Journal of Clinical Lipidology (2016) 10, 594–603

Effect of therapeutic interventions on oxidized

phospholipids on apolipoprotein B100 and
lipoprotein(a)
Calvin Yeang, MD, PhD, Ming-Yow Hung, MD, Young-Sup Byun, MD, Paul Clopton, MSc,
Xiaohong Yang, BS, Joseph L. Witztum, MD, Sotirios Tsimikas, MD*

Division of Cardiovascular Diseases, Sulpizio Cardiovascular Center, Department of Medicine, University of California,
La Jolla, CA, USA (Drs Yeang, Yang, and Tsimikas); Department of Internal Medicine, School of Medicine, College of
Medicine, Taipei Medical University, Taipei, Taiwan (Dr Hung); Division of Cardiology, Department of Internal Medicine,
Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan (Dr Hung); Graduate Institute of Clinical
Medical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan (Dr Hung); Division of Cardiology,
Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea (Dr
Byun); San Diego Veteran’s Administration Medical Center, La Jolla, CA, USA (Dr Clopton); and Division of
Endocrinology and Metabolism, Department of Medicine, University of California, La Jolla, CA, USA (Dr Witztum)

KEYWORDS: BACKGROUND: Oxidized phospholipids (OxPL) on apolipoprotein B-100 (OxPL–apoB) reflect the
Oxidized phospholipids; biological activity of lipoprotein(a) (Lp[a]) and predict cardiovascular disease events. However, studies
Lipoprotein(a); with statins and low-fat diets show increases in OxPL–apoB and Lp(a).
Niacin; OBJECTIVE: This study evaluated changes in OxPL–apoB and Lp(a) with extended-release niacin (N),
Simvastatin; ezetimibe/simvastatin (E/S) and combination E/S/N. A systematic literature review of previously pub-
Ezetimibe; lished trials, measuring both OxPL–apoB and Lp(a) after therapeutic interventions, was also performed.
Statin; METHODS: OxPL–apoB and Lp(a) were measured in 591 patients at baseline and 24 weeks after ther-
Diet apy with N, E/S, or E/S/N in a previously completed randomized trial of hypercholesterolemic patients.
The literature review included 12 trials and 3896 patients evaluating statins, low-fat diets, antisense to
apolipoprotein(a) and lipid apheresis.
RESULTS: Niacin decreased OxPL–apoB levels (median [interquartile range]; 3.5 [2.2–9.2] nM to 3.1
[1.8–7.2] nM, P ,.01) and Lp(a) (10.9 [4.6–38.4] to 9.3 [3.1–32.9] mg/dL, P ,.01). In contrast, E/S and
E/S/N significantly increased OxPL–apoB (3.5 [2.1–7.8] to 4.9 [3.0–11.1] nM, P ,.01) and (3.3 [1.9–9.3]
to 4.3 [2.6–11.2] nM, P ,.01), respectively and Lp(a) (11.5 [6.1–36.4] to 14.9 [6.6–54.6] mg/dL, P ,.01)
and (11.3 [5.4–43.8] to 11.6 [5.9–52.8] mg/dL, P ,.01), respectively. The systematic review of statins and
diet demonstrated 23.8% and 21.3% mean increases in OxPL–apoB and 10.6% and 19.4% increases in
Lp(a), respectively. However 44.1% and 52.0% decreases in OxPL–apoB and Lp(a), respectively, were
present with Lp(a)–lowering therapies.
CONCLUSIONS: This study demonstrates differential changes in OxPL–apoB and Lp(a) with various
lipid-lowering approaches. These changes in OxPL–apoB and Lp(a) may provide insights into the results
and interpretation of recent cardiovascular disease outcomes trials.
Ó 2016 National Lipid Association. All rights reserved.

* Corresponding author. Vascular Medicine Program, University of Cal- E-mail address: stsimikas@ucsd.edu
ifornia San Diego, 9500 Gilman Dr., BSB 1080, La Jolla, CA 92093-0682, Submitted September 22, 2015. Accepted for publication January 26,
USA. 2016.

1933-2874/Ó 2016 National Lipid Association. All rights reserved.

