
FC
ABCA1
Diffusion
SR-B1
Diffusion
SR-B1
ABCG1
Diffusion
SR-B1
ABCG1
Lipid-poor ApoA-I
Discoidal HDL
Small spherical HDL
Large spherical HDL
LCAT
LCAT

24. HDL
apoAI
VLDL/LDL
CECE
Liver
Bile
CECE
CETP
SR-B1SR-B1
LDL-RLDL-R
CECE
FCFC
FCFC
(1)
(2)
(3)
(3)
SR-B1SR-B1
LCAT
Extrahepatic tissuesExtrahepatic tissues
Arterial wallArterial wall
FCFC
ABCA1, ABCG1,ABCA1, ABCG1,
SR-B1SR-B1
Reverse cholesterol transport

25. Homozygous
Proband
LAD
Mixed Plaque
Homozygous Familial ApoA-I Deficiency

26. Homozygous Familial ApoA-I
Deficiency
Santos RD et al, J Lipid Res
2008;49:349-357.

27. Is HDL-C an informative biomarker
of HDL function ?

28. Cholesterol efflux capacity, HDL-C
and Atherosclerosis
• « Cholesterol efflux capacity from
macrophages has a strong inverse
association with both carotid IMT and the
likelihood of angiographic CAD,
independently of HDL-cholesterol »
•

29. Relationship between genetic variants of
HDL and CV risk
Meta-analysis : genetic variations in genes that raise the
concentration of HDL-C are not associated with a decrease in
CV risk.
Genes which increase HDL-C concentration may not increase
HDL function….
Voight et al; Lancet 2012
It is essential that we stop regarding HDL-C as
protective and focus more on the protective functions
of HDL

30. • Is HDL particle function conserved in
metabolic syndrome (prediabetes)
and type 2 diabetes ?

31. NY-160626.038/020131YlsjoLS1
Abnormal Metabolism and Defective Function
of HDL in Diabetic Dyslipidemia
CE
Kontush A, Chapman MJ. Pharmacol Rev 2006; Curr. Diabetes Rep. 2008;8:51-59.
CE
VLDL
TG
Chronic
inflammation
Oxidative
stress
Hyperglycemia
IL-6; TNFα
HL
A-I
A-I
TG
SAA
A-I
Functionally
deficient HDL
↓ Cholesterol efflux capacity
↓ Antioxidative activity
↓ Anti-inflammatory activity
↓ Antiapoptotic activity
↓ Vasodilatory activity
Normal
functional
HDL
A-I
PON1
SAA + altered expression of HDL proteins
(CRP)
CE
CETP
TG
PON1
Liver
Altered
proteome +
lipidome

32. Do elevated levels of
HDL-C reduce CV
risk ?

33. - Epidemiological data
- Experimental animal studies
- Genetic CETP deficiency

34. Low HDL-C Levels Are Associated With High CHD Risk
BUT:
Elevated HDL-C Levels Are Cardioprotective
HDL-CHDL-C
RelativeriskforincidentCHDRelativeriskforincidentCHD
mmol/Lmmol/L
mg/dLmg/dL
Adjusted for age and race, 10-year follow-up; N=12,339.Adjusted for age and race, 10-year follow-up; N=12,339.
Sharrett AR et al.Sharrett AR et al. CirculationCirculation. 2001.. 2001.
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1 2 3 4 5
WomenWomen
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1 2 3 4 5
MenMen
1.01.0
3939
1.21.2
4848
1.41.4
5656
1.71.7
6565
2.12.1
8181
0.80.8
3131
0.90.9
3838
1.11.1
4343
1.21.2
4949
1.61.6
6262
ARIC

35. • Raise HDL-C !

