2424
Se um lipids, including o al choles e ol, low-densi y lipo-
p o ein-choles e ol (LDL-C) and high-densi y lipop o ein-
choles e ol (HDL-C), ha e all been used in isk p edic ion o
a he oscle o ic hea disease, and LDL-C has been es ablished
as he main lipid a ge in he managemen o pa ien s wi h
co ona y a e y disease (CAD). On he basis o b oad lipido-
mic analyses in di e en CAD pa ien coho s, we and o h-
e s ha e epo ed ha o he ci cula ing lipid species may also
hold p ognos ic po en ial in CAD.1–4
In ou ea lie s udies, ce amide molecules Ce (d18:1/16:0),
Ce (d18:1/18:0), and Ce (d18:1/24:1), as well as hei a ios
o Ce (d18:1/24:0), ha e eme ged as no el isk s a i ie s in
pa ien s wi h es ablished CAD. These ce amides a e ana-
ly ically obus and ha e been p o en o p o ide signi ican
inc emen al alue o e ou inely used lipid ma ke s in a sec-
onda y p e en ion se ing, pa icula ly o ha d ou comes
such as ca dio ascula dea h.5 Li e a u e on ce amide biology
associa es hese molecules wi h many cen al a he oscle o ic
p ocesses, such as lipop o ein agg ega ion, up ake o lipop o-
eins and accumula ion o choles e ol wi hin mac ophages,
egula ion o ni ic oxide syn hesis, p oduc ion o supe oxide
anions, and exp ession o di e en cy okines.6–11 Fu he mo e,
expe imen al s udies ha e shown ha ce amides and ela ed
sphingolipids a e associa ed wi h he de elopmen o a h-
e oscle osis.6 Inhibi ion o glycosphingolipid biosyn hesis
dec eased a he oscle osis in mice, and consequen ly, se e al
enzymes o he sphingolipid syn he ic pa hway ha e been
es ed as po en ial d ug a ge s.12,13
As an ex ension o obse a ions in seconda y p e en ion
coho s, he p esen s udy e alua ed ce amide beha io in he
la ge-scale p ospec i e FINRISK s udy o alida e he p og-
nos ic alue o he ce amides a he popula ion le el.
A e ioscle Th omb Vasc Biol is a ailable a h p://a b.ahajou nals.o g DOI: 10.1161/ATVBAHA.116.307497
Objec i e—Ce amides a e molecula lipids implica ed in apop osis, in lamma ion, obesi y, and insulin esis ance. An ea lie
s udy epo ed ha ce amides we e associa ed wi h a al ou come among pa ien s wi h co ona y hea disease. He e,
we examined whe he ce amides a e associa ed wi h majo ad e se ca dio ascula e en s (MACEs) among appa en ly
heal hy indi iduals.
App oach and Resul s—FINRISK 2002 is a popula ion-based isk ac o su ey, which ec ui ed men and women aged 25
o 74 yea s. The coho was ollowed up un il he end o 2014. We quan i ied 4 ci cula ing ce amides, Ce (d18:1/16:0),
Ce (d18:1/18:0), Ce (d18:1/24:0), and Ce (d18:1/24:1), in 8101 se um samples by a a ge ed liquid ch oma og aphy–
andem mass spec ome y assay. P ima y ou come o in e es was inciden MACE (n=813). Seconda y analyses we e
pe o med o MACE dea h (n=116) wi hou p e ious non a al MACE and o ecu en MACE (n=226) among su i o s
o a p e ious inciden MACE. We used Cox p opo ional haza d models adjus ed o he F amingham co a ia es o
de e mine he associa ion o ce amides wi h he ou comes. O he ce amide species, Ce (d18:1/18:0) had he s onges
associa ion wi h inciden MACE and he highes unadjus ed haza d a io o 1.31 (95% con idence in e al, 1.21–1.41),
which emained signi ican a 1.21 (95% con idence in e al, 1.11–1.33) a e F amingham isk ac o adjus men s. The
haza d a ios we e gene ally s onge o ecu en and a al e en s han o i s e en s. Clinical ne eclassi ica ion
imp o emen was 7.5% (P=6.9×10−5) o Ce (d18:1/18:0).
