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(Stroke. 1995;26:743-748.)
© 1995 American Heart Association, Inc.

Articles

Relation of Coronary Atherosclerosis and Apolipoprotein E Genotypes in Alzheimer Patients

O. Kosunen, MD; S. Talasniemi, MD; M. Lehtovirta, MD; O. Heinonen, PhD; S. Helisalmi, MSci; A. Mannermaa, MSci; L. Paljärvi, MD, PhD; M. Ryynänen, MD, PhD; P.J. Riekkinen, Sr, MD, PhD H. Soininen, MD, PhD

From the Departments of Pathology (O.K., L.P.) and Neurology (M.L., O.H., P.J.R., H.S.) and the Unit of Clinical Genetics (S.H., A.M, M.R.) of the Department of Gynecology and Obstetrics, Kuopio University Hospital, University of Kuopio; and the Harjula Hospital (S.T.), Kuopio, Finland.

Correspondence to Dr Hilkka Soininen, MD, PhD, Department of Neurology, University of Kuopio, PO Box 1627, 70 211 Kuopio, Finland.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose Apolipoprotein E (apoE) 4 allele has been associated with a high risk for coronary heart disease. Increased frequency of the 4 allele has also been reported in patients with late-onset familial and sporadic Alzheimer's disease (AD). The aim of this study was to investigate the degree of coronary and cerebral atherosclerosis in a neuropathologically verified series of AD patients with different apoE genotypes. In addition, we studied the relationship between the degree of coronary and cerebral atherosclerosis and the extent of ß-amyloid (Aß) accumulation.

Methods We studied 38 subjects (32 patients with definite AD and 6 age-matched control subjects) for whom postmortem autopsy delay was less than 8 hours. ApoE genotypes were identified through Hha I digestion of the polymerase chain reaction–amplified samples. We used Aß immunohistochemistry to detect diffuse and neuritic plaques as well as cerebrovascular amyloid. The degree of coronary and cerebral atherosclerosis was rated as none, mild, moderate, or severe.

Results The apoE genotypes of the AD patients were 4/4 2, 3/4 19, 3/3 9, and 3/2 2. We found more severe atherosclerosis of the coronary vessels among AD patients with the apoE 4 allele compared with those AD patients without the 4 allele (²=4.1, df=1, P<.05). The extent of cerebral atherosclerosis did not differ among AD subgroups with and without the 4 allele. The degree of coronary or cerebral atherosclerosis was not related to the amount of amyloid accumulation in the frontal and temporal cortices or in the hippocampal structures.

Conclusions This study confirms the association of apoE 4 allele with coronary atherosclerosis in AD patients.

Key Words: Alzheimer's disease • apolipoproteins • atherosclerosis

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Recent studies have indicated that the apolipoprotein E (apoE) allele 4 is a risk factor for both familial and sporadic late-onset Alzheimer's disease (AD).^{1 2 3 4 5 6 7 8} The association of the 4 allele with AD also has been confirmed in a large combined series of autopsy-documented sporadic AD patients.² In late-onset families, risk of AD increased from 20% to 90%, and the mean age of onset decreased with an increasing number of apoE 4 alleles.⁵ An earlier study has proposed that there is linkage of late-onset familial AD to the proximal long arm of chromosome 19 at the region where the apoE gene is localized.⁹

ApoE has been demonstrated by using immunohistochemistry in senile plaques, neurofibrillary tangles, and cerebrovascular amyloid in brain of AD patients.^{10 11} Furthermore, the in vitro binding of apoE of the cerebrospinal fluid to synthetic ß-amyloid protein (Aß) suggests that apoE might be involved in the pathogenesis of AD.¹ Indeed, two studies have indicated that AD patients with the 4 allele have higher counts of amyloid plaques and cerebrovascular amyloid.^{7 12} In addition, the importance of apoE for the nervous system is suggested by its role in the growth and regeneration of both peripheral and central nervous system tissues during development and after various types of injury. In the central nervous system, astrocytes synthesize apoE in response to injury of brain tissue.¹³

ApoE is a plasma protein that binds to the low-density lipoprotein receptor and is involved in the transport of cholesterol and other lipids in various cells of the body.¹⁴ ApoE is a polymorphic protein defined by three alleles, 2, 3, and 4, resulting in six genotypes, 2/2, 2/3, 2/4, 3/3, 3/4, and 4/4. Subjects with the 4 allele have higher levels of total and low-density lipoprotein cholesterol¹⁵ and a higher risk for myocardial infarction and coronary heart disease than those with apoE 3/3.^{16 17}

