Lipoprotein (a) and plasminogen are immunochemically related

Lipoprotein (a): a historical appraisal

Initially, lipoprotein (a) [Lp(a)] was believed to be a genetic variant of lipoprotein (Lp)-B. Because its lipid moiety is almost identical to LDL, Lp(a) has been deliberately considered to be highly atherogenic. Lp(a) was detected in 1963 by Kare Berg, and individuals who were positive for this factor were called Lpa⁺ Lpa⁺ individuals were found more frequently in patients with coronary heart disease than in controls. After the introduction of quantitative methods for monitoring of Lp(a), it became apparent that Lp(a), in fact, is present in all individuals, yet to a greatly variable extent. The genetics of Lp(a) had been a mystery for a long time until Gerd Utermann discovered that apo(a) is expressed by a variety of alleles, giving rise to a unique size heterogeneity. This size heterogeneity, as well as countless mutations, is responsible for the great variability in plasma Lp(a) concentrations. Initially, we proposed to evaluate the risk of myocardial infarction at a cut-off for Lp(a) of 30-50 mg/dl, a value that still is adopted in numerous epidemiological studies. Due to new therapies that lower Lp(a) levels, there is renewed interest and still rising research activity in Lp(a). Despite all these activities, numerous gaps exist in our knowledge, especially as far as the function and metabolism of this fascinating Lp are concerned.

Apolipoproteins: metabolic role and clinical biochemistry applications

Lipoprotein metabolism is dependent on apolipoproteins, multifunctional proteins that serve as templates for the assembly of lipoprotein particles, maintain their structure and direct their metabolism through binding to membrane receptors and regulation of enzyme activity. The three principal functions of lipoproteins are contribution to interorgan fuel (triglyceride) distribution (by means of the fuel transport pathway), to the maintenance of the extracellular cholesterol pool (by means of the overflow pathway) and reverse cholesterol transport. The most important clinical application of apolipoprotein measurements in the plasma is in the assessment of cardiovascular risk. Concentrations of apolipoprotein B and apolipoprotein AI (and their ratio) seem to be better markers of cardiovascular risk than conventional markers such as total cholesterol and LDL-cholesterol. Apolipoprotein measurements are also better standardized than the conventional tests. We suggest that measurements of apolipoprotein AI and apolipoprotein B are included as a part of the specialist lipid profile. We also suggest that lipoprotein (a) should be measured as part of the initial assessment of dyslipidaemias because of its consistent association with cardiovascular risk. Genotyping of apolipoprotein E isoforms remains useful in the investigation of mixed dyslipidaemias. Lastly, the role of postprandial metabolism is increasingly recognized in the context of atherogenesis, obesity and diabetes. This requires better markers of chylomicrons, very-low-density lipoproteins and remnant particles. Measurements of apolipoprotein B48 and remnant lipoprotein cholesterol are currently the key tests in this emerging field.

Lipoprotein (a) in type 2 diabetes mellitus: Relation to LDL:HDL ratio and glycemic control

BACKGROUND

Increased lipoprotein (a) [Lp (a)] concentrations are predictive of coronary artery disease (CAD). Type 2 diabetes mellitus also leads to dyslipidemia, like elevated triglyceride levels and low HDL levels, which are known risk factors for CAD. This study was designed to investigate the levels of Lp (a) in type 2 diabetic patients and their association with LDL: HDL ratio and glycemic control.

MATERIALS AND METHODS

The study included 60 patients of type 2 diabetes and 50 age and sex matched controls. The Lp(a) levels in the diabetic group were compared with the control group and the relationship between the Lp(a) levels and LDL: HDL ratio was evaluated. Diabetic group was further divided into three subgroups according to levels of glycated hemoglobin. Lp(a) levels and glycated hemoglobin in controlled and uncontrolled diabetes mellitus were also compared to find out any correlation between them. Statistical analysis was done using the students 't' test and Chi square test.

RESULTS

Lp(a) levels were found to be significantly increased in the diabetic group as compared to the control group (P< 0.001). LDL: HDL ratio was also increased in the diabetic group as compared to the control group. Lp(a) levels showed no association with LDL: HDL ratio and degree of glycemic control in these patients.

CONCLUSIONS

The results of the present study suggest that Lp(a) levels are increased in type 2 diabetic patients. The elevated Lp(a) levels do not reflect the glycemic status and are also independent of increase in LDL:HDL ratio suggesting different metabolic pathways and the genetic connection for LDL and Lp(a).

Lipoprotein(a): new insights into mechanisms of atherogenesis and thrombosis

Lipoprotein(a) (Lp[a]) continues to be a controversial molecule regarding its role in human vascular disease. Although the physiologic role of this molecule is still unclear, novel discoveries within the last few years have suggested numerous mechanisms whereby Lp(a) may contribute to atherosclerosis and its complications in human subjects. These effects may differentially occur in vascular tissue and circulating blood compartments. A complex interplay between tissue-specific effects is probably more relevant to the pathogenicity of this molecule than one single effect alone. This review briefly describes the structure of Lp(a) in relation to its biochemical function, summarizing the current literature on various pathophysiologic mechanisms of Lp(a)-induced vascular disease and the role of cell and tissue-specific effects in promoting atherogenesis and thrombosis.

Production and characterization of monoclonal antibodies directed to the kringle V and protease domains of human apolipoprotein(a)

Production and use of anti-apolipoprotein(a) monoclonal antibodies (MAbs) specific to single copy regions in the polymorphic lipoprotein(a) (Lp(a)) has been emphasized to be important for the standardization of measurements of the coronary heart disease risk factor, Lp(a). Here, mouse MAbs were prepared against the kringle V (V) and protease (P) domains of human apolipoprotein(a) (apo(a)), which domains are present in single copy in the apo(a) molecule. The cDNA for apo(a)VP was cloned from human liver cDNA library, and the V-P recombinant protein overexpressed in Escherichia coli was used as an antigen for the antibody production. Two antibodies named as MAb(a)20 and MAb(a)23 were finally produced, and they were characterized for their binding specificity and epitopes. The specificity of the antibodies was confirmed by an immunoblotting procedure and an enzyme-linked immunoassay (ELISA). It was shown that the antibodies had little, if any, cross-reactivity with human plasminogen, which is relatively abundant in human serum and is highly homologous (85%) with apo(a) in amino acid (aa) sequence. For epitope analysis, 3'-deletional series of apo(a)VP cDNA were constructed, and expression products of them were analyzed for the binding MAb(a)20 and MAb(a)23 do. It has been revealed that distinct epitopes were recognized by the two MAbs: MAb(a)23 (gamma2b, kappa) bound to the V region about 60 aa downstream from the N-terminal, and MAb(a)20 (gamma1, kappa) bound to the P region close to the C-terminal. A one step-sandwich ELISA system for Lp(a) was developed using MAb(a)20 as a capturing antibody and horseradish peroxidase (HRP)-coupled MAb(a)23 as a detecting antibody. The assay was found to be sensitive and useful for detecting Lp(a) in the range of 4-150 microg/dL (80 pM-3 nM).

Plasma lipoprotein(a) is not a predictor for restenosis after elective high-pressure coronary stenting

BACKGROUND

Lipoprotein(a) is a risk factor for coronary artery disease. Although it has been implicated in restenosis after balloon angioplasty, its role in restenosis within coronary stents is unknown. The aim of the study was to assess the role of plasma lipoprotein(a) as a predictor for restenosis after elective coronary stenting.

