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Supplementary key words high-density lipoprotein cholesterol • atherosclerosis • lipoproteins • epidemiology • European Prospective Investigation into Cancer and NutritionLCAT hydrolyzes the sn-2 acyl group of phosphatidylcholine and subsequently transfers and esterifi es the fatty acid to free cholesterol, thereby using apolipoprotein (apo) A-I as cofactor ( 1 ). The reaction products are thus cholesteryl ester (CE) and lysophosphatidylcholine. The vast majority of CE in the blood circulation is generated by this enzymatic reaction. LCAT is primarily active on HDL and as such drives the maturation of small nascent HDL discs to larger spherical HDL ( 2 ). In catalyzing the esterifi cation of free cholesterol, LCAT has been proposed to maintain a concentration gradient of free cholesterol from cells to HDL, thereby facilitating reverse cholesterol transport ( 3, 4 ). LCAT-defi cient patients present with almost complete HDL defi ciency because they are unable to form mature HDL, which in turn leads to a rapid clearance of nascent HDL from the circulation ( 2, 5 ).Based on our current understanding of HDL metabolism, it is not clear whether LCAT is pro-or antiatherogenic ( 6, 7 ): the generation of CE on HDL by LCAT can be regarded as anti-atherogenic since this action increases HDL cholesterol (HDL-C) levels, but in the presence of cholesteryl ester transfer protein (CETP) and triglyceride-rich lipoproteins, the CE will be transferred to apoBAbstract LCAT plays a key role in the maturation of HDL, as evidenced by low HDL-cholesterol levels in carriers of deleterious mutations in LCAT . However, the role of LCAT in atherosclerosis is unclear. We set out to study this in a prospective study. Plasma LCAT levels, which strongly correlate with LCAT activity, were measured in baseline nonfasting samples of 933 apparently healthy men and women who developed coronary artery disease (CAD) and 1,852 matched controls who remained free of CAD during 6 year follow-up. LCAT levels did not differ between cases and controls but were higher in women than men. Stratifi cation into LCAT quartiles revealed a positive association with plasma LDL-cholesterol and triglyceride levels in the unexpected absence of an association with HDL-cholesterol. In mixed-gender analyses, the odds ratio (OR) for future CAD in the highest LCAT quartile versus the lowest was 1.00 [confi dence interval (CI): 0.76-1.29, P for linearity = 0.902], although opposite trends were observed in men and women. In fact, high LCAT levels were associated with an increased CAD risk in women (unadjusted OR 1.45, CI: 0.94-2.22, P for linearity = 0.036). In contrast to our studies in carriers of LCAT mutations, the current data show that low LCAT plasma levels are not associated with increased atherosclerosis in the general population. -Holleboom, A. G., J. A. Kuivenhoven, M. Vergeer, G. K. Hovingh, J. N. van Miert, N. J. Wareham, J. J. P. Kastelein, K-T. Khaw, and S. M. Boekholdt . Plasma levels of lecithin:choleste...