Sparks and coworkers¹⁸ reported that nondemented patients dying with or as a result of critical coronary artery disease had more abundant senile plaques compared with subjects without heart disease. Recent results by Abe et al¹⁹ showed that hypoxia led to increased expression of ß-amyloid precursor protein in rat brain. Furthermore, studies of AD patients have suggested that there is a consistent relationship between neuronal and vascular pathology, supporting an active role for vascular basement membrane in the pathogenesis of AD.²⁰ A recent study on the presence of Aß immunopositivity in the skin of dementia patients showed that the multi-infarct dementia patients with positive endothelial staining in dermal blood vessels had a higher ischemic score compared with multi-infarct dementia patients with no Aß reactivity in their skin biopsy sample.²¹ Thus, data are accumulating to support a possible contribution of vascular mechanisms in Aß accumulation.

This work is part of a larger study aimed at investigating the pathogenesis of AD. We wanted to examine the relation of apoE genotype and atherosclerosis in patients with definite neuropathologically confirmed AD. Furthermore, we studied the relationship between the degree of atherosclerosis in coronary and cerebral vessels and counts of Aß-immunopositive plaques in the frontal and temporal cortices as well as in the hippocampus.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Patients and Control Subjects
The AD patients were derived from a follow-up study of hospitalized patients with AD and patients with vascular dementia that was started in 1991. Initially, the study population consisted of 100 dementia patients and 19 control subjects. Sixty-three of the dementia patients fulfilled the criteria of probable AD of the National Institute of Neurological Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association.²² By the end of 1993, 55 dementia patients had died, and autopsy was performed for 53 (96%) of them. Thirty-two patients had definite AD and fulfilled the criteria of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD)²³ without evidence of any other pathological changes in the brain possibly contributing to dementia. These 32 definite AD cases were included in the present study. Two of 19 control subjects died during the follow-up, and autopsies were performed. Furthermore, we included 4 control case subjects without history of dementia or neurological or psychiatric disease and with no or only negligible numbers of plaques or tangles in the neocortex and hippocampus detected by silver staining. Table 1 presents the clinical data for the subjects.

View this table: [in this window] [in a new window]   Table 1. Clinical Characteristics of Study Subjects

All the study subjects, except for these 4 control subjects, underwent the following evaluations: medical history; examination of medical records; clinical neurological examination including assessment of clinical severity with the Mini-Mental State Examination,²⁴ activities of daily living with Blessed score,²⁵ extrapyramidal sign with Webster's scale,²⁶ and depressive symptoms with Hamilton's scale²⁷ ; modified ischemic score²⁸ ; neuropsychological tests; electroencephalography; and cerebrospinal fluid examination. The clinical diagnosis of coronary heart disease, cardiac insufficiency, valvular heart disease, atrial fibrillation, and/or hypertension was accepted when it was present in the medical records. For the 4 control subjects, the history of cardiovascular diseases was based on the medical records.

The study was approved by the ethics committee of the University Hospital and the University of Kuopio. The subjects or a close relative gave informed consent for participation in the study.

Autopsy
Postmortem delay was less than 8 hours in all subjects. To determine the degree of ischemic heart disease, coronary arteries were opened using scissors, or if this was not possible due to severe hardening, serial cross sections were cut. Coronary sclerosis was scored as follows: 0, none; 1, mild (<25% stenosis); 2, moderate (25% to 75% stenosis); and 3, severe (>75% stenosis). The myocardium was cut at 1-cm intervals, and scars and fresh infarctions were noted. In uncertain cases, findings were confirmed by histological samples. Sclerosis of cerebral arteries also was scored subjectively from 0 to 3. Sclerosis was considered mild (score of 1) if only a few nonstenosing atheromas were found and severe (score of 3) if stenosing atheromas appeared in several arterial trunks; intermediate cases were scored as moderate (score of 2). Infarctions in the brain tissue were examined in 1- to 1.5-cm-thick coronal sections.

Neuropathological Diagnosis of Alzheimer's Disease
Modified Bielschowsky's silver impregnation staining was used to detect plaques and tangles. Congo red staining was also used for rating cerebrovascular amyloid. The diagnosis of definite AD was based on the guidelines reported in the CERAD criteria.² In the control subjects included in the study, only occasional or no plaques or tangles were demonstrated by silver staining in the neocortex or in the hippocampus.

