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van den Bosch SE, Hutten BA, Corpeleijn WE, Kusters DM. Familial hypercholesterolemia in children and the importance of early treatment. Curr Opin Lipidol 2024; 35:126-132. [PMID: 38363694 PMCID: PMC11188623 DOI: 10.1097/mol.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE OF REVIEW Familial hypercholesterolemia leads to elevated levels of low-density lipoprotein cholesterol (LDL-C) from birth onwards due to a pathogenetic variation in genes in cholesterol metabolism. Early screening to identify and subsequently treat children with familial hypercholesterolemia is crucial to reduce the risk of premature atherosclerotic cardiovascular disease (ASCVD). This review focuses on recent insights in the field of pediatric familial hypercholesterolemia. RECENT FINDINGS Screening in childhood and early initiation of optimal lipid-lowering therapy (LLT) have shown promising outcomes in the prevention of ASCVD. In addition, cost-effectiveness research has demonstrated highly favorable results. With the availability of novel therapies, familial hypercholesterolemia has become a well treatable disease. SUMMARY Children with familial hypercholesterolemia benefit from early detection and optimal treatment of their elevated LDL-C levels.
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Affiliation(s)
- Sibbeliene E. van den Bosch
- Amsterdam UMC location University of Amsterdam, Department of Pediatrics
- Amsterdam Cardiovascular Sciences, Diabetes and Metabolism
- Amsterdam Gastroenterology Endocrinology Metabolism
| | - Barbara A. Hutten
- Amsterdam Cardiovascular Sciences, Diabetes and Metabolism
- Amsterdam UMC location University of Amsterdam, Department of Epidemiology and Data Science, Meibergdreef 9, Amsterdam, The Netherlands
| | - Willemijn E. Corpeleijn
- Amsterdam UMC location University of Amsterdam, Department of Pediatrics
- Amsterdam Cardiovascular Sciences, Diabetes and Metabolism
- Amsterdam Gastroenterology Endocrinology Metabolism
| | - D. Meeike Kusters
- Amsterdam UMC location University of Amsterdam, Department of Pediatrics
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Corpeleijn WE, de Waal WJ, Schipper HS, Wiegman A. Dyslipidaemia as a target for atherosclerotic cardiovascular disease prevention in children with type 1 diabetes: lessons learned from familial hypercholesterolaemia. Diabetologia 2024; 67:19-26. [PMID: 38032368 PMCID: PMC10709243 DOI: 10.1007/s00125-023-06041-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023]
Abstract
In the last few decades, atherosclerotic cardiovascular disease (ASCVD) risk has decreased dramatically among individuals affected by familial hypercholesterolaemia (FH) as a result of the early initiation of statin treatment in childhood. Contemporaneously important improvements in care for people with diabetes have also been made, such as the prevention of mortality from acute diabetic complications. However, individuals with type 1 diabetes still have a two to eight times higher risk of death than the general population. In the last 20 years, a few landmark studies on excess mortality in people with type 1 diabetes, in particular young adults, have been published. Although these studies were carried out in different populations, all reached the same conclusion: individuals with type 1 diabetes have a pronounced increased risk of ASCVD. In this review, we address the role of lipid abnormalities in the development of ASCVD in type 1 diabetes and FH. Although type 1 diabetes and FH are different diseases, lessons could be learned from the early initiation of statins in children with FH, which may provide a rationale for more stringent control of dyslipidaemia in children with type 1 diabetes.
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Affiliation(s)
- Willemijn E Corpeleijn
- Department of Pediatrics, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Wouter J de Waal
- Diabetes Centraal, Children's Diabetic Centre, St Antonius Hospital, Utrecht, the Netherlands
| | - Henk S Schipper
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Albert Wiegman
- Department of Pediatrics, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands.
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands.
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands.
