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Zwol WV, Rimbert A, Kuivenhoven JA. The Future of Lipid-lowering Therapy. J Clin Med 2019; 8:E1085. [PMID: 31340607 PMCID: PMC6678580 DOI: 10.3390/jcm8071085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 12/13/2022] Open
Abstract
The recent introduction of inhibitors of proprotein convertase subtilisin/kexin 9 to lower low-density lipoprotein (LDL) cholesterol on top of statins or as monotherapy is rapidly changing the landscape of treatment of atherosclerotic cardiovascular disease (ASCVD). However, existing lipid-lowering drugs have little impact on lipoprotein(a) (Lp(a)) or plasma triglycerides, two other risk factors for ASCVD. This review summarizes the evidence and the rationale to target Lp(a) and triglycerides and provides an overview of currently tested strategies to lower Lp(a), apolipoprotein C-III and angiopoietin-like protein 3. In addition, it summarizes new findings on the use of omega-3 fatty acids (OM3FA) to fight ASCVD. With the exception of OM3FA supplementation, the promise of the experimental drugs discussed here depends on the long-term safety and efficacy of monoclonal antibodies and/or antisense oligonucleotides Clinical outcome trials will ultimately prove whether these new therapeutic modalities will reduce ASCVD risk.
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Affiliation(s)
- Willemien van Zwol
- Department of Pediatrics, Section Molecular Genetics, University of Groningen, University Medical Centre Groningen, 9713 Groningen, The Netherlands
| | - Antoine Rimbert
- Department of Pediatrics, Section Molecular Genetics, University of Groningen, University Medical Centre Groningen, 9713 Groningen, The Netherlands
| | - Jan Albert Kuivenhoven
- Department of Pediatrics, Section Molecular Genetics, University of Groningen, University Medical Centre Groningen, 9713 Groningen, The Netherlands.
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Ma L, Chan DC, Ooi EMM, Barrett PHR, Watts GF. Fractional turnover of apolipoprotein(a) and apolipoprotein B-100 within plasma lipoprotein(a) particles in statin-treated patients with elevated and normal Lp(a) concentration. Metabolism 2019; 96:8-11. [PMID: 30995439 DOI: 10.1016/j.metabol.2019.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 12/31/2022]
Abstract
CONTEXT Lipoprotein(a) [Lp(a)] is a highly atherogenic lipoprotein characterized by apolipoprotein(a) [apo(a)] covalently bounded to apoB-100 (apoB). However, the metabolism of apo(a) and apoB within plasma Lp(a) particles in patients on statins remains unclear. METHODS The kinetics of Lp(a)-apo(a) and Lp(a)-apoB were determined in 20 patients with elevated Lp(a) (≥0.8 g/L; n = 10) and normal Lp(a) (≤0.3 g/L; n = 10) using stable isotope techniques and compartmental modeling. Plasma apo(a) concentration was measured using liquid chromatography-mass spectrometry. All patients were on statin therapy and were studied in the fasting state. RESULTS The fractional catabolic rate (FCR) of Lp(a)-apo(a) was not significantly different from that of Lp(a)-apoB in statin-treated patients with elevated or normal Lp(a) (P > 0.05 in both). Lp(a)-apo(a) FCR was significantly correlated with Lp(a)-apoB in patients with elevated and normal Lp(a) concentrations (r = 0.970 and r = 0.979, respectively; all P < 0.001) with Lin's concordance test showing substantial agreement between the FCRs of Lp(a)-apo(a) and Lp(a)-apoB in patients with elevated and normal Lp(a) concentrations (rc = 0.978 and rc = 0.966, respectively). CONCLUSION Our data indicate that the apo(a) and apoB proteins within Lp(a) particles have similar FCR and are therefore tightly coupled as an Lp(a) holoparticle in statin-treated patients with elevated and normal Lp(a) concentrations.
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Affiliation(s)
- Louis Ma
- School of Biomedical Sciences, University of Western Australia, Perth, Australia; School of Medicine, University of Western Australia, Perth, Australia
| | - Dick C Chan
- School of Biomedical Sciences, University of Western Australia, Perth, Australia; School of Medicine, University of Western Australia, Perth, Australia
| | - Esther M M Ooi
- School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - P Hugh R Barrett
- Faculty of Medicine and Health, University of New England, Armidale, Australia
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia; Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Australia.
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Miller M. Increased CVD Risk in Young Adults With Elevated Non–HDL-C. J Am Coll Cardiol 2019; 74:80-82. [DOI: 10.1016/j.jacc.2019.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
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Shen Y, Chen S, Dai Y, Wang XQ, Zhang RY, Yang ZK, Hu J, Lu L, Ding FH, Shen WF. Lipoprotein (a) interactions with cholesterol-containing lipids on angiographic coronary collateralization in type 2 diabetic patients with chronic total occlusion. Cardiovasc Diabetol 2019; 18:82. [PMID: 31234867 PMCID: PMC6589890 DOI: 10.1186/s12933-019-0888-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/16/2019] [Indexed: 12/13/2022] Open
Abstract
Background We investigated whether or to what extent the interaction of lipoprotein (a) [Lp(a)] with cholesterol-containing lipids was associated with angiographic coronary collateralization in type 2 diabetic patients with chronic total occlusion. Methods Serum levels of Lp(a), total cholesterol, low-density lipoprotein–cholesterol (LDL-C), high-density lipoprotein–cholesterol (HDL-C), and triglyceride were determined and non-HDL-C was calculated in 706 type 2 diabetic and 578 non-diabetic patients with stable coronary artery disease and angiographic total occlusion of at least one major coronary artery. The degree of collaterals supplying the distal aspect of a total occlusion from the contra-lateral vessel was graded as poor (Rentrop score of 0 or 1) or good coronary collateralization (Rentrop score of 2 or 3). Results For diabetic and non-diabetic patients, Lp(a), total cholesterol, LDL-C, and non-HDL-C levels were higher in patients with poor coronary collateralization than in those with good collateralization, whereas HDL-C and triglyceride levels were similar. After adjustment for potential confounding factors, tertiles of Lp(a), total cholesterol, LDL-C and non-HDL-C remained independent determinants for poor collateralization. A significant interaction between Lp(a) and total cholesterol, LDL-C or non-HDL-C was observed in diabetic patients (all P interaction < 0.001) but not in non-diabetics. At high tertile of total cholesterol (≥ 5.35 mmol/L), LDL-C (≥ 3.36 mmol/L) and non-HDL-C (≥ 4.38 mmol/L), diabetic patients with high tertile of Lp(a) (≥ 30.23 mg/dL) had an increased risk of poor collateralization compared with those with low tertile of Lp(a) (< 12.66 mg/dL) (adjusted OR = 4.300, 3.970 and 4.386, respectively, all P < 0.001). Conclusions Increased Lp(a) confers greater risk for poor coronary collateralization when total cholesterol, LDL-C or non-HDL-C are elevated especially for patients with type 2 diabetes. Electronic supplementary material The online version of this article (10.1186/s12933-019-0888-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ying Shen
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Shuai Chen
- Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Road II, Shanghai, 200025, People's Republic of China
| | - Yang Dai
- Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Road II, Shanghai, 200025, People's Republic of China
| | - Xiao Qun Wang
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Rui Yan Zhang
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Zhen Kun Yang
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Jian Hu
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Lin Lu
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.,Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Road II, Shanghai, 200025, People's Republic of China
| | - Feng Hua Ding
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.
| | - Wei Feng Shen
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China. .,Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Road II, Shanghai, 200025, People's Republic of China.
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Ward NC, Schultz CJ, Watts GF. What’s new on therapies for elevated lipoprotein(a). Expert Rev Clin Pharmacol 2019; 12:495-499. [DOI: 10.1080/17512433.2019.1610391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Natalie C. Ward
- School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Australia
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Carl J. Schultz
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Gerald F. Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
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Abstract
PURPOSE OF REVIEW High lipoprotein(a) levels are observationally and causally, from human genetics, associated with increased risk of cardiovascular disease including myocardial infarction and aortic valve stenosis. The European Atherosclerosis Society recommends screening for elevated lipoprotein(a) levels in high-risk patients. Different therapies have been suggested and some are used to treat elevated lipoprotein(a) levels such as niacin, PCSK9 inhibitors, and CETP inhibitors; however, to date, no randomized controlled trial has demonstrated that lowering of lipoprotein(a) leads to lower risk of cardiovascular disease. RECENT FINDINGS Synthetic oligonucleotides can be used to inactivate genes involved in disease processes. To lower lipoprotein(a), two antisense oligonucleotides have been developed, one targeting apolipoprotein B and one targeting apolipoprotein(a). Mipomersen is an antisense oligonucleotide targeting apolipoprotein B and thereby reducing levels of all apolipoprotein B containing lipoproteins in the circulation. Mipomersen has been shown to lower lipoprotein(a) by 20-50% in phase 3 studies. AKCEA-APO(a)-LRx is the most recent antisense oligonucleotide targeting apolipoprotein(a) and thereby uniquely targeting lipoprotein(a). It has been tested in a phase 2 study and has shown to lower lipoprotein(a) levels by 50-80%. The treatment of elevated lipoprotein(a) levels with the newest antisense oligonucleotides seems promising; however, no improvement in cardiovascular disease risk has yet been shown. However, a phase 3 study of AKCEA-APO(a)-LRx is being planned with cardiovascular disease as outcome, and results are awaited with great anticipation.
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Ellis KL, Chakraborty A, Moses EK, Watts GF. To test, or not to test: that is the question for the future of lipoprotein(a). Expert Rev Cardiovasc Ther 2019; 17:241-250. [PMID: 30916582 DOI: 10.1080/14779072.2019.1596799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Lipoprotein(a) [Lp(a)] is a potent, highly heritable and common risk factor for atherosclerotic cardiovascular disease (ASCVD). Evidence for a causal association between elevated Lp(a) and ASCVD has been provided by large epidemiological investigations that have demonstrated a curvilinear association with increased risk, as well as from genetic examinations and cellular and transgenic animal studies. Although there are several therapies available for lowering Lp(a), none are selective for Lp(a) and there is no clinical trial data that has specifically shown that lowering Lp(a) reduces the risk of ASCVD. Hence, screening for elevated Lp(a) is not routinely incorporated into clinical practice. Areas covered: This paper reviews the current evidence supporting the causal role of Lp(a) in the primary and secondary prevention of ASCVD, screening approaches for high Lp(a), current guidelines on testing Lp(a), and barriers to the routine screening of elevated Lp(a) in clinical practice. Expert opinion: At present, there is a moderate level of evidence supporting the routine screening of elevated Lp(a). Current guidelines recommend testing for elevated Lp(a) in individuals at intermediate or high risk of ASCVD.
