SUPPLEMENTAL MATERIAL

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1 SUPPLEMENTAL MATERIAL A Meta-analysis of LDL-C, non-hdl-c, and apob as markers of cardiovascular risk. Slide # Contents 2 Table A1. List of candidate reports 8 Table A2. List of covariates/model adjustments 9 Figure A1. Forest plot of LDL-C relative risk ratios 10 Figure A2. Forest plot of non-hdl-c relative risk ratios 11 Figure A3. Forest plot of relative apob risk ratios 12 Figure A4. Log apob RRR log non-hdl-c RRR forest plot 13 Figure A5. Log non-hdl-c RRR log LDL-C RRR forest plot 14 Figure A6. Log apob RRR log LDL-C RRR forest plot 15 Figure A7. Subgroup analyses by study attributes 16 Figure A8. Selection bias assessments: funnel plots of precision by difference in log relative risk ratios Note: Citations throughout this appendix refer to the reference list of the main article. 1

2 Table A1. List of candidate reports by inclusion/exclusion categories #A: ERFC-identified report without the requisite non-hdl-c and apob data B: ERFC-identified study with requisite data but without published non-hdl-c and apob relative risk ratios (RRRs) C: ERFC-identified report with published RRRs not included in ERFC meta-analysis D: Reports from ERFC-cited studies included in both analyses E: Reports from studies not cited by ERFC with RRRs F: Reports not cited by ERFC without RRRs 2 Ref # meta-analyses Study citation 1 A Neither *Air Force/Texas Coronary Atherosclerosis Prevention Study Circulation 2000; 101(5): A Neither *Antihypertensive and Lipid-Lowering to prevent Heart Attacks JAMA 2002; 288(23): A Neither *British Regional Heart Study BMJ 1989; 298(6679): A Neither *British Women's Heart and Health Study J Epidemiol Community Health 2003; 57(2): A Neither *Busselton population health J Epidemiol Community Health 1997; 51(5): A Neither *Caerphilly and Speedwell Collaborative Heart Disease Br Heart J 1992; 68(1): A Neither *Cardiovascular Health Study J Am Geriatr Soc 2004; 52(10): A Neither *Edinburgh Artery Study Am J Epidemiol 1992; 135(4): A Neither *Epidemiologische Studie zu Chancen der Verhütung, Pharmacoepidemiol Drug Saf 2008; 17(5): A Neither *Finish Risk Cohort Study Int J Epidemiol 2000; 29(1): A Neither *Finland, Italy and Netherlands Elderly Study Eur Heart J 2001;22(7): A Neither *GOTMONICA J Intern Med 1997; 242(3): A Neither *Glostrup Study Int J Epidemiol 1991; 20(1): A Neither *Göteborg 1943 Study J Intern Med 2000; 247(1): A Neither *Honolulu Heart Program Am J Cardiol 2000; 86(4): A Neither *Hoorn Study Diabetologia 2003; 46(7): A Neither *Israeli IHD/Glucose Intolerance, Obesity, Hypertension Preventive Medicine 2005; 41(1): A Neither *Japanese Am J Epidemiol 2001; 153(5): A Neither *Lower Extremity Arterial Disease Event Reduction Trial Curr Control Trials Cardiovasc Med 2001; 2(4): A Neither *Multiple Risk Factor Intervention Trial 1 Am J Cardiol 1986; 57(8): A Neither *Northwick Park Heart Study II Atherosclerosis 2005; 181(1): *Report cited by ERFC as providing data on triglycerides, HDL-C and non-hdl-c, and other risk factors

