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Liu T, Yoon WS, Lee SR. Recent Updates of Lipoprotein(a) and Cardiovascular Disease. Chonnam Med J 2021; 57:36-43. [PMID: 33537217 PMCID: PMC7840349 DOI: 10.4068/cmj.2021.57.1.36] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022] Open
Abstract
In recent years, epidemiological studies, genome-wide association studies, and Mendelian randomization studies have shown a strong association between increased levels of lipoproteins and increased risks of coronary heart disease and cardiovascular disease (CVD). Although lipoprotein(a) [Lp(a)] was an independent risk factor for ASCVD, the latest international clinical guidelines do not recommend direct reduction of plasma Lp(a) concentrations. The main reason was that there is no effective clinical medicine that directly lowers plasma Lp(a) concentrations. However, recent clinical trials have shown that proprotein convertase subtilisin/kexin-type 9 inhibitors (PCSK9) and second-generation antisense oligonucleotides can effectively reduce plasma Lp(a) levels. This review will present the structure, pathogenicity, prognostic evidences, and recent advances in therapeutic drugs for Lp(a).
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Affiliation(s)
- Taili Liu
- Division of Cardiology, Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Won-Sik Yoon
- Division of Cardiology, Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Sang-Rok Lee
- Division of Cardiology, Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
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152
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Katzmann JL, Packard CJ, Chapman MJ, Katzmann I, Laufs U. Targeting RNA With Antisense Oligonucleotides and Small Interfering RNA: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 76:563-579. [PMID: 32731935 DOI: 10.1016/j.jacc.2020.05.070] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/29/2020] [Accepted: 05/10/2020] [Indexed: 12/11/2022]
Abstract
There is an unmet clinical need to reduce residual cardiovascular risk attributable to apolipoprotein B-containing lipoproteins, particularly low-density lipoprotein and remnant particles. Pharmacological targeting of messenger RNA represents an emerging, innovative approach. Two major classes of agents have been developed-antisense oligonucleotides and small interfering RNA. Early problems with their use have been overcome by conjugation with N-acetylgalactosamine, an adduct that targets their delivery to the primary site of action in the liver. Using these agents to inhibit the translation of key regulatory proteins such as PCSK9, apolipoprotein CIII, apolipoprotein(a), and angiopoietin-like 3 has been shown to be effective in attenuating dyslipidemic states. Cardiovascular outcome trials with N-acetylgalactosamine-conjugated RNA-targeting drugs are ongoing. The advantages of these agents include long dosing intervals of up to 6 months and the potential to regulate the abundance of any disease-related protein. Long-term safety has yet to be demonstrated in large-scale clinical trials.
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Affiliation(s)
- Julius L Katzmann
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany.
| | - Chris J Packard
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - M John Chapman
- Endocrinology-Metabolism Division, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France; National Institute for Health and Medical Research (INSERM), Paris, France
| | - Isabell Katzmann
- Department of Internal Medicine, Zeisigwaldkliniken Bethanien Chemnitz, Chemnitz, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
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153
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Sinning D, Landmesser U. [New Lipid-lowering Agents]. Dtsch Med Wochenschr 2021; 146:92-101. [PMID: 33465805 DOI: 10.1055/a-1199-8496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains a leading cause of morbidity and mortality. The fact that elevated levels of low-density lipoprotein-cholesterol (LDL-C) play a causal role in the development of ASCVD is now well accepted, given the results of numerous epidemiological and genetic studies, as well as randomized controlled clinical trials. Statins have become a primary therapeutic cornerstone in ASCVD prevention since they have been shown to reduce CV events by reducing levels of LDL-C. But despite the proven efficacy and safety of statin therapy, several aspects indicate a substantial need for additional or alternative LDL-C lowering therapies. These aspects include not only a high variability in individual response to therapy, but also possible side effects, potentially reducing adherence to treatment. Most importantly, an elevated risk for cardiovascular (CV) events remains in a large proportion of high-risk patients, especially in those with persistent elevation of LDL-C levels despite a maximum tolerated dose of statin therapy. Also, large clinical trials currently investigate a potential CV benefit of drug therapies targeting elevated levels of triglycerides and lipoprotein (a), respectively.
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154
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Hoogeveen RC, Ballantyne CM. Residual Cardiovascular Risk at Low LDL: Remnants, Lipoprotein(a), and Inflammation. Clin Chem 2021; 67:143-153. [PMID: 33257928 PMCID: PMC7793228 DOI: 10.1093/clinchem/hvaa252] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current guidelines target low-density lipoprotein cholesterol (LDL-C) concentrations to reduce atherosclerotic cardiovascular disease (ASCVD) risk, and yet clinical trials demonstrate persistent residual ASCVD risk despite aggressive LDL-C lowering. CONTENT Non-LDL-C lipid parameters, most notably triglycerides, triglyceride-rich lipoproteins (TGRLs), and lipoprotein(a), and C-reactive protein as a measure of inflammation are increasingly recognized as associated with residual risk after LDL-C lowering. Eicosapentaenoic acid in statin-treated patients with high triglycerides reduced both triglycerides and ASCVD events. Reducing TGRLs is believed to have beneficial effects on inflammation and atherosclerosis. High lipoprotein(a) concentrations increase ASCVD risk even in individuals with LDL-C < 70 mg/dL. Although statins do not generally lower lipoprotein(a), proprotein convertase subtilisin/kexin type 9 inhibitors reduce lipoprotein(a) and cardiovascular outcomes, and newer approaches are in development. Persistent increases in C-reactive protein after intensive lipid therapy have been consistently associated with increased risk for ASCVD events. SUMMARY We review the evidence that biochemical assays to measure TGRLs, lipoprotein(a), and C-reactive protein are associated with residual risk in patients treated to low concentrations of LDL-C. Growing evidence supports a causal role for TGRLs, lipoprotein(a), and inflammation in ASCVD; novel therapies that target TGRLs, lipoprotein(a), and inflammation are in development to reduce residual ASCVD risk.
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Affiliation(s)
- Ron C Hoogeveen
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
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155
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Abstract
Lipoprotein(a) has long been regarded as a risk factor for cardiovascular disease; however, its routine use in clinical practice has been hampered by difficulties inherent in the measurement of this complex lipoprotein. The major challenges relate to its size heterogeneity and related issues including (1) use of appropriate calibrators (2) standardization of calibration protocols (3) traceability and (4) reporting units. In the UK, results from the current EQA schemes for lipoprotein(a) suggest that there is considerable work required to standardize lipoprotein(a) measurement. This is becoming increasingly pertinent with the increasing recognition of lipoprotein(a) as an independent risk factor for cardiovascular disease in international guidelines and the emergence of novel antisense therapies to effectively reduce lipoprotein(a). This article raises awareness of the importance of measurement of lipoprotein(a) for the assessment of cardiovascular disease risk and gives guidance to clinical laboratories regarding choice of appropriate assays.
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Affiliation(s)
- Jaimini Cegla
- Division of Diabetes, Endocrinology and Metabolism, Imperial
College London, London, UK
| | - Michael France
- Department of Clinical Biochemistry, Manchester University NHS
Foundation Trust, Manchester, UK
| | | | - R Dermot G Neely
- Department of Blood Sciences and NIHR MedTech and IVD Centre,
Newcastle Upon Tyne Hospitals, Newcastle Upon Tyne, UK
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156
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Metabolomic Signature of Human Aortic Valve Stenosis. JACC Basic Transl Sci 2020; 5:1163-1177. [PMID: 33426374 PMCID: PMC7775961 DOI: 10.1016/j.jacbts.2020.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 12/17/2022]
Abstract
This study is the first step towards the creation of a metabolomic map of calcified human aortic valves. The study highlights an independent association of LysoPA with CAVS severity. The study demonstrates that LysoPA levels are associated with faster CAVS progression rate.
This study outlines the first step toward creating the metabolite atlas of human calcified aortic valves by identifying the expression of metabolites and metabolic pathways involved at various stages of calcific aortic valve stenosis progression. Untargeted analysis identified 72 metabolites and lipids that were significantly altered (p < 0.01) across different stages of disease progression. Of these metabolites and lipids, the levels of lysophosphatidic acid were shown to correlate with faster hemodynamic progression and could select patients at risk for faster progression rate.
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Key Words
- AS, aortic stenosis
- ATX, autotaxin
- AV, aortic valve
- AVA, aortic valve area
- BAV, bicuspid aortic valve
- CAVS, calcific aortic valve stenosis
- CV, correlation of variation
- Lp(a), lipoprotein(a)
- LysoPA, lysophosphatidic acid
- LysoPC, lysophosphatidylcholine
- LysoPE, lysophosphatidylethanolamine
- MG, monoglyceride
- MPG, mean pressure gradient
- PC, phosphatidylcholine
- QC, quality control
- TAV, tricuspid aortic valve
- Vmax, peak aortic jet velocity
- aortic stenosis
- calcific aortic valve stenosis
- lysophosphatidic acids
- nontargeted metabolomics
- targeted lipidomics
- valvular calcification
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157
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Langsted A, Kamstrup PR, Nordestgaard BG. High lipoprotein(a) and high risk of mortality. Eur Heart J 2020; 40:2760-2770. [PMID: 30608559 DOI: 10.1093/eurheartj/ehy902] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/14/2018] [Accepted: 12/26/2018] [Indexed: 11/12/2022] Open
Abstract
AIMS Several lipoprotein(a)-lowering therapies are currently being developed with the long-term goal of reducing cardiovascular disease and mortality; however, the relationship between lipoprotein(a) and mortality is unclear. We tested the hypothesis that lipoprotein(a) levels are associated with risk of mortality. METHODS AND RESULTS We studied individuals from two prospective studies of the Danish general population, of which 69 764 had information on lipoprotein(a) concentrations, 98 810 on LPA kringle-IV type 2 (KIV-2) number of repeats, and 119 094 on LPA rs10455872 genotype. Observationally, lipoprotein(a) >93 mg/dL (199 nmol/L; 96th-100th percentiles) vs. <10 mg/dL (18 nmol/L; 1st-50th percentiles) were associated with a hazard ratio of 1.50 (95% confidence interval 1.28-1.76) for cardiovascular mortality and of 1.20 (1.10-1.30) for all-cause mortality. The median survival for individuals with lipoprotein(a) >93 mg/dL (199 nmol/L; 96th-100th percentiles) and ≤93 mg/dL (199 nmol/L; 1st-95th percentiles) were 83.9 and 85.1 years (log rank P = 0.005). For cardiovascular mortality, a 50 mg/dL (105 nmol/L) increase in lipoprotein(a) levels was associated observationally with a hazard ratio of 1.16 (1.09-1.23), and genetically with risk ratios of 1.23 (1.08-1.41) based on LPA KIV2 and of 0.98 (0.88-1.09) based on LPA rs10455872. For all-cause mortality, corresponding values were 1.05 (1.01-1.09), 1.10 (1.04-1.18), and 0.97 (0.92-1.02), respectively. Finally, for a similar cholesterol content increase, lipoprotein(a) was more strongly associated with cardiovascular and all-cause mortality than low-density lipoprotein, implying that the mortality effect of high lipoprotein(a) is above that explained by its cholesterol content. CONCLUSION High levels of lipoprotein(a), through corresponding low LPA KIV-2 number of repeats rather than through high cholesterol content were associated with high risk of mortality. These findings are novel.
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Affiliation(s)
- Anne Langsted
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, DK Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, DK Herlev, Denmark
| | - Pia R Kamstrup
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, DK Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, DK Herlev, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, DK Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, DK Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.,Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, DK Frederiksberg, Denmark
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158
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Abstract
Familial hypercholesterolemia (FH) is a rare autosomal gene deficiency disease with increased low-density lipoprotein cholesterol, xanthoma, and premature coronary heart disease. Calcified aortic valve disease (CAVD) is prevalent in FH patients, resulting in adverse events and heavy health care burden. Aortic valve calcification is currently considered an active biological process, which shares several common risk factors with atherosclerosis, including aging, hypertension, dyslipidemia, and so on. Unfortunately, the pathogenesis and therapy of CAVD in FH are still controversial. There is no pharmacological intervention recommended to delay the development of CAVD in FH, and the only effective treatment for severe CAVD is aortic valve replacement. In this review, we summarize the detailed description of the pathophysiology, molecular mechanism, risk factors, and treatment of CAVD in FH patients.