ß-Amyloid Immunohistochemistry
Brain Samples
Formalin-fixed (4%, overnight) 5-µm sections from the frontal and temporal cortices and hippocampal formation (including the dentate gyrus, the hippocampus proper, the subicular complex, and the entorhinal cortex) of 22 definite AD patients were stained with mouse antibody to human ß-amyloid (anti-Aß) (6F/30, Dako, 0.13 µg/mL). The sections were incubated in 90% formic acid for 10 minutes to intensify the staining. Endogenous peroxidase activity was blocked by using 5% hydrogen peroxide for 5 minutes. Normal horse serum (1:67, Vector) was used to inhibit nonspecific staining. Sections were incubated with biotinylated anti-mouse serum (made in horse, 1:200, Vector) for 30 minutes followed by incubation in avidin-biotin-peroxidase complex (Vectastain ABC standard kit, Vector) for 40 minutes. Immunoperoxidase reaction was developed using 0.05% 3,3'-diaminobenzidine (DAB; Sigma) and 0.03% hydrogen peroxide for 5 minutes. Between different steps, the sections were thoroughly washed in phosphate-buffered saline, pH 7.4. Sections were counterstained in Mayer's hematoxylin and eosin, dehydrated, mounted with DePex (BDH Laboratory Supplies Poole), and covered by coverslips. For control staining of each case, the primary serum was omitted; otherwise the procedure was the same.

Quantification of ß-Amyloid Immunopositive Plaques
We used a Nikon Optiphot-2 microscope, x10 or x20 plan objectives, x10 oculars, and an ocular craticule (Nikon Corporation) for quantification of Aß immunopositivity. The numbers of Aß-immunoreactive diffuse and compact neuritic plaques were counted separately per square millimeter in layers 3 and 5 of the frontal and temporal cortices and in the hippocampus, hilus, the CA3 area, the CA1 area, and the subiculum, as well as layers 2, 3, and 4-5 of the entorhinal cortex. The Aß immunoreactivity in meningeal and parenchymal cerebral blood vessel walls was evaluated as positive or negative. Immunostainings were performed and measured before the determination of apoE genotypes.

Determination of Apolipoprotein E Genotype
Genomic DNA Extraction and Polymerase Chain Reaction Amplification
Samples of 10 mL venous blood were collected in EDTA tubes. DNA was extracted by the standard phenol-chloroform extraction.²⁹ In 10 definite AD patients, blood was unavailable, and sections of freshly frozen cerebellum were used. DNA extraction of tissue was carried out by conventional methods after pulverizing the tissue with liquid nitrogen and mortar.³⁰ ApoE genotypes were analyzed using polymerase chain reaction (PCR) as described earlier^{31 32} with slight modifications. In brief, the amplification reaction, at a volume of 50 µL, consisted of 400 ng of genomic DNA, 25 pmol of each primer, 200 µmol/L of each deoxynucleoside triphosphate, and 1.5 U of Taq DNA polymerase (Promega). The buffer concentration was as recommended by the manufacturer (Promega). To relax secondary DNA structures, dimethyl sulfoxide was added to a final concentration of 5%. The samples were denatured at 96°C for 15 minutes before addition of the Taq DNA polymerase. The following cycling reaction conditions were repeated 35 times: denaturing at 96°C for 2 minutes, annealing at 60°C for 2.2 minutes, and extending at 73°C for 2.5 minutes. The reaction was terminated with an extra primer extension step at 73°C for 10 minutes.

