Research Article| Volume 154, ISSUE 3, P529-537, February 15, 2001

Download started.


Apolipoprotein E genotype and cardiovascular disease in the Framingham Heart Study


      Background: Apolipoprotein (apo) E is a constituent of lipoproteins with considerable variation due to cysteine–arginine exchanges. The apo E4 (Arg112-Cys) polymorphism has been associated with dementia and hypercholesterolemia. We investigated the relation of APOE genotype to cardiovascular disease (CVD) in the Framingham Offspring Study. Methods and results: DNA was isolated from 3413 study participants and APOE genotypes were determined utilizing the polymerase chain reaction and restriction isotyping. In the entire group of subjects, 20.7% had apo E4/4 or E3/4 (Group E4); 14.1% had apo E2/2 or E2/3 (Group E2) and 63.9% had the apo E3/3 genotype (Group E3). Subjects with E2/4 (1.3%) were excluded. Period prevalence of CVD between examinations 1 and 5 (1971–1994) (366 events) was related to APOE genotype. Age adjusted period prevalence of CVD in men was 18.6% for Group E4, 18.2% for Group E2 and 12.7% for Group E3 (P=0.004); while in women these rates were 9.9, 4.9, and 6.6%, respectively (P=0.037). After adjustment for non-lipid risk factors the relative odds for CVD in Group E2 men was 1.79 (P=0.0098) and in Group E4 it was 1.63 (P=0.0086) compared with the Group E3; while in Group E4 women it was 1.56 (P=0.054). After adjustment for all CVD risk factors, the relative odds in Group E2 men was 1.94 (P=0.004) and in Group E4 men it was 1.51 (P=0.0262). Conclusions: The presence of the apo E2 or apo E4 alleles in men is associated with significantly greater CVD risk. This genotypic information may help to identify individuals at increased risk for CVD events.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Atherosclerosis
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Exp Panel High Blood Chol Adults. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993;269:3015–3023.

        • Genest Jr, J.J.
        • Martin-Munley S.S.
        • McNamara J.R.
        • et al.
        Familial lipoprotein disorders in patients with premature coronary artery disease.
        Circulation. 1992; 85: 2025-2033
        • Boerwinkle E.
        • Leffert C.C.
        • Lin J.
        • Lackner C.
        • Chiesa G.
        • Hobbs H.H.
        Apolipoprotein(a) gene accounts for greater than 90% of the variation in plasma lipoprotein(a) concentrations.
        J. Clin. Invest. 1992; 90: 52-60
        • Brown M.S.
        • Goldstein J.L.
        A receptor-mediated pathway for cholesterol homeostasis.
        Science. 1986; 232: 34-47
        • Russell D.W.
        • Esser V.
        • Hobbs H.H.
        Molecular basis of familiar hypercholestolemia.
        Arteriosclerosis. 1989; 9: I8-I13
        • Goldstein J.L.
        • Schrott H.G.
        • Hazzard W.R.
        • Bierman E.L.
        • Motulsky A.G.
        Hyperlipidemia in coronary heart disease. II. Genetic analysis of lipid levels in 176 families and delineation of a new inherited disorder, combined hyperlipidemia.
        J. Clin. Invest. 1973; 52: 1544-1568
        • Davignon J.
        • Gregg R.E.
        • Sing C.F.
        Apolipoprotein E polymorphism and atherosclerosis.
        Arteriosclerosis. 1988; 8: 1-21
        • Ordovas J.M.
        • Litwack-Klein L.
        • Wilson P.W.F.
        • Schaefer M.M.
        • Schaefer E.J.
        Apolipoprotein E isoform phenotyping methodology and population frequency with identification of apoE1 and apoE5 isoforms.
        J. Lipid Res. 1987; 28: 371-380
        • Ehnholm C.
        • Lukka M.
        • Kuusi T.
        • Nikkila E.
        • Utermann G.
        Apolipoprotein E polymorphism in the Finnish population: gene frequencies and relation to lipoprotein concentrations.
