[Hyperlipoprotienemias and (not only) atherosclerosis: fragments from history and present]

The examples from the history, as well as the recent view, clearly demonstrate a great change in the perception of hyperlipoprotienemias and dyslipidemias (HLP and DLP) at the end of 20th and at the beginning of 21st century. Our aim is not a complex overview about HLP and DLP. We just want to describe the changing position and importance of these diseases in clinical medicine. We will touch cardiology, angiology, but also diabetology, hepatology and gastroenterology (pancreas). HLP and DLP, which started as a research topic in laboratory became clinically interesting as risk factors of atherosclerosis. They are understood as epidemic occurrence diseases, also in connection with metabolic syndrome. However, some of them, e.g. familial chylomicronemia or homozygous familial hypercholesterolemia fulfill criteria of rare diseases.

Two Patients with Familial Hypercholesterolemia Who Were Successfully Weaned from Low-density Lipoprotein Apheresis after Treatment with Evolocumab

Two elderly patients (a 76-year-old man and a 75-year-old woman), who had been previously diagnosed with familial hypercholesterolemia (at 58 and 48 years of age, respectively) underwent long-term treatment with oral therapy and low-density lipoprotein (LDL) apheresis. As their LDL cholesterol levels remained high (>150 mg/dL and >120 mg/dL, respectively) and their familial hypercholesterolemia was complicated with angina pectoris, we added evolocumab to their prescription. Thereafter, their LDL cholesterol levels decreased rapidly, and the patients were successfully weaned from LDL apheresis. Evolocumab therapy should thus be considered when LDL apheresis cannot achieve the target LDL cholesterol levels, though the prognosis of such treatment remains unclear.

The panorama of familial hypercholesterolemia in Latin America: a systematic review

The burden caused by familial hypercholesterolemia (FH) varies among countries and ethnic groups. The prevalence and characteristics of FH in Latin American (LA) countries is largely unknown. We present a systematic review (following the PRISMA statement) of FH in LA countries. The epidemiology, genetics, screening, management, and unique challenges encountered in these countries are discussed. Published reports discussing FH in Hispanic or LA groups was considered for analysis. Thirty studies were included representing 10 countries. The bulk of the data was generated in Brazil and Mexico. Few countries have registries and there was little commonality in FH mutations between LA countries. LDL receptor mutations predominate; APOB and PCSK9 mutations are rare. No mutation was found in an FH gene in nearly 50% of cases. In addition, some country-specific mutations have been reported. Scant information exists regarding models of care, cascade screening, cost, treatment effectiveness, morbidity, and mortality. In conclusion, FH is largely underdiagnosed and undertreated in the LA region. The genetic admixture with indigenous populations, producing mestizo's groups, may influence the mutational findings in Latin America. Potential opportunities to close gaps in knowledge and health care are identified.

Challenges in the health economics of familial hypercholesterolemia

PURPOSE OF REVIEW

Implementation of effective interventions often requires evidence regarding value, that is, whether they are worth what we pay for them. This review explores recent evidence concerning cost-effectiveness in familial hypercholesterolemia, and discusses the cause of, and likelihood of solutions to, the paucity of such evidence.

RECENT FINDINGS

Cost-effectiveness analysis in familial hypercholesterolemia has been limited almost exclusively to adult populations. However, there is growing evidence that childhood intervention offers substantial benefit in terms of downstream health gains. Statin therapy in adults has been demonstrated to be cost-effective, but the range of novel agents that might be used will require de novo economic evaluation alongside exploration of their effect and safety profile.

SUMMARY

The familial hypercholesterolemia field has limited evidence regarding cost-effectiveness, which limits optimum allocation of resources. Economic evaluations are necessary to appraise new agents and optimal timing of management approaches. Evaluations often have substantial data demands; consequentially, their applicability to medical decision-making or policy will be partly determined by the availability of data, particularly those providing information about the long-term trajectory of health benefit from familial hypercholesterolemia treatment.

Universal Cholesterol Screening in Childhood: A Systematic Review

BACKGROUND

In 2011, a US expert panel recommended universal cholesterol screening for children ages 9 to 11 years. Controversy exists over this recommendation, especially because the most recent systematic review on universal childhood screening was inconclusive.

OBJECTIVES

To conduct an updated systematic review on universal cholesterol screening in childhood and effect on health outcomes, clinical management, screening acceptability, and healthcare costs.