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Affiliation(s)
- Katrina L Ellis
- a Centre for Genetic Origins of Health and Disease, School of Biomedical Sciences, The University of Western Australia and School of Biomedical Sciences , Curtin University , Perth , Australia.,b School of Medicine, Faculty of Medicine and Health Sciences , University of Western Australia , Perth , Australia
| | - Anindita Chakraborty
- b School of Medicine, Faculty of Medicine and Health Sciences , University of Western Australia , Perth , Australia
| | - Eric K Moses
- a Centre for Genetic Origins of Health and Disease, School of Biomedical Sciences, The University of Western Australia and School of Biomedical Sciences , Curtin University , Perth , Australia
| | - Gerald F Watts
- b School of Medicine, Faculty of Medicine and Health Sciences , University of Western Australia , Perth , Australia.,c Lipid Disorders Clinic, Department of Cardiology , Royal Perth Hospital , Perth , Australia
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Chan DC, Watts GF, Coll B, Wasserman SM, Marcovina SM, Barrett PHR. Lipoprotein(a) Particle Production as a Determinant of Plasma Lipoprotein(a) Concentration Across Varying Apolipoprotein(a) Isoform Sizes and Background Cholesterol-Lowering Therapy. J Am Heart Assoc 2019; 8:e011781. [PMID: 30897995 PMCID: PMC6509712 DOI: 10.1161/jaha.118.011781] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 02/12/2019] [Indexed: 12/24/2022]
Abstract
Background Elevated lipoprotein(a) (Lp(a)), a low-density lipoprotein-like particle bound to the polymorphic apolipoprotein(a) (apo(a)), may be causal for cardiovascular disease. However, the metabolism of Lp(a) in humans is poorly understood. Methods and Results We investigated the kinetics of Lp(a)-apo(a) and low-density lipoprotein-apoB-100 in 63 normolipidemic men. The fractional catabolic rate ( FCR ) and production rate PR ) were studied. Plasma apo(a) concentration was significantly and inversely associated with apo(a) isoform size ( r=-0.536, P<0.001) and apo(a) FCR ( r=-0.363, P<0.01), and positively with apo(a) PR ( r=0.877, P<0.001). There were no significant associations between the FCR s of apo(a) and low-density lipoprotein-apoB-100. Subjects with smaller apo(a) isoform sizes (≤22 kringle IV repeats) had significantly higher apo(a) PR ( P<0.05) and lower apo(a) FCR ( P<0.01) than those with larger sizes. Plasma apo(a) concentration was significantly associated with apo(a) PR ( r=0.930, P<0.001), but not with FCR ( r=-0.012, P>0.05) in subjects with smaller apo(a) isoform size. In contrast, both apo(a) PR and FCR were significantly associated with plasma apo(a) concentrations ( r=0.744 and -0.389, respectively, P<0.05) in subjects with larger isoforms. In multiple regression analysis, apo(a) PR and apo(a) isoform size were significant predictors of plasma apo(a) concentration independent of low-density lipoprotein-apoB-100 FCR and background therapy with atorvastatin and evolocumab. Conclusions In normolipidemic men, the plasma Lp(a) concentration is predominantly determined by the rate of production of Lp(a) particles, irrespective of apo(a) isoform size and background therapy with a statin and a proprotein convertase subtilisin-kexin type 9 inhibitor. Our findings underscore the importance of therapeutic targeting of the hepatic synthesis and secretion of Lp(a) particles. Lp(a) particle catabolism may only play a modest role in determining Lp(a) concentration in subjects with larger apo(a) isoform size. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02189837.
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Affiliation(s)
- Dick C. Chan
- School of MedicineUniversity of Western AustraliaPerthAustralia
- School of Biomedical ScienceUniversity of Western AustraliaPerthAustralia
| | - Gerald F. Watts
- School of MedicineUniversity of Western AustraliaPerthAustralia
- The Lipid Disorders ClinicDepartment of CardiologyRoyal Perth HospitalPerthAustralia
| | | | | | - Santica M. Marcovina
- Northwest Lipid Metabolism and Diabetes Research LaboratoriesDivision of Metabolism, Endocrinology, and NutritionDepartment of MedicineUniversity of WashingtonSeattleWA
| | - P. Hugh R. Barrett
- School of Biomedical ScienceUniversity of Western AustraliaPerthAustralia
- Faculty of Medicine and HealthUniversity of New EnglandArmidaleNew South WalesAustralia
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Arora P, Kalra R, Callas PW, Alexander KS, Zakai NA, Wadley V, Arora G, Kissela BM, Judd SE, Cushman M. Lipoprotein(a) and Risk of Ischemic Stroke in the REGARDS Study. Arterioscler Thromb Vasc Biol 2019; 39:810-818. [PMID: 30786745 PMCID: PMC6511401 DOI: 10.1161/atvbaha.118.311857] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/28/2019] [Indexed: 12/24/2022]
Abstract
Objective- Increased Lp(a) [lipoprotein(a)] is associated with coronary heart disease risk, but links with stroke are less consistent. Blacks have higher Lp(a) levels and stroke incidence than whites but have been underrepresented in studies. We hypothesized that Lp(a) is a risk factor for ischemic stroke and that risk differs by race. Approach and Results- REGARDS (Reasons for Geographic and Racial Differences in Stroke) recruited 30 239 black and white US adults aged ≥45 in 2003-2007 to study regional and racial differences in stroke mortality. We measured baseline Lp(a) by immunonephelometric assay in 572 cases of incident ischemic stroke and a 967-person cohort random sample. The hazard ratio of stroke by baseline Lp(a) was calculated using Cox proportional hazards models, stratified by race. Lp(a) was modeled in sex- and race-specific quartiles, given known differences in distributions by race and sex. Interactions were tested by including interaction terms in the proportional hazards models, with P<0.10 considered statistically significant. After adjustment for age, sex, and stroke risk factors, being in the fourth versus the first Lp(a) quartile was weakly associated with ischemic stroke overall, hazard ratio, 1.45 (95% CI, 0.96-2.19). In blacks, the hazard ratio was 1.96 (95% CI, 1.10-3.46), whereas in whites HR was 1.14 (95% CI, 0.64-2.04); P interaction=0.12. Lp(a) was lower in men than women, but associations with stroke in men and women were similar. Conclusions- We confirm that Lp(a) is a risk factor for ischemic stroke. Further research is needed to confirm the role of racial differences of the Lp(a) risk multiplier in ischemic stroke.
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Affiliation(s)
- Pankaj Arora
- Division of Cardiology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Peter W. Callas
- Department of Mathematics, University of Vermont, Burlington, VT
| | - Kristine S. Alexander
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Neil A. Zakai
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
- Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Virginia Wadley
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Garima Arora
- Division of Cardiology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Brett M. Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | - Suzanne E. Judd
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
- Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
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Abstract
INTRODUCTION Despite the consolidated role of statins and ezetimibe to treat hypercholesterolemia, often the desirable low-density lipoprotein cholesterol (LDL-C) values are not achieved, with a consequent increase of the residual cardiovascular (CV) risk. Areas covered: In this review, we summarize the main pharmacological characteristics of new lipid-lowering drugs, such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, cholesteryl ester transfer protein inhibitors, microsomal triglyceride transfer protein inhibitors, ATP citrate lyase inhibitors, antisense oligonucleotides, small interfering RNA, and peroxisome proliferator-activated receptors type α agonists. The available clinical evidence of efficacy and safety as well as the prospects of application, based on the different mechanisms and targets of action, is critically discussed. Expert opinion: Some of these emerging agents represent an excellent therapeutic strategy to treat patients with LDL largely out of target, resistant or intolerant to statins, trying to minimize the residual CV risk, modulating different classes of lipoproteins, not just LDL. The main challenge for the large use of emerging drugs is their cost. Thus, the correct identification of the adequate target population for treatment is a priority. This is particularly true for safe, powerful, and fully developed drugs such as the PCSK9 inhibitors, for which a relatively large use is potentially expected.
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Affiliation(s)
- Marilisa Bove
- a Medical and Surgical Sciences Department , University of Bologna , Bologna , Italy
| | - Arrigo F G Cicero
- a Medical and Surgical Sciences Department , University of Bologna , Bologna , Italy
| | - Claudio Borghi
- a Medical and Surgical Sciences Department , University of Bologna , Bologna , Italy
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Borrelli MJ, Youssef A, Boffa MB, Koschinsky ML. New Frontiers in Lp(a)-Targeted Therapies. Trends Pharmacol Sci 2019; 40:212-225. [PMID: 30732864 DOI: 10.1016/j.tips.2019.01.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 12/13/2022]
Abstract
Interest in lipoprotein (a) [Lp(a)] has exploded over the past decade with the emergence of genetic and epidemiological studies pinpointing elevated levels of this unique lipoprotein as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valve disease (CAVD). This review summarizes the most recent discoveries regarding therapeutic approaches to lower Lp(a) and presents these findings in the context of an emerging, although far from complete, understanding of the biosynthesis and catabolism of Lp(a). Application of Lp(a)-specific lowering agents to outcome trials will be the key to opening this new frontier in the battle against CVD.
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Affiliation(s)
- Matthew J Borrelli
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Amer Youssef
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Michael B Boffa
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; Department of Biochemistry, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Marlys L Koschinsky
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada.