        J. Lipid Res. 1986; 27: 227-235
        • Xhignesse M.
        • Lussier-Cacan S.
        • Sing C.F.
        • Kessling A.M.
        • Davignon J.
        Influences of common variants of apolipoprotein E on measures of lipid metabolism in a sample selected for health.
        Arterioscler. Thromb. 1991; 11: 1100-1110
        • Kamboh M.I.
        • Aston C.E.
        • Ferrell R.E.
        • Hamman R.F.
        Impact of apolipoprotein E polymorphism in determining interindividual variation in total cholesterol and low density lipoprotein cholesterol in Hispanics and non-Hispanic whites.
        Atherosclerosis. 1993; 98: 201-211
        • Schaefer E.J.
        • Lamon-Fava S.
        • Johnson S.
        • Ordovas J.M.
        • Schaefer M.M.
        • Castelli W.P.
        • Wilson P.W.F.
        Effects of gender and menopausal status on the association of apolipoprotein E phenotype with plasma lipoprotein levels: Results from the Framingham Offspring Study.
        Arterioscler. Thromb. 1994; 14: 1105-1113
        • Rall S.C.
        • Weisgraber K.H.
        • Mahley R.W.
        Human apolipoprotein E: the complete amino acid sequence.
        J. Biol. Chem. 1982; 257: 4171-4178
        • Dallongeville J.
        • Lussier-Cacan S.
        • Davignon J.
        Modulation of plasma triglyceride levels by apoE phenotype: A meta-analysis.
        J. Lipid Res. 1992; 33: 447-454
        • Wilson P.W.F.
        • Schaefer E.J.
        • Larson M.G.
        • Ordovas J.M.
        Apolipoprotein E alleles and risk of coronary disease — A meta-analysis.
        Arterioscler. Thromb. Vasc. Biol. 1996; 16: 1250-1255
        • Dawber T.R.
        • Meadors G.F.
        • Moore R.
        Epidemiological approaches to heart disease: The Framingham Study.
        Am. J. Public Health. 1951; 41: 279-286
        • Kannel W.B.
        • Feinleib M.
        • McNamara P.M.
        • Garrison R.J.
        • Castelli W.P.
        An investigation of coronary heart disease in families: the Framingham Offspring Study.
        Am. J. Epidemiol. 1979; 110: 281-290
        • Miller S.A.
        • Dykes D.D.
        • Polesky H.F.
        A simple salting out procedure for extracting DNA from human nucleated cells.
        Nucleic Acids Res. 1989; 16: 1215
        • Hixson J.E.
        • Vernier D.T.
        Restriction isotyping of human apolipoprotein E by gene amplification and cleavage with HhaI.
        J. Lipid Res. 1990; 31: 545-548
      2. Lipid Research Clinics Program. The Coronary Primary Prevention Trial: design and implementation. J Chron Dis 1979;14:1250–1257.

      3. Anonymous. The coronary primary prevention trial: design and implementation: the Lipid Research Clinics Program. J Chron Dis 1979;32:609–631.

        • Gagne E.
        • Genest Jr, J.
        • Zhang H.
        • Clarke L.A.
        • Hayden M.R.
        Analysis of DNA changes in the LPL gene in patients with familial combined hyperlipidemia.
        Arterioscler. Thromb. 1994; 14: 1250-1257
        • Cumming A.M.
        • Robertson F.W.
        Polymorphism at the apoprotein-E locus in relation to risk of coronary disease.
        Clin. Genet. 1984; 25: 310-313
        • Lenzen H.J.
        • Assmann G.
        • Buchwalsky R.
        • Schulte H.
        Association of Apolipoprotein E polymorphism, low-density lipoprotein cholesterol, and coronary artery disease.
        Clin. Chem. 1986; 32: 778-781
        • Eto M.
        • Watanabe K.
        • Makino I.
        Increased frequencies of apolipoprotein E2 and E4 alleles in patients with ischemic heart disease.
        Clin. Genet. 1989; 36: 183-188
        • Yamamura T.
