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Crit Rev Clin Lab Sci, Early Online: 1–16

! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/10408363.2014.992063

REVIEW ARTICLE

Oxidized low-density lipoprotein as a biomarker of cardiovascular

diseases
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Andreja Trpkovic1, Ivana Resanovic1, Julijana Stanimirovic1, Djordje Radak2, Shaker A. Mousa3,
Desanka Cenic-Milosevic4, Danimir Jevremovic4, and Esma R. Isenovic1
1
Laboratory of Radiobiology and Molecular Genetics, Vinca Institute of Nuclear Sciences, University of Belgrade, Belgrade, Serbia, 2Department of
Vascular Surgery, Dedinje Cardiovascular Institute, University of Belgrade, Belgrade, Serbia, 3Pharmaceutical Research Institute, Albany College of
Pharmacy and Health Sciences, Albany, NY, USA, and 4Faculty of Stomatology in Pancevo, University Business Academy in Novi Sad, Novi Sad,
Serbia

Abstract Keywords
Atherosclerosis is a life-long illness that begins with risk factors, which in turn contribute to the Atherogenesis, biomarker, cardiovascular risk
development of subclinical disease, followed by the establishment of overt cardiovascular assessment, lipoprotein (a), oxidized
disease (CVD). Thrombotic-occlusive complications of atherosclerosis are among the most lipoproteins, statins
widespread and costly health problems. Oxidized low-density lipoprotein (OxLDL) plays an
important role in atherogenesis by promoting an inflammatory environment and lipid History
For personal use only.

deposition in the arterial wall. As cardiovascular events occur in individuals without common
risk factors, there is a need for additional tools that may help in CVD risk assessment and Received 23 June 2014
management. The use of biomarkers has improved diagnostic, therapeutic and prognostic Revised 29 September 2014
outcome in cardiovascular medicine. This review elaborates on the value of circulating OxLDL Accepted 20 November 2014
as a biomarker of CVD. Three enzyme-linked immunosorbent assays (4E6, DLH3 and E06) using Published online 24 December 2014
murine monoclonal antibodies for determination of OxLDL blood levels have been developed.
However, none of these assays are currently approved for routine clinical practice. We identified
studies investigating OxLDL in CVD (measured by 4E6, DLH3 or E06 assay) by searching
the PubMed database. Circulating OxLDL was found to be associated with all stages of
atherosclerosis, from early atherogenesis to hypertension, coronary and peripheral arterial
disease, acute coronary syndromes and ischemic cerebral infarction. The results of studies
investigating the usefulness of OxLDL for CVD prediction were also summarized. Furthermore,
OxLDL was found to be associated with pathologic conditions linked to CVD, including diabetes
mellitus, obesity and metabolic syndrome (MetS). In addition, we have addressed the
mechanisms by which OxLDL promotes atherogenesis, and the effects of antiatherogenic
treatments on circulating OxLDL. Finally, we highlight the evidence suggesting that lipoprotein
(a) [Lp(a)] is the preferential carrier of oxidized phospholipids (OxPL) in human plasma. A strong
association between OxPL/apoB level (representing the content of OxPL on apolipoprotein
B-100 particles, measured by E06 assay) and Lp(a) has been determined.

Abbreviations: AMI: acute myocardial infarction; ApoB-100: apolipoprotein B-100; CHD:

coronary heart disease; CHF: chronic heart failure; cIMT: carotid intima-media thickness; CRP:
C-reactive protein; CV: cardiovascular; CVD: cardiovascular diseases; Ig: immunoglobulin; LDL:
low-density lipoprotein; LDL-C: LDL-cholesterol; LFHC: low-fat high-carbohydrate; LOX-1:
lecitin-like oxidized low-density lipoprotein receptor-1; Lp(a): lipoprotein (a); MCP-1: monocyte
chemotactic protein-1; MetS: metabolic syndrome; NF-iB: nuclear factor kappa B; NO: nitric
oxide; OxLDL: oxidized low-density lipoprotein; OxPL: oxidized phospholipids; PCI: percutan-
eous coronary intervention; PCSK9: proprotein convertase subtilisin/kexin type 9; PTCA:
percutaneous transluminal coronary angioplasty; sdLDL: small dense LDL; ROS: reactive oxygen
species; VSMC: vascular smooth muscle cells

Referees: Dr. Francesco Cappello, University of Palermo, Palermo, Italy; Dr. Nebojsa Nick Knezevic, Anesthesiology, University of Illinois, IL, USA;
Dr. Boban Stanojevic, Kyoto University School of Medicine, Kyoto, Japan
Address for correspondence: Prof. Dr Esma R. Isenovic, Laboratory of Radiobiology and Molecular Genetics, Vinca Institute of Nuclear Sciences,
University of Belgrade, Mike Petrovica Alasa 12-14 Street, P.O. Box 522, 11000 Belgrade, Serbia. Tel/ Fax: +38111-3408147. E-mail:
isenovic@yahoo.com
 2 A. Trpkovic et al.
Introduction
Prevention and treatment of cardiovascular disease (CVD) are
among the most important public health issues worldwide. As
cardiovascular (CV) events occur in subjects without estab-
lished risk factors, there is a necessity for additional clinical
tools that may help in screening and management of CVD1.
Among these, biomarkers are an important addition to CV
risk assessment2. A clinically useful biomarker: (a) should be
easily measurable; (b) should add incremental information
regarding the disease of interest; and (c) should help the
clinician to manage patients3.
Over the past decade, numerous biomarkers have been
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related to CV risk, from genomic to imaging tests4. However,
circulating biomarkers are particularly attractive as they are
usually easy to measure and are generally reproducible5. The
focus of this review is on oxidized low-density lipoprotein
(OxLDL), a circulating biomarker associated with CVD. This
biomarker indicates oxidative stress that in a pathophysiologic
setting promotes atherogenesis6. However, none of the assays
used for OxLDL measurement are currently approved for
routine clinical practice.
Here, we discuss the role of OxLDL in atherogenesis and
consider the results of clinical trials examining the value of
this biomarker in CVD management and risk assessment.
Clinical studies utilizing three OxLDL assays (4E6, DLH3
and E06) were identified by searching the PubMed database
(until April 2014). The search terms ‘‘OxLDL and cardio-
For personal use only.
vascular disease’’, ‘‘OxLDL and coronary heart disease’’,
‘‘OxLDL and hypertension’’, ‘‘OxLDL and chronic heart
failure’’, ‘‘OxLDL and carotid artery disease’’, ‘‘OxLDL and
cerebral vascular disease’’, ‘‘OxLDL and femoral artery
disease’’, ‘‘OxLDL and insulin resistance’’, ‘‘OxLDL and
diabetes’’, ‘‘OxLDL and metabolic syndrome’’ and ‘‘OxLDL
and obesity’’ were used. Only articles and abstracts that were
published in English were included.
Oxidative modification of LDL
Low density lipoprotein (LDL) is the major carrier of
cholesterol to body tissues. Elevated LDL-cholesterol (LDL-
C) level is a well-recognized risk factor for CVD. The
measurement of LDL-C is routinely used for CVD risk
assessment and risk management7,8. Nearly 80% of human
LDL is composed of lipids and more than a half of these
molecules contain polyunsaturated fatty acids9. The LDL
particles are grouped into seven density subclasses: large LDL-
I, medium LDL-IIa and -IIb, small LDL-IIIa and III-b and very
small LDL-IVa and -IVb. Individuals tend to cluster into two
broad subgroups, the majority with a predominance of large- or
medium-sized LDL (LDL pattern A) and a substantial minority
with a higher proportion of smaller LDL particles (LDL
pattern B). A significant association between small dense LDL
(sdLDL) and increased CV risk has been established10.
The shell of LDL contains one molecule of apolipoprotein
B-100 (apoB-100) that is recognized by LDL receptors
in peripheral tissues11,12. After endocytosis, both LDL and its
receptor are internalized into the cell followed by hydrolysis
of cholesterol esters in the lysosomes13,14. It is proposed that
proprotein convertase subtilisin/kexin type 9 (PCSK9) plays a
major role in regulation of LDL receptor activity, primary by
Crit Rev Clin Lab Sci, Early Online: 1–16
promoting degradation of the LDL receptor in the liver15.
The mechanisms through which this occurs are complex and
have not been fully elucidated. Recent studies indicate that, in
the liver, PCSK9 directly interacts with the LDL receptor
not only at the surface of the hepatocyte plasma membrane
but also within the cell16,17. It is suggested that extracellular
PCSK9 secreted from cells is subsequently internalized
together with the LDL receptor, leading to LDL receptor
degradation18,19. Furthermore, PCKS9 can interact with the
LDL receptor after biosynthesis, before it reaches the
basolateral surface of the hepatocyte19,20. Interestingly, it
appears that the LDL receptor can control intracellular
trafficking of PCSK9 from the endoplasmic reticulum to
down-stream sites, but the mechanism of interaction between
the LDL receptor and PCSK9 seems to differ in the
endoplasmic reticulum and at the cell surface19,21. In addition,
literature suggests that PCSK9 can promote degradation of
the LDL receptor independent of its proteolytic activity22–24.
However, it was shown that the levels of the LDL receptor do
not change when an inactive enzyme is expressed in the
liver25 or in cultured liver cells26,27. Taken together, these
findings indicate that autocatalytic activity is necessary for
PCSK9 to leave the endoplasmic reticulum, but it is still
unclear if this activity is required for the degradation of
LDL receptor stimulated by PCSK928. Evidence indicates
the existence of a physical association between PCSK9
and the LDL receptor, since the LDL receptor can be
co-immunoprecipitated with PCSK9 after PCSK9 is added
exogenously to cells18,28. When the cell has sufficient
cholesterol, LDL receptor synthesis is reduced so additional
LDL molecules cannot be taken up29. Thus, PCSK9 inhibition
(leading to decreased degradation of the LDL receptor) is
becoming a highly attractive new strategy for lowering LDL-
C levels, especially in combination with antihyperlipidemic
drugs such as statins. We have previously described hypo-
thetical mechanisms of PCSK9 action including possible
target sites for inhibition of PCSK9 activation by lipid
lowering drugs at different levels of regulation, i.e. PCSK9
mRNA transcription, translation, post-translational modifica-
tion and inhibition by competitive binding to the epidermal
growth factor-like repeat A domain on the LDL receptor30.
An increase in plasma LDL levels leads to an increase in
the adherence of circulating monocytes to arterial endothelial
cells, and at the same time, to increased entry of LDL into
the vascular intima31. Native LDL, however, cannot induce
cholesterol accumulation in monocytes/macrophages, rather,
the increase is due to the uptake of one or more modified
forms of LDL32. The major modification that can cause
cholesterol accumulation is oxidation of LDL33. The oxida-
tion of LDL is a complex process during which both the
protein and the lipids undergo oxidative changes through
enzymatic and non-enzymatic pathways and form complex
products32,34,35. It is hypothesized that under conditions of
oxidative stress, OxLDL formation predominantly occurs
within the extracellular space of the vascular wall.
Furthermore, sdLDL particles more easily penetrate into the
subendothelial space of the vascular wall, and were shown to
be more prone to oxidation6. However, LDL oxidation may
not only occur extracellularly; the process of oxidation may
continue as the LDL particles are degraded by lysosomal
 DOI: 10.3109/10408363.2014.992063
enzymes within macrophages36. It seems that many of the
biological effects of OxLDL require generation of additional
intracellular reactive oxygen species (ROS)37. The process of
LDL oxidation is assumed to occur in two main steps. During
the initial stage, lipid oxidation can occur in the absence of
changes or with slight modification in the apoB-100 structure.
Such modified LDL, called minimally modified LDL, retains
its affinity to the LDL receptor32. However, this molecule
activates antiapoptotic signaling and induces inflammatory
changes which, in turn, further promote the oxidation
process38,39. Low-density lipoprotein undergoes various
degrees of oxidation and these oxidation products exert
different biological effects32. Importantly, with further LDL
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oxidization and LDL protein modification, loss of recognition
by the LDL receptor occurs40. The OxLDL binds with high
affinity to several receptors other than the native LDL
receptor. These receptors belong to scavenger receptor class A
(type I and II, MACRO, SRCL), class B (CD36, SR-BI), class
D (CD68, expression responsive to OxLDL but does not act as
receptor), class E (lecitin-like OxLDL receptor-1 [LOX-1]),
class F (SREC), class G (SP-PSOX) and the Fc receptor
family (Fcg)41,42. Among these, SR-A type I and II, CD36 and
LOX-1 are most extensively studied and were shown to be
implicated in receptor-mediated uptake of OxLDL. Thus, the
uptake of OxLDL by macrophages is more rapid, sufficient to
cause cholesterol accumulation. Furthermore, it has been
shown that receptors for OxLDL are not only present on
For personal use only.
macrophages but also on other cells, including endothelial
cells, smooth muscle cells and fibroblasts37,41. It has been
postulated that the physiological role of scavenger receptors
on macrophages is to recognize and phagocytose apoptotic
and necrotic cells, and that these receptors recognize the same
or similar ligands on OxLDL43. Importantly, these receptors
are exposed by the innate immune system in defense against
various pathogens44. Beside oxidative stress, inflammation is
considered to have a major role in the evolution of athero-
sclerotic cardiovascular disease40. Moreover, recent evidence
indicates that these pathophysiologic processes are interre-
lated45,46. C-reactive protein (CRP) is a general marker of
inflammation and its direct role in atherogenesis is plaus-
ible47,48. However, CRP gene polymorphisms associated with
higher CRP levels in humans were found not to be associated
with increased rates of coronary heart disease (CHD)49.
Notably, high-sensitivity CRP (which reflects low-grade
inflammatory process) has already been established as a
biomarker of CVD50. Some biological effects of CRP are
mediated through LOX-1, suggesting an important cross-talk
between CRP and lipid processing45. Accordingly, CRP was
found to bind both OxLDL and LOX-151–53. Importantly, CRP
was shown to enhance the release of soluble LOX-1 from
macrophages and to increase the expression of LOX-1 in
endothelial cells54,55. Moreover, LOX-1 blockade was shown
to decrease pro-atherogenic effects of CRP in the
endothelium56.
OxLDL contributes to atherogenesis
The ingestion of OxLDL transforms macrophages into
foam cells57. The subendothelial accumulation of these cells
containing OxLDL and other lipoproteins represents the
OxLDL: A biomarker of CVD 3
formation of fatty streak lesion, a marker of early atheroscler-
osis58. Onward, the immune response drives the evolution of
the plaque by releasing proinflammatory mediators leading to
a chronic inflammatory reaction59. The evidence that OxLDL
plays an important role in the pathogenesis of atherosclerosis
established the ‘‘oxidative modification’’ hypothesis of
atherogenesis60–62. OxLDL exhibits a range of proatherogenic
properties, dominantly driven by oxidized phospholipids
(OxPL) within its structure63,64. Beside its effects on macro-
phages, OxLDL promotes: (a) activation and dysfunction of
endothelial cells, (b) migration and proliferation of vascular
smooth muscle cells (VSMC) and (c) platelet activation65.
OxLDL was found to upregulate LOX-1 expression in the
endothelial cells65. The adhesion of monocytes to the
endothelium involves both chemokines and adhesion mol-
ecules. Briefly, OxLDL is itself a chemoattractant for
monocytes66. Moreover, OxLDL was shown to stimulate
endothelial release of monocyte chemotactic protein-1 (MCP-
1)67. Recently, OxLDL was found to bind to MCP-168. In
addition, OxLDL was shown to induce endothelial expression
of granulocyte and macrophage colony-stimulating factors69,
and to inhibit the motility of tissue macrophages66.
Furthermore, in the endothelium, OxLDL increased the
expression of adhesion molecules (intercellular- and vascular
cell adhesion molecule-1, E-selectin, P-selectin), which
contributes to leukocyte adhesion70,71. Importantly, OxLDL
was found to (a) inhibit the expression of endothelial nitric
oxide synthase, and (b) inactivate nitric oxide (NO) by
increasing ROS production67,72,73. These negative effects
impair NO-related antiatherogenic properties, most import-
antly endothelium-mediated vasodilation.
OxLDL stimulates the generation of endothelin-1, and the
expression of angiotensin-converting enzyme, which further
contribute to vascular tone impairment65. OxLDL increases
ROS generation in the endothelium and activates nuclear
factor kappa B (NF-kB), which further modulates the
expression of proinflammatory genes65. Furthermore,
OxLDL exerts cytotoxic effects on endothelial cells74,75,
and triggers apoptosis of endothelial cells through activation
of NF-kB, caspase-9 and caspase-3, and increases surface
expression of the Fas receptor76–78. OxLDL also increases the
expression of matrix degrading enzymes (metalloproteinases-
1 and -3) involved in vascular remodeling79, and exerts
several negative effects on endothelial progenitor cells. These
cells are involved in antiatherognic processes by promoting
both the regeneration of the injured endothelium and its
neovascularization65. OxLDL has a multitude of actions on
VSMC, including their migration and proliferation80–82.
At higher concentrations, OxLDL upregulates LOX-1 expres-
sion and induces apoptosis of VSMC which may contribute to
plaque destabilization83. It also increases collagen synthesis
by VSMC84 and fibroblasts85 leading to formation of a fibrous
capsule, thus converting the fatty streak to an atheroma86. In
addition, OxLDL exerts several procoagulant/prothrombotic
activities. Namely, OxLDL induces plasminogen activator
inhibitor-1 upregulation in cultured endothelial cells which
attenuates fibrinolysis87. In vitro studies have shown that
OxLDL induces tissue factor expression in monocyte-derived
macrophages, endothelial cells and VSMC88–90.
Activated platelets internalize significant amounts of
 4 A. Trpkovic et al.
OxLDL through CD36 and LOX-191. OxLDL promotes
platelet activation, and OxLDL-positive platelets further
interact with the endothelium, thus, promoting vascular
inflammation and endothelial dysfunction92,93. Beside its
central role in atherogenesis, there is a possibility that low
levels of OxLDL could have atheroprotective effects through
mechanisms involving cytoprotection and reverse cholesterol
transport94.
Interestingly, OxLDL has been identified as an autoanti-
gen, inducing antibodies against its oxidation-specific
epitopes95,96. Based on experimental and clinical data,
immunoglobulin (Ig) G (IgG) autoantibodies to LDL oxida-
tion-specific epitopes appear to be atherogenic while IgM
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autoantibodies seem to confer atheroprotection97. Recently,
IgM autoantibodies were found to represent a high proportion
(up to 30%) of all circulating IgM antibodies98. Notably, IgM
antibodies to LDL oxidation specific epitopes share com-
plete genetic and structural identity with antibodies that
protect against common infectious pathogens, including
Streptococcus pneumoniae99. This article addresses the utility
of OxLDL, but not the autoantibodies to LDL oxidation
specific epitopes, as a potential biomarker of CVD.
Measurement of circulating OxLDL
There has been growing interest in measuring circulating
OxLDL to evaluate its potential use in clinical practice as a
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biomarker of CVD. The fully oxidized LDL is expected to
have a short half-life in the blood as it is likely to be cleared
rapidly from the circulation by the reticuloendothelial
system6. However, small but significant amounts of OxLDL
are detectable in the blood37. Enzyme-linked immunosorbent
assays utilizing three murine monoclonal antibodies for
determination of OxLDL plasma levels have been developed
since the late 1990s100. The OxLDL-4E6 antibody, directed
against an epitope generated as a result of substitution of
lysine residues in apoB-100 with aldehydes, was first to be
established101. However, the epitope recognized by the 4E6
antibody is generated after modification of at least 60 lysine
groups on apoB-100 and therefore, OxLDL with fewer lysine
modifications cannot be detected using this assay102. Another
limitation of this assay is the correlation between OxLDL and
plasma LDL levels, suggesting cross-reactivity with native
LDL; however, the 4E6 antibody binds approximately 1000
times stronger to OxLDL than native LDL100. Although the
4E6 antibody has been utilized in the largest number of
clinical trials, OxLDL-4E6 does not specifically bind to LDL
oxidation-specific epitopes, which may limit its clinical
utility103. To overcome these problems, the OxLDL-DLH3
antibody, which binds to oxidized products of phosphatidyl-
choline, was introduced104–106. Another monoclonal antibody
was raised, the OxLDL-E06, which recognizes phosphor-
ylcholine, the hydrophilic moiety in phospatidylcholine107,108.
Hence, the OxLDL-E06 and OxLDL-DLH3 antibodies bind
oxidized but not native phospholipids109.
Two assays utilizing the 4E6 antibody have been devel-
oped. In the non-competitive assay, OxLDL is captured from
plasma with the 4E6 antibody attached to a microtiter plate,
while the content of apoB-100 is detected with a secondary
antibody. In the competitive assay, the plasma sample together
Crit Rev Clin Lab Sci, Early Online: 1–16
with the biotinylated 4E6 antibody is added to microtiter
wells plated with a standard human OxLDL preparation.
Reduced binding of the 4E6 antibody to the OxLDL attached
to the plates implies higher plasma OxLDL levels. The results
are presented as units/L (U/L). Diluted plasma is used in
both assays and the results obtained by these procedures
compare fairly well100.
The original DLH3 assay requires isolated LDL instead
of plasma, which is a labor-intensive and time-consuming
procedure100. The methodology is similar to the 4E6 assay,
where the oxidation epitopes are recognized by a DLH3
antibody attached to the microtiter plate, and the captured
apoB-100 is detected with an anti-human apoB polyclonal
antibody. Since the same amount of isolated LDL is applied
to every microtiter well, the result does not directly represent
the OxLDL concentration in plasma, but rather the ratio of
oxidatively modified particles in the LDL fraction, expressed
as ng OxLDL/mg LDL. More recently, a commercial kit
utilizing whole plasma instead of isolated LDL has been
developed. This assay provides the measurement of OxLDL
in plasma. Namely, a reference OxLDL is used to generate the
standard curve and the assay results are presented as units/mL
(U/mL) where 1 unit equals the absorbance of 250 ng of the
reference OxLDL100. However, the values obtained with this
assay do not appear to correlate highly with the results
obtained with isolated LDL102.
With the E06 assay, all plasma apoB-100 is first captured
on the microtiter plates using the specific MB47 antibody.
The biotinylated E06 antibody is then added to bind OxPL on
the captured apoB-100 particles. The E06 antibody is
designated as an OxPL/apoB assay because it captures Ox-
LDL on all apoB-100 containing particles including LDL,
lipoprotein (a) [Lp(a)], intermediate-density lipoprotein and
very low-density lipoprotein. This is detected using a
chemiluminescent technique and reported in relative light
units per 100 milliseconds. Thus, OxPL/apoB is specific to
the number of all OxPL epitopes on individual apoB particles,
but does not measure the total amount of OxPL in plasma. In
a version of this assay prior to 2006, the total amount of apoB
was determined by parallel sandwich assay using MB24 and
MB47 anti-apoB monoclonal antibodies in order to document
that all wells captured the same amount of apoB98. The reader
is notified that in the further text the results of studies carried
out with the E06 assay are referred to as OxLDL levels unless
specifically noted as OxPL/apoB levels.
Use of OxLDL in CV medicine
Although OxLDL immunoassays show acceptable precision,
the results obtained in studies that assessed plasma levels of
OxLDL with different antibody assays could not be easily
compared. These three antibodies detect different epitopes
and the assays use different units of measurement. However,
the assessment of OxLDL has been the most common
oxidative stress biomarker used in studies investigating
CVD110. In addition, none of these assays are currently
approved for routine clinical use. In the general population,
OxLDL levels were shown to vary according to race/ethnicity,
with blacks having the highest levels, followed by whites and
by Hispanics111. The growing number of clinical studies,
 DOI: 10.3109/10408363.2014.992063 OxLDL: A biomarker of CVD 5
Table 1. Clinical studies investigating OxLDL (determined by 4E6, DLH3 or E06 assay) in cardiovascular, peripheral arterial and cerebrovascular
diseases.