METHODS AND RESULTS

Elective, high-pressure stenting of de novo lesions in native coronary arteries with Palmaz-Schatz stents was performed in 325 consecutive patients. Clinical, angiographic, and biochemical data were analyzed prospectively. Angiographic follow-up was performed at 6 months. Lipoprotein(a) levels were compared in patients with and without restenosis. Angiographic follow-up was obtained in 312 patients (96%); recurrence was observed in 67 patients (21.5%). No clinical or biochemical variable was associated with restenosis. Lipoprotein(a) level was 37.81+/-49. 01 mg/dL (median, 22 mg/dL; range, 3 to 262 mg/dL) in restenotic patients and 36.95+/-40.65 mg/dL (median, 22 mg/dL; range, 0 to 244 mg/dL) in nonrestenotic patients (P=NS). The correlations between percent diameter stenosis, minimum luminal diameter, and late loss at follow-up angiography and basal lipoprotein(a) plasma level after logarithmic transformation were 0.006, 0.002, and 0.0017, respectively. Multiple stents were associated with a higher incidence of restenosis (P=0.006), but biochemical data in these patients were similar to those treated with single stents.

CONCLUSIONS

The basal plasma level of lipoprotein(a) measured before the procedure is not a predictor for restenosis after elective high-pressure coronary stenting.

Regulation of endothelin release from human brain microvessel endothelial cells

After approval by the Local Ethical Committee, brain microvessel endothelial cells from human cadavers were isolated by enzymatic digestion and gradient centrifugation. Basal levels of endothelin-1 (ET) in the supernatant increased over time (3 h, 18.3 +/- 4.3 pg/ml; 6 h, 31.3 +/- 1.1 pg/ml; 24 h, 88.0 +/- 5.7 pg/ml; 48 h, 86.3 +/- 11.2 pg/ml, mean +/- SD). Tumor necrosis factor-alpha (TNF-alpha) (270 U/ml) increased ET concentration dose-dependently: 3 h, 190 +/- 70%; 24 h, 217 +/- 39%; 48 h, 207 +/- 5%; TNF-alpha at 210 U/ml: 3 h, 137%; 24 h, 170%; 48 h, 212% (values are relative changes from control, run in parallel to the stimulated wells). Interleukin-1 alpha (IL-1 alpha) (38.8 U/ml) also increased ET dose-dependently: (3 h, 129%; 24 h, 161%; 48 h, 212%; IL-1 alpha 1.4 U/ml: 3 h, 116%; 24 h, 122%; 48 h, 180%). Lipoprotein (a) (Lp(a)) had a dual effect on ET, increasing ET in the first 3 h but reducing it by the end of the 48-h observation period. This effect was not dose-dependent in the concentration range tested: Lp(a) 450 micrograms/ml; 3 h, 188%; 24 h, 91%; 48 h, 85%; Lp(a) 360 micrograms/ml: 3 h, 180%; 24 h, 94%; 48 h, 52%). Lp(a) reduced the stimulatory effect of cytokines on ET release. Maximal values at 48 h were TNF-alpha 207%, TNF-alpha + Lp(a) 91%, IL-1 alpha 212%, IL-1 alpha + Lp(a) 64%. In HPLC analysis, the total ET-like immunoreactivity co-eluted with the synthetic human ET standard. A cell culture of human brain microvessel endothelial cells was established. TNF-alpha and IL-1 alpha increased ET secretion, whereas Lp(a) had a dual effect. When given together, Lp(a) reduced the effect of cytokines on ETs.

Transgenic mice expressing human ApoB95 and ApoB97. Evidence that sequences within the carboxyl-terminal portion of human apoB100 are important for the assembly of lipoprotein

The structural features of apolipoprotein (apo) B that are important for its covalent linkage to apo(a) to form lipoprotein(a) (Lp(a)) are incompletely understood. Although apoB100 cysteine 4326 is required for the disulfide linkage with apo(a), other structural features, aside from a single free cysteine residue, must be important for apoB's initial interaction with apo(a) and for facilitating the formation of the disulfide bond. To determine if sequences carboxyl-terminal to cysteine 4326 affect the efficiency of Lp(a) formation, we used "pop-in, pop-out" gene targeting in a human apoB yeast artificial chromosome to introduce nonsense mutations into exon 29 of the apoB gene. The mutant yeast artificial chromosomes, which coded for the truncated versions of human apoB, apoB95, and apoB97, were then used to express these mutant forms of apoB in transgenic mice. As judged by in vitro assays of Lp(a) formation, apoB95 (4330 amino acids) formed a small amount of Lp(a) but did so slowly. In contrast, apoB97 (4397 amino acids) formed Lp(a) rapidly, although not quite as rapidly as the full-length apoB100 (4536 amino acids). These results were supported by an analysis of double-transgenic mice expressing both human apo(a) and either apoB95 or apoB97. In mice expressing both apoB95 and apo(a), there was only a trace amount of Lp(a) in the plasma, and most of the apo(a) was free, whereas in mice expressing both apoB97 and apo(a), virtually all of the apo(a) was bound to apoB97 in the form of Lp(a). These results show that sequences carboxyl-terminal to apoB95 (amino acids 4331-4536) are not absolutely required for Lp(a) formation, but this segment of the apoB molecule, particularly residues 4331-4397, is necessary for the efficient assembly of Lp(a).

Lipoprotein(a) as a determinant of coronary heart disease in young women

BACKGROUND

Lipoprotein(a) [Lp(a)] appears to be a risk factor for coronary heart disease (CHD) in men. The role of Lp(a) in women, however, is less clear.

METHODS AND RESULTS

We examined the ability of Lp(a) to predict CHD in a population-based case-control study of women 65 years of age or younger who lived in the greater Stockholm area. Subjects were all patients hospitalized for an acute CHD event between February 1991 and February 1994. Control subjects were randomly selected from the city census and were matched to patients by age and catchment area. Lp(a) was measured 3 months after hospitalization by use of an immunoturbidometric method (Incstar) calibrated to the Northwest Lipid Research Laboratories (coefficient of variation was < 9%). Of the 292 consecutive patients, 110 (37%) were hospitalized for an acute myocardial infarction, and 182 were hospitalized (63%) for angina pectoris. The mean age for both patients and control subjects was 56 +/- 7 years. Of participants, 74 patients (25%) and 84 control subjects (29%) were premenopausal. The distributions of Lp(a) were highly skewed in both patients and control subjects, with a range from 0.001 to 1.14 g/L. Age-adjusted odds ratio for CHD in the highest versus the lowest quartile of Lp(a) was 2.3 (95% confidence interval [CI], 1.4 to 3.7). After adjustment for age, smoking, education, body mass index, systolic blood pressure, total cholesterol, triglycerides, and HDL, the odds ratio was 2.9 (95% CI, 1.6 to 5.0). The odds ratios were similar when myocardial infarction and angina patients were compared with their respective control subjects. The odds ratios were 5.1 (95% CI, 1.4 to 18.4) and 2.4 (95% CI, 1.3 to 4.5) in premenopausal and postmenopausal women, respectively.

CONCLUSIONS

These results suggest that Lp(a) is a determinant of CHD in both premenopausal and postmenopausal women.

