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Tarugi P, Bertolini S, Calandra S, Arca M, Angelico F, Casula M, Cefalù AB, D'Erasmo L, Fortunato G, Perrone-Filardi P, Rubba P, Suppressa P, Averna M, Catapano AL. Consensus document on diagnosis and management of familial hypercholesterolemia from the Italian Society for the Study of Atherosclerosis (SISA). Nutr Metab Cardiovasc Dis 2024; 34:1819-1836. [PMID: 38871496 DOI: 10.1016/j.numecd.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/04/2024] [Accepted: 05/03/2024] [Indexed: 06/15/2024]
Abstract
AIMS Familial Hypercholesterolemia (FH) is a genetic disorder of lipoprotein metabolism that causes an increased risk of premature atherosclerotic cardiovascular disease (ASCVD). Although early diagnosis and treatment of FH can significantly improve the cardiovascular prognosis, this disorder is underdiagnosed and undertreated. For these reasons the Italian Society for the Study of Atherosclerosis (SISA) assembled a Consensus Panel with the task to provide guidelines for FH diagnosis and treatment. DATA SYNTHESIS Our guidelines include: i) an overview of the genetic complexity of FH and the role of candidate genes involved in LDL metabolism; ii) the prevalence of FH in the population; iii) the clinical criteria adopted for the diagnosis of FH; iv) the screening for ASCVD and the role of cardiovascular imaging techniques; v) the role of molecular diagnosis in establishing the genetic bases of the disorder; vi) the current therapeutic options in both heterozygous and homozygous FH. Treatment strategies and targets are currently based on low-density lipoprotein cholesterol (LDL-C) levels, as the prognosis of FH largely depends on the magnitude of LDL-C reduction achieved by lipid-lowering therapies. Statins with or without ezetimibe are the mainstay of treatment. Addition of novel medications like PCSK9 inhibitors, ANGPTL3 inhibitors or lomitapide in homozygous FH results in a further reduction of LDL-C levels. LDL apheresis is indicated in FH patients with inadequate response to cholesterol-lowering therapies. CONCLUSION FH is a common, treatable genetic disorder and, although our understanding of this disease has improved, many challenges still remain with regard to its identification and management.
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Affiliation(s)
- Patrizia Tarugi
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy.
| | | | - Sebastiano Calandra
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine (DTPM), Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | | | - Manuela Casula
- Department of Pharmacological and Biomolecular Sciences (DisFeB), Epidemiology and Preventive Pharmacology Service (SEFAP), University of Milan, Milan, Italy; IRCCS Multimedica, Sesto San Giovanni (Milan), Italy
| | - Angelo B Cefalù
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Laura D'Erasmo
- Department of Translational and Precision Medicine (DTPM), Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giuliana Fortunato
- Department of Medicina Molecolare e Biotecnologie Mediche, University of Naples Federico II and CEINGE Biotecnologie avanzate "Franco Salvatore", Naples, Italy
| | | | - Paolo Rubba
- Department of Internal Medicine and Surgery, Federico II University, Naples, Italy
| | - Patrizia Suppressa
- Department of Internal Medicine and Rare Diseases Centre "C. Frugoni", University of Bari A. Moro, Bari, Italy
| | - Maurizio Averna
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; Biophysical Institute CNR, Palermo, Italy
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milano, Italy; IRCCS Multimedica, Milano, Italy
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Homeniuk R, Gallagher J, Collins C. A mixed methods study of the awareness and management of familial hypercholesterolaemia in Irish general practice. Front Med (Lausanne) 2022; 9:1016198. [PMID: 36314005 PMCID: PMC9596980 DOI: 10.3389/fmed.2022.1016198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Familial Hypercholesterolemia (FH) is one of the most common genetic disorders, with an estimated global prevalence of 1:200-500, which leads to premature cardiovascular disease. Nevertheless, public and professional awareness of FH is often lacking, with an estimated 20,000 largely undiagnosed cases in Ireland. Purpose The overall aim of the project was to test the feasibility of a model of care that would include electronic record screening, clinical assessment, and coding of possible FH patients across a network of general practices in Ireland. In addition, a secondary aim was to gauge the awareness and knowledge of FH across the network. Methods This study took part in multiple phases, employing a mixed methods design. The study included a validated questionnaire, tailored online educational resources, a retrospective chart review of patients with a history of elevated LDL cholesterol (LDLc) and an active review with a selection of those patients. Results were analyzed using SPSS V27, where descriptive statistics and relevant correlation tests were employed. Results Eighteen general practices agreed to take part in the study. In the initial survey, respondents rated their personal and practice familiarity with FH as slightly below average. Around one-third of respondents were not aware of FH guidelines. Of over 55,000 adult patient records searched, only 0.2% had a recorded FH diagnosis and 3.9% had ever had an LDLc above 4.9 mmol/l. Eight practices completed 198 chart reviews. Among these, 29.8% of patients had a family history recorded, and 22.2% had a family history of CVD recorded. Female patients had higher averages for highest and recent LDLc. Seventy patients underwent a clinical review-with 27% of these patients identified as "probable" or "definite FH." There was a statistically significant (p = 0.002) relationship between FH status and whether the patient had other CVD risk factors. Conclusion General practitioners in Ireland had similar levels of awareness of FH compared to findings from elsewhere. The activities discussed encouraged clinicians to consider FH when talking to their patients, especially those with elevated LDLc at an early age. Broader awareness of the condition could increase conversations about FH and benefit patient outcomes.
