Pharmacological Inhibition of CETP (Cholesteryl Ester Transfer Protein) Increases HDL (High-Density Lipoprotein) That Contains ApoC3 and Other HDL Subspecies Associated With Higher Risk of Coronary Heart Disease

Arterioscler Thromb Vasc Biol. 2022 Feb;42(2):227-237. doi: 10.1161/ATVBAHA.121.317181. Epub 2021 Dec 23.


Objective: Plasma total HDL (high-density lipoprotein) is a heterogeneous mix of many protein-based subspecies whose functions and associations with coronary heart disease vary. We hypothesize that increasing HDL by CETP (cholesteryl ester transfer protein) inhibition failed to reduce cardiovascular disease risk, in part, because it increased dysfunctional subspecies associated with higher risk such as HDL that contains apoC3. Approach and Results: We studied participants in 2 randomized, double-blind, placebo-controlled trials of a CETP inhibitor on a background of atorvastatin treatment: ACCENTUATE (The Addition of Evacetrapib to Atorvastatin Compared to Placebo, High Intensity Atorvastatin, and Atorvastatin With Ezetimibe to Evaluate LDL-C Lowering in Patients With Primary Hyperlipidemia; 130 mg evacetrapib; n=126) and ILLUMINATE (Phase 3 Multi Center, Double Blind, Randomized, Parallel Group Evaluation of the Fixed Combination Torcetrapib/Atorvastatin, Administered Orally, Once Daily [Qd], Compared With Atorvastatin Alone, on the Occurrence of Major Cardiovascular Events in Subjects With Coronary Heart Disease or Risk Equivalents; 60 mg torcetrapib; n=80). We measured the concentration of apoA1 in total plasma and 17 protein-based HDL subspecies at baseline and 3 months. Both CETP inhibitors increased apoA1 in HDL that contains apoC3 the most of all HDL subspecies (median placebo-adjusted percent increase: evacetrapib 99% and torcetrapib 50%). They also increased apoA1 in other HDL subspecies associated with higher coronary heart disease risk such as those involved in inflammation (α-2-macroglobulin and complement C3) or hemostasis (plasminogen), and in HDL that contains both apoE and apoC3, a complex subspecies associated with higher coronary heart disease risk. ApoA1 in HDL that contains apoC1, associated with lower risk, increased 71% and 40%, respectively. Only HDL that contains apoL1 showed no response to either drug.

Conclusions: CETP inhibitors evacetrapib and torcetrapib increase apoA1 in HDL subspecies that contain apoC3 and other HDL subspecies associated with higher risk of coronary heart disease. Subspecies-specific effects shift HDL subspecies concentrations toward a profile associated with higher risk, which may contribute to lack of clinical benefit from raising HDL by pharmaceutical CETP inhibition.

Keywords: apolipoproteins; cholesterol ester transfer proteins, antagonists & inhibitors; heart diseases; hydroxymethylglutaryl-CoA reductase inhibitors; lipoproteins, HDL.

Publication types

  • Clinical Trial, Phase III
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anticholesteremic Agents / therapeutic use*
  • Apolipoprotein C-III / blood
  • Atorvastatin / therapeutic use
  • Benzodiazepines / therapeutic use*
  • Cholesterol Ester Transfer Proteins / antagonists & inhibitors*
  • Coronary Disease / blood*
  • Coronary Disease / etiology
  • Ezetimibe / therapeutic use
  • Female
  • Heart Disease Risk Factors
  • Humans
  • Hyperlipidemias / blood
  • Hyperlipidemias / complications
  • Hyperlipidemias / drug therapy*
  • Lipoproteins, HDL / blood*
  • Male
  • Middle Aged


  • Anticholesteremic Agents
  • Apolipoprotein C-III
  • CETP protein, human
  • Cholesterol Ester Transfer Proteins
  • Lipoproteins, HDL
  • Benzodiazepines
  • evacetrapib
  • Atorvastatin
  • Ezetimibe