REVIEW

CURRENT
OPINION Prebeta-1 HDL and coronary heart disease
John P. Kane a and Mary J. Malloy b

Purpose of review
A negative correlation between HDL cholesterol levels and risk of coronary artery disease has long been
recognized. Emerging knowledge of the molecular speciation and functional properties of HDL provides an
opportunity to study the atheroprotective effects of specific metabolic processes. The discovery of the
quantum particle among the molecular species of HDL (prebeta-1 HDL) and its role in cholesterol efflux from
the artery wall, offer a means of assessing the efficiency of efflux. This review presents observations on the
structure and metabolism of this particle and its emerging role as a predictor of risk for atherosclerotic
vascular disease.
Recent findings
Prebeta-1 HDL is now recognized as the primary acceptor of cholesterol effluxed by the dominant
ATP-binding cassette A1 (ABCA1) transporter in arterial macrophages, a critical step in reverse cholesterol
transport. Several studies have revealed an association between high levels of this particle and risk of
globally defined coronary artery disease and carotid intima-media thickness. Recently, these findings
have been confirmed and extended to include myocardial infarction. High levels of prebeta-1 HDL may
serve as an index of functional impairment of cholesterol efflux or esterification, either of which would be
expected to impede reverse cholesterol transport.
Summary
Recent studies underscore the critical role of prebeta-1 HDL in reverse cholesterol transport and its use as a
marker of risk for structural coronary disease, myocardial infarction, and cerebral vascular disease.
Keywords
coronary artery disease, myocardial infarction, prebeta-1 HDL, reverse cholesterol transport

INTRODUCTION efflux mediated by the ABCA1 transporter goes to

A contemporary view of atherogenesis assigns a
central etiologic role to the accumulation of choles-
terol and cholesteryl esters in the artery wall within
macrophages and transformed smooth muscle cells,
and in the extracellular matrix. This accumulation
reflects a dynamic balance between ingress of athe-
rogenic lipoproteins and efflux of sterol derived
from them. The mechanisms involved in efflux
have attracted a great deal of investigation, reveal-
ing the participation of at least three pathways
involving the ATP-binding cassette transporter A1
(ABCA1), scavenger receptor type B1 (SR-B1), and
ATP-binding cassette transporter G1 (ABCG1) trans-
porters, and a less well defined process of passive
diffusion. Macrophages mediate the bulk of this
reverse sterol transport and the ABCA1 transporter
probably accounts for about ninety percent of total
efflux [1]. Any factors that modify the rate of efflux
are of importance to the biology of atherosclerotic
vascular disease. A major element is the lipoprotein
particles that serve as acquisitors of effluxed choles-
terol. It is now accepted that virtually all of the
a very small molecular weight species of HDL, pre-
beta-1 HDL. The exact structure and composition of
these particles remains controversial but it is agreed
that they contain only one molecular species of
protein, apolipoprotein (apo)A-I, and that their
unesterified cholesterol is then esterified by the
action of lecithin-cholesterol acyl transferase
(LCAT). They are then subsumed into larger choles-
teryl ester-rich HDL particles from which the esters
can be transferred to acceptor lipoproteins, includ-
ing VLDL and LDL, mediated by cholesteryl
ester transfer protein (CETP). These lipoproteins
a
Department of Medicine, Department of Biochemistry and Biophysics,
Cardiovascular Research Institute, University of California and bDepart-
Department of Pediatrics, Department of Medicine, Cardiovascular
Research Institute, University of C, San Francisco, California, USA
Correspondence to Mary J. Malloy, MD, 555 Mission Bay Blvd. South,
Room 252 M, San Francisco, California, CA 94158, USA. Tel: +1 415
476 2754; fax: +1 415 502 5658; e-mail: mary.malloy@ucsf.edu
Curr Opin Lipidol 2012, 23:367–371
DOI:10.1097/MOL.0b013e328353eef1

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 Hyperlipidaemia and cardiovascular disease

particle among HDL species. Although it turns over

KEY POINTS

Prebeta-1 HDL is the principal acceptor for cholesterol
effluxed from the artery wall, and thus plays a critical
role in reverse cholesterol transport.

The level of prebeta-1 HDL reflects the efficiency of
efflux of cholesterol from the artery wall.

