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Reijman MD, Tromp TR, Hutten BA, Hovingh GK, Blom DJ, Catapano AL, Cuchel M, Dann EJ, Gallo A, Hudgins LC, Raal FJ, Ray KK, Sadiq F, Soran H, Groothoff JW, Wiegman A, Kusters DM. Cardiovascular outcomes in patients with homozygous familial hypercholesterolaemia on lipoprotein apheresis initiated during childhood: long-term follow-up of an international cohort from two registries. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:491-499. [PMID: 38759658 DOI: 10.1016/s2352-4642(24)00073-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Homozygous familial hypercholesterolaemia (HoFH) is a rare genetic disease characterised by extremely high plasma LDL cholesterol from birth, causing atherosclerotic cardiovascular disease at a young age. Lipoprotein apheresis in combination with lipid-lowering drugs effectively reduce LDL cholesterol, but long-term health outcomes of such treatment are unknown. We aimed to investigate the long-term cardiovascular outcomes associated with lipoprotein apheresis initiated in childhood or adolescence. METHODS In this cohort study, data were drawn from the HoFH International Clinical Collaboration (HICC) and the international registry for Children with Homozygous Hypercholesterolemia on Lipoprotein Apheresis (CHAIN). An overall cohort included patients diagnosed with HoFH aged 0-18 years who were alive and in follow-up between Jan 1, 2010, and Nov 8, 2021, and whose high plasma LDL cholesterol concentrations made them eligible for lipoprotein apheresis. To compare cardiovascular outcomes, patients who initiated lipoprotein apheresis in childhood (lipoprotein apheresis group) and patients who only received lipid-lowering drugs (pharmacotherapy-only group) were matched by sex and untreated plasma LDL cholesterol concentrations. The primary outcome was a composite of cardiovascular death, myocardial infarction, ischaemic stroke, percutaneous coronary intervention, coronary artery bypass grafting, aortic valve replacement, peripheral artery disease, carotid endarterectomy, angina pectoris, and supra-aortic or aortic stenosis (collectively referred to as atherosclerotic cardiovascular disease), for which survival analyses were performed in the matched cohort. Cox regression analyses were used to compare disease-free survival between cohorts and to calculate hazard ratio (HR) and 95% CI adjusted for sex, age at diagnosis, untreated plasma LDL cholesterol concentration, and number of lipid-lowering therapies other than lipoprotein apheresis. FINDINGS The overall cohort included 404 patients with a median age at diagnosis of 6·0 years (IQR 3·0-9·5) and median untreated plasma LDL cholesterol of 17·8 mmol/L (14·7-20·8). The matched cohorts included 250 patients (125 patients per group), with a median untreated LDL cholesterol of 17·2 mmol/L (14·8-19·7). Mean reduction in plasma LDL cholesterol concentrations between baseline and final follow-up was greater in the lipoprotein apheresis group (-55% [95% CI -60 to -51] vs -31% [-36 to -25]; p<0·0001). Patients in the lipoprotein apheresis group had longer atherosclerotic cardiovascular disease-free survival (adjusted HR 0·52 [95% CI 0·32-0·85]) and longer cardiovascular death-free survival (0·0301 [0·0021-0·4295]). Cardiovascular death was more common in the pharmacotherapy-only group than in the lipoprotein apheresis group (ten [8%] vs one [1%]; p=0·010), whereas median age at coronary artery bypass grafting was lower in the lipoprotein apheresis group than in the pharmacotherapy-only group (15·0 years [IQR 12·0-24·0] vs 30·5 years [19·0-33·8]; p=0·037). INTERPRETATION Among patients with HoFH, lipoprotein apheresis initiated during childhood and adolescence is associated with reduced long-term risk of atherosclerotic cardiovascular disease and death, and clear benefits of early initiation of high-frequency treatment on reducing plasma cholesterol were found. Consensus recommendations are now needed to guide more widespread and timely use of lipoprotein apheresis for children with HoFH, and research is required to further optimise treatment and ensure benefits of early and aggressive treatment delivery are balanced against effects on quality of life. FUNDING Amsterdam University Medical Centers, Location Academic Medical Center; Perelman School of Medicine at the University of Pennsylvania; European Atherosclerosis Society; and the US National Heart, Lung, and Blood Institute, National Institutes of Health.
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Affiliation(s)
- M Doortje Reijman
- Department of Paediatrics, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Tycho R Tromp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Barbara A Hutten
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Cardiovascular Sciences, Diabetes and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Novo Nordisk, Søborg, Denmark
| | - Dirk J Blom
- Division of Lipidology, Department of Medicine and the Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Marina Cuchel
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eldad J Dann
- Blood Bank and Apheresis Unit, Rambam Health Care Campus, Haifa, Israel
| | - Antonio Gallo
- Sorbonne Université, INSERM, UMR 1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Lisa C Hudgins
- The Rogosin Institute, Weill Cornell Medical College, New York, NY, USA
| | - Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Fouzia Sadiq
- Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Handrean Soran
- Department of Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust and National Institute of Health Research/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Jaap W Groothoff
- Department of Paediatrics, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Albert Wiegman
- Department of Paediatrics, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - D Meeike Kusters
- Department of Paediatrics, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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2
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Alonso R, Arroyo-Olivares R, Díaz-Díaz JL, Fuentes-Jiménez F, Arrieta F, de Andrés R, Gonzalez-Bustos P, Argueso R, Martin-Ordiales M, Martinez-Faedo C, Illán F, Saenz P, Donate JM, Sanchez Muñoz-Torrero JF, Martinez-Hervas S, Mata P. Improved lipid-lowering treatment and reduction in cardiovascular disease burden in homozygous familial hypercholesterolemia: The SAFEHEART follow-up study. Atherosclerosis 2024; 393:117516. [PMID: 38523000 DOI: 10.1016/j.atherosclerosis.2024.117516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024]
Abstract
AIM We aimed to describe clinical and genetic characteristics, lipid-lowering treatment and atherosclerotic cardiovascular disease (ASCVD) outcomes over a long-term follow-up in homozygous familial hypercholesterolemia (HoFH). METHODS SAFEHEART (Spanish Familial Hypercholesterolaemia Cohort Study) is a long-term study in molecularly diagnosed FH. Data analyzed in HoFH were prospectively obtained from 2004 until 2022. ASCVD events, lipid profile and lipid-lowering treatment were determined. RESULTS Thirty-nine HoFH patients were analyzed. The mean age was 42 ± 20 years and nineteen (49%) were women. Median follow-up was 11 years (IQR 6,18). Median age at genetic diagnosis was 24 years (IQR 8,42). At enrolment, 33% had ASCVD and 18% had aortic valve disease. Patients with new ASCVD events and aortic valve disease at follow-up were six (15%), and one (3%), respectively. Median untreated LDL-C levels were 555 mg/dL (IQ 413,800), and median LDL-C levels at last follow-up was 122 mg/dL (IQR 91,172). Most patients (92%) were on high intensity statins and ezetimibe, 28% with PCSK9i, 26% with lomitapide, and 23% with lipoprotein-apheresis. Fourteen patients (36%) attained an LDL-C level below 100 mg/dL, and 10% attained an LDL-C below 70 mg/dL in secondary prevention. Patients with null/null variants were youngers, had higher untreated LDL-C and had the first ASCVD event earlier. Free-event survival is longer in patients with defective variant compared with those patients with at least one null variant (p=0.02). CONCLUSIONS HoFH is a severe life threating disease with a high genetic and phenotypic variability. The improvement in lipid-lowering treatment and LDL-C levels have contributed to reduce ASCVD events.
