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Kien NT, Nghia TT, Hoang NM, Phu TNT, Nga PTN, Mai HTT, Espinoza JL. Prevalent Variants in the LDLR Gene Impair Responsiveness to Rosuvastatin among Family Members of Patients with Premature Myocardial Infarction. J Pers Med 2023; 13:1725. [PMID: 38138952 PMCID: PMC10744399 DOI: 10.3390/jpm13121725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is an inherited metabolic disorder characterized by high levels of low-density lipoprotein cholesterol (LDL-c) from birth. About 85% of all FH cases are caused by pathogenic variants in the LDLR gene. Individuals with FH have increased cardiovascular risk, including a high risk of premature myocardial infarction (PMI). METHODS We conducted an opportunistic exome screening to identify variants in the LDLR gene among Vietnamese patients with PMI treated at a general hospital in southern Vietnam. A cascade testing for LDLR variants was conducted in their relatives within three generations, and the effects of the LDLR variant on the response to rosuvastatin treatment were also studied using a comparative before-and-after study design on those who were eligible. RESULTS A total of 99 participants from the three generations of four PMI patients were recruited, mean age 37.3 ± 18.5 years, 56.6% males. Sanger sequencing revealed two variants in the LDLR gene: variant rs577934998 (c.664T>C), detected in 17 individuals within one family, and variant rs12710260 (c.1060+10G>C), found in 32 individuals (49.5%) in the other three families tested. Individuals harboring the variant c.664T>C had significantly higher baseline LDL-c and total cholesterol levels compared to those with variant c.1060+10G>C (classified as benign) or those without LDLR variants, and among the 47 patients subjected to a 3-month course of rosuvastatin therapy, those with variant c.664T>C had a significantly higher risk of not achieving the LDL-c target after the course of treatment compared to the c.1060+10G>C carriers. CONCLUSIONS These findings provide evidence supporting the existence of pathogenic LDLR variants in Vietnamese patients with PMI and their relatives and may indicate the need for personalizing lipid-lowering therapies. Further studies are needed to delineate the extent and severity of the problem.
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Affiliation(s)
- Nguyen Trung Kien
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho 900000, Vietnam; (N.T.K.); (T.T.N.); (H.T.T.M.)
| | - Tran Tin Nghia
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho 900000, Vietnam; (N.T.K.); (T.T.N.); (H.T.T.M.)
| | | | - Tran Nguyen Trong Phu
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho 900000, Vietnam; (N.T.K.); (T.T.N.); (H.T.T.M.)
- Faculty of Medicine, Chulalongkorn University, 1873, Rama 4 Road, Pathumwan, Bangkok 10330, Thailand
| | - Pham Thi Ngoc Nga
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho 900000, Vietnam; (N.T.K.); (T.T.N.); (H.T.T.M.)
| | - Ha Thi Thao Mai
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho 900000, Vietnam; (N.T.K.); (T.T.N.); (H.T.T.M.)
| | - J. Luis Espinoza
- Faculty of Health Sciences, Kanazawa University, Kanazawa 920-0942, Ishikawa, Japan
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Latkovskis G, Rescenko-Krums R, Nesterovics G, Briviba M, Saripo V, Gilis D, Terauda E, Meiere R, Skudrina G, Erglis A, Chora JR, Bourbon M, Klovins J. Genetic Characteristics of Latvian Patients with Familial Hypercholesterolemia: The First Analysis from Genome-Wide Sequencing. J Clin Med 2023; 12:5160. [PMID: 37568561 PMCID: PMC10419451 DOI: 10.3390/jcm12155160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/14/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND There is limited data on the genetic characteristics of patients with familial hypercholesterolemia (FH) in Latvia. We aim to describe monogenic variants in patients from the Latvian Registry of FH (LRFH). METHODS Whole genome sequencing with 30× coverage was performed in unrelated index cases from the LRFH and the Genome Database of Latvian Population. LDLR, APOB, PCSK9, LDLRAP1, ABCG5, ABCG8, LIPA, LPA, CYP27A1, and APOE genes were analyzed. Only variants annotated as pathogenic (P) or likely pathogenic (LP) using the FH Variant Curation Expert Panel guidelines for LDLR and adaptations for APOB and PCSK9 were reported. RESULTS Among 163 patients, the mean highest documented LDL-cholesterol level was 7.47 ± 1.60 mmol/L, and 79.1% of patients had LDL-cholesterol ≥6.50 mmol/L. A total of 15 P/LP variants were found in 34 patients (diagnostic yield: 20.9%): 14 in the LDLR gene and 1 in the APOB gene. Additionally, 24, 54, and 13 VUS were detected in LDLR, APOB, and PCSK9, respectively. No P/LP variants were identified in the other tested genes. CONCLUSIONS Despite the high clinical likelihood of FH, confirmed P/LP variants were detected in only 20.9% of patients in the Latvian cohort when assessed with genome-wide next generation sequencing.
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Affiliation(s)
- Gustavs Latkovskis
- Institute of Cardiology and Regenerative Medicine, University of Latvia, LV-1004 Riga, Latvia (V.S.); (E.T.)
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia
| | | | - Georgijs Nesterovics
- Institute of Cardiology and Regenerative Medicine, University of Latvia, LV-1004 Riga, Latvia (V.S.); (E.T.)
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia
| | - Monta Briviba
- Latvian Biomedical Research and Study Centre, LV-1067 Riga, Latvia
| | - Vita Saripo
- Institute of Cardiology and Regenerative Medicine, University of Latvia, LV-1004 Riga, Latvia (V.S.); (E.T.)
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
| | - Dainus Gilis
- Institute of Cardiology and Regenerative Medicine, University of Latvia, LV-1004 Riga, Latvia (V.S.); (E.T.)
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia
| | - Elizabete Terauda
- Institute of Cardiology and Regenerative Medicine, University of Latvia, LV-1004 Riga, Latvia (V.S.); (E.T.)
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia
| | - Ruta Meiere
- Institute of Cardiology and Regenerative Medicine, University of Latvia, LV-1004 Riga, Latvia (V.S.); (E.T.)
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
| | - Gunda Skudrina
- Institute of Cardiology and Regenerative Medicine, University of Latvia, LV-1004 Riga, Latvia (V.S.); (E.T.)
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
| | - Andrejs Erglis
- Institute of Cardiology and Regenerative Medicine, University of Latvia, LV-1004 Riga, Latvia (V.S.); (E.T.)
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia
| | - Joana Rita Chora
- Department of Health Promotion and Prevention of Noncommunicable Diseases, National Institute of Health Dr. Ricardo Jorge, 164-9016 Lisbon, Portugal
- Department of Chemistry and Biochemistry, BioISI—BioSystems & Integrative Sciences Institute, Faculty of Sciences, University of Lisbon, 1649-004 Lisbon, Portugal
| | - Mafalda Bourbon
- Department of Health Promotion and Prevention of Noncommunicable Diseases, National Institute of Health Dr. Ricardo Jorge, 164-9016 Lisbon, Portugal
- Department of Chemistry and Biochemistry, BioISI—BioSystems & Integrative Sciences Institute, Faculty of Sciences, University of Lisbon, 1649-004 Lisbon, Portugal
| | - Janis Klovins
- Latvian Biomedical Research and Study Centre, LV-1067 Riga, Latvia
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Tada H, Kojima N, Yamagami K, Nomura A, Nohara A, Usui S, Sakata K, Fujino N, Takamura M, Kawashiri MA. Synergistic effect of lipoprotein (a) and C-reactive protein on prognosis of familial hypercholesterolemia. Am J Prev Cardiol 2022; 12:100428. [PMID: 36386253 PMCID: PMC9661434 DOI: 10.1016/j.ajpc.2022.100428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/26/2022] [Accepted: 11/09/2022] [Indexed: 11/13/2022] Open
Abstract
Lp(a) levels among patients with pathogenic variant FH were significantly elevated. Lp(a) and CRP levels were not associated with MACE by themselves. Lp(a) level was significantly associated with MACE only when the CRP level was elevated.
Objective The synergistic effect of lipoprotein (a) [Lp(a)] and C-reactive protein (CRP) on major adverse cardiovascular events (MACE) among patients with familial hypercholesterolemia (FH) is unknown. This study aimed to investigate the relations between Lp(a) and CRP levels and MACE in patients with FH whose Lp(a) levels are elevated. Methods We retrospectively investigated associations between genotypes and phenotypes, including low-density lipoprotein (LDL) cholesterol level and the occurrence of MACE among patients with FH (N = 786, male/female: 374/412). A Cox proportional hazard model was used to identify factors associated with MACE, adjusting for traditional risk factors. Patients with FH were divided into four groups, based on their Lp(a) and CRP levels, and assessed using Kaplan–Meier curves. Results The median follow-up was 12.6 years (interquartile range [IQR], 9.5–17.9 years). During follow-up, 129 MACE were observed. Median Lp(a) and CRP levels were 21.4 (10.9–38.3) mg/dL and 0.20 (0.11–0.29) mg/dL, respectively. Under these conditions, natural log-transformed Lp(a) and CRP were not associated with MACE (hazard ratio [HR], 1.08; 95% confidence interval [CI], 0.91–1.25; P = 0.220; and HR, 1.12; CI, 0.96–1.28; P = 0.190, respectively). However, in Group 4, Lp(a) and CRP were significantly associated with MACE (HR, 2.44; CI, 1.42–3.46; P = 1.8 × 10−7). Conclusions In patients with FH, Lp(a) was significantly associated with MACE only when the CRP level was elevated. Patients with FH whose Lp(a) and CRP levels are elevated should be treated aggressively.
