[Formulae and special characters can only be approximated here. Please see the pdf version of the abstract for an accurate reproduction.] Atherosclerosis is a common degenerative disease in which the clinical manifestations are often through stroke or myocardial infarction. Some of the established risk factors for atherosclerosis include elevated plasma low-density lipoprotein (LDL)-cholesterol levels, obesity, diabetes mellitus (DM) and cigarette smoking. Of the risk factors, an elevation in plasma LDL is one of the most established and the most researched. This is partly a consequence of the deposition of cholesterol within arterial intima being a crucial step in the progression of atherosclerosis, combined with the finding that LDL particles are a major transporter of cholesterol in circulation. Recently there is increasing evidence showing a role of the other major transporter of cholesterol in circulation, chylomicron remnants, in the progression of atherosclerosis. The notion of atherosclerosis as a postprandial phenomenon has been further substantiated by the emergence of evidence showing a direct role of chylomicron remnants in arterial cholesterol deposition. Based on evidence that chylomicron remnants are proatherogenic, the suggestion arises that accumulation of postprandial lipoproteins in plasma may add another dimension of risk to the development of coronary artery disease (CAD). This thesis tests the general hypothesis that individuals with or at high risk of CAD have postprandial dyslipidaemia and that this metabolic abnormality is correctable with a class of lipid-lowering drugs called statins. To test the hypothesis, clinical studies were conducted in normolipidaemic CAD patients, heterozygous familial hypercholesterolaemia (FH) and postmenopausal women with type 2 DM. Determination of postprandial dyslipidaemia by comparison with control populations were conducted initially in each patient group (Studies 1, 3 and 5), followed by intervention studies investigating possible modulation of the dyslipidaemia with a statin (Studies 2, 4 and 6). Six observation statements based on case-control comparisons of postprandial lipaemia in patients with or at risk of CAD and the effects of statins on postprandial dyslipidaemia in the patient groups were derived from the general hypothesis. The observation statements were examined in the individual studies described below. Postprandial lipoprotein metabolism was assessed using a number of methods. For comparison of postprandial lipaemia in Studies 1 and 2, a classic oral fat challenge was utilised. As markers of chylomicrons and chylomicron remnants, retinyl palmitate and triglyceride were measured postprandially as well as apolipoprotein (apo) B48 concentrations, a specific marker of intestinal lipoproteins. ApoB48 was also measured in the fasting state and found to predict the postprandial responses of retinyl palmitate, triglyceride and apoB48. This suggested that fasting measurement of apoB48 could be used as a simple indicator of postprandial dyslipidaemia. Consequently for Studies 3 - 6, fasting apoB48 measurements were used as primary markers of postprandial dyslipidaemia. Other markers for chylomicrons and their remnants utilised were fasting plasma concentrations of remnant-like particle-cholesterol (RLP-C) and apoC-III. As well as these static markers, chylomicron remnant catabolism was measured using a stable isotope breath test. The breath test involves the intravenous injection of a chylomicron remnant-like emulsion labelled with ¹³C-oleate and measurement of enriched ¹³CO2 in expired breath by isotope ratio mass spectrometry. The fractional catabolic rate (FCR) of the injected emulsion was subsequently calculated using multi-compartmental modeling (SAAM II). The studies are presented in this thesis as published and unpublished works. In Study 1, postprandial lipoprotein metabolism was compared between 18 normolipidaemic CAD patients (cholesterol 4.54 ± 0.12 mmol/L, triglyceride 1.09 ± 0.16) with 13 asymptomatic healthy controls using an oral fat challenge. Normolipidaemic CAD patients had higher postprandial area-under-curve (AUC) for triglyceride (+34%, p=0.019), retinyl palmitate (+74%, p=0.032) and apoB48 (+36%, p<0.001). Fasting apoB48 was also higher (+41%, p=0.001) and found to correlate significantly with AUC of triglyceride (p=0.017), retinyl palmitate (p=0.001) and apoB48 (p<0.001). The data suggest that normolipidaemic CAD patients have increased concentrations of intestinal lipoproteins in the fasting and postprandial state. In addition to these findings, significant correlations of fasting apoB48 with postprandial markers (p<0.02) suggests the fasting marker to be a simpler surrogate marker for the degree of total postprandial lipaemia. Study 2 investigated the effect of atorvastatin treatment on postprandial dyslipidaemia found in the 18 near-normolipidaemic CAD patients from Study 1. The trial