Identification of Apolipoprotein E Genotypes Through Hha I Digestion of the Polymerase Chain Reaction–Amplified Samples
Eighteen microliters of the PCR products were digested with 8 U of Hha I (New England Biolabs) at 37°C for at least 3 hours. Digested DNA fragments were analyzed through a 0.5-mm 10% nondenaturing polyacrylamide gel containing 5% glycerol. Electrophoresis was performed at 400 V for 120 minutes in a Protean II apparatus (Bio-Rad). Separated DNA fragments were visualized through ethidium bromide staining.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The apoE genotypes of the AD patients were 2 4/4, 19 3/4, 9 3/3, and 2 3/2, giving allele frequencies 4 0.36, 3 0.61, and 2 0.03. The frequency of 4 allele among the AD patients was significantly higher compared with the value of 0.11 found earlier in a series of 38 neuropsychologically tested, nondemented control subjects with a mean±SD age of 76±9 years (z=2.7, P=.006). Five neuropathologically examined control subjects were 3/3 homozygotes, and one had 3/4 genotype, resulting in an allele frequency of 0.92 for 3 and 0.08 for 4. There was no significant difference in age among the control subjects and AD patients with or without apoE 4 allele. Only two AD patients were 4 homozygotes: a 79-year-old woman aged 62 years at onset and an 81-year-old woman aged 67 years at onset. Before death, all AD patients were severely demented. The AD groups with or without apoE 4 allele did not differ in clinical severity as assessed by Mini-Mental State Examination scores, activities of daily living estimated by Blessed scores, occurrence of extrapyramidal signs assessed by Webster score, depressive symptoms evaluated by Hamilton score, or in the ischemic score.

History of Cardiovascular and Cerebrovascular Diseases
Because there were only two AD patients with 4/4 genotype, the statistical analysis was performed across the two AD subgroups with and without 4 allele. The occurrence of cardiac insufficiency differed significantly between these two AD subgroups (²=4.7, df=1, P<.05). The presence of clinical coronary heart disease, atrial fibrillation, or hypertension did not differ between the AD subgroups. Cardiovascular disorders were most common among the 4 heterozygote AD patients; seven had cardiac insufficiency and seven had coronary heart disease. The 4 homozygotes had no history of cardiovascular diseases; one, however, died of acute myocardial infarction. One 3/4 and one 3/3 AD patient had a history of stroke (Table 2).

View this table: [in this window] [in a new window]   Table 2. History of Cardiovascular Diseases and Postmortem Cardiovascular Changes in Control Subjects and Alzheimer Patients With Different Apolipoprotein E Genotypes

Postmortem Examination
The causes of death for AD patients were bronchopneumonia (23), myocardial infarction (2), other infection (2), pulmonary embolism (2), cancer (1), gastrointestinal disorder (1), and dementia (1). The control subjects died of bronchopneumonia (2), myocardial infarction (2), esophageal cancer (1), and gastrointestinal disorder (1).

The mean heart weights were 465±167 g for control subjects, 295±42 g for AD 4/4, 317±106 g for AD 3/4, and 277±38 g for AD 3/3. ANOVA and Duncan's test across the study groups (F[3,35]=7.1, P<.01) showed that there were higher heart weights for control subjects compared with AD patients with and without the 4 allele. However, AD patients with and without the 4 allele did not differ significantly.

Severe coronary atherosclerosis was detected in six AD 3/4 patients but in none of the AD 4/4 or 3/3 genotypes. The AD patients carrying one or two 4 alleles more often had severe coronary sclerosis compared with AD patients with no 4 allele (²=4.1, df=1, P<.05) (Table 3). Two 3/4 AD patients and one 3/3 AD patient had an occlusion in at least one coronary artery. Two of the AD patients with 4 allele died of acute myocardial infarct, and five had pathological signs of an old myocardial infarct compared with one new and one old infarct in the AD 3/3 group.

Hypertrophy of the left ventricle was detected in 9 of 19 (47%) AD 3/4 patients and in 1 of 11 (9%) 3/3 patients (²=3.8, df=1, P=.05; AD patients with versus those without the 4 allele). There was no significant difference in the presence of stenotic changes or calcifications in aortic or mitral valvulae among AD patients with different apoE genotypes. The degree of atherosclerosis in the aorta, other large arteries, or carotid, vertebral, or cerebral arteries also did not differ significantly between AD patients with and without 4.

Coronary and Cerebral Atherosclerosis and ß-Amyloid Accumulation
We analyzed the counts of Aß-immunopositive diffuse and neuritic plaques in layers 3 and 5 of the frontal and temporal cortices, the CA3 and CA1 sections of the hippocampus, and in layers 2 and 4 of the entorhinal cortex in two AD subgroups: (1) patients with no or mild coronary sclerosis and (2) patients with moderate or severe coronary sclerosis (Figure). The numbers of Aß-immunoreactive diffuse or neuritic plaques did not differ between these subgroups. The control subjects had negligible amounts of diffuse plaques in the regions of interest. In addition, we found no association between the counts of Aß-positive plaques and the atherosclerosis of the cerebral vessels. There was no significant association between the degree of the coronary or cerebral atherosclerosis and the extent of Aß immunoreactivity in parenchymal or meningeal cerebral blood vessels.