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159
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Wang X, Li J, Ju J, Fan Y, Xu H. Effect of different types and dosages of statins on plasma lipoprotein(a) levels: A network meta-analysis. Pharmacol Res 2020; 163:105275. [PMID: 33166736 DOI: 10.1016/j.phrs.2020.105275] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/06/2020] [Accepted: 10/22/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM Studies differ with respect to the effects of statins and their on lipoprotein(a)[Lp(a)] levels. The aim of the present study was to resolve these differences by determining the effect of various types and dosages of statins on Lp(a) levels. METHODS We searched PubMed, Embase and the Cochrane library for randomized controlled trials (RCTs) investigating the efficacy of statins on plasma Lp(a) levels. Study selection, data extraction and risk of bias assessment were conducted independently by four authors. We conducted pairwise meta-analysis and network meta-analysis (NMA). Consistency models were applied to NMA and the ranking probabilities for each treatment's efficacy were calculated. Node-splitting analysis was used to test inconsistency. This study was registered with PROSPERO, number CRD42020167612. RESULTS Twenty RCTs with 23,605 participants were included, involving 11 interventions. Most of the included studies presented some risks of bias, especially risks of performance and detection bias. In the pairwise meta-analysis, pooled results showed a small but statistically significant difference between high-intensity rosuvastatin and placebo on Lp(a) levels (MD = 1.81, 95 % CI [0.43, 3.19], P = 0.01). In the NMA, different types and dosages of statins showed no significant effect on the level of Lp(a), and there was no obvious difference between them. Subgroup analysis based on different populations and treatment durations did not provide any statistically significant findings about different statins on Lp(a) levels. Node-splitting analysis showed that no significant inconsistency existed (P > 0.05). CONCLUSIONS Statins have no clinically significant effect on Lp(a) levels, and there is no significant difference in the effect on Lp(a) levels between different types and dosages of statins. Moderate-intensity pitavastatin tended to have the best effect on reducing Lp(a) levels; nevertheless, it was insignificant. Our findings highlight the necessity for further study of the effect of statins on Lp(a) levels in future studies.
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Affiliation(s)
- Xinyi Wang
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China; National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Jingen Li
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100007, China
| | - Jianqing Ju
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Yixuan Fan
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China; National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Hao Xu
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
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160
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Berman AN, Biery DW, Ginder C, Hulme OL, Marcusa D, Leiva O, Wu WY, Singh A, Divakaran S, Hainer J, Turchin A, Januzzi JL, Natarajan P, Cannon CP, Di Carli MF, Bhatt DL, Blankstein R. Study of lipoprotein(a) and its impact on atherosclerotic cardiovascular disease: Design and rationale of the Mass General Brigham Lp(a) Registry. Clin Cardiol 2020; 43:1209-1215. [PMID: 32893370 PMCID: PMC7661644 DOI: 10.1002/clc.23456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/24/2022] Open
Abstract
Lipoprotein(a) [Lp(a)] is independently associated with atherosclerotic cardiovascular disease and calcific aortic valve stenosis. Elevated Lp(a) affects approximately one in five individuals and meaningfully contributes to the residual cardiovascular risk in individuals with otherwise well-controlled risk factors. With targeted therapies in the therapeutic pipeline, there is a need to further characterize the clinical phenotypes and outcomes of individuals with elevated levels of this unique biomarker. The Mass General Brigham Lp(a) Registry will be built from the longitudinal electronic health record of two large academic medical centers in Boston, Massachusetts, to develop a detailed cohort of patients who have had their Lp(a) measured. In combination with structured data sources, clinical documentation will be analyzed using natural language processing techniques to accurately characterize baseline characteristics. Important outcome measures including all-cause mortality, cardiovascular mortality, and cardiovascular events will be available for analysis. Approximately 30 000 patients who have had their Lp(a) tested within the Mass General Brigham system from January 2000 to July 2019 will be included in the registry. This large Lp(a) cohort will provide meaningful observational data regarding the differential risk associated with Lp(a) values and cardiovascular disease. With a new frontier of targeted Lp(a) therapies on the horizon, the Mass General Brigham Lp(a) Registry will help provide a deeper understanding of Lp(a)'s role in long term cardiovascular outcomes.
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Affiliation(s)
- Adam N. Berman
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David W. Biery
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Curtis Ginder
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Olivia L. Hulme
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Daniel Marcusa
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Orly Leiva
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Wanda Y. Wu
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Avinainder Singh
- Department of MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Sanjay Divakaran
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Jon Hainer
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Alexander Turchin
- Division of Endocrinology, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - James L. Januzzi
- Cardiology DivisionMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Pradeep Natarajan
- Cardiology DivisionMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Christopher P. Cannon
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Marcelo F. Di Carli
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Deepak L. Bhatt
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Ron Blankstein
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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161
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Afshar M, Rong J, Zhan Y, Chen HY, Engert JC, Sniderman AD, Larson MG, Vasan RS, Thanassoulis G. Risks of Incident Cardiovascular Disease Associated With Concomitant Elevations in Lipoprotein(a) and Low-Density Lipoprotein Cholesterol-The Framingham Heart Study. J Am Heart Assoc 2020; 9:e014711. [PMID: 32892691 PMCID: PMC7726982 DOI: 10.1161/jaha.119.014711] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/29/2020] [Indexed: 12/13/2022]
Abstract
Background Elevated lipoprotein(a) is a well-established risk factor for atherosclerotic vascular disease but is not measured in routine clinical care. Screening of high lipoprotein(a) in individuals with moderate elevations of low-density lipoprotein cholesterol (LDL-C) may identify individuals at high risk of cardiovascular disease. Methods and Results We examined 2606 Framingham Offspring participants (median age, 54 years; 45% men) prospectively with a median follow-up of 15 years (n=392 incident cardiovascular events). Individuals with higher (≥100 nmol/L) versus lower lipoprotein(a) were divided into groups based on LDL-C <135 mg/dL versus ≥135 mg/dL. In Cox models, after adjustment for known risk factors, high lipoprotein(a) (≥100 nmol/L) and LDL-C ≥135 mg/dL were each significant predictors of cardiovascular disease (LDL-C ≥135 mg/dL: hazard ratio [HR], 1.34; 95% CI, 1.09-1.64; P=0.006; high lipoprotein (a): HR, 1.31; 95% CI, 1.03-1.66; P=0.026). Across the groups of high/low lipoprotein (a) and LDL-C ≥135 mg/dL or <135 mg/dL, the absolute cardiovascular disease risks at 15 years were 22.6% (high lipoprotein(a)/LDL-C ≥135 mg/dL, n=248), 17.3% (low lipoprotein(a)/LDL-C ≥135 mg/dL, n=758), 12.7% (high lipoprotein(a)/LDL-C <135 mg/dL, n=275) and 11.5% (low lipoprotein(a)/LDL-C <135 mg/dL, n=1328, reference group). Among individuals with LDL-C ≥135 mg/dL, those with high lipoprotein(a) had a 43% higher risk (HR, 1.43; 95% CI, 1.05-1.97; P=0.02). Presence of high lipoprotein(a) with moderate LDL-C levels (135-159 mg/dL) yielded absolute risks equivalent to those with LDL-C ≥160 mg/dL (23.5%, 95% CI, 17.4%-31.3%; and 20.7%, 95% CI, 16.8%-25.3%, respectively). Conclusions Concomitant elevation of LDL-C ≥135 mg/dL and lipoprotein(a) ≥100 nmol/L is associated with a high absolute risk of incident cardiovascular disease. lipoprotein(a) measurement in individuals with moderate elevations in LDL-C, who do not otherwise meet criteria for statins, may identify individuals at high cardiovascular risk.
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Affiliation(s)
- Mehdi Afshar
- Division of CardiologyUniversity of TorontoTorontoCanada
| | - Jian Rong
- Department of NeurologyBoston University School of MedicineBostonMA
| | - Yang Zhan
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
- Division of CardiologyUniversity of SaskatchewanReginaCanada
| | - Hao Yu Chen
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
| | - James C. Engert
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
| | - Allan D. Sniderman
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
| | - Martin G. Larson
- NHLBI’s and Boston University’s Framingham Heart StudyBostonMA
- Department of BiostatisticsBoston University School of Public HealthBostonMA
| | - Ramachandran S. Vasan
- NHLBI’s and Boston University’s Framingham Heart StudyBostonMA
- Department of EpidemiologyBoston University School of Public HealthBostonMA
- Preventive Medicine and CardiologyBoston University School of MedicineBostonMA
| | - George Thanassoulis
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
- Department of Clinical EpidemiologyMcGill University Health CentreMontrealCanada
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162
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Chou EL, Pettinger M, Haring B, Mell MW, Hlatky MA, Wactawski-Wende J, Allison MA, Wild RA, Shadyab AH, Wallace RB, Snetselaar LG, Eagleton MJ, Conrad MF, Liu S. Lipoprotein(a) levels and risk of abdominal aortic aneurysm in the Women's Health Initiative. J Vasc Surg 2020; 73:1245-1252.e3. [PMID: 32882349 DOI: 10.1016/j.jvs.2020.07.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/26/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Few studies have prospectively examined the associations of lipoprotein(a) [Lp(a)] levels with the risk of abdominal aortic aneurysm (AAA), especially in women. Accounting for commonly recognized risk factors, we investigated the baseline Lp(a) levels and the risk of AAA among postmenopausal women participating in the ongoing national Women's Health Initiative. METHODS Women's Health Initiative participants with baseline Lp(a) levels available who were beneficiaries of Medicare parts A and B fee-for-service at study enrollment or who had aged into Medicare at any point were included. Participants with missing covariate data or known AAA at baseline were excluded. Thoracic aneurysms were excluded owing to the different pathophysiology. The AAA cases and interventions were identified using the International Classification of Diseases, 9th and 10th revision, codes and Current Procedural Terminology codes from claims data. Hazard ratios were computed using Cox proportional hazard models according to the quintiles of Lp(a). RESULTS The mean age of the 6615 participants included in the analysis was 65.3 years. Of the 6615 participants, 66.6% were non-Hispanic white, 18.9% were black, 7% were Hispanic and 4.7% were Asian/Pacific Islander. Compared with the participants in the lowest Lp(a) quintile, those in higher quintiles were more likely to be overweight, black, and former or current smokers, to have hypertension, hyperlipidemia, and a history of cardiovascular disease, and to use menopausal hormone therapy and statins. During 65,476 person-years of follow-up, with a median of 10.4 years, 415 women had been diagnosed with an AAA and 36 had required intervention. More than one half had required intervention for a ruptured AAA. We failed to find a statistically significant association between Lp(a) levels and incident AAA. Additional sensitivity analyses stratified by race, with exclusion of statin users and alternative categorizations of Lp(a) using log-transformed levels, tertiles, and a cutoff of >50 mg/dL, were conducted, which did not reveal any significant associations. CONCLUSIONS We found no statistically significant association between Lp(a) levels and the risk of AAA in a large and well-phenotyped sample of postmenopausal women. Women with high Lp(a) levels were more likely to be overweight, black, and former or current smokers, and to have hypertension, hyperlipidemia, and a history of cardiovascular disease, or to use hormone therapy and statins compared with those with lower Lp(a) levels. These findings differ from previous prospective, case-control, and meta-analysis studies that had supported a significant relationship between higher Lp(a) levels and an increased risk of AAA. Differences in the association could have resulted from study limitations or sex differences.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Mary Pettinger
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Wash
| | - Bernhard Haring
- Department of Internal Medicine, University of Würzburg, Würzburg, Germany
| | - Matthew W Mell
- Division of Vascular Surgery, University of California, Davis, Medical Center, Sacramento, Calif
| | - Mark A Hlatky
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, Calif
| | - Jean Wactawski-Wende
- Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY
| | - Matthew A Allison
- Department of Family Medicine and Public Health, University of California, San Diego, School of Medicine, La Jolla, Calif
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Aladdin H Shadyab
- Department of Family Medicine and Public Health, University of California, San Diego, School of Medicine, La Jolla, Calif
| | - Robert B Wallace
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Linda G Snetselaar
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Simin Liu
- Department of Epidemiology and Medicine, Brown University, Providence, RI
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163
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Bourgeois R, Devillers R, Perrot N, Després AA, Boulanger MC, Mitchell PL, Guertin J, Couture P, Boffa MB, Scipione CA, Pibarot P, Koschinsky ML, Mathieu P, Arsenault BJ. Interaction of Autotaxin With Lipoprotein(a) in Patients With Calcific Aortic Valve Stenosis. ACTA ACUST UNITED AC 2020; 5:888-897. [PMID: 33015412 PMCID: PMC7524777 DOI: 10.1016/j.jacbts.2020.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/24/2022]
Abstract
Our objectives were to determine whether autotaxin (ATX) is transported by lipoprotein(a) [Lp(a)] in human plasma and if could be used as a biomarker of calcific aortic valve stenosis (CAVS). We first found that ATX activity was higher in Lp(a) compared to low-density lipoprotein fractions in isolated fractions of 10 healthy participants. We developed a specific assay to measure ATX-Lp(a) in 88 patients with CAVS and 144 controls without CAVS. In a multivariable model corrected for CAVS risk factors, ATX-Lp(a) was associated with CAVS (p = 0.003). We concluded that ATX is preferentially transported by Lp(a) and might represent a novel biomarker for CAVS.
