Cholesteryl Ester Transfer Protein (CETP) Inhibition Beyond Raising High-Density Lipoprotein Cholesterol Levels Pathways by Which Modulation of CETP Activity May Alter AtherogenesisAnke H.E.M. Klerkx, Karim El Harchaoui, Wim A. van der Steeg, S. Matthijs Boekholdt, Erik S.G. Stroes, John J.P. Kastelein, Jan Albert KuivenhovenAbstract-Raising high-density lipoprotein cholesterol (HDL-C) is a promising strategy in the struggle to prevent cardiovascular disease, and cholesteryl ester transfer protein (CETP) inhibitors have been developed to accomplish this. The first results are encouraging, and, in fact, in rabbits, inhibition of CETP reduces atherosclerosis. Because human data regarding the reduction of atheroma burden require more time, the biochemical mechanisms underlying the putative atheroprotection of CETP inhibitors are currently dissected, and several pathways have emerged. First, CETP inhibition increases HDL-C and reduces low-density lipoprotein cholesterol (LDL-C) levels consistent with CETP lipid transfer activity and its role in reverse cholesterol transport (RCT). This coincides with putative beneficial increases in both HDL and LDL size. However, many aspects regarding the impact of CETP inhibition on the RCT pathway remain elusive, in particular whether the first step concerning cholesterol efflux from peripheral tissues to HDL is influenced. Moreover, the relevance of scavenger receptor BI and consequently the central role of HDL in human RCT is still unclear. Second, CETP inhibition was shown recently to increase antioxidant enzymes associated with HDL, in turn associated with decreased oxidation of LDL. Atheroprotection in man is currently anticipated based on the improvement of these biochemical parameters known to influence atherosclerosis, but final confirmation regarding the impact of CETP inhibition on cardiovascular outcome will have to come from trials evaluating clinical end points. [TGs]) between lipoproteins, and the causes and effects of natural variation in CETP activity, has been the subject of many reviews on CETP and CETP inhibition. 1-6 Therefore, we have chosen to summarize the current understanding of lipoprotein remodeling by CETP ( Figure, 1 and 2). Importantly, in dyslipidemias characterized by increased concentrations of TG-rich particles (mainly very low-density lipoprotein [VLDL] and VLDL remnants), the CE transfer from HDL shifts from LDL toward VLDL, particularly large VLDL1 (Figure, 2). 7,8 This is considered to be atherogenic because CE-enriched VLDLs become substrates for hepatic lipase (HL), resulting in the generation of deleterious small Simplified schematic representation of the effects of CETP inhibition on the RCT pathway and protection against inflammation and oxidation. The numbered flashes indicate impact areas of CETP inhibition, which are further detailed in the respective panels. Flashes with upward or downward arrows indicate upregulation and downregulation, respectively. Black arrows indicate transfer of free cholesterol (FC), CE, or TG; open arrows ...