        • Tajima S.
        • Miyake Y.
        • Nomura S.
        • Yamamoto A.
        • Haze K.
        • Hiramori K.
        Hyperlipoproteinemia as a risk factor for ischemic heart disease.
        Jpn. Circ. J. 1990; 54: 448-456
        • Eichner J.E.
        • Kuller L.H.
        • Orchard T.J.
        • Grandits G.A.
        • McCallum L.M.
        • Ferrell R.E.
        • Neaton J.D.
        Relation of apolipoprotein E phenotype to myocardial infarction and mortality from coronary artery disease.
        Am. J. Cardiol. 1993; 71: 160-165
        • Luc G.
        • Bard J.-M.
        • Arveiler D.
        • et al.
        Impact of apolipoprotein E polymorphism on lipoproteins and risk of myocardial infarction: The ECTIM study.
        Arterioscler. Thromb. 1994; 14: 1412-1419
        • Wilson P.W.F.
        • Myers R.H.
        • Larson M.G.
        • Ordovas J.M.
        • Wolf P.A.
        • Schaefer E.J.
        Apolipoprotein E alleles, dyslipidemia, and coronary heart disease: The Framingham Offspring Study.
        JAMA. 1994; 272: 1666-1671
        • Stengård J.H.
        • Zerba K.E.
        • Pekkanen J.
        • Ehnholm C.
        • Nissinen A.
        • Sing C.F.
        Apolipoprotein E polymorphism predicts death from coronary heart disease in a longitudinal study of elderly Finnish men.
        Circulation. 1995; 91: 265-269
        • Utermann G.
        • Hardewig A.
        • Zimmer F.
        Apolipoprotein E phenotypes in patients with myocardial infarction.
        Hum. Genet. 1984; 65: 237-241
        • Scaglione L.
        • Bergerone S.
        • Gambino R.
        • et al.
        Role of lipid, apolipoprotein levels and apolipoprotein E genotype in young Italian patients with myocardial infarction.
        Nutr. Metab. Cardiovasc. Dis. 1999; 9: 118-124
        • Corbo R.M.
        • Vilardo T.
        • Ruggeri M.
        • Gemma A.T.
        • Scacchi R.
        Apolipoprotein E genotype and plasma levels in coronary artery disease. A case-control study in the Italian population.
        Clin. Biochem. 1999; 32: 217-222
        • Nakai K.
        • Fusazaki T.
        • Zhang T.
        • et al.
        Polymorphism of the apolipoprotein E and angiotensin I converting enzyme genes in Japanese patients with myocardial infarction.
        Coronary Artery Dis. 1998; 9: 329-334
        • Ou T.
        • Yamakawa-Kobayashi K.
        • Arinami T.
        • et al.
        Methylenetetrahydrofolate reductase and apolipoprotein E polymorphisms are independent risk factors for coronary heart disease in Japanese: a case-control study.
        Atherosclerosis. 1998; 137: 23-28
        • Nassar B.A.
        • Dunn J.
        • Title L.M.
        • et al.
        Relation of genetic polymorphisms of apolipoprotein E, angiotensin converting enzyme, apolipoprotein B-100, and glycoprotein IIIa and early-onset coronary heart disease.
        Clin. Biochem. 1999; 32: 275-282
        • Biggart S.
        • Chin D.
        • Fauchon M.
        • et al.
        Association of genetic polymorphisms in the ACE, ApoE, and TGF beta genes with early onset ischemic heart disease.
        Clin. Cardiol. 1998; 21: 831-836
        • Moore J.H.
        • Reilly S.L.
        • Ferrell R.E.
        • Sing C.F.
        The role of the apolipoprotein E polymorphism in the prediction of coronary artery disease age of onset.
        Clin. Genet. 1999; 51: 22-25
        • Raslova K.
        • Smolkova B.
        • Vohnout B.
        • Schifferdecker B.
        • Poledne R.
        • Dusinska M.
        Apolipoprotein E genotypes in offspring with a positive and negative family history of premature myocardial infarction.