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Key Words
- ALR, adiponectin-to-leptin ratio
- ATX, autotaxin
- ATX-apo(a), ATX carried by Lp(a)
- ATX-apoB, ATX carried by apoB-containing lipoproteins
- BMI, body mass index
- CAD, coronary artery disease
- CAVS, calcific aortic valve stenosis
- HDL, high-density lipoprotein
- LDL, low-density lipoprotein
- Lp(a), lipoprotein(a)
- LysoPA, lysophosphatidic acid
- LysoPC, lysophosphatidylcholine
- OxPLs, oxidized phospholipids
- apo(a), apolipoprotein(a)
- apoB, apolipoprotein B
- autotaxin
- calcific aortic valve stenosis
- lipoprotein(a)
- low-density lipoproteins
- obesity
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Affiliation(s)
- Raphaëlle Bourgeois
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Department of Medicine, Faculty of Medicine, Université Laval, Québec, Canada
| | - Romain Devillers
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Department of Surgery, Faculty of Medicine, Université Laval, Québec, Canada
| | - Nicolas Perrot
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Department of Medicine, Faculty of Medicine, Université Laval, Québec, Canada
| | - Audrey-Anne Després
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Department of Medicine, Faculty of Medicine, Université Laval, Québec, Canada
| | - Marie-Chloé Boulanger
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada
| | - Patricia L Mitchell
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada
| | - Jakie Guertin
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Department of Medicine, Faculty of Medicine, Université Laval, Québec, Canada
| | - Patrick Couture
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Centre de Recherche du CHU de Québec, Quebec, Canada
| | - Michael B Boffa
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Corey A Scipione
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Philippe Pibarot
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Department of Medicine, Faculty of Medicine, Université Laval, Québec, Canada
| | - Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Patrick Mathieu
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Department of Surgery, Faculty of Medicine, Université Laval, Québec, Canada
| | - Benoit J Arsenault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada.,Department of Medicine, Faculty of Medicine, Université Laval, Québec, Canada
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164
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Rehberger Likozar A, Zavrtanik M, Šebeštjen M. Lipoprotein(a) in atherosclerosis: from pathophysiology to clinical relevance and treatment options. Ann Med 2020; 52:162-177. [PMID: 32453609 PMCID: PMC7877976 DOI: 10.1080/07853890.2020.1775287] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Lipoprotein(a) (Lp(a)) was discovered more than 50 years ago, and a decade later, it was recognized as a risk factor for coronary artery disease. However, it has gained importance only in the past 10 years, with emergence of drugs that can effectively decrease its levels. Lp(a) is a low-density lipoprotein (LDL) with an added apolipoprotein(a) attached to the apolipoprotein B component via a disulphide bond. Circulating levels of Lp(a) are mainly genetically determined. Lp(a) has many functions, which include proatherosclerotic, prothrombotic and pro-inflammatory roles. Here, we review recent data on the role of Lp(a) in the atherosclerotic process, and treatment options for patients with cardiovascular diseases. Currently 'Proprotein convertase subtilisin/kexin type 9' (PCSK9) inhibitors that act through non-specific reduction of Lp(a) are the only drugs that have shown effectiveness in clinical trials, to provide reductions in cardiovascular morbidity and mortality. The effects of PCSK9 inhibitors are not purely through Lp(a) reduction, but also through LDL cholesterol reduction. Finally, we discuss new drugs on the horizon, and gene-based therapies that affect transcription and translation of apolipoprotein(a) mRNA. Clinical trials in patients with high Lp(a) and low LDL cholesterol might tell us whether Lp(a) lowering per se decreases cardiovascular morbidity and mortality.KEY MESSAGESLipoprotein(a) is an important risk factor in patients with cardiovascular diseases.Lipoprotein(a) has many functions, which include proatherosclerotic, prothrombotic and pro-inflammatory roles.Treatment options to lower lipoprotein(a) levels are currently scarce, but new drugs are on the horizon.
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Affiliation(s)
| | - Mark Zavrtanik
- Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Miran Šebeštjen
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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165
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Patient Management in Aortic Stenosis: Towards Precision Medicine Through Protein Analysis, Imaging and Diagnostic Tests. J Clin Med 2020; 9:jcm9082421. [PMID: 32731585 PMCID: PMC7463596 DOI: 10.3390/jcm9082421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 01/12/2023] Open
Abstract
Aortic stenosis is the most frequent valvular disease in developed countries. It progresses from mild fibrocalcific leaflet changes to a more severe leaflet calcification at the end stages of the disease. Unfortunately, symptoms of aortic stenosis are unspecific and only appear when it is too late, complicating patients' management. The global impact of aortic stenosis is increasing due to the growing elderly population. The disease supposes a great challenge because of the multiple comorbidities of these patients. Nowadays, the only effective treatment is valve replacement, which has a high cost in both social and economic terms. For that reason, it is crucial to find potential diagnostic, prognostic and therapeutic indicators that could help us to detect this disease in its earliest stages. In this article, we comprehensively review several key observations and translational studies related to protein markers that are promising for being implemented in the clinical field as well as a discussion about the role of precision medicine in aortic stenosis.
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166
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Hu X, Yang X, Li X, Luo D, Zhou Y, Dong H. Lipoprotein (a) as a residual risk factor for atherosclerotic renal artery stenosis in hypertensive patients: a hospital-based cross-sectional study. Lipids Health Dis 2020; 19:173. [PMID: 32703301 PMCID: PMC7379345 DOI: 10.1186/s12944-020-01272-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 04/29/2020] [Indexed: 12/24/2022] Open
Abstract
Background Low-density lipoprotein cholesterol (LDL-c) has been proven to be a risk factor for atherosclerotic cardiovascular disease (CVD), while lipoprotein (a) (Lp(a)) is a residual risk factor for CVD, even though LDL-c is well controlled by statin use. Importantly, the role of Lp(a) in atherosclerotic renal artery stenosis (ARAS) is still unknown. Methods For this hospital-based cross-sectional study, patients who simultaneously underwent coronary and renal angiography were examined. ARAS was defined as a 50% reduction in the cross-sectional (two-dimensional plane) area of the renal artery. Data were collected and compared between ARAS and non-ARAS groups, including clinical history and metabolite profiles. Univariate analysis, three tertile LDL-c-based stratified analysis, and multivariate-adjusted logistic analysis were conducted, revealing a correlation between Lp(a) and ARAS. Results A total of 170 hypertensive patients were included in this study, 85 with ARAS and 85 with non-RAS. Baseline information indicated comparability between the two groups. In the univariate and multivariate analysis, common risk factors for atherosclerosis were not significantly different. Stratified analysis of LDL-c revealed a significant increase in the incidence of ARAS in patients who had high Lp(a) concentrations at low LDL-c levels (odds ratio (OR): 4.77, 95% confidence interval (CI): 1.04–21.79, P = 0.044). Further logistic analysis with adjusted covariates also confirmed the result, indicating that high Lp(a) levels were independently associated with ARAS (adjusted OR (aOR): 6.14, 95%CI: 1.03–36.47, P = 0.046). This relationship increased with increasing Lp(a) concentration based on a curve fitting graph. These results were not present in the low and intermediate LDL-c-level groups. Conclusion In hypertensive patients who present low LDL-c, high Lp(a) was significantly associated with atherosclerotic renal artery stenosis and thus is a residual risk factor.
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Affiliation(s)
- Xiangming Hu
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Xing Yang
- Department of Cardiology, Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Center Hospital), Zhuhai, 519040, Guangdong, China
| | - Xida Li
- Department of Cardiology, Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Center Hospital), Zhuhai, 519040, Guangdong, China
| | - Demou Luo
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China
| | - Yingling Zhou
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.
| | - Haojian Dong
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.
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167
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Diet and Lp(a): Does Dietary Change Modify Residual Cardiovascular Risk Conferred by Lp(a)? Nutrients 2020; 12:nu12072024. [PMID: 32646066 PMCID: PMC7400957 DOI: 10.3390/nu12072024] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 02/06/2023] Open
Abstract
Lipoprotein(a) [Lp(a)] is an independent, causal, genetically determined risk factor for cardiovascular disease (CVD). We provide an overview of current knowledge on Lp(a) and CVD risk, and the effect of pharmacological agents on Lp(a). Since evidence is accumulating that diet modulates Lp(a), the focus of this paper is on the effect of dietary intervention on Lp(a). We identified seven trials with 15 comparisons of the effect of saturated fat (SFA) replacement on Lp(a). While replacement of SFA with carbohydrate, monounsaturated fat (MUFA), or polyunsaturated fat (PUFA) consistently lowered low-density lipoprotein cholesterol (LDL-C), heterogeneity in the Lp(a) response was observed. In two trials, Lp(a) increased with carbohydrate replacement; one trial showed no effect and another showed Lp(a) lowering. MUFA replacement increased Lp(a) in three trials; three trials showed no effect and one showed lowering. PUFA or PUFA + MUFA inconsistently affected Lp(a) in four trials. Seven trials of diets with differing macronutrient compositions showed similar divergence in the effect on LDL-C and Lp(a). The identified clinical trials show diet modestly affects Lp(a) and often in the opposing direction to LDL-C. Further research is needed to understand how diet affects Lp(a) and its properties, and the lack of concordance between diet-induced LDL-C and Lp(a) changes.
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168
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Shah NP, Pajidipati NJ, McGarrah RW, Navar AM, Vemulapalli S, Blazing MA, Shah SH, Hernandez AF, Patel MR. Lipoprotein (a): An Update on a Marker of Residual Risk and Associated Clinical Manifestations. Am J Cardiol 2020; 126:94-102. [PMID: 32336532 DOI: 10.1016/j.amjcard.2020.03.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
Lipoprotein (a) [Lp(a)] is a low-density, cholesterol-containing lipoprotein that differs from other low-density lipoproteins due to the presence of apolipoprotein(a) bound to its surface apolipoprotein B100. Multiple epidemiologic studies, including Mendelian Randomization studies, have demonstrated that increasing Lp(a) levels are associated with increased risk of heart disease, including atherosclerotic cardiovascular disease and calcific aortic stenosis. The risk associated with elevations in Lp(a) appears to be independent of other lipid markers. While the current treatment options for elevated Lp(a) are limited, promising new therapies are under development, leading to renewed interest in Lp(a). This review provides an overview of the biology and epidemiology of Lp(a), available outcome studies, and insights into future therapies.