View larger version (33K): [in this window] [in a new window]   Figure 1. Bar graph shows numbers of ß-amyloid immunoreactive diffuse plaques in layers 3 and 5 of the frontal (FC) and temporal (TC) cortices, the CA1 area, the subiculum (SUB) of the hippocampus, and layers 2 and 4 of the entorhinal cortex (EC) for Alzheimer patients with no or mild and moderate or severe coronary atherosclerosis. There is no significant difference between these subgroups. Control subjects showed only low amounts of diffuse plaques in the areas of interest.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
An association of increased frequency of apolipoprotein 4 with coronary artery disease has been reported earlier in different ethnic groups such as Finnish,^{17 33} Scottish,³⁴ Australian,³⁵ American,³⁶ and Japanese³⁷ cohorts. Contrary results also exist; a study in American males who died after an accident³⁸ failed to confirm this association. The present study focused on patients with definite AD. Increased frequency of 4 among both sporadic and familial AD patients compared with control subjects has been found in several studies. The 4 frequency of 0.36 in our study in a neuropathologically confirmed series of AD patients is comparable with that found in earlier reports.^{1 2 3 4 5 6 7 8} Our major finding is that the AD patients carrying the 4 allele suffered significantly more often from severe coronary sclerosis compared with the AD patients without 4. The degree of atherosclerosis of cerebral vessels did not differ among AD patients with different apoE genotypes. We found no association between the extent of coronary or cerebral atherosclerosis and counts of Aß-immunopositive plaques or cerebrovascular amyloid.

Previous studies on the 4 allele as a risk factor for coronary disease have focused mainly on middle-aged patient populations.^{17 33 34 35 36 37 38} Our study showed that the 4 allele also is associated with coronary atherosclerosis in elderly AD patients. Most of our patients carrying the 4 allele were heterozygous. Only two of them were homozygous for 4; one died of acute myocardial infarction and had mild coronary atherosclerosis, and the other had no coronary sclerosis. Previous studies have also shown that age contributes significantly to 4 allele frequencies. A study on Finnish middle-aged men³³ reported an 4 frequency of 24.4% that exceeds the 4 frequency found in our elderly control subjects (11%; unpublished observation, 1994) and frequencies reported in many other ethnic populations.³⁹ Recently, a study in a healthy Swedish population reported that the 4 allele frequency decreased with age and was 14.7% in subjects older than 60 years.⁴⁰ In addition, a study on 338 French centenarians showed that the 4 allele frequency was significantly decreased (5.2% versus 11.2%), whereas the 2 allele frequency was significantly increased (12.8% versus 6.8%) in the centenarian group compared with 161 control subjects aged from 20 to 70 years.⁴¹ These studies suggest that fewer bearers of 4 survive to extreme old age.

In contrast to coronary atherosclerosis, we found no association between the extent of atherosclerosis in cerebral vessels and apoE genotypes. Two earlier studies reported no association between increased 4 allele frequency and ischemic cerebrovascular disease,^{42 43} whereas the study by Pedro-Botet et al⁴⁴ suggested that the 4 allele could be a predisposing genetic marker also for cerebrovascular disease. In the present study, only two AD patients had a history of stroke, which they experienced during their dementing illness. We want to emphasize that our patient population was selected; we excluded all case subjects in whom cerebrovascular disease might be a significant contributor to dementia. This is always the case in AD research when the aim is to identify "pure" AD patients with no other diseases. The selection and exclusion of AD patients with major cerebrovascular disease may bias the results and partly explain the fact that we found an association between the 4 allele and severe coronary atherosclerosis but not between the 4 allele and cerebrovascular atherosclerosis. A recent study from Japan suggested that the 4 allele frequency is also increased in multi-infarct dementia.⁴ They reported a significantly higher 4 allele frequency for 38 AD patients (28%) and for 26 multi-infarct dementia patients (21%) than for 584 nondemented control subjects (9%). We need, however, to keep in mind the possible coexistence of AD and vascular dementia when interpreting the data in a clinically diagnosed series.

