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Trinder M, Cermakova L, Ruel I, Baass A, Paquette M, Wang J, Kennedy BA, Hegele RA, Genest J, Brunham LR. Influence of Polygenic Background on the Clinical Presentation of Familial Hypercholesterolemia. Arterioscler Thromb Vasc Biol 2024; 44:1683-1693. [PMID: 38779854 PMCID: PMC11208056 DOI: 10.1161/atvbaha.123.320287] [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: 10/17/2023] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Heterozygous familial hypercholesterolemia (FH) is among the most common genetic conditions worldwide that affects ≈ 1 in 300 individuals. FH is characterized by increased levels of low-density lipoprotein cholesterol (LDL-C) and increased risk of coronary artery disease (CAD), but there is a wide spectrum of severity within the FH population. This variability in expression is incompletely explained by known risk factors. We hypothesized that genome-wide genetic influences, as represented by polygenic risk scores (PRSs) for cardiometabolic traits, would influence the phenotypic severity of FH. METHODS We studied individuals with clinically diagnosed FH (n=1123) from the FH Canada National Registry, as well as individuals with genetically identified FH from the UK Biobank (n=723). For all individuals, we used genome-wide gene array data to calculate PRSs for CAD, LDL-C, lipoprotein(a), and other cardiometabolic traits. We compared the distribution of PRSs in individuals with clinically diagnosed FH, genetically diagnosed FH, and non-FH controls and examined the association of the PRSs with the risk of atherosclerotic cardiovascular disease. RESULTS Individuals with clinically diagnosed FH had higher levels of LDL-C, and the incidence of atherosclerotic cardiovascular disease was higher in individuals with clinically diagnosed compared with genetically identified FH. Individuals with clinically diagnosed FH displayed enrichment for higher PRSs for CAD, LDL-C, and lipoprotein(a) but not for other cardiometabolic risk factors. The CAD PRS was associated with a risk of atherosclerotic cardiovascular disease among individuals with an FH-causing genetic variant. CONCLUSIONS Genetic background, as expressed by genome-wide PRSs for CAD, LDL-C, and lipoprotein(a), influences the phenotypic severity of FH, expanding our understanding of the determinants that contribute to the variable expressivity of FH. A PRS for CAD may aid in risk prediction among individuals with FH.
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Affiliation(s)
- Mark Trinder
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, Canada (M.T., L.C., L.R.B.)
| | - Lubomira Cermakova
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, Canada (M.T., L.C., L.R.B.)
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre, Montreal, Canada (I.R., J.G.)
| | - Alexis Baass
- Montreal Clinical Research Institute, Canada (A.B., M.P.)
| | | | - Jian Wang
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Canada (J.W., B.A.K., R.A.H.)
| | - Brooke A. Kennedy
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Canada (J.W., B.A.K., R.A.H.)
| | - Robert A. Hegele
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Canada (J.W., B.A.K., R.A.H.)
| | - Jacques Genest
- Research Institute of the McGill University Health Centre, Montreal, Canada (I.R., J.G.)
| | - Liam R. Brunham
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, Canada (M.T., L.C., L.R.B.)
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, Canada (L.R.B.)
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Al-Baldawi Z, Brown L, Ruel I, Baass A, Bergeron J, Cermakova L, Couture P, Gaudet D, Francis GA, Hegele RA, Iatan I, Mancini GBJ, McCrindle BW, Ransom T, Sherman MH, McPherson R, Genest J, Brunham LR. Sex differences in the presentation, treatment and outcomes of patients with homozygous familial hypercholesterolemia. J Clin Lipidol 2024; 18:e189-e196. [PMID: 38281851 DOI: 10.1016/j.jacl.2024.01.003] [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: 11/17/2023] [Revised: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Homozygous familial hypercholesterolemia (HoFH) is a rare, autosomal semi-dominant lipid metabolism disorder characterized by extremely high low-density lipoprotein cholesterol (LDL-C) levels and premature cardiovascular disease. The objective of this study was to investigate sex-differences in the treatment and outcomes of patients with HoFH. METHODS We examined clinical characteristics, lipid-lowering therapy (LLT), and cardiovascular events using descriptive statistics of patients in the Canadian HoFH registry. Major adverse cardiovascular events (MACE) were defined as the composite of cardiovascular death, non-fatal myocardial infarction, and stroke. Sex differences between continuous and categorical variables were analyzed using Mann-Whitney U test and Fisher's Exact test, respectively. RESULTS This study included 48 patients (27 (56%) female). The median age at diagnosis in females was 14.0 (interquartile range (IQR) 9.0-30.0) and in males was 8.0 (IQR 2.0-23.0) (p = 0.07). Baseline clinical characteristics were comparable between both sexes. The median baseline LDL-C was 12.7 mmol/L (10.0-18.3) in females and 15.3 (10.5-20.0) in males (p = 0.51). Follow up LDL-C levels were 7.6 mmol/L (IQR 4.8-11.0) in females and 6.3 (IQR 4.6-7.5) in males (p = 0.1). Most patients were taking 3 or more LLTs, with comparable proportions in both sexes (p = 0.26). Apheresis was similar in both sexes, 14 (51.8%) vs. 10 (47.6%) (p = 0.2). Over a mean of 10 years of follow-up, MACE occurred in 3 females (11.1%) and 4 males (19.1%) (p = 0.2). CONCLUSION Lipid levels and treatment were similar between sexes. MACE occurred in similar proportions between sexes, indicating that HoFH offsets the inherently lower cardiovascular risk in pre-menopausal females. Further investigation into sex-differences in HoFH in larger sample sizes is warranted.