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Schwarz A, Demuth I, Landmesser U, Haghikia A, König M, Steinhagen-Thiessen E. Low-density lipoprotein cholesterol goal attainment in patients with clinical evidence of familial hypercholesterolemia and elevated Lp(a). Lipids Health Dis 2022; 21:114. [PMID: 36324160 PMCID: PMC9628073 DOI: 10.1186/s12944-022-01708-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Although potent lipid-lowering therapies are available, patients commonly fall short of recommended low-density lipoprotein cholesterol (LDL-C) levels. The aim of this study was to examine the relationship between familial hypercholesterolemia (FH) and elevated lipoprotein(a) [Lp(a)] and LDL-C goal attainment, as well as the prevalence and severity of coronary artery disease (CAD). Moreover, we characterized patients failing to meet recommended LDL-C goals. METHODS We performed a cross-sectional analysis in a cohort of patients undergoing cardiac catheterization. Clinical FH was determined by the Dutch Clinical Lipid Network Score, and Lp(a) ≥ 50 mg/dL (≈ 107 nmol/L) was considered elevated. RESULTS A total of 838 participants were included. Overall, the prevalence of CAD was 72%, and 62% received lipid-lowering treatment. The prevalence of clinical FH (probable and definite FH) was 4%, and 19% had elevated Lp(a) levels. With 35%, LDL-C goal attainment was generally poor. Among the participants with clinical FH, none reached their LDL-C target. Among patients with elevated Lp(a), LDL-C target achievement was only 28%. The prevalence and severity of CAD were higher in participants with clinical FH (86% prevalence) and elevated Lp(a) (80% prevalence). CONCLUSION Most participants failed to meet their individual LDL-C goals according to the ESC 2016 and 2019 guidelines. In particular, high-risk patients with clinical FH or elevated Lp(a) rarely met their target for LDL-C. The identification of these patients and more intense treatment approaches are crucial for the improvement of CAD primary and secondary prevention.
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Affiliation(s)
- Andrea Schwarz
- Department of Endocrinology and Metabolic Diseases (Including Division of Lipid Metabolism), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Biology of Aging Working Group, Augustenburger Platz 1, 13353, Berlin, Germany. .,Department of Pediatrics, Charité -Universitätsmedizin Berlin, Division of Cardiology, Berlin, Germany.
| | - Ilja Demuth
- Department of Endocrinology and Metabolic Diseases (Including Division of Lipid Metabolism), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Biology of Aging Working Group, Augustenburger Platz 1, 13353, Berlin, Germany.,BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
| | - Ulf Landmesser
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology, Charité- Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Arash Haghikia
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology, Charité- Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Maximilian König
- Department of Endocrinology and Metabolic Diseases (Including Division of Lipid Metabolism), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Biology of Aging Working Group, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Elisabeth Steinhagen-Thiessen
- Department of Endocrinology and Metabolic Diseases (Including Division of Lipid Metabolism), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Biology of Aging Working Group, Augustenburger Platz 1, 13353, Berlin, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, University of Rostock, Rostock, Germany
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Mashima R, Takada S. Lipid Nanoparticles: A Novel Gene Delivery Technique for Clinical Application. Curr Issues Mol Biol 2022; 44:5013-5027. [PMID: 36286056 PMCID: PMC9600891 DOI: 10.3390/cimb44100341] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/08/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
Lipid nanoparticles (LNPs) are an emerging vehicle for gene delivery that accommodate both nucleic acid and protein. Based on the experience of therapeutic liposomes, current LNPs have been developed based on the chemistry of lipids and RNA and on the biology of human disease. LNPs have been used for the development of Onpattro, an siRNA drug for transthyretin-mediated amyloidosis, in 2018. The subsequent outbreak of COVID-19 required a vaccine for its suppression. LNP-based vaccine production received much attention for this and resulted in great success. In this review, the essential technology of LNP gene delivery has been described according to the chemistry for LNP production and biology for its clinical application.
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Affiliation(s)
- Ryuichi Mashima
- Department of Clinical Laboratory Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan
- Correspondence:
| | - Shuji Takada
- Department of Systems BioMedicine, National Research Institute for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan
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6
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Gitt AK, Laufs U, März W, Paar WD, Bramlage P, Marx N, Parhofer KG. Hypercholesterolemia Diagnosis, Treatment Patterns, and 12-Month Target Achievement in Clinical Practice in Germany in Patients with Familial Hypercholesterolemia. J Clin Med 2022; 11:jcm11133810. [PMID: 35807095 PMCID: PMC9267207 DOI: 10.3390/jcm11133810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Familial hypercholesterolemia (FH) is a highly prevalent disorder and a risk factor for early coronary artery disease. The objective of this registry was to document the clinical characteristics of patients with definite FH in Germany and to document lipid profiles, lipid-lowering therapy, and lipid target achievement during longitudinal follow-up. Methods: HYDRA-FH was a national, prospective, multicenter, non-interventional registry conducted in 35 centers in Germany. Consecutive adult patients with definite FH were included (n = 241). Results: In the cross-sectional analysis (n = 233), lipid-lowering therapy involved statins (82.0%), ezetimibe (31.8%), and PCSK9 antibodies (18.5%); 11.2% of patients were receiving no lipid-lowering drugs. Median lipid levels were: low-density lipoprotein cholesterol (LDL-C) 134 mg/dL (3.5 mmol/L), high-density lipoprotein cholesterol (HDL-C) 48 mg/dL (1.2 mmol/L), triglycerides 160 mg/dL (1.9 mmol/L), total cholesterol 211 mg/dL (5.5 mmol/L). Values were above the normal threshold (150 mg/dL) for LDL-C in 72.9%, total cholesterol in 29.7%, and triglycerides in 45.0% of patients. After the 12-month follow-up (n = 145), only 17.2% had LDL-C < 70 mg/dL, and 20.7% had either LDL-C < 70 mg/dL or a reduction of ≥50% versus baseline. Conclusion: This study provides insight into the clinical characteristics and current treatment status of patients with FH in Germany. Many patients with FH do not achieve recommended lipid levels.
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Affiliation(s)
- Anselm K. Gitt
- Medical Clinic B, Department of Cardiology, Herzzentrum Ludwigshafen, Bremserstr. 79, 67117 Ludwigshafen, Germany;
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, University of Leipzig Medical Center, Liebigstr. 20, 04103 Leipzig, Germany;
| | - Winfried März
- Synlab Academy, 68163 Mannheim, Germany;
- Medical Clinic V, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - W. Dieter Paar
- Medical Department, Sanofi-Aventis Deutschland GmbH, Lützowstr. 107, 10785 Berlin, Germany;
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Bahnhofstr. 20, 49661 Cloppenburg, Germany
- Correspondence:
| | - Nikolaus Marx
- Clinic for Cardiology, Angiology and Intensive Medicine, University Hospital Aachen, Pauwelsstr. 30, 52074 Aachen, Germany;
| | - Klaus G. Parhofer
- Medical Clinic IV—Großhadern, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377 Munich, Germany;
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März W, Beil FU, Dieplinger H. [Genetic diseases of lipid metabolism - Focus familial hypercholesterolemia]. Dtsch Med Wochenschr 2022; 147:e50-e61. [PMID: 35545064 DOI: 10.1055/a-1516-2541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Congenital disorders of lipid metabolism are characterised by LDL-C concentrations > 190 mg/dl (4.9 mM) and/or triglycerides > 200 mg/dl (2.3 mM) in young individuals after having excluded a secondary hyperlipoproteinemia. Further characteristics of this primary hyperlipoproteinemia are elevated lipid values or premature myocardial infarctions within families or xantelasms, arcus lipoides, xanthomas and abdominal pain. This overview summarises our current knowledge of etiology and pathogenesis of primary hyperlipoproteinemia.