A high level of prebeta-1 HDL in plasma is an
independent marker of risk for structural coronary
disease and myocardial infarction.
ultimately deliver most of their cholesteryl esters to
the liver, which can secrete cholesterol, per se, or as
bile acids, into the bile. Prebeta-1 HDL is regenerated
during the CETP-mediated transfer process. This
series of reactions constitutes the prebeta-1 HDL
cycle, which is the chief engine of removal of cho-
lesterol from arteries. (Fig. 1) Because prebeta-1 HDL
enters plasma de novo and is produced or subsumed
in reactions involving the interconversion of mol-
ecular species of HDL, it is emerging as the quantum
rapidly relative to apoA-I, it is possible to measure
accurately its steady state level in plasma. This level
is a reflection of the algebraic sum of the rates of
generation and removal by the diverse metabolic
reactions involving HDL molecular species, but
appears to be dominated kinetically by cholesterol
efflux. Therefore, it is a direct reflection of the
efficiency, together, of efflux and of cholesterol
esterification. The relationship of the prebeta-1 level
to risk of atherosclerotic disease was not predictable,
a priori, because a deficiency of this particle could
impede efflux. If efflux were impaired at the level of
the ABCA1 transporter, or if esterification by LCAT
were impaired, the risk of atherosclerosis would
increase and the level of prebeta-1 HDL would
rise. Recent studies have shown that plasma levels
of prebeta-1 HDL are a strong indicator of risk,
not only of structural coronary disease but also of
myocardial infarction, suggesting that impaired
efflux of cholesterol or its subsequent esterification
is a dominant process in atherogenesis. This
risk relationship is independent of essentially all
known risk factors, including total HDL cholesterol,

Reverse cholesterol transport

the prebeta-1 HDL cycle
-1

A
A

-1

Large
CETP Chylos
spherical VLDL
(alpha) HDL IDL
LDL
LCAT
A-I

ABCA1
transporter

Free
cholesterol SR-BI

Peripheral cell

PLTP

A-I
Removal and degradation De novo synthesis of apo A-I
Prebeta-1 HDL
Liver and intestine
A-I

FIGURE 1. The prebeta-1 HDL cycle. The steady state level of prebeta-1 HDL in plasma reflects opposing rates of formation
and removal. It acquires free cholesterol effluxed by the ABCA1 transporter that is then esterified by lecithin-cholesterol acyl
transferase (LCAT), forming large diameter HDL particles of a mobility. The prebeta-1 HDL accretes into the a particles as they
are formed. Cholesteryl ester transfer protein (CETP) transfers cholesteryl esters from a HDL into acceptor lipoproteins that
ultimately deliver cholesterol to the liver. Prebeta-1 HDL is regenerated in this process. In parallel, cholesteryl esters from a HDL
are delivered to hepatocytes by the SR-BI receptors. ABCA1, ATP-binding cassette A1; PLTP, phospholid transfer protein; SR-BI,
scavenger receptor type B1.

368 www.co-lipidology.com Volume 23
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August 2012