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Affiliation(s)
- Rodrigo Alonso
- Fundación Hipercolesterolemia Familiar, Madrid, Spain; Center for Advanced Metabolic Medicine and Nutrition, Santiago, Chile.
| | | | | | - Francisco Fuentes-Jiménez
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Reina Sofia University Hospital, CIBERObn, Córdoba, Spain
| | | | | | - Pablo Gonzalez-Bustos
- Department of Internal Medicine, Hospital Universitario Virgen de Las Nieves, Granada, Spain
| | - Rosa Argueso
- Department of Endocrinology, Hospital Universitario de Lugo, Lugo, Spain
| | | | | | - Fátima Illán
- Department of Endocrinology, Hospital Morales Meseguer, Murcia, Spain
| | - Pedro Saenz
- Department of Internal Medicine, Hospital de Mérida, Mérida, Spain
| | - José María Donate
- Department of Pediatric Endocrinology, Hospital General Universitario Santa Lucía, Murcia, Spain
| | | | - Sergio Martinez-Hervas
- Department of Endocrinology, Hospital Clínico Universitario de Valencia INCLIVA, CIBER de Diabetes, Spain
| | - Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain.
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3
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Watts GF, Gidding SS, Hegele RA, Raal FJ, Sturm AC, Jones LK, Sarkies MN, Al-Rasadi K, Blom DJ, Daccord M, de Ferranti SD, Folco E, Libby P, Mata P, Nawawi HM, Ramaswami U, Ray KK, Stefanutti C, Yamashita S, Pang J, Thompson GR, Santos RD. International Atherosclerosis Society guidance for implementing best practice in the care of familial hypercholesterolaemia. Nat Rev Cardiol 2023; 20:845-869. [PMID: 37322181 DOI: 10.1038/s41569-023-00892-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/17/2023]
Abstract
This contemporary, international, evidence-informed guidance aims to achieve the greatest good for the greatest number of people with familial hypercholesterolaemia (FH) across different countries. FH, a family of monogenic defects in the hepatic LDL clearance pathway, is a preventable cause of premature coronary artery disease and death. Worldwide, 35 million people have FH, but most remain undiagnosed or undertreated. Current FH care is guided by a useful and diverse group of evidence-based guidelines, with some primarily directed at cholesterol management and some that are country-specific. However, none of these guidelines provides a comprehensive overview of FH care that includes both the lifelong components of clinical practice and strategies for implementation. Therefore, a group of international experts systematically developed this guidance to compile clinical strategies from existing evidence-based guidelines for the detection (screening, diagnosis, genetic testing and counselling) and management (risk stratification, treatment of adults or children with heterozygous or homozygous FH, therapy during pregnancy and use of apheresis) of patients with FH, update evidence-informed clinical recommendations, and develop and integrate consensus-based implementation strategies at the patient, provider and health-care system levels, with the aim of maximizing the potential benefit for at-risk patients and their families worldwide.
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Affiliation(s)
- Gerald F Watts
- School of Medicine, University of Western Australia, Perth, WA, Australia.
- Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia.
| | | | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine, Western University, London, ON, Canada
| | - Frederick J Raal
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy C Sturm
- Department of Genomic Health, Geisinger, Danville, PA, USA
- 23andMe, Sunnyvale, CA, USA
| | - Laney K Jones
- Department of Genomic Health, Geisinger, Danville, PA, USA
| | - Mitchell N Sarkies
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Khalid Al-Rasadi
- Medical Research Centre, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Dirk J Blom
- Division of Lipidology and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
| | - Hapizah M Nawawi
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM) and Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
- Specialist Lipid and Coronary Risk Prevention Clinics, Hospital Al-Sultan Abdullah (HASA) and Clinical Training Centre, Puncak Alam and Sungai Buloh Campuses, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Uma Ramaswami
- Royal Free London NHS Foundation Trust, University College London, London, UK
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, UK
| | - Claudia Stefanutti
- Department of Molecular Medicine, Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Regional Centre for Rare Diseases, Immunohematology and Transfusion Medicine, Umberto I Hospital, 'Sapienza' University of Rome, Rome, Italy
| | - Shizuya Yamashita
- Department of Cardiology, Rinku General Medical Center, Osaka, Japan
| | - Jing Pang
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | | | - Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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Brown L, Ruel I, Baass A, Bergeron J, Brunham LR, Cermakova L, Couture P, Gaudet D, Francis GA, Hegele RA, Iatan I, Mancini GJ, McCrindle BW, Ransom T, Sherman MH, McPherson R, Genest J. Homozygous Familial Hypercholesterolemia in Canada: An Observational Study. JACC. ADVANCES 2023; 2:100309. [PMID: 38939573 PMCID: PMC11198203 DOI: 10.1016/j.jacadv.2023.100309] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 06/29/2024]
Abstract
Background Homozygous familial hypercholesterolemia (HoFH) is a rare genetic disease characterized by very high levels of low-density lipoprotein cholesterol (LDL-C). Untreated patients present with extensive xanthomas and premature atherosclerosis. Lipid-lowering therapy is highly efficacious and has dramatically increased life expectancy of patients with HoFH. Objectives The aim of the study was to obtain a comprehensive registry of HoFH in Canada, known to have several founder effect regions, and describe the clinical characteristics and cardiovascular outcomes of this population over time. Methods Clinical and genetic data on patients with HoFH were collected via a standardized questionnaire sent to academic sites participating in the Familial Hypercholesterolemia Canada network. Results A total of 48 patients with HoFH were enrolled. The median age at diagnosis was 12 years (interquartile range [IQR]: 5-24) and untreated LDL-C levels were 15.0 mmol/L (IQR: 10.5-18.6 mmol/L; 580 mg/dL IQR: 404-717 mg/dL). At last follow-up visit, median age was 40 years (IQR: 26-54 years). Treated LDL-C levels were 6.75 mmol/L (IQR: 4.73-9.51 mmol/L; 261 mg/dL IQR: 183-368 mg/dL) with 95.5% of patients on statins, 88.6% on ezetimibe, 34.1% on proprotein convertase subtilisin/kexin type 9 inhibitors, 27.3% on lomitapide, 13.6% on evinacumab, and 56.8% were treated with low-density lipoprotein apheresis or plasmapheresis. Deaths were reported in 7 (14.5%) and major adverse cardiovascular events were observed in 14.6% of patients with the average onset at 30 years (IQR: 20-36 years). Aortic stenosis was reported in one-half the patients (47.9%) and 10 (20.8%) underwent aortic valve replacement. Conclusions This HoFH patient registry in Canada will provide important new health-related knowledge about the phenotypic manifestations and determinants of cardiovascular risk in this population, allowing for closer examination of quality of life and burden to the health care system.