3 Table A1. List of candidate reports by inclusion/exclusion categories #A: ERFC-identified report without the requisite non-hdl-c and apob data B: ERFC-identified study with requisite data but without published non-hdl-c and apob relative risk ratios (RRRs) C: ERFC-identified report with published RRRs not included in ERFC meta-analysis D: Reports from ERFC-cited studies included in both analyses E: Reports from studies not cited by ERFC with RRRs F: Reports not cited by ERFC without RRRs 3 Ref # meta-analyses Study citation 22 A Neither *Population Study of Women in Göteborg, Sweden Circulation 2004; 109(5): A Neither *Progetto CUORE Eur J Cardiovasc Prev Rehabil 2006; 13(4): A Neither *Rancho Bernardo Study Am J Cardiol 2003; 91(11): A Neither *Reykjavik Study J Cardiovasc Risk 2002; 9(2): A Neither *Risk Factors and Life Expectancy Pooling Project Eur J Epidemiol 1993; 9(5): A Neither *Scottish Heart Health Extended Cohort Heart 2007; 93(2): A Neither *Established Populations for Epidemiologic Study of Elderly Aging (Milano ) 1993; 5(1): A Neither *Tromsø Study Lancet 1977; 1(8019): A Neither *West of Scotland Coronary Prevention Study Circulation 1998; 97(15): A Neither *Yao city Japan J Clin Epidemiol 1994; 47(9): A Neither *Zaragosa study BMC Public Health 2006; 6: A Neither *Zutphen Elderly Study Am J Epidemiol 1996; 143(2): B ERFC *Atherosclerosis Risk in Communities Study Circulation 104(10): B ERFC *BUPA Study Lancet. 1994;343: B ERFC *Bruneck Study Arterioscler Thromb Vasc Biol 1999; 19(6): B ERFC *Cardiovascular Study in the Elderly J Hum Hypertens 1998; 12(9): B ERFC *Diet and Risk of Cardiovascular Disease in Spain Annals of Nutrition and Metabolism 2000; 44(3):10 39 B ERFC *Dubbo Study of the Elderly Am J Cardiol 2002; 89(1): B ERFC *EPIC Norfolk Study Ann Intern Med 2007; 146(9): B ERFC *Göttingen Risk Incidence and Prevalence Study Atherosclerosis 1997; 129(2): B ERFC *Kuopio Ischaemic Heart Disease Study Circulation 1991; 84(1): *Report cited by ERFC as providing data on triglycerides, HDL-C and non-hdl-c, and other risk factors

4 Table A1. List of candidate reports by inclusion/exclusion categories #A: ERFC-identified report without the requisite non-hdl-c and apob data B: ERFC-identified study with requisite data but without published non-hdl-c and apob relative risk ratios (RRRs) C: ERFC-identified report with published RRRs not included in ERFC meta-analysis D: Reports from ERFC-cited studies included in both analyses E: Reports from studies not cited by ERFC with RRRs F: Reports not cited by ERFC without RRRs 4 Ref # meta-analyses Study citation 43 B ERFC *National Health and Nutrition Examination Survey III Am J Cardiol 2000; 86(3): B ERFC *Prospective Cardiovascular Münster Study Am J Cardiol 1992; 70(7): B ERFC *Prospective Epidemiological Study of Myocardial Infarction Arterioscler Thromb Vasc Biol 2002; 22(7): B ERFC *Prospective Study of Pravastatin in the Elderly at Risk Circulation 2005; 112(20): B ERFC *Quebec Cardiovascular Study Atherosclerosis 2000; 153(2): B ERFC *Strong Heart Study Diabetes 1992; 41 Suppl 2:4-11.: B ERFC *Turkish Adult Risk Factor Study J Epidemiol Community Health 1992; 46(5): B ERFC *Uppsala Arterioscler Thromb Vasc Biol 2006; 26(2): B ERFC *VIP/MONICA J Intern Med 1998; 244(5): B ERFC *Whitehall II Study Arterioscler Thromb Vasc Biol 2008; 28(8): C Current *Framingham Offspring Study JAMA. 2007;298: D ERFC *Copenhagen City Heart Study JAMA 2007; 298(3): D Current Copenhagen City Heart Study Arterioscler Thromb Vasc Biol. 2007;27: D Both *Nurses Health Study (11) Circulation.2004;110: D ERFC *Women s Health Study (15) JAMA. 2005;294: D Current Women s Health Study (12) Circulation. 2009;119: E Current Apolipoprotein Related Mortality Risk Study (21) J Intern Med. 2008;264: E Current Casale Monferrato Study (19) Diabetologia. 2006;49: E Current Chin-Shan Cohort (20) J Lipid Res. 2007;48: E Current Health Professionals Follow-up Study (16) Diabetes Care. 2004;27: E Current Health Professionals Follow-up Study (18) Circulation. 2005;1112: *Report cited by ERFC as providing data on triglycerides, HDL-C and non-hdl-c, and other risk factors