http://dx.doi.org/10.1016/j.jacl.2016.01.005
Yeang et al Oxidized phospholipids and therapy
Introduction
Elevated plasma levels of oxidized phospholipids
(OxPL) on apoB100-containing particles (OxPL–apoB)
are associated with increased risk of death, myocardial
infarction, and stroke in prospectively followed populations
for the general community1-3 and in secondary prevention
settings,4,5 correlate with endothelial dysfunction and pro-
gression of coronary calcification,6 predict the development
of peripheral arterial disease7 and progression of femoral/
carotid disease,8 the presence of angiographically deter-
mined coronary artery disease,9 and increase in patients af-
ter acute coronary syndrome10 and percutaneous
intervention.11 Furthermore, both OxPL–apoB and Lp(a)
reclassify w30% to 40% of patients based on intermediate
Framingham Risk and/or Reynolds Risk Scores into higher
or lower categories.3,12 OxPL–apoB levels correlate with
Lp(a) levels broadly, but this association is strongest
(r-values up to 0.85) in patients with elevated Lp(a) levels
and concomitantly small apo(a) isoforms or with the pres-
ence of LPA single nucleotide polymorphisms
rs379822013 and rs1045587214 that are also associated
with elevated levels. The correlation is weakest (r-values
as low as 0.13) in patients with low Lp(a) levels along
with large apo(a) isoforms.15 Based on a large body of clin-
ical and experimental data, it has become evident that Lp(a)
is the preferential lipoprotein carrier of OxPL16,17 and that
OxPL–apoB reflects an important aspect of the biologic ac-
tivity of Lp(a). Lp(a) and OxPL–apoB are highly heritable
cardiovascular risk factors.14 In the Mayo Clinic Study, the
predictive value of both OxPL–apoB and Lp(a) for cardio-
vascular disease (CVD) was dependent on the presence of a
haplotype of single nucleotide polymorphisms in the IL1
gene associated with a highly pro-inflammatory responses,5
consistent with a link between lipoprotein oxidation,
inflammation, atherogenesis, and adverse CVD events.
Lp(a) is a causal, independent, genetic risk factor for
CVD events18-21 and is an independent predictor of CVD
risk, reclassifying w40% of individuals initially catego-
rized as intermediate risk by the Reynolds Risk Score
into higher risk or lower risk categories.12
OxPL, present on OxLDL and Lp(a), are mediators of
inflammation and atherosclerosis, and are particularly
enriched in vulnerable human atherosclerotic lesions.22
Oxidation of phospholipids alters the conformation of the
phosphocholine (PC) head group, allowing it to be recog-
nized by cellular pattern recognition receptors such as
macrophage scavenger receptors CD36 and SR-B1 as
well as TLRs and soluble pattern recognition receptorss
including natural antibodies (NAb) and C-reactive pro-
tein.23 E06, a NAb that binds to PC-containing OxPL, pre-
vents binding and degradation of OxLDL by
macrophages,24 suggesting a role of OxPL in foam cell for-
mation. Lp(a) and OxPL are both potent stimulators of
apoptosis in endoplasmic reticulum–stressed macrophages
in a CD36 and Toll-like receptor 2–dependent pathway.25
Furthermore, endothelial cells exposed to OxPL upregulate
595
adhesion molecules leading to increased monocyte recruit-
ment,26,27 an essential early step in the development of
atherosclerosis.
Surprisingly, and seemingly paradoxically, several ther-
apeutic interventions in relatively short-term studies,
including low-fat diets, garlic supplements and most
statins, have been shown to increase OxPL–apoB
levels.4,28-36 Interestingly, these effects have been associ-
ated with concomitant increases in plasma Lp(a) levels.
The Lp(a)–raising effects of statins and low-fat diets,30,31,36
have been generally underappreciated by the scientific and
medical communities.37 The treatment effect of
Lp(a)–lowering agents, such as niacin(N)38,39 and that of
simvastatin (S) and ezetimibe (E) on OxPL–apoB have
not been studied. The present study examines the effect
of N, E/S, or E/S plus extended release niacin (E/S/N) on
circulating OxPL–apoB and Lp(a) levels. Furthermore, a
systematic review of published trials reporting both
OxPL–apoB and Lp(a) after therapeutic interventions was
performed to gain broader insight into the impact of thera-
peutic interventions on these parameters.