DATA SOURCES

We searched MedLine, EMBASE, Psychinfo, and the Cochrane Registry of Controlled Trials from October 2005 to January 2016. We added new studies identified to those from the previous systematic review (1966-September 2005).

STUDY ELIGIBILITY, PARTICIPANTS, AND INTERVENTIONS

We included controlled trials, pre-post, cohort, survey, and qualitative studies of universal cholesterol screening in children ages 0 to 18 years.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two independent reviewers assessed abstracts and full-text studies, extracted data, and ranked quality. Cost data were inflation-adjusted to 2015 dollars.

RESULTS

Nine new studies met inclusion criteria, taking the total number of relevant studies to 21. Screening was associated with no change in cholesterol in 1 of 1 study on health outcomes. A positive screen for dyslipidemia was associated with diet and/or exercise changes in 29% to 92% of families in 4 of 4 studies. Adherence with new guidelines for universal screening was low (16%-18%) in 3 of 3 studies. Costs per case of familial hypercholesterolemia detected were $12,500 to $20,300.

LIMITATIONS

Included studies were heterogeneous in outcomes.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Universal cholesterol screening might have small, positive effects on lifestyle change, but the effect on health remains understudied.

Defining severe familial hypercholesterolaemia and the implications for clinical management: a consensus statement from the International Atherosclerosis Society Severe Familial Hypercholesterolemia Panel

Familial hypercholesterolaemia is common in individuals who had a myocardial infarction at a young age. As many as one in 200 people could have heterozygous familial hypercholesterolaemia, and up to one in 300 000 individuals could be homozygous. The phenotypes of heterozygous and homozygous familial hypercholesterolaemia overlap considerably; the response to treatment is also heterogeneous. In this Review, we aim to define a phenotype for severe familial hypercholesterolaemia and identify people at highest risk for cardiovascular disease, based on the concentration of LDL cholesterol in blood and individuals' responsiveness to conventional lipid-lowering treatment. We assess the importance of molecular characterisation and define the role of other cardiovascular risk factors and advanced subclinical coronary atherosclerosis in risk stratification. Individuals with severe familial hypercholesterolaemia might benefit in particular from early and more aggressive cholesterol-lowering treatment (eg, with PCSK9 inhibitors). In addition to better tailored therapy, more precise characterisation of individuals with severe familial hypercholesterolaemia could improve resource use.

Screening for Lipid Disorders in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Elevations in levels of total, low-density lipoprotein, and non-high-density lipoprotein cholesterol; lower levels of high-density lipoprotein cholesterol; and, to a lesser extent, elevated triglyceride levels are associated with risk of cardiovascular disease in adults.

OBJECTIVE

To update the 2007 US Preventive Services Task Force (USPSTF) recommendation on screening for lipid disorders in children, adolescents, and young adults.

EVIDENCE REVIEW

The USPSTF reviewed the evidence on screening for lipid disorders in children and adolescents 20 years or younger--1 review focused on screening for heterozygous familial hypercholesterolemia, and 1 review focused on screening for multifactorial dyslipidemia.

FINDINGS

Evidence on the quantitative difference in diagnostic yield between universal and selective screening approaches, the effectiveness and harms of long-term treatment and the harms of screening, and the association between changes in intermediate outcomes and improvements in adult cardiovascular health outcomes are limited. Therefore, the USPSTF concludes that the balance of benefits and harms cannot be determined.

CONCLUSIONS AND RECOMMENDATION

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger. (I statement).

Progress in the care of common inherited atherogenic disorders of apolipoprotein B metabolism

Familial hypercholesterolaemia, familial combined hyperlipidaemia (FCH) and elevated lipoprotein(a) are common, inherited disorders of apolipoprotein B metabolism that markedly accelerate the onset of atherosclerotic cardiovascular disease (ASCVD). These disorders are frequently encountered in clinical lipidology and need to be accurately identified and treated in both index patients and their family members, to prevent the development of premature ASCVD. The optimal screening strategies depend on the patterns of heritability for each condition. Established therapies are widely used along with lifestyle interventions to regulate levels of circulating lipoproteins. New therapeutic strategies are becoming available, and could supplement traditional approaches in the most severe cases, but their long-term cost-effectiveness and safety have yet to be confirmed. We review contemporary developments in the understanding, detection and care of these highly atherogenic disorders of apolipoprotein B metabolism.

Systematic Review of Low-Density Lipoprotein Cholesterol Apheresis for the Treatment of Familial Hypercholesterolemia

BACKGROUND

Apheresis is an important treatment for reducing low-density lipoprotein cholesterol (LDL-C) in patients with familial hypercholesterolemia (FH). We systematically reviewed the current literature surrounding LDL-C apheresis for FH.