5 Table A1. List of candidate reports by inclusion/exclusion categories #A: ERFC-identified report without the requisite non-hdl-c and apob data B: ERFC-identified study with requisite data but without published non-hdl-c and apob relative risk ratios (RRRs) C: ERFC-identified report with published RRRs not included in ERFC meta-analysis D: Reports from ERFC-cited studies included in both analyses E: Reports from studies not cited by ERFC with RRRs F: Reports not cited by ERFC without RRRs 5 Ref # meta-analyses Study citation 64 E Current INTERHEART Study (22) Lancet 2008; 372: E Current International Studies of Infarct Survival (23) Euro Heart J (2009) 30, E Current Monitoring of Trends and Determinants in CVD (17) EurHeart J. 2005;26: F Neither 4S Placebo Wing clinical trial Circulation. 1998;97: F Neither Air Force/Texas Coronary Atherosclerosis Prevention Study Circulation. 2000;101: F Neither Angina Prognosis Study in Stockholm Atherosclerosis. 1997;135: F Neither ApoB and Type 1 Diabetes J Immunol Methods. 2006;260: F Neither Apolipoprotein Related Mortality Risk Study Clin Chem Lab Med 2004; 42: F Neither Apolipoprotein Related Mortality Risk Study Lancet. 2001;358: F Neither Apolipoprotein Related Mortality Risk Study Lancet. 2003;361: F Neither Bezafibrate Coronary Atherosclerosis Intervention Trial J Am Coll Cardiol. 1998;32: F Neither Bugalusu Heart Study Pediatrics. 2008;121: F Neither Caerphilly Prospective Study Eur J Clin Invest 2000; 30: F Neither Cardiovascular Health Study Arterioscler Thromb Vasc Biol.2002;22: F Neither Cardiovascular risk in Young Finns Study J Am CollCardiol. 2008;1: F Neither Diabetes Atherosclerosis Intervention Study Circulation. 2003;107: F Neither Dubbo Study of the Elderly Atherosclerosis 2001; 159: F Neither EPIC Norfolk Study J Am Coll Cardiol.2007;49: F Neither Eastern Finland Heart Survey Am J Cardiol. 1985;56: F Neither Fenofibrate Intervention and Event Lowering in Diabetes Diabetologia : F Neither Framingham Offspring Study J Clin Lipidol. 2007;1: *Report cited by ERFC as providing data on triglycerides, HDL-C and non-hdl-c, and other risk factors