Conclusions—Dis inc se um ce amides a e associa ed wi h he isk o inciden MACE in appa en ly heal hy indi iduals. These
esul s should encou age mo e de ailed analyses o ce amides in ca dio ascula pa hobiology and sugges new bioma ke s
o MACE isk. (A e ioscle Th omb Vasc Biol. 2016;36:2424-2430. DOI: 10.1161/ATVBAHA.116.307497.)
Key Wo ds: ca dio ascula diseases ◼ ce amides ◼ lipids ◼ lipidomics ◼ me abolomics ◼ isk ac o s
Recei ed on: Ma ch 7, 2016; inal e sion accep ed on: Oc obe 3, 2016.
F om he Depa men o Heal h, Na ional Ins i u e o Heal h and Wel a e, Helsinki, Finland (A.S.H., V.S.); Zo a Biosciences Oy, Espoo, Finland
(M.S.-A., M.H., D.K., R.H., K.E., R.L.); Medical School, Uni e si y o Tampe e, Finland (R.L.); and Finnish Clinical Biobank, Uni e si y Hospi al o
Tampe e, Finland (R.L.).
*These au ho s con ibu ed equally o his a icle.
The online-only Da a Supplemen is a ailable wi h his a icle a h p://a b.ahajou nals.o g/lookup/suppl/doi:10.1161/ATVBAHA.116.307497/-/DC1.
Co espondence o Reijo Laaksonen, MD, PhD, Zo a Biosciences Oy, Biologinkuja 1, FI-02150 Espoo, Finland. E-mail [email p o ec ed]
© 2016 The Au ho s. A e ioscle osis, Th ombosis, and Vascula Biology is published on behal o he Ame ican Hea Associa ion, Inc., by Wol e s
Kluwe Heal h, Inc. This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s use, dis ibu ion, and
ep oduc ion in any medium, p o ided ha he o iginal wo k is p ope ly ci ed.
Ci cula ing Ce amides P edic Ca dio ascula Ou comes
in he Popula ion-Based FINRISK 2002 Coho
Aki S. Ha ulinna,* Ma ko Sysi-Aho,* Mika Hil o, Dimple Kauhanen, Reini Hu me,
Kim Ek oos, Veikko Salomaa,* Reijo Laaksonen*
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Ha ulinna e al Ci cula ing Ce amides P edic CVD in FINRISK 2002 2425
Ma e ials and Me hods
Ma e ials and Me hods a e a ailable in he online-only Da a
Supplemen .
Resul s
Ele a ed Ce amide Concen a ions A e Associa ed
Wi h Inc eased Majo Ad e se Ca dio ascula
E en Risk
This s udy included 8101 indi iduals om he FINRISK 2002
gene al popula ion coho . In sho , median age was 48.5
yea s, and 53% o he s udy subjec s we e women. A p eex-
is ing a he oscle o ic ascula disease was p esen in 3.6%,
whe eas 5.5% had diabe es melli us and 25.7% o he subjec s
we e smoke s a s udy baseline. The baseline cha ac e is ics o
he coho a e summa ized in Table I in he online-only Da a
Supplemen . Du ing a ollow-up o 13 yea s, 813 subjec s
expe ienced an inciden majo ad e se ca dio ascula e en
(MACE), o which 116 we e a al (anno a ed as MACE dea h
h oughou his wo k). Table 1 shows se um concen a ions o
o al choles e ol, LDL-C, HDL-C, iglyce ides, ce amides,
and C- eac i e p o ein (CRP) o asymp oma ic subjec s and
o subjec s who expe ienced an inciden MACE du ing he
ollow-up. Inc eased concen a ions o dis inc ce amides we e
obse ed in indi iduals who expe ienced an inciden MACE
du ing he ollow-up compa ed wi h asymp oma ic indi idu-
als. The se um concen a ions o he 3 culp i high- isk species
ha we e p e iously shown o p edic ca dio ascula dea h in
CAD pa ien s we e also highe in FINRISK MACE cases com-
pa ed wi h asymp oma ic subjec s as ollows: Ce (d18:1/16:0),
Ce (d18:1/18:0), and Ce (d18:1/24:1) 11.4%, 21.3%, and
17.0% (P<0.001 o all), espec i ely. Two p ede ined ce amide
a ios, Ce (d18:1/18:0)/Ce (d18:1/24:0) and Ce (d18:1/24:1)/
Ce (d18:1/24:0), we e also signi ican ly highe in subjec s wi h
an inciden MACE compa ed wi h asymp oma ic subjec s.