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Affiliation(s)
- Leslie Brown
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Isabelle Ruel
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Alexis Baass
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Jean Bergeron
- Endocrinology and Nephrology Unit, CHU de Québec - Université Laval Research Center, Québec City, Québec, Canada
| | - Liam R. Brunham
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lubomira Cermakova
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Couture
- Endocrinology and Nephrology Unit, CHU de Québec - Université Laval Research Center, Québec City, Québec, Canada
| | - Daniel Gaudet
- Lipidology Unit, Department of Medicine, Community Genomic Medicine Center, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Québec, Canada
| | - Gordon A. Francis
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert A. Hegele
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Ontario, Canada
| | - Iulia Iatan
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - G.B. John Mancini
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian W. McCrindle
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Ransom
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mark H. Sherman
- Department of Endocrinology, McGill University Health Centre, Montreal, Québec, Canada
| | - Ruth McPherson
- Lipid Clinic & Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jacques Genest
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
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5
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Bélanger AM, Akioyamen LE, Ruel I, Hales L, Genest J. Aortic stenosis in homozygous familial hypercholesterolaemia: a paradigm shift over a century. Eur Heart J 2022; 43:3227-3239. [PMID: 35776569 DOI: 10.1093/eurheartj/ehac339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 05/13/2022] [Accepted: 06/09/2022] [Indexed: 01/31/2023] Open
Abstract
AIMS Homozygous familial hypercholesterolaemia (HoFH) is an orphan disease defined by extreme elevations in low-density lipoprotein cholesterol, cutaneous xanthomas, and pre-mature atherosclerotic cardiovascular disease. Survival has more than doubled over the past three decades. Aortic stenosis (AS) [supravalvular aortic stenosis (SVAS) or valvular aortic stenosis (VAS)] is commonly encountered. There are no medical treatments available and complex high-risk surgeries represent the only available option in severe cases. A systematic review was performed to summarize the current evidence on AS in HoFH and to determine whether pharmacological treatment (statins) have had an impact on clinical presentation, phenotype and clinical course over the past nine decades (PROSPERO CRD42021250565). METHODS AND RESULTS MEDLINE, Embase Classic + Embase, Cochrane Central Register of Controlled Trials, PubMed, AfricaWide, and Scopus were searched from inception to 10 November 2021. Searches identified 381 publications, of which 19 were retained; they were cross-sectional or retrospective studies. Separately, 108 individual case reports were described. Within the 424 HoFH cases, AS was identified in 57% of patients in the pre-statin era vs. 35% in patients reported more recently (>2000, long-term statin period). With an increase in longevity due to statins and lipoprotein apheresis, a change in the proportion of patients with SVAS and VAS with a SVAS:VAS ratio of 47:53 and 10:90 for HoFH patients not on statin and on long-term statin, respectively, was noted. CONCLUSION These data suggest that SVAS and VAS are frequent in HoFH and that the phenotype has shifted towards calcific VAS as statins and lipoprotein apheresis improve survival in these patients.
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Affiliation(s)
- Alexandre M Bélanger
- Research Institute of the McGill University Health Centre, 1001, Boul. Décarie, Office EM1.2212, Montréal, Québec, Canada
| | - Leo E Akioyamen
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre, 1001, Boul. Décarie, Office EM1.2212, Montréal, Québec, Canada
| | - Lindsay Hales
- McGill University Health Centre Medical Libraries, Montréal, Québec, Canada
| | - Jacques Genest
- Research Institute of the McGill University Health Centre, 1001, Boul. Décarie, Office EM1.2212, Montréal, Québec, Canada
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Abstract
PURPOSE OF REVIEW Lipoprotein apheresis has been first line therapy for homozygous familial hypercholesterolaemia (FH) and other severe and refractory forms of dyslpidaemia for over 40 years but the recent advent of novel and potent LDL-lowering compounds necessitates a reappraisal of its role. RECENT FINDINGS During the past decade a substantial amount of evidence has accumulated describing the effect of LDL-lowering with apheresis and conventional drug therapy upon the cardiovascular outcomes associated with homozygous and statin-refractory heterozygous FH. This has necessitated re-defining the target levels of LDL cholesterol needed to arrest progression of atherosclerosis in these situations. At the same time, evidence has accrued regarding the pathogenicity of raised levels of lipoprotein (a) and the promising role of apheresis in mitigating the adverse effects of the latter. The latest advance in treatment has been the introduction of three classes of novel and potent LDL-lowering compounds in the shape of inhibitors of Propertin convertase subtilisin kexin 9 (PCSK9), microsomal triglyceride transfer protein and angiopoietin-like 3. SUMMARY These recent developments raise the question of whether these compounds will be used as adjuvants to bolster lipoprotein apheresis in FH homozygotes or whether they will render it obsolete, as is already occurring with PCSK9 inhibitors in FH heterozygotes.
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Affiliation(s)
- Gilbert R Thompson
- Faculty of Medicine, Hammersmith Hospital Campus, Imperial College London, United Kingdom
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7
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Abstract
After training as a gastroenterologist in the UK, the author became interested in lipidology while he was a research fellow in the USA and switched careers after returning home. Together with Nick Myant, he introduced the use of plasma exchange to treat familial hypercholesterolemia (FH) homozygotes and undertook non-steady state studies of LDL kinetics, which showed that the fractional catabolic rate of LDL remained constant irrespective of pool size. Subsequent steady-state turnover studies showed that FH homozygotes had an almost complete lack of receptor-mediated LDL catabolism, providing in vivo confirmation of the Nobel Prize-winning discovery by Goldstein and Brown that LDL receptor dysfunction was the cause of FH. Further investigation of metabolic defects in FH revealed that a significant proportion of LDL in homozygotes and heterozygotes was produced directly via a VLDL-independent pathway. Management of heterozygous FH has been greatly facilitated by statins and proprotein convertase subtilisin/kexin type 9 inhibitors but remains dependent upon lipoprotein apheresis in homozygotes. In a recent analysis of a large cohort treated with a combination of lipid-lowering measures, survival was markedly enhanced in homozygotes in the lowest quartile of on-treatment serum cholesterol. Emerging therapies could further improve the prognosis of homozygous FH; whereas in heterozygotes, the current need is better detection.
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Affiliation(s)
- Gilbert R Thompson
- Faculty of Medicine, Hammersmith Hospital Campus, Imperial College London, London, United Kingdom.
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Bertolini S, Calandra S, Arca M, Averna M, Catapano AL, Tarugi P, Bartuli A, Bucci M, Buonuomo PS, Calabrò P, Casula M, Cefalù AB, Cicero A, D'Addato S, D'Erasmo L, Fasano T, Iannuzzo G, Ibba A, Negri EA, Pasta A, Pavanello C, Pisciotta L, Rabacchi C, Ripoli C, Sampietro T, Sbrana F, Sileo F, Suppressa P, Trenti C, Zenti MG. Homozygous familial hypercholesterolemia in Italy: Clinical and molecular features. Atherosclerosis 2020; 312:72-78. [DOI: 10.1016/j.atherosclerosis.2020.08.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/07/2020] [Accepted: 08/24/2020] [Indexed: 12/17/2022]
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Mlinaric M, Bratanic N, Dragos V, Skarlovnik A, Cevc M, Battelino T, Groselj U. Case Report: Liver Transplantation in Homozygous Familial Hypercholesterolemia (HoFH)-Long-Term Follow-Up of a Patient and Literature Review. Front Pediatr 2020; 8:567895. [PMID: 33163465 PMCID: PMC7581712 DOI: 10.3389/fped.2020.567895] [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: 05/30/2020] [Accepted: 08/28/2020] [Indexed: 01/15/2023] Open
Abstract
Homozygous familial hypercholesterolemia (HoFH) is a rare inherited metabolic disorder, frequently leading to an early cardiovascular death if not adequately treated. Since standard medications usually fail to reduce LDL-cholesterol (LDL-C) levels satisfactorily, LDL-apheresis is a mainstay of managing HoFH patients but, at the same time, very burdensome and suboptimally effective. Liver transplantation (LT) has been previously shown to be a promising alternative. We report on a 14 year-long follow-up after LT in a HoFH patient. At the age of 4, the patient was referred to our institution because of the gradually increasing number of xanthomas on the knees, elbows, buttocks, and later the homozygous mutation c.1754T>C (p.Ile585Thr) on the LDL-receptor gene was confirmed. Despite subsequent intensive treatment with the combination of diet, statins, bile acid sequestrant, probucol, and LDL-apheresis, the patient developed valvular aortic stenosis and aortic regurgitation by 12 years. At 16 years, the patient successfully underwent deceased-donor orthotopic LT. Nine years post-LT, we found total regression of the cutaneous xanthomas and atherosclerotic plaques and with normal endothelial function. Fourteen years post-LT, his clinical condition remained stable, but LDL-C levels have progressively risen. In addition, a systematic review of the literature and guidelines on the LT for HoFH patients was performed. Six of the 17 identified guidelines did not take LT as a treatment option in consideration at all. But still the majority of guidelines suggest LT as an exceptional therapeutic option or as the last resort option when all the other treatment options are inadequate or not tolerated. Most of the observed patients had some kind of cardiovascular disease before the LT. In 76% of LT, the cardiovascular burden did not progress after LT. According to our experience and in several other reported cases, the LDL-C levels are slowly increasing over time post LT. Most of the follow-up data were short termed; only a few case reports have followed patients for 10 or more years after LT. LT is a feasible therapeutic option for HoFH patients, reversing atherosclerotic changes uncontrollable by conservative therapy, thus importantly improving the HoFH patient's prognosis and quality of life.