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169
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Langhammer R, Laufs U. Lipoprotein(a): Behandlung eines unterschätzten kardiovaskulären Risikomarkers. AKTUELLE KARDIOLOGIE 2020. [DOI: 10.1055/a-1164-6087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
ZusammenfassungAuf der Suche nach weiteren behandelbaren kardiovaskulären Risikofaktoren rückte das Lipoprotein(a) – Lp(a) – in den letzten Jahren in den wissenschaftlichen Fokus. Lp(a) ist ein genetischer, unabhängiger und vermutlich kausaler Marker für Atherosklerose und kalzifizierende Aortenklappenstenose. Sein proatherogenes, prothrombotisches und proinflammatorisches Wirkprofil bedingt eine hohe Pathogenität. Die Definition einer Lp(a)-Hyperlipoproteinämie ist komplex, da verschiedene Messverfahren im Einsatz sind und Grenzwerte für pathologische Lp(a)-Serumkonzentrationen kontrovers diskutiert werden. Aktuell steht nur das invasive Verfahren der Lipoproteinapherese zur Verfügung, mit der Lp(a) moderat gesenkt werden kann. Die in der Phase III befindlichen Lp(a)RNA-Inhibitoren stellen einen wesentlich spezifischeren und potenteren Therapieansatz dar. Laufende randomisierte Endpunktstudien mit diesen Medikamenten werden erheblich zum Verständnis der pathophysiologischen Bedeutung
von Lp(a) unabhängig vom LDL-Cholesterin beitragen.
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Affiliation(s)
- Romy Langhammer
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig
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170
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Lipoprotein(a) and calcific aortic valve stenosis: A systematic review. Prog Cardiovasc Dis 2020; 63:496-502. [PMID: 32526213 DOI: 10.1016/j.pcad.2020.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023]
Abstract
Calcific aortic valve stenosis (AS) is the most common form of acquired valvular heart disease needing intervention and our understanding of this disease has evolved from one of degenerative calcification to that of an active process driven by the interplay of genetic factors and chronic inflammation modulated by risk factors such as smoking, hypertension and elevated cholesterol. Lipoprotein(a) [Lp (a)] is a cholesterol rich particle secreted by the liver which functions as the major lipoprotein carrier of phosphocholine-containing oxidized phospholipids. Lp(a) levels are largely genetically determined by polymorphisms in the LPA gene. While there is an extensive body of evidence linking Lp(a) to atherosclerotic cardiovascular disease, emerging evidence now suggests a similar association of Lp(a) to calcific AS. In this article, we performed a systematic review of all published literature to assess the association between Lp(a) and calcific aortic valve (AV) disease. In addition, we review the potential mechanisms by which Lp(a) influences the progression of valve disease. Our review identified a total of 21 studies, varying from case-control studies, prospective or retrospective observational cohort studies to Mendelian randomized studies that assessed the association between Lp(a) and calcific AS. All but one of the above studies demonstrated significant association between elevated Lp(a) and calcific AS. We conclude that there is convincing evidence supporting a causal association between elevated Lp(a) and calcific AS. In addition, elevated Lp(a) predicts a faster hemodynamic progression of AS, and increased risk of AV replacement, especially in younger patients. Further research into the clinical utility of Lp(a) as a marker for predicting the incidence, progression, and outcomes of sclerodegenerative AV disease is needed.
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171
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Youssef A, Clark JR, Koschinsky ML, Boffa MB. Lipoprotein(a): Expanding our knowledge of aortic valve narrowing. Trends Cardiovasc Med 2020; 31:305-311. [PMID: 32525013 DOI: 10.1016/j.tcm.2020.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 01/05/2023]
Abstract
Elevated levels of lipoprotein(a) [Lp(a)] have been identified as an independent and causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and, more recently, calcific aortic valve disease (CAVD). CAVD is a slow, progressive disorder presenting as severe trileaflet calcification known as aortic valve stenosis (AS) that impairs valve motion and restricts ventricular outflow. AS afflicts 2% of the aging population (≥ 65 years) and tends to be quite advanced by the time it presents clinical symptoms of exertional angina, syncope, or heart failure. Currently, the only effective clinical therapy for AS patients is surgical or transcatheter aortic valve replacement. Evidence is accumulating that Lp(a) can exacerbate pathophysiological processes in CAVD, specifically, endothelial dysfunction, formation of foam cells, and promotion of a pro-inflammatory state. In the valve milieu, the pro-inflammatory effects of Lp(a) are manifested in valve thickening and mineralization through pro-osteogenic signaling and changes in gene expression in valve interstitial cells that is primarily facilitated by the oxidized phospholipid content of Lp(a). In AS pathogenesis, an incomplete understanding of the role of Lp(a) at the molecular level and the absence of appropriate animal models are barriers for the development of specific and effective clinical interventions designed to mitigate the role of Lp(a) in AS. However, the advent of effective therapies that dramatically lower Lp(a) provides the possibility of the first medical treatment to halt AS progression.
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Affiliation(s)
| | | | - Marlys L Koschinsky
- Robarts Research Institute, Canada; Department of Physiology & Pharmacology, Canada.
| | - Michael B Boffa
- Department of Biochemistry, Schulich School of Medicine & Dentistry, The University of Western Ontario, Room 2260 Robarts Research Institute, 1151 Richmond Street North London, London N6A 5B7, ON, Canada
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172
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Langsted A, Nordestgaard BG. Lipoprotein(a): is it more, less or equal to LDL as a causal factor for cardiovascular disease and mortality? Curr Opin Lipidol 2020; 31:125-131. [PMID: 32304380 DOI: 10.1097/mol.0000000000000681] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To summarize the recent studies directly comparing LDL and lipoprotein(a) as causal factors for cardiovascular disease and mortality. RECENT FINDINGS In approximately 100,000 individuals from the Copenhagen General Population Study for risk of myocardial infarction, in observational analyses per 39 mg/dl (1 mmol/l) cholesterol increase, the hazard ratio was 1.3 (95% confidence interval: 1.2-1.3) for LDL cholesterol and 1.6 (1.4-1.9) for lipoprotein(a) cholesterol. In corresponding genetic analyses, the causal risk ratio was 2.1 (1.3-3.4) for LDL and 2.0 (1.6-2.6) for lipoprotein(a). Also, a 15 mg/dl (0.39 mmol/l) cholesterol increase was associated with a hazard ratio for cardiovascular mortality of 1.05 (1.04-1.07) for LDL cholesterol and 1.18 (1.12-1.25) for lipoprotein(a) cholesterol. Corresponding values for all-cause mortality were 1.01 (1.00-1.01) for LDL cholesterol and 1.07 (1.04-1.10) for lipoprotein(a) cholesterol. In genetic, causal analyses, the mortality increases for elevated lipoprotein(a) appeared to be through apolipoprotein(a) kringle IV-2 rather than through lipoprotein(a) levels per se. SUMMARY On cholesterol scales, lipoprotein(a) and LDL appeared equal as causal factors for myocardial infarction; however, lipoprotein(a) was most important for mortality. Lipoprotein(a) effects may not only be due to cholesterol content but could also be due to the structure of lipoprotein(a) resembling plasminogen.
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Affiliation(s)
- Anne Langsted
- Department of Clinical Biochemistry
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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173
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Update Lipidologie. Internist (Berl) 2020; 61:573-586. [DOI: 10.1007/s00108-020-00799-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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174
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Langsted A, Nordestgaard BG, Kamstrup PR. Elevated Lipoprotein(a) and Risk of Ischemic Stroke. J Am Coll Cardiol 2020; 74:54-66. [PMID: 31272552 DOI: 10.1016/j.jacc.2019.03.524] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND High lipoprotein(a) is associated with increased risk of myocardial infarction and aortic valve stenosis. Previous studies have examined the association of lipoprotein(a) and risk of stroke; however, the results are conflicting. OBJECTIVES The purpose of this study was to test if high lipoprotein(a) is associated with high risk of ischemic stroke observationally and causally from human genetics. METHODS The study included 49,699 individuals from the Copenhagen General Population Study and 10,813 individuals from the Copenhagen City Heart Study with measurements of plasma lipoprotein(a), LPA kringle-IV type 2 number of repeats, and LPA rs10455872. The endpoint of ischemic stroke was ascertained from Danish national health registries and validated by medical doctors. RESULTS Compared with individuals with lipoprotein(a) levels <10 mg/dl (<18 nmol/l: first to 50th percentile), the multivariable-adjusted hazard ratio for ischemic stroke was 1.60 (95% confidence interval [CI]:1.24 to 2.05) for individuals with lipoprotein(a) levels >93mg/dl (>199 nmol/L: 96th to 100th percentile). In observational analyses for a 50 mg/dl (105 nmol/l) higher lipoprotein(a) level the age- and sex-adjusted hazard ratio for ischemic stroke was 1.20 (95% CI: 1.13 to 1.28), while the corresponding age- and sex-adjusted genetic causal risk ratio for KIV-2 number of repeats was 1.20 (95% CI: 1.02 to 1.43) and for rs10455872 was 1.27 (95% CI: 1.06 to 1.51). The highest absolute 10-year risk of ischemic stroke was 17% in active smoking individuals >70 years of age with hypertension and lipoprotein(a) levels >93 mg/dl (>199 nmol/l: 96th to 100th percentile). In the Copenhagen City Heart Study, risk estimates for high levels of lipoprotein(a) were in the same direction but did not reach statistical significance. CONCLUSIONS In a large contemporary general population study, high plasma levels of lipoprotein(a) were associated with increased risk of ischemic stroke both observationally and causally from human genetics.
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Affiliation(s)
- Anne Langsted
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Pia R Kamstrup
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark.
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Ballantyne CM. Lipoprotein(a) and Risk for Stroke and Myocardial Infarction: Why Aren't We Screening? J Am Coll Cardiol 2020; 74:67-69. [PMID: 31272553 DOI: 10.1016/j.jacc.2019.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Christie M Ballantyne
- Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Texas.
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176
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Board C, Kelly MS, Shapiro MD, Dixon DL. PCSK9 Inhibitors in Secondary Prevention-An Opportunity for Personalized Therapy. J Cardiovasc Pharmacol 2020; 75:410-420. [PMID: 32379108 DOI: 10.1097/fjc.0000000000000809] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death worldwide. Low-density lipoprotein cholesterol (LDL-C) is the primary cause of ASCVD and reducing LDL-C levels with statin therapy significantly reduces ASCVD risk; however, significant residual risk remains. Two monoclonal antibodies (mAbs), alirocumab and evolocumab, that target proprotein convertase subtilisin/kexin-type 9 (PCSK9), reduce LDL-C levels by up to 60% when used in combination with statins and significantly reduce the risk of recurrent ASCVD events in both stable secondary prevention and acute coronary syndrome populations. Prespecified analyses of recent randomized controlled trials have shed light on how best to prioritize these therapies to maximize their value in select high-risk groups. These data have also informed recent clinical practice guidelines and scientific statements resulting in an expanded role for PCSK9-mAbs compared with previous guidelines, albeit there are notable differences between these recommendations. Ongoing research is exploring the long-term safety of PCSK9-mAbs and their role in the acute setting and patients without prior myocardial infarction or stroke. Novel therapies that inhibit PCSK9 synthesis via small interfering RNA, such as inclisiran, are also in development and may reduce LDL-C levels similar to PCSK9-mAbs, but with less frequent administration. Nonetheless, the PCSK9-mAbs are a breakthrough therapy and warrant consideration in very high-risk patients who are most likely to benefit. Such a personalized approach can help to ensure cost-effectiveness and maximize their value.