36. The Failures : Niacin
AIM-HIGH
•ER-Niacin vs Placebo ( +niacin)
•CVD patients
•High TG / low HDL-C
•LDL-C at entry : 40-80 mg/dl
•Stopped at 3 years :futility
HPS2 – THRIVE
•n = 25,673 : High CV risk
•ER Niacin + LRPT vs Placebo
•Stopped at 3.9 years (median)
•XS myopathy (Chinese
subjects)
•No reduction in MACE

37. The Failures: CETP inhibitors
ILLUMINATE
•Torcetrapib + Atorvastatin vs
Atorvastatin
•HDL-C +72% ; LDL-C -25%
•Increase in CVD events ( +25% ) in
active arm
•Off-target toxicity
•Increase in BP (5mmHg)
Dal – OUTCOMES
•Dalcetrapib + statin vs Statin
•ACS patients
•HDL-C +30%
•No effect on LDL-C
•Stopped for futility

38. The Successes : rHDL infusion
• rHDL / apoAI Milano
infusion
• IVUS
• Coronary plaque
regression
• JAMA 2003
• Symptomatic PAD
• rHDL / CSL 111
• Atherectomy
• Lipid / macrophage
plaque content
• Circ Res 2008

39. Kingwell and Chapman, Circulation 2013
Plaque cholesterol efflux : rHDL

40. Potential mechanisms of rHDL action
Kingwell and Chapman, Circulation 2013

41. Kingwell and Chapman, Circulation 2013
Ongoing HDL Infusion Trials

42. Oral DESIGN N Primary endpoint Expected
RVX-208 2b Placebo vs RVX-208 Coronary artery
disease
324 % change in coronary
atheroma volume
(IVUS)
2013
Evacetrapib
ACCELERATE
3 Placebo vs
evacetrapib
Cardiovascular
diseases
11,000 Time to first
occurrence of
composite CV
endpoint (Death, MI,
stroke, coronary
Revascularization, or
Hospitalization for UA)
2015
Anacetrapib
REVEAL
3 Placebo vs
anacetrapib
Atherosclerotic
cardiovascular
disease
30,000 Major coronary events
(Coronary death, MI or
coronary
revascularization
procedure)
2017
Ongoing clinical trials involving oral HDL- raising agents

43. apoB
Macrophage
VLDL
SR-BI
Liver
CE,FC
ABCA1
A-I
PL FC
LDLLCAT
CE
apoB
Peripheral
tissues
Bile acids
Cholesterol
CETP
HDL metabolism: Impact of potent CETP inhibition
CE
LDL-R
FC
FC
CE
HDL3 TG
CE CECE
E
E
E
HDL
HDL2
AI
AI
Preß-
HDL
apoE-HDL

44. ABCA-1 SR-B1 ABCG-1
Decreased apoA-I/HDL catabolism
Atherogenic lipoproteins
(VLDL, IDL, LDL)
Liver
CETP
inhibitors
SR-B1Bile
HDL2
HDL3Preβ-HDL
Macrophage within Atherosclerotic Plaque
ApoA-I synthesis
HDL infusion
Lipid-free
apoA-I
LCAT
LCAT
CETP
miR-33
ASOs:
-CETP
-apoCIII
miR-33
ASOs:
-CETP
-apoCIII

45. HDL
isolation
Eder & coll.
1951
LCAT
reaction
Glomset
1962
HDL
apolipoprotein
families
Alaupovic
1971
HDL
and RCT
Miller &
Miller
1975
HDL-C
& CV risk
Gordon
& coll.
1977
HDL-C
assay
Albers & coll.
1982
ABCA1
& low HDL-C
Assmann
Genest
Hayden
Schmitz
1999
HDL
dysfunction
Fogelman
& coll.
1995
SR-BI
receptor
Krieger
& coll.
1996
Double
belt
model
Segrest
& coll.
1999
Atherosclerosis
regression
by rHDL
in man
Nissen
& coll.
2003
Trefoil
model
Davidson
& coll.
2008
Clinical
trials
of HDL-
raising
therapies
HDL
heterogeneity
Chapman & coll.
Nichols & coll.
1981
CETP
Zilversmit
& coll.
Barter
& coll.
1977-82
ApoA-I
sequence
Jackson & coll.
Brewer & coll.
1975-78
ABCG1
& HDL
Tall & coll.
2004
CETP
deficiency
Mabuchi
& coll.
1985
ApoA-I
Milano
Sirtori
& coll.
1980
Familial
HDL
deficiency
Schaefer
& coll.
1977-78
Macrophage
RCT
Rader
& coll.
2003
Cholesterol
efflux to HDL
Oram
Phillips
Rothblat
1981-82
Pre-beta
HDLs
Fielding & coll.
Asztalos & coll.
1987-93
Kontush A, Chapman MJ, High-Density Lipoproteins: Structure, Metabolism, Function and Therapeutics.
Wiley & Sons, NY, 2012.
HDL :
TIMELINES