Pathological condition Reference, assay

(I) Hypertension:
1. OxLDL is associated with blood pressure in subjects with pre-hypertension:
114
Positive 4E6
115
Negative E06
116
2. Patients with hypertension have higher OxLDL level than normotensive subjects 4E6; 117E06
118
3. OxLDL is increased in the elderly with hypertension 4E6
119
4. OxLDL is associated with hypertension in patients with normal angiogram DLH3
(II) Coronary heart disease:
123
1. Patients with CHD have higher OxLDL level than subjects without CHD 4E6; 106DLH3; 124DLH3; 122DLH3; 133E06; 1254E6;
131
4E6; 130DLH3; 1264E6; 1324E6; 1284E6; 1274E6;
129
DLH3; 1344E6
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122
2. OxLDL level increases after AMI DLH3; 1234E6; 124DLH3; 119DLH3; 135DLH3; 108E06;
136
DLH3
122
3. OxLDL level is higher in AMI patients than in those with unstable/stable angina DLH3; 137DLH3; 124DLH3; 135DLH3; 138DLH3
139
4. OxLDL level is higher in patients with unstable than in those with stable angina 4E6; 1264E6; 1274E6
140
5. OxLDL level rises after PCI and PTCA DLH3; 141E06; 143DLH3; 142E06; 144E06
6. Association of OxLDL level with the burden of coronary atherosclerosis:
133
Positive E06; 149DLH3; 1394E6; 1274E6; 134
4E6
106
Negative DLH3; 119DLH3; 141E06
7. OxLDL level predicted future CV events:
150
Positive E06; 1514E6; 152E06; 153
4E6; 154
DLH3; 155
4E6;
156
4E6; 1574E6
161
Negative 4E6
8. OxLDL level predicted stent restenosis:
140
Positive DLH3
162
Negative 4E6; 141E06
(III) CHF:
163
1. OxLDL level is higher in severe form of CHF than in patients with mild CHF 4E6
164
2. OxLDL level predicted future mortality/morbidity in CHF patients DLH3
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(IV) Carotid artery disease:

165
1. Early atherosclerosis: OxLDL level is associated with cIMT 4E6; 1664E6; 167
4E6; 168
4E6; 169
4E6; 170
4E6; 171
4E6
170
2. OxLDL level is increased in patients with carotid artery disease 4E6
173
3. OxLDL is associated with carotid plaque instability DLH3
4. Association of OxLDL level with the burden of carotid atherosclerosis:
177 178
Positive 4E6; E06
179
Negative 4E6
(V) Cerebral infarction:
176 184
1. OxLDL level increases after ischemic cerebral infarction DLH3; DLH3
(VI) Femoral artery disease:
179 178 170
1. OxLDL is associated with the presence of femoral plaques 4E6; E06; 4E6
180
2. OxLDL is associated with femoral plaque instability 4E6

OxLDL: oxidized low-density lipoprotein; CHD: coronary heart disease; AMI: acute myocardial infarction; PCI: percutaneous coronary intervention;
PTCA: percutaneous transluminal coronary angioplasty; CV: cardiovascular; CHF: chronic heart failure; cIMT: carotid intima-media thickness.

utilizing the aforementioned assays yielded intriguing con-
cordance in OxLDL values in CVD. We will further discuss
the results of these studies not only in CVD but also in
pathologic conditions linked to CVD, like diabetes, obesity
and metabolic syndrome (MetS) (Tables 1 and 2).
OxLDL in early atherosclerosis
Circulating OxLDL was found to correlate with epicardial
and resistant coronary vasodilator responses to bradykinin in
patients with normal coronary angiogram, thus implying that
OxLDL could be used as a determinant of coronary endothe-
lial function112. In a population of apparently healthy subjects,
aged 35–55 years, elevated OxLDL levels were associated
with an increase in left ventricule wall thickness and a
decrease in left ventricule diastolic and systolic function.
These findings suggest the role of OxLDL in early cardiac
functional and structural damage113.
OxLDL in patients with hypertension
In a large sample (n ¼ 3042) of CVD-free adults, an
association of increased level of OxLDL (measured with the
4E6 assay) with both systolic and diastolic blood pressure was
found in subjects with pre-hypertension114. In contrast, there
was no difference in OxPL level (measured with the E06
assay) between normotensive and subjects with borderline
hypertension115. Patients with hypertension were found to
have increased OxLDL levels compared with normotensive
subjects116,117, and elderly individuals with hypertension were
also found to have increased OxLDL levels118. In addition,
hypertension was associated with plasma OxLDL level in
patients with normal coronary angiograms119.
OxLDL in patients with coronary heart disease
In patients with CHD, OxLDL was associated with impaired
acetylcholine-induced endothelium-dependent coronary
 6 A. Trpkovic et al. Crit Rev Clin Lab Sci, Early Online: 1–16

Table 2. Clinical studies investigating OxLDL (determined by 4E6, DLH3 or E06 assay) in insulin resistance, diabetes, MetS, obesity and
hypothyroidism.