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Affiliation(s)
- Robyn Homeniuk
- Research Centre, Irish College of General Practitioners, Dublin, Ireland
| | - Joseph Gallagher
- Cardiovascular Clinical Lead, Irish College of General Practitioners, Dublin, Ireland
| | - Claire Collins
- Research Centre, Irish College of General Practitioners, Dublin, Ireland,*Correspondence: Claire Collins
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Griffith N, Bigham G, Sajja A, Gluckman TJ. Leveraging Healthcare System Data to Identify High-Risk Dyslipidemia Patients. Curr Cardiol Rep 2022; 24:1387-1396. [PMID: 35994196 DOI: 10.1007/s11886-022-01767-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW While randomized controlled trials have historically served as the gold standard for shaping guideline recommendations, real-world data are increasingly being used to inform clinical decision-making. We describe ways in which healthcare systems are generating real-world data related to dyslipidemia and how these data are being leveraged to improve patient care. RECENT FINDINGS The electronic medical record has emerged as a major source of clinical data, which alongside claims and pharmacy dispending data is enabling healthcare systems the ability to identify care gaps (underdiagnosis and undertreatment) in patients with dyslipidemia. Availability of this data also allows healthcare systems the ability to test and deliver interventions at the point-of-care. Real-world data possess great potential as a complement to randomized controlled trials. Healthcare systems are uniquely positioned to not only define care gaps and areas of opportunity, but to also to leverage tools (e.g., clinical decision support, case identification) aimed at closing them.
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Affiliation(s)
- Nayrana Griffith
- Department of Internal Medicine, Medstar Georgetown University Hospital, Washington, DC, USA.
| | - Grace Bigham
- Department of Internal Medicine, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Aparna Sajja
- Division of Cardiology, Medstar Georgetown University Hospital-Washington Hospital Center, Washington, DC, USA
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence Research Network, Portland, OR, USA
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Relationship between Brain Metabolic Disorders and Cognitive Impairment: LDL Receptor Defect. Int J Mol Sci 2022; 23:ijms23158384. [PMID: 35955522 PMCID: PMC9369234 DOI: 10.3390/ijms23158384] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 02/07/2023] Open
Abstract
The low-density-lipoprotein receptor (LDLr) removes low-density lipoprotein (LDL), an endovascular transporter that carries cholesterol from the bloodstream to peripheral tissues. The maintenance of cholesterol content in the brain, which is important to protect brain function, is affected by LDLr. LDLr co-localizes with the insulin receptor and complements the internalization of LDL. In LDLr deficiency, LDL blood levels and insulin resistance increase, leading to abnormal cholesterol control and cognitive deficits in atherosclerosis. Defects in brain cholesterol metabolism lead to neuroinflammation and blood–brain-barrier (BBB) degradation. Moreover, interactions between endoplasmic reticulum stress (ER stress) and mitochondria are induced by ox-LDL accumulation, apolipoprotein E (ApoE) regulates the levels of amyloid beta (Aβ) in the brain, and hypoxia is induced by apoptosis induced by the LDLr defect. This review summarizes the association between neurodegenerative brain disease and typical cognitive deficits.