was conducted in a randomised, placebo-controlled design, using oral fat challenges before and after 12-weeks atorvastatin/placebo treatment. Compared with the placebo group, atorvastatin decreased the total postprandial AUC for iii triglyceride (-22%, p=0.05) and apoB48 (-34%, p=0.013). Fasting markers of apoB48 (-35%, p=0.019) and RLP-C (-36%, p=0.032) also decreased significantly. Atorvastatin was also found to increase LDL-receptor activity by +218% (p<0.001) as reflected in binding studies. The data suggest atorvastatin reduces the fasting levels of intestinal lipoproteins as well as total postprandial lipaemia, but without acute dynamic changes in postprandial lipaemia. The reduction in fasting and total postprandial lipoprotein levels could be partly attributed to an increase in LDL-receptor mediated removal from circulation. In Study 3, postprandial lipaemia was compared in 15 heterozygous FH patients with 15 healthy controls. FH patients had higher fasting concentrations of apoB48 (+56%, p<0.001) and RLP-C (+48%, p=0.003). The elevation in these fasting markers of chylomicrons and their remnants suggests FH patients have postprandial dyslipidaemia due to an accumulation of these particles in plasma. Study 4 examined the effects of long- (> 6 months) and short-term (4 weeks) simvastatin treatment on modulating postprandial dyslipidaemia found in the 15 FH patients from Study 3. Short- and long-term simvastatin treatment decreased the fasting concentrations of apoB48 (-29% and 15% respectively, p<0.05) and RLP-C (both -38%, p<0.001), but did not significantly alter the FCR of the injected chylomicron remnant-like emulsion. The data suggest that in heterozygous FH both long- and short-term simvastatin treatments decrease the fasting markers of postprandial lipoproteins by mechanisms that may not be mediated via processes differentiated by the 13CO2 breath test. This implies that the effect on postprandial lipaemia may be from a decrease in production and/or a possible increase in catabolism of triglyceride-rich lipoproteins (TRLs). In Study 5, postprandial lipaemia was compared in 24 postmenopausal women age and body mass index matched with 14 postmenopausal women with type 2 DM. Postmenopausal diabetic women were found to have higher fasting concentrations of apoB48 (+21%, p=0.021) and apoC-III (+16%, p=0.042) as well as lower FCR of the chylomicron remnant-like emulsion (-50%, p<0.001). The data suggest that postmenopausal diabetic women have postprandial dyslipidaemia, and that this is due to delayed catabolism of chylomicron remnants. Study 6 was an hypothesis-generating exercise examining the effects of 4-weeks pravastatin treatment on postprandial dyslipidaemia found in 7 postmenopausal women with type 2 DM from Study 5. Although plasma LDL-cholesterol was reduced (-19%, p=0.028), there were no significant effects found on fasting apoB48 concentrations (-12%, p=0.116) or the FCR of the chylomicron remnant-like emulsion (+38%, p=0.345). A larger sample size of patients and/or treatment with a more potent statin at a dosage known to affect chylomicron remnant metabolism would be required to demonstrate a significant reduction in postprandial dyslipidaemia in postmenopausal women with type 2 DM. The results of the above mentioned studies combined support the general hypothesis that postprandial dyslipidaemia is a feature of patients with or at risk of CAD. This defect may be demonstrated using fasting apoB48 as an indicator of the degree of postprandial lipaemia. Postprandial dyslipidaemia may reflect a reduction in catabolism, as suggested with the breath test in type 2 DM, and/or an over overproduction of chylomicrons. Both these mechanisms would also increase competition for lipolysis and clearance pathways between hepatically and intestinally-derived lipoproteins. The exact mechanisms by which postprandial dyslipidaemia occurs are yet to be determined. Statins appear to improve defective postprandial lipaemia in patients with or at risk of CAD, which is in agreement with the general hypothesis. The effectiveness of a statin is dependant on their potency in inhibiting cholesterol biosynthesis and increasing receptor mediated clearance of LDL and chylomicron remnants. The studies conducted in this thesis show that postprandial dyslipidaemia can be reduced by statins but not to the extent demonstrated in controls. However, the demonstrated reduction in fasting and total postprandial lipaemia translates to a lowering in overall arterial exposure to circulating proatherogenic particles. The elevation in fasting and postprandial levels of proatherogenic chylomicron remnants found in the patient groups described in this thesis indicates another dimension to their risk of coronary disease. The reductions in the overall levels of proatherogenic particles in patients with or at high CAD risk, infers a possible reduction in the risk of coronary disease in these patients.