Pathological condition Reference, assay

(I) Impaired glucose tolerance and insulin resistance:
186
1. OxLDL is increased in patients with impaired glucose tolerance 4E6
187 188 189
2. OxLDL is associated with insulin resistance 4E6; 4E6; 4E6
(II) Diabetes mellitus:
190 106 167
1. Increased OxLDL levels found in patients with diabetes in comparison to non-diabetics 4E6; DLH3; 4E6
193
2. OxLDL is associated with diabetes duration 4E6
(III) Obesity:
195 196 197 188 187 179
1. OxLDL is associated with obesity 4E6; 4E6; 4E6; 4E6; 4E6; 4E6
198 199
2. OxLDL is associated with visceral obesity and high waist circumference 4E6; 4E6
(IV) MetS:
203
1. Increased OxLDL levels found in subjects with MetS in comparison to those without MetS 4E6; 2044E6; 2004E6; 201
DLH3; 202
4E6;
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205
4E6; 2064E6
210
2. Increased OxLDL level is associated with increased incidence of MetS 4E6
(V) Hypothyroidism:
209
Increased OxLDL levels found in patients with overt hypothyroidism 4E6

OxLDL: oxidized low-density lipoprotein; MetS: metabolic syndrome.

vasodilation120. Furthermore, the arterial constrictive
remodeling, estimated with intravascular ultrasound imaging,
was associated with OxLDL level in de novo coronary disease
patients121. In a large number of studies, OxLDL plasma
levels were shown to be significantly elevated in CHD
patients compared to subjects with no CHD106,119,122–133. In
heart transplant patients, OxLDL plasma levels were signifi-
cantly lower in patients with angiographically normal coron-
For personal use only.
macrophage-derived foam cells124. These findings imply that
increased levels of OxLDL relate to plaque instability in
human atherosclerotic lesions. Intriguingly, in their recent
study, Uchida et al.148 have found that the incidence of
deposition of OxLDL in coronary arteries was highest in
yellow plaques followed by white plaques and normal
segments, respectively. Yellow plaques are generally asso-
ciated with greater vulnerability. However, there was a