Materials and methods
Patients and study design
Plasma samples were obtained from the previously
completed study by Guyton et al (National Institutes of
Health clinical trial NCT00271817).40,41 This was a ran-
domized, double-blind study in which patients were
initially randomized to 3 arms: extended release niacin
titrated up to 2 g (N), ezetimibe 10 mg/simvastatin 20 mg
(E/S), or triple combination therapy of E/S/N after an initial
4-week washout period. Men and women aged 18 to
79 years with low-density lipoprotein (LDL-C) levels 130
to 190 mg/dL, triglyceride levels ,500 mg/dL, and meta-
bolic and clinical stability (eg, euthyroid, creatinine
, 2 mg/dL, creatinine kinase less than twice upper limit
of normal, transaminases less than 1.5 ! upper limit of
normal) were treated for 24 weeks. The samples included
in this study reflect trial completers (75%) that included
591 patients treated to 24 weeks, encompassing 119 in
the niacin-treated group, 162 in the E/S group, and 300 sub-
jects in the E/S/N group.
Measurement of OxPL–apoB levels
OxPL–apoB levels were measured in a chemilumines-
cent immunoassay using the murine monoclonal antibody
E06 that recognizes the PC group on oxidized but not on
native phospholipids (Taleb et al37 and references therein).
E06 similarly recognizes the PC covalently bound to bovine
serum albumin (BSA), as in PC-BSA. A 1:50 dilution of
plasma in 1% BSA in tris buffered saline was added to mi-
crotiter wells coated with the apoB100-specific monoclonal
antibody MB47, which binds a saturating amount of
596
apoB100 to each well with dilutions used, and biotinylated
E06 was then used to determine the content of OxPL–apoB.
These values were recorded as relative light units and then
converted to nanomolar (nM) PC-OxPL using a standard
curve of nM PC equivalents, as recently described.7
Because each well contains equal numbers of apoB100 par-
ticles, the OxPL–apoB value reflects the content of OxPL
per apoB lipoprotein. In prior studies,3,5,37,42,43 this variable
was expressed as OxPL/apoB, reflecting the fact that this
measure quantitates the number of OxPL moles per unit
mass of apolipoprotein B-100 present on microtiter well
plates (and not the level in the circulation). The nomencla-
ture is now changed to OxPL–apoB to minimize confusion
that this measure represents a ratio of OxPL divided by
plasma levels of apoB. Within-person 5-year reproduc-
ibility of frozen samples has been shown to be high
(r 5 0.78)8 and pilot-tests showed that OxPL–apoB levels
are stable over 24 hours on ice (intraclass correlation coef-
ficient 0.96)7 as well as frozen samples stored under long-
term conditions.1,2,8,34
Determination of Lp(a) levels
Lp(a) mass quantification was performed with a double-
antibody enzyme-linked immunosorbent assay as previ-
ously described.5 Plasma from each sample is diluted 1:400
and added to microtiter wells coated with the monoclonal
antibody MB47 (5 mg/mL). Biotinylated LPA4, a mono-
clonal antibody that recognizes unique sites on apolipopro-
tein(a) not present on KIV-2 repeats, was added to
determine the amount bound detected by a chemilumines-
cent technique. The coefficient of variation of the assay is
6.0% to 7.4%.
Lipid measurements
Plasma lipid and lipoprotein cholesterol measurements were
described in Guyton et al40 Briefly, LDL-C was determined us-
ing the Friedewald equation: LDL-C 5 Plasma-C 2 HDL-C 2
TG/5, where HDL-C represents high-density lipoprotein
cholesterol and TG represents triglycerides. Plasma cholesterol
and triglycerides were determined using enzymatic methods.
Systematic review of the literature
A search of PubMed (Medline), up to May 2015, was
conducted for studies examining changes in OxPL–apoB
and Lp(a) as a result of pharmacologic and dietary
interventions. PubMed search terms were (‘‘Lipopro-
tein(a)’’ [MeSH] or ‘‘Oxidized phospholipids’’ [MeSH])
and (‘‘Statin’’ [MeSH], ‘‘Apheresis’’ [MeSH], or ‘‘Diet’’
[MeSH]). For inclusion in this analysis, identified articles
must have reported baseline and follow-up levels of
OxPL-apoB and Lp(a) after the respective intervention.
The Treating to New Targets trial was excluded due to
having an 8-week run-in period on 10 mg of atorvastatin
before blood samples being available,4 as this affects both
Journal of Clinical Lipidology, Vol 10, No 3, June 2016
OxPL-apoB and Lp(a) levels. Percent changes in OxPL–
apoB and Lp(a) were determined based on the reported
baseline and on-treatment levels. In studies that included
a placebo group (Table 1), the difference between the
percent change in each lipid parameter between the treat-
ment and placebo group was analyzed. Table 1 summa-
rizes the characteristics of each study included in the
systematic review.