Lipoprotein(a) concentration and phenotypes in primary biliary cirrhosis

We studied a selected group of 39 female patients suffering from primary biliary cirrhosis (PBC). This disease is characterized by typical lipoprotein alterations and elevated concentrations of serum cholesterol. Despite the increased concentration of atherogenic lipoproteins, enhanced atherogenesis is not characteristic of PBC. Serum total cholesterol, triglycerides, HDL2 and HDL3-cholesterol concentrations were measured by enzymatic methods or in combination with precipitation procedures. Apolipoproteins were determined by using immunonephelometric methods. ELISA sandwich method was used for lipoprotein(a) determinations. Apoprotein(a) phenotyping (isoforms) was performed by Western blotting with specific antibodies. The concentrations of serum lipids, lipoproteins and apoproteins (AI, AII and B) were found in the range of earlier investigations. The serum lipoprotein(a) concentration did not differ between the PBC patients and control subjects (10.0/0.1-54/, median 2.55 vs. 11.5/0-75/, median 5.2 mg/dl). In the advanced stages of PBC we found a higher number of patients with low lipoprotein concentration (lower than 1 mg/dl). In patients with shorter durations and milder histological alterations high HDL2 cholesterol subfractions has been detected (stage I = 0.42 +/- 0.18, stage II = 0.53 +/- 0.29 and stage III = 0.62 +/- 0.41 vs. stage IV = 0.26 +/- 0.15 mmol/l, P < 0.05). Despite the elevation of atherogenic lipoproteins, high HDL2-cholesterol and normal lipoprotein(a) concentrations may be one of the reasons why patients with advanced PBC are not placed at increased risk for atherosclerosis.

Identification of cryptic peanut agglutinin-reactive sites in human lipoprotein(a)

After treatment of human lipoprotein(a) (Lp(a)) with neuraminidase, formerly cryptic sites became available for binding to peanut agglutinin (PNA) lectin and a Thomsen-Friedenreich antigen (T-antigen)-specific monoclonal antibody. The PNA-reactive sites were localized to the apo(a) moiety of Lp(a) and O-specific carbohydrate side chains. Lp(a) with larger isoforms of apo(a) contained more potential PNA reactivity per molecule of Lp(a) apoB than did smaller isoforms. Very low density lipoproteins (VLDL), low density lipoproteins (LDL), and high density lipoproteins (HDL) did not contain comparable amounts of the cryptic PNA-reactive sites.

Plasma Lp(a) and t-PA-PAI-1 complex levels in coronary heart disease

In this study we investigated serum Lp(a) and plasma t-PA-PAI-1 complex levels in patients with coronary heart disease (CHD). Serum total cholesterol, triglyceride, LDL and VDL cholesterol levels (p < 0.001) and HDL cholesterol levels (p < 0.01) in patients group were found to be significantly different from those in control group. The mean Lp(a) and t-PA-PAI-1 complex levels in patients with coronary heart disease were significantly higher as compared to control group (p < 0.001). This data indicate that the elevated levels of serum Lp(a) and plasma t-PA-PAI-1 complex may play an important role in the pathogenesis of coronary atherosclerosis.

Lipoprotein(a) in patients with acute cerebral ischemia

BACKGROUND AND PURPOSE

In several cross-sectional studies, a high serum lipoprotein(a) [Lp(a)] level was found to be an independent risk factor for cerebral infarction. In a recent prospective study, however, no association was found between Lp(a) levels at baseline and future risk of stroke. Whether Lp(a) is a prognostic factor in a high-risk population of patients with acute ischemic stroke remains unclear.

METHODS

We assessed Lp(a) level on admission to study its relationship with cardiovascular risk profile, stroke severity, and prognosis in 151 consecutive patients with acute cerebral ischemia. The mean follow-up period was 2.5 +/- 1.2 years. Lp(a) was measured by means of a solid-phase two-site immunoradiometric assay.

RESULTS

Increased Lp(a) levels were found in 53 (35%) of the patients with cerebral ischemia. Median (5th and 95th percentile) values of Lp(a) were 191 (12 and 1539) mg/L and 197 (10 and 1255) mg/L for patients with transient ischemic attack and patients with ischemic stroke, respectively. No relationship was found between Lp(a) levels and stroke severity (P=.68) or the occurrence of vascular events during follow-up (P log rank=0.81).

CONCLUSIONS

We conclude that Lp(a) is increased in about one third of patients with acute cerebral ischemia, but it does not appear to be associated with the cardiovascular risk profile, stroke characteristics, or the prognosis of such patients.

Oxidized lipoprotein (a) induces cell adhesion molecule Mac-1 (CD 11b) and enhances adhesion of the monocytic cell line U937 to cultured endothelial cells

Because of structural similarities between low density lipoproteins (LDL) and lipoprotein (a) (Lp(a)), we have investigated the properties and the functional activities of oxidized Lp(a) and focused on whether oxidized Lp(a), like oxidized LDL, can induce monocyte differentiation and adhesion of monocytic cells to endothelial cells grown in culture. Oxidized Lp(a), prepared in vitro by cupric ion oxidation, gave absorption curves of conjugated dienes with a lag-phase of 61.7 +/- 6.6 min (mean +/- S.D.) as compared to 85.2 +/- 7.2 min (n = 6, P < 0.01) for oxidized LDL from the same donors and at equimolar concentrations. Degradation of oxidized 125I Lp(a) by the monocytic cell line U937 at 37 degrees C was 1.6 +/- 0.3 nmol/g of cell protein, significantly (P < 0.01) greater than the degradation of oxidized 125I-LDL, which was 1.15 +/- 0.2 nmol/g of cell protein. Equimolar concentrations of oxidized Lp(a) and LDL inhibited the growth of U937 by 82 +/- 8.2% and 64 +/- 7.1%, respectively, when compared with the effect (negligible) produced by native Lp(a) and LDL. In addition, equimolar concentrations of oxidized Lp(a) and LDL induced adhesion molecule, Mac-1 (CD 11b), expression in U937 by 64 +/- 7.1% and 58 +/- 6.1% (P > 0.05), respectively, of the effect produced by phorbol esters (PMA) (P < 0.01). U937 cells incubated with oxidized Lp(a) and LDL, showed an adherence to cultured endothelial cells at 42 +/- 5.2% and 34 +/- 4.8%, respectively (P < 0.05), of the adherence shown by the same cells activated by PMA (P < 0.01). Our results suggest that oxidized Lp(a) like oxidized LDL plays an important role in the development of atherogenesis by inducing adhesion of monocytes to the arterial intimal and by stimulating intimal monocytes to differentiate into macrophages.