METHODS AND RESULTS

Electronic databases were searched for publications of LDL-C apheresis in patients with FH. Inclusion criteria include articles in English published in 2000-2013 that provide descriptions of practice patterns, efficacy/effectiveness, and costs related to LDL-C apheresis in patients with FH. Data were stratified by country and FH genotype where possible. Thirty-eight studies met the inclusion criteria: 8 open-label clinical trials, 11 observational studies, 17 reviews/guidelines, and 2 health technology assessments. The prevalence of FH was not well characterized by country, and underdiagnosis was a barrier to FH treatment. Treatment guidelines varied by country, with some guidelines recommending LDL-C apheresis as first-line treatment in patients with homozygous FH and after drug therapy failure in patients with heterozygous FH. Additionally, guidelines typically recommended weekly or biweekly LDL-C apheresis treatments conducted at apheresis centers that may last 2 to >3 hours per session. Studies reported a range for mean LDL-C reduction after apheresis: 57-75% for patients with homozygous FH and 58-63% for patients with heterozygous FH. Calculated annual costs (in US$2015) may reach US$66 374 to US$228 956 per patient for weekly treatment.

CONCLUSIONS

LDL-C apheresis treatment may be necessary for patients with FH when drug therapy is inadequate in reducing LDL-C to target levels. While apheresis reduces LDL-C, high per-session costs and the frequency of guideline-recommended treatment result in substantial annual costs, which are barriers to the optimal treatment of FH.

My Approach to the Patient With Familial Hypercholesterolemia

Familial hypercholesterolemia (FH), a relatively common Mendelian genetic disorder, is associated with a dramatically increased lifetime risk of premature atherosclerotic cardiovascular disease due to elevated plasma low-density lipoprotein cholesterol (LDL-C) levels. The diagnosis of FH is based on clinical presentation or genetic testing. Early identification of patients with FH is of great public health importance because preventive strategies can lower the absolute lifetime cardiovascular risk and screening can detect affected relatives. However, low awareness, detection, and control of FH pose hurdles in the prevention of FH-related cardiovascular events. Of the estimated 0.65 million to 1 million patients with FH in the United States, less than 10% carry a diagnosis of FH. Based on registry data, a substantial proportion of patients with FH are receiving no or inadequate lipid-lowering therapy. Statins remain the mainstay of treatment for patients with FH. Lipoprotein apheresis and newly approved lipid-lowering drugs are valuable adjuncts to statin therapy, particularly when the LDL-C-lowering response is suboptimal. Monoclonal antibodies targeting proprotein convertase subtilisin/kexin type 9 provide an additional approximately 60% lowering of LDL-C levels and are approved for use in patients with FH. For homozygous FH, 2 new drugs that work independent of the LDL receptor pathway are available: an apolipoprotein B antisense oligonucleotide (mipomersen) and a microsomal triglyceride transfer protein inhibitor (lomitapide). This review attempts to critically examine the available data to provide a summary of the current evidence for managing patients with FH, including screening, diagnosis, treatment, and surveillance.

Familial hypercholesterolaemia reduces the quality of life of patients not reaching treatment targets

INTRODUCTION

Familial hypercholesterolaemia (FH) is the most common monogenic disorder associated with premature cardiovascular disease. If untreated, life expectancy in heterozygous FH patients is shortened by 20-30 years compared with the general population. Nevertheless, treatment goals are only met in approximately 50% of patients. This comparative study examined the quality of life (QoL) impact of FH in patients who had and had not reached the target of treatment.

METHODS

Two qualitative focus group interviews were carried out with a total of ten FH patients. A semi-structured interview guide included questions identified in a preceding literature study. The data were analysed using a medical anthropological approach.

RESULTS

While having FH did not have much impact on well-treated patients' QoL, patients who had not reached the treatment target had markedly more concerns. They had experienced severe side-effects and worried about their own and their relatives' health. They were concerned about the long-term impact of not being effectively treated including the risk that coronary heart disease could cause their premature death or disability and inability to care for their children, in particular. The women had issues with stigma and self-efficacy.

CONCLUSIONS

The QoL impact of FH is related to treatment efficacy. These findings need to be addressed in the management of FH patients. Particular attention should be paid to those who are not presently reaching the target of treatment.

FUNDING

The study was funded by a research grant from Amgen.