Ce amide (d18:1/18:0) Associa es
Wi h Inciden MACE
The associa ion be ween ce amides and MACE was u he
e alua ed by he Cox eg ession analyses. Figu e 1 shows he
associa ions o he ce amides wi h inciden MACE, including
a al and non a al MACE, and sepa a ely o MACE dea h only.
The 3 high- isk ce amides we e associa ed wi h inciden
MACE and MACE dea h. The Ce (d18:1/18:0) displayed he
highes uni a ia e haza d a io (HR) o inciden MACE (1.31;
95% con idence in e al, 1.21–1.41), which emained signi i-
can (1.21; 95% con idence in e al, 1.11–1.33) a e adjus -
ing o he F amingham Risk Sco e ac o s. Also, he highes
uni a ia e HR o MACE dea h (1.46; 95% con idence in e -
al, 1.20–1.78) was obse ed o Ce (d18:1/18:0), bu i did
no emain signi ican a e adjus men o he F amingham
Risk Sco e ac o s. Subjec s wi h a known p e alen MACE
we e excluded om hese analyses.
Ce amide (d18:1/18:0) Imp o es Clinical
NRI in he FINRISK 2002 Popula ion
The inc emen al p ognos ic alue o ce amides was es ed
by compa ing he F amingham sco e base model wi h a new
model adding ce amides on op o he F amingham sco e. The
p edic ed p obabili ies o a 10-yea isk o inciden MACE by
c oss- alida ed Weibull eg ession yielded signi ican clinical
ne eclassi ica ion index (NRI) o he 3 high- isk ce amide
Nons anda d Abb e ia ions and Ac onyms
CAD co ona y a e y disease
HDL-C high-densi y lipop o ein-choles e ol
LDL-C low-densi y lipop o ein-choles e ol
MACE majo ad e se ca dio ascula e en
NRI ne eclassi ica ion index
Table 1. Medians and In e qua ile Ranges o Es ablished Lipid Ma ke s and Ce amides in
Pa icipan s Wi hou MACE Du ing he Follow-Up and Wi h Inciden MACE
MACE− (n=6892) MACE+ (n=813) Signi icance
Ce (d18:1/16:0) 0.28 (0.24–0.33) 0.33 (0.28–0.38) ***
Ce (d18:1/18:0) 0.11 (0.09–0.15) 0.15 (0.11–0.19) ***
Ce (d18:1/24:0) 2.28 (1.86–2.77) 2.60 (2.14–3.14) ***
Ce (d18:1/24:1) 1.52 (1.25–1.85) 1.77 (1.47–2.19) ***
Ce (d18:1/16:0)/Ce (d18:1/24:0) 0.13 (0.11–0.14) 0.13 (0.11–0.14)
Ce (d18:1/18:0)/Ce (d18:1/24:0) 0.05 (0.04–0.06) 0.06 (0.05–0.07) ***
Ce (d18:1/24:1)/Ce (d18:1/24:0) 0.67 (0.59–0.76) 0.70 (0.61–0.79) ***
LDL-C 3.30 (2.72–3.90) 3.70 (3.09–4.34) ***
HDL-C 1.46 (1.21–1.75) 1.28 (1.12–1.57)
TC 5.48 (4.85–6.22) 5.94 (5.21–6.62) ***
TG 1.16 (0.84–1.66) 1.50 (1.16–2.18) **
CRP 1.10 (0.51–2.44) 1.94 (0.95–4.63) *
CRP indica es C- eac i e p o ein; HDL-C, high-densi y lipop o ein-choles e ol; LDL-C, low-densi y lipop o ein-choles e ol;
MACE, majo ad e se ca dio ascula e en ; TC, o al choles e ol; and TG, iglyce ides.