ary arteries than in patients with mild or severe coronary
artery stenosis134. Notably, OxLDL was found to rise after
acute myocardial infarction (AMI)108,119,122–124,135. Peak
plasma OxLDL levels were seen 7 days after AMI136, with
a tendency to decrease over the following months108. The
OxLDL levels in patients with AMI were significantly higher
than in patients with unstable or stable angina122,124,135,137,138.
Similarly, patients with unstable angina exhibited marked
elevations in OxLDL levels when compared to patients with
stable angina126,127,139. Moreover, plasma OxLDL levels were
found to significantly increase after percutaneous coronary
intervention (PCI) and percutaneous transluminal angioplasty
in both patients with acute coronary syndromes and those
with stable angina140–144. After PCI, OxLDL levels were
found to return to baseline by 6 h142. However, in patients
with total coronary occlusion, OxLDL rose gradually and
progressively over the next 7 days after PCI144. The observed
increase in circulating OxLDL levels is believed to be due to
the release of OxLDL from the atherosclerotic plaque upon
rupture in AMI or disruption caused by PCI145. Interestingly,
OxLDL levels among persons with high CHD risk, but before
any CHD events, were found to be higher than in patients with
established CHD. A likely explanation is that once CHD is
diagnosed, individuals are frequently treated with a statin,
which is associated with lowering of LDL-C and OxLDL
levels146.
The presence of OxLDL within atherosclerotic coronary
lesions was confirmed by the application of monoclonal
antibodies139,144,147. The content of OxLDL-positive macro-
phages was significantly higher in the atherectomy specimens
obtained from patients with unstable angina than in those with
stable angina122. Furthermore, the strong positivity for
OxLDL was found in ruptured lipid cores with abundant
tendency that the incidence of OxLDL in yellow plaques
with necrotic cores was lower than in those without a necrotic
core. These results may imply that OxLDL begins to deposit
in the wall of the human coronary artery before plaque
formation and increasingly deposits with plaque growth, but
tends to decrease after the necrotic core is formed148.
Studies investigating association between circulating
OxLDL and the burden of coronary atherosclerosis yielded
conflicting results. In several studies, OxLDL levels were not
significantly related to the extent of CHD106,119,141. In
contrast, Tsimikas et al.133 found a strong and graded
association with the extent of CHD, particularly in patients
60 years of age and younger. Furthermore, in patients with
unstable angina, circulating OxLDL levels were shown to
correlate with the presence and number of angiographically
complex lesions127,139,149, and in heart transplant patients,
OxLDL plasma levels correlated with the extent of CHD134.
These conflicting results may be attributed to the spectrum of
patients with CHD, where the assays used do not detect the
same epitopes, and, importantly, the number of studies is
small.
The usefulness of OxLDL for CVD prediction was also
investigated. The OxLDL plasma level was associated with a
significantly higher risk of future cardiac events, independent
of traditional risk factors in patients without CHD150–153, as
well as in patients with prior CHD154–156. Moreover, OxPL/
apoB levels predicted future CV events beyond the informa-
tion provided by the Framingham Risk Score152. In heart
transplant patients, baseline levels of OxLDL predicted
cardiac transplant vasculopathy, and the development of
CHD was associated with a further increase of circulating
OxLDL157. In addition, subjects with high plasma OxLDL/
total cholesterol ratio were found to be at increased risk for
 DOI: 10.3109/10408363.2014.992063
development of AMI158. However, the results of other studies
showed that circulating OxLDL can predict the risk of CHD,
but not independently of other risk factors among which the
apoB and total cholesterol/high-density lipoprotein choles-
terol ratio had the strongest predictive value159,160.
Furthermore, Zuliani et al.161 could not demonstrate any
association between higher OxLDL plasma levels and CVD/
cardiac mortality rate in the elderly. After primary stent
implantation in patients with AMI, persistence of increased
OxLDL at hospital discharge was a strong independent
predictor of stent restenosis after 6-month follow-up140.
However, in other studies, serial measurements of circulating
OxLDL after PCI were found not to be predictive for
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restenosis141,162.
OxLDL in patients with chronic heart failure
In chronic heart failure (CHF) patients, circulating OxLDL
levels were significantly higher in those with severe forms of
the disease than in patients with mild heart failure. Notably,
exercise induced an increase in OxLDL in patients with CHF,
while this effect was not observed in control subjects163.
In patients with congestive disease, plasma OxLDL was
predictive for future mortality and morbidity164.
OxLDL in patients with peripheral arterial disease
A significant association was found between circulating
For personal use only.
OxLDL and carotid artery intima-media thickness (cIMT)
in clinically healthy subjects, in patients with hypertension,
hyperlipidemia and diabetes165–171. However, in children, no
significant correlation was observed between OxLDL levels
and cIMT172.
Plasma OxLDL levels were significantly higher in patients
with carotid atherosclerosis than in age-matched controls
without ischemic vascular disease or vascular risk factors173.
Accordingly, the amount of OxLDL in carotid plaques was
shown to be nearly 70 times higher than in plasma. There was
a strong correlation between carotid plaque OxLDL level and
the extent of macrophage infiltration. OxLDL level was
associated with the occurrence of echolucent (unstable)
carotid plaques174. Moreover, OxLDL was found to be
significantly higher in unstable than stable carotid pla-
ques175,176. In addition, high plasma and plaque OxLDL
levels were found to be associated with the vulnerability of
carotid lesions173.
The association between circulating OxLDL and the
burden of carotid atherosclerosis was also investigated.
Importantly, OxLDL, but not LDL, was associated with the
occurrence and extent of carotid atherosclerosis in clinically
healthy men177. Furthermore, OxLDL levels were strongly
associated with the presence, extent and development of
carotid atherosclerosis178. However, in the Asklepios study,
the presence of carotid plaques was not found to be
independently associated with OxLDL levels179.
Similar to patients with carotid atherosclerosis, OxLDL
was associated with femoral atherosclerosis170,179. Circulating
OxLDL was also shown to be associated with the occurrence
of echolucent femoral plaques180. In the Bruneck study,
OxLDL levels were strongly associated with the presence,
extent and development of femoral atherosclerosis178.
OxLDL: A biomarker of CVD 7
In the elderly, elevated plasma OxLDL was associated
with higher arterial stiffness (estimated by aortic pulse wave
velocity), a prominent feature of vascular aging strongly
related to CVD181. In children and adults, OxLDL and OxLDL/
apoB-100 levels were associated with a decrease in nitrogly-
cerin-mediated endothelium-dependent dilatation of brachial
artery, which has been shown to predict CV events182,183.
OxLDL in patients with cerebral vascular disease
Patients suffering from acute ischemic cerebral infarction, but
not cerebral hemorrhage, were found to have elevated OxLDL
levels. Interestingly, elevated plasma OxLDL levels were
found in patients with moderate cortical infarctions, but not in
those with massive hemispheric lesions184,185. In most
patients, plasma OxLDL levels were increased after cerebral
infarction and returned to baseline level over the following
30 days184.
OxLDL in patients with insulin resistance and diabetes
Increased levels of OxLDL were observed in patients with
impaired glucose tolerance186. Moreover, OxLDL was sig-
nificantly associated with insulin resistance in children, young
adults and the elderly187–189. In patients with diabetes,
significantly higher levels of OxLDL were found compared
with non-diabetics106,167,190. Furthermore, OxLDL was posi-
tively associated with diabetes type 2, fasting glucose and
insulin levels, and negatively with adiponectin188,191.
Oxidized LDL concentration corrected by apoB level
(OxLDL/apoB) was associated with macrovascular disease
and peripheral neuropathy in patients with type 2 diabetes192.
In addition, OxLDL was positively associated with diabetes
duration193. A significant association between plasma
OxLDL/LDL-C and CHD was found in males with diabetes
in a 10-year prospective study194.
OxLDL in patients with obesity and MetS
Obesity was also associated with elevated OxLDL
levels187,188,195–197. In addition, visceral obesity198 and high
waist circumference199 were associated with increased
OxLDL level. The OxLDL plasma levels found in subjects
with MetS were significantly higher than in those without
MetS200–204. In addition, higher OxLDL levels were found
in post-menopausal women with MetS205,206. In contrast, no
increase of OxLDL was found in 62- to 64-year-old men with
MetS207. On the other hand, smoking and low serum
testosterone were both associated with a high concentration
of OxLDL in men208. Patients with overt hypothyroidism, a
disease associated with impaired metabolic profile, were
found to have increased OxLDL levels than patients with mild
thyroid failure and control subjects209. In another study, a
higher level of OxLDL was associated with increased
incidence of MetS in subjects aged 18–30 years that were
followed for up to 20 years210.
Diet- and statin-induced changes in OxLDL level –
impact of assay used
Exercise- and diet-induced weight losses were shown
to reduce OxLDL levels in adults with MetS211, and
 8 A. Trpkovic et al.
Table 3. The effects of diet and statin treatment on OxLDL and OxPL/apoB levels.
Studies Diet
211
Studies utilizing 4E6 Decrease in OxLDL level in adults
or DLH3 assay with MetS and subjects at high
CV risk
Studies utilizing Increase in OxPL/apoB level
E06 assay (content of OxPL on individual
apoB-100 particles) after low-
fat diet
Increase in OxPL/apoB level in
subjects on garlic extract
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supplement
OxLDL: oxidized low-density lipoprotein; MetS: metabolic syndrome; CV: cardiovascular; CHD: coronary heart disease; OxPL: oxidized
phospholipids; ApoB-100: apolipoprotein B-100.
subjects with high CV risk212. A Mediterranean-style low-
glycemic-load diet reduced OxLDL levels in women with
MetS213. The results of these three studies were obtained
using the 4E6 assay. Likewise, treatment with statins resulted
in a decrease in OxLDL levels in studies which utilized
OxLDL-4E6 and OxLDL-DLH3 monoclonal antibodies
(Table 3). Accordingly, the levels of circulating OxLDL
were shown to significantly decrease by treatment with statins
For personal use only.
in patients with CHD214,215, hypercholesterolemia, heterozy-
gous familial hypercholesterolemia216–218 and in patients with
type 2 diabetes219 and MetS220. In addition, rosuvastatin was
found to reduce OxLDL accumulation within atherosclerotic
plaques and inhibit plaque progression in mice with combined
LDL-receptor and leptin deficiency221.
However, the studies carried out using the OxLDL-E06
antibody yielded intriguing results (Table 3). For example, the
study in New Zealand using white rabbits and cynomolgus
monkeys revealed that total apoB/OxPL plasma levels (OxPL/
apoB multiplied by independently measured plasma apoB-
100 levels), reflecting the OxPL content on all apoB-100
particles, increased during hypercholesterolemia and
decreased during reversion to normocholesterolemia after
dietary regime. Surprisingly, OxPL/apoB levels (representing
the content of OxPL on individual apoB-100 particles)
decreased during hypercholesterolemia and increased during
reversion to normocholesterolemia. Importantly, this increase
of OxPL/apoB in plasma was associated with reduced content
of OxPL in the vessel wall222. Similar findings were obtained
in humans. Namely, when determined with OxLDL-E06
antibody, plasma OxPL/apoB, together with Lp(a) levels were
shown to increase in response to low-fat diet in healthy
women223. Moreover, plasma concentrations of OxPL/apoB
were significantly higher in healthy human subjects consum-
ing low-fat high-carbohydrate (LFHC) diet compared to
subjects on high-fat low-carbohydrate diet224. In addition,
LFHC diet resulted in OxPL associated-increase of plasma
Lp(a). The increase in OxPL/apoB levels was also observed in
subjects with intermediate CV risk after garlic extract
supplement consumption225,226.
High dose of atorvastatin (80 mg daily) significantly
reduced total apoB-OxPL plasma levels in patients with
Crit Rev Clin Lab Sci, Early Online: 1–16
Treatment
Reference, Reference,
assay Statins assay
4E6; 2124E6; Decrease in OxLDL level in 214
4E6; 2154E6; 217DLH3;
213 219
4E6 patients with CHD, hyperlipid- 4E6; 2164E6
emia, diabetes and MetS
223,224 227,229,230,231,216,228
Increase in OxPL/apoB level
[content of OxPL on individual
apoB-100 particles] in patients
with CHD and hyperlipidemia
226,225 227
Decrease in total apoB-OxPL
plasma level [OxPL/apoB mul-
tiplied by apoB-100 level] in
patients with CHD
acute coronary syndrome. However, the amount of oxidized
modifications per an apoB-containing particle (OxPL/apoB)
actually increased after statin therapy. These results suggest
that high-dose atorvastatin significantly reduced the total
content of OxPL present on all circulating apoB-100 particles,
but at the same time, some apoB-100 particles were actually
enriched in OxPL. Notably, in parallel to the rise in OxPL/
apoB, Lp(a) levels also increased in response to atorvasta-
tin227. With the use of the same monoclonal antibody (E06), a
similar observation was found in patients with CHD and
hyperlipidemia after statin treatment216,228–231. Thus, in
studies utilizing the E06 assay, diet and statin treatment
were found to decrease total apoB-OxPL plasma levels
altogether, with an increase of OxPL content on individual
apoB-100 particles. The study of Ky et al. tested both 4E6 and
E06 assays in patients with hypercholesterolemia treated with
statins. The level of OxLDL (measured by the 4E6 assay)
decreased while the level of OxPL/apoB (measured by the
E06 assay) increased after 16 weeks of statin treatment. No
correlation was found between OxLDL and OxPL/apoB levels
at baseline, while a slight inverse correlation was found after
16 weeks of treatment216. It is plausible that diet and statins
ensure mobilization (reverse transport) of OxPL from the
vessel wall223,227. In a large series of clinical studies, a very
strong correlation was found between plasma levels of Lp(a)
and the content of OxPL on apoB-100 particles232.
The proposed role of Lp(a) in binding of OxPL
Importantly, most of the OxLDL-E06-detectable phospho-
lipids were actually present on Lp(a) particles rather than
LDL232. In the study by Bergmark et al.233, approximately
85% of OxPL associated with apoB lipoproteins were found
to be present on Lp(a). In vitro transfer studies showed that