6 Table A1. List of candidate reports by inclusion/exclusion categories #A: ERFC-identified report without the requisite non-hdl-c and apob data B: ERFC-identified study with requisite data but without published non-hdl-c and apob relative risk ratios (RRRs) C: ERFC-identified report with published RRRs not included in ERFC meta-analysis D: Reports from ERFC-cited studies included in both analyses E: Reports from studies not cited by ERFC with RRRs F: Reports not cited by ERFC without RRRs 6 Ref # meta-analyses Study citation 85 F Neither Glostrup Study Atherosclerosis 1997; 132: F Neither Guernsey Atherosclerosis 1992; 92: F Neither Incremental Decrease in End points Through Aggressive Lipidlowering Ann Med. 2008: F Neither Kuopio Ischaemic Heart Disease Study Circulation 1992; 86: F Neither Kuopio Ischaemic Heart Disease Study Arterioscler Thromb Vasc Biol 1999; 19: F Neither Leiden Heart Study. Arterioscler Thromb Vasc Biol. 2000;20: F Neither Long-term Intervention with Pravastatin in Ischaemic Disease Circulation. 2002;105: F Neither Monitoring of Trends and Determinants in CVD Eur Heart J 2005;26: F Neither National Health and Nutrition Examination Survey Am J Cardiol. 2006;98: F Neither Northwick Park Heart Study Arterioscler Thromb Vasc Biol.2002;22: F Neither Quebec Cardiovascular Study Arterioscler Thromb Vasc Biol 2005; 25: F Neither Quebec Cardiovascular Study Circulation. 1996;94: F Neither Quebec Cardiovascular Study Am J Cardiol. 2006;97: F Neither Reykjavik Study Am J Cardiol 1992; 69: F Neither Simon et al Atherosclerosis.2005;179: F Neither TEKHARF Survey Anadolu Kardiyol Derg. 2007;2: F Neither THROMBO Metabolic Syndrome Atherosclerosis. 2004;177: F Neither TNT/IDEAL Circulation. 2008; 117: F Neither Thrombosis Prevention Trial Circulation. 1999;99: F Neither U.S. Physicians Health Study N Engl J Med 1991; 325: *Report cited by ERFC as providing data on triglycerides, HDL-C and non-hdl-c, and other risk factors

7 Table A1. List of candidate reports by inclusion/exclusion categories #A: ERFC-identified report without the requisite non-hdl-c and apob data B: ERFC-identified study with requisite data but without published non-hdl-c and apob relative risk ratios (RRRs) C: ERFC-identified report with published RRRs not included in ERFC meta-analysis D: Reports from ERFC-cited studies included in both analyses E: Reports from studies not cited by ERFC with RRRs F: Reports not cited by ERFC without RRRs 7 Ref # meta-analyses Study citation 105 F Neither Uppsala Longitudinal Study of Adult Men Am Heart J 2004; 148: F Neither VA_HIT Circulation. 2006;113: F Neither Women s Health Study Circulation.2002;106: *Report cited by ERFC as providing data on triglycerides, HDL-C and non-hdl-c, and other risk factors

8 Table A2. List of covariates/model adjustments Study abbreviation Health Professionals (16) Nurses' Health(11) MONICA/KORA(17) Health Professionals(18) Women's Health(15) Casale Monferrato(19) Copenhagen Heart(13) Chin-Shan Cohort(20) Fram Offspring (10) AMORIS(21) INTERHEART(22) Women's Health(12) ISIS(23) ADJUSTMENTS age, BMI, family history of MI, physical activity, smoking (never, past, or current), alcohol consumption, fasting status, history of hypertension, aspirin use, HbA1c age, smoking, fasting status, CRP, homocysteine, BMI, family history, hypertension, diabetes, hormone use, physical activity, alcohol intake, blood draw parameters age, diabetes, regular smoking, BMI, alcohol intake age, smoking, blood draw, BMI, parent MI < 60, hypertension, alcohol intake, physical activity age, Framingham BP category, BMI, diabetes, current smoking age, sex, hypertension, smoking, CHD, AER, fibrinogen, cumulative average HbA1c, referring physician age age group, gender, BMI, smoking, alcohol, marital status, education, occupation, exercise, family CHD history, hypertension, diabetes age, SBP, antihypertensive treatment, diabetes, smoking age sex age, sex, smoking, geographic region age, randomized treatment assignment, smoking status, postmenopausal hormone use, blood pressure, diabetes, BMI age, sex, smoking, BMI 8