The Wilcoxon es ***P<0.001; **P<0.01 and *P<0.05.
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2426 A e ioscle Th omb Vasc Biol Decembe 2016
species (Table II in he online-only Da a Supplemen ). In line
wi h he abo e-men ioned associa ion esul s, Ce (d18:1/18:0)
showed he la ges clinical NRI (7.5%; P=6.9×10−5), which
was mainly d i en by down-classi ica ion (6.9%; P=1.2×10−5)
o isk among people in he in e media e isk g oup (5%–20%
10-yea MACE isk). Howe e , C-index as a disc imina ion
measu e emained nonsigni ican , as well as he NRI o he
a al end poin s.
Ce amide (d18:1/18:0) Adds Value o
Cu en Lipid and CRP Measu emen s
The signi ican associa ions be ween inciden MACE and
dis inc ce amides p omp ed us o es whe he ce amides
could add p ognos ic alue o he cu en ly used ou ine clini-
cal labo a o y measu es, such as CRP, HDL-C, o LDL-C.
Co ela ion analysis showed weak o mode a e co ela ions o
measu ed ce amides and hei a ios wi h CRP and ou inely
Figu e 1. Unadjus ed (UHR, blue) and adjus ed (MHR, ed) haza d a ios o inciden majo ad e se ca dio ascula e en (MACE) and
a al inciden MACE o pa icipan s wi h no MACE be o e baseline (n=7705). Adjus men o F amingham isk ac o s: o al choles e ol,
high-densi y lipop o ein-choles e ol (HDL-C), blood p essu e (adjus ed +15 mm Hg o an ihype ensi e medica ion), diabe es melli us,
and smoking. Unadjus ed (UHR, blue) and adjus ed (MHR, ed) haza d a ios o ecu en MACE and a al ecu en MACE o pa ien s
wi h p e alen MACE a baseline (n=396). Adjus men o F amingham isk ac o s: o al choles e ol, HDL-C, blood p essu e (adjus ed +15
mm Hg o blood p essu e medica ion), diabe es melli us, and smoking. Age was used as he ime scale in all models, and he models
we e s a i ied by sex. The e o e, he unadjus ed models a e essen ially equi alen o age- and sex-adjus ed models.
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Ha ulinna e al Ci cula ing Ce amides P edic CVD in FINRISK 2002 2427
used lipids (Table III in he online-only Da a Supplemen ). O
no e a e he ela i ely s ong co ela ions o Ce (d18:1/18:0)
wi h CRP and lipids, excep o HDL-C. Howe e , despi e he
obse ed co ela ion be ween ce amides and CRP, he asso-
cia ion be ween ce amides and MACE emained p ac ically
unchanged a e addi ional adjus men o CRP on op o
he F amingham isk sco e a iables (Figu e I in he online-
only Da a Supplemen ) compa ed wi h adjus men o he
F amingham a iables only (Figu e 1).
We selec ed Ce (d18:1/18:0) o mo e de ailed analy-
ses because i showed he s onges associa ion wi h inci-
den MACE in he analyses summa ized abo e. To assess
he po en ial syne gy be ween cu en ly used clinical assays
and Ce (d18:1/18:0), we di ided he samples in o concen a-
ion qua iles by CRP and Ce (d18:1/18:0), by HDL-C and
Ce (d18:1/18:0), and by LDL-C and Ce (d18:1/18:0), and cal-
cula ed he inciden MACE a e pe cen ages in hese o e lap-
ping qua iles ac oss he combina ions (Figu e 2).