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Affiliation(s)
- Matej Mlinaric
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nevenka Bratanic
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vlasta Dragos
- Department of Dermatovenereology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ajda Skarlovnik
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matija Cevc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Urh Groselj
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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10
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Marusic T, Sustar U, Sadiq F, Kotori V, Mlinaric M, Kovac J, Shafi S, Khan I, Cevc M, Trebusak Podkrajsek K, Battelino T, Groselj U. Genetic and Clinical Characteristics of Patients With Homozygous and Compound Heterozygous Familial Hypercholesterolemia From Three Different Populations: Case Series. Front Genet 2020; 11:572176. [PMID: 33093846 PMCID: PMC7528874 DOI: 10.3389/fgene.2020.572176] [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: 06/12/2020] [Accepted: 08/20/2020] [Indexed: 11/17/2022] Open
Abstract
Homozygous familial hypercholesterolemia (HoFH) and compound heterozygous familial hypercholesterolemia (cHeFH) are rare disorders generated by disease-causing variants in both alleles of the LDLR or other familial hypercholesterolemia (FH)-related genes. HoFH and cHeFH are characterized by severely elevated low-density lipoprotein-cholesterol (LDL-C), frequently leading to early cardiovascular disease. We investigated the genetic and clinical characteristics of HoFH and cHeFH patients from the Slovenian FH registry and/or those who were previously diagnosed or managed at our institution (Slovenian, Pakhtun and Albanian ethnicity), where genetic testing is not available. Our study includes seven patients. Their median age at the time of clinical diagnosis was 6.3 years (2.9-12.9 years); 2/7 were females. Two patients were diagnosed through the universal FH screening and five patients were diagnosed due to the presence of xanthomas. All the mutations are present in LDLR gene: 7 different genotypes for HoFH (p.Cys167Leu, p.Asp178Asn, p.Cys243Tyr, p.Gly549Asp, p.Cys27Trp, p.Ile585Thr and p.Val797Met) and p.Gly549Asp/p.Gln384Pro genotype for cHeFH patient. The median initial level of LDL-C was 17.0 mmol/L [655 mg/dL] (range 7.6-21.6 mmol/L). The HoFH/cHeFH patients are clinically and genetically very diverse. The clinical criteria (as Simon Broome criteria) might be applicable already in children to raise suspicion of FH but in some cases fail to distinguish heterozygous FH and HoFH/cHeFH patients. However, genetic testing is helpful in confirming the diagnosis, also for a prompt awareness, better compliance to treatment and family screening.
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Affiliation(s)
- Tatiana Marusic
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
| | - Ursa Sustar
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
| | - Fouzia Sadiq
- Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Vjosa Kotori
- Department of Endocrinology, Pediatric Clinic, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Matej Mlinaric
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
| | - Jernej Kovac
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
| | - Saeed Shafi
- Department of Anatomy, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Iqbal Khan
- Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Department of Vascular Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Matija Cevc
- Division of Medicine, Centre for Preventive Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katarina Trebusak Podkrajsek
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Urh Groselj
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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11
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PCSK9 Inhibitors for Homozygous Familial Hypercholesterolemia. J Am Coll Cardiol 2020; 76:143-145. [DOI: 10.1016/j.jacc.2020.05.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 11/22/2022]
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12
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Truong TH, Kim NT, Nguyen MNT, Pang J, Hooper AJ, Watts GF, Do DL. Homozygous familial hypercholesterolaemia in Vietnam: Case series, genetics and cascade testing of families. Atherosclerosis 2019; 277:392-398. [PMID: 30270076 DOI: 10.1016/j.atherosclerosis.2018.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/15/2018] [Accepted: 06/07/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolaemia has not been previously described in the Vietnamese population. We aimed to describe the features of patients with homozygous familial hypercholesterolaemia (hoFH) in Vietnam and the outcomes of screening family members using genetic and cholesterol testing. METHODS Mutation testing by massively parallel sequencing for genes causative of FH was undertaken in five index cases presenting to a single cardiac center with a presumptive diagnosis of hoFH. Cascade testing of all available family members was subsequently undertaken. The number of new cases of FH detected and commenced on lipid-lowering treatment was evaluated. RESULTS All five index cases had true homozygous mutations in the LDL receptor gene (LDLR). Cascade screening was undertaken in four families. 107 relatives were screened and FH was identified in 56 relatives (52%), including 3 new cases of hoFH. Only 5 FH relatives (9%) were subsequently treated owing to the adverse perceptions and comparative high cost of drug treatment, and lack of awareness of FH among patients and local doctors. CONCLUSIONS HoFH due to LDLR mutations is a severe disorder in Vietnam that needs early detection and treatment with LDL-cholesterol lowering drugs. Cascade testing of families allows effective detection of new cases of FH that may also benefit from early treatment. However, convincing patients to commence statin treatment is a challenge. Extended education and awareness programs and treatment subsidies are imperative to improve the care of patients and families suffering from FH in Vietnam.
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Affiliation(s)
- Thanh Huong Truong
- Department of Cardiology, Hanoi Medical University, Hanoi, Vietnam; Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
| | - Ngoc Thanh Kim
- Department of Cardiology, Hanoi Medical University, Hanoi, Vietnam; Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam.
| | | | - Jing Pang
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Amanda J Hooper
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia; Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Doan Loi Do
- Department of Cardiology, Hanoi Medical University, Hanoi, Vietnam; Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
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Kayikcioglu M, Tokgozoglu L, Dogan V, Ceyhan C, Tuncez A, Kutlu M, Onrat E, Alici G, Akbulut M, Celik A, Yesilbursa D, Sahin T, Sonmez A, Ozdogan O, Temizhan A, Kilic S, Bayram F, Sabuncu T, Coskun FY, Ildizli M, Durakoglugil E, Kirilmaz B, Yilmaz MB, Yigit Z, Yildirim AB, Gedikli O, Topcu S, Oğuz A, Demir M, Yenerçağ M, Yıldırır A, Demircan S, Yilmaz M, Kaynar LG, Aktan M, Durmus RB, Gokce C, Ozcebe Oİ, Akyol TK, Okutan H, Sag S, Gul OO, Salcioglu Z, Altunkeser BB, Kuku I, Yasar HY, Kurtoglu E, Kose MD, Demircioglu S, Pekkolay Z, Ilhan O, Can LH. What have we learned from Turkish familial hypercholesterolemia registries (A-HIT1 and A-HIT2)? Atherosclerosis 2019; 277:341-346. [PMID: 30270069 DOI: 10.1016/j.atherosclerosis.2018.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 07/03/2018] [Accepted: 08/17/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is a common genetic disease of high-level cholesterol leading to premature atherosclerosis. One of the key aspects to overcome FH burden is the generation of large-scale reliable data in terms of registries. This manuscript underlines the important results of nation-wide Turkish FH registries (A-HIT1 and A-HIT2). METHODS A-HIT1 is a survey of homozygous FH patients undergoing low density lipoprotein (LDL) apheresis (LA). A-HIT2 is a registry of adult FH patients (homozygous and heterozygous) admitted to outpatient clinics. Both registries used clinical diagnosis of FH. RESULTS A-HIT1 evaluated 88 patients (27 ± 11 years, 41 women) in 19 centers. All patients were receiving regular LA. There was a 7.37 ± 7.1-year delay between diagnosis and initiation of LA. LDL-cholesterol levels reached the target only in 5 cases. Mean frequency of apheresis sessions was 19 ± 13 days. None of the centers had a standardized approach for LA. Mean frequency of apheresis sessions was every 19 ± 13 (7-90) days. Only 2 centers were aware of the target LDL levels. A-HIT2 enrolled 1071 FH patients (53 ± 8 years, 606 women) from 31 outpatients clinics specialized in cardiology (27), internal medicine (1), and endocrinology (3); 96.4% were heterozygous. 459 patients were on statin treatment. LDL targets were attained in 23 patients (2.1% of the whole population, 5% receiving statin) on treatment. However, 66% of statin-receiving patients were on intense doses of statins. Awareness of FH was 9.5% in the whole patient population. CONCLUSIONS The first nationwide FH registries revealed that FH is still undertreated even in specialized centers in Turkey. Additional effective treatment regiments are urgently needed.