Statistics
Analysis of the changes in lipid and lipoprotein
parameters on treatment with N, E/S, or E/S/N was
performed comparing 24-week treatment levels to baseline
levels. OxPL–apoB and Lp(a) data were distributed in a
non-Gaussian fashion. The significance of the absolute on
treatment change was determined by Wilcoxon signed-
ranks test with a 2-tailed alpha of 0.05. The other
parameters studied were distributed in a Gaussian fashion,
and significance was evaluated using 1-way t-test with
alpha of 0.050. Statistical significance of comparisons of
the percent changes in lipid parameters across treatment
regimens were evaluated using 2-tailed independent t-test
assuming unequal variance between data within each treat-
ment group, after significance between all 3 groups was
determined by one-way ANOVA.
Results
Baseline characteristics
This study is comprised of hyperlipidemic patients
treated with niacin alone, E/S, or E/S/N for 24 weeks
evaluating changes in lipid and lipoprotein parameters. A
complete analysis of the baseline demographics for the
original study has been detailed by Guyton et al.40 The
mean age of study participants was 56.9 years, and 49.6%
of them were female, and 28% had coronary heart disease
or coronary heart disease equivalents. There were no signif-
icant differences in the distribution of baseline lipid and li-
poprotein characteristics between the treatment groups
(Table 2). Baseline mean (6standard deviation) levels of
LDL-C and high-density lipoprotein cholesterol were
156.3 6 22.3 mg/dL and 50.4 6 12.7 mg/dL, respectively.
Baseline median levels (interquartile range) of OxPL–apoB
and Lp(a) were 3.5 (2.2–8.7) nM and 11.2 (5.4–40.4) mg/
dL, respectively.
Treatment-related changes in OxPL–apoB and
Lp(a)
After 24 weeks of niacin monotherapy, OxPL–apoB
decreased from 3.5 (2.2–9.2) nM to 3.1 (1.8–7.2) nM,
P , .01 and Lp(a) decreased from 10.9 (4.6–38.4) mg/dL to
9.3 (3.1–32.9) mg/dL, P , .01. These changes corresponded
 Yeang et al
Oxidized phospholipids and therapy
Table 1 Characteristics of trials included in the meta-analysis
Mean % Mean %
Study # Subjects on % Change Mean % # Subjects change change
Authors Year Journal name active therapy OxPL-apoB change Lp(a) Type of intervention on placebo OxPL-apoB Lp(a)
Tsimikas et al 35
2004 Circulation MIRACL 1151 9.5 8.8 Atorvastatin 80 mg 1190 23.9 20.7
Silaste et al36 2004 ATVB 37 27.0 7.0 Low-fat, low vegetable diet N/A N/A N/A
37 19.0 9.0 Low-fat, high vegetable diet N/A N/A N/A
Rodenberg et al34 2006 JACC 90 48.7 21.9 Pravastatin 20–40 mg 88 29.3 10.7
Ky et al32 2008 JACC PROXI 29 8.0 12.0 Atorvastatin 10 mg 27 22.1 16.0
26 20.0 26.0 Atorvastatin 80 mg
24 26.0 26.0 Pravastatin 40 mg
Choi et al33 2008 JACC REVERSAL 108 39.0 14.0 Pravastatin 40 mg N/A
106 48.0.0 14.0 Atorvastatin 80 mg
Budoff et al31 2009 Prev. Med. 33 54 79.0 Aged garlic supplement 32 36.0 28.0
Faghihnia et al30 2010 JLR 63 11.8 12.7 Low-fat, high carbohydrate diet N/A
Arai et al43 2012 JLR 18 261.3 273.0 Lipid apheresis N/A
Yoshida et al29 2012 Atherosclerosis VISION 21 15.6 26.9 Pitavastatin 2 mg N/A
21 22.9 3.5 Atorvastatin 10 mg
Tsimikas et al44 2015 Lancet ISIS-APO(a)Rx 8 261.3 277.8 Apo(a) antisense 300 mg 6 26.2 0.3
9 255.1 259.0 Apo(a) antisense 200 mg
8 226.1 239.6 Apo(a) antisense 100 mg
Capoulade et al28 2015 JACC ASTRONOMER 112 46.0 20.0 Rosuvastatin 40 mg 108 13.0 3.0
Yeang et al 2015 current study 119 217.3 212.4 Niacin 2g N/A
162 38.1 23.1 Ezetimibe/simvastatin 10/40 mg
300 26.0 2.7 Niacin/ezetimibe/simvastatin
2 g/10/40 mg
Total 2445 1451
N/A, not applicable.

