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Background  Apolipoprotein E is a glycoprotein best known as a mediator and regulator of lipid transport and uptake. The  APOE- ε4 allele has long been associated with increased risks of Alzheimer's disease and mortality, but the effect of the less prevalent  APOE- ε2 allele on diseases in the elderly and survival remains elusive.    Methods  We aggregated data of 38,537 individuals of European ancestry (mean age 65.5 years; 55.6% women) from six population-based cohort studies (Rotterdam Study, AGES-Reykjavik Study, Cardiovascular Health Study, Health-ABC Study, and the family-based Framingham Heart Study and Long Life Family Study) to determine the association of  APOE , and in particular  APOE- ε2, with survival in the population.    Results  During a mean follow-up of 11.7 years, 17,021 individuals died. Compared with homozygous  APOE- ε3 carriers,  APOE- ε2 carriers were at lower risk of death (hazard ratio,95% confidence interval: 0.94,0.90–0.99;  P  = 1.1*10 −2 ), whereas  APOE- ε4 carriers were at increased risk of death (HR 1.17,1.12–1.21;  P  = 2.8*10 −16 ).  APOE  was associated with mortality risk in a dose-dependent manner, with risk estimates lowest for homozygous  APOE- ε2 (HR 0.89,0.74–1.08), and highest for homozygous  APOE- ε4 (HR 1.52,1.37–1.70). After censoring for dementia, effect estimates remained similar for  APOE- ε2 (HR 0.95,0.90–1.01), but attenuated for  APOE- ε4 (HR 1.07,1.01–1.12). Results were broadly similar across cohorts, and did not differ by age or sex.  APOE  genotype was associated with baseline lipid fractions (e.g. mean difference(95%CI) in LDL(mg/dL) for ε2 versus ε33: -17.1(-18.1–16.0), and ε4 versus ε33: +5.7(4.8;6.5)), but the association between  APOE  and mortality was unaltered after adjustment for baseline LDL or cardiovascular disease. Given the European ancestry of the study population, results may not apply to other ethnicities.    Conclusion  Compared with  APOE -ε3,  APOE- ε2 is associated with prolonged survival, whereas mortality risk is increased for  APOE- ε4 carriers. Further collaborative efforts are needed to unravel the role of  APOE  and in particular  APOE- ε2 in health and disease.

The impact of APOE genotype on survival: Results of 38,537 participants from six population-based cohorts (E2-CHARGE)