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strongly supporting the emerging concept that
studies of the molecular speciation and functional
properties of HDL will be superior indicators of risk
to measurements of HDL cholesterol.
WHAT IS PREBETA-1 HDL?
The discovery that preparative ultracentrifugation, a
technique that had provided facile isolation of other
lipoproteins, leads to destruction and loss of a num-
ber of molecular species of HDL, demonstrated the
need for nondenaturing means of isolating HDL
if their detailed structures were to be revealed [2]
Development of the strategy of selected-affinity
immunosorption [3] provided the means for
retrieval of HDL particles under minimally denatur-
ing conditions. In addition to other species of HDL,
this method revealed a particle with prebeta mobi-
lity that could be isolated in bulk by electrophoresis
[4]. This species has a particle mass of about 65 kDa.
About ninety percent of the mass is protein, exclu-
sively apoA-I. This amount of protein would accom-
modate two copies of apoA-I per particle. The
remainder of the mass is comprised of unesterified
cholesterol and phospholipid, a small amount of
cholesteryl esters, and no triglyceride. The apoA-I in
these particles has less helical conformation than in
other HDL species [5]. Later studies characterized a
monoclonal antibody that discriminates between
the conformation of apoA-I in prebeta-1 HDL and
larger HDL particles [6]. This difference may be the
primary basis for the diminished affinity of prebeta-
1 HDL for binding to human hepatocytes [7] and to
the SR-BI receptor [8], properties that signaled a
special role or roles for this particle in lipid metab-
olism. Prebeta-1 HDL particles disappear when
plasma is incubated at 378, adding to the mass of
larger a HDL. An LCAT inhibitor blocked conver-
sion, indicating that prebeta-1 HDL is a substrate for
cholesterol esterification by that enzyme. The pre-
beta particles were shown to acquire cholesterol
from fibroblasts, and incubation of large a HDL
particles with CETP released prebeta-1 HDL [7].
Subsequent studies confirmed that prebeta-1 HDL
is a substrate for LCAT, and that it is produced
during cholesteryl ester transfer by CETP. They also
demonstrated an important role for phospholid
transfer protein in its formation [9].
The structure of the particle has been a matter of
controversy. It has been proposed by many that it is
actually lipid-free monomeric apoA-I. Despite use of a
number of experimental approaches, we have been
unable to demonstrate the presence of monomeric,
lipid-free apoA-I in normal human plasma (Ishida B
and Kane JP, personal communication). The lack of
formation of cross linked dimers after exposure of
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Prebeta-1 HDL and coronary heart disease Kane and Malloy
prebeta-1 HDL to a crosslinking reagent was inferred
to indicate that there is a single copy of apoA-I in the
particle [9], but the conformation of the protein may
not be susceptible to crosslinking. Also, the relative
proportion of lipid–protein is appropriate for a
particle containing two copies of apoA-I. We have
obtained cryoelectronmicroscopic images that are
compatible with a twisted ellipse conformation con-
taining two copies of apoA-I (Schumaker VN, Phillips
ML, and Kane JP personal communication). Many
studies have been carried out with reconstituted HDL
particles that form when apoA-I is sonicated with an
excess of phospholipid. The resulting particles are
discoidal. Similar particles are not found in normal
plasma, but discoidal forms are demonstrable by
electronmicroscopy in LCAT deficient plasma.
METABOLISM OF PREBETA-1 HDL AND
REVERSE CHOLESTEROL TRANSPORT
Prebeta-1 HDL enters the plasma compartment via
newly synthesized apoA-I from hepatocytes and
intestinal epithelial cells, in a monomeric form after
cleavage of an N-terminal hexapeptide. It appears to
be acted upon initially by the ABCA1 transporter
[10] to form a particle of larger Stokes radius before it
can participate in lipid efflux. ApoA-I is also found
in nascent VLDL and chylomicrons that release it to
plasma upon hydrolysis of their triglycerides by
lipoprotein lipase. A major pathway of removal is
filtration at the glomerulus, although proteolytic
degradation also occurs in tissues and in plasma.
Endocytosis of apoA-I particles via the F(0)F(1)
ATPase beta chain may also contribute to removal
of prebeta-1 HDL from plasma [11]. The concen-
tration of prebeta-1 HDL is a major determinant of
the rate of efflux of cholesterol from macrophages in
vitro, accounting for much of the difference in efflux
into samples of plasma from different individuals,
even in the presence of similar levels of total HDL
&&
cholesterol [12 ]. Thus, the capacity of an individ-
ual plasma to accept effluxed cholesterol, reflecting
the level of prebeta-1 HDL and perhaps other fac-
tors, is emerging as a possible determinant of the
rate of atherogenesis. On the other hand, efficiency
of esterification by LCAT and of efflux via the
ABCA1 transporter, and perhaps to some extent
the other transporters, are also likely to be comp-
lementary determinants of the rate of reverse
cholesterol transport.
PREBETA-1 HDL AND DISEASE
Prebeta-1 HDL can now be measured in plasma
and tissue fluids by several techniques: ultrafiltra-
&&
tion-isotope dilution [13]; immunofixation [14 ];
www.co-lipidology.com 369
 Hyperlipidaemia and cardiovascular disease
Western blotting of two-dimensional gels [15]; and
an immunochemical technique that discriminates
the alternative conformation of apoA-I in the
particle [6]. Most of the published techniques have
not been standardized to isolated prebeta-1 HDL but
yield relative values with respect to other HDL
species, possibly reflecting significant differences in
chromogenicity. It is not clear, in the case of the
conformationally discriminating antibody, whether
it might also react with one or more of the additional