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Syal S, Rao S, Joshi R, Keshwani R, Bodhanwala M. Inherited Lipid Disorders in Children: Experience from a Tertiary Care Centre. Indian J Endocrinol Metab 2023; 27:230-236. [PMID: 37583406 PMCID: PMC10424103 DOI: 10.4103/ijem.ijem_248_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/31/2022] [Accepted: 11/20/2022] [Indexed: 08/17/2023] Open
Abstract
Background Primary dyslipidaemia in children is a rare inherited disorder of lipoprotein metabolism with debilitating sequelae and poor outcomes. Lipid-lowering drugs have less often been used in children and long-term outcome studies are scarce. The purpose of this study was to understand the clinical and laboratory profile, response to treatment on follow up and outcome of primary dyslipidaemia in Indian children. Methods Clinical records, including historical details, examination features and laboratory and radiological evaluation of children diagnosed with primary dyslipidaemia, presenting over the last 9 years were studied. Cascade screening was done for family members of the patients to detect dyslipidaemia in parents and siblings. All children were followed up 3 to 6 monthly for clinical and laboratory evaluation. Diet and drug therapy, initiated as appropriate, were modified as necessary. Results Of nine children with primary dyslipidaemia, seen over the last 9 years, homozygous familial hypercholesterolaemia (HoFH) (n = 4/9), familial hypertriglyceridaemia (FHT) (n = 3/9), familial combined hyperlipidemia (FCH) (n = 1/9), mutation proven chylomicronaemia syndrome (n = 1/9) were the phenotypes seen. Multiple xanthomas (n = 4/9), recurrent pancreatitis (n = 2/9) and incidentally found biochemical abnormality (n = 3/9) were the chief presenting features. Medical nutrition therapy and lipid-lowering drugs, as appropriate, were instituted in all. Follow-up over 16 months (range 4 to 90 months) revealed no deaths and no new onset of symptoms. Atherosclerotic plaques in the carotid artery were seen in one child, who presented late, despite fair compliance to treatment. Interestingly, lipid levels decreased in all cases and were normalised in two. Conclusion Primary dyslipidaemia when detected early and treated aggressively can improve short-term outcomes.
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Affiliation(s)
- Simran Syal
- Department of Pediatrics, Division of Pediatric Endocrinology, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Sudha Rao
- Department of Pediatrics, Division of Pediatric Endocrinology, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Rajesh Joshi
- Department of Pediatrics, Division of Pediatric Endocrinology, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Rachna Keshwani
- Department of Pediatrics, Division of Pediatric Endocrinology, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Minnie Bodhanwala
- Department of Pediatrics, Division of Pediatric Endocrinology, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
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How Genetic Variants in Children with Familial Hypercholesterolemia Not Only Guide Detection, but Also Treatment. Genes (Basel) 2023; 14:genes14030669. [PMID: 36980941 PMCID: PMC10048736 DOI: 10.3390/genes14030669] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
Familial hypercholesterolemia (FH) is a hereditary disorder that causes severely elevated low-density lipoprotein (LDL-C) levels, which leads to an increased risk for premature cardiovascular disease. A variety of genetic variants can cause FH, namely variants in the genes for the LDL receptor (LDLR), apolipoprotein B (APOB), proprotein convertase subtilisin/kexin type 9 (PCSK9), and/or LDL-receptor adaptor protein 1 (LDLRAP1). Variants can exist in a heterozygous form (HeFH) or the more severe homozygous form (HoFH). If affected individuals are diagnosed early (through screening), they benefit tremendously from early initiation of lipid-lowering therapy, such as statins, and cardiovascular imaging to detect possible atherosclerosis. Over the last years, due to intensive research on the genetic basis of LDL-C metabolism, novel, promising therapies have been developed to reduce LDL-C levels and subsequently reduce cardiovascular risk. Results from studies on therapies focused on inhibiting PCSK9, a protein responsible for degradation of the LDLR, are impressive. As the effect of PCSK9 inhibitors (PCSK9-i) is dependent of residual LDLR activity, this medication is less potent in patients without functional LDLR (e.g., null/null variant). Novel therapies that are expected to become available in the near future focused on inhibition of another major regulatory protein in lipid metabolism (angiopoietin-like 3 (ANGPTL3)) might dramatically reduce the frequency of apheresis in children with HoFH, independently of their residual LDLR. At present, another independent risk factor for premature cardiovascular disease, elevated levels of lipoprotein(a) (Lp(a)), cannot be effectively treated with medication. Further understanding of the genetic basis of Lp(a) metabolism, however, offers a possibility for the development of novel therapies.
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Helk O, Böck A, Stefanutti C, Widhalm K. Lp(a) does not affect intima media thickness in hypercholesterolemic children -a retrospective cross sectional study. ATHEROSCLEROSIS PLUS 2023; 51:1-7. [PMID: 36969701 PMCID: PMC10037085 DOI: 10.1016/j.athplu.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/30/2022] [Accepted: 11/21/2022] [Indexed: 06/18/2023]
Abstract
PURPOSE Combined hyperlipidaemia results in premature atherosclerosis and a high burden of cardiovascular morbidity and mortality. Early identification of highly affected subjects within this population is of utmost importance to enable informed treatment decisions. The measurement of intima media thickness (IMT) is a readily available, non-invasive method to investigate evidence of early atherosclerosis. To assess the usefulness of this method in pediatric subjects with hypercholesterolemia, we here examined a possible interaction of LDL-C and Lp(a) on IMT. METHODS Blood lipids (Lp(a), LDL-cholesterol, total cholesterol, triglycerides, high density lipoprotein (HDL) -cholesterol, apolipoprotein A1, apolipoprotein B), anthropometric parameters (age, height, weight, body mass index (BMI)) and possibly existing early evidence of atherosclerotic lesions measured by intima media thickness (IMT zscore).as a surrogate parameter was examined retrospectively in 113 children and adolescents (aged 1-18 years) with elevated Lp(a) and/or LDL-cholesterol (Lp(a) > 30 mg/dL, LDL>130 mg/dL). Furthermore, we compared hsCRP levels between groups. RESULTS There were no significant differences in IMT Zscore or hsCRP between groups. Regression analysis did not reveal a statistically significant interaction between Lp(a) and LDL-C. CONCLUSIONS At the age of 6-18 years, we found no significant differences in early markers of atherosclerosis between subjects with high Lp(a)- and/or high LDL-cholesterol with no detectable synergistic effects between the two lipoproteins.