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Jiang L, Stoekenbroek RM, Zhang F, Wang Q, Yu W, Yuan H, Cai G, Chen Y, Li G, Yang Y, Zhang Y, Cheng X, Zhu H, Zhou H, Ye P, Yan S, Wang X, Wu W, Li R, Xie J, Jiao J, Cheng S, Niu W, Chen J, Yang S, Zhou Y, Kastelein JJ, Yang Y, Wang L. Homozygous Familial Hypercholesterolemia in China: Genetic and Clinical Characteristics from a Real-World, Multi-Center, Cohort Study. J Clin Lipidol 2022; 16:306-314. [DOI: 10.1016/j.jacl.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 12/26/2022]
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Hamasaki M, Hosaka N, Freeman LA, Sato M, Hara K, Remaley AT, Kotani K. A novel loop-mediated isothermal amplification-based genotyping method and its application for identifying proprotein convertase subtilisin/kexin type 9 variants in familial hypercholesterolemia. Biochim Biophys Acta Gen Subj 2022; 1866:130063. [PMID: 34848321 DOI: 10.1016/j.bbagen.2021.130063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/14/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays a key role in regulating low-density lipoprotein levels in plasma. While PCSK9 variants are causatively associated with familial hypercholesterolemia (FH), additional genotyping methods for FH targeting PCSK9 variants are required in a clinical setting. Loop-mediated isothermal amplification (LAMP) is a unique amplification method that amplifies a target gene under isothermal conditions (60-65 °C). However, a robust standardized method has not yet been established for LAMP-based genetic screening tests for genetic diseases, including FH. The present study aimed to develop a novel modification of the LAMP method designed to genotype single nucleotide variants (SNVs) and to apply it for the detection of PCSK9 variants. METHODS Using short quenching probes (≤ 10 nucleotides) for the loop structures of LAMP amplicons, accurate detection of SNVs was verified separately for each allele, without any additional procedures, within 3 h. The diagnostic performance of this method in detecting PCSK9 variants was validated in FH patients. RESULTS All PCSK9 variants tested via conventional sequencing in FH patients were successfully detected using this novel LAMP method. CONCLUSIONS We developed a LAMP-based genotyping method to detect PCSK9 variants in FH. Compared to conventional sequencing, our genotyping method is relatively convenient and time-efficient and is suitable for the screening of FH in clinical settings. Future studies on various genes are also warranted.
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Affiliation(s)
- Masato Hamasaki
- Division of Community and Family Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-City, Tochigi 329-0498, Japan; Eiken Chemical Co., Ltd., 143 Nogi, Nogi-Town, Shimotsuga, Tochigi 329-0114, Japan.
| | - Norimitsu Hosaka
- Eiken Chemical Co., Ltd., 143 Nogi, Nogi-Town, Shimotsuga, Tochigi 329-0114, Japan.
| | - Lita A Freeman
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Bethesda, MD 20892, USA.
| | - Masaki Sato
- Eiken Chemical Co., Ltd., 143 Nogi, Nogi-Town, Shimotsuga, Tochigi 329-0114, Japan; Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Bethesda, MD 20892, USA
| | - Kazuo Hara
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-City, Saitama 330-8503, Japan
| | - Alan T Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Bethesda, MD 20892, USA.
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-City, Tochigi 329-0498, Japan.
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Hamasaki M, Sakane N, Hara K, Kotani K. LDL-cholesterol and PCSK9 in patients with familial hypercholesterolemia: influence of PCSK9 variants under lipid-lowering therapy. J Clin Lab Anal 2021; 35:e24056. [PMID: 34652028 PMCID: PMC8605117 DOI: 10.1002/jcla.24056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/02/2021] [Accepted: 10/02/2021] [Indexed: 11/25/2022] Open
Abstract
Background Familial hypercholesterolemia (FH), an autosomal dominant genetic disease with the elevated levels of low‐density lipoprotein (LDL) cholesterol (LDL‐C), increases the risk of coronary artery disease (CAD). The proprotein convertase subtilisin/kexin type 9 (PCSK9) gene is associated with FH. There is a positive relationship between circulating LDL‐C and PCSK9 levels, a potential CAD condition, without lipid‐lowering therapy (LLT); however, we do not know whether their correlation exists in FH patients under LLT. Methods This study compared the correlation of PCSK9 variants among patients with FH under LLT (n = 70; mean age, 53 years; male, 63%). LDLR, PCSK9 and APOB variants were analyzed using next‐generation sequencing. Results The LDL‐C and PCSK9 levels in patients with gain‐of‐function (GOF) variants of PCSK9 (n = 7) were mostly similar to those in patients with LDLR variants (n = 17) or variant‐negative patients (n = 46). A significant positive correlation was observed between LDL‐C and PCSK9 levels in patients with GOF variants of PCSK9 (r = 0.79, p = 0.04), but not in patients with LDLR variants or variant‐negative patients. Conclusion The LDL‐C‐PCSK9 correlation is suggested to be retained in FH patients with GOF variants of PCSK9 even under LLT, and these variants can be used as molecular markers for additional treatment with statins in FH patients.
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Affiliation(s)
- Masato Hamasaki
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke-City, Japan
| | - Naoki Sakane
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto-City, Japan
| | - Kazuo Hara
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Omiya-City, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke-City, Japan
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Fath F, Bengeser A, Barresi M, Binner P, Schwab S, Ray KK, Krämer BK, Fraass U, März W. FH ALERT: efficacy of a novel approach to identify patients with familial hypercholesterolemia. Sci Rep 2021; 11:20421. [PMID: 34650182 PMCID: PMC8516913 DOI: 10.1038/s41598-021-99961-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 09/27/2021] [Indexed: 01/22/2023] Open
Abstract
Diagnosis rates of familial hypercholesterolemia (FH) remain low. We implemented FH ALERT to assess whether alerting physicians for the possibility of FH impacted additional diagnostic activity. The study was conducted from SYNLAB laboratory Weiden (Bavaria). Beyond common reporting of LDL-C or TC, 1411 physicians covering approximately a population of 1.5 million people were eligible to receive an alert letter (AL) including information on FH, if laboratory results exceeded thresholds as follows: adults LDL-C ≥ 190–250 mg/dl (to convert into mmol/l multiply with 0.0259), TC ≥ 250 to ≤ 310 mg/dl (probable suspicion); LDL-C > 250 mg/dl and TC > 310 mg/dl (strong suspicion). Persons below 18 years were alerted for LDL-C 140 mg/dl and TC ≥ 200 mg/dl (strong suspicion). Patients above 60 years were excluded. Our readouts were characteristics of involved physicians, rate of ALs issued, acceptance, and subsequent diagnostic activity. Physicians were mainly general practitioners in ambulatory care. 75% of the ordered tests were for TC, 25% for LDL-C. We issued 3512 ALs (~ 5% of tests) triggered by 2846 patients. 86% of eligible physicians stayed with the initiative, 32.7% were alerted, and 70% were positive upon call-center survey. We registered 101 new visitors of www.fhscore.eu and sent out 93 kits for genetics. Thereof, 26 were returned and 5 patients were positive for FH. Physicians were in general open to our approach. Although genetic testing was taken up with caution, this 3-months pilot examination resulted in a greater rate of patients with FH diagnosed than previous screening projects. Further education on FH in primary care is required to improve FH detection in the community.
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Affiliation(s)
- Felix Fath
- SYNLAB Holding Germany GmbH, SYNLAB Academy, Mannheim, Germany. .,Vth Department of Medicine (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
| | | | | | | | | | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Bernhard K Krämer
- Vth Department of Medicine (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.,European Center for Angioscience ECAS, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Winfried März
- SYNLAB Holding Germany GmbH, SYNLAB Academy, Mannheim, Germany.,Vth Department of Medicine (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.,Clinical Institute of Medical and Chemical Laboratory Diagnostics Medical, University of Graz, Graz, Austria.,D A CH Society Prevention of Cardiovascular Diseases e.V., Hamburg, Germany
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12
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[32/f-Has a 38-year-old brother with heart attack and wants to protect herself : Preparation for the medical specialist examination: part 76]. Internist (Berl) 2021; 62:501-505. [PMID: 34448012 DOI: 10.1007/s00108-021-01116-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
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13
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Alves AC, Azevedo S, Benito-Vicente A, Graça R, Galicia-Garcia U, Barros P, Jordan P, Martin C, Bourbon M. LDLR variants functional characterization: Contribution to variant classification. Atherosclerosis 2021; 329:14-21. [PMID: 34167030 DOI: 10.1016/j.atherosclerosis.2021.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/28/2021] [Accepted: 06/02/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolaemia (FH) is an autosomal disorder of lipid metabolism presenting with increased cardiovascular risk. LDLR mutations are the cause of disease in 90% of the cases but functional studies have only been performed for about 15% of all LDLR variants. In the Portuguese Familial Hypercholesterolemia Study (PFHS), 142 unique LDLR alterations were identified and 44 (30%) lack functional characterization. The aim of the present work is to increase evidence for variant classification by performing functional characterization of 13 LDLR missense alterations found in Portugal and in 20 other countries. METHODS Different LDLR mutants were generated by site-directed mutagenesis and expressed in CHO-ldlA7 cells lacking endogenous expression of LDLR. To determine the effects of alterations on LDLR function, cell surface expression, binding and uptake of FITC-LDL were assessed by flow cytometry and Western blot. RESULTS Of the 13 variants studied 7 were shown to affect LDLR function - expression, binding or uptake, with rates lower than 60%: p.(Cys184Tyr), p.(Gly207_Ser213del); p.(His211Asp); p.(Asp221Tyr); p.(Glu288Lys); p.(Gly592Glu) and p.(Asp601Val)). The remaining 6 variants do not alter the LDLR function. CONCLUSIONS These studies contributed to an update of these variants classification: from the 9 variants classified as variants of unknown significance, 7 have reached now a final classification and 3 variants have improved classification from likely pathogenic to pathogenic. In Portugal, an additional 55 patients received an FH definite diagnosis thanks to these studies. Since only likely pathogenic and pathogenic variants are clinically actionable, this work shows the importance of functional studies for variant classification.