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Affiliation(s)
- Zobaida Al-Baldawi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada (Dr Al-Baldawi)
| | - Leslie Brown
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada (Drs Brown, Ruel, Baass, Sherman, Genest)
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada (Drs Brown, Ruel, Baass, Sherman, Genest)
| | - Alexis Baass
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada (Drs Brown, Ruel, Baass, Sherman, Genest)
| | - Jean Bergeron
- Endocrinology and Nephrology Unit, CHU de Québec - Université Laval Research Center, Québec City, QC, Canada (Drs Bergeron, Couture)
| | - Lubomira Cermakova
- Centre for Heart Lung Innovation, Providence Health Care Research, Institute, Department of Medicine, University of British Columbia, Vancouver, BC, Canada (Drs Cermakova, Francis, Iatan, Brunham)
| | - Patrick Couture
- Endocrinology and Nephrology Unit, CHU de Québec - Université Laval Research Center, Québec City, QC, Canada (Drs Bergeron, Couture)
| | - Daniel Gaudet
- ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, QC, Canada (Dr Gaudet)
| | - Gordon A Francis
- Centre for Heart Lung Innovation, Providence Health Care Research, Institute, Department of Medicine, University of British Columbia, Vancouver, BC, Canada (Drs Cermakova, Francis, Iatan, Brunham)
| | - Robert A Hegele
- Departments of Medicine and Biochemistry, Schulich School of, Medicine and Robarts Research Institute, Western University, London, ON, Canada (Dr Hegele)
| | - Iulia Iatan
- Centre for Heart Lung Innovation, Providence Health Care Research, Institute, Department of Medicine, University of British Columbia, Vancouver, BC, Canada (Drs Cermakova, Francis, Iatan, Brunham)
| | - G B John Mancini
- Centre for, Cardiovascular Innovation, University of British Columbia, Vancouver, BC, Canada (Dr Mancini)
| | - Brian W McCrindle
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada (Dr McCrindle)
| | - Thomas Ransom
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada (Dr Ransom)
| | - Mark H Sherman
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada (Drs Brown, Ruel, Baass, Sherman, Genest); Department of Endocrinology, McGill University, Health Centre, Montreal, QC, Canada (Dr Sherman)
| | - Ruth McPherson
- Lipid Clinic & Atherogenomics Laboratory, University, of Ottawa Heart Institute, Ottawa, ON, Canada (Dr McPherson)
| | - Jacques Genest
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada (Drs Brown, Ruel, Baass, Sherman, Genest)
| | - Liam R Brunham
- Centre for Heart Lung Innovation, Providence Health Care Research, Institute, Department of Medicine, University of British Columbia, Vancouver, BC, Canada (Drs Cermakova, Francis, Iatan, Brunham)
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Alshibani B, Iatan I, Guerin A, Ruel I, Cermakova L, Ramanakumar AV, Pilote L, Coutinho T, Brunham LR, Genest J. Sex differences in the perception of cardiovascular risk in familial hypercholesterolemia. J Clin Lipidol 2024; 18:e97-e104. [PMID: 37926591 DOI: 10.1016/j.jacl.2023.10.007] [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: 06/19/2023] [Revised: 09/18/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Familial hypercholesterolemia (FH), a common genetic condition, is characterized by elevated low-density lipoprotein cholesterol (LDL-C) and premature atherosclerotic cardiovascular disease (ASCVD). Recent data indicate an undertreatment of females with FH. OBJECTIVE To characterize the role of sex in the perception of FH, its associated ASCVD risk and treatment. METHODS A survey investigating for sex differences in the perception of FH was sent to 1073 patients with FH using a cross sectional study design. RESULTS A total of 412 patients (51.9 % male) responded to the survey; mean age was 56.2 ± 14.4 years. There was a higher proportion of males with ASCVD than females (41.5 % vs. 16.5 %, respectively, p<0.001). Analyses of the survey responses showed that a majority of both males and females agreed that their risk of ASCVD is higher than healthy individuals of same age (70.8 % vs. 74.7 %, respectively, p = 0.434). Females were more concerned about having high LDL-C levels (67.5 % vs. 56.5 % in males, p = 0.024), especially those in secondary prevention programs. As for treatment of FH, approximately 75 % of both sex groups considered statins to be efficient in reducing the risk of myocardial infarction, but less than half of the females considered statins to be safe (44.8 % vs. 60.0 % in males, p = 0.003). No major sex differences were noted regarding the influence of the doctor in their understanding of FH as a disease. CONCLUSION Overall, both males and females with FH were well informed about FH, although females were more concerned about having high LDL-C levels and they feared the safety of statins.
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Affiliation(s)
- Balaqis Alshibani
- Research Institute of the McGill University Health Centre (Drs Alshibani; Guerin; Ruel; Ramanakumar; Pilote; Genest), Montreal, QC, Canada
| | - Iulia Iatan
- Centre for Heart Lung Innovation (Drs Iatan; Cermakova; Brunham), Providence Health Care Research Institute, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Amanda Guerin
- Research Institute of the McGill University Health Centre (Drs Alshibani; Guerin; Ruel; Ramanakumar; Pilote; Genest), Montreal, QC, Canada
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre (Drs Alshibani; Guerin; Ruel; Ramanakumar; Pilote; Genest), Montreal, QC, Canada
| | - Lubomira Cermakova
- Centre for Heart Lung Innovation (Drs Iatan; Cermakova; Brunham), Providence Health Care Research Institute, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Agnihotram V Ramanakumar
- Research Institute of the McGill University Health Centre (Drs Alshibani; Guerin; Ruel; Ramanakumar; Pilote; Genest), Montreal, QC, Canada
| | - Louise Pilote
- Research Institute of the McGill University Health Centre (Drs Alshibani; Guerin; Ruel; Ramanakumar; Pilote; Genest), Montreal, QC, Canada
| | - Thais Coutinho
- Canadian Women's Heart Health Centre (Dr Coutinho), University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Liam R Brunham
- Centre for Heart Lung Innovation (Drs Iatan; Cermakova; Brunham), Providence Health Care Research Institute, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jacques Genest
- Research Institute of the McGill University Health Centre (Drs Alshibani; Guerin; Ruel; Ramanakumar; Pilote; Genest), Montreal, QC, Canada.