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Affiliation(s)
- Oliver Helk
- Department of Nephrology and Dialysis, Medical University of Vienna, Austria
| | - Andreas Böck
- University Department for Paediatrics and Adolescent Medicine, Medical University of Vienna, Austria
| | - Claudia Stefanutti
- Extracorporeal Therapeutic Techniques, Lipid Clinic and Atherosclerosis Prevention Centre, Department of Molecular Medicine and Department of Immunohematology and Transfusion Medicine, ‘Sapienza’ University of Rome, Italy
| | - Kurt Widhalm
- University Department for Paediatrics and Adolescent Medicine, Medical University of Vienna, Austria
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Lischka J, Arbeiter K, de Gier C, Willfort-Ehringer A, Walleczek NK, Gellai R, Boehm M, Wiegman A, Greber-Platzer S. Vascular access for lipid apheresis: a challenge in young children with homozygous familial hypercholesterolemia. BMC Pediatr 2022; 22:131. [PMID: 35279116 PMCID: PMC8917672 DOI: 10.1186/s12887-022-03192-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Homozygous familial hypercholesterolemia (hoFH) is a rare genetic disorder leading to extremely increased LDL-cholesterol (LDL-C), resulting in high cardiovascular risk in early childhood. Lipid apheresis (LA) is an effective treatment and should be started as early as possible to prevent premature cardiovascular events. As peripheral punctures in children can be challenging due to small vessels and anxiety, this study aimed to evaluate feasibility and safety of central venous catheters (CVCs) as vascular access for LA in young children with hoFH. Methods Retrospective analysis (2016-2019) on four children with hoFH aged 3-5 years, performing weekly or biweekly LA with a CVC. Results LDL-C decreased by> 60%. In three children, the use of a permanent CVC for 698, 595, and 411 days, respectively, avoided difficult peripheral access, without the occurrence of occlusion or thrombosis. Unfortunately, one child had recurrent CVC-related infections and needed an arteriovenous fistula from the age of 5.
Although the mean dwell time per catheter was 212 days, there were, as expected, severe side effects of early catheter infections with sepsis and accidental self-removal. Starting LA at an early age improved or stabilized carotid intima-media thickness (IMT) in three children. However, IMT did increase in one child caused by intolerance to peripheral punctures and LA interruption. Conclusions Permanent CVCs are a viable temporary access choice for LA in young children with hoFH until peripheral venipuncture is practicable. The risk of CVC-related infections needs to be taken into account. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03192-7.