597
 598
Table 2 Treatment differences between ezetimibe/simvastatin, extended release niacin, or triple combination compared with baseline
E/S E/S/N Niacin
N 5 162 N 5 300 N 5 119
Absolute change Mean percent Absolute change Mean Percent Absolute change Mean percent
change, mean change, mean change, mean P
Baseline 24 wk (SD) Baseline 24 wk (SD) Baseline 24 wk (SD) ANOVA
LDL-C (mg/dL), 155.5 (21.6) 285.1 (23.7)* 252.7 (13.5) †
156.8 (23.0) 294.8 (31.2)* 258.6 (19.6) †
157.0 (22.0) 232.1 (26.6)* 220.4 (32.0)† ,.001
mean (SD)
HDL-C (mg/dL), 49.8 (13.8) 3.2 (6.1)* 8.4 (14.2)† 50.5 (13.2) 14.2 (10.7)* 30.1 (22.6)† 50.5 (13.8) 13.2 (9.1)* 27.7 (19.6)† ,.001
mean (SD)
Non-HDL-C 191.0 (28.0) 293.1 (28.6)* 247.2 (13.4)† 190.6 (26.1) 2109.2 (34.7)* 255.6 (18.8)† 190.7 (28.1) 242.8 (28.3)* 222.3 (14.9)† ,.001
(mg/dL),
mean (SD)
TG (mg/dL), 161.0 (105.0) 235.0 (64.3)‡ 217.6 (32.5)† 161.0 (94.0) 268.0 (66.0)‡ 236.4 (31.8)† 145.0 (90.0) 244.0 (61.5)‡ 224.0 (35.7)† ,.001
median (IQR)
hsCRP (mg/L), 1.9 (3.5) 20.7 (2.1)‡ 236.0 (82.3)† 3.4 (3.7) 20.4 (2.4)‡ 233.4 (110.9)† 2.2 (4.0) 0.3 (3.2) 26.8 (89.3) ,.001
median (IQR)

Journal of Clinical Lipidology, Vol 10, No 3, June 2016

OxPL-apoB (nM), 3.5 (5.6) 1.4 (2.9)‡ 38.1 (149.1)† 3.3 (7.3) 1.0 (2.9)‡ 26.0 (110.5)† 3.5 (7.0) 20.4 (1.9)‡ 217.3 (90.7)† ,.001
median (IQR)
Lp(a) (mg/dL), 11.5 (30.2) 2.5 (12.4)‡ 23.1 (50.9)† 11.3 (38.4) 0.3 (7.3)‡ 2.7 (48.4)† 10.9 (33.7) 21.6 (5.4)‡ 212.4 (32.0)† ,.001
median (IQR)
ApoB (mg/dL), 150.9 (21.9) 261.6 (21.3)* 239.9 (12.4)† 151.4 (20.9) 274.7 (25.8)* 248.1 (17.1)† 149.9 (20.1) 229.3 (21.6)* 219.5 (14.0)† ,.001
mean (SD)
ANOVA, analysis of variance; Apo, apolipoprotein; HDL-C, high-density lipoprotein; hsCRP, high-sensitivity C-reactive protein; IQR, interquartile range; LDL-C, low-density lipoprotein cholesterol;
Lp(a), lipoprotein(a); SD, standard deviation; TG, triglycerides.
P ANOVA values are for comparison of absolute changes across treatment groups at 24 weeks on treatment.
*Denotes P , .01 determined by 2-tailed paired t-test for comparisons between baseline and 24-week values.
†Denotes P , .01 determined by 1-sample t-test for comparison of percent changes within a treatment group.
‡Denotes P , .01 determined by Wilcoxon signed-ranks test for comparisons between baseline and 24-week values.