A relação entre transferência de lipídeos, idade e aterogênese são complexas e ainda não estão claras. É possível que a troca de lipídeos esteja alterada com a avançar da idade e relacionada com a Doença Arterial Coronariana (DAC). O objetivo deste trabalho foi verificar a hipótese se em indivíduos mais jovens a habilidade da HDL de receber lipídeos é diferente de indivíduos mais velhos com e sem a evidência clínica da DAC. Dentro desses aspectos, foram determinados o diâmetro da partícula desta lipoproteína, a atividade da Paraoxonase (PON1) e sua capacidade de receber lipídeos. Para tanto, foram estudados 86 indivíduos divididos em quatro grupos: adulto jovem (25±4), meia-idade (42±8), idosos sem evidência clínica de DAC (75±6) e idosos com DAC (74±5). Uma nanoemulsão artificial rica em colesterol (LDE) marcada com 3H-TG e 14C-CL ou 3H-CE e 14C-FL foi incubada com plasma. Após a precipitação de outras lipoproteínas, o sobrenadante contendo HDL foi separado e em seguida, medida a radioatividade. O diâmetro da HDL foi medido por laser scattering (nm). Foram constatadas diferenças significativas entre as taxas de transferência de 3H-éster de colesterol (CE) entre os grupos: adulto jovem (3.7±1.0%); meia idade (4.1 ±0.7%) e idosos (5.3±1.8%);p= 0.024. Também ocorreu diferença entre as taxas de transferência do 14C-fosfolipídeo (FL): adulto jovem (18.7±4.6%), meia idade (18.3 ±4.0%) e idosos (20.6±5.3); p=0.0368. Com relação ao tamanho das partículas de HDL, foi encontrada diferença entre os grupos: os grupos adulto jovem (8.9± 0.3nm) e meia idade (8.9± 0.3nm) apresentaram menores diâmetros de HDL quando comparados ao do grupo de idosos sem evidência clínica da DAC (9.7± 1.6);p= 0,0444. As transferências de lipídeos foram expressas em % de radioatividade. A idade correlacionou-se positivamente com a taxa de transferência do 3H- éster de colesterol (r=0.3365; p=0.0036), com a concentração de colesterol total (r=0.4965; p=0.0001) e com a concentração de HDL colesterol (r=0.3559; p=0.0023). Também houve correlação positiva com o tamanho de HDL (r=0.3695; p=0.0013). Em princípio, os indivíduos idosos sem evidência clínica da DAC, aparentemente têm alguma proteção contra a mesma. Desse modo, com o intuito de saber se os resultados encontrados no presente trabalho sustentam a afirmação acima, foi realizada a comparação desse grupo com um grupo de idosos que apresentavam a DAC. O grupo com DAC apresentou menor tamanho de partícula de HDL (8,7±0,7). As taxas de transferência de 3H-CE e de 14C-FL também foram menores neste grupo (3H-CE=3,1 ±2,3 e 3H-TG= 5,1 ±1 ,6). Devido ao importante papel antiaterogênico da HDL, esses resultados podem ser relevantes para estabelecer novos mecanismos existentes entre os aspectos qualitativos dessa lipoproteína, o avanço da idade e a presença da DAC. / The relationship between transfer of lipids, age and atherogenesis are complex and yet unclear and is possible that the shift of lipids to HDL may be altered by the aging process and related with coronary artery disease (CAD). We tested the hypothesis whether in younger patients the ability of HDL to receive lipids is different from that of elderly patients with or without CAD. Inside of these aspects, the HDL size, the activity of Paraoxonase (PON1) and its capacity to receive lipids was determined. It was studied, 25 younger, 25 middle age, 36 elderly patients with a coronariography and/or a perfusion scintilography on the last 6 months (11 with CAD, 74±5 yo; and 25 patients without proved CAD, 75±6 yo). An artificial cholesterol-rich nanoemulsion labeled with 3H-TG and 14C-FC or H-CE and 14C-PL was incubated, per 1 hour, with plasma. After chemical precipitation of apoB-containing lipoproteins and the nanoemulsion, the supernatant containing HDL was counted for radioactivity. The HDL diameter was measured by laser-light-scattering. Transfer of CE and PL to HDL was smaller in young patients than in the elderly patients without CAD, but the transfer of the other lipids are equal (CE: young= 3.7±1.0%; middle age= 4.1 ±0.7%; elderly without CAD= 5.3±1.8%; p= 0.024 and PL: young= 18.7±4.6%; middle age= 18.3 ±4.0%; elderly without CAD= 20.6±5.3; p=0.0368). The HDL size was greater in elderly group without CAD (9.7± 1.6nm) than in younger (8.9± 0.3nm) and middle age patients (8.9± 0.3nm); p=0,0444. Transfer of lipids to HDL was expressed as % of total incubated radioactivity. The age positively correlated with the transfer of CE (r=0.3365; p=0.0036), with the total cholesterol concentration (r=0.4965; p=0.0001) and with the HDL concentration cholesterol (r=0.3559; p=0.0023). Also had positive correlation with the size of HDL (; p=0.0013). In principle, the aged patients without CAD, have some protection against the same one. In this aspect, with intention to know if the results found in the present work support the affirmation above, was compared this group with a group of aged that presented the CAD. Comparing elderly patients without CAD with elderly patients with CAD, the transfer of CE and FL as well as HDL size was smaller in the CAD group (CE=3.1±2.3 and TG= 5.1±1.6; 8.7±0.7nm). Due to HDL important antiatherogenic roles, this result can be relevant to establish new mechanisms and risk factors in aging and in CAD.