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Tromp TR, Hartgers ML, Hovingh GK, Vallejo-Vaz AJ, Ray KK, Soran H, Freiberger T, Bertolini S, Harada-Shiba M, Blom DJ, Raal FJ, Cuchel M. Worldwide experience of homozygous familial hypercholesterolaemia: retrospective cohort study. Lancet 2022; 399:719-728. [PMID: 35101175 PMCID: PMC10544712 DOI: 10.1016/s0140-6736(21)02001-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Homozygous familial hypercholesterolaemia (HoFH) is a rare inherited disorder resulting in extremely elevated low-density lipoprotein cholesterol levels and premature atherosclerotic cardiovascular disease (ASCVD). Current guidance about its management and prognosis stems from small studies, mostly from high-income countries. The objective of this study was to assess the clinical and genetic characteristics, as well as the impact, of current practice on health outcomes of HoFH patients globally. METHODS The HoFH International Clinical Collaborators registry collected data on patients with a clinical, or genetic, or both, diagnosis of HoFH using a retrospective cohort study design. This trial is registered with ClinicalTrials.gov, NCT04815005. FINDINGS Overall, 751 patients from 38 countries were included, with 565 (75%) reporting biallelic pathogenic variants. The median age of diagnosis was 12·0 years (IQR 5·5-27·0) years. Of the 751 patients, 389 (52%) were female and 362 (48%) were male. Race was reported for 527 patients; 338 (64%) patients were White, 121 (23%) were Asian, and 68 (13%) were Black or mixed race. The major manifestations of ASCVD or aortic stenosis were already present in 65 (9%) of patients at diagnosis of HoFH. Globally, pretreatment LDL cholesterol levels were 14·7 mmol/L (IQR 11·6-18·4). Among patients with detailed therapeutic information, 491 (92%) of 534 received statins, 342 (64%) of 534 received ezetimibe, and 243 (39%) of 621 received lipoprotein apheresis. On-treatment LDL cholesterol levels were lower in high-income countries (3·93 mmol/L, IQR 2·6-5·8) versus non-high-income countries (9·3 mmol/L, 6·7-12·7), with greater use of three or more lipid-lowering therapies (LLT; high-income 66% vs non-high-income 24%) and consequently more patients attaining guideline-recommended LDL cholesterol goals (high-income 21% vs non-high-income 3%). A first major adverse cardiovascular event occurred a decade earlier in non-high-income countries, at a median age of 24·5 years (IQR 17·0-34·5) versus 37·0 years (29·0-49·0) in high-income countries (adjusted hazard ratio 1·64, 95% CI 1·13-2·38). INTERPRETATION Worldwide, patients with HoFH are diagnosed too late, undertreated, and at high premature ASCVD risk. Greater use of multi-LLT regimens is associated with lower LDL cholesterol levels and better outcomes. Significant global disparities exist in treatment regimens, control of LDL cholesterol levels, and cardiovascular event-free survival, which demands a critical re-evaluation of global health policy to reduce inequalities and improve outcomes for all patients with HoFH. FUNDING Amsterdam University Medical Centers, Location Academic Medical Center; Perelman School of Medicine at the University of Pennsylvania; and European Atherosclerosis Society.
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Affiliation(s)
- Tycho R Tromp
- Department of Vascular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Merel L Hartgers
- Department of Vascular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands; Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Antonio J Vallejo-Vaz
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK; Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Seville, IBiS/Hospital Universitario Virgen del Rocío/Universidad de Seville/CSIC, Seville, Spain; Department of Medicine, Faculty of Medicine, University of Seville, Seville, Spain
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Handrean Soran
- Department of Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust and National Institute of Health Research/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Tomas Freiberger
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Stefano Bertolini
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Mariko Harada-Shiba
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Dirk J Blom
- Department of Medicine, Division of Lipidology and Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Marina Cuchel
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Kramer AI, Akioyamen LE, Lee S, Bélanger A, Ruel I, Hales L, Genest J, Brunham LR. Major adverse cardiovascular events in homozygous familial hypercholesterolaemia: a systematic review and meta-analysis. Eur J Prev Cardiol 2021; 29:817-828. [PMID: 34957506 DOI: 10.1093/eurjpc/zwab224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/30/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022]
Abstract
AIMS Homozygous familial hypercholesterolaemia (HoFH) is a genetic condition characterized by extremely elevated levels of low-density lipoprotein cholesterol and premature atherosclerotic cardiovascular disease and death. Due to its rarity, accurate assessment of cardiovascular outcomes associated with HoFH and how they have changed over time has been challenging. The goal of this study was to assess the prevalence and age-of-onset of major adverse cardiovascular events (MACE) among patients with HoFH. METHODS AND RESULTS We searched MEDLINE, EMBASE, Pubmed, Cochrane Central Register of Controlled Trials, Scopus, Africa-Wide, Google Scholar, Open Grey, and various clinical trial registries from inception to February 2020 to identify studies reporting on MACE in HoFH patients. We determined the pooled prevalence and mean age-of-onset of MACE outcomes individually using a random effects inverse variance model. We identified 94 studies that met our eligibility criteria. Myocardial infarction and coronary revascularization were common with a prevalence of 15.1% [95% confidence interval (95% CI) 10.7-20.0] and 28.3% (95% CI 22.5-34.3), respectively. The mean age-of-onset was 24.5 (95% CI 19.2-29.8) years for myocardial infarction and 32.2 (95% CI 26.6-37.8) years for revascularization. Sub-group analyses based on the year of publication revealed significant delays in the onset of MACE outcomes post-1990 compared to pre-1990. Egger's regression suggested possible bias, likely due to small study effects. CONCLUSIONS Atherosclerotic cardiovascular disease is common among HoFH patients and occurs at a young age. Age-of-onset of myocardial infarction was delayed by more than a decade from pre-1990 to post-1990, likely attributable to widespread use of statins and other therapies, reflecting substantial progress in the management of this rare but severe disorder.