OxLDL preferentially donates OxPL to Lp(a), in a time- and
temperature-dependent manner. Immediately after PCI,
approximately 50% of OxPL were found on Lp(a), whereas
the other half was bound to other non-Lp(a) apoB particles.
However, 6 h after PCI more than 90% of OxPL were again
present on Lp(a)142. Thus, Lp(a) is proposed to bind and
transport OxPL. It is also possible that Lp(a) directly
 DOI: 10.3109/10408363.2014.992063
contributes to the degradation of OxPL227. However, the
source of OxPL that are present on Lp(a) and the sites of
binding are not yet fully determined. Lp(a) is an atherogenic
particle that structurally resembles LDL. Lp(a) is secreted by
the liver and consists of one molecule of apoB-100 that is
covalently attached by a single disulfide bond to carbohy-
drate-rich lipoprotein(a)234. Lp(a) was shown to be an
independent, genetic risk factor for CV death and AMI, and
this risk is linear with increasing Lp(a) levels109. Elevated
Lp(a) may induce a prothrombotic/anti-fibrinolytic effect
because lipoprotein a resembles both plasminogen and
plasmin but has no fibrinolytic activity, and/or may accelerate
atherosclerosis due to its cholesterol-rich structure235.
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by University of Auckland on 01/20/15
Moreover, Lp(a) has been shown to enter the arterial intima
of humans236. Importantly, the size of the major lipoprotein a
isoform was found to be negatively associated with Lp(a) and
OxPL/apoB levels98. There was a weak correlation between
OxPL/apoB and Lp(a) at Lp(a) levels 530 nmol/L while, in
contrast, very strong correlation was found above this
threshold111. This finding may imply that low level of Lp(a)
could have a beneficial role in binding and transport of
proinflammatory OxPL109. Thus, the apparent paradox arises:
increased OxPL/apoB level is predictive for CVD, but at the
same time, increased OxPL/apoB level was found after
effective anti-atherogenic treatment (diet, statin therapy). It is
proposed that after an initial efflux of OxPL into the plasma,
continued therapy would revert increased OxPL/apoB to
For personal use only.
baseline or lower levels. This is now a subject of prospective
trials, and if confirmed, an early rise in OxPL/apoB might be
used as surrogate marker of a beneficial therapeutic
intervention98.
Antiatherogenic treatments and OxLDL:
experimental evidence and clinical data
In addition to the effects of statins and dietary regimes on
OxLDL, we will briefly address the interaction of other
antiatherogenic treatments with OxLDL. Namely, the experi-
mental evidence on drug-related atheroprotective properties
(e.g. inhibition of LDL oxidation, inhibition of OxLDL
uptake by macrophages, inhibition of OxLDL-induced endo-
thelial dysfunction, decrease in scavenger receptors expres-
sion) is summarized. In addition, the results of the few
existing clinical studies investigating the effects of these
treatments on circulating OxLDL are reported.
Angiotensin converting enzyme inhibitors and
angiotensin II receptor subtype AT-1 blockers
Captopril was found to inhibit copper-induced oxidation of
human LDL237. Ramipril administration blocked the progres-
sion of atherosclerotic lesions in apolipoprotein E-deficient
mice, a phenomenon that could be related to ramipril-induced
inhibition of OxLDL uptake by macrophages238. Ramipril
was also shown to prevent impairment in endothelial function
induced by human OxLDL in aortas isolated from rats239. The
administration of zofenopril reduced the susceptibility of
plasma LDL to in vitro oxidation, and significantly decreased
the immunohistochemical presence of oxidation-specific
epitopes in the arterial wall of apolipoprotein E-deficient
mice and Watanabe heritable hyperlipidemic rabbits240,241.
OxLDL: A biomarker of CVD 9
Perindopril was found to decrease scavenger receptor class A
expression and macrophage infiltration in renal tubulointer-
stitium of diabetic rats242. Angiotensin II receptor subtype
AT-1 blockers, candesartan and losartan, suppressed OxLDL-
derived formation of foam cells243. Treatment with ramipril,
telmisartan or their combination, was found to significantly
reduce OxLDL level (measured by 4E6 assay) in patients with
type 2 diabetes244.
Calcium channel antagonists
Nifedipine displayed a significant dose-dependent capacity to
protect LDL during copper-mediated oxidation245. The posi-
tively charged calcium channel blocker amlodipine was found
to inhibit OxLDL aggregation246. Felodipine and amlodipine
inhibited LDL oxidation and oxidized LDL-induced endo-
thelial toxicity, and this effect was markedly enhanced in the
presence of ascorbic acid247. In addition, dihydropyridine
calcium channel blockers (especially lacidipine) were found
to decrease OxLDL induced proliferation and oxidative stress
of human umbilical VSMC248.
Beta adrenergic receptors blockers
Carvedilol inhibited human LDL oxidation by macrophages
and copper249. Both, carvediol and atenolol were found to
decrease OxLDL levels (measured by the 4E6 assay) in post-
myocardial infarction patients. Notably, this effect was more
pronounced in the carvedilol group250. Nebivolol and meto-
prolol significantly reduced OxLDL levels (measured by the
4E6 assay) in patients with essential hypertension251. OxLDL
levels, measured by the 4E6 assay, did not change signifi-
cantly after carvedilol/lisinopril combination therapy in obese
patients with hypertension252.
Aspirin
Aspirin, in a dose- and time-dependent manner, reduced
OxLDL-mediated LOX-1 expression in human coronary
endothelial cells253. Aspirin inhibited ROS production in
human endothelial cells exposed to OxLDL254. In addition,
aspirin and pravastatin were shown to reduce LOX1 expres-
sion and oxidative stress in human coronary artery endothelial
cells255. The aspirin-mediated decrease of OxLDL-induced
inflammatory responses in human endothelial cells may be
associated with NF-kB activation pathway and inhibition of
p38 mitogen-activated protein kinase phosphorylation256.
Aspirin, in a daily dose of 150 mg, significantly reduced
OxLDL level in healthy volunteers after 2 months of therapy
(the assay detecting malondialdehyde-modified apoB was
used). However, this effect was not observed in subjects
receiving 100 mg of aspirin/day257. OxLDL level (measured
by the 4E6 assay) was not affected by aspirin in post-ischemic
cerebral infarction patients258.
Vitamin E and dietary polyphenols
Alpha-tocopherol was found to inhibit the uptake of OxLDL
in cultured human aortic smooth muscle cells259. The dietary
consumption of red wine, or its polyphenols quercetin and, at
a lesser extent catechin, was associated with reduced suscep-
tibility of LDL to oxidation and aggregation in apolipoprotein
 10 A. Trpkovic et al.
E-deficient mice260. Plant flavonoids, like kaempferol, also
inhibited OxLDL uptake by macrophages261.
Concluding remarks
Oxidized LDL is strongly implicated in various aspects of
CVD. Three enzyme-linked immunosorbent assays utilizing
monoclonal antibodies were developed for OxLDL measure-
ment. However, these antibodies detect different epitopes: the
4E6 antibody cross-reacts with native LDL, DLH3 binds to
phosphatidylcholine in the LDL, and E06 recognizes
phosphorylcholine on all apoB-100 containing particles. The
following findings were obtained regardless of assay used: (a)
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by University of Auckland on 01/20/15
the levels of OxLDL were elevated in patients with coronary,
carotid and femoral artery disease, and (b) the levels of
OxLDL rose after AMI, cerebral ischemic infarction and PCI.
Studies estimating the association of OxLDL levels with the
burden of coronary and carotid atherosclerosis, and usefulness
of OxLDL for CVD prediction and stent restenosis, yielded
conflicting results. Increased OxLDL levels were found in
patients with MetS and diabetes, and OxLDL levels were
associated with insulin resistance and obesity. When estimat-
ing the effects of diet and statin therapy on OxLDL levels,
crucial differences arose regarding the assay used. After
dietary and statin treatment, OxLDL levels decreased in
studies utilizing the 4E6 and DLH3 assays, while OxPL/apoB
levels increased in studies using the E06 assay. Notably,
For personal use only.
substantial amounts of OxPL associated with apoB lipopro-
teins were present on Lp(a). It seems that OxPL transfers
between the vessel wall, OxLDL and Lp(a); therefore, further
investigation considering these interactions is eagerly awaited.
To evaluate the clinical data on circulating OxLDL, the
development of a more standardized assay for OxLDL
measurement would be useful.
Declaration of interest
The Authors declare that there is no conflict of interest. This
work was supported by grants funded by the Ministry of
Education and Science, Republic of Serbia, No. 173033 (to E.
R. I.) and No. 41002 (to Dj. R.).
References
1. Marcovina SM, Crea F, Davignon J, et al. Biochemical and
bioimaging markers for risk assessment and diagnosis in major
cardiovascular diseases: a road to integration of complementary
diagnostic tools. J Intern Med 2007;261:214–34.
2. Gilstrap LG, Wang TJ. Biomarkers and cardiovascular risk
assessment for primary prevention: an update. Clin Chem 2012;
58:72–82.
3. Morrow DA, de Lemos JA. Benchmarks for the assessment of
novel cardiovascular biomarkers. Circulation 2007;115:949–52.
4. Vasan RS. Biomarkers of cardiovascular disease: molecular basis
and practical considerations. Circulation 2006;113:2335–62.
5. Biomarkers Definitions Working Group. Biomarkers and surro-
gate endpoints: preferred definitions and conceptual framework.
Clin Pharmacol Ther 2001;69:89–95.
6. Verhoye E, Langlois MR. Circulating oxidized low-density
lipoprotein: a biomarker of atherosclerosis and cardiovascular
risk? Clin Chem Lab Med 2009;47:128–37.
7. Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein
management in patients with cardiometabolic risk: consensus
conference report from the American Diabetes Association and
Crit Rev Clin Lab Sci, Early Online: 1–16
the American College of Cardiology Foundation. J Am Coll
Cardiol 2008;51:1512–24.
8. National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol
in Adults (Adult Treatment Panel III). Third Report of the
National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol
in Adults (Adult Treatment Panel III) final report. Circulation
2002;106:3143–421.
9. Stocker R. Lipoprotein oxidation: mechanistic aspects, methodo-
logical approaches and clinical relevance. Curr Opin Lipidol
1994;5:422–33.
10. Mikhailidis DP, Elisaf M, Rizzo M, et al. ‘‘European panel on low
density lipoprotein (LDL) subclasses’’: a statement on the
pathophysiology, atherogenicity and clinical significance of LDL
subclasses. Curr Vasc Pharmacol 2011;9:533–71.
11. Knott TJ, Pease RJ, Powell LM, et al. Complete protein sequence
and identification of structural domains of human apolipoprotein
B. Nature 1986;323:734–8.
12. Goldstein JL, Brown MS. The LDL receptor. Arterioscler Thromb
Vasc Biol 2009;29:431–8.
13. Brown MS, Goldstein JL. Receptor-mediated endocytosis: insights
from the lipoprotein receptor system. Proc Natl Acad Sci USA
1979;76:3330–7.
14. Yancey PG, Jerome WG. Lysosomal sequestration of free and
esterified cholesterol from oxidized low density lipoprotein in
macrophages of different species. J Lipid Res 1998;39:1349–61.
15. Farnier M. The role of proprotein convertase subtilisin/kexin type
9 in hyperlipidemia: focus on therapeutic implications. Am J
Cardiovasc Drugs 2011;11:145–52.
16. Qian YW, Schmidt RJ, Zhang Y, et al. Secreted PCSK9
downregulates low density lipoprotein receptor through receptor-
mediated endocytosis. J Lipid Res 2007;48:1488–98.
17. Tibolla G, Norata GD, Artali R, et al. Proprotein convertase
subtilisin/kexin type 9 (PCSK9): from structure-function relation
to therapeutic inhibition. Nutr Metab Cardiovasc Dis 2011;21:
835–43.
18. Lagace TA, Curtis DE, Garuti R, et al. Secreted PCSK9 decreases
the number of LDL receptors in hepatocytes and in livers of
parabiotic mice. J Clin Invest 2006;116:2995–3005.
19. Lambert G, Charlton F, Rye KA, Piper DE. Molecular basis of
PCSK9 function. Atherosclerosis 2009;203:1–7.
20. Alborn WE, Cao G, Careskey HE, et al. Serum proprotein
convertase subtilisin kexin type 9 is correlated directly with serum
LDL cholesterol. Clin Chem 2007;53:1814–19.
21. Nassoury N, Blasiole DA, Tebon Oler A, et al. The cellular
trafficking of the secretory proprotein convertase PCSK9 and its
dependence on the LDLR. Traffic 2007;8:718–32.
22. Zhang DW, Lagace TA, Garuti R, et al. Binding of proprotein
convertase subtilisin/kexin type 9 to epidermal growth factor-like
repeat A of low density lipoprotein receptor decreases receptor
recycling and increases degradation. J Biol Chem 2007;282:
18602–12.
23. Li J, Tumanut C, Gavigan JA, et al. Secreted PCSK9 promotes
LDL receptor degradation independently of proteolytic activity.
Biochem J 2007;406:203–7.
24. McNutt MC, Lagace TA, Horton JD. Catalytic activity
is not required for secreted PCSK9 to reduce low density
lipoprotein receptors in HepG2 cells. J Biol Chem 2007;282:
20799–803.
25. Park SW, Moon YA, Horton JD. Post-transcriptional regulation of
low density lipoprotein receptor protein by proprotein convertase
subtilisin/kexin type 9a in mouse liver. J Biol Chem 2004;279:
50630–8.
26. Sun XM, Eden ER, Tosi I, et al. Evidence for effect of mutant
PCSK9 on apolipoprotein B secretion as the cause of unusually
severe dominant hypercholesterolaemia. Hum Mol Genet 2005;14:
1161–9.
27. Maxwell KN, Fisher EA, Breslow JL. Overexpression of PCSK9
accelerates the degradation of the LDLR in a post-endoplasmic
reticulum compartment. Proc Natl Acad Sci USA 2005;102:
2069–74.
28. Horton JD, Cohen JC, Hobbs HH. Molecular biology of
PCSK9: its role in LDL metabolism. Trends Biochem Sci 2007;
32:71–7.
 DOI: 10.3109/10408363.2014.992063
29. Brown MS, Goldstein JL. Regulation of the activity of the low
density lipoprotein receptor in human fibroblasts. Cell 1975;6:
307–16.
30. Banach M, Rizzo M, Obradovic M, et al. PCSK9 inhibition – a
novel mechanism to treat lipid disorders? Curr Pharm Des 2013;
19:3869–77.
31. Steinberg D. Low density lipoprotein oxidation and its pathobio-
logical significance. J Biol Chem 1997;272:20963–6.
32. Yoshida H, Kisugi R. Mechanisms of LDL oxidation. Clin Chim
Acta 2010;411:1875–82.
33. Morel DW, Hessler JR, Chisolm GM. Low density lipoprotein
cytotoxicity induced by free radical peroxidation of lipid. J Lipid
Res 1983;24:1070–6.
34. Rizzo M, Berneis K, Koulouris S, et al. Should we measure
routinely oxidised and atherogenic dense low-density lipoproteins
in subjects with type 2 diabetes? Int J Clin Pract 2010;64:
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by University of Auckland on 01/20/15
1632–42.
35. Parthasarathy S, Raghavamenon A, Garelnabi MO, Santanam N.
Oxidized low-density lipoprotein. Methods Mol Biol 2010;610:
403–17.
36. Wen Y, Leake DS. Low density lipoprotein undergoes oxidation
within lysosomes in cells. Circ Res 2007;100:1337–43.
37. Levitan I, Volkov S, Subbaiah PV. Oxidized LDL: diversity,
patterns of recognition, and pathophysiology. Antioxid Redox
Signal 2010;13:39–75.
38. Cushing SD, Berliner JA, Valente AJ, et al. Minimally modified
low density lipoprotein induces monocyte chemotactic protein 1 in