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Affiliation(s)
- Chase Board
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
| | - Michael S Kelly
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA; and
| | - Michael D Shapiro
- Section on Cardiovascular Medicine, Center for the Prevention of Cardiovascular Disease, Wake Forest Baptist Health, Winston-Salem, NC
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
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177
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Tromp TR, Stroes ESG, Hovingh GK. Gene-based therapy in lipid management: the winding road from promise to practice. Expert Opin Investig Drugs 2020; 29:483-493. [PMID: 32349563 DOI: 10.1080/13543784.2020.1757070] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is a leading cause of morbidity and mortality. High plasma low-density lipoprotein cholesterol (LDL-C) levels are a key CVD-risk factor. Triglyceride-rich remnant particles and lipoprotein(a) (Lp[a]) are also causally related to CVD. Consequently, therapeutic strategies for lowering LDL-C and triglyceride levels are widely used in routine clinical practice; however, specific Lp(a) lowering agents are not available. Many patients do not achieve guideline-recommended lipid levels with currently available therapies; hence, novel targets and treatment modalities are eagerly sought. AREAS COVERED We discuss the milestones on the trajectory toward the full application of gene-based therapies in daily clinical practice. We describe the different methods, ranging from antisense oligonucleotides to liver-directed gene therapy and Crispr-cas9 modification to target the pivotal players in lipid metabolism: PCSK9, APOB, ANGPTL3, Lp(a), LDLR, and apoC-III. EXPERT OPINION While acknowledging their different stages of development, gene-based therapies are likely to invoke a paradigm shift in lipid management because they allow us to target previously undruggable targets. Moreover, their low dosing frequency, high target selectivity, and relatively predictable adverse event profile are considered major advantages over current lipid-lowering therapies.
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Affiliation(s)
- Tycho R Tromp
- Department of Vascular Medicine, Amsterdam UMC , Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam UMC , Amsterdam, The Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam UMC , Amsterdam, The Netherlands.,Global Chief Medical Office, Novo Nordisk A/S , Copenhagen, Denmark
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178
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Coassin S, Hermann-Kleiter N, Haun M, Wahl S, Wilson R, Paulweber B, Kunze S, Meitinger T, Strauch K, Peters A, Waldenberger M, Kronenberg F, Lamina C. A genome-wide analysis of DNA methylation identifies a novel association signal for Lp(a) concentrations in the LPA promoter. PLoS One 2020; 15:e0232073. [PMID: 32343731 PMCID: PMC7188291 DOI: 10.1371/journal.pone.0232073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/19/2020] [Indexed: 12/24/2022] Open
Abstract
Lipoprotein(a) [Lp(a)] is a major cardiovascular risk factor, which is largely genetically determined by one major gene locus, the LPA gene. Many aspects of the transcriptional regulation of LPA are poorly understood and the role of epigenetics has not been addressed yet. Therefore, we conducted an epigenome-wide analysis of DNA methylation on Lp(a) levels in two population-based studies (total n = 2208). We identified a CpG site in the LPA promoter which was significantly associated with Lp(a) concentrations. Surprisingly, the identified CpG site was found to overlap the SNP rs76735376. We genotyped this SNP de-novo in three studies (total n = 7512). The minor allele of rs76735376 (1.1% minor allele frequency) was associated with increased Lp(a) values (p = 1.01e-59) and explained 3.5% of the variation of Lp(a). Statistical mediation analysis showed that the effect on Lp(a) is rather originating from the base change itself and is not mediated by DNA methylation levels. This finding is supported by eQTL data from 208 liver tissue samples from the GTEx project, which shows a significant association of the rs76735376 minor allele with increased LPA expression. To evaluate, whether the association signal at rs76735376 may actually be derived from a stronger eQTL signal in LD with this SNP, eQTL association results of all correlated SNPs (r2≥0.1) were integrated with genetic association results. This analysis pinpointed to rs10455872 as the potential trigger of the effect of rs76735376. Furthermore, both SNPs coincide with short apo(a) isoforms. Adjusting for both, rs10455872 and the apo(a) isoforms diminished the effect size of rs76735376 to 5.38 mg/dL (p = 0.0463). This indicates that the effect of rs76735376 can be explained by both an independent effect of the SNP and a strong correlation with rs10455872 and apo(a) isoforms.
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Affiliation(s)
- Stefan Coassin
- Department of Genetics and Pharmacology, Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Natascha Hermann-Kleiter
- Department of Genetics and Pharmacology, Institute of Cell Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Margot Haun
- Department of Genetics and Pharmacology, Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Simone Wahl
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
| | - Rory Wilson
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
| | - Bernhard Paulweber
- First Department of Internal Medicine, Paracelsus Private Medical University, Salzburg, Austria
| | - Sonja Kunze
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
| | - Thomas Meitinger
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- Institute of Human Genetics, Technische Universität München, Munich, Germany
- German Research Center for Environmental Health, Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | - Konstantin Strauch
- German Research Center for Environmental Health, Institute of Genetic Epidemiology, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Medical Informatics, Biometry, and Epidemiology, Ludwig-Maximilians-Universität, Munich, Germany
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Annette Peters
- Institute of Epidemiology II, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Melanie Waldenberger
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Florian Kronenberg
- Department of Genetics and Pharmacology, Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Lamina
- Department of Genetics and Pharmacology, Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
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Mahmood T, Minnier J, Ito MK, Li QH, Koren A, Kam IW, Fazio S, Shapiro MD. Discordant responses of plasma low-density lipoprotein cholesterol and lipoprotein(a) to alirocumab: A pooled analysis from 10 ODYSSEY Phase 3 studies. Eur J Prev Cardiol 2020; 28:816-822. [PMID: 34298554 DOI: 10.1177/2047487320915803] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/09/2020] [Indexed: 12/24/2022]
Abstract
AIMS Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors consistently reduce low-density lipoprotein cholesterol (LDL-C) by 50-60% and lipoprotein(a) (Lp(a)) by 20-30%, but the mechanism of Lp(a) lowering remains unclear. If Lp(a) is cleared by the LDL receptor, similar to LDL-C, then one would expect PCSK9 inhibition to induce a concordant LDL-C/Lp(a) response in an approximately 2:1 ratio. We aim to determine the prevalence of discordant plasma LDL-C/Lp(a) response to the PCSK9 inhibitor alirocumab. METHODS This is a post hoc, pooled analysis of 10 randomized controlled trials from the ODYSSEY Phase 3 clinical trial program for alirocumab. Patients enrolled in the trials were high cardiovascular risk and/or with heterozygous familial hypercholesterolemia. The primary end point was prevalence of discordant LDL-C/Lp(a) response to alirocumab at 24 weeks. Discordant response was defined as LDL-C reduction >35% and Lp(a) reduction ≤10%, or LDL-C reduction ≤35% and Lp(a) reduction >10%. RESULTS Of the 1709 patients in the pooled study cohort, 62.4% were male, and the mean age was 59.2 (SD: 11.0) years. Baseline mean LDL-C was 126.5 (SD: 46.3) mg/dL and baseline median Lp(a) was 46.9 (interquartile range: 21.8-89.0) mg/dL. Total prevalence of discordant LDL-C/Lp(a) response was 21.5% (12.6% with LDL-C >35% reduction and Lp(a) ≤10% reduction; 8.9% with LDL-C ≤35% reduction and Lp(a) >10% reduction). Baseline Lp(a) and familial hypercholesterolemia status did not affect discordance. CONCLUSION A high prevalence of discordant LDL-C/Lp(a) response was observed with alirocumab, further suggesting that PCSK9 inhibitor therapy with alirocumab reduces plasma Lp(a) through alternative pathways to LDL receptor clearance.
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Affiliation(s)
- Tahir Mahmood
- Oregon Health & Science University, Knight Cardiovascular Institute, Center for Preventive Cardiology, USA
| | - Jessica Minnier
- Oregon Health & Science University, Knight Cardiovascular Institute, Center for Preventive Cardiology, USA.,Oregon Health & Science University, OHSU-PSU School of Public Health, USA
| | | | | | | | | | - Sergio Fazio
- Oregon Health & Science University, Knight Cardiovascular Institute, Center for Preventive Cardiology, USA
| | - Michael D Shapiro
- Center for Preventive Cardiology, Wake Forest University Baptist Medical Center, Section on Cardiovascular Medicine, USA
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180
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What do we know about the role of lipoprotein(a) in atherogenesis 57 years after its discovery? Prog Cardiovasc Dis 2020; 63:219-227. [PMID: 32277995 DOI: 10.1016/j.pcad.2020.04.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022]
Abstract
Elevated circulating concentrations of lipoprotein(a) [Lp(a)] is strongly associated with increased risk of atherosclerotic cardiovascular disease (CVD) and degenerative aortic stenosis. This relationship was first observed in prospective observational studies, and the causal relationship was confirmed in genetic studies. Everybody should have their Lp(a) concentration measured once in their lifetime. CVD risk is elevated when Lp(a) concentrations are high i.e. > 50 mg/dL (≥100 mmol/L). Extremely high Lp(a) levels >180 mg/dL (≥430 mmol/L) are associated with CVD risk similar to that conferred by familial hypercholesterolemia. Elevated Lp(a) level was previously treated with niacin, which exerts a potent Lp(a)-lowering effect. However, niacin is currently not recommended because, despite the improvement in lipid profile, no improvements on clinical outcomes have been observed. Furthermore, niacin use has been associated with severe adverse effects. Post hoc analyses of clinical trials with proprotein convertase subtilisin/kexin type-9 (PCSK9) inhibitors have shown that these drugs exert clinical benefits by lowering Lp(a), independent of their potent reduction of low-density lipoprotein cholesterol (LDL-C). It is not yet known whether PCSK9 inhibitors will be of clinical use in patients with elevated Lp(a). Apheresis is a very effective approach to Lp(a) reduction, which reduces CVD risk but is invasive and time-consuming and is thus reserved for patients with very high Lp(a) levels and progressive CVD. Studies are ongoing on the practical application of genetic approaches to therapy, including antisense oligonucleotides against apolipoprotein(a) and small interfering RNA (siRNA) technology, to reduce the synthesis of Lp(a).
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181
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Kaltoft M, Langsted A, Nordestgaard BG. Triglycerides and remnant cholesterol associated with risk of aortic valve stenosis: Mendelian randomization in the Copenhagen General Population Study. Eur Heart J 2020; 41:2288-2299. [DOI: 10.1093/eurheartj/ehaa172] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/17/2019] [Accepted: 03/09/2020] [Indexed: 01/12/2023] Open
Abstract
AbstractAimsWe tested the hypothesis that higher levels of plasma triglycerides and remnant cholesterol are observationally and genetically associated with increased risk of aortic valve stenosis.Methods and resultsWe included 108 559 individuals from the Copenhagen General Population Study. Plasma triglycerides, remnant cholesterol (total cholesterol minus low-density lipoprotein and high-density lipoprotein cholesterol), and 16 genetic variants causing such increased or decreased levels were determined. Incident aortic valve stenosis occurred in 1593 individuals. Observationally compared to individuals with triglycerides <1 mmol/L (<89 mg/dL), the multifactorially adjusted hazard ratio for aortic valve stenosis was 1.02 [95% confidence interval (CI) 0.87–1.19] for individuals with triglycerides of 1.0–1.9 mmol/L (89–176 mg/dL), 1.22 (1.02–1.46) for 2.0–2.9 mmol/L (177–265 mg/dL), 1.40 (1.11–1.77) for 3.0–3.9 mmol/L (266–353 mg/dL), 1.29 (0.88–1.90) for 4.0–4.9 mmol/L (354–442 mg/dL), and 1.52 (1.02–2.27) for individuals with triglycerides ≥5 mmol/L (≥443 mg/dL). By age 85, the cumulative incidence of aortic valve stenosis was 5.1% for individuals with plasma triglycerides <2.0 mmol/L (77 mg/dL), 6.5% at 2.0–4.9 mmol/L (177–442 mg/dL), and 8.2% for individuals with plasma triglycerides ≥5.0 mmol/L (443 mg/dL). The corresponding values for remnant cholesterol categories were 4.8% for <0.5 mmol/L (19 mg/dL), 5.6% for 0.5–1.4 mmol/L (19–57 mg/dL), and 7.4% for ≥1.5 mmol/L (58 mg/dL). Genetically, compared to individuals with allele score 13–16, odds ratios for aortic valve stenosis were 1.30 (95% CI 1.20–1.42; Δtriglycerides +12%; Δremnant cholesterol +11%) for allele score 17–18, 1.41 (1.31–1.52; +25%; +22%) for allele score 19–20, and 1.51 (1.22–1.86; +51%; +44%) for individuals with allele score 21–23.ConclusionHigher triglycerides and remnant cholesterol were observationally and genetically associated with increased risk of aortic valve stenosis.