TRIAL REGISTRATION

not relevant.

[New guidelines for screening and management of familial dyslipidemia]

Familial dyslipidemia, a frequent genetic cause of premature cardiovascular disease, is still underdiagnosed and undertreated. According to recent European studies, the prevalence of familial hypercholesterolemia is higher than previously suspected and reaches 1/200-300 persons, while familial combined hyperlipidemia affects 1-3% of the population. Screening is important, as familial dyslipidemia often leads to cardiovascular event before 60 years of age, and usual scores of risk are not appropriate for these patients. Screening is recommended in childhood in case of family history of premature cardiovascular disease or severe hyperlipidemia in first degree relatives. Lifestyle modifications, eviction of any additive cardiovascular risk factor and tailored drug therapy are the cornerstones of an optimal management.

[Hyperlipoproteinemia in children]

Hyperlipoproteinemia (HLP) is one of the most common metabolic disorder in childhood. We assume that 20 % of children have a disorder of the lipid metabolism. Some HLP are very common in the population, and moderate, and some are very rare, but are very severe. These may occur secondary to pathological conditions, or are formed on the basis of the primary monogenic or polygenic disorders of lipid metabolism. The detection of children with HLP in the Czech Republic is either random, or more often by selective screening of children with familial history of cardiovascular disease, provided by general pediatric practitioners for children and adolescents. Treatment in childhood is primarily dietetic, some of them, especially children with familial hypercholesterolemia are treated from 8-10 years pharmacologically.Key words: diagnosis - hyperlipoproteinemia - children - treatment.

[Severe familial hypercholesterolemia treatment]

Familial hypercholesterolemia (FH) represents the most frequent of inborn errors of metabolism. It is a group of disorders with a codominant mode of inheritance characterized by marked elevations of LDL-cholesterol as well as atherosclerotic cardiovascular disease risk. Clinical (phenotypic) picture of FH varies widely depending on genotype and concomitant risk factors. Identification of most seriously affected FH individuals is necessary for proper clinical management. The therapeutic approach must be complex and comprehensive. The corner stone of pharmacotherapy is high-intensity statin therapy usually combined with ezetimibe (possibly complemented with bile acid sequestrant). Even this multi-drug combination do not lead majority of patients to their treatment goals. Thus, combinations with other pharmacological (PCSK9 inhibitors, apoB-100 anti-sense therapy, MTP inhibition) and non-pharmacological (LDL-apheresis, liver transplantation) approaches is being used.Key words: ezetimibe - LDL-apheresis - lomitapide - mipomersen - PCSK9 inhibitors - severe familial hypercholesterolemia - statins.

[Hyperlipoproteinemia and dyslipidemia as rare diseases. Diagnostics and treatment]

Hyperlipoproteinemia (HLP) and dyslipidemia (DLP) are of course mainly perceived as diseases of common incidence and are typically seen as the greatest risk factors (RF) in the context of the pandemic of cardiovascular diseases. This is certainly true and HLP or DLP overall affect tens of percents of adults. However we cannot overlook the fact that disorders (mostly congenital) of lipid metabolism exist which, though not formally defined as such, amply satisfy the conditions for classification as rare diseases. Our account only includes a brief overview of the rare HLPs based on the dominant disorder of lipid metabolism, i.e. we shall mention the rare primary forms of hypercholesterolemia, primary forms of hypertriglyceridemia and the rare primary combined forms of HLP. In recent years an amazing progress has been reached relating to these diseases, in particular in the area of exact identification of the genetic defect and the mechanism of defect formation, however each of these diseases would require a separate article, though outside the field of clinical internal medicine. Therefore we shall discuss homozygous familial hypercholesterolemia (FH) in greater depth, partially also the "severe" form of heterozygous FH and in the following part the lipoprotein lipase deficiency; that means, diseases which present an extreme and even fatal risk for their carriers at a young age, but on the other hand, new therapeutic possibilities are offered within their treatment. An internist then should be alert to the suspicion that the described diseases may be involved, know about their main symptoms, where to refer the patient and how to treat them. Also dysbetalipoproteinemia (or type III HLP) will be briefly mentioned. Homozygous FH occurs with the frequency of 1 : 1 000 000 (maybe even more frequently, 1 : 160 000), it is characterized by severe isolated hypercholesterolemia (overall cholesterol typically equal to 15 mmol/l or more), xanthomatosis and first of all by a very early manifestation of a cardiovascular disease. Myocardial infarction is not an exception even in childhood. The therapy is based on high-dose statins, statins in combination with ezetimib and now also newly on PCSK9 inhibitors. Lomitapid and partly also mipomersen hold great promise for patients. LDL apheresis then represents an aggressive form of treatment. Lipoprotein lipase deficiency (type I HLP) is mainly characterized by severe hypertriglyceridemia, serum milky in colour, and xanthomatosis. A fatal complication is acute recurrent pancreatitis. A critical part of the treatment is diet, however it alone is not enough to control a genetic disorder. The only approved treatment is gene therapy. Experimentally, as an "off label" therapy, it is used in case studies with a lomitapid effect. We have our own experience with this experimental therapy. Dysbetalipoproteinemia is a congenital disorder of lipoprotein metabolism, characterized by high cholesterol (CH) and triglyceride (TG) levels. The underlying cause of this disease is the defect of the gene providing for apolipoprotein E. It is clinically manifested by xanthomatosis, however primarily by an early manifestation of atherosclerosis (rather peripheral than coronary).Key words: Lipoprotein lipase deficiency - dysbetalipoproteinemia - familial hypercholesterolemia - gene therapy - homozygous FH - LDL apheresis - lomitapid - mipomersen - PCSK9 inhibitors - rare diseases.