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Vuorio A, Watts GF, Kovanen PT. Lipoprotein(a) as a risk factor for calcific aortic valvulopathy in heterozygous familial hypercholesterolemia. Atherosclerosis 2019; 281:25-30. [DOI: 10.1016/j.atherosclerosis.2018.11.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/17/2018] [Accepted: 11/28/2018] [Indexed: 12/24/2022]
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Geladari E, Tsamadia P, Vallianou NG. ANGPTL3 Inhibitors - Their Role in Cardiovascular Disease Through Regulation of Lipid Metabolism. Circ J 2018; 83:267-273. [PMID: 30504621 DOI: 10.1253/circj.cj-18-0442] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Elevated plasma lipid levels are linked to atherosclerosis, a hallmark for coronary artery disease (CAD), documented by animal studies as well as angiographic and clinical studies. The ability to treat hyperlipidemia through lifestyle changes and lipid-lowering agents has been related to the slow progression of atherosclerosis and decreased incidence of major coronary events. Angiopoietin-like proteins (ANGPTLs) are a family of secreted glycoproteins expressed in the liver that share common domain characteristics with angiopoietins, the main regulators of angiogenesis. Although ANGPTLs cannot bind the angiopoietin receptors expressed on endothelial cells, 2 ANGPTL family members (ANGPTL3 and ANGPTL4) have clinical importance because of their unambiguous effects on lipoprotein metabolism in mice and humans. The regulation of plasma lipid levels by ANGPTL3 is controlled via affecting lipoprotein lipase and endothelial lipase-mediated hydrolysis of triglycerides (TGs) and phospholipids. ANGPTL 3, along with the other 2 members, 4 and 8, is a key to balancing the distribution of circulating TGs between white adipose tissue (WAT) and oxidative tissues. Thus, ongoing trials with newly discovered medications in the form of monoclonal antibodies or antisense oligonucleotides with novel targets are under analysis and may represent a fresh frontier in the treatment of hyperlipidemia and CAD.
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Affiliation(s)
- Eleni Geladari
- Department of Internal Medicine, Evangelismos General Hospital
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Novel pharmacological targets for calcific aortic valve disease: Prevention and treatments. Pharmacol Res 2018; 136:74-82. [DOI: 10.1016/j.phrs.2018.08.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 12/24/2022]
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Lee SH, Choi JH. Involvement of inflammatory responses in the early development of calcific aortic valve disease: lessons from statin therapy. Anim Cells Syst (Seoul) 2018; 22:390-399. [PMID: 30533261 PMCID: PMC6282465 DOI: 10.1080/19768354.2018.1528175] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 12/15/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is the most common degenerative heart valve disease. Among the many risk factors for this disease are age, hypercholesterolemia, hypertension, smoking, type-2 diabetes, rheumatic fever, and chronic kidney disease. Since many of these overlap with risk factors for atherosclerosis, the molecular and cellular mechanisms of CAVD development have been presumed to be similar to those for atherogenesis. Thus, attempts have been made to evaluate the therapeutic efficacy of statins, representative anti-atherosclerosis drugs with lipid-lowering and anti-inflammatory effects, against CAVD. Unfortunately, statins have shown little or no effect on CAVD development. But some reports suggest that statins may prevent or reduce the development of early stage CAVD in which having calcification is absent or minimal. These results suggest that therapeutic approaches should differ according to the stage of disease, and that a precise understanding of the mechanism of aortic valve calcification is required to identify novel therapeutic targets for advanced CAVD. Given the involvement of inflammatory processes in the development and progression of CAVD, current therapeutic approaches for chronic inflammatory cardiovascular disease like atherosclerosis may help to prevent or minimize the early development of CAVD. In this review, we focus on several inflammatory cellular and molecular components involved in CAVD that might be considered drug targets for preventing CAVD.
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Affiliation(s)
- Seung Hyun Lee
- Department of Life Science, College of Natural Sciences, Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea
| | - Jae-Hoon Choi
- Department of Life Science, College of Natural Sciences, Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea
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66
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Abstract
Lipoprotein (a) is a low-density lipoprotein-like particle covalently bound to a glycoprotein called apolipoprotein(a) that is under potent genetic control. Plasma levels of lipoprotein (a) vary by up to 1000-fold among individuals, with 1 in 4 having levels that increase the risk of atherosclerotic cardiovascular disease. New evidence supports a causal role for lipoprotein (a) in atherosclerotic cardiovascular disease and aortic valve stenosis. Individuals with elevated lipoprotein (a) have a high life-time burden of atherosclerotic cardiovascular disease. This notion is important for coronary prevention. But is lipoprotein (a) ready for prime-time use in coronary prevention clinics?
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Affiliation(s)
- Katrina L Ellis
- School of Medicine, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia; School of Biomedical Sciences, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia
| | - Gerald F Watts
- School of Medicine, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia; Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, GPO Box X2213, Perth, WA 6001, Australia.
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67
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Zhang H, de Aguiar Vallim TQ, Martel C. Translational and Therapeutic Approaches to the Understanding and Treatment of Dyslipidemia. Arterioscler Thromb Vasc Biol 2018; 36:e56-61. [PMID: 27335468 DOI: 10.1161/atvbaha.116.307808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Hanrui Zhang
- From the Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY (H.Z.); Division of Cardiology, School of Medicine, University of California Los Angeles (T.Q. de A. V.); and Department of Medicine, Montreal Heart Institute Research Center, Université de Montréal, Montreal, Quebec, Canada (C.M.).
| | - Thomas Q de Aguiar Vallim
- From the Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY (H.Z.); Division of Cardiology, School of Medicine, University of California Los Angeles (T.Q. de A. V.); and Department of Medicine, Montreal Heart Institute Research Center, Université de Montréal, Montreal, Quebec, Canada (C.M.).
| | - Catherine Martel
- From the Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY (H.Z.); Division of Cardiology, School of Medicine, University of California Los Angeles (T.Q. de A. V.); and Department of Medicine, Montreal Heart Institute Research Center, Université de Montréal, Montreal, Quebec, Canada (C.M.).
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68
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Abstract
PURPOSE OF REVIEW Treatment of diabetic dyslipidemia is necessary because of its impact on cardiovascular disease, which is the leading cause of death in patients with diabetes. In the past, standard treatment of diabetic dyslipidemia focused only on correcting lipids. Although this remains the mainstay of treatment, because new antihyperglycemic treatments reduce cardiovascular events with minimal effect on dyslipidemia, a new approach is both timely and relevant. RECENT FINDINGS LDL-lowering remains the focus of treatment for diabetic dyslipidemia, especially in patients with both diabetes and cardiovascular disease (CVD). Higher intensity statin therapy or lower LDL cholesterol goals are recommended in these patients. Combination therapy, especially with ezetimibe, fibrates, bile acid sequestrants, PCSK9 inhibitors and omega 3 fatty acids should be considered along with selected new agents to reduce glycemia. SUMMARY As diabetic dyslipidemia plays a key role in CVD, aggressive treatment is indicated. New research targets include apo-CIII and lipoprotein(a) [Lp(a)]. In addition, new antihyperglycemic therapy is changing diabetes care and altering treatment guidelines. The most recent American Diabetes Association Standards of Care has expanded its recommendations for people with CVD and diabetes, suggesting that medications validated to improve cardiac health should be strongly considered.
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Affiliation(s)
- Valentina Rodriguez
- Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine, New York, USA
| | - Jonathan D. Newman
- Division of Cardiology, New York University School of Medicine, New York, USA
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69
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Sathiyakumar V, Kapoor K, Jones SR, Banach M, Martin SS, Toth PP. Novel Therapeutic Targets for Managing Dyslipidemia. Trends Pharmacol Sci 2018; 39:733-747. [PMID: 29970260 DOI: 10.1016/j.tips.2018.06.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 11/16/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in developed nations. Therapeutic modulation of dyslipidemia by inhibiting 3'-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase is standard practice throughout the world. However, based on findings from Mendelian studies and genetic sequencing in prospective longitudinal cohorts from around the world, novel therapeutic targets regulating lipid and lipoprotein metabolism, such as apoprotein C3, angiopoietin-like proteins 3 and 4, and lipoprotein(a), have been identified. These targets may provide additional avenues to prevent and treat atherosclerotic disease. We therefore review these novel molecular targets by addressing available Mendelian and observational data, therapeutic agents in development, and early outcomes results.
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Affiliation(s)
- Vasanth Sathiyakumar
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karan Kapoor
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven R Jones
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
| | - Seth S Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peter P Toth
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, CGH Medical Center, Sterling, IL, USA.
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70
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Dai W, Long J, Cheng Y, Chen Y, Zhao S. Elevated plasma lipoprotein(a) levels were associated with increased risk of cardiovascular events in Chinese patients with stable coronary artery disease. Sci Rep 2018; 8:7726. [PMID: 29769559 PMCID: PMC5955944 DOI: 10.1038/s41598-018-25835-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 04/27/2018] [Indexed: 12/13/2022] Open
Abstract
Recent studies have suggested that lipoprotein(a) [Lp(a)] is associated with cardiovascular disease (CVD). However, the contribution of Lp(a) to residual risk of CVD has not been determined in Chinese populations. We conducted a prospective study to evaluate the association between Lp(a) and the risk of major adverse cardiovascular events (MACEs) in patients with stable coronary artery disease (CAD) who received optimal medication treatment (OMT). The study enrolled 1602 patients with stable CAD from 5 hospitals in China. The baseline clinical characteristics and follow-up MACE data for the patients were recorded. Coronary lesion severity was assessed by the Gensini scoring system. All-cause death, non-fatal myocardial infarction, non-fatal stroke and unplanned coronary revascularization were considered MACEs. We found that plasma Lp(a) levels were positively associated with coronary lesion severity at baseline (p < 0.001). During a mean follow-up period of 39.6 months, 166 (10.4%) patients suffered MACEs. There were significant differences in the adjusted event-free survival rates among the Lp(a) quartile subgroups (p = 0.034). The hazard ratio for MACEs was 1.291 (95% confidence interval: 1.091-1.527, p = 0.003) per standardized deviation in the log-transformed Lp(a) level after adjustment for traditional cardiovascular risk factors. Therefore, Lp(a) was an independent predictor of MACEs in Chinese patients with stable CAD who received OMT.
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Affiliation(s)
- Wen Dai
- Department of Cardiology, The Second Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, 410011, China
| | - Junke Long
- Department of Cardiology, The Second Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, 410011, China
| | - Ying Cheng
- Department of Endocrinology, The Second Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, 410011, China
| | - Yaqin Chen
- Department of Cardiology, The Second Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, 410011, China
| | - Shuiping Zhao
- Department of Cardiology, The Second Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, 410011, China.