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Affiliation(s)
- Ana Catarina Alves
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Sílvia Azevedo
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Asier Benito-Vicente
- Biofisika Institute (UPV/EHU, CSIC) and Departamento de Bioquímica y Biología Molecular, Universidad Del País Vasco, Apdo. 644, 48080, Bilbao, Spain
| | - Rafael Graça
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Unai Galicia-Garcia
- Biofisika Institute (UPV/EHU, CSIC) and Departamento de Bioquímica y Biología Molecular, Universidad Del País Vasco, Apdo. 644, 48080, Bilbao, Spain; Department of Molecular Biophysics, Fundación Biofísica Bizkaia, 48940, Leioa, Spain
| | - Patrícia Barros
- BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal; Departamento de Genética Humana, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Peter Jordan
- BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal; Departamento de Genética Humana, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Cesar Martin
- Biofisika Institute (UPV/EHU, CSIC) and Departamento de Bioquímica y Biología Molecular, Universidad Del País Vasco, Apdo. 644, 48080, Bilbao, Spain
| | - Mafalda Bourbon
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal.
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14
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Improvement of Definite Diagnosis of Familial Hypercholesterolemia Using an Expanding Genetic Analysis. JACC: ASIA 2021; 1:82-89. [PMID: 36338372 PMCID: PMC9627923 DOI: 10.1016/j.jacasi.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/24/2021] [Accepted: 04/06/2021] [Indexed: 11/24/2022]
Abstract
Background The deeper understanding of the complex hereditary basis of familial hypercholesterolemia (FH) has raised the rationale of genetic testing, which has been underutilized in clinical practice. Objectives The present study aimed to explore the variant spectrum of FH in an expanding manner and compare its diagnostic performance. Methods A total of 169 Chinese individuals (124 index cases and 45 relatives) with clinical definite/probable FH were consecutively enrolled. Next-generation sequencing was performed for genetic analysis of 9 genes associated with hypercholesterolemia (major genes: LDLR, APOB, and PCSK9; minor genes: LDLRAP1, LIPA, STAP1, APOE, ABCG5, and ABCG8) including the evaluations of small-scale variants and large-scale copy number variants (CNVs). Results Among the 169 clinical FH patients included, 98 (58.0%) were men. A total of 85 (68.5%) index cases carried FH-associated variants. The proportion of FH caused by small-scale variants in LDLR, APOB, and PCSK9 genes was 62.1% and then increased by 6.5% when other genes and CNVs were further included. Furthermore, the variants in LDLR, APOB, and PCSK9 genes occupied 75% of all FH-associated variants. Of note, there were 8 non-LDLR CNVs detected in the present study. Conclusions LDLR, APOB, and PCSK9 genes should be tested in the initial genetic screening, although variants in minor genes also could explain phenotypic FH, suggesting that an expanding genetic testing may be considered to further explain phenotypic FH.
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15
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Gazzotti M, Casula M, Olmastroni E, Averna M, Arca M, Catapano AL. How registers could enhance knowledge and characterization of genetic dyslipidaemias: The experience of the LIPIGEN in Italy and of other networks for familial hypercholesterolemia. ATHEROSCLEROSIS SUPP 2020; 42:e35-e40. [PMID: 33589222 DOI: 10.1016/j.atherosclerosissup.2021.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Familial hypercholesterolemia (FH) is a common genetic disorder of lipid metabolism, still underdiagnosed and undertreated in the general population. Pathology registers could play a crucial role in the creation of a comprehensive and integrated global approach to cover all aspects of this disease. Systematic data collection of patients affected by FH has increased dramatically worldwide in the past few years. Moreover, results from registers already established for the longest time showed their potentialities in the implementation of the knowledge of FH, comparing country-specific approaches and providing real-world data about identification, management and treatment of FH individuals in the clinical practice. The potential fields of research through registers are related to the deepening of the genetic basis of disease, the study of genotype-phenotype correlation, the local adaption and implementation of diagnostic algorithms, the comparison of pharmacological approaches and treatment gaps in real-life clinical practice, the evaluation of specific subpopulations, and the identification of factors modifying cardiovascular disease risk. Registers could become also a valid resource for other rare dyslipidaemias, contributing towards the evidence-based enhancement in the worldwide care of uncommon diseases.
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Affiliation(s)
- Marta Gazzotti
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto San Giovanni (MI), Italy
| | - Elena Olmastroni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Maurizio Averna
- Department ProMISE (Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties), University of Palermo, Palermo, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Alberico L Catapano
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto San Giovanni (MI), Italy
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16
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de Paiva Silvino JP, Jannes CE, Tada MT, Lima IR, Silva IDFO, Pereira AC, Gomes KB. Cascade screening and genetic diagnosis of familial hypercholesterolemia in clusters of the Southeastern region from Brazil. Mol Biol Rep 2020; 47:9279-9288. [PMID: 33231818 DOI: 10.1007/s11033-020-06014-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/16/2020] [Indexed: 01/04/2023]
Abstract
Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease characterized by high levels of low-density lipoprotein-cholesterol (LDLc), associated to premature cardiovascular disease. The detection of the variants related to FH is important to improve the early diagnosis in probands / index-cases (ICs) and their relatives. We included ICs with FH and their relatives, living in a small region of Minas Gerais state-Brazil, which were classified according to Dutch Lipid Clinic Network Criteria (DLCNC) and submitted to sequencing of genes related to FH (LDLR, APOB, PCSK9, LDLRAP1, LIPA, STAP1, APOE, ABCG5 e ABCG8). In a total of 143 subjects (32 ICs and 111 relatives), eight variants were identified in 91 individuals. From these variants, five were in LDLR [p.(Asp224Asn), p.(Ser854Gly), p.(Cys34Arg), p.(Asp601His), deletion of exon15 in LDLR)], one in APOB [p.(Met499Val)], one in PCSK9 [p.(Arg237Trp)] and one in APOE [p.(Pro28Leu)] genes. The variants were detected in 100% of those subjects classified as definitive, 87% as probable and 69% as possible FH cases based on DLCNC. The LDLc level was higher in individuals with corneal arch and xanthomas or xanthelasmas, as well as in pathogenic or probably pathogenic variants carriers. This study showed higher frequency of LDLR gene variants compared to other genes related to LDL metabolism in individuals with FH in Minas Gerais - Brazil and the presence of FH in relatives without previous diagnosis. Our data reinforce the importance of molecular and clinical evaluation of FH relatives in order to early diagnosis the FH, as well as cardiovascular diseases prevention.
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Affiliation(s)
| | - Cinthia Elim Jannes
- Laboratório de Genética e Cardiologia Molecular do Instituto do Coração de São Paulo (INCOR), Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Mauricio Teruo Tada
- Laboratório de Genética e Cardiologia Molecular do Instituto do Coração de São Paulo (INCOR), Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Isabella Ramos Lima
- Laboratório de Genética e Cardiologia Molecular do Instituto do Coração de São Paulo (INCOR), Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Iêda de Fátima Oliveira Silva
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Antônio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, Brazil
| | - Alexandre Costa Pereira
- Laboratório de Genética e Cardiologia Molecular do Instituto do Coração de São Paulo (INCOR), Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Karina Braga Gomes
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerias, Brazil. .,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Antônio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, Brazil.
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17
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Abstract
Familial hypercholesterolemia (FH) is considered the genetic cause of coronary heart disease and ischemic stroke. FH is mainly an autosomal codominant pattern-based disorder and is primarily determined by point mutations within the low-density lipoprotein receptor, apolipoprotein B, and proprotein convertase subtilisin/kexin type 9 genes, causing increased low-density lipoprotein cholesterol levels in the serum of untreated individuals. The accumulation will eventually lead to atherosclerotic cardiovascular disease. Although clinical criteria comprising several prognosis scores, such as the Simon Broome, Dutch Lipid Clinic Network, Make Early Diagnosis to Prevent Early Death, and the recently proposed Montreal-FH-SCORE, are the conventional basis of diagnosing FH, the genetic diagnosis made by single nucleotide polymorphism genotyping, multiplex ligation-dependent probe amplification analysis, and sequencing (both Sanger and Next-Generation sequencing) offers unequivocal diagnosis. Given the heterogeneity of known mutations, the genetic diagnosis of FH is often difficult to establish, despite the growing evidence of the causative mutations, as well as the polygenic aspect of this pathology and the importance of cascade screening of the FH patient’s healthy family members. This review article details different genetic techniques that can be used in FH identification when there is a clinical FH suspicion based on criteria comprised in prognosis scores, knowing that none of these are exhaustive in the diagnosis, yet they efficaciously overlap and complement each other for confirming the disease at the molecular level.