Yeang et al Oxidized phospholipids and therapy
Figure 1 Percent change in lipid parameters from baseline. Comparison between changes in OxPL-apoB (A) and Lp(a) (B) on simva-
statin plus ezetimibe (E/S), E/S plus niacin, or niacin alone. Data are represented as mean percent change from baseline with error bars
depicting 6 1 standard error of the mean. Statistical significance determined with independent t-tests after significance across all groups
was demonstrated with one-way ANOVA.
to a 17% decrease in OxPL–apoB and a 12% decrease in
Lp(a; Fig. 1A and B). In contrast, E/S increased OxPL–
apoB from 3.5 (2.1–7.8) nM to 4.9 (3.0–11.1) nM,
P , .01 and Lp(a) from 11.5 (6.1–36.4) mg/dL to 14.9
(6.6–54.6) mg/dL, P , .01 (Table 2), representing a 38% in-
crease in OxPL–apoB and a 22% increase in Lp(a; Fig. 1A
and B). E/S/N increased OxPL–apoB from 3.3 (1.9–9.3) nM
to 4.3 (2.6–11.2) nM, P , .01 and Lp(a) from 11.3 (5.4–
43.8) mg/dL to 11.6 (5.9–52.8) mg/dL, P , .01, representing
26% and 2.7%, increases from baseline, respectively. The
percent increase of OxPL–apoB with E/S was numerically
greater than that with E/S/N treatment (38% vs 26%
[Fig. 1A]) but not statistically significant. However, the
percent increase of Lp(a) with E/S was significantly greater
than that with E/S/N (22% vs 2.7% [Fig. 1B]).
Systematic review of published trials with
concomitant measurements of OxPL–apoB and
Lp(a) levels
The systematic review included 12 unique trials
including the current trial, 7 with statins, 3 with low-fat
diets and/or aged garlic supplements and 3 with Lp(a)–
lowering drugs or procedures, including niacin, antisense
oligonucleotide to apo(a), and apheresis. A total of 2445
patients on active therapy were included and a total of 1451
patients on placebo (Table 1). The 7 statin trials, which re-
ported OxPL–apoB and Lp(a) measurements, included a to-
tal of 1688 subjects treated with atorvastatin,4,32,33,35
pravastatin,32,34 pitavastatin,29 and rosuvastatin.28 Statin
monotherapy resulted in a mean 23.8% (95% confidence in-
terval [CI] 23.3%–24.3%) increase of OxPL–apoB ranging
from 8% to 48% and a mean 10.6% (95% CI 10.2%–
11.0%) increase of Lp(a), ranging from 26.5% to 26%
(Fig. 2). Subjects who received placebo experienced a
mean 9.1% (95% CI 8.3%–9.8%) increase of OxPL–apoB
599
ranging from 23.9% to 29.3% and a mean 7.3% (95% CI
6.9–7.6%) increase of Lp(a), ranging from 20.7% to
16%. Moreover, potentially beneficial dietary interventions
in humans encompassing 133 subjects, such as low-fat
diets30,36 and aged garlic supplementation31 were also asso-
ciated with a mean 21.3% increase of OxPL–apoB, ranging
from 11.8% to 54% and a mean 19.4% increase of Lp(a),
ranging from 7% to 79% (Fig. 2). In contrast, lipid apher-
esis,43 antisense oligonucleotide targeted toward apo(a),44
and niacin monotherapy (this study), encompassing a total
of 145 subjects, resulted in a mean 44.1% decrease in
OxPL–apoB ranging from 17% to 61% reduction and asso-
ciated mean decrease of 52.0% in Lp(a) ranging from 12%
to 78% reduction (Fig. 2).
Discussion
This study demonstrates a significant decrease in
OxPL–apoB levels with niacin up to 2 g/d, in concert
with similar decrease in Lp(a). In contrast, significant
increases in OxPL–apoB and Lp(a) were noted with E/S
and E/S/N although the increase was attenuated due to the
addition of niacin. A systematic literature review of all
statin trials in which both OxPL–apoB and Lp(a) mea-
surements were measured concurrently, which included 4
different statins, conclusively demonstrates that the in-
crease in OxPL–apoB and Lp(a) is a class effect. In
contrast, drugs or procedures that lower Lp(a), including
LDL apheresis, antisense to apo(a) and niacin, are also
associated with a lowering of OxPL–apoB. As baseline
levels of both OxPL–apoB and Lp(a) are strongly
associated with increased cardiovascular risk, it implies
that these changes may influence and/or attenuate cardio-
vascular event rates and may also affect appropriate
interpretation of clinical trial results.