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Persson Lindell O, Karlsson LO, Nilsson S, Charitakis E, Hagström E, Muhr T, Nilsson L, Henriksson M, Janzon M. Clinical decision support for familial hypercholesterolemia (CDS-FH): Rationale and design of a cluster randomized trial in primary care. Am Heart J 2022; 247:132-148. [PMID: 35181275 DOI: 10.1016/j.ahj.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/21/2022] [Accepted: 02/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is an underdiagnosed and undertreated genetic disorder with high risk of premature atherosclerotic cardiovascular disease and death. Clinical decision support (CDS) systems have the potential to aid in the identification and management of patients with FH. Prior studies using computer-based systems to screen patients for FH have shown promising results, but there has been no randomized controlled trial conducted. The aim of the current cluster randomized study is to evaluate if a CDS can increase the identification of FH. METHODS We have developed a CDS integrated in the electronic health records that will be activated in patients with elevated cholesterol levels (total cholesterol >8 mmol/L or low-density lipoprotein-cholesterol >5.5 mmol/L, adjusted for age, ongoing lipid lowering therapy and presence of premature coronary artery disease) at increased risk for FH. When activated, the CDS will urge the physician to send an automatically generated referral to the local lipid clinic for further evaluation. To evaluate the effects of the CDS, all primary care clinics will be cluster randomized 1:1 to either CDS intervention or standard care in a Swedish region with almost 500,000 inhabitants. The primary endpoint will be the number of patients diagnosed with FH at 30 months. Resource use and long-term health consequences will be estimated to assess the cost-effectiveness of the intervention. CONCLUSION Despite increasing awareness of FH, the condition remains underdiagnosed and undertreated. The present study will investigate whether a CDS can increase the number of patients being diagnosed with FH.
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Affiliation(s)
- Olof Persson Lindell
- Department of Cardiology, University Hospital, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping Sweden.
| | - Lars O Karlsson
- Department of Cardiology, University Hospital, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping Sweden
| | - Staffan Nilsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping Sweden; Division of Primary Health Care, Region Östergötland, Linköping, Sweden
| | - Emmanouil Charitakis
- Department of Cardiology, University Hospital, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping Sweden
| | - Emil Hagström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Thomas Muhr
- Department of Cardiology, University Hospital, Linköping, Sweden
| | - Lennart Nilsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping Sweden; Department of Medicine, County Hospital Ryhov, Jönköping, Sweden
| | - Martin Henriksson
- Center for Medical Technology Assessment, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Magnus Janzon
- Department of Cardiology, University Hospital, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping Sweden
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Borg SÁ, Sørensen Bork C, Skjelbo Nielsen MR, Berg Schmidt E, Kollslíð R, Lundbye-Christensen S, Joensen AM. Lipids, lipoproteins and prevalence of familial hypercholesterolemia in the Faroe Islands - Results from a nationwide laboratory database. ATHEROSCLEROSIS PLUS 2022; 48:55-59. [PMID: 36644563 PMCID: PMC9833255 DOI: 10.1016/j.athplu.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is one of the most common hereditary disorders. The population of the Faroe Islands was established by few founders, and genetic drift may have influenced lipid levels. The aim of this study was to describe the lipid distribution by providing age and sex-specific lipid values and to investigate the prevalence of FH in the Faroe Islands. METHODS We used an electronic nationwide laboratory database that included lipid measurements obtained in the Faroe Islands between January 2006 and September 2020. Percentiles of lipid levels were calculated using quantile regression. The prevalence of FH was estimated according to the Make Early Diagnosis Prevent Early Death (MEDPED) diagnostic criteria and according to the LDL-C cut-off levels included in the Dutch Lipid Clinic Network (DLCN) criteria using generalized linear models with robust variance. RESULTS According to the MEDPED age-specific cut-offs for LDL-C, a total of 216 subjects met the criteria for definite FH among 30,711 individuals corresponding to a prevalence of 0.70% (1:142). According to the LDL-C cut-offs included in the DLCN criteria, a total of 3,823 (1:8) subjects could be classified as having possible FH, and 10 (1:3,071) subjects could be classified as probable FH corresponding to a prevalence of 12.4% and 0.03%, respectively. Also, we found significant differences in lipid levels according to sex and age groups. CONCLUSION The Faroe Islands might represent a founder population with a prevalence of possible FH as high as 1 in 8. Further investigation of genetic and clinical characteristics of FH in the Faroe Islands is needed.