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71
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Abstract
Lipoprotein (a) [Lp(a)] and its measurement, structure and function, the impact of ethnicity and environmental factors, epidemiological and genetic associations with vascular disease, and new prospects in drug development have been extensively examined throughout this Thematic Review Series on Lp(a). Studies suggest that the kidney has a role in Lp(a) catabolism, and that Lp(a) levels are increased in association with kidney disease only for people with large apo(a) isoforms. By contrast, in those patients with large protein losses, as in the nephrotic syndrome and continuous ambulatory peritoneal dialysis, Lp(a) is increased irrespective of apo(a) isoform size. Such acquired abnormalities can be reversed by kidney transplantation or remission of nephrosis. In this Thematic Review, we focus on the relationship between Lp(a), chronic kidney disease, and risk of cardiovascular events.
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Affiliation(s)
- Jemma C Hopewell
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
| | - Richard Haynes
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Medical Research Council Population Health Research Unit, Oxford, United Kingdom
| | - Colin Baigent
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Medical Research Council Population Health Research Unit, Oxford, United Kingdom
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72
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Gencer B, Kronenberg F, Stroes ES, Mach F. Lipoprotein(a): the revenant. Eur Heart J 2018; 38:1553-1560. [PMID: 28329241 DOI: 10.1093/eurheartj/ehx033] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/16/2017] [Indexed: 11/12/2022] Open
Abstract
In the mid-1990s, the days of lipoprotein(a) [Lp(a)] were numbered and many people would not have placed a bet on this lipid particle making it to the next century. However, genetic studies brought Lp(a) back to the front-stage after a Mendelian randomization approach used for the first time provided strong support for a causal role of high Lp(a) concentrations in cardiovascular disease and later also for aortic valve stenosis. This encouraged the use of therapeutic interventions to lower Lp(a) as well numerous drug developments, although these approaches mainly targeted LDL cholesterol, while the Lp(a)-lowering effect was only a 'side-effect'. Several drug developments did show a potent Lp(a)-lowering effect but did not make it to endpoint studies, mainly for safety reasons. Currently, three therapeutic approaches are either already in place or look highly promising: (i) lipid apheresis (specific or unspecific for Lp(a)) markedly decreases Lp(a) concentrations as well as cardiovascular endpoints; (ii) PCSK9 inhibitors which, besides lowering LDL cholesterol also decrease Lp(a) by roughly 30%; and (iii) antisense therapy targeting apolipoprotein(a) which has shown to specifically lower Lp(a) concentrations by up to 90% in phase 1 and 2 trials without influencing other lipids. Until the results of phase 3 outcome studies are available for antisense therapy, we will have to exercise patience, but with optimism since never before have we had the tools we have now to prove Koch's extrapolated postulate that lowering high Lp(a) concentrations might be protective against cardiovascular disease.
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Affiliation(s)
- Baris Gencer
- Cardiology Division, Geneva University Hospitals, Switzerland
| | - Florian Kronenberg
- Department of Medical Genetics, Division of Genetic Epidemiology, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Austria
| | - Erik S Stroes
- Academic Medical Center, Amsterdam, AZ 1100, The Netherlands
| | - François Mach
- Cardiology Division, Geneva University Hospitals, Switzerland
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73
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Viney NJ, Yeang C, Yang X, Xia S, Witztum JL, Tsimikas S. Relationship between "LDL-C", estimated true LDL-C, apolipoprotein B-100, and PCSK9 levels following lipoprotein(a) lowering with an antisense oligonucleotide. J Clin Lipidol 2018; 12:702-710. [PMID: 29574075 DOI: 10.1016/j.jacl.2018.02.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/21/2018] [Accepted: 02/24/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND The laboratory measurement of "low-density lipoprotein cholesterol (LDL-C)" includes the cholesterol content of lipoprotein(a) (Lp(a)-C). OBJECTIVE To estimate the "true" LDL-C in relation to changes in apolipoprotein B-100 (apoB-100) and assess changes in proprotein convertase subtilisin/kexin 9 (PCSK9) levels in patients with elevated Lp(a) treated with IONIS-APO(a)Rx. METHODS: A pooled placebo group (n = 29), and cohort A (n = 24, baseline Lp(a) 50-175 mg/dL) and cohort B (n = 8, baseline Lp(a) > 175 mg/dL) treated with IONIS-APO(a)Rx were studied. Lp(a) particle number, ultracentrifugation-measured "LDL-C", apoB-100, total PCSK9, and lipoprotein-associated PCSK9 (PCSK9-Lp(a), PCSK9-apoB, PCSK9-apoAI) were measured. Lp(a)-cholesterol (Lp(a)-C) and LDL-C corrected for Lp(a)-C (LDL-Ccorr) were calculated. RESULTS Baseline mean (standard deviation) "LDL-C" was 120 (42), 128 (45), and 112 (39) mg/dL in placebo, cohorts A and B, respectively, whereas LDL-Ccorr was 86 (48), 96 (43), and 57 (37) mg/dL (P < .001 compared with placebo), representing 28%, 25%, and 50% lower levels than "LDL-C". Following IONIS-APO(a)Rx treatment at day 85/99, Lp(a) particle number and Lp(a)-C decreased -66.8% and -71.6%, apoB-100 -10.3% and -17.5%, "LDL-C" -11.8% and -22.7%, (P < .001 for all vs placebo), whereas LDL-Ccorr increased +10.4% (P = .66) and +49.9% (P < .001) in cohorts A and B, respectively. Total PCSK9 did not change but PCSK9-Lp(a) decreased with IONIS-APO(a)Rx vs placebo (-39.0% vs +8.4%, P < .001). CONCLUSION LDL-Ccorr is lower than laboratory "LDL-C" in patients with elevated Lp(a). Following apolipoprotein(a) inhibition and decline in Lp(a) and Lp(a)-C, the decline in apoB-100 is consistent with the notion that LDL devoid of apo(a) is cleared faster than Lp(a). These types of analyses may provide insights into the mechanisms of drugs affecting Lp(a) levels in clinical trials.
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Affiliation(s)
| | - Calvin Yeang
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Xiaohong Yang
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Joseph L Witztum
- Division of Endocrinology and Metabolism, University of California San Diego, La Jolla, CA, USA
| | - Sotirios Tsimikas
- Ionis Pharmaceuticals, Carlsbad, CA, USA; Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA.
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74
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Nordestgaard BG, Nicholls SJ, Langsted A, Ray KK, Tybjærg-Hansen A. Advances in lipid-lowering therapy through gene-silencing technologies. Nat Rev Cardiol 2018; 15:261-272. [PMID: 29417937 DOI: 10.1038/nrcardio.2018.3] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
New treatment opportunities are emerging in the field of lipid-lowering therapy through gene-silencing approaches. Both antisense oligonucleotide inhibition and small interfering RNA technology aim to degrade gene mRNA transcripts to reduce protein production and plasma lipoprotein levels. Elevated levels of LDL, remnant lipoproteins, and lipoprotein(a) all cause cardiovascular disease, whereas elevated levels of triglyceride-rich lipoproteins in some patients can cause acute pancreatitis. The levels of each of these lipoproteins can be reduced using gene-silencing therapies by targeting proteins that have an important role in lipoprotein production or removal (for example, the protein products of ANGPTL3, APOB, APOC3, LPA, and PCSK9). Using this technology, plasma levels of these lipoproteins can be reduced by 50-90% with 2-12 injections per year; such dramatic reductions are likely to reduce the incidence of cardiovascular disease or acute pancreatitis in at-risk patients. The reported adverse effects of these new therapies include injection-site reactions, flu-like symptoms, and low blood platelet counts. However, newer-generation drugs are more efficiently delivered to liver cells, requiring lower drug doses, which leads to fewer adverse effects. Although these findings are promising, robust evidence of cardiovascular disease reduction and long-term safety is needed before these gene-silencing technologies can have widespread implementation. Before the availability of such evidence, these drugs might have roles in patients with unmet medical needs through orphan indications.
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Affiliation(s)
- Børge G Nordestgaard
- Department of Clinical Biochemistry and The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Faculty of Health and Medical Sciences, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark
| | - Stephen J Nicholls
- South Australian Health and Medical Research Institute, University of Adelaide, North Terrace, Adelaide 5000, South Australia, Australia
| | - Anne Langsted
- Department of Clinical Biochemistry and The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Faculty of Health and Medical Sciences, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College, Reynolds Building, St Dunstan's Road, London W6 8RP, UK
| | - Anne Tybjærg-Hansen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsveg 3B, 2200 Copenhagen, Denmark
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75
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Boffa MB, Koschinsky ML. Therapeutic Lowering of Lipoprotein(a). CIRCULATION-GENOMIC AND PRECISION MEDICINE 2018; 11:e002052. [DOI: 10.1161/circgen.118.002052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Michael B. Boffa
- From the Department of Biochemistry (M.B.B.) and Robarts Research Institute (M.L.K.), Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Marlys L. Koschinsky
- From the Department of Biochemistry (M.B.B.) and Robarts Research Institute (M.L.K.), Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
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76
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Update on the laboratory investigation of dyslipidemias. Clin Chim Acta 2018; 479:103-125. [PMID: 29336935 DOI: 10.1016/j.cca.2018.01.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/03/2018] [Accepted: 01/09/2018] [Indexed: 01/08/2023]
Abstract
The role of the clinical laboratory is evolving to provide more information to clinicians to assess cardiovascular disease (CVD) risk and target therapy more effectively. Current routine methods to measure LDL-cholesterol (LDL-C), the Friedewald calculation, ultracentrifugation, electrophoresis and homogeneous direct methods have established limitations. Studies suggest that LDL and HDL size or particle concentration are alternative methods to predict future CVD risk. At this time there is no consensus role for lipoprotein particle or subclasses in CVD risk assessment. LDL and HDL particle concentration are measured by several methods, namely gradient gel electrophoresis, ultracentrifugation-vertical auto profile, nuclear magnetic resonance and ion mobility. It has been suggested that HDL functional assays may be better predictors of CVD risk. To assess the issue of lipoprotein subclasses/particles and HDL function as potential CVD risk markers robust, simple, validated analytical methods are required. In patients with small dense LDL particles, even a perfect measure of LDL-C will not reflect LDL particle concentration. Non-HDL-C is an alternative measurement and includes VLDL and CM remnant cholesterol and LDL-C. However, apolipoprotein B measurement may more accurately reflect LDL particle numbers. Non-fasting lipid measurements have many practical advantages. Defining thresholds for treatment with new measurements of CVD risk remain a challenge. In families with genetic variants, ApoCIII and lipoprotein (a) may be additional risk factors. Recognition of familial causes of dyslipidemias and diagnosis in childhood will result in early treatment. This review discusses the limitations in current laboratory technologies to predict CVD risk and reviews the evidence for emergent approaches using newer biomarkers in clinical practice.