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18
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Rieck L, Bardey F, Grenkowitz T, Bertram L, Helmuth J, Mischung C, Spranger J, Steinhagen-Thiessen E, Bobbert T, Kassner U, Demuth I. Mutation spectrum and polygenic score in German patients with familial hypercholesterolemia. Clin Genet 2020; 98:457-467. [PMID: 32770674 DOI: 10.1111/cge.13826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
Autosomal-dominant familial hypercholesterolemia (FH) is characterized by increased plasma concentrations of low-density lipoprotein cholesterol (LDL-C) and a substantial risk to develop cardiovascular disease. Causative mutations in three major genes are known: the LDL receptor gene (LDLR), the apolipoprotein B gene (APOB) and the proprotein convertase subtilisin/kexin 9 gene (PCSK9). We clinically characterized 336 patients suspected to have FH and screened them for disease causing mutations in LDLR, APOB, and PCSK9. We genotyped six single nucleotide polymorphisms (SNPs) to calculate a polygenic risk score for the patients and 1985 controls. The 117 patients had a causative variant in one of the analyzed genes. Most variants were found in the LDLR gene (84.9%) with 11 novel mutations. The mean polygenic risk score was significantly higher in FH mutation negative subjects than in FH mutation positive patients (P < .05) and healthy controls (P < .001), whereas the score of the two latter groups did not differ significantly. However, the score explained only about 3% of the baseline LDL-C variance. We verified the previously described clinical and genetic variability of FH for German hypercholesterolemic patients. Evaluation of a six-SNP polygenic score recently proposed for clinical use suggests that it is not a reliable tool to classify hypercholesterolemic patients.
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Affiliation(s)
- Lorenz Rieck
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frieda Bardey
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Grenkowitz
- Department of Cardiology, Charité - University Medicine Berlin (Campus Benjamin Franklin), Berlin, Germany
| | - Lars Bertram
- Lübeck Interdisciplinary Platform for Genome Analytics, Institutes of Neurogenetics and Cardiogenetics, University of Lübeck, Lübeck, Germany.,Center for Lifespan Changes in Brain and Cognition (LCBC), Dept of Psychology, University of Oslo, Oslo, Norway
| | - Johannes Helmuth
- Department Molecular Diagnostics, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Claudia Mischung
- Department Molecular Diagnostics, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Joachim Spranger
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Elisabeth Steinhagen-Thiessen
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Bobbert
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ursula Kassner
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ilja Demuth
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Charité - Universitätsmedizin Berlin, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
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19
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Setia N, Movva S, Balakrishnan P, Biji IK, Sawhney JPS, Puri R, Arora A, Puri RD, Saxena R, Mishra S, Apte S, Kulshrestha S, Ramprasad VL, Verma IC. Genetic analysis of familial hypercholesterolemia in Asian Indians: A single-center study. J Clin Lipidol 2020; 14:35-45. [PMID: 32044282 DOI: 10.1016/j.jacl.2019.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 12/27/2019] [Accepted: 12/27/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Familial hypercholesterolemia (FH), an autosomal codominant disorder characterized by very high low-density lipoprotein cholesterol, is strongly associated with premature coronary artery disease. OBJECTIVES Molecular landscape of FH in Asian Indians is not well studied, although this ethnic group comprises a large proportion of the world population. Knowledge of mutations in these groups is useful for identifying persons affected with FH, saving their lives, and cascade screening in their relatives. METHODS Potential cases of FH (n = 100) were identified by criteria adapted for the Indian population from Dutch Lipid Clinic Network criteria. Pathogenic variants were analyzed in LDLR, APOB 100 (exons 26 and 29), PCSK9, and APOE genes using Sanger sequencing and multiplex ligation-dependent probe amplification technique. Cases in whom there were no pathogenic variants were tested by next-generation sequencing using a targeted panel of genes. RESULTS Thirty-eight pathogenic variants were identified in 47 of 100 unrelated probands. Of these variants, 33 were identified in LDLR, 3 in APOB, and 2 in PCSK9 genes. Ten pathogenic variants were novel. Mutations were detected in 91.4% of those subjects classified as definite, 40% as probable, and in 18.8% as possible FH cases based on modified Dutch Lipid Clinic Network criteria. A likely founder mutation in intron 10 (c.1587-1G>A) of LDLR gene was observed in 6 North Indian families. The conventional pathogenic variants in APOB and PCSK9 genes and those previously reported in LDLR gene among Asian Indians were not detected in this cohort. CONCLUSION This study demonstrates genetic heterogeneity of FH in India. The variants observed were different from those described in Western populations. Next-generation sequencing technology helped identify new mutations in APOB gene, suggesting that in less-studied populations, it is better to sequence the whole gene rather than test for specific mutations.
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Affiliation(s)
- Nitika Setia
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India.
| | - Sireesha Movva
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Prahlad Balakrishnan
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Ishpreet K Biji
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Raman Puri
- Department of Cardiology, Indrapratha Apollo Hospital, New Delhi, India
| | - Anjali Arora
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ratna D Puri
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Renu Saxena
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | | | | | - Samarth Kulshrestha
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Ishwar C Verma
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India.
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20
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Garg A, Fazio S, Duell PB, Baass A, Udata C, Joh T, Riel T, Sirota M, Dettling D, Liang H, Garzone PD, Gumbiner B, Wan H. Molecular Characterization of Familial Hypercholesterolemia in a North American Cohort. J Endocr Soc 2019; 4:bvz015. [PMID: 31993549 DOI: 10.1210/jendso/bvz015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/25/2019] [Indexed: 01/16/2023] Open
Abstract
Background Familial hypercholesterolemia (FH) confers a very high risk of premature cardiovascular disease and is commonly caused by mutations in low-density lipoprotein receptor (LDLR), apolipoprotein B (APOB), or proprotein convertase subtilisin/kexin type 9 (PCSK9) and very rarely in LDLR adaptor protein 1 (LDLRAP1) genes. Objective To determine the prevalence of pathogenic mutations in the LDLR, APOB, and PCSK9 in a cohort of subjects who met Simon Broome criteria for FH and compare the clinical characteristics of mutation-positive and mutation-negative subjects. Methods Ninety-three men and 107 women aged 19 to 80 years from lipid clinics in the United States and Canada participated. Demographic and historical data were collected, physical examination performed, and serum lipids/lipoproteins analyzed. Targeted sequencing analyses of LDLR and PCSK9 coding regions and exon 26 of APOB were performed followed by detection of LDLR deletions and duplications. Results Disease-causing LDLR and APOB variants were identified in 114 and 6 subjects, respectively. Of the 58 LDLR variants, 8 were novel mutations. Compared with mutation-positive subjects, mutation-negative subjects were older (mean 49 years vs 57 years, respectively) and had a higher proportion of African Americans (1% vs 12.5%), higher prevalence of hypertension (21% vs 46%), and higher serum triglycerides (median 86 mg/dL vs 122 mg/dL) levels. Conclusions LDLR mutations were the most common cause of heterozygous FH in this North American cohort. A strikingly high proportion of FH subjects (40%) lacked mutations in known culprit genes. Identification of underlying genetic and environmental factors in mutation-negative patients is important to further our understanding of the metabolic basis of FH and other forms of severe hypercholesterolemia.
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Affiliation(s)
- Abhimanyu Garg
- Division of Nutrition and Metabolic Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Sergio Fazio
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - P Barton Duell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Alexis Baass
- Institut de Recherches Cliniques de Montreal, Montreal, Canada
| | | | | | - Tom Riel
- Pfizer Inc., South San Francisco, California
| | | | | | - Hong Liang
- Pfizer Inc., South San Francisco, California
| | | | | | - Hong Wan
- Pfizer Inc., South San Francisco, California
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21
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Lipid-modifying therapy and low-density lipoprotein cholesterol goal attainment in patients with familial hypercholesterolemia in Germany: The CaReHigh Registry. Atherosclerosis 2019; 277:314-322. [PMID: 30270065 DOI: 10.1016/j.atherosclerosis.2018.08.050] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is amongst the most common genetic disorders encountered in primary care. Yet, only a minority of affected patients is diagnosed and treated. This interim analysis of the CaRe High Registry aims at examining the state of treatment and attainment of lipid goals in German FH patients. METHODS The CaRe High registry includes FH patients from lipid clinics and private practices. Data have been collected using questionnaires filled in by the recruiting physicians and by interviewing the participating patients. RESULTS We examined 512 F H patients diagnosed according to clinical criteria. Median age at the time of the first FH diagnosis was 39 (25th and 75th percentile: 27-50) years, median treatment naïve LDL cholesterol (LDL-C) was 239.4 mg/dl (6.19 mmol/l), 25th to 75th percentile 191.8-342.5 mg/dl (4.96-8.86 mmol/l). 27% of the participants did not receive lipid-lowering drugs. Among the patients treated with lipid-lowering drugs, 19% received a PCSK9 inhibitor (PCSK9i) in combination with a statin, 9% were treated with a PCSK9i alone and 3% were treated with a combination of PCSK9i and a non-statin drug. Patients with pre-existing CVD were more likely to be treated with lipid-lowering drugs and more likely to receive a PCSK9i, but LDL-C targets were only achieved by a minority of patients (<20%). Gap to target LDL-C was lowest and the median achieved LDL-C reduction was 1.4 times higher with PCSK9i treatment than with (oral) lipid-lowering therapy without PCSK9i. CONCLUSIONS The Care High registry has included patients with the typical clinical features of familial hypercholesterolemia. PCSK9i treatment in addition to standard therapy allows attainment of target values in many patients with initially very high LDL-C.