9 LDL C relative risk ratio (RRR) Study name Subgroup within study Statistics for each study Hazard ratio and 95% CI Hazard Lower Upper ratio limit limit Z-Value p-value Health Professionals (16) men Nurses' Health(11) women Health Professionals (18) men Casale Monferrato(19) pooled Copenhagen Heart(13) men Copenhagen Heart(13) women Chin-Shan Cohort(20) pooled Fram Offspring (10) men Fram Offspring (10) women AMORIS(21) pooled INTERHEART(22) pooled Women's Health(12) women ISIS(23) pooled Overall anti-atherogenic atherogenic Meta Analysis Figure A1. Forest plot of LDL-C relative risk ratios among 13 studies in 11 reports with both apob and non-hdl-c relative risk ratios. The relative risk ratio was significantly greater (p<0.05) than 1.0 within 9 of the 13 studies and highly significant (p<0.001) overall. Heterogeneity was also highly significant (p <0.001). 9

10 Non-HDL C relative risk ratio (RRR) Study name Subgroup within study Statistics for each study Hazard ratio and 95% CI Hazard Lower Upper ratio limit limit Z-Value p-value Health Professionals (16) men Nurses' Health(11) women MONICA/KORA(17) men MONICA/KORA(17) women Health Professionals (18) men Casale Monferrato(19) pooled Copenhagen Heart(13) men Copenhagen Heart(13) women Chin-Shan Cohort(20) pooled Fram Offspring (10) men Fram Offspring (10) women AMORIS(21) pooled INTERHEART(22) pooled Women's Health(12) women ISIS(23) pooled Overall anti-atherogenic atherogenic Meta Analysis Figure A2. Forest plot of non-hdl-c relative risk ratios among 15 independent studies in 12 reports with both apob and non-hdl-c relative risk ratios. The relative risk ratio was significantly greater (p<0.05) than 1.0 within 12 of the 15 studies and highly significant (p<0.001) overall. Heterogeneity was also highly significant (p <0.001). 10

11 ApoB relative risk ratio (RRR) Study name Subgroup within study Statistics for each study Hazard ratio and 95% CI Hazard Lower Upper ratio limit limit Z-Value p-value Health Professionals (16) men Nurses' Health(11) women MONICA/KORA(17) men MONICA/KORA(17) women Health Professionals (18) men Casale Monferrato(19) pooled Copenhagen Heart(13) men Copenhagen Heart(13) women Chin-Shan Cohort(20) pooled Fram Offspring (10) men Fram Offspring (10) women AMORIS(21) pooled INTERHEART(22) pooled Women's Health(12) women ISIS(23) pooled Overall anti-atherogenic atherogenic Meta Analysis Figure A3. Forest plot of apob relative risk ratios among 12 independent published reports with both apob and non-hdl-c relative risk ratios. The relative risk ratio is significantly greater (p<0.05) than 1.0 within each study and highly significant (p<0.001) overall. Heterogeneity was also highly significant (p <0.001). 11

12 Log apob relative risk ratio (RRR) - non-hdl C RRR Study name Subgroup within study Statistics for each study Point estimate and 95% CI Point Standard Lower Upper estimate error Variance limit limit Z-Value p-value Health Professionals (16) men Nurses' Health(11) women MONICA/KORA(10) men MONICA/KORA(10) women Health Professionals(18) men Casale Monferrato(19) pooled Copenhagen Heart(13) men Copenhagen Heart(13) women Chin-Shan Cohort(20) pooled Fram Offspring (10) men Fram Offspring (10) women AMORIS(21) pooled INTERHEART(22) pooled Women's Health(12) women ISIS(23) pooled Overall non-hdl C <- favors->apob Meta Analysis Figure A4. Log apob RRR log non-hdl-c RRR forest plot of 12 independent published studies with both apob and non-hdl-c vascular risk associations. This analysis counts the three reports stratified by sex as six separate studies and excludes a Women s Health Study report(12) based on a subset of the later Women s Health Study report (19). The overall mean difference in log relative risk ratios (95% confidence interval) of (0.024, 0.087) equates to a 5.7% (2.4%, 9.1%), p<0.001, advantage favoring apob over non-hdl-c as a marker of atherogenic risk