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Affiliation(s)
- Adam I Kramer
- Department of Medicine, University of British Columbia, Vancouver V5Z 1M9, Canada
| | - Leo E Akioyamen
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Seohyuk Lee
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Alexandre Bélanger
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Lindsay Hales
- McGill University Health Center Medical Libraries, Montreal, QC H3G 1A4, Canada
| | - Jacques Genest
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Liam R Brunham
- Department of Medicine, University of British Columbia, Vancouver V5Z 1M9, Canada.,Centre for Heart Lung Innovation, University of British Columbia, 1081 Burrard Street - Room 166, Vancouver V6Z 1Y6, Canada
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Pu X, Sale M, Yang F, Zhang Y, Davis JD, Al-Huniti N. Population pharmacokinetics and exposure-response modeling for evinacumab in homozygous familial hypercholesterolemia. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:1412-1421. [PMID: 34585515 PMCID: PMC8592514 DOI: 10.1002/psp4.12711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/16/2021] [Accepted: 08/22/2021] [Indexed: 12/13/2022]
Abstract
Evinacumab, an angiopoietin‐like protein 3 (ANGPTL3) inhibitor, has been shown to significantly reduce low‐density lipoprotein cholesterol (LDL‐C) in patients with homozygous familial hypercholesterolemia (HoFH). This work characterized the population pharmacokinetics (PK)/pharmacodynamics (PD) of evinacumab using pooled phase III clinical data. Total evinacumab PK were described by a two‐compartment model with combined linear and saturable (Michaelis–Menten) elimination, and first‐order absorption. At clinically relevant concentrations, plasma drug concentrations were mainly influenced by the linear clearance pathway. Although the maximum target‐mediated rate of elimination (Vmax) parameter for the saturable pathway was found to be positively related to baseline ANGPLTL3, variability in body weight contributed more to the variability in evinacumab exposure than variability in ANGPTL3. An effect of HoFH versus healthy volunteers on Vmax was also identified. Weight‐based dosing regimens resulted in consistent evinacumab exposure across weight ranges. An indirect exposure–response model adequately described the relationship between evinacumab and LDL‐C, where drug concentration is assumed to inhibit LDL‐C production. The final population PK/PD model included two nonclinically significant covariates (race and baseline body weight) on the maximum drug‐induced inhibitory effect (Imax) and one (baseline LDL‐C) on the evinacumab concentration inducing 50% of Imax (IC50). A smaller IC50 was observed in patients with higher baseline LDL‐C, suggesting greater sensitivity to treatment. Population exposure–response analysis permitted estimation of derived PD parameters and individual LDL‐C levels over time for patients with HoFH. The model accurately predicted the proportion of patients with HoFH achieving prespecified LDL‐C goals with evinacumab during the ELIPSE HoFH study, further supporting a dosing strategy.
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Affiliation(s)
- Xia Pu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Mark Sale
- Nuventra, Durham, North Carolina, USA
| | - Feng Yang
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Yi Zhang
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - John D Davis
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
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Cohen H, Stefanutti C. Current Approach to the Diagnosis and Treatment of Heterozygote and Homozygous FH Children and Adolescents. Curr Atheroscler Rep 2021; 23:30. [PMID: 33963467 PMCID: PMC8105241 DOI: 10.1007/s11883-021-00926-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 02/07/2023]
Abstract
Purpose of Review To elucidate the current approach of care in pediatric patients with familial hypercholesterolemia (FH). We sought an answer to the question whether the advances and major changes in lipid management are relevant and apply to children and adolescents. Recent Findings Latest research findings clearly demonstrate that lowering cholesterol levels at a young age prevents vascular atherosclerotic changes and decreases cardiovascular events in adulthood and emphasizes the importance of early detection and intervention in the pediatric FH patients group. Summary FH is a common genetic disease caused by mutations in genes associated with the metabolism of low-density lipoproteins (LDL). The hallmark of FH is elevated LDL cholesterol (LDL-C) levels from birth and premature atherosclerotic cardiovascular disease (ASCVD). Often FH is either undiagnosed or diagnosed with a considerable delay, leading to vascular atherosclerotic changes and cardiovascular disease. Prompt identification of FH subjects is essential, to initiate early preventive measures. Safe and efficient pharmacological agents are approved for use in children and adolescents. Statins are the first line of therapy, in combination of ezetimibe. Unfortunately, these drugs do not warrant the achievement of therapeutic target, especially in HoFH patient. In the latter, lipoprotein apheresis (LA), which has been shown to be safe and effective, is strongly recommended. Finally, the new drugs still under study will allow a multimodal customized treatment. Lowering cholesterol levels at a young age hinders vascular atherosclerotic changes decreasing cardiovascular events in adulthood. Therefore, early detection, diagnosis, and intervention in FH patients are priority objectives.
