MultiEthnic Study of Atherosclerosis MESA 1 MESA is

Multi-Ethnic Study of Atherosclerosis (MESA) 1. MESA is a large (n=6, 814) multi-center NIH/NHLBI observational study of the pathogenesis and progression of subclinical atherosclerosis. • • Mean age 61. 4 years Study population- 38% White, 28% African American, 22% Hispanic, and 12% Chinese, with 53% women 2. Baseline blood samples permit study of relations of lipids and lipoproteins to carotid atherosclerosis (intima-media thickness, IMT), and shortly also to incident CVD events. 3. Lipoprotein particle measurements were performed by nuclear magnetic resonance (NMR) spectroscopy at Lipo. Science (Raleigh, NC) Publications to date: Mora S et al. , Atherosclerosis 2007; 192: 211 -217. Otvos et al. J of Clinical Lipidology 2011, epub. 1

Concordance/Discordance Between LDL-C and LDL-P in MESA Discordant LDL-P >LDL-C by +20 percentile Concordant < 20 percentile difference Discordant LDL-P < LDL-C by -20 percentile N (%) Cholesterol Molecules per LDL Particle 822 1837 (15%) Cholesterol-poor 3, 677 2392 863 3085 (69%) (16%) Cholesterol-rich LDL-C LDL-P (percentile) 105 1480 mg/d. L nmol/L (37 th) (73 rd) 119 1300 (55 th) 136 1145 (75 th) (36 th) Lipo. Science unpublished data 2

Cumulative Probability of Incident CVD Event LDL-P and LDL-C Discordance in MESA Relations with Incident CVD Events 0. 04 LDL-P>LDL-C 0. 03 0. 02 0. 01 LDL-P LDL-C 1448 107 1296 118 1175 133 Concordant LDL-P<LDL-C Follow-Up (Days) Otvos et al. J of Clinical Lipidology 2011

The Clinical Relevance of LDL-P vs LDL-C: The Issue of Discordance N (%) Overall 5, 362 Discordant 3, 071 ± 10 percentile Discordant ± 20 percentile Discordant ± 30 percentile IMT in µm per 1 SD LDL-P IMT in µm per 1 SD LDL-C 40. 8 35. 8 (p<0. 0001) 39. 4 23. 7 (57%) (p<0. 0001) (p=0. 0005) 1, 685 37. 0 4. 9 (31%) (p<0. 0002) (p=0. 62) 834 56. 1 1. 0 (16%) (p=<0. 0001) LDL-P 1592 nmol/l LDL-C 97 mg/dl (p=0. 94) LDL-P 1058 nmol/l LDL-C 147 mg/dl 4

COMETS Study Design Patients (n=401) RSV 10 mg (n=165) RSV 20 mg ATV 10 mg (n=157) ATV 20 mg Placebo (n=79) RSV 20 mg Metabolic syndrome CHD risk >10% Statin-naïve ≥ 18 years Visit: 1 Week: – 4 2 – 2 Dietary run in/ eligibility 3 0 4 6 5 12 Lipids hs. CRP Safety RSV=rosuvastatin; ATV=atorvastatin; hs. CRP=high-sensitivity C-reactive protein n=number of patients randomised Stalenhoef AFH et al. Eur Heart J 2005: 24: 2664 -72 5

COMETS: Percent LDL Lowering by Statin Monotherapy in Metabolic Syndrome Patients Rosuvastatin Percent Reduction 0 Atorvastatin 0 168 1960 10 10 20 20 30 1260 40 1210 38% 93 50 84 60 Baseline 6 weeks (10 mg) 50% 171 1870 Fewer LDL particles 1300 30 40 1260 105 95 50 33% 44% Less cholesterol per particle 60 12 weeks (20 mg) Less cholesterol per LDL particle LDL-C (mg/d. L) Baseline 6 weeks (10 mg) 12 weeks (20 mg) Less cholesterol per LDL particle LDL-P (nmol/L) 6 Rosenson RS and Otvos J, unpublished data

7 J of Clin Lipid. 2009, 3, 45 -50

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LDL-P Reduction on S 20, S 80 and S 20/N at 12 months -10% -22% -35% -8% -21% -38% 9