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77
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Hippe DS, Phan BAP, Sun J, Isquith DA, O'Brien KD, Crouse JR, Anderson T, Huston J, Marcovina SM, Hatsukami TS, Yuan C, Zhao XQ. Lp(a) (Lipoprotein(a)) Levels Predict Progression of Carotid Atherosclerosis in Subjects With Atherosclerotic Cardiovascular Disease on Intensive Lipid Therapy: An Analysis of the AIM-HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes) Carotid Magnetic Resonance Imaging Substudy-Brief Report. Arterioscler Thromb Vasc Biol 2018; 38:673-678. [PMID: 29301785 DOI: 10.1161/atvbaha.117.310368] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 12/21/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess whether Lp(a) (lipoprotein(a)) levels and other lipid levels were predictive of progression of atherosclerosis burden as assessed by carotid magnetic resonance imaging in subjects who have been treated with LDL-C (low-density lipoprotein cholesterol)-lowering therapy and participated in the AIM-HIGH trial (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes). APPROACH AND RESULTS AIM-HIGH was a randomized, double-blind study of subjects with established vascular disease, elevated triglycerides, and low HDL-C (high-density lipoprotein cholesterol). One hundred fifty-two AIM-HIGH subjects underwent both baseline and 2-year follow-up carotid artery magnetic resonance imaging. Plaque burden was measured by the percent wall volume (%WV) of the carotid artery. Associations between annualized change in %WV with baseline and on-study (1 year) lipid variables were evaluated using multivariate linear regression and the Bonferroni correction to account for multiple comparisons. Average %WV at baseline was 41.6±6.8% and annualized change in %WV over 2 years ranged from -3.2% to 3.7% per year (mean: 0.2±1.1% per year; P=0.032). Increases in %WV were significantly associated with higher baseline Lp(a) (β=0.34 per 1-SD increase of Lp(a); 95% confidence interval, 0.15-0.52; P<0.001) after adjusting for clinical risk factors and other lipid levels. On-study Lp(a) had a similar positive association with %WV progression (β=0.33; 95% confidence interval, 0.15-0.52; P<0.001). CONCLUSIONS Despite intensive lipid therapy, aimed at aggressively lowering LDL-C to <70 mg/dL, carotid atherosclerosis continued to progress as assessed by carotid magnetic resonance imaging and that elevated Lp(a) levels were independent predictors of increases in atherosclerosis burden.
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Affiliation(s)
- Daniel S Hippe
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Binh An P Phan
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Jie Sun
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Daniel A Isquith
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Kevin D O'Brien
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - John R Crouse
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Todd Anderson
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - John Huston
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Santica M Marcovina
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Thomas S Hatsukami
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Chun Yuan
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.)
| | - Xue-Qiao Zhao
- From the Department of Radiology (D.S.H., J.S., C.Y.), Division of Cardiology (D.A.I., K.D.O., X.-Q.Z.), and Department of Surgery, Division of Vascular Surgery (T.S.H.), University of Washington School of Medicine, Seattle; Division of Cardiology, San Francisco General Hospital, University of California (B.A.P.P.); Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.R.C.); Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (T.A.); Department of Radiology, Mayo Clinic, Rochester, MN (J.H.); and Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.).
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Pessentheiner AR, Ramms B, Gordts PL. ANGPTL3 targeting: The power of versatile lipid-lowering. Atherosclerosis 2018; 268:185-187. [PMID: 29111225 DOI: 10.1016/j.atherosclerosis.2017.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 10/05/2017] [Indexed: 01/26/2023]
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Onat A, Kaya A, Ademoglu E. Modified risk associations of lipoproteins and apolipoproteins by chronic low-grade inflammation. Expert Rev Cardiovasc Ther 2017; 16:39-48. [PMID: 29241386 DOI: 10.1080/14779072.2018.1417839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Lipoproteins and the apolipoproteins (apo) that they carry are major determinants of cardiovascular diseases (CVD) as well as metabolic, renal and inflammatory chronic disorders either directly or through mediation of risk factors. The notion that elevated low-density lipoprotein cholesterol (LDL-C) and apoB levels are related to the acquisition of CVD and, high-density lipoprotein cholesterol (HDL-C) and apoA-I indicate protection against CVD has been challenged in the past decade. Advanced age, adiposity, ethnicity or impaired glucose intolerance rendered autoimmune activation in an environment of pro-inflammatory state/oxidative stress and may disrupt the linear risk association between lipoproteins. Areas covered: This review summarizes the modified risk associations of lipoproteins and apolipoprotein by an environment of chronic systemic low-grade inflammation with special emphasis on the non-linear relationship of lipoprotein(a) [Lp(a)], a biomarker of renewed interest in cardiometabolic risk. Expert commentary: It seems that autoimmune activation in an environment of pro-inflammatory state/oxidative stress not only disrupts the linear risk association between lipoproteins, but also may cause interference in immunoassays. Hence, methodological improvement in immunoassays and much further research focusing on population segments susceptible to a pro-inflammatory state is necessary for further advances in knowledge.
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Affiliation(s)
- Altan Onat
- a Department of Cardiology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Aysem Kaya
- b Laboratory of Biochemistry, Institute of Cardiology , Istanbul University , Istanbul , Turkey
| | - Evin Ademoglu
- c Department of Biochemistry, Istanbul Faculty of Medicine , Istanbul University , Istanbul , Turkey
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80
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Scipione CA, Koschinsky ML, Boffa MB. Lipoprotein(a) in clinical practice: New perspectives from basic and translational science. Crit Rev Clin Lab Sci 2017; 55:33-54. [PMID: 29262744 DOI: 10.1080/10408363.2017.1415866] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Elevated plasma concentrations of lipoprotein(a) (Lp(a)) are a causal risk factor for coronary heart disease (CHD) and calcific aortic valve stenosis (CAVS). Genetic, epidemiological and in vitro data provide strong evidence for a pathogenic role for Lp(a) in the progression of atherothrombotic disease. Despite these advancements and a race to develop new Lp(a) lowering therapies, there are still many unanswered and emerging questions about the metabolism and pathophysiology of Lp(a). New studies have drawn attention to Lp(a) as a contributor to novel pathogenic processes, yet the mechanisms underlying the contribution of Lp(a) to CVD remain enigmatic. New therapeutics show promise in lowering plasma Lp(a) levels, although the complete mechanisms of Lp(a) lowering are not fully understood. Specific agents targeted to apolipoprotein(a) (apo(a)), namely antisense oligonucleotide therapy, demonstrate potential to decrease Lp(a) to levels below the 30-50 mg/dL (75-150 nmol/L) CVD risk threshold. This therapeutic approach should aid in assessing the benefit of lowering Lp(a) in a clinical setting.
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Affiliation(s)
- Corey A Scipione
- a Department of Advanced Diagnostics , Toronto General Hospital Research Institute, UHN , Toronto , Canada
| | - Marlys L Koschinsky
- b Robarts Research Institute , Western University , London , Canada.,c Department of Physiology & Pharmacology , Schulich School of Medicine & Dentistry, Western University , London , Canada
| | - Michael B Boffa
- d Department of Biochemistry , Western University , London , Canada
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81
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Lawler PR, Mora S. Partitioning the Genetic Architecture of Plasma Lipoprotein(a) and Kringle IV Type 2 Repeats: Implications for Therapeutic Lowering. Clin Chem 2017; 63:1792-1794. [PMID: 29038149 DOI: 10.1373/clinchem.2017.280172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 09/26/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, and the Heart and Stroke Richard Lewar Centre of Excellence, University of Toronto, Toronto, ON, Canada
| | - Samia Mora
- Center for Lipid Metabolomics, Divisions of Preventive and Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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82
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Ellis KL, Boffa MB, Sahebkar A, Koschinsky ML, Watts GF. The renaissance of lipoprotein(a): Brave new world for preventive cardiology? Prog Lipid Res 2017; 68:57-82. [DOI: 10.1016/j.plipres.2017.09.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/01/2017] [Accepted: 09/05/2017] [Indexed: 12/24/2022]
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Abstract
PURPOSE OF REVIEW This article reviews current knowledge concerning diabetic dyslipidemia and cardiovascular disease (CVD). It reviews strategies to reduce diabetes-associated CVD, including reducing low-density lipoprotein levels, lowering triglycerides, and increasing high-density lipoproteins (HDL). Special considerations, such as the multifactorial chylomicronemia syndrome and partial lipodystrophy, and the role of glucose-lowering strategies in the management of diabetic dyslipidemia are discussed. RECENT FINDINGS The strongest evidence to date for reducing CVD in diabetes comes from the use of statins. While triglyceride lowering remains inconclusive, an ongoing trial might provide some finality to this question. The role of increasing HDL remains elusive, and HDL cholesterol appears to be an unsatisfactory metric for monitoring therapy. The use of statins offers the best current way to reduce diabetes-associated CVD. However, several novel and promising approaches for the management of diabetic dyslipidemia aimed at reducing CVD are in the pipeline.