The apoE polymorphism modulates the metabolism of lipoproteins, and increased levels of total and low-density lipoprotein cholesterol have been found to be associated with the 4 allele.^{17 36 45} In addition to the role of apoE in the lipid metabolism, other effects of apoE may influence the development of coronary atherosclerosis, such as involvement of apoE in regenerative processes⁴⁶ and the immune system (for review, see Reference 45). Moreover, in a multifaceted disorder such as atherosclerosis, several other independent factors (eg, smoking and altered glucose metabolism) may contribute to the end result of coronary heart disease. In this study, lipoprotein levels were not available.

The failure to show any association between the degree of coronary or cerebral atherosclerosis and the extent of amyloid accumulation suggests that, at least in definite AD, atherosclerosis is not a major contributor to Aß deposition. In the interpretation of this result, we need to note the selection of our patient material and exclusion of all patients with marked cerebrovascular disorders. In addition, in this study we counted the absolute numbers of Aß deposits, but this does not necessarily demonstrate the amyloid load in a distinct brain area.

	Acknowledgments

 
This study was supported by The Medical Research Council of the Academy of Finland. The authors thank Seija Hynynen and Pasi Hakulinen, BSci, for skillful technical help.

Received January 10, 1995; accepted February 17, 1995.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 
1. Strittmatter WJ, Saunders AM, Schmechel D, Pericak-Vance M, Enghild J, Salvesen G, Roses AD. Apolipoprotein E: high-avidity binding to ß-amyloid and increased frequency of type 4 allele in late-onset familial Alzheimer's disease. Proc Natl Acad Sci U S A. 1993;90:1977-1981. [Abstract/Free Full Text]

2. Saunders AM, Strittmatter WJ, Schmechel D, St George-Hyslop PH, Pericak-Vance MA, Joo SH, Rosi BL, Gusella JF, Grapper-McLachlan DR, Alberts MJ, Hulette C, Crain B, Goldgaber D, Roses AD. Association of apolipoprotein E allele 4 with late-onset familial and sporadic Alzheimer's disease. Neurology. 1993;43:1467-1472. [Abstract/Free Full Text]

3. Poirier J, Davignon J, Bouthillier D, Kogan S, Betrand P, Gauthier S. Apolipoprotein polymorphism and Alzheimer's disease. Lancet. 1993;342:697-699. [Medline] [Order article via Infotrieve]

4. Noguchi S, Murakami K, Yamada N. Apolipoprotein genotype and Alzheimer's disease. Lancet. 1993;342:737. Letter. [Medline] [Order article via Infotrieve]

5. Corder EH, Saunders AM, Strittmatter WJ, Schmechel DE, Gaskell PC, Small GW, Roses AD, Haines JL, Pericak-Vance MA. Gene dose of apolipoprotein E type 4 allele and the risk of Alzheimer's disease in late onset families. Science. 1993;261:921-923. [Abstract/Free Full Text]

6. Mayeux R, Stern Y, Ottman R, Tatemichi TK, Tang MX, Maestre G, Ngai C, Tycko B, Ginsberg H. The apolipoprotein 4 allele in patients with Alzheimer's disease. Ann Neurol. 1993;34:752-754. [Medline] [Order article via Infotrieve]

7. Rebeck GW, Reiter JS, Strickland DK, Hyman BT. Apolipoprotein E in sporadic Alzheimer's disease: allelic variation and receptor interactions. Neuron. 1993;11:575-580. [Medline] [Order article via Infotrieve]

8. Saunders AM, Schmader K, Breitner JCS, Benson MD, Brown WT, Goldfarb L, Goldgaber D, Manwaring MG, Szymanski MH, McCown N, Dole KC, Schmechel DE, Strittmatter WJ, Pericak-Vance MA, Roses AD. Apolipoprotein E 4 allele distributions in late-onset Alzheimer's disease and in other amyloid-forming diseases. Lancet. 1993;342:710-711. [Medline] [Order article via Infotrieve]

9. Pericak-Vance MA, Bebout JL, Gaskell PC Jr, Yamaoka LH, Hung W-Y, Alberts MJ, Walker AP, Bartlett RJ, Haynes CA, Welsh KA, Earl NL, Heyman A, Clark CM, Roses AD. Linkage studies in familial Alzheimer's disease: evidence for chromosome 19 linkage. Am J Hum Genet. 1991;48:1034-1050. [Medline] [Order article via Infotrieve]