Role of Lipoproteins in Type 2 Diabetes 13

Time Course of Type 2 Diabetes • Metabolic changes in T 2 DM occurs over time and hepatic insulin resistance manifests its earliest measurable abnormalities in changes in lipoprotein metabolism with modest change in fasting glucose levels. • The metabolic changes induced by or accompanying insulin resistance produce more extensive abnormalities in lipoprotein subclass levels and particle size distributions, elevation in triglycerides, and reductions in HDL cholesterol. • More specifically, NMR measured large VLDL and small LDL subclass particle concentrations are higher and large HDL subclass levels are lower in insulin resistant. NMR-measured VLDL, and HDL particle sizes also reflect insulin resistance status. 14

Results From the Insulin Resistance Atherosclerosis Study Normal Glucose Tolerance (NGT) Impaired Glucose Tolerance (IGT) Diabetes (DM) P values 433. 1 550. 8 636. 3 0. 0001 21. 4 21. 2 20. 9 0. 0001 2. 6 3. 5 4. 7 0. 0001 48. 1 51. 3 55. 2 0. 0001 Large HDL-P (umol/L) 5. 1 4. 5 3. 9 0. 0001 HDL-P size (nm) 9. 0 8. 9 8. 8 0. 0001 Small LDL-P (nmol/L) LDL-P size (nm) Large VLDL-P (nmol/L) VLDL-P size (nm) NMR Lipoprotein Particle Concentrations In Normal Glucose Tolerance (NGT), Impaired Glucose Tolerance (IGT), Diabetes (DM) Subjects 15 Goff, Metabolism 2005; 54: 264 -70

Women’s Health Study Adjusted hazard ratios for the association of lipoprotein measure with incident type 2 diabetes in quintiles 1 through 5 Small LDL-P (nmol/L) LDL-P size (nm) Large VLDL-P (nmol/L) VLDL-P size (nm) Large HDL-P (µmol/L) HDL-P (nm) Quintile 1 (<346) Quintile 2 (347 -553) Quintile 3 (554 -774) Quintile 4 (775 -1134) Quintile 5 (>1134) Ref. 1. 54 2. 09 2. 62 4. 04 Quintile 1 (<20. 5) Quintile 2 (20. 6 -21. 0) Quintile 3 (21. 1 -21. 5) Quintile 4 (21. 6 -21. 9) Quintile 5 (>21. 9) 4. 16 3. 04 2. 21 1. 63 Ref. Quintile 1 (<0. 1) Quintile 2 (0. 2 -0. 5) Quintile 3 (0. 6 -1. 8) Quintile 4 (1. 9 -3. 8) Quintile 5 (>3. 8) Ref. 1. 49 2. 54 2. 98 3. 11 Quintile 1 (<40. 6) Quintile 2 (40. 7 -43. 8) Quintile 3 (43. 9 -47. 3) Quintile 4 (47. 4 -52. 0) Quintile 5 (>52. 0) Ref. 1. 25 1. 67 2. 22 2. 80 Quintile 1 (<4. 0) Quintile 2 (4. 1 -5. 8) Quintile 3 (5. 9 -7. 7) Quintile 4 (7. 8 -10. 0) Quintile 5 (>10. 0) 4. 51 3. 19 2. 54 1. 72 Ref. Quintile 1 (<8. 5) Quintile 2 (8. 6 -8. 7) Quintile 3 (8. 8 -9. 0) Quintile 4 (9. 1 -9. 4) Quintile 5 (>9. 4) 4. 56 3. 97 3. 08 1. 72 Ref. Mora et al. 2010. Diabetes 16

Time Course of the Pathogenesis of Type 2 Diabetes 17

Decreasing Density / Density (g/ml) What are various types of Lipoproteins? 0. 95 VLDL IDL 1. 006 1. 02 Apo A 1 1. 06 1. 10 LDL Cholesterol HDL 2 HDL 3 1. 20 5 Chylomicron Remnants HDL Cholesterol 10 20 Triglycerides (mainly) Apo B 40 60 Increasing Size /Diameter (nm) 80 1000

Lipoprotein Particle Structure (VLDL, IDL) Apolipoprotein B (Apo B) POLAR SURFACE COAT NONPOLAR LIPID CORE Phospholipid Free cholesterol Cholesterol Ester Triglyceride

Lipoprotein Particle Structure (HDL) Apolipoprotein A 1 (Apo A 1) POLAR SURFACE COAT NONPOLAR LIPID CORE Phospholipid Free cholesterol Cholesterol Ester Triglyceride Apolipoprotein A 1 (Apo A 1)