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Affiliation(s)
- Morten Kaltoft
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 73, Elevator 7, DK-2730 Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, DK-2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Anne Langsted
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 73, Elevator 7, DK-2730 Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, DK-2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 73, Elevator 7, DK-2730 Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, DK-2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight our emerging understanding of lipoprotein(a) [Lp(a)]'s role in atherosclerotic cardiovascular disease (ASCVD), its structure-function relationship, and promising developments within the therapeutic pipeline. RECENT FINDINGS Elevated levels of Lp(a) are strongly associated with an increased risk of coronary heart disease, calcific aortic valve stenosis, and ischemic stroke. With circulating levels almost exclusively genetically mediated, increased levels of Lp(a) contribute significantly to the residual cardiovascular disease risk in individuals with otherwise well controlled risk factors. The unique structure of Lp(a) - comprised of a genetically heterogeneous apolipoprotein(a) molecule bound to an LDL-like moiety - provides insight into its pathogenic role in cardiovascular disease and also complicates its accurate measurement. Emerging therapies targeting the apolipoprotein(a) component of Lp(a) have the potential to revolutionize the management of individuals with elevated Lp(a). SUMMARY With promising therapies on the horizon, there has been a renewed focus on the role of Lp(a) in ASCVD. Given Lp(a)'s strong and independent association with key cardiovascular outcomes, it is hopeful that these promising targeted therapies will add another therapeutic option for the prevention of cardiovascular disease.
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183
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Jones GT, Marsman J, Bhat B, Phillips VL, Chatterjee A, Rodger EJ, Williams MJA, van Rij AM, McCormick SPA. DNA methylation profiling identifies a high effect genetic variant for lipoprotein(a) levels. Epigenetics 2020; 15:949-958. [PMID: 32237968 DOI: 10.1080/15592294.2020.1739797] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Changes in whole blood DNA methylation levels at several CpG sites have been associated with circulating blood lipids, specifically high-density lipoprotein and triglycerides. This study performs a discovery and validation epigenome-wide association study (EWAS) for circulating lipoprotein(a) [Lp(a)], an independent risk factor for cardiovascular diseases. Whole-blood DNA methylation profiles were assessed in a cohort of 1020 elderly individuals using the Illumina EPIC array and independent validation in 359 elderly males using the Illumina 450 k array. Plasma Lp(a) was measured using an apolipoprotein(a)-size-independent ELISA. Epigenome-wide rank regression analysis identified and validated a single CpG site, cg17028067 located in intron 1 of the LPA gene, that was significantly associated with plasma Lp(a) levels after correction for multiple testing. Genotyping of the site identified a relatively uncommon SNP (rs76735376, MAF <0.02) at the CpG site that largely explained the observed methylation effect. Rs76735376 is an expression quantitative trait loci for the LPA gene and could affect expression by altering enhancer activity. This EWAS for plasma Lp(a) identified a single CpG site within LPA. This association is due to an uncommon, but highly effective genetic variant, which was not in significant linkage disequilibrium with other variants known to influence Lp(a) levels or apo(a) isoform size. This study highlights the utility of CpG site methylation to identify potentially important genetic associations that would not be readily apparent in a comparable size genetic association study.
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Affiliation(s)
- Gregory T Jones
- Departments of Surgical Sciences, University of Otago , Dunedin, New Zealand
| | - Judith Marsman
- Departments of Surgical Sciences, University of Otago , Dunedin, New Zealand
| | - Basharat Bhat
- Departments of Surgical Sciences, University of Otago , Dunedin, New Zealand
| | - Victoria L Phillips
- Departments of Surgical Sciences, University of Otago , Dunedin, New Zealand
| | | | - Euan J Rodger
- Pathology, University of Otago , Dunedin, New Zealand
| | | | - André M van Rij
- Departments of Surgical Sciences, University of Otago , Dunedin, New Zealand
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184
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Sabouret P, Angoulvant D, Ray KK. Lipoprotein(a), the rediscovered risk factor, or how to get "back to the future". Arch Cardiovasc Dis 2020; 113:147-151. [PMID: 32205042 DOI: 10.1016/j.acvd.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Pierre Sabouret
- Heart Institute, Pitié-Salpétrière Hospital, ACTION-Group, Pierre and Marie Curie University, 47-83 boulevard de L'Hôpital, 75013 Paris, France.
| | - Denis Angoulvant
- Department of Cardiology, CHRU de Tours and EA4245 T2i, Loire Valley Cardiovascular Collaboration, Tours University, 37000 Tours, France
| | - Kausik K Ray
- Department of Public Health, Imperial College, W6 8RP London, UK
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185
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Hedayatnia M, Asadi Z, Zare-Feyzabadi R, Yaghooti-Khorasani M, Ghazizadeh H, Ghaffarian-Zirak R, Nosrati-Tirkani A, Mohammadi-Bajgiran M, Rohban M, Sadabadi F, Rahimi HR, Ghalandari M, Ghaffari MS, Yousefi A, Pouresmaeili E, Besharatlou MR, Moohebati M, Ferns GA, Esmaily H, Ghayour-Mobarhan M. Dyslipidemia and cardiovascular disease risk among the MASHAD study population. Lipids Health Dis 2020; 19:42. [PMID: 32178672 PMCID: PMC7075010 DOI: 10.1186/s12944-020-01204-y] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 02/18/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Dyslipidemia may be defined as increased levels of serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), or a decreased serum high-density lipoprotein cholesterol (HDL-C) concentration. Dyslipidemia is an established risk factor for cardiovascular disease (CVD). We aimed to investigate the association of dyslipidemia and CVD events among a population sample from Mashhad, in northeastern Iran. Material and methods This prospective cohort study comprised a population of 8698 men and women aged 35–65 years who were recruited from the Mashhad Stroke and Heart Atherosclerotic Disorder (MASHAD) study. Socioeconomic and demographic status, anthropometric parameters, laboratory evaluations, lifestyle factors, and medical history were gathered through a comprehensive questionnaire and laboratory and clinical assessment for all participants. Cox regression model and 95% confidence interval (CI) were used to evaluate the association of dyslipidemia and its components with CVD incidence. Results After 6 years of follow-up, 233 cases of CVD (including 119 cases of unstable angina [US], 74 cases of stable angina [SA], and 40 cases of myocardial infarction [MI]) were identified in the study population. Unadjusted baseline serum LDL-C, TC, and TG levels were positively associated with the risk of total CVD events among the entire population (HR: 1.54, 95% CI: 1.19–2; P-value< 0.01; HR: 1.53; 95% CI: 1.18–1.98; P < 0.01; HR: 1.57; 95% CI: 1.27–2.03; P < 0.01, respectively). However, after adjusting for confounding factors (age, body mass index [BMI], family history of CVD, smoking status [non-smoker, ex-smoker and current smoker], lipid lowering drug treatment, anti-hypertensive drug treatment, hypertension, healthy eating index [HEI], total energy intake, and presence of diabetes mellitus), a significant direct association only remained between TC and MI risk in men (HR: 2.71; 95%CI: 1.12–6.57; P-value< 0.05). Conclusion In the present study, TC baseline level was significantly associated with the risk of MI among men.
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Affiliation(s)
- Mahshad Hedayatnia
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Asadi
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Zare-Feyzabadi
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdiyeh Yaghooti-Khorasani
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamideh Ghazizadeh
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran.,Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Roshanak Ghaffarian-Zirak
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abolfazl Nosrati-Tirkani
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Mohammadi-Bajgiran
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohadese Rohban
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Sadabadi
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid-Reza Rahimi
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Marzieh Ghalandari
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Asa Yousefi
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elnaz Pouresmaeili
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohsen Moohebati
- Cardiovascular Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gordon A Ferns
- Division of Medical Education, Brighton & Sussex Medical School, Falmer, Brighton, Sussex, UK
| | - Habibollah Esmaily
- Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Majid Ghayour-Mobarhan
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. .,International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
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186
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Zheng KH, Tsimikas S, Pawade T, Kroon J, Jenkins WSA, Doris MK, White AC, Timmers NKLM, Hjortnaes J, Rogers MA, Aikawa E, Arsenault BJ, Witztum JL, Newby DE, Koschinsky ML, Fayad ZA, Stroes ESG, Boekholdt SM, Dweck MR. Lipoprotein(a) and Oxidized Phospholipids Promote Valve Calcification in Patients With Aortic Stenosis. J Am Coll Cardiol 2020; 73:2150-2162. [PMID: 31047003 PMCID: PMC6494952 DOI: 10.1016/j.jacc.2019.01.070] [Citation(s) in RCA: 170] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 01/05/2023]
Abstract
Background Lipoprotein(a) [Lp(a)], a major carrier of oxidized phospholipids (OxPL), is associated with an increased incidence of aortic stenosis (AS). However, it remains unclear whether elevated Lp(a) and OxPL drive disease progression and are therefore targets for therapeutic intervention. Objectives This study investigated whether Lp(a) and OxPL on apolipoprotein B-100 (OxPL-apoB) levels are associated with disease activity, disease progression, and clinical events in AS patients, along with the mechanisms underlying any associations. Methods This study combined 2 prospective cohorts and measured Lp(a) and OxPL-apoB levels in patients with AS (Vmax >2.0 m/s), who underwent baseline 18F-sodium fluoride (18F-NaF) positron emission tomography (PET), repeat computed tomography calcium scoring, and repeat echocardiography. In vitro studies investigated the effects of Lp(a) and OxPL on valvular interstitial cells. Results Overall, 145 patients were studied (68% men; age 70.3 ± 9.9 years). On baseline positron emission tomography, patients in the top Lp(a) tertile had increased valve calcification activity compared with those in lower tertiles (n = 79; 18F-NaF tissue-to-background ratio of the most diseased segment: 2.16 vs. 1.97; p = 0.043). During follow-up, patients in the top Lp(a) tertile had increased progression of valvular computed tomography calcium score (n = 51; 309 AU/year [interquartile range: 142 to 483 AU/year] vs. 93 AU/year [interquartile range: 56 to 296 AU/year; p = 0.015), faster hemodynamic progression on echocardiography (n = 129; 0.23 ± 0.20 m/s/year vs. 0.14 ± 0.20 m/s/year] p = 0.019), and increased risk for aortic valve replacement and death (n = 145; hazard ratio: 1.87; 95% CI: 1.13 to 3.08; p = 0.014), compared with lower tertiles. Similar results were noted with OxPL-apoB. In vitro, Lp(a) induced osteogenic differentiation of valvular interstitial cells, mediated by OxPL and inhibited with the E06 monoclonal antibody against OxPL. Conclusions In patients with AS, Lp(a) and OxPL drive valve calcification and disease progression. These findings suggest lowering Lp(a) or inactivating OxPL may slow AS progression and provide a rationale for clinical trials to test this hypothesis.