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Affiliation(s)
- Hofit Cohen
- The Bert W. Strassburger Lipid Center, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Claudia Stefanutti
- Department of Molecular Medicine, Lipid Clinic and Atherosclerosis Prevention Centre, Immunohematology and Transfusion Medicine, Regional Centre for Rare Diseases, Extracorporeal Therapeutic Techniques Unit – Severe Genetic Dyslipidemias, Umberto I Hospital, ‘Sapienza’ University of Rome, Rome, Italy
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Zhang R, Xie J, Zhou J, Xu L, Pan Y, Qu Y, Li R, Chong M, Song L, Wen W, Wu Y, Li J, Wang L, Yang Y. Supravalvular Aortic Stenosis and the Risk of Premature Death Among Patients With Homozygous Familial Hypercholesterolemia. Am J Cardiol 2021; 145:58-63. [PMID: 33454344 DOI: 10.1016/j.amjcard.2020.12.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 12/13/2022]
Abstract
Patients with homozygous familial hypercholesterolemia (HoFH) have a high risk for premature death. Supravalvular aortic stenosis (SVAS) is a common and the feature lesion of the aortic root in HoFH. The relation between SVAS and the risk of premature death in patients with HoFH has not been fully investigated. The present study analysis included 97 HoFH patients with mean age of 14.7 (years) from the Genetic and Imaging of Familial Hypercholesterolemia in Han Nationality Study. During the median (±SD) follow-up 4.0 (±4.0) years, 40 (41.2%) participants had SVAS and 17 (17.5%) participants experienced death. The proportion of premature death in the non-SVAS and SVAS group was 7.0% and 32.5%, respectively. Compared with the non-SVAS group, SVAS group cumulative survival was lower in the HoFH (log-rank test, p <0.001). This result was further confirmed in the multivariable Cox regression models. After adjusting for age, sex, low density lipoprotein cholesterol (LDL_C)-year-score, lipid-lowering drugs, cardiovascular disease, and carotid artery plaque, SVAS was an independent risk factor of premature death in HoFH on the multivariate analysis (hazard ratio 4.45; 95% confidence interval, 1.10 to 18.12; p = 0.037). In conclusion, a significantly increased risk of premature death was observed in HoFH patients with SVAS. Our study emphasized the importance of careful and aggressive management in these patients when appropriate.
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Marusic T, Sustar U, Sadiq F, Kotori V, Mlinaric M, Kovac J, Shafi S, Khan I, Cevc M, Trebusak Podkrajsek K, Battelino T, Groselj U. Genetic and Clinical Characteristics of Patients With Homozygous and Compound Heterozygous Familial Hypercholesterolemia From Three Different Populations: Case Series. Front Genet 2020; 11:572176. [PMID: 33093846 PMCID: PMC7528874 DOI: 10.3389/fgene.2020.572176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/20/2020] [Indexed: 11/17/2022] Open
Abstract
Homozygous familial hypercholesterolemia (HoFH) and compound heterozygous familial hypercholesterolemia (cHeFH) are rare disorders generated by disease-causing variants in both alleles of the LDLR or other familial hypercholesterolemia (FH)-related genes. HoFH and cHeFH are characterized by severely elevated low-density lipoprotein-cholesterol (LDL-C), frequently leading to early cardiovascular disease. We investigated the genetic and clinical characteristics of HoFH and cHeFH patients from the Slovenian FH registry and/or those who were previously diagnosed or managed at our institution (Slovenian, Pakhtun and Albanian ethnicity), where genetic testing is not available. Our study includes seven patients. Their median age at the time of clinical diagnosis was 6.3 years (2.9–12.9 years); 2/7 were females. Two patients were diagnosed through the universal FH screening and five patients were diagnosed due to the presence of xanthomas. All the mutations are present in LDLR gene: 7 different genotypes for HoFH (p.Cys167Leu, p.Asp178Asn, p.Cys243Tyr, p.Gly549Asp, p.Cys27Trp, p.Ile585Thr and p.Val797Met) and p.Gly549Asp/p.Gln384Pro genotype for cHeFH patient. The median initial level of LDL-C was 17.0 mmol/L [655 mg/dL] (range 7.6–21.6 mmol/L). The HoFH/cHeFH patients are clinically and genetically very diverse. The clinical criteria (as Simon Broome criteria) might be applicable already in children to raise suspicion of FH but in some cases fail to distinguish heterozygous FH and HoFH/cHeFH patients. However, genetic testing is helpful in confirming the diagnosis, also for a prompt awareness, better compliance to treatment and family screening.