Lipoprotein(a) inhibits collagen-induced aggregation of thrombocytes

Lipoprotein(a) [Lp(a)] is known to interact with human platelets in vitro. In the present study the effect of physiological concentrations of Lp(a) on platelet aggregation was studied. Freshly prepared gel-filtered platelets from healthy donors were incubated for 30 minutes at 37 degrees C with various concentrations of Lp(a); aggregation was triggered with ADP, thrombin, and collagen. Control incubations were performed with Tyrode's solution or LDL. Thrombin- and ADP-triggered aggregations were only slightly influenced by Lp(a), but aggregation of platelets stimulated with collagen (4 micrograms/mL) was markedly inhibited. Measurable effects occurred at low concentrations (0.05 mg/mL) of total Lp(a); at 0.5 mg/mL, maximum aggregation of platelets was inhibited by 54 +/- 20%, and the aggregation rate was attenuated by 47 +/- 19% compared with platelets incubated with Tyrode's solution. Preincubation of collagen (4 micrograms/mL) with Lp(a) yielded similar results. The effect of Lp(a) on platelet aggregation was accompanied by a significant reduction of serotonin release and TXA2 formation. Higher concentrations of collagen ( > or = 10 micrograms/ mL) caused the inhibitory effect on Lp(a) on collagen-induced aggregation to disappear. In contrast, incubation of platelets with 5 mg/mL LDL led to a significant increase of aggregation rate, maximum aggregation, serotonin release, and formation of TXA2 when aggregation was induced with 4 micrograms/mL collagen. In an adhesion assay using fresh whole blood, which mimics the in vitro situation of vessel injury. Lp(a) reduced platelet adhesion at shear rates of 300 and 1600/s by 22.6% and 11.6%, respectively. In addition, Lp(a) reduced the size of platelet aggregates significantly (up to 63%); this reduction was more distant at the higher shear rate. Unlike LDL, Lp(a) is not a proaggregatory lipoprotein; rather, collagen-triggered aggregation in vitro is attenuated by Lp(a).

The role of lipoprotein(a) in atherogenesis and thrombosis

Lipoprotein(a) [Lp(a)] represents an important independent risk factor for atherosclerotic cardiovascular disease. Lp(a) constitutes a class of low-density lipoprotein-like particles that are structurally heterogeneous due to variability within the distinguishing apoprotein, apolipoprotein(a) [Apo(a)]. Apo(a) bears a high degree of homology to the fibrinolytic zymogen, plasminogen, the parent molecule of the serine protease plasmin. Apo(a) contains a variable number of tandemly repeated triple-loop units called kringles, which appear to mediate Lp(a)'s interactions with fibrin and cell surface receptors. Although the mechanism of its atherogenicity is unknown, Lp(a) has been implicated in the delivery of cholesterol to the injured blood vessel, in blockade of plasmin generation on fibrin and cell surfaces, and as a stimulus for smooth muscle cell proliferation. In addition, new members of the plasminogen/Apo(a) gene family have been defined, creating a potential link between Lp(a) and the control of angiogenesis in both health and disease. Pharmacologic therapy of elevated Lp(a) levels has been only modestly successful; apheresis remains the most effective therapeutic modality.

Lipoprotein(a) in renal disease

Lipoprotein(a) [Lp(a)] is a genetically determined risk factor for atherosclerotic vascular disease. Several studies have described a correlation between high Lp(a) plasma levels and coronary heart disease, stroke, and peripheral atherosclerosis. In healthy individuals Lp(a) plasma concentrations are almost exclusively controlled by the apolipoprotein(a) [apo(a)] gene locus on chromosome 6q2.6-q2.7. More than 30 alleles at this highly polymorphic gene locus determine a size polymorphism of apo(a). There exists an inverse correlation between the size (molecular weight) of apo(a) isoforms and Lp(a) plasma concentrations. Average Lp(a) levels are high in individuals with low molecular weight isoforms and low in those with high molecular weight isoforms. Mean Lp(a) plasma levels are elevated over controls in patients with renal disease. Patients with nephrotic syndrome exhibit excessively high Lp(a) plasma concentrations, which can be reduced with antiproteinuric treatment. The mechanism underlying this elevation is unclear, but the general increase in protein synthesis caused by the liver due to high urinary protein loss is a likely explanation. Patients with end-stage renal disease (ESRD) also have elevated Lp(a) levels. These are even higher in patients treated by continuous ambulatory peritoneal dialysis than in those receiving hemodialysis. Lipoprotein(a) concentrations decrease to values observed in controls matched for apo(a) type following renal transplantation. This clearly demonstrates the nongenetic origin of Lp(a) elevation in ESRD. Both the increase in ESRD and the decrease following renal transplantation are apo(a) phenotype dependent. Only patients with high molecular weight phenotypes show the described changes in Lp(a) levels. In patients with low molecular weight types the Lp(a) concentrations remain unchanged during both phases of renal disease. As in the general population, Lp(a) is a risk factor for cardiovascular events in ESRD patients. In this patient group the apo(a) phenotype seems to be equally or better predictive of the degree of atherosclerosis than is Lp(a) concentration. Further prospective studies will be necessary to confirm these observations. Whether Lp(a) also plays a key role in the pathogenesis and progression of renal diseases needs further study. Controversial data on the role of the kidney in Lp(a) metabolism result from insufficient sample sizes of several studies. Due to the broad range and skewed distribution of Lp(a) plasma concentrations, large study groups must be investigated to obtain reliable results.

Microparticle-enhanced nephelometric immunoassay of human plasminogen

A microparticle-enhanced nephelometric immunoassay was developed for plasminogen quantitation in human plasma. It is based on the nephelometric measurement of the light scattered by microparticle clusters formed during a sandwich reaction between plasminogen, microparticle--anti-plasminogen conjugate, and the free antibodies of anti-plasminogen rabbit antiserum. This immunoassay was sensitive (detection limit in reaction mixture, 34 micrograms/L) and could be performed in 500-fold diluted human plasma, excluding any interference or sample pretreatment. It allowed the quantitation of plasminogen on a large range of concentrations (17-550 mg/L), with a security in antigen excess reaching 1,100 mg/L, with accuracy (linear recovery in dilution-overloading assay and correlation with conventional immunonephelometry), and precision (within- and between-run coefficients of variation lower than 8%). A normal reference range from 54 to 148 mg/L (mean +/- 2 SD) was calculated from plasminogen concentration in plasma from 130 adults. Easy to perform (no washing or phase separation) and rapid (two steps of 30 minutes then 1 hour of incubation at room temperature), this microparticle-enhanced nephelometric immunoassay could be an interesting alternative method for human plasminogen quantitation.

Lipoprotein(a) in health and disease

Lipoprotein(a) [Lp(a)] represents an LDL-like particle to which the Lp(a)-specific apolipoprotein(a) is linked via a disulfide bridge. It has gained considerable interest as a genetically determined risk factor for atherosclerotic vascular disease. Several studies have described a correlation between elevated Lp(a) plasma levels and coronary heart disease, stroke, and peripheral atherosclerosis. In healthy individuals, Lp(a) plasma concentrations are almost exclusively controlled by the apo(a) gene locus on chromosome 6q2.6-q2.7. More than 30 alleles at this highly polymorphic gene locus determine a size polymorphism of apo(a). There exists an inverse correlation between the size (molecular weight) of apo(a) isoforms and Lp(a) plasma concentrations. The standardization of Lp(a) quantification is still an unresolved task due to the large particle size of Lp(a), the presence of two different apoproteins [apoB and apo(a)], and the large size polymorphism of apo(a) and its homology with plasminogen. A working group sponsored by the IFCC is currently establishing a stable reference standard for Lp(a) as well as a reference method for quantitative analysis. Aside from genetic reasons, abnormal Lp(a) plasma concentrations are observed as secondary to various diseases. Lp(a) plasma levels are elevated over controls in patients with nephrotic syndrome and patients with end-stage renal disease. Following renal transplantation, Lp(a) concentrations decrease to values observed in controls matched for apo(a) type. Controversial data on Lp(a) in diabetes mellitus result mainly from insufficient sample sizes of numerous studies. Large studies and those including apo(a) phenotype analysis came to the conclusion that Lp(a) levels are not or only moderately elevated in insulin-dependent patients. In noninsulin-dependent diabetics, Lp(a) is not elevated. Conflicting data also exist from studies in patients with familial hypercholesterolemia. Several case-control studies reported elevated Lp(a) levels in those patients, suggesting a role of the LDL-receptor pathway for degradation of Lp(a). However, recent turnover studies rejected that concept. Moreover, family studies also revealed data arguing against an influence of the LDL receptor for Lp(a) concentrations. Several rare diseases or disorders, such as LCAT- and LPL-deficiency as well as liver diseases, are associated with low plasma levels or lack of Lp(a).