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Guerin A, Iatan I, Ruel I, Ngufor LF, Genest J. Genetic testing for familial hypercholesterolemia in Quebec, Canada: a single-centre retrospective cohort study. CMAJ Open 2023; 11:E754-E764. [PMID: 37607748 PMCID: PMC10449021 DOI: 10.9778/cmajo.20220108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is associated with premature atherosclerotic cardiovascular disease caused by elevated low-density lipoprotein cholesterol (LDL-C) levels. We determined the impact of a full next-generation sequencing (NGS) genetic panel on reclassification of patients with a clinical diagnosis of FH in Quebec compared to the partial genetic panel currently offered by the Quebec Ministère de la Santé et des Services sociaux (Ministry of Health and Social Services) (MSSS), which includes 11 variants that are common in French Canadians. METHODS We conducted a retrospective cohort study in a subgroup of patients in the Canadian FH Registry seen at the McGill University Health Centre Preventive Cardiology/Lipid Clinic, Montréal, between September 2017 and September 2021 who were clinically diagnosed with severe hypercholesterolemia, probable FH or definite FH according to the Canadian definition of FH. Next-generation sequencing of the LDLR, APOB and PCSK9 genes, and multiplex ligation-dependent probe amplification of the LDLR gene to detect genetic variants, were performed. RESULTS Among 335 consecutive patients with heterozygous FH (184 men [54.9%] and 151 women [45.1%]), the baseline LDL-C level was 6.96 (standard deviation 1.79) mmol/L. Patients identified through cascade screening were 11 years younger on average than index patients, and smaller proportions presented to the clinic with cardiovascular risk factors. A pathogenic FH variant was identified in 169 (73.8%) of the 229 patients who underwent genetic testing; the majority had variants in the LDLR (146 [86.4%]) or APOB (24 [14.2%]) gene. The genetic panel offered by the MSSS accounted for only 48% of the variants identified with the full NGS panel. Of the 229 patients, 90 (39.3%, 95% confidence interval 32.9%-46.0%) were reclassified from a clinical diagnosis of probable FH to definite FH after genetic screening with a full FH panel. INTERPRETATION Genetic testing in patients suspected of having FH provided diagnostic certainty and permitted many patients with a clinical diagnosis of probable FH to be reclassified as having definite FH. Genetic screening allows for increased identification of patients with FH and may therefore help reduce the burden of cardiovascular disease and mortality rates among Canadians with FH. Trial registration: ClinicalTrials.gov, no. NCT02009345.
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Affiliation(s)
- Amanda Guerin
- Research Institute of the McGill University Health Centre (Guerin, Ruel, Fri Ngufor, Genest), Montréal, Que.; Centre for Heart Lung Innovation (Iatan), Healthy Heart Program Prevention Clinic, St. Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver, BC
| | - Iulia Iatan
- Research Institute of the McGill University Health Centre (Guerin, Ruel, Fri Ngufor, Genest), Montréal, Que.; Centre for Heart Lung Innovation (Iatan), Healthy Heart Program Prevention Clinic, St. Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver, BC
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre (Guerin, Ruel, Fri Ngufor, Genest), Montréal, Que.; Centre for Heart Lung Innovation (Iatan), Healthy Heart Program Prevention Clinic, St. Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver, BC
| | - Linda Fri Ngufor
- Research Institute of the McGill University Health Centre (Guerin, Ruel, Fri Ngufor, Genest), Montréal, Que.; Centre for Heart Lung Innovation (Iatan), Healthy Heart Program Prevention Clinic, St. Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver, BC
| | - Jacques Genest
- Research Institute of the McGill University Health Centre (Guerin, Ruel, Fri Ngufor, Genest), Montréal, Que.; Centre for Heart Lung Innovation (Iatan), Healthy Heart Program Prevention Clinic, St. Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver, BC
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5
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Brown L, Ruel I, Baass A, Bergeron J, Brunham LR, Cermakova L, Couture P, Gaudet D, Francis GA, Hegele RA, Iatan I, Mancini GJ, McCrindle BW, Ransom T, Sherman MH, McPherson R, Genest J. Homozygous Familial Hypercholesterolemia in Canada: An Observational Study. JACC. ADVANCES 2023; 2:100309. [PMID: 38939573 PMCID: PMC11198203 DOI: 10.1016/j.jacadv.2023.100309] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 06/29/2024]
Abstract
Background Homozygous familial hypercholesterolemia (HoFH) is a rare genetic disease characterized by very high levels of low-density lipoprotein cholesterol (LDL-C). Untreated patients present with extensive xanthomas and premature atherosclerosis. Lipid-lowering therapy is highly efficacious and has dramatically increased life expectancy of patients with HoFH. Objectives The aim of the study was to obtain a comprehensive registry of HoFH in Canada, known to have several founder effect regions, and describe the clinical characteristics and cardiovascular outcomes of this population over time. Methods Clinical and genetic data on patients with HoFH were collected via a standardized questionnaire sent to academic sites participating in the Familial Hypercholesterolemia Canada network. Results A total of 48 patients with HoFH were enrolled. The median age at diagnosis was 12 years (interquartile range [IQR]: 5-24) and untreated LDL-C levels were 15.0 mmol/L (IQR: 10.5-18.6 mmol/L; 580 mg/dL IQR: 404-717 mg/dL). At last follow-up visit, median age was 40 years (IQR: 26-54 years). Treated LDL-C levels were 6.75 mmol/L (IQR: 4.73-9.51 mmol/L; 261 mg/dL IQR: 183-368 mg/dL) with 95.5% of patients on statins, 88.6% on ezetimibe, 34.1% on proprotein convertase subtilisin/kexin type 9 inhibitors, 27.3% on lomitapide, 13.6% on evinacumab, and 56.8% were treated with low-density lipoprotein apheresis or plasmapheresis. Deaths were reported in 7 (14.5%) and major adverse cardiovascular events were observed in 14.6% of patients with the average onset at 30 years (IQR: 20-36 years). Aortic stenosis was reported in one-half the patients (47.9%) and 10 (20.8%) underwent aortic valve replacement. Conclusions This HoFH patient registry in Canada will provide important new health-related knowledge about the phenotypic manifestations and determinants of cardiovascular risk in this population, allowing for closer examination of quality of life and burden to the health care system.