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Affiliation(s)
- Alan Chait
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA.
| | - Ira Goldberg
- Division of Endocrinology, New York University, New York, NY, USA
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84
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Boffa MB. Emerging Therapeutic Options for Lowering of Lipoprotein(a): Implications for Prevention of Cardiovascular Disease. Curr Atheroscler Rep 2017; 18:69. [PMID: 27761705 DOI: 10.1007/s11883-016-0622-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Elevated plasma concentrations of lipoprotein(a) (Lp(a)) are an independent and causal risk factor for cardiovascular diseases including coronary artery disease, ischemic stroke, and calcific aortic valve stenosis. This review summarizes the rationale for Lp(a) lowering and surveys relevant clinical trial data using a variety of agents capable of lowering Lp(a). RECENT FINDINGS Contemporary guidelines and recommendations outline populations of patients who should be screened for elevated Lp(a) and who might benefit from Lp(a) lowering. Therapies including drugs and apheresis have been described that lower Lp(a) levels modestly (∼20 %) to dramatically (∼80 %). Existing therapies that lower Lp(a) also have beneficial effects on other aspects of the lipid profile, with the exception of Lp(a)-specific apheresis and an antisense oligonucleotide that targets the mRNA encoding apolipoprotein(a). No clinical trials conducted to date have managed to answer the key question of whether Lp(a) lowering confers a benefit in terms of ameliorating cardiovascular risk, although additional outcome trials of therapies that lower Lp(a) are ongoing. It is more likely, however, that Lp(a)-specific agents will provide the most appropriate approach for addressing this question.
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Affiliation(s)
- Michael B Boffa
- Department of Biochemistry, Room 4245A Robarts Research Institute, University of Western Ontario, 1151 Richmond Street North, London, ON, Canada, N6A 5B7.
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85
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Tsimikas S. A Test in Context: Lipoprotein(a): Diagnosis, Prognosis, Controversies, and Emerging Therapies. J Am Coll Cardiol 2017; 69:692-711. [PMID: 28183512 DOI: 10.1016/j.jacc.2016.11.042] [Citation(s) in RCA: 621] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/10/2016] [Accepted: 11/21/2016] [Indexed: 12/14/2022]
Abstract
Evidence that elevated lipoprotein(a) (Lp[a]) levels contribute to cardiovascular disease (CVD) and calcific aortic valve stenosis (CAVS) is substantial. Development of isoform-independent assays, in concert with genetic, epidemiological, translational, and pathophysiological insights, have established Lp(a) as an independent, genetic, and likely causal risk factor for CVD and CAVS. These observations are consistent across a broad spectrum of patients, risk factors, and concomitant therapies, including patients with low-density lipoprotein cholesterol <70 mg/dl. Statins tend to increase Lp(a) levels, possibly contributing to the "residual risk" noted in outcomes trials and at the bedside. Recently approved proprotein convertase subtilisin/kexin-type 9 inhibitors and mipomersen lower Lp(a) 20% to 30%, and emerging RNA-targeted therapies lower Lp(a) >80%. These approaches will allow testing of the "Lp(a) hypothesis" in clinical trials. This review summarizes the current landscape of Lp(a), discusses controversies, and reviews emerging therapies to reduce plasma Lp(a) levels to decrease risk of CVD and CAVS.
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Affiliation(s)
- Sotirios Tsimikas
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California.
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86
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Lipid Metabolism and Emerging Targets for Lipid-Lowering Therapy. Can J Cardiol 2017; 33:872-882. [DOI: 10.1016/j.cjca.2016.12.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/12/2016] [Accepted: 12/26/2016] [Indexed: 12/25/2022] Open
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Torzewski M, Ravandi A, Yeang C, Edel A, Bhindi R, Kath S, Twardowski L, Schmid J, Yang X, Franke UFW, Witztum JL, Tsimikas S. Lipoprotein(a) Associated Molecules are Prominent Components in Plasma and Valve Leaflets in Calcific Aortic Valve Stenosis. ACTA ACUST UNITED AC 2017; 2:229-240. [PMID: 29147686 PMCID: PMC5685511 DOI: 10.1016/j.jacbts.2017.02.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The LPA gene is the only monogenetic risk factor for CAVS, and OxPL and lysophosphatidic acid, generated by autotaxin from OxPL, are pro-inflammatory. Both autotaxin–apolipoprotein B and autotaxin–apo(a) were measureable in plasma. Immunohistochemistry revealed a strong presence of apo(a), OxPL, malondialdehyde-lysine, autotaxin, and macrophages, particularly in advanced lesions rich in cholesterol crystals and calcification. Six species of OxPL and lysophosphatidic acid, with aldehyde-containing phosphocholine-based OxPL most abundant, were identified and quantified after extraction from valve leaflets. We demonstrate the presence of a constellation of pathologically linked, Lp(a)-associated molecules in plasma and in aortic valve leaflets of patients with CAVS. These data are consistent with the hypothesis that Lp(a) is a key etiologic factor in patients with CAVS.
The LPA gene is the only monogenetic risk factor for calcific aortic valve stenosis (CAVS). Oxidized phospholipids (OxPL) and lysophosphatidic acid generated by autotaxin (ATX) from OxPL are pro-inflammatory. Aortic valve leaflets categorized pathologically from both ATX–apolipoprotein B and ATX–apolipoprotein(a) were measureable in plasma. Lipoprotein(a) (Lp[a]), ATX, OxPL, and malondialdehyde epitopes progressively increased in immunostaining (p < 0.001 for all). Six species of OxPL and lysophosphatidic acid were identified after extraction from valve leaflets. The presence of a constellation of pathologically linked, Lp(a)-associated molecules in plasma and in aortic valve leaflets of patients with CAVS suggest that Lp(a) is a key etiologic factor in CAVS.
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Affiliation(s)
| | - Amir Ravandi
- Cardiac Sciences Program, University of Manitoba and Institute of Cardiovascular Sciences, St. Boniface Hospital
| | - Calvin Yeang
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tuebingen, Stuttgart, Germany
| | - Andrea Edel
- Cardiac Sciences Program, University of Manitoba and Institute of Cardiovascular Sciences, St. Boniface Hospital
| | - Rahul Bhindi
- Cardiac Sciences Program, University of Manitoba and Institute of Cardiovascular Sciences, St. Boniface Hospital
| | - Stefan Kath
- Department of Laboratory Medicine, Robert-Bosch-Hospital, Germany
| | - Laura Twardowski
- Department of Laboratory Medicine, Robert-Bosch-Hospital, Germany
| | - Jens Schmid
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tuebingen, Stuttgart, Germany
| | - Xiaohong Yang
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla CA
| | - Ulrich F W Franke
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Germany
| | - Joseph L Witztum
- Division of Endocrinology and Metabolism, University of California San Diego, La Jolla CA
| | - Sotirios Tsimikas
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla CA
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Girelli D, Piubelli C, Martinelli N, Corrocher R, Olivieri O. A decade of progress on the genetic basis of coronary artery disease. Practical insights for the internist. Eur J Intern Med 2017; 41:10-17. [PMID: 28395986 DOI: 10.1016/j.ejim.2017.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 12/24/2022]
Abstract
Clinicians are well aware of the importance of a positive family history for coronary artery disease (CAD). Nonetheless, elucidation of the genetic basis of CAD has long proven difficult. The scenario changed in the last decade through the application of modern genomic technologies, like genome-wide association studies (GWAS) and next generation sequencing (NGS). GWAS have discovered over 60 common variants highly associated with CAD. For predictive purposes, such variants have been used to build up Genetic Risk Scores (GRSs), but their incorporation into classical prediction models does not appear substantially outperform the simple addition of family history. To date, the only strong case for the utility of incorporating genetic testing into clinical practice is represented by the diagnosis of Familial Hypercholesterolemia (FH). On the other hand, utilization of genomic techniques has driven formidable advances into the knowledge of CAD pathophysiology, particularly by addressing controversies on the causality of some lipid fractions that had long remained unsolved because of limitations of observational epidemiology. For example, NGS-derived rare variants with strong functional effects on key-genes like ANGPTL4, APOA5, APOC3, LPL, and SCARB1, have proven useful as proxies to demonstrate the causality of triglyceride-rich lipoproteins (TRLs) at variance with HDL-cholesterol concentration, thus contributing to tear down a dogma from classical epidemiology. Moreover, such variants have paved the way for the development of new biologic drugs (i.e. monoclonal antibodies or antisense oligonucleotides) targeting key proteins like PCSK9, Lipoprotein(a), and apolipoprotein C3. Such drugs are currently under active investigation, with first results being extremely promising.
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Affiliation(s)
- Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona, Italy.
| | - Chiara Piubelli
- Department of Medicine, Section of Internal Medicine, University of Verona, Italy
| | - Nicola Martinelli
- Department of Medicine, Section of Internal Medicine, University of Verona, Italy
| | - Roberto Corrocher
- Department of Medicine, Section of Internal Medicine, University of Verona, Italy
| | - Oliviero Olivieri
- Department of Medicine, Section of Internal Medicine, University of Verona, Italy
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Brown WV, Handelsman Y, Martin SS, Morris PB. JCL roundtable: Future of the lipid laboratory: Choosing valuable measures among the lipoproteins (part 1). J Clin Lipidol 2017; 11:587-595. [DOI: 10.1016/j.jacl.2017.04.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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90
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Incidence of elevated lipoprotein (a) levels in a large cohort of patients with cardiovascular disease. Clin Res Cardiol Suppl 2017; 12:55-59. [PMID: 28229283 PMCID: PMC5352766 DOI: 10.1007/s11789-017-0087-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background Recently it has been demonstrated that elevated lipoprotein (a) (LPA) levels are associated with an increased risk of cardiovascular disease across multiple ethnic groups. However, there is only scanty data about the incidence of elevated LPA levels in different patient cohorts. As a consequence, we aimed to examine whether patients with elevated LPA levels might be seen more often in a cardiovascular center in comparison to the general population. Methods We reviewed LPA concentrations of 52,898 consecutive patients who were admitted to our hospital between January 2004 and December 2014. We subdivided them into different groups according to their LPA levels. Data was compared to available information in medical literature. Results 26.4% of the patients had LPA levels >30 mg/dl which is in line with the data from literature. Mean level of LPA concentration in our study was twice as high in comparison to the general population (25.8% vs. 13.3%). 4.6% had LPA levels >98 mg/dl (general population <0.3%). Conclusion In patients admitted to a cardiovascular center the proportion of LPA >30 mg/dl is comparable to the general population but mean levels over all are twice as high and the proportion of patients with LPA levels of >98 mg/dl is extremely higher.