13 Log non-hdl C relative risk ratio (RRR) - log LDL C RRR Study name Subgroup within study Statistics for each study Point estimate and 95% CI Point Standard Lower Upper estimate error Variance limit limit Z-Value p-value Health Professionals(16) men Nurses' Health(11) women Health Professionals(18) men Casale Monferrato(19) pooled Copenhagen Heart(13) men Copenhagen Heart(13) women Chin-Shan Cohort(20) pooled Fram Offspring (10) men Fram Offspring (10) women AMORIS(21) pooled INTERHEART(22) pooled Women's Health(12) women ISIS(23) pooled Overall LDL C <- favors -> non-hdl C Meta Analysis Figure A5. Log non-hdl-c RRR log LDL-C RRR forest plot of the 11 independent published reports with both non-hdl-c and LDL-C relative risk ratios among the 13 published reports with both apob and non-hdl-c relative risk ratios. This analysis counts the two reports stratified by sex as four separate studies and excludes a Women s Health Study report(12) based on a subset of the later Women s Health Study report (19). The overall mean difference in log relative risk ratios (95% confidence interval) of (0.009, 0.091) equates to a 5.1% (0.9%, 9.5%), p=0.017, advantage favoring non-hdl-c over LDL-C as a marker of atherogenic risk. 13

14 Log apob relative risk ratio (RRR) - log LDL C RRR Study name Subgroup within study Statistics for each study Point estimate and 95% CI Point Standard Lower Upper estimate error Variance limit limit Z-Value p-value Health Professionals (16) men Nurses' Health(11) women Health Professionals(18) men Casale Monferrato(19) pooled Copenhagen Heart(13) men Copenhagen Heart(13) women Chin-Shan Cohort(20) pooled Fram Offspring (10) men Fram Offspring (10) women AMORIS(21) pooled INTERHEART(22) pooled Women's Health(12) women ISIS(23) pooled Overall LDL C <- favors -> apob C Meta Analysis Figure A6. Log apob RRR log LDL-C RRR forest plot of the 11 independent published reports with both apob and LDL-C relative risk ratios among the 13 reports with both apob and non-hdl-c relative risk ratios. This analysis counts the two reports stratified by sex as four separate studies and excludes a Women s Health Study report(12) based on a subset of the later Women s health Study report (19). The overall mean difference in log relative risk ratios (95% confidence interval) of = (0.085, 0.154) = equates to a 12.7% (8.9%, 16.6%), p<0.001, advantage apob over LDL-C as a marker of atherogenic risk. 14

15 Figure A7. Subgroup analyses by study attributes. The p-values for each section indicate result from testing equality of the difference between the apob and non-hdl-c log relative risk ratios across the section s subgroups. Assay well documented reflects the authors judgment regarding reported assurances re: assay/specimen quality. Mean of subgroup comparison versus 0%: *p<0.05, ** p<0.01, ***p<0.001 % 15

16 A 500 B C 200 A. ApoB versus NonHDL-C B. NonHDL-C versus LDL-C C. ApoB versus LDL-C Precision (1/standard error) (0.024, 0.087) (0.016, 0.078) (0.009, 0.091) (0.005, 0.084) (0.085, 0.154) (0.024, 0.093) Figure A8. Selection bias assessments: funnel plots of precision by difference in log relative risk ratios. The empty circles represent the observed studies while the empty diamonds represents the overall random effects means and 95% confidence intervals of the observed studies. If smaller studies were not published owning to non-significant findings, one would expect the distribution of empty circles to be skewed to the right. The black filled circles represent studies imputed to balance the distribution around the overall estimate and the black diamonds represent overall average adjusted by including the imputed studies. After adjustment each overall difference remains statistically significant. 16

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