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Affiliation(s)
| | | | - Volkan Dogan
- Mugla Sitki Kocman Univ Faculty of Med, Mugla, Turkey
| | | | | | - Merih Kutlu
- Karadeniz Teknik Univ Faculty of Med, Trabzon, Turkey
| | | | - Gokhan Alici
- Kartal Kosuyolu Res & Training Hosp, Istanbul, Turkey
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Zerrin Yigit
- Istanbul University Cardiology Institute, Istanbul, Turkey
| | | | | | - Selim Topcu
- Ataturk Univ Faculty of Med, Erzurum, Turkey
| | | | | | | | | | | | | | | | - Melih Aktan
- Istanbul University Istanbul Univ Faculty of Med, Istanbul, Turkey
| | | | | | | | | | - Harika Okutan
- Diskapi Yildirim Beyazit Res & Training Hosp, Ankara, Turkey
| | - Saim Sag
- Uludag Univ Faculty of Med, Bursa, Turkey
| | | | - Zafer Salcioglu
- Kanuni Sultan Suleyman Res & Training Hosp, Istanbul, Turkey
| | | | - Irfan Kuku
- Inonu Univ Faculty of Med, Malatya, Turkey
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14
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Stefanutti C, Pang J, Di Giacomo S, Wu X, Wang X, Morozzi C, Watts GF, Lin J. A cross-national investigation of cardiovascular survival in homozygous familial hypercholesterolemia: The Sino-Roman Study. J Clin Lipidol 2019; 13:608-617. [DOI: 10.1016/j.jacl.2019.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/02/2019] [Accepted: 05/07/2019] [Indexed: 12/11/2022]
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15
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Abstract
Purpose of Review Lipoprotein apheresis is a very efficient but time-consuming and expensive method of lowering levels of low-density lipoprotein cholesterol, lipoprotein(a)) and other apoB containing lipoproteins, including triglyceride-rich lipoproteins. First introduced almost 45 years ago, it has long been a therapy of “last resort” for dyslipidaemias that cannot otherwise be managed. In recent years new, very potent lipid-lowering drugs have been developed and the purpose of this review is to define the role of lipoprotein apheresis in the current setting. Recent Findings Lipoprotein apheresis still plays an important role in managing patients with homozygous FH and some patients with other forms of hypercholesterolaemia and cardiovascular disease. In particular, patients not achieving treatment goals despite modern lipid-lowering drugs, either because these are not tolerated or the response is insufficient. Recently, lipoprotein(a) has emerged as an important cardiovascular risk factor and lipoprotein apheresis has been used to decrease lipoprotein(a) concentrations in patients with marked elevations and cardiovascular disease. However, there is considerable heterogeneity concerning the recommendations by scientific bodies as to which patient groups should be treated with lipoprotein apheresis. Summary Lipoprotein apheresis remains an important tool for the management of patients with severe drug-resistant dyslipidaemias, especially those with homozygous FH.
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Affiliation(s)
- Gilbert Thompson
- Department of Metabolic Medicine, Imperial College London, Hammersmith Hospital, Ducane Road, London, W12 0NN, UK.
| | - Klaus G Parhofer
- Medical Dept. IV - Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
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16
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Vaverkova H, Tichy L, Karasek D, Freiberger T. A case of autosomal recessive hypercholesterolemia caused by a new variant in the LDL receptor adaptor protein 1 gene. J Clin Lipidol 2019; 13:405-410. [PMID: 30876877 DOI: 10.1016/j.jacl.2019.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/08/2018] [Accepted: 02/10/2019] [Indexed: 01/26/2023]
Abstract
We report a new variant in the LDLRAP1 gene associated with autosomal recessive hypercholesterolemia in a woman of central European ancestry.
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Affiliation(s)
- Helena Vaverkova
- Third Department of Internal Medicine - NRE, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic.
| | - Lukas Tichy
- Department of Internal Medicine, Hematology and Oncology, Centre of Molecular Biology and Therapy, University Hospital Brno, Brno, Czech Republic
| | - David Karasek
- Third Department of Internal Medicine - NRE, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Tomas Freiberger
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Central European Institute of Technology and Medical Faculty, Masaryk University, Brno, Czech Republic
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17
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Thompson GR. Atherosclerosis in cholesterol-fed rabbits and in homozygous and heterozygous LDL receptor-deficient humans. Atherosclerosis 2018; 276:148-154. [DOI: 10.1016/j.atherosclerosis.2018.07.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/10/2018] [Accepted: 07/25/2018] [Indexed: 12/20/2022]
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18
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Current Role of Lipoprotein Apheresis in the Treatment of High-Risk Patients. J Cardiovasc Dev Dis 2018; 5:jcdd5020027. [PMID: 29747383 PMCID: PMC6023350 DOI: 10.3390/jcdd5020027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 04/25/2018] [Accepted: 05/04/2018] [Indexed: 12/14/2022] Open
Abstract
Lipoprotein apheresis (LA) is a therapeutic approach to save the lives of patients who are at an extremely high risk of developing cardiovascular events (CVE), especially after all other therapeutic options were not tolerated, or appeared not to be effective enough. Homozygous familial hypercholesterolemia represents a clear indication to start LA therapy. Another recognized indication is a severe hypercholesterolemia, which induced CVE, often in association with other risk factors. In the last years, an expressive elevation of lipoprotein(a) (Lp(a)) emerged as an indication for LA. In Germany, progress of atherosclerosis should have been documented before the permission to start LA therapy is given in these patients. Usually, all LA methods acutely decrease both LDL-C and Lp(a). However, specific columns which reduce only Lp(a) are available. Case reports and prospective observations comparing the situation before and during LA therapy clearly show a high efficiency with respect to the reduction of CVE, especially in patients with high Lp(a) levels. PCSK9 inhibitors may reduce the need for LA in patients with heterozygous or polygenetic hypercholesterolemia, but in some patients, a combination of these drugs with LA will be necessary. In the future, an antisense oligonucleotide against apolipoprotein(a) may offer an alternative therapeutic approach.