human endothelial cells and smooth muscle cells. Proc Natl Acad
Sci USA 1990;87:5134–8.
39. Liao F, Berliner JA, Mehrabian M, et al. Minimally modified low
density lipoprotein is biologically active in vivo in mice. J Clin
Invest 1991;87:2253–7.
40. Grundtman C, Wick G. The autoimmune concept of atheroscler-
osis. Curr Opin Lipidol 2011;22:327–34.
For personal use only.
41. Goyal T, Mitra S, Khaidakov M, et al. Current concepts of the role
of oxidized LDL receptors in atherosclerosis. Curr Atheroscler
Rep 2012;14:150–9.
42. Stanton LW, White RT, Bryant CM, et al. A macrophage Fc
receptor for IgG is also a receptor for oxidized low density
lipoprotein. J Biol Chem 1992;267:22446–51.
43. Steinberg D, Witztum JL. Oxidized low-density lipoprotein and
atherosclerosis. Arterioscler Thromb Vasc Biol 2010;30:2311–6.
44. Hazen SL. Oxidized phospholipids as endogenous pattern recog-
nition ligands in innate immunity. J Biol Chem 2008;283:
15527–31.
45. Obradovic MM, Trpkovic A, Bajic V, et al. Interrelatedness
between C-reactive protein and oxidized low-density lipoprotein.
Clin Chem Lab Med 2014. doi: 10.1515/cclm-2014-0590. [Epub
ahead of print].
46. Tabuchi M, Inoue K, Usui-Kataoka H, et al. The association of
C-reactive protein with an oxidative metabolite of LDL and its
implication in atherosclerosis. J Lipid Res 2007;48:768–81.
47. Lowe GD, Pepys MB. C-reactive protein and cardiovascular
disease: weighing the evidence. Curr Atheroscler Rep 2006;8:
421–8.
48. Jialal I, Devaraj S, Venugopal SK. C-reactive protein: risk marker
or mediator in atherothrombosis? Hypertension 2004;44:6–11.
49. Zacho J, Tybjaerg-Hansen A, Jensen JS, et al. Genetically elevated
C-reactive protein and ischemic vascular disease. N Engl J Med
2008;359:1897–908.
50. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA
guideline for assessment of cardiovascular risk in asymptomatic
adults: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice
Guidelines. J Am Coll Cardiol 2010;56:e50–103.
51. Shih HH, Zhang S, Cao W, et al. CRP is a novel ligand for the
oxidized LDL receptor LOX-1. Am J Physiol Heart Circ Physiol
2009;296:H1643–50.
52. Chang MK, Binder CJ, Torzewski M, Witztum JL. C-reactive
protein binds to both oxidized LDL and apoptotic cells through
recognition of a common ligand: phosphorylcholine of oxidized
phospholipids. Proc Natl Acad Sci USA 2002;99:13043–8.
53. Fujita Y, Kakino A, Nishimichi N, et al. Oxidized LDL receptor
LOX-1 binds to C-reactive protein and mediates its vascular
effects. Clin Chem 2009;55:285–94.
OxLDL: A biomarker of CVD 11
54. Zhao XQ, Zhang MW, Wang F, et al. CRP enhances soluble LOX-
1 release from macrophages by activating TNF-alpha converting
enzyme. J Lipid Res 2011;52:923–33.
55. Li L, Roumeliotis N, Sawamura T, Renier G. C-reactive protein
enhances LOX-1 expression in human aortic endothelial cells:
relevance of LOX-1 to C-reactive protein-induced endothelial
dysfunction. Circ Res 2004;95:877–83.
56. Hein TW, Qamirani E, Ren Y, et al. Selective activation of
lectin-like oxidized low-density lipoprotein receptor-1 mediates
C-reactive protein-evoked endothelial vasodilator dysfunction in
coronary arterioles. Circ Res 2014;114:92–100.
57. Goldstein JL, Ho YK, Basu SK, Brown MS. Binding site on
macrophages that mediates uptake and degradation of acetylated
low density lipoprotein, producing massive cholesterol deposition.
Proc Natl Acad Sci USA 1979;76:333–7.
58. Orso E, Grandl M, Schmitz G. Oxidized LDL-induced
endolysosomal phospholipidosis and enzymatically modified
LDL-induced foam cell formation determine specific lipid species
modulation in human macrophages. Chem Phys Lipids 2011;164:
479–87.
59. Samson S, Mundkur L, Kakkar VV. Immune response to
lipoproteins in atherosclerosis. Cholesterol 2012;2012:571846.
60. Steinberg D, Parthasarathy S, Carew TE, et al. Beyond cholesterol.
Modifications of low-density lipoprotein that increase its ather-
ogenicity. N Engl J Med 1989;320:915–24.
61. Steinberg D. Atherogenesis in perspective: hypercholesterolemia
and inflammation as partners in crime. Nat Med 2002;8:1211–17.
62. Steinberg D. The LDL modification hypothesis of atherogenesis:
an update. J Lipid Res 2009;50:S376–81.
63. Witztum JL, Berliner JA. Oxidized phospholipids and isoprostanes
in atherosclerosis. Curr Opin Lipidol 1998;9:441–8.
64. Boullier A, Bird DA, Chang MK, et al. Scavenger receptors,
oxidized LDL, and atherosclerosis. Ann N Y Acad Sci 2001;947:
214–22.
65. Pirillo A, Norata GD, Catapano AL. LOX-1, OxLDL, and
atherosclerosis. Mediators Inflamm 2013;2013:152786–97.
66. Quinn MT, Parthasarathy S, Fong LG, Steinberg D. Oxidatively
modified low density lipoproteins: a potential role in recruitment
and retention of monocyte/macrophages during atherogenesis.
Proc Natl Acad Sci USA 1987;84:2995–8.
67. Liao F, Andalibi A, Lusis AJ, Fogelman AM. Genetic control
of the inflammatory response induced by oxidized lipids. Am J
Cardiol 1995;75:65B–6B.
68. Wiesner P, Tafelmeier M, Chittka D, et al. MCP-1 binds to
oxidized LDL and is carried by lipoprotein(a) in human plasma.
J Lipid Res 2013;54:1877–83.
69. Rajavashisth TB, Andalibi A, Territo MC, et al. Induction of
endothelial cell expression of granulocyte and macrophage
colony-stimulating factors by modified low-density lipoproteins.
Nature 1990;344:254–7.
70. Cominacini L, Garbin U, Pasini AF, et al. Antioxidants inhibit the
expression of intercellular cell adhesion molecule-1 and vascular
cell adhesion molecule-1 induced by oxidized LDL on human
umbilical vein endothelial cells. Free Radic Biol Med 1997;22:
117–27.
71. Li D, Chen H, Romeo F, et al. Statins modulate oxidized
low-density lipoprotein-mediated adhesion molecule expression
in human coronary artery endothelial cells: role of LOX-1.
J Pharmacol Exp Ther 2002;302:601–5.
72. Cominacini L, Rigoni A, Pasini AF, et al. The binding of oxidized
low density lipoprotein (ox-LDL) to ox-LDL receptor-1 reduces
the intracellular concentration of nitric oxide in endothelial cells
through an increased production of superoxide. J Biol Chem 2001;
276:13750–5.
73. Ma FX, Zhou B, Chen Z, et al. Oxidized low density lipoprotein
impairs endothelial progenitor cells by regulation of endothelial
nitric oxide synthase. J Lipid Res 2006;47:1227–37.
74. Henriksen T, Evensen SA, Carlander B. Injury to human
endothelial cells in culture induced by low density lipoproteins.
Scand J Clin Lab Invest 1979;39:361–8.
75. Hessler JR, Robertson Jr AL, Chisolm III GM. LDL-induced
cytotoxicity and its inhibition by HDL in human vascular smooth
muscle and endothelial cells in culture. Atherosclerosis 1979;32:
213–29.
 12 A. Trpkovic et al.
76. Salvayre R, Auge N, Benoist H, Negre-Salvayre A. Oxidized low-
density lipoprotein-induced apoptosis. Biochim Biophys Acta
2002;1585:213–21.
77. Chen J, Mehta JL, Haider N, et al. Role of caspases in Ox-LDL-
induced apoptotic cascade in human coronary artery endothelial
cells. Circ Res 2004;94:370–6.
78. Imanishi T, Hano T, Sawamura T, et al. Oxidized low density
lipoprotein potentiation of Fas-induced apoptosis through lectin-
like oxidized-low density lipoprotein receptor-1 in human umbil-
ical vascular endothelial cells. Circ J 2002;66:1060–4.
79. Li D, Liu L, Chen H, et al. LOX-1 mediates oxidized low-density
lipoprotein-induced expression of matrix metalloproteinases in
human coronary artery endothelial cells. Circulation 2003;107:
612–17.
80. Shen CM, Mao SJ, Huang GS, et al. Stimulation of smooth muscle
cell proliferation by ox-LDL- and acetyl LDL-induced macro-
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by University of Auckland on 01/20/15
phage-derived foam cells. Life Sci 2001;70:443–52.
81. Auge N, Garcia V, Maupas-Schwalm F, et al. Oxidized LDL-
induced smooth muscle cell proliferation involves the EGF
receptor/PI-3 kinase/Akt and the sphingolipid signaling pathways.
Arterioscler Thromb Vasc Biol 2002;22:1990–5.
82. Autio I, Jaakkola O, Solakivi T, Nikkari T. Oxidized low-density
lipoprotein is chemotactic for arterial smooth muscle cells in
culture. FEBS Lett 1990;277:247–9.
83. Kataoka H, Kume N, Miyamoto S, et al. Oxidized LDL modulates
Bax/Bcl-2 through the lectinlike Ox-LDL receptor-1 in vascular
smooth muscle cells. Arterioscler Thromb Vasc Biol 2001;21:
955–60.
84. Jimi S, Saku K, Uesugi N, et al. Oxidized low density lipoprotein
stimulates collagen production in cultured arterial smooth muscle
cells. Atherosclerosis 1995;116:15–26.
85. Hu C, Dandapat A, Sun L, et al. Regulation of TGFbeta1-
mediated collagen formation by LOX-1: studies based on forced
overexpression of TGFbeta1 in wild-type and lox-1 knock-out
For personal use only.
mouse cardiac fibroblasts. J Biol Chem 2008;283:10226–31.
86. Mitra S, Goyal T, Mehta JL. Oxidized LDL, LOX-1 and
atherosclerosis. Cardiovasc Drugs Ther 2011;25:419–29.
87. Sangle GV, Zhao R, Shen GX. Transmembrane signaling pathway
mediates oxidized low-density lipoprotein-induced expression of
plasminogen activator inhibitor-1 in vascular endothelial cells. Am
J Physiol Endocrinol Metab 2008;295:E1243–54.
88. Drake TA, Hannani K, Fei HH, et al. Minimally oxidized low-
density lipoprotein induces tissue factor expression in cultured
human endothelial cells. Am J Pathol 1991;138:601–7.
89. Meisel SR, Xu XP, Edgington TS, et al. Dose-dependent
modulation of tissue factor protein and procoagulant activity in
human monocyte-derived macrophages by oxidized low density
lipoprotein. J Atheroscler Thromb 2011;18:596–603.
90. Cui MZ, Penn MS, Chisolm GM. Native and oxidized low density
lipoprotein induction of tissue factor gene expression in smooth
muscle cells is mediated by both Egr-1 and Sp1. J Biol Chem
1999;274:32795–802.
91. Chen M, Kakutani M, Naruko T, et al. Activation-dependent
surface expression of LOX-1 in human platelets. Biochem Biophys
Res Commun 2001;282:153–8.
92. Daub K, Seizer P, Stellos K, et al. Oxidized LDL-activated
platelets induce vascular inflammation. Semin Thromb Hemost
2010;36:146–56.
93. Kakutani M, Masaki T, Sawamura T. A platelet-endothelium
interaction mediated by lectin-like oxidized low-density lipopro-
tein receptor-1. Proc Natl Acad Sci USA 2000;97:360–4.
94. Yu BL, Zhao SP, Huang XS. Oxidized low-density lipoprotein: a
double-edged sword on atherosclerosis. Med Hypotheses 2007;69:
553–6.
95. Salonen JT, Yla-Herttuala S, Yamamoto R, et al. Autoantibody
against oxidised LDL and progression of carotid atherosclerosis.
Lancet 1992;339:883–7.
96. Hartvigsen K, Chou MY, Hansen LF, et al. The role of innate
immunity in atherogenesis. J Lipid Res 2009;50:S388–93.
97. Tsimikas S, Brilakis ES, Lennon RJ, et al. Relationship of IgG and
IgM autoantibodies to oxidized low density lipoprotein with
coronary artery disease and cardiovascular events. J Lipid Res
2007;48:425–33.
98. Taleb A, Tsimikas S. The OxPL/apoB assay: a predictor of
cardiovascular disease and events. In: Maisel AS, ed. Cardiac
Crit Rev Clin Lab Sci, Early Online: 1–16
Biomarkers – Expert Advice for Clinicians. New Delhi, India:
Jaypee Brothers Medical Publishers (P) Ltd.; 2012:12–42.
99. Binder CJ, Horkko S, Dewan A, et al. Pneumococcal vaccination
decreases atherosclerotic lesion formation: molecular mimicry
between Streptococcus pneumoniae and oxidized LDL. Nat Med
2003;9:736–43.
100. Itabe H, Ueda M. Measurement of plasma oxidized low-density
lipoprotein and its clinical implications. J Atheroscler Thromb
2007;14:1–11.
101. Holvoet P, Zhao Z, Deridder E, et al. Effects of deletion of the
carboxyl-terminal domain of ApoA-I or of its substitution with
helices of ApoA-II on in vitro and in vivo lipoprotein association.
J Biol Chem 1996;271:19395–401.
102. Subbaiah PV. Biomarkers of oxidative stress in plasma and urine.
In: Caroli S, Záray G, eds. Analytical Techniques for Clinical
Chemistry: Methods and Applications. Hoboken (NJ): John Wiley
& Sons, Inc.; 2012:555–94.
103. Holvoet P, Macy E, Landeloos M, et al. Analytical perform-
ance and diagnostic accuracy of immunometric assays for the
measurement of circulating oxidized LDL. Clin Chem 2006;52:
760–4.
104. Itabe H, Yamamoto H, Imanaka T, et al. Sensitive detection of
oxidatively modified low density lipoprotein using a monoclonal
antibody. J Lipid Res 1996;37:45–53.
105. Itabe H, Yamamoto H, Suzuki M, et al. Oxidized phosphatidyl-
cholines that modify proteins. Analysis by monoclonal antibody
against oxidized low density lipoprotein. J Biol Chem 1996;271:
33208–17.
106. Toshima S, Hasegawa A, Kurabayashi M, et al. Circulating
oxidized low density lipoprotein levels. A biochemical risk marker
for coronary heart disease. Arterioscler Thromb Vasc Biol 2000;
20:2243–7.
107. Palinski W, Horkko S, Miller E, et al. Cloning of monoclonal
autoantibodies to epitopes of oxidized lipoproteins from apolipo-
protein E-deficient mice. Demonstration of epitopes of oxidized
low density lipoprotein in human plasma. J Clin Invest 1996;98:
800–14.
108. Tsimikas S, Bergmark C, Beyer RW, et al. Temporal increases in
plasma markers of oxidized low-density lipoprotein strongly
reflect the presence of acute coronary syndromes. J Am Coll
Cardiol 2003;41:360–70.
109. Taleb A, Witztum JL, Tsimikas S. Oxidized phospholipids on
apoB-100-containing lipoproteins: a biomarker predicting cardio-
vascular disease and cardiovascular events. Biomark Med 2011;5:
673–94.
110. Strobel NA, Fassett RG, Marsh SA, Coombes JS. Oxidative stress
biomarkers as predictors of cardiovascular disease. Int J Cardiol
2011;147:191–201.
111. Tsimikas S, Clopton P, Brilakis ES, et al. Relationship of oxidized
phospholipids on apolipoprotein B-100 particles to race/ethnicity,
apolipoprotein(a) isoform size, and cardiovascular risk factors:
results from the Dallas Heart Study. Circulation 2009;119:
1711–19.
112. Matsumoto T, Takashima H, Ohira N, et al. Plasma level
of oxidized low-density lipoprotein is an independent deter-
minant of coronary macrovasomotor and microvasomotor
responses induced by bradykinin. J Am Coll Cardiol 2004;44:
451–7.
113. Rietzschel ER, Langlois M, De Buyzere ML, et al. Oxidized low-
density lipoprotein cholesterol is associated with decreases in
cardiac function independent of vascular alterations. Hypertension
2008;52:535–41.
114. Chrysohoou C, Panagiotakos DB, Pitsavos C, et al. The associ-
ation between pre-hypertension status and oxidative stress
markers related to atherosclerotic disease: the ATTICA study.
Atherosclerosis 2007;192:169–76.
115. Wu R, de Faire U, Lemne C, et al. Autoantibodies to OxLDL
are decreased in individuals with borderline hypertension.
Hypertension 1999;33:53–9.
116. Uzun H, Karter Y, Aydin S, et al. Oxidative stress in white coat
hypertension; role of paraoxonase. J Hum Hypertens 2004;18:
523–8.
117. Frostegard J, Wu R, Lemne C, et al. Circulating oxidized low-
density lipoprotein is increased in hypertension. Clin Sci (Lond)
2003;105:615–20.
 DOI: 10.3109/10408363.2014.992063
118. Guxens M, Fito M, Martinez-Gonzalez MA, et al. Hypertensive
status and lipoprotein oxidation in an elderly population at high
cardiovascular risk. Am J Hypertens 2009;22:68–73.
119. Imazu M, Ono K, Tadehara F, et al. Plasma levels of oxidized low
density lipoprotein are associated with stable angina pectoris and
modalities of acute coronary syndrome. Int Heart J 2008;49:
515–24.
120. Nakaishi T, Tamura A, Watanabe T, et al. Relationship between
plasma oxidized low-density lipoprotein and the coronary vaso-