Hot Topics in Primary Care: Familial Hypercholesterolemia in Youth

Worldwide, guidelines support early identification, aggressive lifestyle management, and pharmacologic lipid lowering therapies when appropriate in youth with FH. These guidelines are aimed at improving the unending cycle of premature CHD in families despite the vast body of knowledge regarding the natural history of undiagnosed and untreated FH. Although valid concerns have been raised about treating youth other than those with FH with lipid-lowering pharmaceuticals, we believe the preponderance of the evidence laid forth by multiple professional societies from the United States and abroad is clearly weighted in favor of early diagnosis and treatment with lifestyle modification, to prevent the acquisition of other risk factors, and habituation to lifelong low-fat diet and adequate physical activity. We can think of no other instance where providers in the field of family medicine could have such a profound impact on the current and future health of child and parent and even future generations.

The hinterland of familial hypercholesterolaemia: what do we not know?

PURPOSE OF REVIEW

Familial hypercholesterolaemia is the commonest autosomal dominant disorder in man, but many questions about familial hypercholesterolaemia remain to be answered. Guidelines are increasing in importance as healthcare becomes standardized. The review suggests areas that require more investigation or where pertinent guidelines may need to be reviewed.

RECENT FINDINGS

Familial hypercholesterolaemia is commoner than previously thought, but its epidemiology needs further investigation against a background of changing environmental and lifestyle factors that may bear on its phenotypic expression. Screening for familial hypercholesterolaemia may be more difficult than might be thought as cascade testing may not capture all cases effectively and universal screening appears compelling, but requires testing and evaluation. Cardiovascular disease guidelines are moving to being risk based, but familial hypercholesterolaemia stands alone as defined by large database of lipids-cholesterol criteria. A risk-based approach may need to be considered for familial hypercholesterolaemia, but a good evidence base is required. The effects of older therapies on prognosis in familial hypercholesterolaemia are based on surrogate as opposed to cardiovascular disease outcomes. Novel efficacious but expensive therapies are on the horizon, but no specific outcome trials in familial hypercholesterolaemia are planned and they may not be cost-effective outside very severe familial hypercholesterolaemia. Further research is also required to trial and test different models of care for familial hypercholesterolaemia.

SUMMARY

Despite familial hypercholesterolaemia being a common genetic condition, aspects of basic epidemiology, risk assessment, treatment, and models of care remain uncertain.

Cardiac computed tomography imaging in familial hypercholesterolaemia: implications for therapy and clinical trials

PURPOSE OF REVIEW

The purpose of the present review is to summarize the potential clinical applications of computed tomographic angiography (CTA) in familial hypercholesterolemia so far and recent advances of CTA research in other high-risk patients.

RECENT FINDINGS

Long-term, aggressively statin-treated, asymptomatic familial hypercholesterolemia patients may still have dramatic coronary artery disease (CAD). A clear association between the presence and the extent of nonobstructive CAD and all-cause mortality was found in the COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry. Notably, baseline statin therapy was associated with a significantly lower mortality for individuals with atherosclerotic plaque on CTA, but not for individuals with normal coronary arteries.