Lipoprotein (a)

Lipoprotein (a) is similar to low-density lipoprotein but is unique in having an additional apolipoprotein called apolipoprotein (a) (apo(a)) covalently linked to it. apo(a), which is a member of the plasminogen gene superfamily, has a protease domain which cannot be activated to cause fibrinolysis. Its sequence of kringles is much longer than that of plasminogen and there is remarkable genetic variation in its length. The consequent inherited differences in apo(a) molecular mass are largely responsible for the wide range of serum Lp(a) concentrations in different individuals with low levels predominating in Europid populations. Physiologically Lp(a) may participate in haemocoagulation or in wound-healing. Epidemiological evidence that it is a risk factor for atherosclerosis, particularly in populations with high serum LDL levels, has led to research to uncover its role in atherogenesis and thrombosis. Diseases such as renal disease, and probably atherogenesis and thrombosis. Diseases such as renal disease, and probably atherosclerosis itself, are associated with an increase in Lp(a) above its genetically determined level and it remains a subject of speculation as to whether such increases are as closely involved in atherothrombosis as are spontaneously high levels resulting from low-molecular-mass apo(a) variants.

Transfer of lipoprotein(a) and LDL into aortic intima in normal and in cholesterol-fed rabbits

To study the relative atherogenic potential of lipoprotein(a) [Lp(a)], the transfer of Lp(a) and LDL into the arterial wall was compared in normal rabbits, cholesterol-fed rabbits, and normal rabbits in which the plasma concentration of Lp(a) before injection of labeled lipoproteins was increased by an intravenous mass injection of 45 mg Lp(a). Aorta was removed either 60 minutes or 180 minutes after intravenous injection of a mixed preparation of human 125I-Lp(a) and 131I-LDL; intimal clearance was calculated as radioactivity in aortic intima/inner media divided by the average concentration of the appropriate radioactivity in plasma and by the length of the exposure time. The intimal clearance of labeled Lp(a) and LDL in the aortic arch after 60 minutes of exposure was 87 +/- 9 and 47 +/- 7 nL.cm-2.h-1 (n = 9) in normal rabbits and 82 +/- 14 and 62 +/- 10 nL.cm-2.h-1 (n = 10) in cholesterol-fed rabbits; after 180 minutes of exposure, the intimal clearance of labeled Lp(a) and LDL was 62 +/- 14 and 84 +/- 21 nL.cm-2.h-1 (n = 6) and 30 +/- 6 and 47 +/- 12 nL.cm-2.h-1 (n = 4) in cholesterol-fed and Lp(a)-injected rabbits, respectively. Linear regression analysis showed positive associations between intimal clearance of the two lipoproteins in all four groups of rabbits in the aortic arch, the thoracic aorta, and the abdominal aorta. Aortic immunoreactivity of human apolipoprotein(a) was detected in the intima in association with fatty streak lesions, predominantly within the cytoplasm of foam cells. These results suggest that Lp(a) is transferred into the aortic intima by a mechanism similar to that for LDL and that Lp(a) can be taken up by intimal foam cells; however, Lp(a) and LDL may be metabolized differently upon entrance into the arterial wall.

Does increased lipoprotein (a) impair the effectiveness of thrombolysis with streptokinase?

Although lipoprotein (a) [Lp(a)] has been shown to interfere with thrombolysis in vitro, its effects on thrombolytic therapy in patients with acute myocardial infarction (MI) are not clear. The authors evaluated 32 male patients ages thirty-five to seventy-five (mean fifty-two +/- ten) with the diagnosis of acute MI who underwent thrombolytic therapy with 1,500,000 units of intravenous streptokinase. All patients underwent coronary angiography within seven days of the infarction from which the thrombolysis in myocardial infarction (TIMI) flow grades of the infarct-related artery, coronary scores, and ejection fraction were determined. Anterior MI was found in 19 patients (59.4%), inferior MI in 12 (37.5%), and posterolateral MI in 1 patient (3.1%). They found that 6 patients (18.8%) had TIMI flow 0 to 1, and 26 patients (81.2%) had TIMI flow grade 2 or 3. The Lp(a) levels ranged from 0.1 to 60 mg/dL with a mean of 8.6 +/- 17 mg/dL. Eight (25%) of the patients had Lp(a) levels above 30 mg/dL. The TIMI flow rates were not found to be lower in patients with high Lp(a) levels (P > 0.05), and there was no significant correlation between the TIMI flow rates and the Lp(a) levels (r = 0.28). There was a good correlation between coronary scores and Lp(a) levels (r = 0.87). They conclude that although there is a good correlation between the extent of coronary atherosclerosis and Lp(a) levels, Lp(a) is not a strong predictor of the outcome of thrombolytic therapy.

Fibrinolysis and atherosclerosis

The link between impaired fibrinolytic function and CHD has been reinforced considerably in the past couple of years. This has been achieved by a combination of epidemiological, clinical, cell biological and molecular biological studies. The molecular mechanisms for the identified associations between more established risk factors for atherosclerotic disease and impaired fibrinolytic function now need to be disentangled to promote the design of specific drugs that may pave the way for intervention. The possibility that some of the observed relations are epiphenomena should also not be disregarded. The concept of genotype-specific differences in the susceptibility of the individual to common metabolic disturbances needs to be examined in greater detail. Basic research on the role of fibrinolysis in atherosclerosis and its thrombotic complications should be given high priority, because the modulation of fibrinolytic function is likely to become an important approach to prevention.

High lipoprotein(a) levels with predominance of high molecular weight apo(a) isoforms in patients with pulmonary embolism

Lipoprotein(a) (Lp(a)) may interact with the cellular components and protein co-factors of fibrinolysis. To evaluate the effect of Lp(a) in thromboembolic diseases of the venous system, we measured serum levels and the isoform distribution of apo(a) in 25 patients with pulmonary embolism (18 men, 7 women, aged 21-77 years). The control group was adjusted for sex and age (P = 0.189). Serum Lp(a) concentration was significantly higher in the study group (median: 9.3 vs. 4.3 mg dL-1). As the distribution of high and low molecular weight subtypes of apo(a) did not show any differences (P = 0.127) between the two groups, the elevated Lp(a) levels in patients with pulmonary embolism could not be attributed to the investigated kringle-4 polymorphism of the apo(a) gene and therefore other genetic or non-genetic implications are indicated.