Figu e 2A shows ha he lowes 13-yea inciden MACE
isk (2.6%) was obse ed in subjec s ha ing bo h CRP and
Ce (d18:1/18:0) in he lowes concen a ion qua ile ( i s
qua ile [Q1]) and he highes isk (20.9%) was ound in sub-
jec s ha ing bo h CRP and Ce (d18:1/18:0) in he highes con-
cen a ion qua ile ( ou h qua ile [Q4]). High >15% isk was
obse ed in subjec s ha ing CRP concen a ions >0.52 mg/dL
(Q2–Q4) and Ce (d18:1/18:0) in Q4. The syne gy o he CRP
and Ce (d18:1/18:0) combina ion was u he e idenced by
he Kaplan–Meie es ima es o inciden MACE showing he
high isk in subjec s wi h op qua ile se um concen a ions o
bo h CRP and Ce (d18:1/18:0) (Figu e 3).
HDL-C seemed o pe o m simila ly as Ce (d18:1/18:0),
bu when combined, mo e cases mapped o he highe concen-
a ion Ce (d18:1/18:0) (Q4) and lowe concen a ion HDL-C
(Q1) qua iles whe e he MACE isk was 18.4% (Figu e 2B).
When mapped oge he wi h LDL-C, he case en ichmen was
mainly e iden because o he e ec s o highe concen a ions
o Ce (d18:1/18:0) ac oss Q4 (Figu e 2C). These da a a e u -
he illus a ed in Figu e 4 sepa a ely o Ce (d18:1/18:0) and
LDL-C by Kaplan–Meie cu es o inciden MACE pe con-
cen a ion qua ile showing a s eepe slope and highe HRs o
Ce (d18:1/18:0).
Ce amide (d18:1/16:0) and (d18:1/24:1)
Associa e Wi h Recu en MACE
Ou p e ious s udies indica e ha ce amides se e as p ognos-
ic ma ke s o a al ou come in pa ien s wi h CAD.5,14 Wi h
his in mind, we sepa a ely analyzed subjec s who al eady had
expe ienced MACE be o e he baseline measu emen (n=396)
and as he end poin hose who had a ecu en MACE (n=226)
o a al ecu en MACE (n=70) du ing ollow-up. Fo ecu -
en MACE, Ce (d18:1/16:0) and Ce (d18:1/24:1) showed
signi ican uni a ia e associa ions, wi h Ce (d18:1/16:0)
ha ing he highes uni a ia e HR a 1.28 (1.10–1.49), which
emained signi ican a HR=1.50 (1.22–1.83) also a e adjus -
ing o he F amingham Risk Sco e ac o s (Figu e 1).
Fo hose pa ien s who had expe ienced MACE be o e
baseline measu emen , he associa ion wi h MACE dea h was
signi ican o Ce (d18:1/16:0) and Ce (d18:1/24:1). The uni-
a ia e HR was highes a 1.51 (1.15–1.99) o Ce (d18:1/16:0),
and i emained signi ican a HR=1.54 (1.07–2.20) a e adjus -
ing o he F amingham Risk Sco e ac o s.
Figu e 2. A–C, Inciden majo ad e se ca dio ascula e en (MACE)
a e (%) in di e en concen a ion qua iles o Ce (d18:1/18:0),
C- eac i e p o ein (CRP), low-densi y lipop o ein-choles e ol (LDL-
C), and high-densi y lipop o ein-choles e ol (HDL-C).
Figu e 3. Kaplan–Meie es ima es o inciden majo ad e se ca -
dio ascula e en (MACE) o subpopula ions wi h Ce (d18:1/18:0)
in Q4 s no in Q4, C- eac i e p o ein (CRP) in Q4 s no in Q4,
and Ce (d18:1/18:0) in Q4 and CRP in Q4 s i s complemen .