SUMMARY

CTA imaging has made clear that an increased plaque burden can be present even among asymptomatic, long-term aggressively statin-treated familial hypercholesterolemia patients. In the COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry, nonobstructive CAD predicted all-cause mortality and statin treatment improved the life span of persons with nonobstructive CAD. Clinical trials with CTA are required to develop and test identification of CAD and personalized treatment strategies for familial hypercholesterolemia.

Cytochrome c oxidase subunit VIIb as a potential target in familial hypercholesterolemia by bioinformatical analysis

OBJECTIVE

The aim of the study is to explore the potential familial hypercholesterolemia markers by comparing with healthy controls.

MATERIAL AND METHODS

We downloaded the gene expression profile GSE13985 from Gene Expression Omnibus database including five patients diagnosed with familial hypercholesterolemia (FH) and five age, sex, status matched controls. We applied t-test, Wilcox test and Fisher test in Multtest package of R language to identify the differentially expressed genes (DEGs) with p < 0.05 and |logFC| > 1, and constructed the interaction network of the top 3 up- and down-regulated genes using STRING. Besides, the modules of network were analyzed with Cytoscape and screened out with Mcode plugin, and the functional annotation of the genes involved in the modules was analyzed with BiNGO (Biological Networks Gene Ontology).

RESULTS

Firstly, totally 101 differentially expressed genes were identified in FH samples compared with control samples, the genes ranked in top 3 up- and down-regulated genes were selected. Then, basing on the interaction network of these selected genes, ribosomal L24 domain containing 1 (RSL24D1) and cytochrome c oxidase subunit VIIb (COX7B) showed a central position in the interaction network, and also exited in the modules of the network. The functional annotation of the genes in modules showed that COX7B was associated with oxidative phosphorylation.

CONCLUSIONS

COX7B might play vital roles in FH via oxidative phosphorylation system, and might be potential target in the treatment of FH.

[Position of lipoprotein apheresis in present]

Lipoprotein apheresis (LA) is an effective treatment method the patients with severe hypercholesterolemia, resistant to the standard therapy. LA is an extracorporeal elimination technique, which specifically removes low density lipoprotein (LDL) cholesterol from the circulation. At present, lipoprotein apheresis, combined with high-dose statin and ezetimibe therapy, is the best available means of treating patients with homozygous and statin refractory heterozygous familial hypercholesterolaemia (FH). However, the extent of cholesterol-lowering achieved is often insufficient to meet the targets set by current guidelines. The recent advent of new classes of lipid-lowering agents provides new hope that the latter objective may now be achievable. These compounds act either by reducing low density lipoprotein (LDL) cholesterol production by inhibiting apolipoprotein B synthesis with an antisense oligonucleotide (mipomersen), or by inhibiting microsomal triglyceride transfer protein (lomitapid), or by enhancing LDL catabolism via monoclonal antibody-mediated inhibition of the activity of proprotein convertase subtilisin/kexin 9 (PCSK9-alirocumab, evolocumab etc). The promising is the combination of LDL-apheresis with new drugs, namely for its potential to further decrease of LDL-cholesterol between apheresis. Depending on the outcome of current trials, it seems likely that these compounds, used alone or combined with lipoprotein apheresis, will markedly improve the management of refractory FH.

Familial hypercholesterolemia: clues to catching it early

Here's how to spot the red flags that could signal your patient is at risk and steps you can take to potentially extend his or her life.

Importance of early recognition of heterozygous familial hypercholesterolaemia

PURPOSE OF REVIEW

To outline recent updates in the diagnosis and management of heterozygous familial hypercholesterolaemia.

RECENT FINDINGS

Recent guidelines have suggested that familial hypercholesterolaemia is vastly underdiagnosed in most countries worldwide. Improvements in next-generation sequencing have led to the detection of novel mutations and the cheaper cost of this technology makes the early identification of asymptomatic individuals a feasible option. With more widespread use of high doses of more potent statins in affected adults, cardiovascular mortality has decreased in adults with hypercholesterolaemia.

SUMMARY

Barriers to cascade testing of relatives of index cases remain worldwide despite improvements in gene technology and the marked recent decrease in costs of genetic testing. Recent guidelines recommending screening of young children, for example, 8-10 years with measurement of LDL cholesterol concentrations will increase the diagnosis of familial hypercholesterolaemia among children but long-term safety data of the use of statins in this young age group are not available. To date, the benefit of statin-induced decreases in LDL cholesterol concentration in children is based on effects of treatment on proxy measures of cardiovascular disease and not a reduction in cardiovascular events.