10. Namba Y, Tomonaga M, Kawasaki H, Otomo E, Ikeda K. Apolipoprotein E immunoreactivity in cerebral amyloid deposits and neurofibrillary tangles in Alzheimer's disease and kuru plaque amyloid in Creutzfeldt-Jacob disease. Brain Res. 1991;541:163-166. [Medline] [Order article via Infotrieve]

11. Wisniewski T, Frangione B. Apolipoprotein E: a pathological chaperone protein in patients with cerebral and systemic amyloid. Neurosci Lett. 1992;135:235-238. [Medline] [Order article via Infotrieve]

12. Schmechel DE, Saunders AM, Strittmatter WJ, Crain BJ, Hulette CM, Joo SH, Pericak-Vance MA, Goldgaber D, Roses AD. Increased amyloid ß-peptide deposition as a consequence of apolipoprotein E genotype in late-onset Alzheimer's disease. Proc Natl Acad Sci U S A. 1993;90:9649-9653. [Abstract/Free Full Text]

13. Poirier J, Hess M, May P, Finch CE. Apolipoprotein E- and GFAP-RNA in hippocampus during reactive synaptogenesis and terminal proliferation. Mol Brain Res. 1991;11:97-106. [Medline] [Order article via Infotrieve]

14. Mahley RW. Apolipoprotein E: cholesterol transport protein with expanding role in cell biology. Science. 1988;240:622-630. [Abstract/Free Full Text]

15. Utermann G, Kindermann I, Kaffarnik H, Steinmetz A. Apolipoprotein E phenotypes and hyperlipidemia. Hum Genet. 1984;65:232-236. [Medline] [Order article via Infotrieve]

16. Menzel HJ, Kladetzky RG, Assmann G. Apolipoprotein E polymorphism and coronary heart disease. Atherosclerosis. 1983;3:310-315.

17. Laakso M, Kesäniemi A, Kervinen K, Jauhiainen M, Pyörälä K. Relation of coronary heart disease and apolipoprotein E phenotype in patients with non-insulin dependent diabetes. Br Med J. 1991;303:1159-1162.

18. Sparks DL, Hunsaker JC, Scheff SW, Kryscio RJ, Henson JL, Markesbery WR. Cortical senile plaques in coronary artery disease, aging and Alzheimer's disease. Neurobiol Aging. 1990;11:601-607. [Medline] [Order article via Infotrieve]

19. Abe K, Tanzi RE, Kogure K. Selective induction of Kunitz-type protease inhibitor domain containing amyloid precursor protein mRNA after persistent focal ischemia in rat cerebral cortex. Neurosci Lett. 1991;125:172-174. [Medline] [Order article via Infotrieve]

20. Perlmutter LS, Chui CH. Microangiopathy, the vascular basement membrane and Alzheimer's disease: a review. Brain Res Bull. 1990;24:677-786. [Medline] [Order article via Infotrieve]

21. Soininen H, Syrjänen S, Heinonen O, Neittaanmäki H, Miettinen R, Paljärvi L, Syrjänen K, Beyreuther K, Riekkinen P Sr. Amyloid-ß-protein deposition in skin of patients with dementia. Lancet. 1992;339:245. Letter.

22. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer's disease. Neurology. 1984;34:939-944. [Abstract/Free Full Text]

23. Mirra SS, Heyman A, McKeel D, Sumi SM, Crain BJ, Brownlee LM, Vogel FS, Hughes JP, van Belle G, Berg L, participating CERAD neuropathologists. The Consortium to Establish a Registry for Alzheimer's disease (CERAD), II: standardization of the neuropathologic assessment of Alzheimer's disease. Neurology. 1991;41:479-486. [Abstract/Free Full Text]

24. Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198. [Medline] [Order article via Infotrieve]

25. Blessed G, Tomlinson BE, Roth M. The association between quantitative measures of dementia and of senile change in the cerebral gray matter of elderly subjects. Br J Psychiatry. 1968;114:797-811. [Abstract/Free Full Text]

26. Webster DD. Clinical analysis of the disability on Parkinson's disease. Mod Treat. 1968;5:257-262. [Medline] [Order article via Infotrieve]

27. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.

28. Rosen WG, Terry RD, Fuld PA, Katzman R, Beck A. Pathological verification of ischemic score in differentiation of dementias. Ann Neurol. 1980;17:486-488.