        Clin. Genet. 1999; 53: 387-390
        • Tiret L.
        • de Knijff P.
        • Menzel H.-J.
        • Ehnholm C.
        • Nicaud V.
        • Havekes L.M.
        ApoE polymorphism and predisposition to coronary heart disease in youths of different European populations: The EARS Study.
        Arterioscler. Thromb. 1994; 14: 1617-1624
        • Menzel H.J.
        • Kladetzky R.G.
        • Assmann G.
        Apolipoprotein E polymorphism and coronary artery disease.
        Arteriosclerosis. 1983; 3: 310-315
        • Kuusi T.
        • Nieminen M.S.
        • Ehnholm C.
        • et al.
        Apolipoprotein E polymorphism and coronary artery disease. Increased prevalence of apolipoprotein E-4 in angiographically verified coronary patients.
        Arteriosclerosis. 1989; 9: 237-241
        • Stuyt P.M.J.
        • Brenninkmeijer B.J.
        • Demacker P.N.M.
        • et al.
        Apolipoprotein E phenotypes, serum lipoproteins and apolipoproteins in angiographically assessed coronary heart disease.
        Scand. J. Clin. Lab. Invest. 1991; 51: 425-435
        • Van Bockxmeer F.M.
        • Mamotte C.D.S.
        Apolipoprotein ε4 homozygosity in young men with coronary heart disease.
        Lancet. 1992; 340: 879-880
        • Lehtinen S.
        • Lehtimäki T.
        • Sisto T.
        • et al.
        Apolipoprotein E polymorphism, serum lipids, myocardial infarction and severity of angiographically verified coronary artery disease in men and women.
        Atherosclerosis. 1995; 114: 83-91
        • Wang X.L.
        • McCredie R.M.
        • Wilcken D.E.L.
        Polymorphisms of the apolipoprotein E gene and severity of coronary artery disease defined by angiography.
        Arterioscler. Thromb. Vasc. Biol. 1995; 15: 1030-1034
        • De Andrade M.
        • Thandi I.
        • Brown S.
        • et al.
        Relationship of the apolipoprotein E polymorphism with carotid artery atherosclerosis.
        Am. J. Hum. Genet. 1995; 56: 1379-1390
        • Kardia S.L.
        • Haviland M.B.
        • Ferrell R.E.
        • Sing C.F.
        The relationship between risk factor levels and presence of coronary artery calcification is dependent on apolipoprotein E genotype.
        Arterioscler. Thromb. Vasc. Biol. 1999; 19: 427-435
        • Cattin L.
        • Fisicaro M.
        • Tonizzo M.
        • et al.
        Polymorphism of the apolipoprotein E gene and early carotid atherosclerosis defined by ultrasonography in asymptomatic adults.
        Arterioscler. Thromb. Vasc. Biol. 1997; 17: 91-94
      4. Hixson JE, PDAY Research Group. Apolipoprotein E polymorphisms affect atherosclerosis in young males. Arterioscler Thromb 1991;11:1237–1244.

        • Scheer W.D.
        • Boudreau D.A.
        • Malcom G.T.
        • Middaugh J.P.
        Apolipoprotein E and atherosclerosis in Alaska Natives.
        Atherosclerosis. 1995; 114: 197-202
        • Ilveskoski E.
        • Perola M.
        • Lehtimaki T.
        • et al.
        Age-dependent association of apolipoprotein E genotype with coronary and aortic atherosclerosis in middle-aged men — An autopsy study.
        Circulation. 1999; 100: 608-613
        • Boer J.M.
        • Feskens E.J.
        • Schouten E.G.
        • Havekes L.M.
        • Seidell J.C.
        • Kromhout D.
        Lipid profiles reflecting high and low risk for coronary heart disease: contribution of apolipoprotein E polymorphism and lifestyle.
        Atherosclerosis. 1998; 136: 395-402
        • Boerwinkle E.
        • Brown S.
        • Sharrett A.R.
        • Heiss G.
        • Patsch W.