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Affiliation(s)
- Leslie Brown
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Isabelle Ruel
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Alexis Baass
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Jean Bergeron
- Endocrinology and Nephrology Unit, CHU de Québec - Université Laval Research Center, Québec City, Québec, Canada
| | - Liam R. Brunham
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lubomira Cermakova
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Couture
- Endocrinology and Nephrology Unit, CHU de Québec - Université Laval Research Center, Québec City, Québec, Canada
| | - Daniel Gaudet
- Lipidology Unit, Department of Medicine, Community Genomic Medicine Center, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Québec, Canada
| | - Gordon A. Francis
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert A. Hegele
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Ontario, Canada
| | - Iulia Iatan
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - G.B. John Mancini
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian W. McCrindle
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Ransom
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mark H. Sherman
- Department of Endocrinology, McGill University Health Centre, Montreal, Québec, Canada
| | - Ruth McPherson
- Lipid Clinic & Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jacques Genest
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
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Sarkies M, Jones LK, Pang J, Sullivan D, Watts GF. How Can Implementation Science Improve the Care of Familial Hypercholesterolaemia? Curr Atheroscler Rep 2023; 25:133-143. [PMID: 36806760 PMCID: PMC10027803 DOI: 10.1007/s11883-023-01090-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE OF REVIEW Describe the application of implementation science to improve the detection and management of familial hypercholesterolaemia. RECENT FINDINGS Gaps between evidence and practice, such as underutilization of genetic testing, family cascade testing, failure to achieve LDL-cholesterol goals and low levels of knowledge and awareness, have been identified through clinical registry analyses and clinician surveys. Implementation science theories, models and frameworks have been applied to assess barriers and enablers in the literature specific to local contextual factors (e.g. stages of life). The effect of implementation strategies to overcome these factors has been evaluated; for example, automated identification of individuals with FH or training and education to improve statin adherence. Clinical registries were identified as a key infrastructure to monitor, evaluate and sustain improvements in care. The expansion in evidence supporting the care of familial hypercholesterolaemia requires a similar expansion of efforts to translate new knowledge into clinical practice.
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Affiliation(s)
- Mitchell Sarkies
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia.
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
| | - Laney K Jones
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, USA
- Heart and Vascular Institute, Geisinger, Danville, PA, USA
| | - Jing Pang
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - David Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, WA, Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
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Cost-Effectiveness of Pediatric Universal Screening for Familial Hypercholesterolemia in Argentina. Value Health Reg Issues 2023; 33:33-41. [PMID: 36209514 DOI: 10.1016/j.vhri.2022.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 08/09/2022] [Accepted: 08/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Our study aimed to evaluate the expected cost-effectiveness of pediatric universal screening for the early diagnosis of familial hypercholesterolemia in Argentina using a probabilistic model. METHODS Two different healthcare technologies were compared: (1) Universal screening of hypercholesterolemia at 6 years of age and (2) previous diagnostic situation (comparator). The perspective of the public Argentine healthcare system funded by the National Ministry of Health was used, considering only direct costs. Effectiveness was evaluated in terms of the number of life-years gained (LYG) and quality-adjusted life-years (QALYs) obtained by identifying familial hypercholesterolemia through each of the screening strategies. Only direct costs of screening and treatment of each strategy were evaluated. The time horizon was extended to 60 years. Future avoided costs of prevented coronary events were also included. Cost-effectiveness was measured in terms of the incremental cost-effectiveness ratio (ICER) per LYG and QALYs. Different scenarios were evaluated: (1) only index case, (2) index case and first-degree relatives, and (3) index case and first-degree relatives measuring QALYs. Sensitivity studies were conducted. RESULTS Each identified child complying with follow-up visits and treatment gains 8.14 life-years. The ICER values obtained were 1465.35 USD/LYG and 1726.50 USD/LYG when applying a discount rate of 5%. The ICER was 10%-17% of the gross domestic product per capita in Argentina (mean 2010-2019: 12 446 USD) and did not exceed the minimum annual retirement income. CONCLUSION Pediatric universal screening for familial hypercholesterolemia could be considered a cost-effective health technology in Argentina.
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Abstract
PURPOSE OF REVIEW Lipid registry-based research is a valuable tool for assessing current lipid management in patients at risk of cardiovascular disease (CVD). Results of several registries are useful for improving clinical practice highlight gaps between guidelines and their implementation and potential impact on population health. We summarize recent clinical studies based on lipid registries. RECENT FINDINGS Current guidelines for lipid management recommend high-intensity statins and concomitant therapies such as ezetimibe and proprotein convertase subtilisin-kexin type 9 inhibitors for high-risk patients. However, recent observational studies show that the majority of patients received inadequate lipid-lowering therapy (LLT), and the low-density lipoprotein-cholesterol (LDL-C) goal attainment rates are still unsatisfactory. SUMMARY There is a clear gap between lipid guidelines and lipid management in clinical practice. Clinical studies based on registry databases represent real-world conditions, as opposed to clinical trials. Contemporary registry data reveal that only half of the patients received high-intensity statins, and less than half achieve the LDL-C <70 mg/dL in secondary prevention. In addition, the major reasons for insufficient therapy have been shown to be not only side effects of LLT, but poor adherence by patients to medication regimens and low use of combination therapies by physicians. The real-world evidence from lipid registries clarifies gaps, areas for focus for implementation, to improve CVD prevention.