Rapid angiographic progression of coronary artery disease in patients with elevated lipoprotein(a)

BACKGROUND

The mechanisms underlying rapid angiographic progression of coronary artery disease are still unknown. Intravascular thrombosis with or without plaque rupture may be involved.

METHODS AND RESULTS

In a prospective study in 79 patients with coronary artery disease and at least one coronary diameter stenosis > or = 50%, possible risk factors for rapid progression were investigated. Quantitative coronary angiography was performed twice at a mean time interval of 66 +/- 25 days. Rapid progression of coronary disease defined as (1) an increase > 10% in stenosis severity in at least one stenosis > or = 50%, (2) occurrence of a new stenosis > or = 50%, or (3) occlusion of a formerly patent vessel was found in 21 patients (27%). Between patients with rapid progression and those without, there were no significant differences in sex distribution, age, smoking history, frequency of hypertension or diabetes mellitus, and serum LDL cholesterol, HDL cholesterol, and apolipoprotein B concentrations. In contrast, serum lipoprotein(a) [Lp(a)] concentrations > or = 25 mg/dL were found in 14 of 21 patients (67%) with rapid progression of coronary artery disease but in only 19 of 58 (33%) in the group without progression (P = .007). The respective median Lp(a) concentrations were 66 mg/dL (range, 2 to 139) and 13 mg/dL (range, 2 to 211; P = .01).

CONCLUSIONS

Lp(a) appears to be a risk factor for the rapid angiographic progression of coronary artery disease. The pathophysiological link between Lp(a) and rapid progression may be an interference with thrombolysis through the partial structural homology of Lp(a) with plasminogen.

A kringle-specific monoclonal antibody

Kringle domains are found in several plasma proteins of blood coagulation and fibrinolysis. A murine monoclonal antibody, designated alpha HII-5, was produced against a synthetic peptide representing residues 216-231 of human prothrombin kringle 2. The sequence of the hexadecapeptide (Glu-Asn-Phe-Cys-Arg-Asn-Pro-Asp-Gly-Asp-Glu-Glu-Gly-Val-Gly-Cys) is conserved in several kringle-containing proteins, represents a predicted region of high local hydrophilicity in prothrombin kringle 2, and contains the anionic (Asp-223 and Asp-225) residues that contribute to lysine binding by plasminogen kringle 4. In a solution-phase immunoassay, antibody alpha HII-5 bound prothrombin and the kringle 5 light chain fragment of plasminogen (miniplasminogen), but not plasminogen or plasmin. In contrast, using a solid-phase assay with antigen immobilized onto a surface (polystyrene microtiter plates, glass, or nitrocellulose) antibody alpha HII-5 specifically bound prothrombin, plasminogen, recombinant tissue plasminogen activator (tPA), and the apo(a) subunit of lipoprotein(a). By immunoblotting analysis antibody alpha HII-5 bound determinants on prothrombin fragment 2 and plasminogen kringle 5. These observations suggest that a subset of kringle domains on plasma proteins, including prothrombin kringle 2 and plasminogen kringle 5, contains a homologous antigenic determinant in the region of the kringle lysine-binding site. In contrast to prothrombin kringle 2, the homologous peptide site on plasminogen is not available for antibody binding except when plasminogen is adsorbed to a nonphysiological surface, or when kringles 1-4 are removed.

Lipoprotein(a) levels in patients with myocardial infarction treated with anistreplase: no prediction of efficacy but inverse correlation with plasminogen activation in non-patency

The aim of this study was to investigate whether failure of thrombolytic treatment might be due to inhibition of fibrinolysis by high lipoprotein(a) levels. Fifty-eight patients with acute myocardial infarction were treated intravenously within 4 h after onset of symptoms with anistreplase (30 units) and heparin (30,000 IU/24 h). Blood samples for measurement of coagulation parameters were taken before and 1.5 h after treatment. Coronary angiography was performed after 48 h. Levels of lipoprotein(a) were measured 6 months after discharge from hospital. The patency rate was 74% (43/58). Median lipoprotein(a) levels were not different between the patients with a patent and those with a non-patent vessel (10 and 8 mg/dl, respectively), however, in patients with a non-patent infarct-related vessel, a significant inverse correlation was found between the lipoprotein(a) level and the decrease of plasminogen in the first 1.5 h after treatment. It is concluded that high lipoprotein(a) levels, although not directly associated with a poor outcome of anistreplase therapy, might contribute to insufficient fibrinolysis in patients with a non-patent infarct-related vessel.

Structure and possible biological roles of Lp(a)

Lipoprotein(a) [Lp(a)] is a plasma macromolecular complex that is assembled from low-density lipoproteins (LDL) and a large hydrophilic glycoprotein, named apolipoprotein(a) [apo(a)], linked by a disulfide bond to apolipoprotein B-100. Apo(a) is formed by different structural domains one of which is present in multiple copies, the number of which is determined by variation in the hypervariable apo(a) gene. Sequence homology of apo(a) with plasminogen may explain the competition of Lp(a) for some physiological functions of plasminogen in the coagulation and fibrinolytic cascade in vitro. There is evidence that high plasma levels of Lp(a) may have atherogenic and/or thrombogenic potential. More work will have to be done to understand the exact role of Lp(a) in atherogenesis, to evaluate the potential synergy between Lp(a) and LDL in promoting coronary artery disease, and to assess the therapeutic benefits of a reduction of Lp(a) levels.

Lysine-binding species of lipoprotein(a) in coronary artery disease

Elevated levels of plasma lipoprotein(a) [Lp(a)] have frequently been associated with coronary artery disease (CAD). Recently Lp(a) was fractionated into two species with different affinities for Lysine-Sepharose. The influence of lysine-binding heterogeneity of Lp(a) on its cardiovascular pathogenicity has not previously been studied. The authors have determined plasma levels of total Lp(a), its lysine-binding [lys+] and unretained [lys-] species in 67 male CAD patients undergoing cardiac catheterization. Forty-three patients have severe CAD (two- or three-vessel disease) and 24 patients have less pronounced CAD (one-vessel disease or less than 50% narrowing of coronary vessels). All patients were ranked in order of their Lp(a) levels and then grouped into quartiles. The prevalence of severe CAD was significantly higher in the upper Lp(a) quartile as compared with the other three quartiles (odds ratio 10-5; chi-square 11.2; P = 0.0008). Similar results were obtained when the same analysis was carried out for [lys+] and [lys-] species of Lp(a) (odds ratio 11.52 and 3.3, respectively; chi-square 12.3 and 4.34, respectively; P = 0.0004 and 0.037, respectively). Thus, measurement of either species of Lp(a) does not provide any additional improvement in the prediction of CAD as compared to the estimation of total Lp(a) levels.

Lipoprotein(A): physiologic function, association with atherosclerosis, and effects of lipid-lowering drug therapy

OBJECTIVE

To review the structure and physiologic function of lipoprotein(a) [Lp(a)], review the association of Lp(a) with the development of atherosclerosis, and to critically evaluate the current literature regarding the effects of lipid-lowering drug therapy on Lp(a) serum concentrations.

DATA SOURCES

English language clinical and animal studies, abstracts, and review articles pertaining to Lp(a).

STUDY SELECTION AND DATA EXTRACTION

Relevant human and animal studies examining Lp(a)'s role in atherosclerosis and the effect of drug therapy on Lp(a) serum concentrations.