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Affiliation(s)
- Tatiana Marusic
- University Children's Hospital, University Medical Center, Ljubljana, Slovenia
| | - Ursa Sustar
- University Children's Hospital, University Medical Center, Ljubljana, Slovenia
| | - Fouzia Sadiq
- Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Vjosa Kotori
- Department of Endocrinology, Pediatric Clinic, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Matej Mlinaric
- University Children's Hospital, University Medical Center, Ljubljana, Slovenia
| | - Jernej Kovac
- University Children's Hospital, University Medical Center, Ljubljana, Slovenia
| | - Saeed Shafi
- Department of Anatomy, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Iqbal Khan
- Shifa Tameer-e-Millat University, Islamabad, Pakistan.,Department of Vascular Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Matija Cevc
- Division of Medicine, Centre for Preventive Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katarina Trebusak Podkrajsek
- University Children's Hospital, University Medical Center, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- University Children's Hospital, University Medical Center, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Urh Groselj
- University Children's Hospital, University Medical Center, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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13
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Di Taranto MD, Giacobbe C, Buonaiuto A, Calcaterra I, Palma D, Maione G, Iannuzzo G, Di Minno MND, Rubba P, Fortunato G. A Real-World Experience of Clinical, Biochemical and Genetic Assessment of Patients with Homozygous Familial Hypercholesterolemia. J Clin Med 2020; 9:jcm9010219. [PMID: 31947532 PMCID: PMC7019873 DOI: 10.3390/jcm9010219] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/30/2019] [Accepted: 01/10/2020] [Indexed: 01/09/2023] Open
Abstract
Homozygous familial hypercholesterolemia (HoFH), the severest form of familial hypercholesterolemia (FH), is characterized by very high LDL-cholesterol levels and a high frequency of coronary heart disease. The disease is caused by the presence of either a pathogenic variant at homozygous status or of two pathogenic variants at compound heterozygous status in the LDLR, APOB, PCSK9 genes. We retrospectively analyzed data of 23 HoFH patients (four children and 19 adults) identified during the genetic screening of 724 FH patients. Genetic screening was performed by sequencing FH causative genes and identifying large rearrangements of LDLR. Among the HoFH patients, four out of 23 (17.4%) were true homozygotes, whereas 19 out of 23 (82.6%) were compound heterozygotes for variants in the LDLR gene. Basal LDL-cholesterol was 12.9 ± 2.9 mmol/L. LDL-cholesterol levels decreased to 7.2 ± 1.8 mmol/L when treated with statin/ezetimibe and to 5.1 ± 3.1 mmol/L with anti-PCSK9 antibodies. Homozygous patients showed higher basal LDL-cholesterol and a poorer response to therapy compared with compound heterozygotes. Since 19 unrelated patients were identified in the Campania region (6,000,000 inhabitants) in southern Italy, the regional prevalence of HoFH was estimated to be at least 1:320,000. In conclusion, our results revealed a worse phenotype for homozygotes compared with compound heterozygotes, thereby highlighting the role of genetic screening in differentiating one genetic status from the other.
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Affiliation(s)
- Maria Donata Di Taranto
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (C.G.); (D.P.); (G.M.)
- CEINGE S.C.a r.l. Biotecnologie Avanzate, 80131 Naples, Italy
- Correspondence: (M.D.D.T.); (G.F.); Tel.: +39-081-7463530 (M.D.D.T.); +39-081-7464200 (G.F.)
| | - Carola Giacobbe
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (C.G.); (D.P.); (G.M.)
- CEINGE S.C.a r.l. Biotecnologie Avanzate, 80131 Naples, Italy
| | - Alessio Buonaiuto
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (A.B.); (I.C.); (G.I.); (P.R.)
| | - Ilenia Calcaterra
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (A.B.); (I.C.); (G.I.); (P.R.)
| | - Daniela Palma
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (C.G.); (D.P.); (G.M.)
- CEINGE S.C.a r.l. Biotecnologie Avanzate, 80131 Naples, Italy
| | - Giovanna Maione
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (C.G.); (D.P.); (G.M.)
- CEINGE S.C.a r.l. Biotecnologie Avanzate, 80131 Naples, Italy
| | - Gabriella Iannuzzo
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (A.B.); (I.C.); (G.I.); (P.R.)
| | - Matteo Nicola Dario Di Minno
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, 80131 Naples, Italy;
| | - Paolo Rubba
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (A.B.); (I.C.); (G.I.); (P.R.)
| | - Giuliana Fortunato
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (C.G.); (D.P.); (G.M.)
- CEINGE S.C.a r.l. Biotecnologie Avanzate, 80131 Naples, Italy
- Correspondence: (M.D.D.T.); (G.F.); Tel.: +39-081-7463530 (M.D.D.T.); +39-081-7464200 (G.F.)
