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. 2020 Mar 23;17(3):e1003062.
doi: 10.1371/journal.pmed.1003062. eCollection 2020 Mar.

Evaluating the Relationship Between Circulating Lipoprotein Lipids and Apolipoproteins With Risk of Coronary Heart Disease: A Multivariable Mendelian Randomisation Analysis

Free PMC article

Evaluating the Relationship Between Circulating Lipoprotein Lipids and Apolipoproteins With Risk of Coronary Heart Disease: A Multivariable Mendelian Randomisation Analysis

Tom G Richardson et al. PLoS Med. .
Free PMC article


Background: Circulating lipoprotein lipids cause coronary heart disease (CHD). However, the precise way in which one or more lipoprotein lipid-related entities account for this relationship remains unclear. Using genetic instruments for lipoprotein lipid traits implemented through multivariable Mendelian randomisation (MR), we sought to compare their causal roles in the aetiology of CHD.

Methods and findings: We conducted a genome-wide association study (GWAS) of circulating non-fasted lipoprotein lipid traits in the UK Biobank (UKBB) for low-density lipoprotein (LDL) cholesterol, triglycerides, and apolipoprotein B to identify lipid-associated single nucleotide polymorphisms (SNPs). Using data from CARDIoGRAMplusC4D for CHD (consisting of 60,801 cases and 123,504 controls), we performed univariable and multivariable MR analyses. Similar GWAS and MR analyses were conducted for high-density lipoprotein (HDL) cholesterol and apolipoprotein A-I. The GWAS of lipids and apolipoproteins in the UKBB included between 393,193 and 441,016 individuals in whom the mean age was 56.9 y (range 39-73 y) and of whom 54.2% were women. The mean (standard deviation) lipid concentrations were LDL cholesterol 3.57 (0.87) mmol/L and HDL cholesterol 1.45 (0.38) mmol/L, and the median triglycerides was 1.50 (IQR = 1.11) mmol/L. The mean (standard deviation) values for apolipoproteins B and A-I were 1.03 (0.24) g/L and 1.54 (0.27) g/L, respectively. The GWAS identified multiple independent SNPs associated at P < 5 × 10-8 for LDL cholesterol (220), apolipoprotein B (n = 255), triglycerides (440), HDL cholesterol (534), and apolipoprotein A-I (440). Between 56%-93% of SNPs identified for each lipid trait had not been previously reported in large-scale GWASs. Almost half (46%) of these SNPs were associated at P < 5 × 10-8 with more than one lipid-related trait. Assessed individually using MR, LDL cholesterol (odds ratio [OR] 1.66 per 1-standard-deviation-higher trait; 95% CI: 1.49-1.86; P < 0.001), triglycerides (OR 1.34; 95% CI: 1.25-1.44; P < 0.001) and apolipoprotein B (OR 1.73; 95% CI: 1.56-1.91; P < 0.001) had effect estimates consistent with a higher risk of CHD. In multivariable MR, only apolipoprotein B (OR 1.92; 95% CI: 1.31-2.81; P < 0.001) retained a robust effect, with the estimate for LDL cholesterol (OR 0.85; 95% CI: 0.57-1.27; P = 0.44) reversing and that of triglycerides (OR 1.12; 95% CI: 1.02-1.23; P = 0.01) becoming weaker. Individual MR analyses showed a 1-standard-deviation-higher HDL cholesterol (OR 0.80; 95% CI: 0.75-0.86; P < 0.001) and apolipoprotein A-I (OR 0.83; 95% CI: 0.77-0.89; P < 0.001) to lower the risk of CHD, but these effect estimates attenuated substantially to the null on accounting for apolipoprotein B. A limitation is that, owing to the nature of lipoprotein metabolism, measures related to the composition of lipoprotein particles are highly correlated, creating a challenge in making exclusive interpretations on causation of individual components.

Conclusions: These findings suggest that apolipoprotein B is the predominant trait that accounts for the aetiological relationship of lipoprotein lipids with risk of CHD.

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: BAF reports receiving grants from Amgen, Merck & Co., Novartis, and Esperion Therapeutics; consulting or advisory board fees from Amgen, Regeneron, Sanofi, Merck & Co., Pfizer, CiVi BioPhama, and KrKA Pharmaceuticals; and grants from Merck & Co., Amgen, Novartis, Novo Nordisk, Regeneron, Sanofi, Pfizer, Eli Lilly, Mylan, Ionis, dalCOR, Silence Therapeutics, Integral Therapeutics, CiVi Pharma, KrKa Phamaceuticals, American College of Cardiology, European Atherosclerosis Society, and European Society of Cardiology. MVH has collaborated with Boehringer Ingelheim in research, and in accordance with the policy of the The Clinical Trial Service Unit and Epidemiological Studies Unit (University of Oxford), did not accept any personal payment. GDS is an Academic Editor on PLOS Medicine's editorial board. All other authors report no potential conflicts of interest.


Fig 1
Fig 1. Manhattan plots showing findings from the GWAS of lipoprotein lipid-related traits in the UKBB.
Horizontal dotted line illustrates the Y-axis value conventionally used to denote a SNP that reaches statistical significance in the GWAS, i.e., at P < 5 × 10−8. GWAS, genome-wide association study; HDL, high-density lipoprotein; LDL, low-density lipoprotein; SNP, single nucleotide polymorphism; UKBB, UK Biobank.
Fig 2
Fig 2. Characteristics of genetic instruments developed for lipoprotein lipid-related traits.
(A) Overlap of SNPs and (B) associations with lipids and apolipoproteins. In Panel A, SNPs are grouped according to whether they associate with only the primary lipid-related trait of interest or whether they associate with other traits, based on P < 5 × 10−8. Panel B displays the associations of genetic instruments with lipid-related traits using the inverse variance weighting approach. Whilst we note the potential for overfitting of estimates displayed in Panel B, we present these data for illustrative purposes; the MR estimates presented in Fig 3 use a two-sample approach (with no overlapping data). CI, confidence interval; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MR, Mendelian randomisation; NA, not applicable; SD, standard deviation; SNP, single nucleotide polymorphism.
Fig 3
Fig 3
Univariable and multivariable MR of so-called (A) atherogenic and (B) protective lipoprotein lipids and apolipoproteins and risk of CHD. In both (A) and (B), univariable MR estimates were derived using the inverse variance weighted approach. For a more comprehensive repertoire of estimates derived from univariable MR approaches, please see S2 Fig. CHD, coronary heart disease; CI, confidence interval; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MR, Mendelian randomisation; SD, standard deviation; SNP, single nucleotide polymorphism.

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Grant support

TGR, ES, and GDS work in the Medical Research Council Integrative Epidemiology Unit at the University of Bristol, which is supported by the Medical Research Council (MC_UU_00011/1 and MC_UU-00011/2). TGR is a UKRI Innovation Research Fellow (MR/S003886/1). MAK is supported by a Senior Research Fellowship from the National Health and Medical Research Council (NHMRC) of Australia (APP1158958) and a research grant from the Sigrid Juselius Foundation, Finland. BAF is supported by the National Institute for Health Research (NIHR) Cambridge Biomedical Research Centre at the Cambridge University Hospitals NHS Foundation Trust. MVH works in a unit that receives funding from the UK Medical Research Council and is supported by a British Heart Foundation Intermediate Clinical Research Fellowship (FS/18/23/33512) and the National Institute for Health Research Oxford Biomedical Research Centre. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.