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91
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Sjouke B, Yahya R, Tanck MWT, Defesche JC, de Graaf J, Wiegman A, Kastelein JJP, Mulder MT, Hovingh GK, Roeters van Lennep JE. Plasma lipoprotein(a) levels in patients with homozygous autosomal dominant hypercholesterolemia. J Clin Lipidol 2017; 11:507-514. [PMID: 28502508 DOI: 10.1016/j.jacl.2017.02.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 02/15/2017] [Accepted: 02/17/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with autosomal dominant hypercholesterolemia (ADH), caused by mutations in either low-density lipoprotein receptor (LDLR), apolipoprotein B (APOB), or proprotein convertase subtilisin-kexin type 9 (PCSK9) are characterized by high low-density lipoprotein cholesterol levels and in some studies also high lipoprotein(a) (Lp(a)) levels were observed. The question remains whether this effect on Lp(a) levels is gene-dose-dependent in individuals with either 0, 1, or 2 LDLR or APOB mutations. OBJECTIVE We set out to study whether Lp(a) levels differ among bi-allelic ADH mutation carriers, and their relatives, in the Netherlands. METHODS Bi-allelic ADH mutation carriers were identified in the database of the national referral laboratory for DNA diagnostics of inherited dyslipidemias. Family members were invited by the index cases to participate. Clinical parameters and Lp(a) levels were measured in bi-allelic ADH mutation carriers and their heterozygous and unaffected relatives. RESULTS We included a total of 119 individuals; 34 bi-allelic ADH mutation carriers (20 homozygous/compound heterozygous LDLR mutation carriers (HoFH), 2 homozygous APOB mutation carriers (HoFDB), and 12 double heterozygotes for an LDLR and APOB mutation), 63 mono-allelic ADH mutation carriers (50 heterozygous LDLR [HeFH], 13 heterozygous APOB [HeFDB] mutation carriers), and 22 unaffected family members. Median Lp(a) levels in unaffected relatives, HeFH, and HoFH patients were 19.9 (11.1-41.5), 24.4 (5.9-70.6), and 47.3 (14.9-111.7) mg/dL, respectively (P = .150 for gene-dose dependency). Median Lp(a) levels in HeFDB and HoFDB patients were 50.3 (18.7-120.9) and 205.5 (no interquartile range calculated), respectively (P = .012 for gene-dose-dependency). Double heterozygous carriers of LDLR and APOB mutations had median Lp(a) levels of 27.0 (23.5-45.0), which did not significantly differ from HoFH and HoFDB patients (P = .730 and .340, respectively). CONCLUSION A (trend toward) increased plasma Lp(a) levels in homozygous ADH patients compared with both heterozygous ADH and unaffected relatives was observed. Whether increased Lp(a) levels in homozygous ADH patients add to the increased cardiovascular disease risk and whether this risk can be reduced by therapies that lower both low-density lipoprotein cholesterol and Lp(a) levels remains to be elucidated.
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Affiliation(s)
- Barbara Sjouke
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.
| | - Reyhana Yahya
- Department of Internal Medicine, Erasmus Medical Centre, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Joep C Defesche
- Department of Clinical Genetics, Academic Medical Center, Amsterdam, The Netherlands
| | - Jacqueline de Graaf
- Division of Vascular Medicine, Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Albert Wiegman
- Department of Pediatrics, Academic Medical Center, Amsterdam, The Netherlands
| | - John J P Kastelein
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Monique T Mulder
- Department of Internal Medicine, Erasmus Medical Centre, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Jeanine E Roeters van Lennep
- Department of Internal Medicine, Erasmus Medical Centre, Erasmus University of Rotterdam, Rotterdam, The Netherlands
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Moriarty PM, Varvel SA, Gordts PLSM, McConnell JP, Tsimikas S. Lipoprotein(a) Mass Levels Increase Significantly According to APOE Genotype: An Analysis of 431 239 Patients. Arterioscler Thromb Vasc Biol 2017; 37:580-588. [PMID: 28062489 DOI: 10.1161/atvbaha.116.308704] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/21/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Lipoprotein(a) [Lp(a)] levels are genetically determined by hepatocyte apolipoprotein(a) synthesis, but catabolic pathways also influence circulating levels. APOE genotypes have different affinities for the low-density lipoprotein (LDL) receptor and LDL-related protein-1, with ε2 having the weakest binding to LDL receptor at <2% relative to ε3 and ε4. APPROACH AND RESULTS: APOE genotypes (ε2/ε2, ε2/ε3, ε2/ε4, ε3/ε3, ε3/ε4, and ε4/ε4), Lp(a) mass, directly measured Lp(a)-cholesterol levels, and a variety of apoB-related lipoproteins were measured in 431 239 patients. The prevalence of APOE traits were ε2: 7.35%, ε3: 77.56%, and ε4: 15.09%. Mean (SD) Lp(a) levels were 65% higher in ε4/ε4 compared with ε2/ε2 genotypes and increased significantly according to APOE genotype: ε2/ε2: 23.4 (29.2), ε2/ε3: 31.3 (38.0), ε2/ε4: 32.8 (38.5), ε3/ε3: 33.2 (39.1), ε3/ε4: 35.5 (41.6), and ε4/ε4: 38.5 (44.1) mg/dL (P<0.0001). LDL-cholesterol, apoB, Lp(a)-cholesterol, LDL-cholesterol corrected for Lp(a)-cholesterol content, LDL-particle number, and small, dense LDL also had similar patterns. Patients with LDL-cholesterol ≥250 mg/dL, who are more likely to have LDL receptor mutations and reduced affinity for apoB, had higher Lp(a) levels across all apoE isoforms, but particularly in patients with ε2 alleles, compared with LDL <250 mg/dL. The lowest Lp(a) mass levels were present in patients with ε2 isoforms and lowest LDL-cholesterol. CONCLUSIONS APOE genotypes strongly influence Lp(a) and apoB-related lipoprotein levels. This suggests that differences in affinity of apoE proteins for lipoprotein clearance receptors may affect Lp(a) catabolism, suggesting a competition between Lp(a) and apoE protein for similar receptors.
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Affiliation(s)
- Patrick M Moriarty
- From the Division of Clinical Pharmacology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City (P.M.M.); Salveo Diagnostics, Inc, Richmond, VA (S.A.V., J.P.M.); Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center (P.L.S.M.G.), Department of Medicine, Division of Endocrinology and Metabolism (P.L.S.M.G.), and Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center (S.T.), University of California San Diego, La Jolla
| | - Stephen A Varvel
- From the Division of Clinical Pharmacology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City (P.M.M.); Salveo Diagnostics, Inc, Richmond, VA (S.A.V., J.P.M.); Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center (P.L.S.M.G.), Department of Medicine, Division of Endocrinology and Metabolism (P.L.S.M.G.), and Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center (S.T.), University of California San Diego, La Jolla
| | - Philip L S M Gordts
- From the Division of Clinical Pharmacology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City (P.M.M.); Salveo Diagnostics, Inc, Richmond, VA (S.A.V., J.P.M.); Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center (P.L.S.M.G.), Department of Medicine, Division of Endocrinology and Metabolism (P.L.S.M.G.), and Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center (S.T.), University of California San Diego, La Jolla
| | - Joseph P McConnell
- From the Division of Clinical Pharmacology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City (P.M.M.); Salveo Diagnostics, Inc, Richmond, VA (S.A.V., J.P.M.); Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center (P.L.S.M.G.), Department of Medicine, Division of Endocrinology and Metabolism (P.L.S.M.G.), and Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center (S.T.), University of California San Diego, La Jolla
| | - Sotirios Tsimikas
- From the Division of Clinical Pharmacology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City (P.M.M.); Salveo Diagnostics, Inc, Richmond, VA (S.A.V., J.P.M.); Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center (P.L.S.M.G.), Department of Medicine, Division of Endocrinology and Metabolism (P.L.S.M.G.), and Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center (S.T.), University of California San Diego, La Jolla.
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93
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Chan DC, Barrett PHR, Watts GF. Recent explanatory trials of the mode of action of drug therapies on lipoprotein metabolism. Curr Opin Lipidol 2016; 27:550-556. [PMID: 27749370 DOI: 10.1097/mol.0000000000000348] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Dysregulated lipoprotein metabolism leads to increased plasma concentrations of atherogenic lipoproteins. We highlight the findings from recent studies of the effect of lipid-regulating therapies on apolipoprotein metabolism in humans employing endogenous labelling with stable isotopically labelled isotopomers. RECENT FINDINGS Fish oil supplementation and niacin treatment both reduce fasting and postprandial triglyceride levels by decreasing the hepatic secretion of VLDL-apoB-100 (apoB) and apoB-48-containing chylomicron particles in obese and/or type 2 diabetes. Niacin also lowers plasma LDL-apoB and Lp(a) levels by increasing catabolism of LDL-apoB and decreasing secretion of Lp(a), respectively. In subjects with hypercholesterolaemia, inhibition of cholesteryl ester transfer protein raises apoA-I and lowers apoB by decreasing and increasing the catabolism of HDL-apoA-I and LDL-apoB, respectively. Antisense oligonucleotides directed at apoB mRNA lowers plasma LDL-cholesterol and apoB chiefly by increasing the catabolism and decreasing the secretion of LDL-apoB in healthy subjects. That apoB ASO treatment does not lower hepatic secretion in humans is unexpected and merits further investigation. SUMMARY Kinetic studies provide mechanistic insight into the mode of action of lipid lowering therapies and lipoprotein disorders. Understanding the mode of action of new drugs in vivo is important to establish their effective use in clinical practice.
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Affiliation(s)
- Dick C Chan
- Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
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94
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Kostner KM, Kostner GM. Lipoprotein (a): a historical appraisal. J Lipid Res 2016; 58:1-14. [PMID: 27821413 DOI: 10.1194/jlr.r071571] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/01/2016] [Indexed: 11/20/2022] Open
Abstract
Initially, lipoprotein (a) [Lp(a)] was believed to be a genetic variant of lipoprotein (Lp)-B. Because its lipid moiety is almost identical to LDL, Lp(a) has been deliberately considered to be highly atherogenic. Lp(a) was detected in 1963 by Kare Berg, and individuals who were positive for this factor were called Lpa+ Lpa+ individuals were found more frequently in patients with coronary heart disease than in controls. After the introduction of quantitative methods for monitoring of Lp(a), it became apparent that Lp(a), in fact, is present in all individuals, yet to a greatly variable extent. The genetics of Lp(a) had been a mystery for a long time until Gerd Utermann discovered that apo(a) is expressed by a variety of alleles, giving rise to a unique size heterogeneity. This size heterogeneity, as well as countless mutations, is responsible for the great variability in plasma Lp(a) concentrations. Initially, we proposed to evaluate the risk of myocardial infarction at a cut-off for Lp(a) of 30-50 mg/dl, a value that still is adopted in numerous epidemiological studies. Due to new therapies that lower Lp(a) levels, there is renewed interest and still rising research activity in Lp(a). Despite all these activities, numerous gaps exist in our knowledge, especially as far as the function and metabolism of this fascinating Lp are concerned.