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19
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D'Erasmo L, Minicocci I, Nicolucci A, Pintus P, Roeters Van Lennep JE, Masana L, Mata P, Sánchez-Hernández RM, Prieto-Matos P, Real JT, Ascaso JF, Lafuente EE, Pocovi M, Fuentes FJ, Muntoni S, Bertolini S, Sirtori C, Calabresi L, Pavanello C, Averna M, Cefalu AB, Noto D, Pacifico AA, Pes GM, Harada-Shiba M, Manzato E, Zambon S, Zambon A, Vogt A, Scardapane M, Sjouke B, Fellin R, Arca M. Autosomal Recessive Hypercholesterolemia: Long-Term Cardiovascular Outcomes. J Am Coll Cardiol 2018; 71:279-288. [PMID: 29348020 DOI: 10.1016/j.jacc.2017.11.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/16/2017] [Accepted: 11/06/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Autosomal recessive hypercholesterolemia (ARH) is a rare lipid disorder characterized by premature atherosclerotic cardiovascular disease (ASCVD). There are sparse data for clinical management and cardiovascular outcomes in ARH. OBJECTIVES Evaluation of changes in lipid management, achievement of low-density lipoprotein cholesterol (LDL-C) goals and cardiovascular outcomes in ARH. METHODS Published ARH cases were identified by electronic search. All corresponding authors and physicians known to treat these patients were asked to provide follow-up information, using a standardized protocol. RESULTS We collected data for 52 patients (28 females, 24 males; 31.1 ± 17.1 years of age; baseline LDL-C: 571.9 ± 171.7 mg/dl). During a mean follow-up of 14.1 ± 7.3 years, there was a significant increase in the use of high-intensity statin and ezetimibe in combination with lipoprotein apheresis; in 6 patients, lomitapide was also added. Mean LDL-C achieved at nadir was 164.0 ± 85.1 mg/dl (-69.6% from baseline), with a better response in patients taking lomitapide (-88.3%). Overall, 23.1% of ARH patients reached LDL-C of <100 mg/dl. During follow-up, 26.9% of patients had incident ASCVD, and 11.5% had a new diagnosis of aortic valve stenosis (absolute risk per year of 1.9% and 0.8%, respectively). No incident stroke was observed. Age (≥30 years) and the presence of coronary artery disease at diagnosis were the major predictors of incident ASCVD. CONCLUSIONS Despite intensive treatment, LDL-C in ARH patients remains far from targets, and this translates into a poor long-term cardiovascular prognosis. Our data highlight the importance of an early diagnosis and treatment and confirm the fact that an effective treatment protocol for ARH is still lacking.
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Affiliation(s)
- Laura D'Erasmo
- Department of Internal Medicine and Clinical Specialties, Sapienza University of Rome, Rome, Italy.
| | - Ilenia Minicocci
- Department of Internal Medicine and Clinical Specialties, Sapienza University of Rome, Rome, Italy
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Coreresearch, Inc., Pescara, Italy
| | - Paolo Pintus
- Dipartimento Internistico, Centro per le Malattie Dismetaboliche e l'Arteriosclerosi, Cagliari, Italy
| | | | - Luis Masana
- Research Unit on Lipids and Atherosclerosis, Vascular Medicine and Metabolism Unit, Sant Joan University Hospital, Universitat Rovira i Virgili, IISPV, Reus, Spain, and Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
| | - Pedro Mata
- Fundación Hipercoesterolaemia Familiar, Madrid, Spain
| | - Rosa Maria Sánchez-Hernández
- Sección de Endocrinología y Nutrición, Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Instituto Universitario de Investigación Biomédica y Sanitaria (IUIBS) de la Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Pablo Prieto-Matos
- Unidad de Endocrinología Pediátrica Hospital Universitario de Salamanca Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Josè T Real
- Servicio de Endocrinología y Nutrición, Hospital Clínico Valencia, Valencia, Spain, and Department of Medicine, University of Valencia, INCLIVA, CIBERDEM, Madrid, Spain
| | - Juan F Ascaso
- Servicio de Endocrinología y Nutrición, Hospital Clínico Valencia, Valencia, Spain, and Department of Medicine, University of Valencia, INCLIVA, CIBERDEM, Madrid, Spain
| | | | - Miguel Pocovi
- Departamento de Bioquímica y Biología Molecular y Celular, Facultad de Ciencias, Universidad de Zaragoza & IIS Aragón, CIBERCV, Zaragoza, Spain
| | - Francisco J Fuentes
- Instituto Maimónides de Investigación Biomédica de Córdoba, Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain, and Centro de Investigación Biomédica en Red de Fisiopatolgía de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, Spain
| | - Sandro Muntoni
- Department of Biomedical Sciences, University of Cagliari and Centre for Metabolic Diseases and Atherosclerosis, The ME.DI.CO Association, Cagliari, Italy
| | - Stefano Bertolini
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Cesare Sirtori
- Center E. Grossi Paoletti, Dipartimento di Scienze Farmacologiche e Biomolecolari, Universita' degli Studi di Milano, and Dyslipidemia Center, Niguarda Hospital, Milan, Italy
| | - Laura Calabresi
- Center E. Grossi Paoletti, Dipartimento di Scienze Farmacologiche e Biomolecolari, Universita' degli Studi di Milano, and Dyslipidemia Center, Niguarda Hospital, Milan, Italy
| | - Chiara Pavanello
- Center E. Grossi Paoletti, Dipartimento di Scienze Farmacologiche e Biomolecolari, Universita' degli Studi di Milano, and Dyslipidemia Center, Niguarda Hospital, Milan, Italy
| | - Maurizio Averna
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Angelo Baldassare Cefalu
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Davide Noto
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Adolfo Arturo Pacifico
- Unità Operativa Diabetologia e Malattie Metaboliche, Azienda Ospedaliero Universitaria, Sassari, Italy
| | - Giovanni Mario Pes
- Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Mariko Harada-Shiba
- Department of Molecular Innovation in Lipidology, National Cardiovascular Center Research Institute, Suita, Osaka, Japan
| | | | | | | | - Anja Vogt
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität (LMU) Klinikum der Universität München, Munich, Germany
| | - Marco Scardapane
- Center for Outcomes Research and Clinical Epidemiology, Coreresearch, Inc., Pescara, Italy
| | - Barbara Sjouke
- Department of Internal and Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Renato Fellin
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Marcello Arca
- Department of Internal Medicine and Clinical Specialties, Sapienza University of Rome, Rome, Italy.
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20
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Hegele RA. Learning From Patients With Ultrarare Conditions. J Am Coll Cardiol 2018; 71:289-291. [DOI: 10.1016/j.jacc.2017.09.1158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 09/19/2017] [Indexed: 01/19/2023]
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21
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Ajufo E, Cuchel M. Recognition, diagnosis and treatment of homozygous familial hypercholesterolemia. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1394841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ezim Ajufo
- Departments of Medicine, Division of Translational Medicine & Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marina Cuchel
- Departments of Medicine, Division of Translational Medicine & Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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23
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Bruckert E, Gallo A. Is lomitapide a life-saving drug in homozygous familial hypercholesterolemia. Eur J Prev Cardiol 2017; 24:1841-1842. [PMID: 28952803 DOI: 10.1177/2047487317734387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Eric Bruckert
- Department of Endocrinology and Cardiovascular Disease Prevention, Hôpital Pitié-Salpêtrière, France
| | - Antonio Gallo
- Department of Endocrinology and Cardiovascular Disease Prevention, Hôpital Pitié-Salpêtrière, France
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24
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Thompson GR, Blom DJ, Marais AD, Seed M, Pilcher GJ, Raal FJ. Survival in homozygous familial hypercholesterolaemia is determined by the on-treatment level of serum cholesterol. Eur Heart J 2017; 39:1162-1168. [DOI: 10.1093/eurheartj/ehx317] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 05/25/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- Gilbert R Thompson
- Department of Metabolic Medicine, Faculty of Medicine, Imperial College London, Hammersmith Campus, Ducane Road, London W12 0NN, UK
| | - Dirk J Blom
- Division of Lipidology, Department of Medicine, UCT Faculty Health Sciences, University of Cape Town, Anzio Road, 7925 Observatory, Cape Town, South Africa
| | - A David Marais
- Division of Chemical Pathology, Department of Pathology, UCT Faculty Health Sciences, University of Cape Town, Anzio Road, 7925 Observatory, Cape Town, South Africa
| | - Mary Seed
- Department of Cardiology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Gillian J Pilcher
- Carbohydrate and Lipid Metabolism Research Unit, Department of Medicine, University of the Witwatersrand, 7 York Rd, Parktown 2193, Johannesburg, South Africa
| | - Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Department of Medicine, University of the Witwatersrand, 7 York Rd, Parktown 2193, Johannesburg, South Africa
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25
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Managing the challenging homozygous familial hypercholesterolemia patient: Academic insights and practical approaches for a severe dyslipidemia, a National Lipid Association Masters Summit. J Clin Lipidol 2017; 11:602-616. [DOI: 10.1016/j.jacl.2017.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 12/13/2022]
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26
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Janus ED. Homozygous familial hypercholesterolaemia - Early recognition and early treatment improve outcomes. Atherosclerosis 2017; 260:147-149. [PMID: 28341574 DOI: 10.1016/j.atherosclerosis.2017.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 02/10/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Edward D Janus
- General Internal Medicine Unit, Western Health and Department of Medicine Melbourne Medical School - Western Precinct, University of Melbourne, Sunshine Hospital, St Albans, VIC 3021, Australia.