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Affiliation(s)
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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9
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Influence of the LDL-receptor genotype on statin response in heterozygous familial hypercholesterolemia: insights from the Canadian FH Registry. Can J Cardiol 2021; 38:311-319. [PMID: 34774719 DOI: 10.1016/j.cjca.2021.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/28/2021] [Accepted: 10/31/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Whether LDL receptor (LDLR) residual activity influences the LDL-lowering effect of statins in heterozygous familial hypercholesterolemia (HeFH) remains unclear. The objective of this study was to investigate the relationship between the LDLR genotype and statin-induced LDL-C reductions in HeFH. METHODS A total of 615 individuals with HeFH (receptor defective (RD) genotype, n=226; receptor negative (RN) genotype, n=389) from 7 lipid clinics across Canada who initiated statin monotherapy were included in this retrospective longitudinal study. Statin-induced reductions in LDL-C among individuals with RD and RN genotypes were compared using linear models. RESULTS There were 334 women and 281 men with a mean untreated LDL-C concentrations of 6.97 ± 1.65 mmol/L. Untreated and on-statin LDL-C levels where higher among patients with a RN genotype [Untreated: RN: 7.24 (95% CI: 6.98, 7.50) mmol/L vs. RD: 6.70 (95% CI: 6.41, 6.98) mmol/L; P=0.0002; on-statin: RN: 4.50 (95% CI: 4.31, 4.70) vs. RD: 4.05 (95% CI: 3.84, 4.26) mmol/L; P=0.0004)]. After adjustments for age, sex, smoking status, untreated LDL-C concentrations and statin type and dose as well as the clinic where the patients were treated, the LDL-C lowering effect of statins was significantly weaker for individuals with a RN mutation compared with individuals with a RD mutation [RN: -31.1% (95% CI: (-34.7, -27.4) vs. RD: -36.5% (95% CI: -40.4, -32.6); P<0.0001]. The LDLR genotype was the strongest non-modifiable independent correlate of statin-induced LDL-C reductions (R2=2.3%; P=0.0001). CONCLUSION The LDLR genotype is significantly associated with statin-induced reductions in LDL-C concentrations in HeFH.
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10
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Familial Hypercholesterolemia (FH) Registry Worldwide: A Systematic Review. Curr Probl Cardiol 2021; 47:100999. [PMID: 34571102 DOI: 10.1016/j.cpcardiol.2021.100999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 12/29/2022]
Abstract
Familial hypercholesterolemia (FH) is the most common genetic disease which accelerates the development of premature coronary artery disease (CAD) in young adults if remains untreated. The overall prevalence of FH is currently unknown and is usually underdiagnosed and undertreated worldwide. FH registry in different geographical area is a mission that helps early diagnosis of FH patients in the general population. PubMed, ISI Web of Science, Scopus, and Google Scholar were searched systematically for studies and reports on the FH registry using related keywords. Finally, 27 studies were included in this review. Most of the studies used the CASCADE screening method based on 1 or more than 1 of the 3 well-established FH criteria namely, the Dutch Lipid Clinic Network, Simon Broome Register, or Make Early Diagnosis to Prevent Early Death criteria. Except for a small number of studies that the genetic and molecular methods were used, in other studies only clinical diagnosis was applied. All these studies claimed that the FH registry causes the identification of many new cases as a result of used CASCADE screening and referral to lipid clinics. They concluded that the FH registry increases general and also physician awareness on FH prevalence and its related complications which in the long-term will improve FH management. This indicates that in other parts of the world, the FH registry should be established as well so that more accurate statistics on the prevalence of this disease can be found worldwide which would help in diagnosis and prevention.
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11
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Kim H, Lee CJ, Kim SH, Kim JY, Choi SH, Kang HJ, Park KS, Cho BR, Kim BJ, Sung KC, Jeong IK, Jeong JO, Bae JW, Park JM, Lee Y, Jeong I, Han H, Lee JH, Lee SH. Phenotypic and Genetic Analyses of Korean Patients with Familial Hypercholesterolemia: Results from the KFH Registry 2020. J Atheroscler Thromb 2021; 29:1176-1187. [PMID: 34456200 PMCID: PMC9371750 DOI: 10.5551/jat.63062] [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] [Indexed: 12/03/2022] Open
Abstract
Aims: Familial hypercholesterolemia (FH) is currently a worldwide health issue. Understanding the characteristics of patients is important for proper diagnosis and treatment. This study aimed to analyze the phenotypic and genetic features, including threshold cholesterol levels, of Korean patients with FH.
Methods: A total of 296 patients enrolled in the Korean FH registry were included, according to the following criteria: low-density lipoprotein-cholesterol (LDL-C) >190 mg/dL with tendon xanthoma or family history compatible with FH, or LDL-C >225 mg/dL. DNA sequences of three FH-associated genes were obtained using whole-exome or target exome sequencing. Threshold cholesterol levels for differentiating patients with FH/pathogenic variant (PV) carriers and predictors of PVs were identified.
Results: Of the 296 patients, 104 had PVs and showed more obvious clinical findings, including higher cholesterol levels. PV rates ranged from 30% to 64% when patients were categorized by possible or definite type according to the Simon Broome criteria. Frequent PV types included missense variants and copy number variations (CNVs), while the most frequent location of PVs was p.P685L inLDLR. The threshold LDL-C levels for patient differentiation and PV prediction were 177 and 225 mg/dL, respectively. Younger age, tendon xanthoma, and higher LDL-C levels were identified as independent predictors of PVs, while traditional cardiovascular risk factors were predictors of coronary artery disease.