DATA SYNTHESIS

Possible physiologic functions and potential atherogenic mechanisms of Lp(a) are discussed. Evidence supporting the association of Lp(a) with atherosclerosis is presented. Studies evaluating the effects of lipid-lowering drug therapy on Lp(a) concentrations are reviewed and critiqued.

CONCLUSIONS

Lp(a) concentrations are correlated with the risk of atherosclerotic vascular disease (AVD) in both animals models and human studies. Drug therapies that have produced a consistent reduction in Lp(a) concentration include niacin alone or in combination with a bile acid sequestrant or neomycin. However, additional, larger studies are needed to evaluate the ability of drug therapies to specifically reduce elevated Lp(a) concentrations. Preliminary information suggests that reduction in Lp(a) concentrations may be associated with atherosclerotic plaque regression. Although drugs are available to lower Lp(a), one cannot conclude that lowering of Lp(a) is warranted until clinical trials demonstrating beneficial effects have been published.

Lipoproteins inhibit the secretion of tissue plasminogen activator from human endothelial cells

We studied the effect of lipoprotein(a) [Lp(a)], low-density lipoprotein (LDL), and high-density lipoprotein (HDL) on tissue plasminogen activator (TPA) secretion from human endothelial cells. At 1 mumol/L, Lp(a) inhibited constitutive TPA secretion by 50% and phorbol myristate acetate- and histamine-enhanced TPA secretion by 40%. LDL and HDL also depressed TPA secretion by 45% and 35% (constitutive) and 40% to 60% (stimulated). TPA mRNA levels were also examined and found to change in parallel with antigen secretion. In contrast to TPA, plasminogen activator inhibitor type-1 secretion and mRNA levels were not affected by any of the three lipoproteins. These results suggest that the interaction of lipoproteins with certain cell-surface binding sites may interfere with the proper production and/or secretion of TPA.

Identification of glycoprotein IIb as the lipoprotein(a)-binding protein on platelets. Lipoprotein(a) binding is independent of an arginyl-glycyl-aspartate tripeptide located in apolipoprotein(a)

Lipoprotein(a) [Lp(a)] plays an important role in atherosclerosis. The amino acid sequence of apolipoprotein(a) [apo(a)] reveals an arginyl-glycyl-aspartate (RGD) tripeptide that is the consensus sequence for binding of adhesive plasma proteins of the fibrinolytic system, such as fibrinogen and von Willebrand factor, to the platelet membrane glycoprotein IIb-IIIa (GPIIb-IIIa) complex. Therefore, we undertook the present study to further investigate the role of Lp(a) in hemostasis. Binding of 125I-Lp(a) to a single platelet membrane-associated protein (137 +/- 6 kD) comigrating with platelet GPIIb (140 kD) was found to be specific, saturable, and Ca2+ independent. Binding of 125I-Lp(a) to resting human blood platelets was saturable, insensitive to temperature, and independent of the apo(a) isoform (B, S1 through S3). Scatchard analysis revealed a Kd of 7.2 +/- 1.8 x 10(-9) mol/L, with 729 +/- 313 Lp(a) molecules bound per platelet. Monoclonal anti-GPIIb IgG diminished Lp(a) binding by approximately 80%, monoclonal anti-GPIIb-IIIa IgG by 60%, and anti-GPIIIa IgG by just 15%. 125I-Lp(a) binding was competitively inhibited to the same extent by either unlabeled Lp(a) or fibrinogen. Low- and high-density lipoproteins were much weaker competitors. A polyclonal antibody raised against the RGDGQSYRGT sequence of apo(a) was used to verify the presence of an RGD sequence in the different Lp(a) preparations investigated. However, two lines of evidence indicated that the RGD sequence is not the binding domain mediating Lp(a) binding to platelets. First, incubation of platelets with isolated RGD tripeptide did not influence Lp(a) binding.(ABSTRACT TRUNCATED AT 250 WORDS)

High allele frequency of apolipoprotein(a) phenotype LpS4 is associated with low serum Lp(a) concentrations in Koreans

We determined apo(a) phenotypes using SDS-PAGE followed by immunoblotting in samples from a control group of 179 and from 68 Korean patients with coronary artery disease (CAD). The CAD group showed significantly higher Lp(a) levels than the control group, which might be partially attributable to the differences in apo(a) phenotype frequencies although it was not statistically significant, and was partially attributable to the significant difference in Lp(a) levels of S2 or null phenotypes between the two groups. The apo(a) allele frequencies between ethnic groups already reported (Austrians, American blacks, Japanese, and Koreans), were compared by the Chi-square test. In the Korean population, the apo(a) allele frequencies demonstrated a high frequency of the LpS4 allele associated with a low Lp(a) concentration. This result suggests that the concentration and allele frequency of Lp(a) might be one of the factors in explaining the low incidence of CAD in the Korean population.

Effects of lipoprotein(a) on thrombolysis

Lipoprotein(a) (Lp(a)) and plasminogen share a high degree of structural homology. Therefore it has been suggested that elevated levels of Lp(a) may inhibit the profibrinolytic activity at the cell surface and increase the risk of thrombosis by competitive inhibition of plasminogen. In the present study we evaluated whether high levels of Lp(a) affect thrombolytic therapy in patients with acute myocardial infarction. Forty-one patients with acute myocardial infarction were treated with a combination of recombinant tissue-type plasminogen activator and human single-chain urokinase-type plasminogen activator. Coronary patency was assessed angiographically 90 min after initiation of treatment. Thrombolysis was successful in 30 and unsuccessful in 11 patients. Patients with high Lp(a) levels (> 25 mg/dl) (n = 9) responded equally well to thrombolytic therapy (8 of 9, patency 89%) as did patients with normal or low levels of Lp(a) (22 of 32, patency 70%, difference P > 0.1). The results demonstrate that high levels of Lp(a) do not influence thrombolysis in patients with acute myocardial infarction when low-dose pharmacologic concentrations of recombinant tissue-type plasminogen activator and human single chain urokinase-type plasminogen activator are applied in combination.

Lipoprotein (a) regulates plasmin generation and inhibition

The relationship between lipoprotein (a) (Lp(a)) and atherosclerosis has been appreciated for a number of years. Only in recent years, however, has the structural relationship of Lp(a) to plasminogen resulted in studies of the effect of this lipoprotein on fibrinolysis. Lp(a) inhibits activation of plasminogen by tissue-type (t-PA) and urinary-type (u-PA) plasminogen activators. These inhibitory reactions are surface-dependent. When Lp(a) binds to fibrin, fibrinogen, heparin or cells it blocks activation of plasminogen by t-PA. u-PA-mediated activation of plasminogen is blocked on surfaces including heparin and chondroitin sulfate. Lp(a) also favors inhibition of plasmin by alpha 2-antiplasmin (alpha 2-AP). The ability of Lp(a) to compete with plasmin for fibrin binding displaces plasmin into solution where alpha 2-AP rapidly inhibits this proteinase. These effects are all antifibrinolytic. Lp(a) also exhibits one profibrinolytic effect, since it blocks inhibition of t-PA by plasminogen activator type 1 in the presence of fibrinogen or heparin. Thus, Lp(a) modulates most of the reactions involved in plasmin generation and inhibition. Its overall effect will depend primarily on the concentrations of Lp(a), PAI-1 and t-PA in vivo.