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Affiliation(s)
- Kang H Zheng
- Department of Vascular Medicine, Academic Medical Center, Amsterdam UMC, Amsterdam, the Netherlands. https://twitter.com/Zheng_KH
| | - Sotirios Tsimikas
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, La Jolla, California
| | - Tania Pawade
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jeffrey Kroon
- Department of Vascular Medicine, Academic Medical Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - William S A Jenkins
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Mhairi K Doris
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Audrey C White
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Nyanza K L M Timmers
- Department of Vascular Medicine, Academic Medical Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jesper Hjortnaes
- Department of Cardiothoracic Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Maximillian A Rogers
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elena Aikawa
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benoit J Arsenault
- Centre de recherche de l'Institut Universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Joseph L Witztum
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, La Jolla, California
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marlys L Koschinsky
- Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik S G Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Academic Medical Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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187
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Nader J, Metzinger L, Maitrias P, Caus T, Metzinger-Le Meuth V. Aortic valve calcification in the era of non-coding RNAs: The revolution to come in aortic stenosis management? Noncoding RNA Res 2020; 5:41-47. [PMID: 32195449 PMCID: PMC7075756 DOI: 10.1016/j.ncrna.2020.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/04/2020] [Accepted: 02/24/2020] [Indexed: 01/08/2023] Open
Abstract
Aortic valve stenosis remains the most frequent structural heart disease, especially in the elderly. During the last decade, we noticed an important consideration and a huge number of publications related to the medical and surgical treatment of this disease. However, the molecular aspect of this degenerative issue has also been more widely studied recently. As evidenced in oncologic but also cardiac research fields, the emergence of microRNAs in the molecular screening and follow-up makes them potential biomarkers in the future, for the diagnosis, follow-up and treatment of aortic stenosis. Herein, we present a review on the implication of microRNAs in the aortic valve disease management. After listing and describing the main miRNAs of interest in the field, we provide an outline to develop miRNAs as innovative biomarkers and innovative therapeutic strategies, and describe a groundbreaking pre-clinical study using inhibitors of miR-34a in a pre-clinical model of aortic valve stenosis.
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Affiliation(s)
- Joseph Nader
- Department of Cardiac Surgery, Amiens University Hospital, Amiens, France
| | - Laurent Metzinger
- HEMATIM EA4666, C.U.R.S, Université de Picardie Jules Verne, 80025, AMIENS Cedex 1, France
| | - Pierre Maitrias
- Department of Vascular Surgery, Polyclinique Saint Côme, Compiègne, France
| | - Thierry Caus
- Department of Cardiac Surgery, Amiens University Hospital, Amiens, France
| | - Valérie Metzinger-Le Meuth
- HEMATIM EA4666, C.U.R.S, Université de Picardie Jules Verne, 80025, AMIENS Cedex 1, France.,INSERM U1148, Laboratory for Vascular Translational Science (LVTS), UFR SMBH, Université Paris 13-Sorbonne Paris Cité, 93017, BOBIGNY CEDEX, France
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188
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Fauvel C, Capoulade R, Durand E, Béziau DM, Schott JJ, Le Tourneau T, Eltchaninoff H. Durability of transcatheter aortic valve implantation: A translational review. Arch Cardiovasc Dis 2020; 113:209-221. [PMID: 32113816 DOI: 10.1016/j.acvd.2019.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 10/24/2022]
Abstract
Until recently, transcatheter aortic valve implantation was restricted to high-risk and inoperable patients. The updated 2017 European Society of Cardiology Guidelines has widened the indication to include intermediate-risk patients, based on two recently published trials (PARTNER 2 and SURTAVI). Moreover, two other recent trials (PARTNER 3 and EVOLUT LOW RISK) have demonstrated similar results with transcatheter aortic valve implantation in low-risk patients. Thus, extension of transcatheter aortic valve implantation to younger patients, who are currently treated by surgical aortic valve replacement, raises the crucial question of bioprosthesis durability. In this translational review, we propose to produce a state-of-the-art overview of the durability of transcatheter aortic valve implantation by integrating knowledge of the basic science of bioprosthesis degeneration (pathophysiology and biomarkers). After summarising the new definition of structural valve deterioration, we will present what is known about the pathophysiology of aortic stenosis and bioprosthesis degeneration. Next, we will consider how to identify a population at risk of early degeneration, and how basic science with the help of biomarkers could identify and predict structural valve deterioration. Finally, we will present data on the differences in durability of transcatheter aortic valve implantation compared with surgical aortic valve replacement.
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Affiliation(s)
- Charles Fauvel
- Department of Cardiology, Rouen University Hospital, FHU REMOD-VHF, 76000 Rouen, France
| | - Romain Capoulade
- L'institut du Thorax, INSERM 1087, CNRS, CHU de Nantes, Université de Nantes, 44007 Nantes, France
| | - Eric Durand
- Department of Cardiology, Rouen University Hospital, FHU REMOD-VHF, 76000 Rouen, France; Normandie université, UNIROUEN, INSERM U1096, 76000 Rouen, France
| | - Delphine M Béziau
- Normandie Université, UNIROUEN, INSERM U1096, Rouen University Hospital, Department of Cardiology, FHU REMOD-VHF, 76000 Rouen, France
| | - Jean-Jacques Schott
- L'institut du Thorax, INSERM 1087, CNRS, CHU de Nantes, Université de Nantes, 44007 Nantes, France
| | - Thierry Le Tourneau
- L'institut du Thorax, INSERM 1087, CNRS, CHU de Nantes, Université de Nantes, 44007 Nantes, France
| | - Hélène Eltchaninoff
- Department of Cardiology, Rouen University Hospital, FHU REMOD-VHF, 76000 Rouen, France; Normandie université, UNIROUEN, INSERM U1096, 76000 Rouen, France.
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189
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Zheng KH, Tzolos E, Dweck MR. Pathophysiology of Aortic Stenosis and Future Perspectives for Medical Therapy. Cardiol Clin 2020; 38:1-12. [DOI: 10.1016/j.ccl.2019.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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190
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Ravalli F, Kossar AP, Takayama H, Grau JB, Ferrari G. Aortic Valve Regurgitation: Pathophysiology and Implications for Surgical Intervention in the Era of TAVR. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2020; 4:87-98. [PMID: 32529168 PMCID: PMC7288848 DOI: 10.1080/24748706.2020.1719446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/16/2020] [Accepted: 01/17/2020] [Indexed: 10/25/2022]
Abstract
Aortic insufficiency (AI) or regurgitation is caused by the malcoaptation of the aortic valve (AV) cusps due to intrinsic abnormalities of the valve itself, a dilatation or geometric distortion of the aortic root, or by some combination thereof. In recent years, there has been an increase in the number of studies suggesting that AI is an active disease process caused by a combination of factors including but not limited to alteration of specific molecular pathways, genetic predisposition, and changes in the mechanotransductive properties of the AV apparatus. As the surgical management of AV disease continues to evolve, increasingly sophisticated surgical and percutaneous techniques for AV repair and replacement, including transcatheter aortic valve replacement (TAVR), have become more commonplace and will likely continue to expand as new devices are introduced. However, these techniques necessitate frequent reappraisal of the biological and mechanobiological mechanisms underlying AV regurgitation to better understand the risk factors for AI development and recurrence following surgical intervention as well as expand our limited knowledge on patient selection for such procedures. The aim of this review is to describe some of the putative mechanisms implicated in the development of AI, dissect some of the cross-talk among known and possible signaling pathways leading to valve remodeling, identify association between these pathways and pharmacological approaches, and discuss the implications for surgical and percutaneous approaches to AV repair in replacement in the TAVR era.
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191
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Larsen LE, Stoekenbroek RM, Kastelein JJP, Holleboom AG. Moving Targets: Recent Advances in Lipid-Lowering Therapies. Arterioscler Thromb Vasc Biol 2020; 39:349-359. [PMID: 30676072 DOI: 10.1161/atvbaha.118.312028] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Statin therapy has delivered tremendous value to society by improving the burden of atherosclerotic cardiovascular disease. Nonetheless, atherosclerotic cardiovascular disease remains the leading cause of death globally. Technological advances such as in the field of genomics have revolutionized drug discovery and development and have revealed novel therapeutic targets to lower low-density lipoprotein cholesterol (LDL-C), as well as other detrimental lipids and lipoproteins. Therapeutic LDL-C lowering prevents atherosclerotic cardiovascular disease with an effect size proportional to absolute LDL-C reductions and time of exposure. This understanding supports the notion that reducing cumulative LDL-C exposure should be a key therapeutic target. PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibiting monoclonal antibodies provides the possibility of reducing LDL-C to very low levels. Novel therapeutic platforms such as RNA inhibition present opportunities to combine robust lipid lowering with infrequent dosing regimens, introducing therapies with vaccine-like properties. The position of lipid-lowering therapies with targets other than LDL-C, such as Lp(a) [lipoprotein(a)], TRL (triglyceride-rich lipoproteins), and remnant cholesterol, will likely be determined by the results of ongoing clinical trials. Current evidence suggests that reducing Lp(a) or TRLs could attenuate atherosclerotic cardiovascular disease risk in specific categories of patients. This review provides an overview of the latest therapeutic developments, focusing on their mechanisms, efficacy, and safety.
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Affiliation(s)
- Lars E Larsen
- From the Department of Vascular Medicine, Amsterdam University Medical Center, The Netherlands
| | - Robert M Stoekenbroek
- From the Department of Vascular Medicine, Amsterdam University Medical Center, The Netherlands
| | - John J P Kastelein
- From the Department of Vascular Medicine, Amsterdam University Medical Center, The Netherlands
| | - Adriaan G Holleboom
- From the Department of Vascular Medicine, Amsterdam University Medical Center, The Netherlands
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192
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Gencer B, Mach F. Potential of Lipoprotein(a)-Lowering Strategies in Treating Coronary Artery Disease. Drugs 2020; 80:229-239. [DOI: 10.1007/s40265-019-01243-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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193
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de Oliveira Sá MPB, Cavalcanti LRP, Perazzo ÁM, Gomes RAF, Clavel MA, Pibarot P, Biondi-Zoccai G, Zhigalov K, Weymann A, Ruhparwar A, Lima RC. Calcific Aortic Valve Stenosis and Atherosclerotic Calcification. Curr Atheroscler Rep 2020; 22:2. [PMID: 31912380 DOI: 10.1007/s11883-020-0821-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the pathophysiology of calcific aortic valve stenosis (CAVS) and surveys relevant clinical data and basic research that explain how CAVS arises. RECENT FINDINGS Lipoprotein(a) [Lp(a)], lipoprotein-associated phospholipase A2 (Lp-PLA2), oxidized phospholipids (OxPL), autotaxin, and genetic driving forces such as mutations in LPA gene and NOTCH gene seem to play a major role in the development of CAVS. These factors might well become targets of medical therapy in the coming years. CVAS seems to be a multifactorial disease that has much in common with coronary artery disease, mainly regarding lipidic accumulation and calcium deposition. No clinical trials conducted to date have managed to answer the key question of whether Lp(a) lowering and anti-calcific therapies confer a benefit in terms of reducing incidence or progression of CAVS, although additional outcome trials are ongoing.
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Affiliation(s)
- Michel Pompeu Barros de Oliveira Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil. .,University of Pernambuco, UPE, Recife, Brazil. .,Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Instituite, FCM/ICB, Recife, Brazil.
| | - Luiz Rafael P Cavalcanti
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil.,University of Pernambuco, UPE, Recife, Brazil
| | - Álvaro M Perazzo
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil.,University of Pernambuco, UPE, Recife, Brazil
| | - Rafael A F Gomes
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil.,University of Pernambuco, UPE, Recife, Brazil.,Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Instituite, FCM/ICB, Recife, Brazil
| | - Marie-Annick Clavel
- Québec Heart and Lung Institute/Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, 2725 Chemin Sainte Foy, #A-2075, Quebec, QC, G1V4G5, Canada
| | - Philippe Pibarot
- Québec Heart and Lung Institute/Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, 2725 Chemin Sainte Foy, #A-2075, Quebec, QC, G1V4G5, Canada
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Konstantin Zhigalov
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Ricardo Carvalho Lima
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil.,University of Pernambuco, UPE, Recife, Brazil.,Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Instituite, FCM/ICB, Recife, Brazil
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194
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Madsen CM, Kamstrup PR, Langsted A, Varbo A, Nordestgaard BG. Lipoprotein(a)-Lowering by 50 mg/dL (105 nmol/L) May Be Needed to Reduce Cardiovascular Disease 20% in Secondary Prevention. Arterioscler Thromb Vasc Biol 2020; 40:255-266. [DOI: 10.1161/atvbaha.119.312951] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective:
High Lp(a) (lipoprotein[a]) cause cardiovascular disease (CVD) in a primary prevention setting; however, it is debated whether high Lp(a) lead to recurrent CVD events. We tested the latter hypothesis and estimated the Lp(a)-lowering needed for 5 years to reduce CVD events in a secondary prevention setting.