Conclusions: Korean patients with FH had variable PV rates depending on diagnostic criteria and distinctive PV locations. The reported threshold LDL-C levels pave the way for efficient patient care in this population.
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Affiliation(s)
- Hyoeun Kim
- Department of Health Promotion, Yonsei University Health System
| | - Chan Joo Lee
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine
| | - Sang-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine
| | - Jang Young Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine
| | - Sung Hee Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Hyun-Jae Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Kyong Soo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Byung Ryul Cho
- Cardiology Division, Department of Internal Medicine, Kangwon National University, School of Medicine
| | - Byung Jin Kim
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Ki Chul Sung
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - In-Kyung Jeong
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine
| | - Jin-Ok Jeong
- Department of Internal Medicine, Cardiovascular Center, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University College of Medicine
| | - Jung Mi Park
- Department of Biostatistics and Computing, Yonsei University Graduate School
| | | | | | | | - Ji Hyun Lee
- Department of Clinical Pharmacology and Therapeutics, Kyung Hee University School of Medicine
| | - Sang-Hak Lee
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine
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12
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Mehta R, Martagon AJ, Galan Ramirez GA, Antonio-Villa NE, Vargas-Vázquez A, Elias-Lopez D, Gonzalez-Retana G, Rodríguez-Encinas B, Ceballos-Macías JJ, Romero-Zazueta A, Martinez-Alvarado R, Morales-Portano JD, Alvarez-Lopez H, Sauque-Reyna L, Gomez-Herrera LG, Simental-Mendia LE, Garcia-Aguilar H, Ramirez-Cooremans E, Peña-Aparicio B, Mendoza-Zubieta V, Carrillo-Gonzalez PA, Ferreira-Hermosillo A, Caracas-Portilla N, Jimenez-Dominguez G, Ruiz-Garcia AY, Arriaga-Cazares HE, Gonzalez-Gonzalez JR, Mendez-Valencia CV, Padilla FG, Madriz-Prado R, De Los Rios-Ibarra MO, Vazquez-Cardenas A, Arjona-Villicaña RD, Acevedo-Rivera KJ, Allende-Carrera R, Alvarez JA, Amezcua-Martinez JC, de Los Reyes Barrera-Bustillo M, Carazo-Vargas G, Contreras-Chacon R, Figueroa-Andrade MH, Flores-Ortega A, Garcia-Alcala H, Garcia de Leon LE, Garcia-Guzman B, Garduño-Garcia JJ, Garnica-Cuellar JC, Gomez-Cruz JR, Hernandez-Garcia A, Holguin-Almada JR, Juarez-Herrera U, Lugo-Sobrevilla F, Marquez-Rodriguez E, Martinez-Sibaja C, Medrano-Rodriguez AB, Morales-Oyervides JC, Perez-Vazquez DI, Reyes-Rodriguez EA, Robles-Osorio ML, Rosas-Saucedo J, Torres-Tamayo M, Valdez-Talavera LA, Vera-Arroyo LE, Zepeda-Carrillo EA, Aguilar-Salinas CA. Familial hypercholesterolemia in Mexico: Initial insights from the national registry. J Clin Lipidol 2020; 15:124-133. [PMID: 33422452 DOI: 10.1016/j.jacl.2020.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/18/2020] [Accepted: 12/04/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) remains underdiagnosed and undertreated. OBJECTIVE Report the results of the first years (2017-2019) of the Mexican FH registry. METHODS There are 60 investigators, representing 28 federal states, participating in the registry. The variables included are in accordance with the European Atherosclerosis Society (EAS) FH recommendations. RESULTS To date, 709 patients have been registered, only 336 patients with complete data fields are presented. The mean age is 50 (36-62) years and the average time since diagnosis is 4 (IQR: 2-16) years. Genetic testing is recorded in 26.9%. Tendon xanthomas are present in 43.2%. The prevalence of type 2 diabetes is 11.3% and that of premature CAD is 9.8%. Index cases, male gender, hypertension and smoking were associated with premature CAD. The median lipoprotein (a) level is 30.5 (IQR 10.8-80.7) mg/dl. Statins and co-administration with ezetimibe were recorded in 88.1% and 35.7% respectively. A combined treatment target (50% reduction in LDL-C and an LDL-C <100 mg/dl) was achieved by 13.7%. Associated factors were index case (OR 3.6, 95%CI 1.69-8.73, P = .002), combination therapy (OR 2.4, 95%CI 1.23-4.90, P = .011), type 2 diabetes (OR 2.8, 95%CI 1.03-7.59, P = .036) and age (OR 1.023, 95%CI 1.01-1.05, P = .033). CONCLUSION The results confirm late diagnosis, a lower than expected prevalence and risk of ASCVD, a higher than expected prevalence of type 2 diabetes and undertreatment, with relatively few patients reaching goals. Recommendations include, the use of combination lipid lowering therapy, control of comorbid conditions and more frequent genetic testing in the future.
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Affiliation(s)
- Roopa Mehta
- Unidad de Investigación de Enfermedades Metabolicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, México City, Mexico; Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Alexandro J Martagon
- Unidad de Investigación de Enfermedades Metabolicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, México City, Mexico; Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Gabriela A Galan Ramirez
- Unidad de Investigación de Enfermedades Metabolicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, México City, Mexico
| | - Neftali Eduardo Antonio-Villa
- Unidad de Investigación de Enfermedades Metabolicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, México City, Mexico
| | - Arsenio Vargas-Vázquez
- Unidad de Investigación de Enfermedades Metabolicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, México City, Mexico
| | - Daniel Elias-Lopez
- Unidad de Investigación de Enfermedades Metabolicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, México City, Mexico; Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Gustavo Gonzalez-Retana
- Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Bethsabel Rodríguez-Encinas
- Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Guadalupe Jimenez-Dominguez
- Hospital General Zona #46 IMSS, Villahermosa, Tabasco, Mexico; Hospital Angeles de Villahermosa, Tabasco, Mexico
| | | | - Hector E Arriaga-Cazares
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico; Centro Medico Nacional del Noreste IMSS, Monterrey, Nuevo Leon, Mexico
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Carlos A Aguilar-Salinas
- Unidad de Investigación de Enfermedades Metabolicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, México City, Mexico; Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubiran, Mexico City, Mexico; Direccion de Nutricion, Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubiran, Mexico City, Mexico; Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico.