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Evaluation of the role of STAP1 in Familial Hypercholesterolemia. Sci Rep 2019; 9:11995. [PMID: 31427613 PMCID: PMC6700100 DOI: 10.1038/s41598-019-48402-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 08/02/2019] [Indexed: 02/02/2023] Open
Abstract
Familial hypercholesterolemia (FH) is characterised by elevated serum levels of low-density lipoprotein cholesterol (LDL-C) and a substantial risk for cardiovascular disease. The autosomal-dominant FH is mostly caused by mutations in LDLR (low density lipoprotein receptor), APOB (apolipoprotein B), and PCSK9 (proprotein convertase subtilisin/kexin). Recently, STAP1 has been suggested as a fourth causative gene. We analyzed STAP1 in 75 hypercholesterolemic patients from Berlin, Germany, who are negative for mutations in canonical FH genes. In 10 patients with negative family history, we additionally screened for disease causing variants in LDLRAP1 (low density lipoprotein receptor adaptor protein 1), associated with autosomal-recessive hypercholesterolemia. We identified one STAP1 variant predicted to be disease causing. To evaluate association of serum lipid levels and STAP1 carrier status, we analyzed 20 individuals from a population based cohort, the Cooperative Health Research in South Tyrol (CHRIS) study, carrying rare STAP1 variants. Out of the same cohort we randomly selected 100 non-carriers as control. In the Berlin FH cohort STAP1 variants were rare. In the CHRIS cohort, we obtained no statistically significant differences between carriers and non-carriers of STAP1 variants with respect to lipid traits. Until such an association has been verified in more individuals with genetic variants in STAP1, we cannot estimate whether STAP1 generally is a causative gene for FH.
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Sun D, Zhou BY, Li S, Sun NL, Hua Q, Wu SL, Cao YS, Guo YL, Wu NQ, Zhu CG, Gao Y, Cui CJ, Liu G, Li JJ. Genetic basis of index patients with familial hypercholesterolemia in Chinese population: mutation spectrum and genotype-phenotype correlation. Lipids Health Dis 2018; 17:252. [PMID: 30400955 PMCID: PMC6220500 DOI: 10.1186/s12944-018-0900-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 10/24/2018] [Indexed: 11/18/2022] Open
Abstract
Background Although there have been many reports in the genetics of familial hypercholesterolemia (FH) worldwide, studies in regard of Chinese population are lacking. In this multi-center study, we aim to characterize the genetic spectrum of FH in Chinese population, and examine the genotype-phenotype correlations in detail. Methods A total of 285 unrelated index cases from China with clinical FH were consecutively recruited. Next-generation sequencing and bioinformatics tools were used for mutation detection of LDLR, APOB and PCSK9 genes and genetic analysis. Results Overall, the detection rate is 51.9% (148/285) in the unrelated index cases with a total of 119 risk variants identified including 84 in the LDLR gene, 31 in APOB and 4 in PCSK9 gene. Twenty-eight variants were found in more than one individual and LDLR c.1448G > A (p. W483X) was most frequent one detected in 9 patients. Besides, we found 8 (7 LDLR and 1 APOB) novel variants referred as “pathogenic (or likely pathogenic) variants” according to in silico analysis. In the phenotype analysis, patients with LDLR null mutation had significantly higher LDL cholesterol level than LDLR defective and APOB/PCSK9 mutation carriers and those with no mutations (p < 0.001). Furthermore, 13 double heterozygotes, 16 compound heterozygotes and 5 true LDLR homozygotes were identified and the true LDLR homozygotes had the most severe phenotypes. Conclusions The present study confirmed the heterogeneity of FH genetics in the largest Chinese cohort, which could replenish the knowledge of mutation spectrum and contribute to early screening and disease management.
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Affiliation(s)
- Di Sun
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Bing-Yang Zhou
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Sha Li
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Ning-Ling Sun
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Qi Hua
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Shu-Lin Wu
- Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangzhou, 510080, China
| | - Yun-Shan Cao
- Department of Cardiology, Gansu Provincial People's Hospital, Lanzhou, 730000, Gansu, China
| | - Yuan-Lin Guo
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Na-Qiong Wu
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Cheng-Gang Zhu
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Ying Gao
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Chuan-Jue Cui
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Geng Liu
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Jian-Jun Li
- Division of Dyslipidemia, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
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24
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Further evidence of novel APOB mutations as a cause of familial hypercholesterolaemia. Atherosclerosis 2018; 277:448-456. [DOI: 10.1016/j.atherosclerosis.2018.06.819] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/06/2018] [Accepted: 06/14/2018] [Indexed: 01/02/2023]
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25
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Bucholz EM, Rodday AM, Kolor K, Khoury MJ, de Ferranti SD. Prevalence and Predictors of Cholesterol Screening, Awareness, and Statin Treatment Among US Adults With Familial Hypercholesterolemia or Other Forms of Severe Dyslipidemia (1999-2014). Circulation 2018; 137:2218-2230. [PMID: 29581125 PMCID: PMC6381601 DOI: 10.1161/circulationaha.117.032321] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 01/30/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) and other extreme elevations in low-density lipoprotein cholesterol significantly increase the risk of atherosclerotic cardiovascular disease; however, recent data suggest that prescription rates for statins remain low in these patients. National rates of screening, awareness, and treatment with statins among individuals with FH or severe dyslipidemia are unknown. METHODS Data from the 1999 to 2014 National Health and Nutrition Examination Survey were used to estimate prevalence rates of self-reported screening, awareness, and statin therapy among US adults (n=42 471 weighted to represent 212 million US adults) with FH (defined using the Dutch Lipid Clinic criteria) and with severe dyslipidemia (defined as low-density lipoprotein cholesterol levels ≥190 mg/dL). Logistic regression was used to identify sociodemographic and clinical correlates of hypercholesterolemia awareness and statin therapy. RESULTS The estimated US prevalence of definite/probable FH was 0.47% (standard error, 0.03%) and of severe dyslipidemia was 6.6% (standard error, 0.2%). The frequency of cholesterol screening and awareness was high (>80%) among adults with definite/probable FH or severe dyslipidemia; however, statin use was uniformly low (52.3% [standard error, 8.2%] of adults with definite/probable FH and 37.6% [standard error, 1.2%] of adults with severe dyslipidemia). Only 30.3% of patients with definite/probable FH on statins were taking a high-intensity statin. The prevalence of statin use in adults with severe dyslipidemia increased over time (from 29.4% to 47.7%) but not faster than trends in the general population (from 5.7% to 17.6%). Older age, health insurance status, having a usual source of care, diabetes mellitus, hypertension, and having a personal history of early atherosclerotic cardiovascular disease were associated with higher statin use. CONCLUSIONS Despite the high prevalence of cholesterol screening and awareness, only ≈50% of adults with FH are on statin therapy, with even fewer prescribed a high-intensity statin; young and uninsured patients are at the highest risk for lack of screening and for undertreatment. This study highlights an imperative to improve the frequency of cholesterol screening and statin prescription rates to better identify and treat this high-risk population. Additional studies are needed to better understand how to close these gaps in screening and treatment.
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Affiliation(s)
- Emily M Bucholz
- Department of Medicine (E.M.B.)
- Boston Children's Hospital, MA. Harvard Medical School, Boston, MA (E.M.B., S.D.d.F.)
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (A.M.R.)
| | - Katherine Kolor
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, GA (K.K., M.J.K.)
| | - Muin J Khoury
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, GA (K.K., M.J.K.)
| | - Sarah D de Ferranti
- Department of Cardiology (S.D.d.F.)
- Boston Children's Hospital, MA. Harvard Medical School, Boston, MA (E.M.B., S.D.d.F.)