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27
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Bruckert E, Kalmykova O, Bittar R, Carreau V, Béliard S, Saheb S, Rosenbaum D, Bonnefont-Rousselot D, Thomas D, Emery C, Khoshnood B, Carrié A. Long-term outcome in 53 patients with homozygous familial hypercholesterolaemia in a single centre in France. Atherosclerosis 2017; 257:130-137. [DOI: 10.1016/j.atherosclerosis.2017.01.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/03/2017] [Accepted: 01/13/2017] [Indexed: 01/09/2023]
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28
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Widhalm K, Benke IM, Fritz M, Geiger H, Helk O, Fritsch M, Hoermann G, Kostner G. Homozygous familial hypercholesterolemia: Summarized case reports. Atherosclerosis 2017; 257:86-89. [PMID: 28126585 DOI: 10.1016/j.atherosclerosis.2017.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/28/2016] [Accepted: 01/11/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND AIMS Homozygous familial hypercholesterolemia (hoFH) is a rare genetic disorder with potential severe atherosclerosis in the pediatric age. METHODS We report on 9 patients with hoFH, who had been diagnosed within the last 30 years and who were consequently treated with apheresis and drugs. RESULTS Two deaths occurred: one at age 36 years and the other at age four and a half years before effective treatment was commenced. All other patients are still in good clinical condition today, although four of them have proven aortic stenosis or arterial plaques. CONCLUSIONS Our case report highlights that adequate treatment should start as early as possible to delay the onset of clinical manifestations of atherosclerosis. It can be assumed that the introduction of new drugs can improve the outcome and possibly lengthen the life expectancy of patients affected by hoFH.
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Affiliation(s)
- Kurt Widhalm
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria.
| | - Ina Michel Benke
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria
| | - Michael Fritz
- Hospital Feldkirch, Department of Pediatrics, Austria
| | | | - Oliver Helk
- Institute for Medical Sciences, University of Aberdeen, UK
| | - Maria Fritsch
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria
| | - Gregor Hoermann
- Department of Laboratory Medicine, Medical University of Vienna, Austria
| | - Gerhard Kostner
- Department of Biochemistry, Medical University of Graz, Austria
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29
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France M, Rees A, Datta D, Thompson G, Capps N, Ferns G, Ramaswami U, Seed M, Neely D, Cramb R, Shoulders C, Barbir M, Pottle A, Eatough R, Martin S, Bayly G, Simpson B, Halcox J, Edwards R, Main L, Payne J, Soran H. HEART UK statement on the management of homozygous familial hypercholesterolaemia in the United Kingdom. Atherosclerosis 2016; 255:128-139. [DOI: 10.1016/j.atherosclerosis.2016.10.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/03/2016] [Accepted: 10/07/2016] [Indexed: 12/16/2022]
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30
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Sánchez-Hernández RM, Civeira F, Stef M, Perez-Calahorra S, Almagro F, Plana N, Novoa FJ, Sáenz-Aranzubía P, Mosquera D, Soler C, Fuentes FJ, Brito-Casillas Y, Real JT, Blanco-Vaca F, Ascaso JF, Pocovi M. Homozygous Familial Hypercholesterolemia in Spain. ACTA ACUST UNITED AC 2016; 9:504-510. [DOI: 10.1161/circgenetics.116.001545] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 09/28/2016] [Indexed: 11/16/2022]
Abstract
Background—
Homozygous familial hypercholesterolemia (HoFH) is a rare disease characterized by elevated plasma levels of low-density lipoprotein cholesterol (LDL-C) and extremely high risk of premature atherosclerotic cardiovascular disease. HoFH is caused by mutations in several genes, including LDL receptor (
LDLR
), apolipoprotein B (
APOB
), proprotein convertase subtilisin/kexin type 9 (
PCSK9
), and LDL protein receptor adaptor 1 (
LDLRAP1
). No epidemiological studies have assessed HoFH prevalence or the clinical and molecular characteristics of this condition. Here, we aimed to characterize HoFH in Spain.
Methods and Results—
Data were collected from the Spanish Dyslipidemia Registry of the Spanish Atherosclerosis Society and from all molecular diagnoses performed for familial hypercholesterolemia in Spain between 1996 and 2015 (n=16 751). Clinical data included baseline lipid levels and atherosclerotic cardiovascular disease events. A total of 97 subjects were identified as having HoFH—of whom, 47 were true homozygous (1 for
APOB
, 5 for
LDLRAP1
, and 41 for
LDLR
), 45 compound heterozygous for
LDLR
, 3 double heterozygous for
LDLR
and
PSCK9
, and 2 double heterozygous for
LDLR
and
APOB
. No
PSCK9
homozygous cases were identified. Two variants in
LDLR
were identified in 4.8% of the molecular studies. Over 50% of patients did not meet the classical HoFH diagnosis criteria. The estimated HoFH prevalence was 1:450 000. Compared with compound heterozygous cases, true homozygous cases showed more aggressive phenotypes with higher LDL-C and more atherosclerotic cardiovascular disease events.
Conclusions—
HoFH frequency in Spain was higher than expected. Clinical criteria would underestimate the actual prevalence of individuals with genetic HoFH, highlighting the importance of genetic analysis to improve familial hypercholesterolemia diagnosis accuracy.
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31
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Julius U. Lipoprotein apheresis in the management of severe hypercholesterolemia and of elevation of lipoprotein(a): current perspectives and patient selection. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:349-360. [PMID: 27785114 PMCID: PMC5067066 DOI: 10.2147/mder.s98889] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
This review reports the current situation with respect to therapeutic options (lifestyle and drugs) reducing the concentrations of atherogenic low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp[a]). Three lipoprotein apheresis (LA) principles have been realized: precipitation, filtration, and adsorption. Available LA methods are herein described in detail - major components, pumps, extracorporeal volume, treated volume, and anticoagulation. General features of all LA methods as well as pleotropic effects are elaborated. Indications for LA therapy are quoted: homozygous familial hypercholesterolemia (HCH), severe HCH, and isolated elevation of Lp(a) and progress of atherosclerotic disease. A major focus is on the evidence of the effect of LA on cardiovascular outcome data, and the most important publications are cited in this context. The best studies have been performed in patients with elevated Lp(a) in whom cardiovascular events were reduced by more than 80%. Major adverse effects and contraindications are listed. The impact of an LA therapy on patient quality of life and the requirements they have to fulfill are also highlighted. Finally, the future role of LA in treating high-risk patients with high LDL-C and/or high Lp(a) is discussed. It is probable that the significance of LA for treating patients with elevated LDL-C will decrease (with the exception of homozygous familial HCH) due to the application of PCSK9 inhibitors. The antisense oligonucleotide against apolipoprotein(a) could replace LA in patients with high Lp(a), provided positive outcome data are generated.