Approach and Results:
From the CGPS (Copenhagen General Population Study; 2003–2015) of 58 527 individuals with measurements of Lp(a), 2527 aged 20 to 79 with a history of CVD were studied. The primary end point was major adverse cardiovascular event (MACE). We also studied 1115 individuals with CVD from the CCHS (Copenhagen City Heart Study; 1991–1994) and the CIHDS (Copenhagen Ischemic Heart Disease Study; 1991–1993). During a median follow-up of 5 years (range, 0–13), 493 individuals (20%) experienced a MACE in the CGPS. MACE incidence rates per 1000 person-years were 29 (95% CI, 25–34) for individuals with Lp(a)<10 mg/dL, 35 (30–41) for 10 to 49 mg/dL, 42 (34–51) for 50 to 99 mg/dL, and 54 (42–70) for ≥100 mg/dL. Compared with individuals with Lp(a)<10 mg/dL (18 nmol/L), the multifactorially adjusted MACE incidence rate ratios were 1.28 (95% CI, 1.03–1.58) for 10 to 49 mg/dL (18–104 nmol/L), 1.44 (1.12–1.85) for 50 to 99 mg/dL (105–213 nmol/L), and 2.14 (1.57–2.92) for ≥100 mg/dL (214 nmol/L). Independent confirmation was obtained in individuals from the CCHS and CIHDS. To achieve 20% and 40% MACE risk reduction in secondary prevention, we estimated that plasma Lp(a) should be lowered by 50 mg/dL (95% CI, 27–138; 105 nmol/L [55–297]) and 99 mg/dL (95% CI, 54–273; 212 nmol/L [114–592]) for 5 years.
Conclusions:
High concentrations of Lp(a) are associated with high risk of recurrent CVD in individuals from the general population. This study suggests that Lp(a)-lowering by 50 mg/dL (105 nmol/L) short-term (ie, 5 years) may reduce CVD by 20% in a secondary prevention setting.
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Affiliation(s)
- Christian M. Madsen
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (C.M.M., A.L., A.V., B.G.N.)
| | - Pia R. Kamstrup
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
| | - Anne Langsted
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (C.M.M., A.L., A.V., B.G.N.)
| | - Anette Varbo
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (C.M.M., A.L., A.V., B.G.N.)
| | - Børge G. Nordestgaard
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen City Heart Study, Frederiksberg Hospital (B.G.N.), Copenhagen University Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (C.M.M., A.L., A.V., B.G.N.)
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195
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Kaltoft M, Langsted A, Nordestgaard BG. Obesity as a Causal Risk Factor for Aortic Valve Stenosis. J Am Coll Cardiol 2020; 75:163-176. [DOI: 10.1016/j.jacc.2019.10.050] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/26/2022]
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196
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Clemente A, Traghella I, Mazzone A, Sbrana S, Vassalle C. Vascular and valvular calcification biomarkers. Adv Clin Chem 2020; 95:73-103. [PMID: 32122525 DOI: 10.1016/bs.acc.2019.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Vascular and valvular calcification constitutes a major health problem with serious clinical consequences. It is important for medical laboratorians to improve their knowledge on this topic and to know which biological markers may have a potential interest and might be useful for diagnosis and for management of ectopic calcifications. This review focuses on the pathophysiological mechanisms of vascular and valvular calcification, with emphasis on the mechanisms that are different for the two types of events, which underscore the need for differentiated healthcare, and explain different response to therapy. Available imaging and scoring tools used to assess both vascular and valvular calcification, together with the more studied and reliable biological markers emerging in this field (e.g., Fetuin A and matrix Gla protein), are discussed. Recently proposed functional assays, measuring the propensity of human serum to calcify, appear promising for vascular calcification assessment and are described. Further advancement through omic technologies and statistical tools is also reported. Clinical chemistry and laboratory medicine practitioners overlook this new era that will engage them in the near future, where a close cooperation of professionals with different competencies, including laboratorists, is required. This innovative approach may truly revolutionize practice of laboratory and of whole medicine attitude, making progression in knowledge of pathways relevant to health, as the complex calcification-related pathways, and adding value to patient care, through a precision medicine strategy.
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197
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Gudbjartsson DF, Thorgeirsson G, Sulem P, Helgadottir A, Gylfason A, Saemundsdottir J, Bjornsson E, Norddahl GL, Jonasdottir A, Jonasdottir A, Eggertsson HP, Gretarsdottir S, Thorleifsson G, Indridason OS, Palsson R, Jonasson F, Jonsdottir I, Eyjolfsson GI, Sigurdardottir O, Olafsson I, Danielsen R, Matthiasson SE, Kristmundsdottir S, Halldorsson BV, Hreidarsson AB, Valdimarsson EM, Gudnason T, Benediktsson R, Steinthorsdottir V, Thorsteinsdottir U, Holm H, Stefansson K. Lipoprotein(a) Concentration and Risks of Cardiovascular Disease and Diabetes. J Am Coll Cardiol 2019; 74:2982-2994. [PMID: 31865966 DOI: 10.1016/j.jacc.2019.10.019] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 09/05/2019] [Accepted: 10/06/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lipoprotein(a) [Lp(a)] is a causal risk factor for cardiovascular diseases that has no established therapy. The attribute of Lp(a) that affects cardiovascular risk is not established. Low levels of Lp(a) have been associated with type 2 diabetes (T2D). OBJECTIVES This study investigated whether cardiovascular risk is conferred by Lp(a) molar concentration or apolipoprotein(a) [apo(a)] size, and whether the relationship between Lp(a) and T2D risk is causal. METHODS This was a case-control study of 143,087 Icelanders with genetic information, including 17,715 with coronary artery disease (CAD) and 8,734 with T2D. This study used measured and genetically imputed Lp(a) molar concentration, kringle IV type 2 (KIV-2) repeats (which determine apo(a) size), and a splice variant in LPA associated with small apo(a) but low Lp(a) molar concentration to disentangle the relationship between Lp(a) and cardiovascular risk. Loss-of-function homozygotes and other subjects genetically predicted to have low Lp(a) levels were evaluated to assess the relationship between Lp(a) and T2D. RESULTS Lp(a) molar concentration was associated dose-dependently with CAD risk, peripheral artery disease, aortic valve stenosis, heart failure, and lifespan. Lp(a) molar concentration fully explained the Lp(a) association with CAD, and there was no residual association with apo(a) size. Homozygous carriers of loss-of-function mutations had little or no Lp(a) and increased the risk of T2D. CONCLUSIONS Molar concentration is the attribute of Lp(a) that affects risk of cardiovascular diseases. Low Lp(a) concentration (bottom 10%) increases T2D risk. Pharmacologic reduction of Lp(a) concentration in the 20% of individuals with the greatest concentration down to the population median is predicted to decrease CAD risk without increasing T2D risk.
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Affiliation(s)
- Daniel F Gudbjartsson
- deCODE genetics/Amgen, Reykjavik, Iceland; School of Engineering and Natural Sciences, University of Iceland, Reykjavik, Iceland
| | - Gudmundur Thorgeirsson
- deCODE genetics/Amgen, Reykjavik, Iceland; Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; Division of Cardiology and Cardiovascular Research Center, Internal Medicine Services, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | | | | | | | | | - Eythor Bjornsson
- deCODE genetics/Amgen, Reykjavik, Iceland; Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | | | | | | | - Hannes P Eggertsson
- deCODE genetics/Amgen, Reykjavik, Iceland; School of Engineering and Natural Sciences, University of Iceland, Reykjavik, Iceland
| | | | | | - Olafur S Indridason
- Division of Nephrology, Internal Medicine Services, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | - Runolfur Palsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; Division of Nephrology, Internal Medicine Services, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | - Fridbert Jonasson
- deCODE genetics/Amgen, Reykjavik, Iceland; Department of Ophthalmology, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | - Ingileif Jonsdottir
- deCODE genetics/Amgen, Reykjavik, Iceland; Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; Department of Immunology, Landspitali, The National University Hospital of Iceland
| | | | | | - Isleifur Olafsson
- Department of Clinical Biochemistry, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | - Ragnar Danielsen
- Division of Cardiology and Cardiovascular Research Center, Internal Medicine Services, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Snaedis Kristmundsdottir
- deCODE genetics/Amgen, Reykjavik, Iceland; School of Science and Engineering, Reykjavik University, Reykjavik, Iceland
| | - Bjarni V Halldorsson
- deCODE genetics/Amgen, Reykjavik, Iceland; School of Science and Engineering, Reykjavik University, Reykjavik, Iceland
| | - Astradur B Hreidarsson
- Division of Endocrinology and Metabolic Medicine, Internal Medicine Services, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | - Einar M Valdimarsson
- Department of Neurology, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | - Thorarinn Gudnason
- Division of Cardiology and Cardiovascular Research Center, Internal Medicine Services, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | - Rafn Benediktsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; Division of Endocrinology and Metabolic Medicine, Internal Medicine Services, Landspitali, The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Unnur Thorsteinsdottir
- deCODE genetics/Amgen, Reykjavik, Iceland; Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Hilma Holm
- deCODE genetics/Amgen, Reykjavik, Iceland
| | - Kari Stefansson
- deCODE genetics/Amgen, Reykjavik, Iceland; Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland.
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198
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Abstract
Elevated levels of lipoprotein(a) (Lp(a)) contribute to the risk of early and severe cardiovascular disease (CVD) and Lp(a) is acknowledged as a risk factor to be included in risk assessment. The established lipid-modifying medical therapies do not lower Lp(a) except niacin but no data of endpoint trials are available. Of the new lipid-modifying drugs a few have some impact on Lp(a). Whether the Lp(a) lowering effect contributes to the reduction of CVD events would have to be shown in Lp(a) dedicated trials. None of the available agents is indicated to lower Lp(a). Lipoprotein apheresis lowers levels of Lp(a) significantly by >60% per treatment. Trial data and data of the German Lipoprotein Apheresis Registry show that regular apheresis reduces cardiovascular events. The Apo(a) antisense oligonucleotide is the only approach to specifically lower Lp(a). The IONIS-APO(a)Rx phase 1 and 2 trials showed very substantial decreases of Lp(a) and good tolerability. The hepatospecific variant IONIS-APO(a)-LRx is 30 times more potent. The results of the IONIS-APO(a)-LRx phase 2 trial were presented recently. The highest dosages reduced Lp(a) by 72 and 80%; in about 81 and 98% Lp(a) levels <50 mg/dl were achieved. Tolerability and safety were confirmed, whereby injection site reactions were the most common side effects. This raises hope that the planned phase 3 trial will reproduce these findings and show a reduction of cardiovascular events.
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199
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Prediction of cardiovascular risk by Lp(a) concentrations or genetic variants within the LPA gene region. Clin Res Cardiol Suppl 2019; 14:5-12. [PMID: 30859385 DOI: 10.1007/s11789-019-00093-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
In the middle of the 1990s the interest in Lp(a) vanished after a few badly performed studies almost erased Lp(a) from the map of biological targets. However, since roughly 10 years the interest has begun to grow again mainly for two reasons: first, genetic studies using easily accessible and high-throughput techniques for genotyping of single-nucleotide polymorphisms (SNPs) have allowed large studies in patients with cardiovascular disease and controls to be performed. This strengthened the earlier findings on a copy number variation in the LPA gene and its association with cardiovascular outcomes. Second, new therapies are on the horizon raising strong and justified hope that in a few years drugs will become available which tremendously lower Lp(a) concentrations. This review article should provide an introduction to the genetic determination of Lp(a) concentrations and considerations whether Lp(a) concentrations or genetic variants are important for the prediction of cardiovascular risk.
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200
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HEART UK consensus statement on Lipoprotein(a): A call to action. Atherosclerosis 2019; 291:62-70. [DOI: 10.1016/j.atherosclerosis.2019.10.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 12/24/2022]
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