motor response to acetylcholine in patients with coronary artery
disease. Jpn Circ J 2000;64:856–60.
121. Yoneyama S, Arakawa K, Yonemura A, et al. Oxidized low-
density lipoprotein and high-density lipoprotein cholesterol
modulate coronary arterial remodeling: an intravascular ultra-
sound study. Clin Cardiol 2003;26:31–5.
122. Ehara S, Ueda M, Naruko T, et al. Elevated levels of oxidized low
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by University of Auckland on 01/20/15
density lipoprotein show a positive relationship with the severity
of acute coronary syndromes. Circulation 2001;103:1955–60.
123. Holvoet P, Vanhaecke J, Janssens S, et al. Oxidized LDL and
malondialdehyde-modified LDL in patients with acute coronary
syndromes and stable coronary artery disease. Circulation 1998;
98:1487–94.
124. Kayo S, Ohsawa M, Ehara S, et al. Oxidized low-density
lipoprotein levels circulating in plasma and deposited in the
tissues: comparison between Helicobacter pylori-associated gas-
tritis and acute myocardial infarction. Am Heart J 2004;148:
818–25.
125. Holvoet P, Mertens A, Verhamme P, et al. Circulating oxidized
LDL is a useful marker for identifying patients with coronary
artery disease. Arterioscler Thromb Vasc Biol 2001;21:844–8.
126. Faviou E, Vourli G, Nounopoulos C, et al. Circulating oxidized
low density lipoprotein, autoantibodies against them and homo-
cysteine serum levels in diagnosis and estimation of severity of
coronary artery disease. Free Radic Res 2005;39:419–29.
For personal use only.
127. Anselmi M, Garbin U, Agostoni P, et al. Plasma levels of
oxidized-low-density lipoproteins are higher in patients with
unstable angina and correlated with angiographic coronary
complex plaques. Atherosclerosis 2006;185:114–20.
128. Weinbrenner T, Cladellas M, Isabel Covas M, et al. High oxidative
stress in patients with stable coronary heart disease.
Atherosclerosis 2003;168:99–106.
129. Suzuki T, Kohno H, Hasegawa A, et al. Diagnostic implications of
circulating oxidized low density lipoprotein levels as a biochem-
ical risk marker of coronary artery disease. Clin Biochem 2002;35:
347–53.
130. Kugiyama K, Sugiyama S, Soejima H, et al. Increase in plasma
levels of oxidized low-density lipoproteins in patients with
coronary spastic angina. Atherosclerosis 2001;154:463–7.
131. Huang H, Ma R, Liu D, et al. Oxidized low-density lipoprotein
cholesterol and the ratio in the diagnosis and evaluation of
therapeutic effect in patients with coronary artery disease. Dis
Markers 2012;33:295–302.
132. Huang H, Mai W, Liu D, et al. The oxidation ratio of LDL: a
predictor for coronary artery disease. Dis Markers 2008;24:341–9.
133. Tsimikas S, Brilakis ES, Miller ER, et al. Oxidized phospholipids,
Lp(a) lipoprotein, and coronary artery disease. N Engl J Med
2005;353:46–57.
134. Holvoet P, Stassen JM, Van Cleemput J, et al. Oxidized
low density lipoproteins in patients with transplant-associated
coronary artery disease. Arterioscler Thromb Vasc Biol 1998;18:
100–7.
135. Ehara S, Naruko T, Shirai N, et al. Small coronary calcium
deposits and elevated plasma levels of oxidized low density
lipoprotein are characteristic of acute myocardial infarction.
J Atheroscler Thromb 2008;15:75–81.
136. Fujii H, Shimizu M, Ino H, et al. Oxidative stress correlates with
left ventricular volume after acute myocardial infarction. Jpn
Heart J 2002;43:203–9.
137. Ehara S, Ueda M, Naruko T, et al. Pathophysiological role of
oxidized low-density lipoprotein in plaque instability in coronary
artery diseases. J Diabetes Complications 2002;16:60–4.
138. Zhang YC, Wei JJ, Wang F, et al. Elevated levels of oxidized low-
density lipoprotein correlate positively with C-reactive protein in
patients with acute coronary syndrome. Cell Biochem Biophys
2012;62:365–72.
OxLDL: A biomarker of CVD 13
139. Niccoli G, Mongiardo R, Lanza GA, et al. The complex link
between oxidised low-density lipoprotein and unstable angina.
J Cardiovasc Med (Hagerstown) 2007;8:387–91.
140. Naruko T, Ueda M, Ehara S, et al. Persistent high levels of plasma
oxidized low-density lipoprotein after acute myocardial infarction
predict stent restenosis. Arterioscler Thromb Vasc Biol 2006;26:
877–83.
141. Segev A, Strauss BH, Witztum JL, et al. Relationship of a
comprehensive panel of plasma oxidized low-density lipoprotein
markers to angiographic restenosis in patients undergoing percu-
taneous coronary intervention for stable angina. Am Heart J 2005;
150:1007–14.
142. Tsimikas S, Lau HK, Han KR, et al. Percutaneous coronary
intervention results in acute increases in oxidized phospholipids
and lipoprotein(a): short-term and long-term immunologic
responses to oxidized low-density lipoprotein. Circulation 2004;
109:3164–70.
143. Fujii H, Shimizu M, Ino H, et al. Acute increases in plasma
oxidized low-density lipoprotein immediately after percutan-
eous transluminal coronary angioplasty. Am J Cardiol 2001;87:
102–3, A8.
144. Fefer P, Tsimikas S, Segev A, et al. The role of oxidized
phospholipids, lipoprotein (a) and biomarkers of oxidized lipo-
proteins in chronically occluded coronary arteries in sudden
cardiac death and following successful percutaneous revascular-
ization. Cardiovasc Revasc Med 2012;13:11–19.
145. Itabe H, Obama T, Kato R. The dynamics of oxidized LDL during
atherogenesis. J Lipids 2011;2011:Article ID 418313, 9 pages,
doi:10.1155/2011/13.
146. Holvoet P, Harris TB, Tracy RP, et al. Association of high
coronary heart disease risk status with circulating oxidized LDL in
the well-functioning elderly: findings from the Health, Aging, and
Body Composition study. Arterioscler Thromb Vasc Biol 2003;23:
1444–8.
147. Itabe H, Takeshima E, Iwasaki H, et al. A monoclonal antibody
against oxidized lipoprotein recognizes foam cells in atheroscler-
otic lesions. Complex formation of oxidized phosphatidylcholines
and polypeptides. J Biol Chem 1994;269:15274–9.
148. Uchida Y, Maezawa Y, Uchida Y, et al. Localization of oxidized
low-density lipoprotein and its relation to plaque morphology in
human coronary artery. PLoS One 2013;8:e55188.
149. Yamashita H, Ehara S, Yoshiyama M, et al. Elevated plasma levels
of oxidized low-density lipoprotein relate to the presence of
angiographically detected complex and thrombotic coronary
artery lesion morphology in patients with unstable angina.
Circ J 2007;71:681–7.
150. Tsimikas S, Mallat Z, Talmud PJ, et al. Oxidation-specific
biomarkers, lipoprotein(a), and risk of fatal and nonfatal coronary
events. J Am Coll Cardiol 2010;56:946–55.
151. Drogan D, Weikert C, Dierkes J, et al. Plasma gamma-
glutamyltransferase, cysteinyl-glycine, and oxidized low-density
lipoprotein: a pathway associated with myocardial infarction risk?
Arterioscler Thromb Vasc Biol 2010;30:2053–8.
152. Kiechl S, Willeit J, Mayr M, et al. Oxidized phospholipids,
lipoprotein(a), lipoprotein-associated phospholipase A2 activity,
and 10-year cardiovascular outcomes: prospective results from the
Bruneck study. Arterioscler Thromb Vasc Biol 2007;27:1788–95.
153. Meisinger C, Baumert J, Khuseyinova N, et al. Plasma oxidized
low-density lipoprotein, a strong predictor for acute coronary heart
disease events in apparently healthy, middle-aged men from the
general population. Circulation 2005;112:651–7.
154. Shimada K, Mokuno H, Matsunaga E, et al. Circulating oxidized
low-density lipoprotein is an independent predictor for cardiac
event in patients with coronary artery disease. Atherosclerosis
2004;174:343–7.
155. Johnston N, Jernberg T, Lagerqvist B, et al. Oxidized low-density
lipoprotein as a predictor of outcome in patients with unstable
coronary artery disease. Int J Cardiol 2006;113:167–73.
156. Gomez M, Valle V, Aros F, et al. Oxidized LDL, lipoprotein (a)
and other emergent risk factors in acute myocardial infarction
(FORTIAM study). Rev Esp Cardiol 2009;62:373–82.
157. Holvoet P, Van Cleemput J, Collen D, Vanhaecke J. Oxidized low
density lipoprotein is a prognostic marker of transplant-associated
coronary artery disease. Arterioscler Thromb Vasc Biol 2000;20:
698–702.
 14 A. Trpkovic et al.
158. Nordin Fredrikson G, Hedblad B, Berglund G, Nilsson J. Plasma
oxidized LDL: a predictor for acute myocardial infarction?
J Intern Med 2003;253:425–9.
159. Koenig W, Karakas M, Zierer A, et al. Oxidized LDL and the risk
of coronary heart disease: results from the MONICA/KORA
Augsburg Study. Clin Chem 2011;57:1196–200.
160. Wu T, Willett WC, Rifai N, et al. Is plasma oxidized low-density
lipoprotein, measured with the widely used antibody 4E6, an
independent predictor of coronary heart disease among U.S. men
and women? J Am Coll Cardiol 2006;48:973–9.
161. Zuliani G, Morieri ML, Volpato S, et al. Determinants
and clinical significance of plasma oxidized LDLs in older
individuals. A 9 years follow-up study. Atherosclerosis 2013;226:
201–7.
162. Braun S, Ndrepepa G, von Beckerath N, et al. Lack of association
between circulating levels of plasma oxidized low-density lipo-
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by University of Auckland on 01/20/15
proteins and clinical outcome after coronary stenting. Am Heart J
2005;150:550–6.
163. Jorde UP, Colombo PC, Ahuja K, et al. Exercise-induced
increases in oxidized low-density lipoprotein are associated with
adverse outcomes in chronic heart failure. J Card Fail 2007;13:
759–64.
164. Tsutsui T, Tsutamoto T, Wada A, et al. Plasma oxidized low-
density lipoprotein as a prognostic predictor in patients with
chronic congestive heart failure. J Am Coll Cardiol 2002;39:
957–62.
165. Caparevic Z, Kostic N, Ilic S, et al. Oxidized LDL and C-reactive
protein level in relation to carotid intima-media thickness in
population with risk factors for atherosclerosis. Srp Arh Celok Lek
2009;137:140–5.
166. Kampus P, Kals J, Ristimae T, et al. Augmentation index
and carotid intima-media thickness are differently related to age,
C-reactive protein and oxidized low-density lipoprotein.
J Hypertens 2007;25:819–25.
For personal use only.
167. Gokulakrishnan K, Deepa R, Velmurugan K, et al. Oxidized low-
density lipoprotein and intimal medial thickness in subjects with
glucose intolerance: the Chennai Urban Rural Epidemiology
Study-25. Metabolism 2007;56:245–50.
168. Liu ML, Ylitalo K, Salonen R, et al. Circulating oxidized low-
density lipoprotein and its association with carotid intima-media
thickness in asymptomatic members of familial combined hyper-
lipidemia families. Arterioscler Thromb Vasc Biol 2004;24:
1492–7.
169. Metso S, Loimaala A, Mercuri MF, et al. Circulating oxidized
low-density lipoprotein and common carotid artery intima-media
thickness in a random sample of middle-aged men. J Biomed Sci
2004;11:356–61.
170. Hulthe J, Fagerberg B. Circulating oxidized LDL is associated
with subclinical atherosclerosis development and inflammatory
cytokines (AIR Study). Arterioscler Thromb Vasc Biol 2002;22:
1162–7.
171. Calmarza P, Trejo JM, Lapresta C, Lopez P. LDL oxidation and its
association with carotid artery intima-media thickness and other
cardiovascular risk factors in a sample of Spanish general
population. Angiology 2014;65:357–62.
172. Okur I, Tumer L, Ezgu FS, et al. Oxidized low-density lipoprotein
levels and carotid intima-media thickness as markers of early
atherosclerosis in prepubertal obese children. J Pediatr
Endocrinol Metab 2013;26:657–62.
173. Nishi K, Itabe H, Uno M, et al. Oxidized LDL in carotid plaques
and plasma associates with plaque instability. Arterioscler Thromb
Vasc Biol 2002;22:1649–54.
174. Sigurdardottir V, Fagerberg B, Wikstrand J, et al. Circulating
oxidized LDL is associated with the occurrence of echolucent
plaques in the carotid artery in 61-year-old men. Scand J Clin Lab
Invest 2008;68:292–7.
175. Sigala F, Kotsinas A, Savari P, et al. Oxidized LDL in human
carotid plaques is related to symptomatic carotid disease and
lesion instability. J Vasc Surg 2010;52:704–13.
176. Uno M, Kitazato KT, Suzue A, et al. Contribution of an imbalance
between oxidant-antioxidant systems to plaque vulnerability in
patients with carotid artery stenosis. J Neurosurg 2005;103:
518–25.
177. Wallenfeldt K, Fagerberg B, Wikstrand J, Hulthe J. Oxidized low-
density lipoprotein in plasma is a prognostic marker of subclinical
Crit Rev Clin Lab Sci, Early Online: 1–16
atherosclerosis development in clinically healthy men. J Intern
Med 2004;256:413–20.
178. Tsimikas S, Kiechl S, Willeit J, et al. Oxidized phospholipids
predict the presence and progression of carotid and femoral
atherosclerosis and symptomatic cardiovascular disease: five-year
prospective results from the Bruneck study. J Am Coll Cardiol
2006;47:2219–28.
179. Langlois MR, Rietzschel ER, De Buyzere ML, et al. Femoral
plaques confound the association of circulating oxidized low-
density lipoprotein with carotid atherosclerosis in a general
population aged 35 to 55 years: the Asklepios Study.
Arterioscler Thromb Vasc Biol 2008;28:1563–8.
180. Sigurdardottir V, Fagerberg B, Wikstrand J, et al. Circulating
oxidized low-density lipoprotein is associated with echolucent
plaques in the femoral artery independently of hsCRP in 61-year-
old men. Atherosclerosis 2007;190:187–93.
181. Brinkley TE, Nicklas BJ, Kanaya AM, et al. Plasma oxidized low-
density lipoprotein levels and arterial stiffness in older adults: the
health, aging, and body composition study. Hypertension 2009;53:
846–52.
182. Jarvisalo MJ, Lehtimaki T, Raitakari OT. Determinants of arterial
nitrate-mediated dilatation in children: role of oxidized low-
density lipoprotein, endothelial function, and carotid intima-media
thickness. Circulation 2004;109:2885–9.
183. van der Zwan LP, Teerlink T, Dekker JM, et al. Circulating
oxidized LDL: determinants and association with brachial flow-
mediated dilation. J Lipid Res 2009;50:342–9.
184. Uno M, Kitazato KT, Nishi K, et al. Raised plasma oxidised LDL
in acute cerebral infarction. J Neurol Neurosurg Psychiatry 2003;
74:312–16.
185. Uno M, Harada M, Takimoto O, et al. Elevation of plasma
oxidized LDL in acute stroke patients is associated with ischemic
lesions depicted by DWI and predictive of infarct enlargement.
Neurol Res 2005;27:94–102.
186. Kopprasch S, Pietzsch J, Kuhlisch E, et al. In vivo evidence for
increased oxidation of circulating LDL in impaired glucose
tolerance. Diabetes 2002;51:3102–6.
187. Kelly AS, Jacobs Jr DR, Sinaiko AR, et al. Relation of circulating
oxidized LDL to obesity and insulin resistance in children. Pediatr
Diabetes 2010;11:552–5.
188. Njajou OT, Kanaya AM, Holvoet P, et al. Association between
oxidized LDL, obesity and type 2 diabetes in a population-based
cohort, the Health, Aging and Body Composition Study. Diabetes
Metab Res Rev 2009;25:733–9.
189. Park K, Gross M, Lee DH, et al. Oxidative stress and insulin
resistance: the coronary artery risk development in young adults
study. Diabetes Care 2009;32:1302–7.
190. Hoogeveen RC, Ballantyne CM, Bang H, et al. Circulating
oxidised low-density lipoprotein and intercellular adhesion
molecule-1 and risk of type 2 diabetes mellitus: the
Atherosclerosis Risk in Communities Study. Diabetologia 2007;
50:36–42.
191. Lautamaki R, Ronnemaa T, Huupponen R, et al. Low serum
adiponectin is associated with high circulating oxidized low-
density lipoprotein in patients with type 2 diabetes mellitus and
coronary artery disease. Metabolism 2007;56:881–6.
192. Tsuzura S, Ikeda Y, Suehiro T, et al. Correlation of plasma