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14
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Kuang H, Zhou X, Li L, Yi Q, Shou W, Lu T. Early severe coronary heart disease and ischemic heart failure in homozygous familial hypercholesterolemia: A case report. Medicine (Baltimore) 2018; 97:e12869. [PMID: 30335000 PMCID: PMC6211926 DOI: 10.1097/md.0000000000012869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Familial hypercholesterolemia (FH) is a common inherited cause of coronary heart disease (CHD) and premature death in an early age. Nevertheless, an ischemic heart failure (IHF) associated with FH seems to be rare, and an early diagnosis and therapy could influence the prognosis. PATIENT CONCERNS In this 13-year-old girl, multiple xanthomas began to develop from the first day of birth. Until June, 2017, she was admitted to our center due to edema, oliguria, and dyspnea during exertion, which was attributed to a recent respiratory infection. DIAGNOSIS Homozygous FH (HoFH), CHD, and IHF. INTERVENTIONS The patient has been treated with statin, ezetimibe, aspirin, and traditional heart failure (HF) medications. In addition, the beta-blocker was simultaneously administered. OUTCOMES Genotypes of this proband indicated homozygous mutations of low-density lipoprotein receptor (LDLR) and some co-segregated mutations, such as von Willebrand factor (VWF) and fibroblast growth factor receptors. At 6-month follow-up, we found a decreased level of plasma lipid profile, in addition to a significant improvement in 6-minute walk distance and functional class. Echocardiography indicated nonsignificant improvements in the structure and function of the heart. LESSONS This case report indicates that HoFH can lead to dramatically progressive endothelial damages and ventricular remodeling, severe atherosclerosis, even IHF. Genetic outcomes indicate IHF with HoFH could possibly result from LDLR mutations and some co-segregated mutations influencing endothelial function and cardiovascular remodeling. In a short-term follow-up, a combination of statins, ezetimibe, aspirin, and traditional HF agents is safe and effective for IHF with HoFH, and there is a need for further identification of drugs to ameliorate endothelial function and cardiovascular remodeling which may play an important role in long-term treatment.
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Affiliation(s)
- Hongyu Kuang
- Department of Cardiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing
| | - Xue Zhou
- Department of Cardiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing
| | - Li Li
- Department of Cardiology, West China Affiliated Second University Hospital, Sichuan, China
| | - Qijian Yi
- Department of Cardiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing
| | - Weinian Shou
- Riley Heart Center, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN
| | - Tiewei Lu
- Department of Cardiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing
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15
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Su X, Peng DQ. New insights into ANGPLT3 in controlling lipoprotein metabolism and risk of cardiovascular diseases. Lipids Health Dis 2018; 17:12. [PMID: 29334984 PMCID: PMC5769531 DOI: 10.1186/s12944-018-0659-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/05/2018] [Indexed: 02/07/2023] Open
Abstract
Dyslipidemia, characterized by elevation of plasma low density lipoprotein cholesterol (LDL-C), triglyceride (TG) and reduction of plasma high density lipoprotein cholesterol (HDL-C), has been verified as a causal risk factor for cardiovascular diseases (CVD), leading to a high mortality rate in general population. It is important to understand the molecular metabolism underlying dyslipidemia in order to reduce the risk and to develop effective therapeutic approaches against CVD. ANGPTL3 (human) or Angptl3 (mouse), one member of the angiopoietin-like protein (ANGPTL) family, has been identified as an important regulator of lipid metabolism by inhibiting LPL and EL activity. Results have demonstrated that inactivation of Angptl3 in mice could obviously reduce the level of TG, LDL-C and the atherosclerotic lesion size, leading to a lower risk for dyslipidemia and CVD. Additionally, in humans, carriers with homozygous LOF mutations in ANGPTL3 have lower plasma LDL-C, TG levels and lower risk of atherosclerosis compared to the non-carriers. Here, we collect the latest data and results, giving a new insight into the important role of ANGPTL3 in controlling lipoprotein metabolism. Finally, we introduce two update reports on the antisense oligonucleotide and monoclonal antibody-based inactivation of ANGPTL3 in human clinical trials, to identify that ANGPTL3 could be a novel and effective target for the treatment of dyslipidemia and CVD.
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Affiliation(s)
- Xin Su
- Department of Cardiovascular Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China
| | - Dao-Quan Peng
- Department of Cardiovascular Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
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16
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Janus ED. Homozygous familial hypercholesterolaemia - Early recognition and early treatment improve outcomes. Atherosclerosis 2017; 260:147-149. [PMID: 28341574 DOI: 10.1016/j.atherosclerosis.2017.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 02/10/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Edward D Janus
- General Internal Medicine Unit, Western Health and Department of Medicine Melbourne Medical School - Western Precinct, University of Melbourne, Sunshine Hospital, St Albans, VIC 3021, Australia.
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