600 Journal of Clinical Lipidology, Vol 10, No 3, June 2016

Figure 2 Systematic review of trials with OxPL-apoB and Lp(a) levels after intervention with statins (brown), beneficial diets (blue), and
Lp(a)–lowering therapies (black). Each filled symbol represents the mean percent change, or the delta mean percent change between the
intervention and placebo group where available, from each respective trial. Diamond symbols represent the mean change within each
respective interventional category and span the 95% confidence interval. Data from trials with larger of subjects are represented with larger
symbol. (Color version of figure is available online.)

This is the first report demonstrating that niacin is an
effective agent for lowering OxPL–apoB levels. This
result is not surprising because more than 85% of plasma
OxPL is bound to Lp(a), and niacin is known to lower
Lp(a).38,39 Consistent with this finding is the recent obser-
vation that ISIS-APO(a)Rx, an antisense oligonucleotide
targeted against apolipoprotein(a), was recently shown in
a phase I clinical trial to significantly lower Lp(a) and
OxPL–apoB (up to mean 78%) in humans.44 Niacin has
pleotropic effects on plasma lipoproteins, but its Lp(a)-
lowering effect appears to be through transcriptional
repression of the LPA gene45 which encodes for
apo(a).46 Interestingly, a more dramatic decline in Lp(a),
compared with that of OxPL–apoB, after niacin treatment
as well as a statistically smaller increase in Lp(a), but not
OxPL–apoB, after E/S/N compared with E/S was noted.
OxPL resides on Lp(a) in 2 pools, one that is covalently
attached to apo(a) and another (30%–70% of OxPL as de-
tected by E06 immunoreactivity) is lipid soluble and likely
associated with the LDL moiety.16 It is plausible that
Lp(a) lowering by niacin results in OxPL enrichment of
the remaining Lp(a) particles within the lipid phase. It is
also possible that Lp(a)–lowering leads to OxPL accumu-
lation on LDL particles.
This study also demonstrates for the first time that E/S
raises Lp(a) by 22% and OxPL–apoB by 38%. The
systematic review of trials that have examined these
parameters demonstrates a mean 10.6% increase in Lp(a)
and a mean 23.8% increase in OxPL–apoB by statin
therapy. However, it should be noted that some trials have
demonstrated a statistically insignificant decrease in Lp(a)
from 5.0%39 to 9.0%.29 Most of these statin trials were rela-
tively short term, ranging from 12 weeks to 2 years. It is
possible that the longer term studies may show a return
to baseline as shown in the recent SPARCL trial where
the median percent change in OxPL–apoB levels from
baseline to 5 years was a significant 217.6% (interquartile
range 248.3% to 132.1%) reduction (Lp[a] levels were not
measured).47 Moreover, beneficial dietary interventions in
humans, such as low-fat diets30,36 and aged garlic supple-
mentation31 are also associated with increases in OxPL–
apoB and Lp(a). Although it appears paradoxical that bene-
ficial treatments would be associated with higher levels of
these atherogenic lipoprotein particles, 1 explanation may
Yeang et al Oxidized phospholipids and therapy
be that the short-term elevation of plasma OxPL–apoB may
be a marker of atherosclerosis regression, with associated
efflux of OxPL from atheromas to plasma apoB100-
containing particles. Indeed, work in animal models
demonstrated that OxPL content of atheromas, as detected
by E06 immunostaining, increased during progression of
dietary-induced atherosclerosis, but decreased during
dietary-induced regression.48 Concomitantly with a reduc-
tion in atheroma content of OxPL, an increase in plasma
OxPL-apoB was observed during regression of atheroscle-
rosis in both rabbits, which lack plasma Lp(a), and cyno-
molgous monkeys, which have Lp(a) but due to
variability in the lysine-binding pocket in apo(a), it does
not bind OxPL.48 In these models, the OxPL accumulated
on apoB100, but in humans whose Lp(a) can bind OxPL,
the OxPL seems to be associated with the increases in
Lp(a). By analogy, it would be predicted that statin therapy
is leading to improved lesion dynamics/regression such that
OxPL, which are more soluble, are preferentially being
removed. Whether a similar mechanistic explanation occurs
with statin therapy is unknown, but it might imply that in
response to statin therapy, initially OxPL–apoB and Lp(a)
levels increase, but at some time in the future, when ho-
meostasis has been achieved, levels of OxPL–apoB and
Lp(a) should return toward normal.