oxidized low-density lipoprotein levels to vascular complications
and human serum paraoxonase in patients with type 2 diabetes.
Metabolism 2004;53:297–302.
193. Nakhjavani M, Khalilzadeh O, Khajeali L, et al. Serum oxidized-
LDL is associated with diabetes duration independent of main-
taining optimized levels of LDL-cholesterol. Lipids 2010;45:
321–7.
194. Stephens JW, Gable DR, Hurel SJ, et al. Increased plasma
markers of oxidative stress are associated with coronary heart
disease in males with diabetes mellitus and with 10-year risk
in a prospective sample of males. Clin Chem 2006;52:446–52.
195. Kim M, Paik JK, Kang R, et al. Increased oxidative stress in
normal-weight postmenopausal women with metabolic syndrome
compared with metabolically healthy overweight/obese individ-
uals. Metabolism 2013;62:554–60.
196. Norris AL, Steinberger J, Steffen LM, et al. Circulating oxidized
LDL and inflammation in extreme pediatric obesity. Obesity
(Silver Spring) 2011;19:1415–19.
 DOI: 10.3109/10408363.2014.992063
197. Kassi E, Dalamaga M, Faviou E, et al. Circulating oxidized LDL
levels, current smoking and obesity in postmenopausal women.
Atherosclerosis 2009;205:279–83.
198. Indulekha K, Anjana RM, Surendar J, Mohan V. Association
of visceral and subcutaneous fat with glucose intolerance, insulin
resistance, adipocytokines and inflammatory markers in Asian
Indians (CURES-113). Clin Biochem 2011;44:281–7.
199. Weinbrenner T, Schroder H, Escurriol V, et al. Circulating
oxidized LDL is associated with increased waist circumference
independent of body mass index in men and women. Am J Clin
Nutr 2006;83:30–5.
200. Holvoet P, Kritchevsky SB, Tracy RP, et al. The metabolic
syndrome, circulating oxidized LDL, and risk of myocardial
infarction in well-functioning elderly people in the health, aging,
and body composition cohort. Diabetes 2004;53:1068–73.
201. Ueba T, Nomura S, Nishikawa T, et al. Circulating oxidized LDL,
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by University of Auckland on 01/20/15
measured with FOH1a/DLH3 antibody, is associated with meta-
bolic syndrome and the coronary heart disease risk score in
healthy Japanese. Atherosclerosis 2009;203:243–8.
202. Sigurdardottir V, Fagerberg B, Hulthe J. Circulating oxidized low-
density lipoprotein (LDL) is associated with risk factors of the
metabolic syndrome and LDL size in clinically healthy 58-year-
old men (AIR study). J Intern Med 2002;252:440–7.
203. Bae YJ, Kim SH, Chung JH, et al. Evaluation of adiposity-related
biomarkers as metabolic syndrome indicators. Clin Nutr Res 2013;
2:91–9.
204. Valle Gottlieb MG, da Cruz IB, Duarte MM, et al. Associations
among metabolic syndrome, ischemia, inflammatory, oxidatives,
and lipids biomarkers. J Clin Endocrinol Metab 2010;95:586–91.
205. Park SH, Kim JY, Lee JH, Park HY. Elevated oxidized low-density
lipoprotein concentrations in postmenopausal women with the
metabolic syndrome. Clin Chim Acta 2011;412:435–40.
206. Lapointe A, Couillard C, Piche ME, et al. Circulating oxidized
LDL is associated with parameters of the metabolic syndrome in
For personal use only.
postmenopausal women. Atherosclerosis 2007;191:362–8.
207. Sjogren P, Basu S, Rosell M, et al. Measures of oxidized low-
density lipoprotein and oxidative stress are not related and not
elevated in otherwise healthy men with the metabolic syndrome.
Arterioscler Thromb Vasc Biol 2005;25:2580–6.
208. Linna MS, Ahotupa M, Irjala K, et al. Smoking and low serum
testosterone associates with high concentration of oxidized LDL.
Ann Med 2008;40:634–40.
209. Duntas LH, Mantzou E, Koutras DA. Circulating levels of
oxidized low-density lipoprotein in overt and mild hypothyroid-
ism. Thyroid 2002;12:1003–7.
210. Holvoet P, Lee DH, Steffes M, et al. Association between
circulating oxidized low-density lipoprotein and incidence of the
metabolic syndrome. JAMA 2008;299:2287–93.
211. Rector RS, Warner SO, Liu Y, et al. Exercise and diet induced
weight loss improves measures of oxidative stress and insulin
sensitivity in adults with characteristics of the metabolic syn-
drome. Am J Physiol Endocrinol Metab 2007;293:E500–6.
212. Fito M, Guxens M, Corella D, et al. Effect of a traditional
Mediterranean diet on lipoprotein oxidation: a randomized
controlled trial. Arch Intern Med 2007;167:1195–203.
213. Barona J, Jones JJ, Kopec RE, et al. A Mediterranean-style low-
glycemic-load diet increases plasma carotenoids and decreases
LDL oxidation in women with metabolic syndrome. J Nutr
Biochem 2012;23:609–15.
214. Tavridou A, Efthimiadis A, Efthimiadis I, Paschalidou H.
Antioxidant effects of simvastatin in primary and secondary
prevention of coronary heart disease. Eur J Clin Pharmacol 2006;
62:485–9.
215. Ndrepepa G, Braun S, von Beckerath N, et al. Oxidized low
density lipoproteins, statin therapy and severity of coronary artery
disease. Clin Chim Acta 2005;360:178–86.
216. Ky B, Burke A, Tsimikas S, et al. The influence of pravastatin and
atorvastatin on markers of oxidative stress in hypercholesterolemic
humans. J Am Coll Cardiol 2008;51:1653–62.
217. Inami S, Okamatsu K, Takano M, et al. Effects of statins on
circulating oxidized low-density lipoprotein in patients with
hypercholesterolemia. Jpn Heart J 2004;45:969–75.
218. van Tits LJ, van Himbergen TM, Lemmers HL, et al. Proportion
of oxidized LDL relative to plasma apolipoprotein B
does not change during statin therapy in patients with
OxLDL: A biomarker of CVD 15
heterozygous familial hypercholesterolemia. Atherosclerosis
2006;185:307–12.
219. Akalin A, Temiz G, Akcar N, Sensoy B. Short term
effects of atorvastatin on endothelial functions and oxidized
LDL levels in patients with type 2 diabetes. Endocr J 2008;55:
861–6.
220. Singh U, Devaraj S, Jialal I, Siegel D. Comparison effect of
atorvastatin (10 versus 80 mg) on biomarkers of inflammation
and oxidative stress in subjects with metabolic syndrome.
Am J Cardiol 2008;102:321–5.
221. Verreth W, De Keyzer D, Davey PC, et al. Rosuvastatin restores
superoxide dismutase expression and inhibits accumulation
of oxidized LDL in the aortic arch of obese dyslipidemic mice.
Br J Pharmacol 2007;151:347–55.
222. Tsimikas S, Aikawa M, Miller Jr FJ, et al. Increased plasma
oxidized phospholipid:apolipoprotein B-100 ratio with concomi-
tant depletion of oxidized phospholipids from atherosclerotic
lesions after dietary lipid-lowering: a potential biomarker of early
atherosclerosis regression. Arterioscler Thromb Vasc Biol 2007;
27:175–81.
223. Silaste ML, Rantala M, Alfthan G, et al. Changes in dietary
fat intake alter plasma levels of oxidized low-density lipoprotein
and lipoprotein(a). Arterioscler Thromb Vasc Biol 2004;24:
498–503.
224. Faghihnia N, Tsimikas S, Miller ER, et al. Changes in lipopro-
tein(a), oxidized phospholipids, and LDL subclasses with a low-fat
high-carbohydrate diet. J Lipid Res 2010;51:3324–30.
225. Ahmadi N, Tsimikas S, Hajsadeghi F, et al. Relation of oxidative
biomarkers, vascular dysfunction, and progression of coronary
artery calcium. Am J Cardiol 2010;105:459–66.
226. Budoff MJ, Ahmadi N, Gul KM, et al. Aged garlic extract
supplemented with B vitamins, folic acid and L-arginine retards
the progression of subclinical atherosclerosis: a randomized
clinical trial. Prev Med 2009;49:101–7.
227. Tsimikas S, Witztum JL, Miller ER, et al. High-dose atorvastatin
reduces total plasma levels of oxidized phospholipids and immune
complexes present on apolipoprotein B-100 in patients with acute
coronary syndromes in the MIRACL trial. Circulation 2004;110:
1406–12.
228. Penny WF, Ben-Yehuda O, Kuroe K, et al. Improvement of
coronary artery endothelial dysfunction with lipid-lowering ther-
apy: heterogeneity of segmental response and correlation with
plasma-oxidized low density lipoprotein. J Am Coll Cardiol 2001;
37:766–74.
229. Fraley AE, Schwartz GG, Olsson AG, et al. Relationship of
oxidized phospholipids and biomarkers of oxidized low-density
lipoprotein with cardiovascular risk factors, inflammatory bio-
markers, and effect of statin therapy in patients with acute
coronary syndromes: results from the MIRACL (Myocardial
Ischemia Reduction With Aggressive Cholesterol Lowering) trial.
J Am Coll Cardiol 2009;53:2186–96.
230. Choi SH, Chae A, Miller E, et al. Relationship between
biomarkers of oxidized low-density lipoprotein, statin therapy,
quantitative coronary angiography, and atheroma: volume obser-
vations from the REVERSAL (Reversal of Atherosclerosis with
Aggressive Lipid Lowering) study. J Am Coll Cardiol 2008;52:
24–32.
231. Rodenburg J, Vissers MN, Wiegman A, et al. Oxidized low-
density lipoprotein in children with familial hypercholesterolemia
and unaffected siblings: effect of pravastatin. J Am Coll Cardiol
2006;47:1803–10.
232. Tsimikas S, Witztum JL. The role of oxidized phospholipids in
mediating lipoprotein(a) atherogenicity. Curr Opin Lipidol 2008;
19:369–77.
233. Bergmark C, Dewan A, Orsoni A, et al. A novel function of
lipoprotein [a] as a preferential carrier of oxidized phospholipids
in human plasma. J Lipid Res 2008;49:2230–9.
234. Scanu AM, Fless GM. Lipoprotein (a). Heterogeneity and
biological relevance. J Clin Invest 1990;85:1709–15.
235. Nordestgaard BG, Chapman MJ, Ray K, et al. Lipoprotein(a) as a
cardiovascular risk factor: current status. Eur Heart J 2010;31:
2844–53.
236. Nielsen LB, Gronholdt ML, Schroeder TV, et al. In vivo transfer
of lipoprotein(a) into human atherosclerotic carotid arterial
intima. Arterioscler Thromb Vasc Biol 1997;17:905–11.
 16 A. Trpkovic et al.
237. Godfrey EG, Stewart J, Dargie HJ, et al. Effects of ACE inhibitors
on oxidation of human low density lipoprotein. Br J Clin
Pharmacol 1994;37:63–6.
238. Hayek T, Kaplan M, Raz A, et al. Ramipril administration to
atherosclerotic mice reduces oxidized low-density lipoprotein
uptake by their macrophages and blocks the progression of
atherosclerosis. Atherosclerosis 2002;161:65–74.
239. Berkenboom G, Langer I, Carpentier Y, et al. Ramipril prevents
endothelial dysfunction induced by oxidized low-density lipopro-
teins: a bradykinin-dependent mechanism. Hypertension 1997;30:
371–6.
240. de Nigris F, D’Armiento FP, Somma P, et al. Chronic treatment
with sulfhydryl angiotensin-converting enzyme inhibitors reduce
susceptibility of plasma LDL to in vitro oxidation, formation of
oxidation-specific epitopes in the arterial wall, and atherogenesis
in apolipoprotein E knockout mice. Int J Cardiol 2001;81:107–15;
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by University of Auckland on 01/20/15
discusssion 15–16.
241. Napoli C, Cicala C, D’Armiento FP, et al. Beneficial effects of
ACE-inhibition with zofenopril on plaque formation and low-
density lipoprotein oxidation in watanabe heritable hyperlipidemic
rabbits. Gen Pharmacol 1999;33:467–77.
242. Sun L, Wen JH, Sun HL, et al. Perindopril attenuates renal
tubulointerstitium injury by inhibiting scavenger receptor A over-
expression in diabetic rats. J Endocrinol Invest 2012;35:511–15.
243. Osada-Oka M, Kita H, Yagi S, et al. Angiotensin AT1 receptor
blockers suppress oxidized low-density lipoprotein-derived for-
mation of foam cells. Eur J Pharmacol 2012;679:9–15.
244. Koulouris S, Symeonides P, Triantafyllou K, et al. Comparison of
the effects of ramipril versus telmisartan in reducing serum levels
of high-sensitivity C-reactive protein and oxidized low-density
lipoprotein cholesterol in patients with type 2 diabetes mellitus.
Am J Cardiol 2005;95:1386–8.
245. Lesnik P, Dachet C, Petit L, et al. Impact of a combination of a
calcium antagonist and a beta-blocker on cell- and copper-
For personal use only.
mediated oxidation of LDL and on the accumulation and efflux of
cholesterol in human macrophages and murine J774 cells.
Arterioscler Thromb Vasc Biol 1997;17:979–88.
246. Phillips JE, Preston Mason R. Inhibition of oxidized LDL
aggregation with the calcium channel blocker amlodipine: role
of electrostatic interactions. Atherosclerosis 2003;168:239–44.
247. Sevanian A, Shen L, Ursini F. Inhibition of LDL oxidation and
oxidized LDL-induced cytotoxicity by dihydropyridine calcium
antagonists. Pharm Res 2000;17:999–1006.
248. Zou J, Li Y, Fan HQ, Wang JG. Effects of dihydropyridine
calcium channel blockers on oxidized low-density lipoprotein
induced proliferation and oxidative stress of vascular smooth
muscle cells. BMC Res Notes 2012;5:168.
249. Yue TL, McKenna PJ, Lysko PG, et al. Carvedilol, a new
antihypertensive, prevents oxidation of human low density lipo-
protein by macrophages and copper. Atherosclerosis 1992;97:
209–16.
Crit Rev Clin Lab Sci, Early Online: 1–16
250. Jonsson G, Abdelnoor M, Seljeflot I, et al. The antioxidative
effects of long-term treatment are more pronounced for carvedilol
than for atenolol in post-myocardial infarction patients.
J Cardiovasc Pharmacol 2007;49:27–32.
251. Serg M, Kampus P, Kals J, et al. Nebivolol and metoprolol: long-
term effects on inflammation and oxidative stress in essential
hypertension. Scand J Clin Lab Invest 2012;72:427–32.
252. Kelly AS, Gonzalez-Campoy JM, Rudser KD, et al. Carvedilol-
lisinopril combination therapy and endothelial function in obese
individuals with hypertension. J Clin Hypertens (Greenwich)
2012;14:85–91.
253. Mehta JL, Chen J, Yu F, Li DY. Aspirin inhibits ox-LDL-mediated
LOX-1 expression and metalloproteinase-1 in human coronary
endothelial cells. Cardiovasc Res 2004;64:243–9.
254. Chen B, Zhao J, Zhang S, et al. Aspirin inhibits the production of
reactive oxygen species by downregulating Nox4 and inducible
nitric oxide synthase in human endothelial cells exposed to
oxidized low-density lipoprotein. J Cardiovasc Pharmacol 2012;
59:405–12.
255. Chen JW, Zhou SB, Tan ZM. Aspirin and pravastatin reduce
lectin-like oxidized low density lipoprotein receptor-1 expression,
adhesion molecules and oxidative stress in human coronary artery
endothelial cells. Chin Med J (Engl) 2010;123:1553–6.
256. Zhao J, Qi R, Li R, et al. Protective effects of aspirin against
oxidized LDL-induced inflammatory protein expression in human
endothelial cells. J Cardiovasc Pharmacol 2008;51:32–7.
257. Kurban S, Mehmetoglu I. Effects of acetylsalicylic acid on serum
paraoxonase activity, Ox-LDL, coenzyme Q10 and other oxidative
stress markers in healthy volunteers. Clin Biochem 2010;43:
287–90.
258. Serebruany V, Sani Y, Eisert C, et al. Effects of Aggrenox and
aspirin on plasma endothelial nitric oxide synthase and oxidised
low-density lipoproteins in patients after ischaemic stroke. The
AGgrenox versus aspirin therapy evaluation (AGATE) biomarker
substudy. Thromb Haemost 2011;105:81–7.
259. Ricciarelli R, Zingg JM, Azzi A. Vitamin E reduces the uptake of
oxidized LDL by inhibiting CD36 scavenger receptor expression
in cultured aortic smooth muscle cells. Circulation 2000;102:
82–7.
260. Hayek T, Fuhrman B, Vaya J, et al. Reduced progression
of atherosclerosis in apolipoprotein E-deficient mice follow-
ing consumption of red wine, or its polyphenols quercetin or
catechin, is associated with reduced susceptibility of LDL to
oxidation and aggregation. Arterioscler Thromb Vasc Biol 1997;
17:2744–52.
261. Li XY, Kong LX, Li J, et al. Kaempferol suppresses lipid
accumulation in macrophages through the downregulation of
cluster of differentiation 36 and the upregulation of scavenger
receptor class B type I and ATP-binding cassette transporters A1
and G1. Int J Mol Med 2013;31:331–8.