Cholesterol efflux capacity (CEC) may improve atherosclerotic cardiovascular disease (ASCVD) risk prediction beyond using coronary artery calcium (CAC), family history and high-sensitivity C-reactive protein (hs-CRP), according to a study published May 23 in the Journal of the American College of Cardiology.

Purav Mody, MD, and colleagues examined 1,972 participants in the Dallas Heart Study who were free of ASCVD at baseline. Participants completed risk factor assessment, laboratory testing, imaging studies and CAC scans.

Results showed that prevalent CAC (>0) was found in 52 percent of participants, family history and premature family history were reported in 31 percent and 10 percent of participants, respectively, and hs-CRP >2 mg/l was found in 58 percent of participants. Over a median follow-up of 9.4 years, 97 participants experienced a first ASCVD event. Those with CEC more than the median vs. less than the median had a decreased risk of ASCVD (3.1 percent vs. 6.7 percent; p = 0.0003).

In addition, in a fully adjusted model including prevalent CAC, family history and elevated hs-CRP, CEC remained “inversely associated with incident ASCVD without attenuation.” Further, among patients with these risk markers, “CEC was able to meaningfully stratify ASCVD risk.” Moving forward, the authors conclude that their findings “support efforts to standardize CEC methods and develop assays that are amenable for clinical use.”

In an accompanying editorial comment, Winirief März, MD, and Andreas Ritsch, PhD, write that “a number of questions … need to be addressed before this measure is exploited in risk stratification: Are there assays for CEC on the basis of stable components avoiding the use of cultured cells? To which extent does CEC reflect the net traffic of cholesterol on its road from of the vessel wall into the bile? Finally, is cholesterol efflux indeed a rate-limiting step for reverse cholesterol transport, ultimately turning its modification into a target for pharmacological intervention?” 

Keywords: Atherosclerosis, Bile, C-Reactive Protein, Calcium, Dietary, Cells, Cultured, Cholesterol, Coronary Vessels, Follow-Up Studies, Risk Factors

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