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Affiliation(s)
- Ulrich Julius
- Lipidology and Center for Extracorporeal Therapy, Department for Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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32
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Santos RD, Gidding SS, Hegele RA, Cuchel MA, Barter PJ, Watts GF, Baum SJ, Catapano AL, Chapman MJ, Defesche JC, Folco E, Freiberger T, Genest J, Hovingh GK, Harada-Shiba M, Humphries SE, Jackson AS, Mata P, Moriarty PM, Raal FJ, Al-Rasadi K, Ray KK, Reiner Z, Sijbrands EJG, Yamashita S. Defining severe familial hypercholesterolaemia and the implications for clinical management: a consensus statement from the International Atherosclerosis Society Severe Familial Hypercholesterolemia Panel. Lancet Diabetes Endocrinol 2016; 4:850-61. [PMID: 27246162 DOI: 10.1016/s2213-8587(16)30041-9] [Citation(s) in RCA: 286] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/24/2016] [Accepted: 04/06/2016] [Indexed: 12/26/2022]
Abstract
Familial hypercholesterolaemia is common in individuals who had a myocardial infarction at a young age. As many as one in 200 people could have heterozygous familial hypercholesterolaemia, and up to one in 300 000 individuals could be homozygous. The phenotypes of heterozygous and homozygous familial hypercholesterolaemia overlap considerably; the response to treatment is also heterogeneous. In this Review, we aim to define a phenotype for severe familial hypercholesterolaemia and identify people at highest risk for cardiovascular disease, based on the concentration of LDL cholesterol in blood and individuals' responsiveness to conventional lipid-lowering treatment. We assess the importance of molecular characterisation and define the role of other cardiovascular risk factors and advanced subclinical coronary atherosclerosis in risk stratification. Individuals with severe familial hypercholesterolaemia might benefit in particular from early and more aggressive cholesterol-lowering treatment (eg, with PCSK9 inhibitors). In addition to better tailored therapy, more precise characterisation of individuals with severe familial hypercholesterolaemia could improve resource use.
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Affiliation(s)
- Raul D Santos
- Lipid Clinic Heart Institute (InCor), University of São Paulo Medical School Hospital, and Preventive Medicine Centre and Cardiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Samuel S Gidding
- Nemours Cardiac Center, A I DuPont Hospital for Children, Wilmington, DE, USA
| | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine, Western University, London, ON, Canada
| | - Marina A Cuchel
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Philip J Barter
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Gerald F Watts
- Lipid Disorders Clinic, Royal Perth Hospital, The University of Western Australia, Perth, WA, Australia
| | - Seth J Baum
- Preventive Cardiology, Christine E Lynn Women's Health & Wellness Institute, Boca Raton Regional Hospital, Boca Raton, FL, USA
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS Multimedica, Milan, Italy
| | | | - Joep C Defesche
- University of Amsterdam, Academic Medical Center (AMC), Amsterdam, Netherlands
| | | | - Tomas Freiberger
- Molecular Genetics Lab, Centre for Cardiovascular Surgery and Transplantation, and Ceitec, Masaryk University, Brno, Czech Republic
| | - Jacques Genest
- McGill University Health Center, Royal Victoria Hospital, Montreal, QC, Canada
| | - G Kees Hovingh
- University of Amsterdam, Academic Medical Center (AMC), Amsterdam, Netherlands
| | - Mariko Harada-Shiba
- National Cerebral and Cardiovascular Center Research Institute, Suita, Osaka, Japan
| | - Steve E Humphries
- Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, University College of London, London, UK
| | - Ann S Jackson
- International Atherosclerosis Society, Houston, TX, USA
| | - Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
| | - Patrick M Moriarty
- Atherosclerosis and Lipoprotein-Apheresis Center, University of Kansas Medical Center, Kansas City, KS, USA
| | - Frederick J Raal
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Kausik K Ray
- School of Public Health, Imperial College London, London, UK
| | - Zelijko Reiner
- European Association for Cardiovascular Prevention and Rehabilitations, Zagreb, Croatia
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33
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Foody JM, Vishwanath R. Familial hypercholesterolemia/autosomal dominant hypercholesterolemia: Molecular defects, the LDL-C continuum, and gradients of phenotypic severity. J Clin Lipidol 2016; 10:970-986. [DOI: 10.1016/j.jacl.2016.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 04/19/2016] [Accepted: 04/26/2016] [Indexed: 01/17/2023]
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34
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Clinical and molecular characteristics of homozygous familial hypercholesterolemia patients: Insights from SAFEHEART registry. J Clin Lipidol 2016; 10:953-961. [DOI: 10.1016/j.jacl.2016.04.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 04/12/2016] [Accepted: 04/12/2016] [Indexed: 11/24/2022]
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35
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Rabacchi C, Bigazzi F, Puntoni M, Sbrana F, Sampietro T, Tarugi P, Bertolini S, Calandra S. Phenotypic variability in 4 homozygous familial hypercholesterolemia siblings compound heterozygous for LDLR mutations. J Clin Lipidol 2016; 10:944-952.e1. [DOI: 10.1016/j.jacl.2016.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 12/31/2022]
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36
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Safarova MS, Kullo IJ. My Approach to the Patient With Familial Hypercholesterolemia. Mayo Clin Proc 2016; 91:770-86. [PMID: 27261867 PMCID: PMC5374743 DOI: 10.1016/j.mayocp.2016.04.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/18/2016] [Accepted: 04/12/2016] [Indexed: 02/07/2023]
Abstract
Familial hypercholesterolemia (FH), a relatively common Mendelian genetic disorder, is associated with a dramatically increased lifetime risk of premature atherosclerotic cardiovascular disease due to elevated plasma low-density lipoprotein cholesterol (LDL-C) levels. The diagnosis of FH is based on clinical presentation or genetic testing. Early identification of patients with FH is of great public health importance because preventive strategies can lower the absolute lifetime cardiovascular risk and screening can detect affected relatives. However, low awareness, detection, and control of FH pose hurdles in the prevention of FH-related cardiovascular events. Of the estimated 0.65 million to 1 million patients with FH in the United States, less than 10% carry a diagnosis of FH. Based on registry data, a substantial proportion of patients with FH are receiving no or inadequate lipid-lowering therapy. Statins remain the mainstay of treatment for patients with FH. Lipoprotein apheresis and newly approved lipid-lowering drugs are valuable adjuncts to statin therapy, particularly when the LDL-C-lowering response is suboptimal. Monoclonal antibodies targeting proprotein convertase subtilisin/kexin type 9 provide an additional approximately 60% lowering of LDL-C levels and are approved for use in patients with FH. For homozygous FH, 2 new drugs that work independent of the LDL receptor pathway are available: an apolipoprotein B antisense oligonucleotide (mipomersen) and a microsomal triglyceride transfer protein inhibitor (lomitapide). This review attempts to critically examine the available data to provide a summary of the current evidence for managing patients with FH, including screening, diagnosis, treatment, and surveillance.
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Affiliation(s)
- Maya S Safarova
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN
| | - Iftikhar J Kullo
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN.
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37
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Affiliation(s)
- Dirk Jacobus Blom
- Division of Lipidology, Department of Medicine, University of Cape Town, MRC Cape Heart Group, Cape Town, South Africa
| | - A. David Marais
- Division of Chemical Pathology, Department of Clinical Laboratory Sciences, University of Cape Town, MRC Cape Heart Group, Cape Town, South Africa
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