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Séguro F, Rabès JP, Taraszkiewicz D, Ruidavets JB, Bongard V, Ferrières J. Genetic diagnosis of familial hypercholesterolemia is associated with a premature and high coronary heart disease risk. Clin Cardiol 2018; 41:385-391. [PMID: 29574850 DOI: 10.1002/clc.22881] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is a common autosomal dominant disease associated with premature coronary heart disease (CHD). Studies tend to show that patients with FH associated with an identified mutation (mutation+ FH) are at higher risk than patients without an identified mutation (mutation- FH). We compared the clinical and biological profile and the risk of CHD in patients with mutation+ FH and mutation- FH. HYPOTHESIS In addition to LDL-C, a pathogenic mutation predicts premature CHD in FH. METHODS We successively included all patients with suspected FH (LDL-C > 190 mg/dL if age > 18 years; LDL-C > 160 mg/dL if age < 18 years) and compared patients with a pathogenic mutation with those without an identified pathogenic mutation. RESULTS We studied 179 patients with mutation+ FH and 147 with mutation- FH. The mean age was 44 (± 18) years. The lipid profile was more atherogenic in those with mutation+ FH, who had higher LDL-C (254 ± 69 mg/dL vs 218 ± 35 mg/dL; P < 0.01) and lower HDL-C (53 ± 14 mg/dL vs 58 ± 17 mg/dL; P < 0.01). Despite the more atherogenic nonlipid cardiovascular profile of patients with mutation- FH, the age of CHD onset was earlier in patients with mutation+ FH (48 vs 56 years; P = 0.026). After multiple adjustment, the presence of a positive mutation was significantly associated with premature CHD (OR: 3.0, 95% CI: 1.38-6.55, P < 0.01). CONCLUSIONS Patients with mutation+ FH have a more atherogenic lipid profile and a 3-fold higher risk of premature CHD, as well as earlier onset of CHD, than patients with mutation- FH.
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Affiliation(s)
- Florent Séguro
- Department of Epidemiology, Health Economics and Public Health, UMR 1027 INSERM-Université Toulouse 3, Toulouse, France.,Department of Cardiology, Toulouse-Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
| | - Jean-Pierre Rabès
- Service de Biochimie et Génétique Moléculaire, AP-HP, Hôpitaux Universitaires Paris Ile-de-France Ouest, Boulogne-Billancourt, France.,UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin-en-Yvelines, France
| | - Dorota Taraszkiewicz
- Department of Cardiology, Toulouse-Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
| | - Jean-Bernard Ruidavets
- Department of Epidemiology, Health Economics and Public Health, UMR 1027 INSERM-Université Toulouse 3, Toulouse, France
| | - Vanina Bongard
- Department of Epidemiology, Health Economics and Public Health, UMR 1027 INSERM-Université Toulouse 3, Toulouse, France
| | - Jean Ferrières
- Department of Epidemiology, Health Economics and Public Health, UMR 1027 INSERM-Université Toulouse 3, Toulouse, France.,Department of Cardiology, Toulouse-Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
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27
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Abstract
PURPOSE OF REVIEW Familial hypercholesterolaemia (FH) is an inherited disorder of low-density lipoprotein cholesterol (LDL-C) which is characterised by a raised cholesterol level from birth and a high risk of premature coronary heart disease. In this paper, we review the genetic basis of FH and its impact on the clinical presentation. RECENT FINDINGS Mutations in any of three genes (LDLR, APOB and PCSK9) are known to cause autosomal dominant FH, but a mutation can be found in only ∼40% of patients with a clinical diagnosis of FH. In the remainder, a polygenic aetiology is most likely, due to the co-inheritance of common LDL-C-raising variants. The cardiovascular presentation and management of FH will differ between patients based on their underlying genetic factors. New genotyping methods such as next-generation sequencing will provide us with better understanding of the genetic architecture of FH.
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Affiliation(s)
- Mahtab Sharifi
- Institute of Cardiovascular Science, University College London, 5 University St, London, WC1E 6JF, UK.,Department of Clinical Biochemistry, the Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Marta Futema
- Institute of Cardiovascular Science, University College London, 5 University St, London, WC1E 6JF, UK
| | - Devaki Nair
- Department of Clinical Biochemistry, the Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Steve E Humphries
- Institute of Cardiovascular Science, University College London, 5 University St, London, WC1E 6JF, UK.
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28
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Scicali R, Di Pino A, Platania R, Purrazzo G, Ferrara V, Giannone A, Urbano F, Filippello A, Rapisarda V, Farruggia E, Piro S, Rabuazzo AM, Purrello F. Detecting familial hypercholesterolemia by serum lipid profile screening in a hospital setting: Clinical, genetic and atherosclerotic burden profile. Nutr Metab Cardiovasc Dis 2018; 28:35-43. [PMID: 28958694 DOI: 10.1016/j.numecd.2017.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is underdiagnosed and public cholesterol screening may be useful to find new subjects. In this study, we aim to investigate the prevalence of FH patients in a hospital screening program and evaluate their atherosclerotic burden using intima-media thickness (IMT). METHODS AND RESULTS We screened 1575 lipid profiles and included for genetic analysis adults with a low-density lipoprotein (LDL) cholesterol >190 mg/dL and triglycerides <200 mg/dL and first-degree child relatives with LDL cholesterol >160 mg/dL and triglycerides <200 mg/dL. The diagnosis of FH was presumed by Dutch Lipid Clinic Network (DLCN) criteria and confirmed by the presence of the genetic variant. Mean common carotid intima-media thickness (IMT) was assessed using consensus criteria. After confirming LDL cholesterol value and excluding secondary hypercholesterolemia, 56 subjects with a DLCN ≥4 performed genetic analysis. Of these, 26 had an FH genetic variant. The proportion of patients with a mutation having a DLCN score of 6-8 was 75%; in individuals with a DLCN score >8 it was 100%. Mean IMT was higher in FH patients compared to non FH (0.73 [0.61-0.83] vs 0.71 [0.60-0.75] mm, p < 0.01). Moreover, we detected two mutations not previously described. Finally, simple regression analysis showed a correlation of IMT with LDL cholesterol >190 mg/dL and corneal arcus (p < 0.01 and p < 0.001, respectively). CONCLUSIONS A hospital screening was useful to detect FH subjects with increased atherosclerosis. Also, next-generation sequencing was able to detect new FH mutations.
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Affiliation(s)
- R Scicali
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - A Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - R Platania
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - G Purrazzo
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - V Ferrara
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - A Giannone
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - F Urbano
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - A Filippello
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - V Rapisarda
- Department of Clinical and Experimental Medicine, Section of Occupational Medicine, University of Catania, Italy
| | - E Farruggia
- Occupational Medicine Division, Garibaldi Hospital of Catania, Catania, Italy
| | - S Piro
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - A M Rabuazzo
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - F Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Italy.
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Pek SLT, Dissanayake S, Fong JCW, Lin MX, Chan EZL, Tang JIS, Lee CW, Ong HY, Sum CF, Lim SC, Tavintharan S. Spectrum of mutations in index patients with familial hypercholesterolemia in Singapore: Single center study. Atherosclerosis 2017; 269:106-116. [PMID: 29353225 DOI: 10.1016/j.atherosclerosis.2017.12.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/13/2017] [Accepted: 12/21/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease characterized by the presence of high plasma low density lipoproteins cholesterol (LDL-c). Patients with FH, with mutation detected, are at increased risk of premature cardiovascular disease compared to those without mutations. The aim of the study was to assess the type of mutations in patients, clinically diagnosed with FH in Singapore. METHODS Patients (probands) with untreated/highest on-treatment LDL-c>4.9 mmol/l were recruited (June 2015 to April 2017). Anthropometric, biochemical indices, blood and family history were collected. DNA was extracted and Next Generation Sequencing (NGS) was performed in 26 lipid-related genes, including LDLR, APOB and PCSK9, and validated using Sanger. Multiplex-ligation probe analyses for LDLR were performed to identify large mutation derangements. Based on HGVS nomenclature, LDLR mutations were classified as "Null"(nonsense, frameshift, large rearrangements) and "Defective"(point mutations which are pathogenic). RESULTS Ninety-six probands were recruited: mean age: (33.5 ± 13.6) years. 52.1% (n = 50) of patients had LDLR mutations, with 15 novel mutations, and 4.2% (n = 4) had APOB mutations. Total cholesterol (TC) and LDL-c were significantly higher in those with LDLR mutations compared to APOB and no mutations [(8.53 ± 1.52) vs. (6.93 ± 0.47) vs. (7.80 ± 1.32)] mmol/l, p = 0.012 and [(6.74 ± 0.35) vs. (5.29 ± 0.76) vs. (5.98 ± 1.23)] mmol/l, p=0.005, respectively. Patients with "null LDLR" mutations (n = 13) had higher TC and LDL-c than "defective LDLR" mutations (n = 35): [(9.21 ± 1.60) vs. (8.33 ± 1.41)]mmol/l, p = 0.034 and [(7.43 ± 1.47) vs. (6.53 ± 1.21)]mmol/l, p=0.017, respectively. CONCLUSIONS To our knowledge, this is the first report of mutation detection in patients with clinically suspected FH by NGS in Singapore. While percentage of mutations is similar to other countries, the spectrum locally differs.
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Affiliation(s)
| | | | | | | | | | | | - Chee Wan Lee
- Cardiology, Khoo Teck Puat Hospital, 768828, Singapore
| | - Hean Yee Ong
- Cardiology, Khoo Teck Puat Hospital, 768828, Singapore
| | - Chee Fang Sum
- Diabetes Centre, Admiralty Medical Centre, 730676, Singapore; Division of Endocrinology, Khoo Teck Puat Hospital, 768828, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, 768828, Singapore; Diabetes Centre, Admiralty Medical Centre, 730676, Singapore; Division of Endocrinology, Khoo Teck Puat Hospital, 768828, Singapore; Saw Swee Hock School of Public Health, National University Hospital, 117549, Singapore
| | - Subramaniam Tavintharan
- Clinical Research Unit, Khoo Teck Puat Hospital, 768828, Singapore; Diabetes Centre, Admiralty Medical Centre, 730676, Singapore; Division of Endocrinology, Khoo Teck Puat Hospital, 768828, Singapore.