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2428 A e ioscle Th omb Vasc Biol Decembe 2016
Ce amide Sco e Associa es Wi h
MACE a Popula ion Le el
Because he da a abo e show ha he occu ence o inciden
MACE on one hand, and ecu en MACE on he o he hand,
may be associa ed wi h di e en ce amides, we applied a p e i-
ously de eloped ce amide isk sco e14 o e alua e he associa ion
be ween ce amides and MACE in he whole s udy popula ion. On
he basis o his sco e, he pa ien s we e placed in o 4 isk ca ego-
ies (low, mode a e, inc eased, and high), and bo h MACE and
MACE dea h isk we e inc eased along wi h he inc easing sco e
(Table 2). A 2.7- and 4.3- old ela i e isk inc ease was obse ed
o MACE and MACE dea h, espec i ely, when compa ing he
high- wi h low- isk ca ego y. When subjec s we e so ed acco d-
ing o hei LDL-C concen a ions and spli in o 4 ca ego ies in
he same p opo ion as o he ce amide isk sco e, he en ich-
men o high- isk pa ien s was 1.4- and 1.8- old, espec i ely.
Discussion
The ce amide analysis o he FINRISK coho showed ha
dis inc ce amide species associa e wi h majo ca dio ascula
e en s a he popula ion le el. In ou p e ious wo k,5,14 we ha e
shown s ong associa ions o ce amides and CAD ou comes
in seconda y p e en ion. These associa ions we e u he ali-
da ed in his la ge-scale p ima y p e en ion s udy. Because o
hei associa ion wi h bo h non a al inciden and a al MACE,
i seems ha ce amides may associa e wi h bo h he de elop-
men o he a he oscle o ic ascula disease and i s p og es-
sion o ascula ad e se e en s. The ela i ely s ong uni a ia e
associa ions o ce amides wi h a al e en s sugges ha ce ami-
des may play a ole in he up u e o a he oscle o ic plaques.
The clinical NRI calcula ions demons a ed ha
Ce (d18:1/18:0) holds he po en ial o imp o ing he isk
classi ica ion o e he F amingham isk sco e a a popula ion
le el. The majo i y o eclassi ica ion seemed o be mainly
because o a shi om he in e media e- isk g oup o he low-
isk g oup. This inding is in line wi h he ea lie epo s on
isk o e es ima ion when using he F amingham isk sco e.15–20
The combined analysis o Ce (d18:1/18:0) wi h CRP,
HDL-C, and LDL-C was in e es ing and po en ially appli-
cable o imp o ed iden i ica ion o high- isk pa ien s. In
pa icula , he highes CRP and Ce (d18:1/18:0) qua iles
iden i ied a subs an ial p opo ion o inciden MACE cases
demons a ing a syne gy be ween CRP and Ce (d18:1/18:0)
(Figu e 2). This ma ke combina ion could be use ul o he
iden i ica ion o subjec s in need o p e en i e ca e because
Figu e 4. A and B, Kaplan–Meie es i-
ma es o inciden majo ad e se ca dio-
ascula e en (MACE) Ce (d18:1/18:0)
and low-densi y lipop o ein-choles e ol
(LDL-C) qua iles. A haza d a io in he
legend indica es he qua ile-speci ic
haza d ela i e o he i s qua ile (models
s a i ied o sex).
Table 2. Ce amide Sco e and Risk o MACE and MACE Dea h in FINRISK 2002 Popula ion
MACE MACE Dea h
No MACE MACE % Rela i e Risk
No
Dea h Dea h % Rela i e Risk
Sco e
0–2 2358 252 9.7 1.0 2579 31 1.2 1.0
3–6 2854 448 13.6 1.4 3239 63 1.9 1.6
7–9 1199 339 22.0 2.3 1479 59 3.8 3.2
10–12 481 170 26.1 2.7 618 33 5.1 4.3
LDL, mmol/L
≤2.88 2271 339 13.0 1.0 2562 48 1.8 1.0
2.88–3.83 2807 495 15.0 1.2 3229 73 2.2 1.2
3.83–4.66 1281 257 16.7 1.3 1495 43 2.8 1.5
≥4.66 533 118 18.1 1.4 629 22 3.4 1.8
LDL indica es low-densi y lipop o ein; and MACE, majo ad e se ca dio ascula e en .