Lipoprotein (a): a risk factor for peripheral vascular disease

Lipoprotein (a) [Lp(a)] is a serum protein that has been reported to be predictive of complications from coronary and cerebrovascular atherosclerotic disease. This study was designed to compare plasma levels of Lp(a) in 100 white male patients with and without peripheral vascular disease (PVD) and to determine the role of Lp(a) as a risk factor for PVD independent of known risk factors such as cigarette smoking (CIG), diabetes mellitus (DM), and coronary artery disease (CAD). Patients with PVD (mean age = 67.6 years, n = 50) had a statistically significant (p = 0.04) elevation of Lp(a) (29.8 +/- 3.9 mg/dl) as compared to patients without PVD (20.0 +/- 2.9 mg/dl (mean age = 68.3 years, n = 50). Further analysis revealed that patients with PVD had a significantly higher incidence of CIG (86% vs. 68%, p = 0.03), DM (34% vs. 14%, p = 0.02), and CAD (52% vs. 30%, p = 0.02) than those without PVD. However, there was no statistically significant difference in Lp(a) levels in patients with CIG or CAD compared to those without. Patients with DM had significantly (p = 0.04) lower levels of Lp(a) (17.8 +/- 3.5 mg/dl) than those without DM (27.1 +/- 3.0 mg/dl). Stepwise regression analysis of these various risk factors for PVD revealed that Lp(a) was the strongest significant individual predictor for the presence of PVD (R2 = 0.07) as compared to DM (R2 = 0.05) and CIG (R2 = 0.04). We conclude that there is a significant correlation of Lp(a) levels and the incidence of PVD, which is independent of other major risk factors for PVD.

Effects of lipoprotein(a) on in vitro lysis of whole blood thrombi from healthy volunteers

Elevated levels of lipoprotein(a) [Lp(a)] were shown to be an independent cardiovascular risk factor. Structural homologies between Lp(a) and plasminogen could be of importance for this. In the present study, the influence of Lp(a) on in vitro lysis of thrombi produced in recalcified whole blood was investigated. Of 120 healthy volunteers, 21 (18%) had serum Lp(a) levels > or = 25 mg/dl (median 70 mg/dl). Compared to 46 controls with serum Lp(a) < 25 mg/dl (median 7 mg/dl), the weight of whole blood thrombi generated in vitro was similar (96 +/- 11 vs. 94 +/- 13 mg). Thrombolysis with exogenously added tissue plasminogen activator (TPA; 0.1, 0.4 and 1.6 mg/l) was not affected by the ex vivo concentration of Lp(a). In persons with elevated Lp(a), plasma TPA levels were higher than in persons with low Lp(a) [15.7 +/- 1.5 vs. 11.7 +/- 1.2 micrograms/l; p = 0.051], but plasminogen activator inhibitor (PAI) activity and the plasma concentrations of PAI-1 were also higher. When Lp(a) was added in vitro to blood with low baseline Lp(a) [median final concentration 47 mg/dl], thrombolysis was significantly inhibited with low doses of TPA (0.1 and 0.4 mg/l), but remained unaffected with TPA 1.6 mg/l. Thus, the inhibitory effect of Lp(a) on thrombolysis seems to be counterregulated in blood of healthy volunteers with elevated Lp(a).

Relationships between lipoprotein(a), lipids, apolipoproteins, basal and stimulated fibrinolytic regulators, and D-dimer

In 191 newly referred hyperlipidemic patients, our specific aim was to assess relationships between levels of lipoprotein(a) [Lp(a)], lipids, apolipoproteins, regulators of basal and stimulated fibrinolytic activity, and D-dimer, a measure of in vivo fibrinolysis. Lp(a) levels correlated with none of the measures of basal fibrinolytic regulators or D-dimer. In 25 patients, levels of stimulated regulators of fibrinolytic activity and D-dimer were measured after 10-minute cuff venous occlusion. Lp(a) levels again correlated with none of the stimulated regulators of fibrinolytic activity or D-dimer. However, both basal and stimulated levels of fibrinolytic regulators and D-dimer were closely related to other major risk factors for coronary heart disease (CHD) including triglyceride, apolipoprotein (apo) A1, apo B, Quetelet index (QI), and sex. By stepwise regression in 191 patients, the following standardized partial regression coefficients were significant (P < or = .05), and model R2 and P values were as follows: basal tissue plasminogen activator (tPA) with apo B-.18, with time .17, with QI -.28, R2 = 17%, P < or = .0001; basal plasminogen activator inhibitor (PAI) with apo B..25, with time -.15, with QI .17, R2 = 14%, P < or = .0001; basal alpha 2-antiplasmin with apo A1.14, with apo B.24, with QI.17, with sex .30, R2 = 25%, P < .0001; basal plasminogen with A1.15, with apo B.21, with QI.17, with sex.17, R2 = 15%, P < or = .0001; basal fibrinogen with Lp(a).17, with QI.21, with sex.26, R2 = 14%, P < or = .0001; D-dimer with sex.15, R2 = 21%, P < or = .048. Given the absence of any relationship between Lp(a) levels and inhibition or stimulation of fibrinolysis regulators or D-dimer either in the basal or stimulated state, we postulate that Lp(a)'s major atherogenic effects are mediated by mechanisms other than reduction of fibrinolysis stimulation or in vivo fibrinolysis.

Immunoquantification of lipoprotein(a): comparison of nephelometry with electroimmunodiffusion

A new fully automated nephelometric immunoassay for lipoprotein(a) quantification in human serum was evaluated using the Behring Nephelometer Analyzer. The assay exhibited a good linearity in the concentration range of 110-1,770 mg/l; at higher concentrations, samples were automatically diluted by a factor of 4. The method is simple, robust, and shows an excellent stability of the calibration curve over several weeks. Intra-assay and day-to-day coefficients of variation were 2% and 4.5%, respectively. The method correlated well with electroimmunodiffusion (r = 0.977; n = 123; P = 0.0001). Unspecific turbidity as expressed by an elevated blank value occurred in 3% of all freshly measured samples (n = 392). Storage of the samples for 1 week at 4 degrees C had no significant influence on the results. Frozen sera, on the other hand, cannot be assayed by this method. We believe that this assay is well suited for use in clinical routine work.

Plasma lipoprotein (a) concentration and phenotypes in diabetes mellitus

Patients with Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetes mellitus are at increased risk of developing atherosclerotic vascular diseases. A variety of lipoprotein abnormalities have been described as being associated with this increased risk. In this study, apo(a) isoform frequencies and lipoprotein(a) [Lp(a)] concentrations were determined in Type 1 and Type 2 diabetic patients in order to investigate a possible contribution of Lp(a) to the increased risk for atherosclerosis in diabetes. No significant differences in plasma Lp(a) concentrations were found in two ethnically different populations (Austrians from the province of Tyrol and Hungarians from Budapest) in either type of diabetes when compared to respective control groups (91 Type 1 and 112 Type 2 diabetic patients vs 202 control subjects in the Hungarian study and 44 Type 1 diabetic and 44 Type 2 diabetic vs 125 control subjects in the Austrian study). There were also no significant apo(a) isoform frequency differences between both patient groups and control subjects in the two study groups. These data, obtained from two large ethnically different populations, provide no evidence of a contribution of Lp(a) to the increased risk for atherosclerosis in diabetes.