molecular species of HDL that have prebeta electro-
phoretic mobility and which may appear in certain
disorders of lipid metabolism.
Using the ultrafiltration-isotope dilution tech-
nique standardized to isolated prebeta-1 HDL, it was
determined that higher levels are found in normal
men than in normal women (mean 84, versus 68
microgram/ml), representing 7.2 versus 5.5 percent
of total apoA-I [16]. The distribution was skewed to
higher levels. Absolute levels of apoA-I in prebeta-1
HDL are positively correlated with total apoA-I and
negatively with HDL cholesterol levels. Absolute
levels of prebeta-1 HDL increase linearly with the
content of triglycerides in plasma, and to a lesser
degree with LDL cholesterol levels (O’Connor PM,
Malloy MJ and Kane JP personal communication), a
finding also observed in individuals with HDL
deficiency states [17].
Azstalos, et al. [15] studied the distribution of
HDL species by two-dimensional gel analysis in the
Framingham Offspring Study and in the Veterans
Affairs HDL Intervention Trial [18]. Employing a
composite of coronary disease endpoints, they
found a strong negative correlation of large diameter
HDL particles with risk. Though prebeta-1 HDL was
positively correlated with disease in the Veterans
Affairs Trial, this was limited to univariate analysis
and did not extend to myocardial infarction. The
negative association with HDL particles of larger
diameter supports the concept of increased risk of
atherosclerotic disease when the efflux, esterifica-
tion, and further processing of artery-derived cho-
lesterol is impeded.
&&
Sethi, et al. [14 ] using an immunofixation
technique, reported a positive relationship of pre-
beta-1 HDL with a composite index of coronary
heart disease, when compared with controls. They
were also able to detect a relationship of ischemic
heart disease with decreased LCAT activity. Com-
bining the two factors increased the association with
cardiac disease, suggesting that it reflects the effects
of two additive determinants of reverse cholesterol
transport, and that LCAT kinetics may have a con-
tributory role in coronary disease.
&&
Guey et al. [19 ] using an ultrafiltration-
isotope dilution technique standardized to purified
370 www.co-lipidology.com
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prebeta-1 HDL, studied a cohort of 1255 individuals
including those with structural coronary disease
without infarction and those with myocardial
infarction, in comparison with controls. The critical
variable was the percent of total apoA-I associated
with prebeta-1 particles. Whereas the data from mul-
tivariate analysis confirmed a significant positive
association of prebeta-1 HDL with coronary disease
without infarct, it demonstrated for the first time an
even stronger association with risk of myocardial
infarction. In multivariate analysis, patients in the
highest tertile of prebeta-1 HDL had an odds ratio
(OR) of 1.65 relative to patients in the lowest tertile of
prebeta-1 HDL, with respect to risk of composite
coronary heart disease (P ¼ 0.01). For myocardial
infarction, the OR was 1.94 across the tertiles
(P ¼ 0.004). The association was independent of all
variables tested, including age, gender, BMI, ethnic-
ity, hypertension, current smoking status, diabetes,
and all lipoprotein lipid levels including total
HDL cholesterol. The effect of adding prebeta-1
HDL tertiles to risk-prediction models revealed a
minimum impact on the receiver operating charac-
teristic curves, as is the case with total HDL chole-
sterol. However, the net reclassification improve-
ment index was significant for coronary heart
disease (P ¼ 0.01), and for myocardial infarction
(P ¼ 0.008), supporting a predictive value for pre-
beta-1 HDL.
Observations in two patient cohorts of a positive
relationship of levels of prebeta-1 HDL with carotid
intima-media thickness lend further support to the
informative value of this measurement. A cohort of
&
nondiabetic patients [20 ], and another of diabetic
patients [21], both showed a significant correlation
with intima-media thickness measurements.
CONCLUSION
The measurement of the absolute level of prebeta-1
HDL is emerging as an independent indicator of risk
for both structural coronary disease and myocardial
infarction, and apparently for carotid disease as well.
Its independence of other risk parameters reflects
the fact that it is an indicator of the relative effi-
ciency of a critical atheroprotective process, efflux of
cholesterol from the artery wall. This process could
not be readily evaluated quantitatively heretofore.
Measurement of prebeta-1 HDL has promise for
contributing materially to the determination of risk
for clinical coronary disease. It takes its place among
other determinants of defects in the structure and
function of HDL, such as complementary defects in
the acceptor properties of HDL for cholesterol efflux
&&
[22 ]. It is likely that defects in other important
functions of HDL such as anti-inflammatory and
Volume 23
Number 4
August 2012

antioxidant activities, the ability to sequester endo-
toxins, the activity of LCAT, and other emerging
factors, will eventually reveal the basis of ‘wounded
HDL’ to complement the quantitative assessment
of reverse cholesterol transport. Also, measurement
of the molecular speciation and atheroprotective
properties of HDL may ultimately lead to rational
definition of phenotypes of atherogenesis, affording
the opportunity to address them individually with
specific therapeutic strategies.
Acknowledgements
The authors’ work was supported in part by National
Institutes of Health grants HL3120, HL50782,
HL50779, and AA11275; and by grants from the Leducq
Foundation, Paris, France; the Joseph Drown Founda-
tion, Los Angeles CA; and the Campini Foundation, San
Francisco CA.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
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& of special interest
&& of outstanding interest
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