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Ha ulinna e al Ci cula ing Ce amides P edic CVD in FINRISK 2002 2429
o a high MACE isk. In co ela ion analyses, only ela i ely
modes co ela ions among ce amides, CRP, and HDL-C we e
obse ed, sugges ing ha he obse ed p edic i e e ec o
Ce (d18:1/18:0) is independen and canno be explained by
associa ions be ween hese molecules. Howe e , u he s ud-
ies a e needed o es ablish he biological mechanisms o he
ce amide e ec s and he clinical u ili y o he measu emen s.
The subanalysis o subjec s who had had MACE be o e 2002
baseline sugges ed ha Ce (d18:1/16:0) and Ce (d18:1/24:1)
associa ed s onge han Ce (d18:1/18:0) wi h new ca dio ascu-
la e en s in pa ien s wi h p eexis ing disease, which is in ag ee-
men wi h ou ea lie esul s on s able CAD and acu e co ona y
synd ome pa ien s.4,5,14 Fu u e mechanis ic s udies a e needed
o e alua e his di e ence in ce amide beha io be ween p i-
ma y and seconda y p e en ion. We ha e p e iously de eloped
a ce amide sco e ha akes in o accoun all 3 culp i ce amides
and hei a ios wi h Ce (d18:1/24:0) o simpli y he clinical use
o he ce amide da a. We applied he same ce amide sco e in he
p esen s udy o he whole FINRISK 2002 coho and obse ed
a solid sco e pe o mance a he popula ion le el.
In ou p e ious s udies in pa ien s wi h es ablished CAD,
Ce (d18:1/24:0) appea ed ca diop o ec i e, whe eas in he
cu en s udy Ce (d18:1/24:0) was weakly associa ed wi h he
inc eased isk o MACE and MACE dea h. The eason o his
di e ence emains o be in es iga ed in u u e s udies. One
may specula e ha he di e en beha io o Ce (d18:1/24:0)
in p ima y and seconda y p e en ion s udies may be ela ed
o i s associa ion wi h bo h lipop o ein pa icles and in lam-
ma o y p ocesses. In ac , Ce (d18:1/24:0) beha io seems o
mi o ha o LDL-C. LDL-C ypically associa es wi h ca -
dio ascula isk in p ima y p e en ion, whe eas in pa ien s
wi h an es ablished CAD he e is an in e se ela ionship o no
associa ion. This has been sugges ed o ela e o in lamma o y
con ol o hepa ic LDL ecep o egula ion.21 Thus, i is pos-
sible ha Ce (d18:1/24:0) is biologically less ac i e compa ed
wi h o he ce amide species, and in he isk p edic ion, i is
me ely a measu e o lipop o ein me abolism.
By design, ou s udy is an obse a ional coho s udy, and
he e o e, i is no possible o es ablish causali y o po en ial
ea men consequences. Thus, i is no known a he momen ,
whe he ea ing ca dio ascula isk on he basis o ce amide
classi ica ion would p oduce any be e clinical esul s han he
ea men s based on cu en isk es ima ion algo i hms, such as
he F amingham o he SCORE equa ion (Sys ema ic Co ona y
Risk E alua ion). Ano he limi a ion is he ac ha ou s udy
coho consis s almos o ally o whi es. Thus, u he s ud-
ies in e hnically mo e di e se popula ions a e wa an ed. The
s eng hs o he s udy include he la ge FINRISK 2002 coho ,
which is ep esen a i e o he gene al Finnish popula ion and
has a long and comp ehensi e ollow-up o ca dio ascula
e en s. Ano he s eng h is he mode n and sophis ica ed mass
spec ome y echnology, which enabled he measu emen o
ci cula ing ce amides in 8000 indi iduals wi h good accu acy.