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Affiliation(s)
- Karam M Kostner
- Department of Cardiology, Mater Hospital and University of Queensland, Brisbane, 4101 Queensland, Australia
| | - Gert M Kostner
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, A-8010 Graz, Austria
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95
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Nordestgaard BG, Langsted A. Lipoprotein (a) as a cause of cardiovascular disease: insights from epidemiology, genetics, and biology. J Lipid Res 2016; 57:1953-1975. [PMID: 27677946 DOI: 10.1194/jlr.r071233] [Citation(s) in RCA: 337] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 12/24/2022] Open
Abstract
Human epidemiologic and genetic evidence using the Mendelian randomization approach in large-scale studies now strongly supports that elevated lipoprotein (a) [Lp(a)] is a causal risk factor for cardiovascular disease, that is, for myocardial infarction, atherosclerotic stenosis, and aortic valve stenosis. The Mendelian randomization approach used to infer causality is generally not affected by confounding and reverse causation, the major problems of observational epidemiology. This approach is particularly valuable to study causality of Lp(a), as single genetic variants exist that explain 27-28% of all variation in plasma Lp(a). The most important genetic variant likely is the kringle IV type 2 (KIV-2) copy number variant, as the apo(a) product of this variant influences fibrinolysis and thereby thrombosis, as opposed to the Lp(a) particle per se. We speculate that the physiological role of KIV-2 in Lp(a) could be through wound healing during childbirth, infections, and injury, a role that, in addition, could lead to more blood clots promoting stenosis of arteries and the aortic valve, and myocardial infarction. Randomized placebo-controlled trials of Lp(a) reduction in individuals with very high concentrations to reduce cardiovascular disease are awaited. Recent genetic evidence documents elevated Lp(a) as a cause of myocardial infarction, atherosclerotic stenosis, and aortic valve stenosis.
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Affiliation(s)
- Børge G Nordestgaard
- Department of Clinical Biochemistry and Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Langsted
- Department of Clinical Biochemistry and Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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96
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Tsimikas S. The re-emergence of lipoprotein(a) in a broader clinical arena. Prog Cardiovasc Dis 2016; 59:135-144. [PMID: 27497506 DOI: 10.1016/j.pcad.2016.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 07/24/2016] [Indexed: 01/13/2023]
Abstract
Lipoprotein(a) [Lp(a)] is a genetic, independent and likely causal risk factor for cardiovascular disease (CVD) and calcific aortic valve stenosis (CAVS). Lp(a) levels are primarily genetically determined and tend to fluctuate only mildly around a pre-determined level. In primary care settings, one Lp(a) measurement can reclassify up to 40% of patients in intermediate risk score categories. In secondary care settings, recent data from the JUPITER and AIM-HIGH trials demonstrate that elevated Lp(a) remains part of the "residual risk" despite achievement of low-density lipoprotein cholesterol levels <70 mg/dL. Recent reports suggest that statins can increase Lp(a) levels, potentially further contributing to this residual risk. Current therapies to lower Lp(a) are limited to niacin, mipomersen and proprotein convertase subtilisin kexin-type 9 inhibitors, but these drugs are limited by weak efficacy and not specifically approved for Lp(a) lowering. Emerging therapies to lower Lp(a) may shed new light into the potential clinical benefit of lowering Lp(a) in CVD and CAVS.
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Affiliation(s)
- Sotirios Tsimikas
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA.
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97
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Abstract
PURPOSE OF REVIEW Currently, different methods for extracorporeal elimination of atherogenic apolipoprotein B100 containing lipoprotein particles are used in clinical practice. Most of them effectively remove both lipoprotein(a) [Lp(a)] and LDL. The aim of this review is to highlight research describing the clinical advantages of specific Lp(a) immunosorption compared with other lipoprotein apheresis systems. RECENT FINDINGS Data on the utility of lipoprotein apheresis in patients with elevated Lp(a) level are limited. However, several longitudinal studies demonstrated improvement in cardiovascular outcomes when both Lp(a) and LDL cholesterol levels were decreased with different apheresis systems. The main limitation of these trials is the absence of a control group. First developed in 1991, studies on apheresis with a specific immunosorbent to Lp(a) were small and noncontrolled before 2000s. The only prospective controlled clinical trial utilising Lp(a) apheresis (Clinicaltrials.gov NCT02133807), demonstrated regression of coronary and carotid atherosclerosis when Lp(a) was removed weekly for 18 months. SUMMARY Lipoprotein apheresis usually affects multiple lipoproteins, and there are minimal data regarding the effect of specific removal of Lp(a) alone. There is a need for randomized controlled trial with specific Lp(a) apheresis to investigate its effect on cardiovascular outcomes.
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Affiliation(s)
- Sergei N Pokrovsky
- 'Russian Cardiology Research and Production Complex' of Ministry of Health of the Russian Federation, Moscow, Russia
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98
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Ellis KL, Hooper AJ, Burnett JR, Watts GF. Progress in the care of common inherited atherogenic disorders of apolipoprotein B metabolism. Nat Rev Endocrinol 2016; 12:467-84. [PMID: 27199287 DOI: 10.1038/nrendo.2016.69] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Katrina L Ellis
- School of Medicine and Pharmacology, The University of Western Australia, PO Box X2213, Perth, Western Australia 6847, Australia
- Centre for Genetic Origins of Health and Disease, The University of Western Australia and Curtin University, 35 Stirling Highway, Crawley, Perth, Western Australia 6009, Australia
| | - Amanda J Hooper
- School of Medicine and Pharmacology, The University of Western Australia, PO Box X2213, Perth, Western Australia 6847, Australia
- PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia
- School of Pathology and Laboratory Medicine, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, Western Australia 6009, Australia
| | - John R Burnett
- School of Medicine and Pharmacology, The University of Western Australia, PO Box X2213, Perth, Western Australia 6847, Australia
- PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Wellington Street Perth, Western Australia, Australia
| | - Gerald F Watts
- School of Medicine and Pharmacology, The University of Western Australia, PO Box X2213, Perth, Western Australia 6847, Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Wellington Street Perth, Western Australia, Australia
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99
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Lakshminarayan D, Elajami TK, Devabhaktuni S, Welty FK. Ischemic stroke in a young adult with extremely elevated lipoprotein(a): A case report and review of literature. J Clin Lipidol 2016; 10:1266-71. [PMID: 27678446 DOI: 10.1016/j.jacl.2016.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/28/2016] [Accepted: 06/30/2016] [Indexed: 11/16/2022]
Abstract
Lipoprotein(a) [Lp(a)] is an apolipoprotein(a) molecule bound to 1 apolipoprotein B-100. Elevated levels of Lp(a) are thought to be an independent risk factor for atherosclerosis and to promote thrombosis through incompletely understood mechanisms. We report a 34-year-old man with an ischemic stroke in the setting of an extremely high Lp(a) level-212 mg/dL. He developed severe carotid artery stenosis over a 6-year period and had thrombus formation post-carotid endarterectomy. To our knowledge, this case is unique because the Lp(a) is the highest reported level in a patient without renal disease. Moreover, this is the first reported case of the youngest individual with a stroke presumably related to development of carotid plaque over a 6-year period. The thrombotic complication after endarterectomy may have been related to the prothrombotic properties of Lp(a). Of note, the Lp(a) level did not respond to atorvastatin but did decrease 15% after aspirin 325 mg was added although his Lp(a) levels were variable, and it is not clear that this was cause and effect. This case highlights the need to better understand the relation between Lp(a) and vascular disease and the need to screen family members for elevated Lp(a). We also review treatment options to lower Lp(a) and ongoing clinical trials of newer lipid-lowering drugs that can also lower Lp(a).
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Affiliation(s)
- Dharshan Lakshminarayan
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Tarec K Elajami
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Suresh Devabhaktuni
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Francine K Welty
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA.
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Wierzbicki AS, Viljoen A. Anti-sense oligonucleotide therapies for the treatment of hyperlipidaemia. Expert Opin Biol Ther 2016; 16:1125-34. [PMID: 27248482 DOI: 10.1080/14712598.2016.1196182] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Anti-sense oligonucleotide (ASO) therapies are a new development in clinical pharmacology offering greater specificity compared to small molecule inhibitors and the ability to target intracellular process' not susceptible to antibody-based therapies. AREAS COVERED This article reviews the chemical biology of ASOs and related RNA therapeutics. It then reviews the data on their use to treat hyperlipidaemia. Data on mipomersen - an ASO to apolipoprotein B-100(apoB) licensed for treatment of homozygous familial hypercholesterolaemia (FH) is presented. Few effective therapies are available to reduce atehrogenic lipoprotein (a) levels. An ASO therapy to apolipoprotein(a) (ISIS Apo(a)Rx) specifically reduced lipoprotein (a) levels by up to 78%. Treatment options for patients with familial chylomicronaemia syndrome (lipoprotein lipase deficiency; LPLD) or lipodystrophies are highly limited and often inadequate. Volanesorsen, an ASO to apolipoprotein C-3, shows promise in the treatment of LPLD and severe hypertriglyceridaemia as it increases clearance of triglyceride-rich lipoproteins and can normalise triglycerides in these patients. EXPERT OPINION The uptake of the novel ASO therapies is likely to be limited to selected niche groups or orphan diseases. These will include homozygous FH, severe heterozygous FH for mipomersen; LPLD deficiency and lipodystrophy syndromes for volanesorsen and treatment of patients with high elevated Lp(a) levels.
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Affiliation(s)
- Anthony S Wierzbicki
- a Department of Metabolic Medicine/Chemical Pathology , Guy's and St Thomas' Hospitals , London , UK
| | - Adie Viljoen
- b Consultant in Metabolic Medicine/Chemical Pathology , Lister Hospital , Stevenage , UK
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