The mechanism of the increase in Lp(a) with statins is not
known, but it could be speculated that somehow it is linked to
changes in OxPL, although the alternative scenario might also
be envisioned, in which changes in Lp(a) occur first, for
example due to changes in interleukin 6, which has recently
been shown to acutely change apo(a) synthesis.49 The mecha-
nisms responsible for changes in Lp(a) should be investigated,
particularly with approved agents that also lower Lp(a) such as
mipomersen50 and investigational agents such as PCSK9
monoclonal antibodies,51 antisense oligonucleotides to
apo(a),44 and CETP inhibitors52 that may be used in patients
on background statin therapy. In addition, evaluating the
changes in OxPL-apoB and Lp(a) after long-term therapeutic
interventions in existing or future trials with cardiovascular
outcomes will be essential to understand the kinetics of these
atherogenic lipoprotein particles (as discussed in the previous
section) and whether changes in these biomarkers are associ-
ated with cardiovascular risk, independent of baseline values.
Our findings that niacin lowers OxPL–apoB, whereas
most statins including, simvastatin in combination with
ezetimibe elevates OxPL-apoB, raises the question of
whether the benefit of these treatments are offset by
increases in atherogenic OxPL-apoB and Lp(a). Alterna-
tively, these biomarkers may be indicators of disease
regression. Examining how niacin, simvastatin, and ezeti-
mibe affect OxPL–apoB and Lp(a) levels in clinical trials
with cardiovascular outcomes will clarify this question. The
AIM-HIGH study examined whether a population with high
prevalence of metabolic syndrome and atherosclerotic
cardiovascular disease but relatively low baseline LDL-C
levels (mean 74 mg/dL) would benefit more from niacin plus
simvastatin compared with simvastatin alone.53 Although
601
the overall trial was negative, it will be valuable to under-
stand how changes in OxPL–apoB and Lp(a), which will
presumably be increased on simvastatin but have an attenu-
ated increase on niacin plus simvastatin, correlates with car-
diovascular outcomes. Likewise, additional insights may
come from the recent IMPROVE IT trial, which evaluated
intensive LDL-C lowering with simvastatin plus ezetimibe
compared with simvastatin alone and showed that combined
therapy improved cardiovascular outcomes in patients with
recent acute coronary syndrome but with low baseline
LDL-C (mean 69.9 mg/dL).54 Determination of OxPL–
apoB and Lp(a) levels within this trial may add to our under-
standing of how ezetimibe affects these lipoprotein particles,
and how the presumed increases in OxPL-apoB and Lp(a) on
simvastatin and ezetimibe correlate with cardiovascular out-
comes. To further investigate whether increases in OxPL–
apoB and Lp(a) on statin therapy is associated with concom-
itant plaque regression in humans, trials with longitudinal
evaluation of atheroma volume using technology capable
of interrogating lesional lipid content are necessary. Existing
invasive, catheter-based modalities, such as histology intra-
vascular ultrasound, optical coherence tomography, and
near-infrared spectroscopy that can distinguish lipid, fibrous,
and necrotic components of an atheroma may be useful tech-
niques for future study. However, a more direct approach to-
ward tracking the flux of these biomarkers during various
treatments, including statins, would be the potential use of
molecular imaging with targeted probes specific for OxPL.55
Study limitations
This study design did not include simvastatin alone or
ezetimibe alone arms; therefore, the respective changes of
such monotherapy on OxPL–apoB and Lp(a) could not be
determined. For the systematic review, the studies and
doses used are heterogeneous in nature, which may limit
generalizability of percent changes in each measure,
although the trends within therapeutic classes were consis-
tent for the most part. Finally, although patient-level data
are available, the heterogeneity of the studies precludes
lumping them together for meta-analyses.
Significance
OxPL–apoB and its lipoprotein carrier Lp(a) are decreased
with niacin. In contrast, short-term treatment with statins as a
class, including simvastatin plus ezetimibe, increases both
measures. Changes in OxPL–apoB may provide insights into
the results of recent outcomes trials, including AIM-HIGH,
HPS2-THRIVE, and IMPROVE-IT trials.
Acknowledgments
The authors are indebted to all the trial participants for
their commitment to this study.
602
Financial disclosure
This study was funded by a research grant from Merck
to University of California at San Diego.
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