In conclusion, ou esul s show ha dis inc ci cula ing
ce amides a e associa ed wi h he isk o inciden MACE in
heal hy indi iduals. These esul s add insigh o ou unde -
s anding o he pa hogenesis o MACE and sugges new
op ions o isk es ima ion.
Acknowledgmen s
We hank M s Si pa Su ela-Tuominen and M s Ri a Seppänen o
expe echnical suppo and sample p epa a ion.
Sou ces o Funding
The esea ch leading o hese esul s has ecei ed unding om he
Eu opean Union’s Se en h F amewo k P og amme FP7/2007 o 2013
unde g an ag eemen n° 305739 (RiskyCAD). V.S. was suppo ed
by he Finnish Founda ion o Ca dio ascula Resea ch.
Disclosu es
Zo a Biosciences holds pa en s o he diagnos ic use o ce amides,
and R.H. and R.L. a e sha eholde s o Zo a Biosciences. R.H., R.L.,
M.S.-A., M.H., K.E., and D.K. a e employees o Zo a Biosciences.
The o he au ho s epo no con lic s.
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Highligh s
• The ce amide analysis o he FINRISK coho showed ha dis inc ce amide species associa e wi h majo ca dio ascula e en s a he
popula ion le el.
• Ce amides may be new bioma ke s o majo ad e se ca dio ascula e en isk.
• The combina ion o Ce (d18:1/18:0) and C- eac i e p o ein could be use ul o he iden i ica ion o subjec s a high majo ad e se ca dio as-
cula e en isk.
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Veikko Salomaa and Reijo Laaksonen
Aki S. Ha ulinna, Ma ko Sysi-Aho, Mika Hil o, Dimple Kauhanen, Reini Hu me, Kim Ek oos,
FINRISK 2002 Coho
Ci cula ing Ce amides P edic Ca dio ascula Ou comes in he Popula ion-Based
P in ISSN: 1079-5642. Online ISSN: 1524-4636
Copy igh © 2016 Ame ican Hea Associa ion, Inc. All igh s ese ed.
G een ille A enue, Dallas, TX 75231
is published by he Ame ican Hea Associa ion, 7272A e ioscle osis, Th ombosis, and Vascula Biology
doi: 10.1161/ATVBAHA.116.307497
2016;
2016;36:2424-2430; o iginally published online Oc obe 20,A e ioscle Th omb Vasc Biol.
F ee ia Open Access
h p://a b.ahajou nals.o g/con en /36/12/2424
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h p://www.lww.com/ ep in s
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‘su i al’ package) and all models we e adequa e. We es ima ed he clinical NRI in he
5…20% isk ca ego y
11
, i.e. NRI among hose who we e a he in e media e (5…20%)
isk g oup when p edic ed by he e e ence model wi hou ce amides.
The calcula ion o ce amide sco e has been es ablished ecen ly
12
. In b ie , o each
indi idual all h ee ce amide a ios and each concen a ion, excep o Ce (d18:1/24:0),
we e compa ed o he whole s udy popula ion. I he a iable belonged o he 3 d
qua ile, he indi idual ecei ed +1 poin , and i o he 4 h qua ile, +2 poin s. Based on
he sco es, he subjec s we e spli in o ou isk ca ego ies (low=0-2, mode a e=3-6,
inc eased=7-9 and high=10-12). When compa ing he esul wi h LDL-C, he subjec s
we e so ed acco ding o hei LDL-C concen a ions and spli in o ou ca ego ies in he
same p opo ion as o he ce amide isk sco e.
R e sion 3.2.2 (R Co e Team (2015), Vienna, Aus ia) was used o all s a is ical
analyses. p<0.05 was conside ed as s a is ically signi ican and all es s we e wo-sided.
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