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13
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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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14
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Kavey REW. Public Policy to Promote Healthy Cardiovascular Lifestyles in Children. Can J Cardiol 2020; 36:1429-1439. [PMID: 32492400 DOI: 10.1016/j.cjca.2020.02.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/04/2020] [Accepted: 02/09/2020] [Indexed: 10/24/2022] Open
Abstract
Health policy is an important component of prevention of cardiovascular disease (CVD) and promotion of health in childhood and adolescence, when major health behaviours are formed. Development of CVD-related health policy begins with continuous systematic collection, analysis, and interpretation of health-related data to establish the baseline prevalence of CV risk factors and behaviours. These findings allow identification of problems, initiation of focused research, and development of evidence-based interventions. Ultimately, these results inform development and implementation of population-level policies. This review focuses on CVD health-promotion policies in North American youth, for whom health surveillance is an ongoing part of public health policy, providing direct, objective, measurements of growth, lipids, blood pressure, physical activity and tobacco exposure for development of CV health research and policy. When national surveillance data identified significant risk of CVD in youth in the 1970s, major pediatric epidemiologic studies established the strong association between these risk factors and behaviours in childhood and the initiation and progression of atherosclerosis. This knowledge promoted development of the targeted public policies, which are reviewed in this paper. Public policy can directly and positively address cardiovascular health promotion in youth; the effective approach to smoking cessation exemplifies this. For more complex risk factors and behaviours, health policy can be a significant element in a comprehensive CV health promotion program.
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Affiliation(s)
- Rae-Ellen W Kavey
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York, USA.
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15
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Mszar R, Buscher S, Taylor HL, Rice-DeFosse MT, McCann D. Familial Hypercholesterolemia and the Founder Effect Among Franco-Americans: A Brief History and Call to Action. CJC Open 2020; 2:161-167. [PMID: 32462130 PMCID: PMC7242505 DOI: 10.1016/j.cjco.2020.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 01/19/2020] [Indexed: 01/01/2023] Open
Abstract
Familial hypercholesterolemia (FH) is an inherited disorder characterized by chronically elevated low-density lipoprotein cholesterol levels and an increased risk of premature atherosclerotic cardiovascular disease. FH has been shown to disproportionately affect French Canadians and other ethnic populations due to the presence of a founder effect characterized by reduced genetic diversity resulting from relatively few individuals with FH-causing genetic mutations establishing self-contained populations. Beginning in the mid-1800s, approximately 1 million French Canadians immigrated to the Northeastern United States and largely remained in these small, tight-knit communities. Despite extensive genetic- and population-based research involving the French-Canadian founder population, primarily in the Province of Quebec, little is known regarding Franco-Americans in the United States. Concurrent with addressing the underdiagnosis rate of FH in the general population, we propose the following steps to leverage this founder effect and meet the cardiovascular needs of Franco-Americans: (1) increase cascade screening in regions of the United States with a high proportion of individuals of French-Canadian descent; (2) promote registry-based, epidemiological research to elucidate accurate prevalence estimates as well as diagnostic and treatment gaps in Franco-Americans; and (3) validate contemporary risk stratification strategies such as the Montreal-FH-SCORE to enable optimal lipid management and prevention of premature atherosclerotic cardiovascular disease among French-Canadian descendants.
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Affiliation(s)
- Reed Mszar
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Sara Buscher
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Heidi L. Taylor
- Department of Sociology, Bates College, Lewiston, Maine, USA
| | - Mary T. Rice-DeFosse
- Department of French and Francophone Studies, Bates College, Lewiston, Maine, USA
| | - Dervilla McCann
- Department of Cardiology, Central Maine Medical Center, Lewiston, Maine, USA
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16
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Page MM, Bell DA, Watts GF. Widening the spectrum of genetic testing in familial hypercholesterolaemia: Will it translate into better patient and population outcomes? Clin Genet 2019; 97:543-555. [PMID: 31833051 DOI: 10.1111/cge.13685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/25/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022]
Abstract
Familial hypercholesterolaemia (FH) is caused by pathogenic variants in LDLR, APOB or PCSK9. Impaired low-density lipoprotein (LDL) receptor function leads to decreased LDL catabolism and premature atherosclerotic cardiovascular disease (ASCVD). Thousands of LDLR variants are known, but assignation of pathogenicity requires accurate phenotyping, family studies and assessment of LDL receptor function. Precise, genetic diagnosis of FH using targeted next generation sequencing allows for optimal treatment, distinguishing FH from pathogenically distinct disorders requiring different treatment. Polygenic hypercholesterolaemia resulting from an accumulation of LDL cholesterol-raising single nucleotide polymorphisms (SNPs) could also be suspected by this approach. Similarly, ASCVD risk could be estimated by broader sequencing of cholesterol and non-cholesterol-related genes. Both of these areas require further research. The clinical management of FH, focusing on the primary or secondary prevention of ASCVD, has been boosted by PCSK9 inhibitor therapy. The efficacy of PCSK9 inhibitors in homozygous FH may be partly predicted by the LDLR variants. While expanded genetic testing in FH is clinically useful in providing an accurate diagnosis and enabling cost-effective testing of relatives, further research is needed to establish its value in improving clinical outcomes.