29. Vandenplas S, Grobler-Rabie A, Brebner K, Ricketts M, Wallis G, Bester A, Boyd C, Mathew C. Blot hybridization of genomic DNA. J Med Genet. 1984;21:164-172. [Abstract/Free Full Text]

30. Maniatis T, Fritsch EF, Sambrook J. A Laboratory Manual. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory; 1982.

31. Hixon JE, Vernier DT. Restriction isotyping of human apolipoprotein E by gene amplification and cleavage with HhaI. J Lipid Res. 1990;31:545-548. [Abstract]

32. Tsukamoto K, Watanabe T, Matsushima T, Kinoshita M, Kato H, Hashimoto Y, Kurokawa K, Teramoto T. Determination by PCR-RFLP of apoE genotype in a Japanese population. J Lab Clin Med. 1993;121:598-602. [Medline] [Order article via Infotrieve]

33. Enholm C, Lukka M, Kuusi T, Nikkilä E. Apolipoprotein E polymorphism in the Finnish population: gene frequencies and relation to lipoprotein concentrations. J Lipid Res. 1986;27:227-235. [Abstract]

34. Cumming AM, Robertson F. Polymorphism at the apoE locus in relation to risk of coronary heart disease. Clin Genet. 1984;25:310-313. [Medline] [Order article via Infotrieve]

35. Van Bockxmeer FM, Mamotte CDS. Apolipoprotein 4 homozygosity in young men with coronary heart disease. Lancet. 1992;340:879-880. [Medline] [Order article via Infotrieve]

36. Eichner JE, Kuller LH, Orchard TJ, Grandits GA, McCallum LM, Ferrell RE, Neaton JD. Relation of apolipoprotein E phenotype to myocardial infarction and mortality from coronary heart disease. Am J Cardiol. 1993;71:160-165. [Medline] [Order article via Infotrieve]

37. Eto M, Watanabe K, Makino I. Increased frequencies of apolipoprotein E2 and E4 alleles in patients with ischemic heart disease. Clin Genet. 1989;39:183-189.

38. Hixson JE, P-DAY Research Group. Apolipoprotein E polymorphisms affect atherosclerosis in young males. Arterioscler Thromb. 1991;11:1237-1244. [Abstract/Free Full Text]

39. Hallman DM, Boerwinkle E, Saha N, Sandholzer C, Menzel HJ, Csázár A, Uterman G. The apolipoprotein E polymorphism: a comparison of allele frequencies and effects in nine populations. Am J Hum Genet. 1991;49:338-349. [Medline] [Order article via Infotrieve]

40. Eggertsen G, Tegelman R, Ericsson S, Angelin B, Berlund L. Apolipoprotein polymorphism in a healthy Swedish population: variation of allele frequency with age and relation to serum lipid concentrations. Clin Chem. 1993;39:2125-2129. [Abstract]

41. Schächter F, Faure-Delanef L, Guénot F, Rouger H, Froguel P, Lesueur-Ginot L, Cohen D. Genetic association with human longevity at the APOE and ACE loci. Nat Genet. 1994;6:29-32. [Medline] [Order article via Infotrieve]

42. Saunders AM, Roses AD. Apolipoprotein E4 allele frequency, ischemic cerebrovascular disease, and Alzheimer's disease. Stroke. 1993;24:1416. Letter. [Free Full Text]

43. Couder R, Mahieux F, Bailleu S, Fenelon G, Mary R, Fermanian J. Prevalence of apolipoprotein phenotypes in ischemic cerebrovascular disease: a case control study. Stroke. 1993;24:661-664. [Abstract/Free Full Text]

44. Pedro-Botet J, Senti M, Nogues X, Rubies-Prat J, Roquer J, D'Olhaberriague L, Olive J. Lipoprotein and apolipoprotein profile in men with ischemic stroke: role of lipoprotein(a), triglyceride-rich lipoproteins, and lipoprotein E polymorphism. Stroke. 1992;23:1556-1562. [Abstract/Free Full Text]

45. Davignon J, Gregg RE, Sing CF. Apolipoprotein E polymorphism and atherosclerosis. Arteriosclerosis. 1988;8:1-21. [Abstract/Free Full Text]

46. Poirier J, Baccichet A, Dea D, Gauthier S. Cholesterol synthesis and lipoprotein reuptake during synaptic remodelling in hippocampus in adult rat. Neuroscience. 1993;55:81-90.[Medline] [Order article via Infotrieve]

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