        Apolipoprotein E polymorphism influences postprandial retinyl palmitate but not triglyceride concentrations.
        Am. J. Hum. Genet. 1994; 54: 341-360
        • Dallongeville J.
        • Tiret L.
        • Visvikis S.
        • et al.
        Effect of apo E phenotype on plasma postprandial triglyceride levels in young male adults with and without a familial history of myocardial infarction: the EARS II study. European Atherosclerosis Research Study.
        Atherosclerosis. 1999; 145: 381-388
        • Orchard T.J.
        • Eichner J.
        • Kuller L.H.
        • Becker D.J.
        • McCallum L.M.
        • Grandits G.A.
        Insulin as a predictor of coronary heart disease: interaction with apolipoprotein E phenotype, A report from the Multiple Risk Factor Intervention Trial.
        Ann. Epidemiol. 1994; 4: 40-45
        • Karpe F.
        Mechanisms of postprandial hyperlipidemia — remnants and coronary artery disease.
        Diabetic Med. 1997; 14: S60-S66
        • Brussaard H.E.
        • Gevers Leuven J.A.
        • Frolich M.
        • Kluft C.
        • Krans H.M.
        Short-term oestrogen replacement therapy improves insulin resistance, lipids and fibrinolysis in postmenopausal women with NIDDM.
        Diabetologia. 1997; 40: 843-849
        • Wilcox J.G.
        • Hwang J.
        • Hodis H.N.
        • Sevanian A.
        • Stanczyk F.Z.
        • Lobo R.A.
        Cardioprotective effects of individual conjugated equine estrogens through their possible modulation of insulin resistance and oxidation of low-density lipoprotein.
        Fertil. Steril. 1997; 67: 57-62
        • Huang Y.
        • Schwender S.W.
        • Rall Jr S.C.
        • Sanan D.A.
        • Mahley R.W.
        Apolipoprotein E2 transgenic rabbits.
        J. Biol. Chem. 1997; 272: 22685-22694
        • Srivastava R.A.
        • Srivastava N.
        • Averna M.
        • Lin R.C.
        • Korach K.S.
        • Lubahn D.B.
        • Schonfeld G.
        Estrogen up-regulates apolipoprotein E (ApoE) gene expression by increasing ApoE mRNA in the translating pool via the estrogen receptor alpha-mediated pathway.
        J. Biol. Chem. 1997; 272: 33360-33366
        • Ordovas J.M.
        • Schaefer E.J.
        Genes, variation of cholesterol and fat intake and serum lipids.
        Curr. Opin. Lipidol. 1999; 10: 15-22
        • Ordovas J.M.
        The genetics of serum lipid responsiveness to dietary interventions.
        Proc. Nutr. Soc. 1999; 58: 171-187
        • Rantala M.
        • Savolainen M.J.
        • Kervinen K.
        • Kesäniemi Y.A.
        Apolipoprotein E phenotype and diet-induced alteration in blood pressure.
        Am. J. Clin. Nutr. 1997; 65: 543-550
        • Aguilar C.A.
        • Talavera G.
        • Ordovas J.M.
        • et al.
        The apolipoprotein E4 allele is not associated with an abnormal lipid profile in a Native American population following its traditional lifestyle.
        Atherosclerosis. 1999; 142: 409-414
        • Kamboh M.I.
        • Weiss K.M.
        • Ferrell R.E.
        Genetic studies of human apolipoproteins. XVI. APOE polymorphism and cholesterol levels in the Mayans of the Yucatan Peninsula, Mexico.
        Clin. Genet. 1991; 39: 26-32
        • Deiana L.
        • Pes G.M.
        • Carru C.
        • et al.
        Lack of influence of apolipoprotein E4 on lipoprotein levels in the island population of Sardinia.
        Eur. J. Clin. Invest. 1998; 28: 290-294
        • Sandholzer C.
        • Delport R.
        • Vermaak H.
        • Utermann G.
        High frequency of the apo epsilon 4 allele in Khoi San from South Africa.
        Hum. Genet. 1995; 95: 46-48