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Toell T, Mayer L, Pechlaner R, Krebs S, Willeit K, Lang C, Boehme C, Prantl B, Knoflach M, Ferrari J, Fuchs P, Prokop W, Griesmacher A, Lang W, Kiechl S, Willeit J. Familial hypercholesterolaemia in patients with ischaemic stroke or transient ischaemic attack. Eur J Neurol 2017; 25:260-267. [PMID: 29053901 DOI: 10.1111/ene.13485] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/16/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Identification of patients with familial hypercholesterolaemia (FH) is a prerequisite for the appropriate management of their excess cardiovascular risk. It is currently unknown how many patients with acute ischaemic stroke or transient ischaemic attack (TIA) are affected by FH and whether systematic screening for FH is warranted in these patients. METHODS The prevalence of a clinical diagnosis of FH was estimated in a large representative series of patients with acute ischaemic stroke or TIA (ABCD2 score ≥ 3) using the Dutch Lipid Clinic Network Algorithm (DLCNA; possible FH ≥3, probable/definite FH ≥6). RESULTS Out of 1054 patients included in the present analysis, 14 had probable/definite FH (1.3%; 95% confidence interval 0.6-2.0) and 107 possible FH (10.2%; 8.4-12.0) corresponding to an overall prevalence of potential FH of 11.5%. Prevalences were even higher in patients with stroke/TIA manifestation before age 55 in men or 60 in women (3.1%, 0.6-5.6; and 13.1%, 8.3-17.9) and those with a prior history of cardiovascular disease (2.6%, 0.9-4.3; and 15.1%, 11.3-18.9). Of note, in two-thirds of our patients with probable/definite and possible FH, stroke or TIA was the initial clinical disease manifestation. CONCLUSIONS The frequency of potential FH, based on clinical criteria, in patients with acute ischaemic stroke or TIA was 11.5% and that of probable/definite FH (1.3%) was similar to recently reported counts for patients with acute coronary syndrome (1.6%). FH screening using the DLCNA is feasible in clinical routine and should be considered as part of the usual diagnostic work-up.
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Affiliation(s)
- T Toell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - L Mayer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - R Pechlaner
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - S Krebs
- Department of Neurology, Hospital Barmherzige Brueder, Vienna, Austria
| | - K Willeit
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - C Lang
- Department of Neurology, Hospital Barmherzige Brueder, Vienna, Austria
| | - C Boehme
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - B Prantl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Ferrari
- Department of Neurology, Hospital Barmherzige Brueder, Vienna, Austria
| | - P Fuchs
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - W Prokop
- Central Institute of Medical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - A Griesmacher
- Central Institute of Medical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - W Lang
- Department of Neurology, Hospital Barmherzige Brueder, Vienna, Austria
| | - S Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Willeit
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Schmidt N, Schmidt B, Dressel A, Gergei I, Klotsche J, Pieper L, Scharnagl H, Kleber ME, März W, Lehnert H, Pittrow D, Stalla G, Wittchen HU, Grammer TB. Familial hypercholesterolemia in primary care in Germany. Diabetes and cardiovascular risk evaluation: Targets and Essential Data for Commitment of Treatment (DETECT) study. Atherosclerosis 2017; 266:24-30. [DOI: 10.1016/j.atherosclerosis.2017.08.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 08/14/2017] [Accepted: 08/18/2017] [Indexed: 01/31/2023]
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Chora JR, Medeiros AM, Alves AC, Bourbon M. Analysis of publicly available LDLR, APOB, and PCSK9 variants associated with familial hypercholesterolemia: application of ACMG guidelines and implications for familial hypercholesterolemia diagnosis. Genet Med 2017; 20:591-598. [PMID: 29261184 DOI: 10.1038/gim.2017.151] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/26/2017] [Indexed: 01/15/2023] Open
Abstract
PurposeFamilial hypercholesterolemia (FH) is an autosomal disorder of lipid metabolism presenting with increased cardiovascular risk. Although more than 1,700 variants have been associated with FH, the great majority have not been functionally proved to affect the low-density lipoprotein receptor cycle. We aimed to classify all described variants associated with FH and to establish the proportion of variants that lack evidence to support their pathogenicity.MethodsWe followed American College of Medical Genetics and Genomics (ACMG) guidelines for the classification, and collected information from a variety of databases and individual reports. A worldwide overview of publicly available FH variants was also performed.ResultsA total of 2,104 unique variants were identified as being associated with FH, but only 166 variants have been proven by complete in vitro functional studies to be causative of disease. Additionally, applying the ACMG guidelines, 1,097 variants were considered pathogenic or likely pathogenic. Only seven variants were found in all five continents.ConclusionThe lack of functional evidence for about 85% of all variants found in FH patients can compromise FH diagnosis and patient prognosis. ACMG classification improves variant interpretation, but functional studies are necessary to understand the effect of about 40% of all variants reported. Nevertheless, ACMG guidelines need to be adapted to FH for a better diagnosis.
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Affiliation(s)
- Joana Rita Chora
- Unidade I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisbon, Portugal.,University of Lisboa, Faculty of Sciences, BioISI-Biosystems & Integrative Sciences Institute, Lisbon, Portugal
| | - Ana Margarida Medeiros
- Unidade I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisbon, Portugal.,University of Lisboa, Faculty of Sciences, BioISI-Biosystems & Integrative Sciences Institute, Lisbon, Portugal
| | - Ana Catarina Alves
- Unidade I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisbon, Portugal.,University of Lisboa, Faculty of Sciences, BioISI-Biosystems & Integrative Sciences Institute, Lisbon, Portugal
| | - Mafalda Bourbon
- Unidade I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisbon, Portugal.,University of Lisboa, Faculty of Sciences, BioISI-Biosystems & Integrative Sciences Institute, Lisbon, Portugal
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März W, Grammer TB, Delgado G, Kleber ME. Angeborene Störungen im Lipoproteinstoffwechsel. Herz 2017; 42:449-458. [DOI: 10.1007/s00059-017-4578-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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TICHÝ L, FAJKUSOVÁ L, ZAPLETALOVÁ P, SCHWARZOVÁ L, VRABLÍK M, FREIBERGER T. Molecular Genetic Background of an Autosomal Dominant Hypercholesterolemia in the Czech Republic. Physiol Res 2017; 66:S47-S54. [DOI: 10.33549/physiolres.933587] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Autosomal dominant hypercholesterolemia (ADH), more known as familial hypercholesterolemia (FH), is a lipid metabolism disorder characterized by an elevation in low-density lipoprotein cholesterol (LDL-C) and increased risk for cardiovascular disease. In this study, we assessed a spectrum of mutations causing ADH in 3914 unrelated Czech patients with clinical diagnosis of hypercholesterolemia. Samples have been collected within the framework of the MedPed project running in the Czech Republic since 1998. So far we have found 432 patients (11.0 %) with the APOB gene mutation p.(Arg3527Gln) and 864 patients (22.1 %) with the LDLR gene mutation. In 864 probands carrying the LDLR gene mutation, 182 unique allelic variants were detected. We have identified 14 patients homozygous for mutations in the LDLR or APOB genes. We performed function analyses of p.(Leu15Pro) and p.(Gly20Arg) sequence variations.
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Affiliation(s)
| | | | | | | | | | - T. FREIBERGER
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czech Republic
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Bourbon M, Alves AC, Sijbrands EJ. Low-density lipoprotein receptor mutational analysis in diagnosis of familial hypercholesterolemia. Curr Opin Lipidol 2017; 28:120-129. [PMID: 28169869 DOI: 10.1097/mol.0000000000000404] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW To present up to date evidence on the pathogenicity of low-density lipoprotein receptor (LDLR) variants and to propose a strategy that is suitable for implementation in the clinical work-up of familial hypercholesterolaemia. RECENT FINDINGS More than 1800 variants have been described in the LDLR gene of patients with a clinical diagnosis of familial hypercholesterolaemia; however, less than 15% have functional evidence of pathogenicity. SUMMARY The spectrum of variants in the LDLR identified in patients with clinical familial hypercholesterolaemia is increasing as novel variants are still being reported. However, over 50% of all LDLR variants need further evidence before they can be confirmed as mutations causing disease. Even with applying the recent American College of Medical Genetics variant classification, a large number of variants are still considered variants of unknown significance. Before obtaining an undisputable confirmation of the effect on the expression and activity of the LDLR, reporting these variants as part of a clinical diagnosis to the patient holds the risk that it might need to be withdrawn in a later stage. An investment should be made to develop functional assays to characterize LDLR variants of unknown significance for a better patient diagnosis and to prevent confusion in the physician's office.
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Affiliation(s)
- Mafalda Bourbon
- aUnidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge bBioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal cDepartment of internal Medicine, Erasmus University Rotterdam, Rotterdam, the Netherlands
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