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Affiliation(s)
- Michael M Page
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Department of Clinical Biochemistry, Western Diagnostic Pathology, Perth, Australia
| | - Damon A Bell
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital and Royal Perth Hospital, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia.,Department of Clinical Biochemistry, Clinipath Pathology, Perth, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
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17
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Brunham LR, Ruel I, Aljenedil S, Rivière JB, Baass A, Tu JV, Mancini GBJ, Raggi P, Gupta M, Couture P, Pearson GJ, Bergeron J, Francis GA, McCrindle BW, Morrison K, St-Pierre J, Henderson M, Hegele RA, Genest J, Goguen J, Gaudet D, Paré G, Romney J, Ransom T, Bernard S, Katz P, Joy TR, Bewick D, Brophy J. Canadian Cardiovascular Society Position Statement on Familial Hypercholesterolemia: Update 2018. Can J Cardiol 2019; 34:1553-1563. [PMID: 30527143 DOI: 10.1016/j.cjca.2018.09.005] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/16/2018] [Indexed: 11/18/2022] Open
Abstract
Familial hypercholesterolemia (FH) is the most common monogenic disorder causing premature atherosclerotic cardiovascular disease. It affects 1 in 250 individuals worldwide, and of the approximately 145,000 Canadians estimated to have FH, most are undiagnosed. Herein, we provide an update of the 2014 Canadian Cardiovascular Society position statement on FH addressing the need for case identification, prompt recognition, and treatment with statins and ezetimibe, and cascade family screening. We provide a new Canadian definition for FH and tools for clinicians to make a diagnosis. The risk of atherosclerotic cardiovascular disease in patients with "definite" FH is 10- to 20-fold that of a normolipidemic individual and initiating treatment in youth or young adulthood can normalize life expectancy. Target levels for low-density lipoprotein cholesterol are proposed and are aligned with the Canadian Cardiovascular Society guidelines on dyslipidemia. Recommendation for the use of inhibitors of proprotein convertase kexin/subtilisin type 9 are made in patients who cannot achieve therapeutic low-density lipoprotein cholesterol targets on maximally tolerated statins and ezetimibe. The writing committee used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology in the preparation of the present document, which offers guidance for practical evaluation and management of patients with FH. This position statement also aims to raise awareness of FH nationally, and to mobilize patient support, promote knowledge translation, and availability of treatment and health care resources for this under-recognized, but important medical condition.
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Affiliation(s)
- Liam R Brunham
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre, Royal Victoria Hospital, Montréal, Quebec, Canada
| | - Sumayah Aljenedil
- Research Institute of the McGill University Health Centre, Royal Victoria Hospital, Montréal, Quebec, Canada
| | - Jean-Baptiste Rivière
- Research Institute of the McGill University Health Centre, Royal Victoria Hospital, Montréal, Quebec, Canada
| | - Alexis Baass
- Department of Medicine, McGill University, Montréal, Quebec, Canada; Nutrition, Metabolism and Atherosclerosis Clinic, Institut de recherches cliniques de Montréal, Montréal, Quebec, Canada
| | - Jack V Tu
- Faculty of Medicine, University of Toronto, Institute for Clinical Evaluative Sciences, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - G B John Mancini
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Milan Gupta
- Department of Medicine, McMaster University, Hamilton, and Canadian Collaborative Research Network, Brampton, Ontario, Canada
| | - Patrick Couture
- Departments of Medicine and Laboratory Medicine, CHU de Québec-Université Laval, Québec City, Quebec, Canada
| | - Glen J Pearson
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Jean Bergeron
- Departments of Medicine and Laboratory Medicine, CHU de Québec-Université Laval, Québec City, Quebec, Canada
| | - Gordon A Francis
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian W McCrindle
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Katherine Morrison
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Julie St-Pierre
- Department of Pediatrics, McGill University, Clinique 180, Montréal, Quebec, Canada
| | - Mélanie Henderson
- Department of Pediatrics, Université de Montréal, CHU Sainte-Justine, Montréal, Quebec, Canada
| | - Robert A Hegele
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Ontario, Canada
| | - Jacques Genest
- Research Institute of the McGill University Health Centre, Royal Victoria Hospital, Montréal, Quebec, Canada; Department of Medicine, McGill University, Montréal, Quebec, Canada
| | - Jeannette Goguen
- Department of Medicine, University of Toronto and Division of Endocrinology, St Michael's Hospital, Toronto Ontario, Canada
| | - Daniel Gaudet
- Lipidology Unit, Community Genomic Medicine Centre and ECOGENE-21, Department of Medicine, Université de Montréal, Saguenay, Quebec, Canada
| | - Guillaume Paré
- Department of Pathology and Molecular Medicine, Department of Clinical Epidemiology and Biostatistics, Population Health Research Institute and Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jacques Romney
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas Ransom
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sophie Bernard
- Nutrition, Metabolism and Atherosclerosis Clinic, Institut de recherches cliniques de Montréal, Montréal, Quebec, Canada; Department of Medicine, Division of Endocrinology, Université de Montreal, Montréal, Quebec, Canada
| | - Pamela Katz
- Department of Medicine, Section of Endocrinology and Metabolism, University of Manitoba, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Tisha R Joy
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - David Bewick
- Division of Cardiology, Department of Medicine, Dalhousie University, St John, New Brunswick, Canada
| | - James Brophy
- Research Institute of the McGill University Health Centre, Royal Victoria Hospital, Montréal, Quebec, Canada; Department of Medicine, McGill University, Montréal, Quebec, Canada
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Stock JK. Highlights from the 87th EAS congress, 26-29th May 2019. Atherosclerosis 2019; 287:186-188. [PMID: 31326112 DOI: 10.1016/j.atherosclerosis.2019.06.913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 06/26/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Jane K Stock
- European Atherosclerosis Society, World Trade Center Göteborg, Mässans Gata 18, SE-412 51, Gothenburg, Sweden.
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