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Affiliation(s)
- Sanna á Borg
- Department of Medicine, National Hospital of the Faroe Islands, Faroe Islands
| | | | | | | | - Rudi Kollslíð
- Department of Medicine, National Hospital of the Faroe Islands, Faroe Islands
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Prevalence and patient characteristics of familial hypercholesterolemia in a middle-aged Chinese population: Results from China PEACE Million Persons Project. Atherosclerosis 2022; 350:58-64. [DOI: 10.1016/j.atherosclerosis.2022.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/17/2022] [Accepted: 03/29/2022] [Indexed: 11/24/2022]
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Qureshi N, Da Silva MLR, Abdul-Hamid H, Weng SF, Kai J, Leonardi-Bee J. Strategies for screening for familial hypercholesterolaemia in primary care and other community settings. Cochrane Database Syst Rev 2021; 10:CD012985. [PMID: 34617591 PMCID: PMC8495769 DOI: 10.1002/14651858.cd012985.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Familial hypercholesterolaemia is a common inherited condition that is associated with premature cardiovascular disease. The increased cardiovascular morbidity and mortality, resulting from high levels of cholesterol since birth, can be prevented by starting lipid-lowering therapy. However, the majority of patients in the UK and worldwide remain undiagnosed. Established diagnostic criteria in current clinical practice are the Simon-Broome and Dutch Lipid Clinical network criteria and patients are classified as having probable, possible or definite familial hypercholesterolaemia. OBJECTIVES To assess the effectiveness of healthcare interventions strategies to systematically improve identification of familial hypercholesterolaemia in primary care and other community settings compared to usual care (incidental approaches to identify familial hypercholesterolaemia in primary care and other community settings). SEARCH METHODS We searched the Cochrane Inborn Errors of Metabolism Trials Register. Date of last search: 13 September 2021. We also searched databases (Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science, and SCOPUS) as well as handsearching relevant conference proceedings, reference lists of included articles, and the grey literature. Date of last searches: 05 March 2020. SELECTION CRITERIA: As per the Effective Practice and Organisation of Care (EPOC) Group guidelines, we planned to include randomised controlled trials (RCTs), cluster-RCTs and non-randomised studies of interventions (NRSI). Eligible NRSI were non-randomised controlled trials, prospective cohort studies, controlled before-and-after studies, and interrupted-time-series studies. We planned to selected studies with healthcare interventions strategies that aimed to systematically identify people with possible or definite clinical familial hypercholesterolaemia, in primary care and other community settings. These strategies would be compared with usual care or no intervention. We considered participants of any age from the general population who access primary care and other community settings. DATA COLLECTION AND ANALYSIS Two authors planned to independently select studies according to the inclusion criteria, to extract data and assess for risk of bias and the certainty of the evidence (according to the GRADE criteria). We contacted corresponding study authors in order to obtain further information for all the studies considered in the review. MAIN RESULTS No eligible RCTs or NRSIs were identified for inclusion, however, we excluded 28 studies. AUTHORS' CONCLUSIONS Currently, there are no RCTs or controlled NRSI evidence to determine the most appropriate healthcare strategy to systematically identify possible or definite clinical familial hypercholesterolaemia in primary care or other community settings. Uncontrolled before-and-after studies were identified, but were not eligible for inclusion. Further studies assessing healthcare strategies of systematic identification of familial hypercholesterolaemia need to be conducted with diagnosis confirmed by genetic testing or validated through clinical phenotype (or both).
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Affiliation(s)
- Nadeem Qureshi
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Hasidah Abdul-Hamid
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Stephen F Weng
- Cardiovascular and Metabolism, Janssen Research & Development , High Wycombe , UK
| | - Joe Kai
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jo Leonardi-Bee
- Centre for Evidence Based Healthcare, Division of Epidemiology and Public Health, Clinical Sciences Building Phase 2, University of Nottingham, Nottingham, UK
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Silva L, Qureshi N, Abdul-Hamid H, Weng S, Kai J, Leonardi-Bee J. Systematic Identification of Familial Hypercholesterolaemia in Primary Care-A Systematic Review. J Pers Med 2021; 11:302. [PMID: 33920869 PMCID: PMC8071332 DOI: 10.3390/jpm11040302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/24/2021] [Accepted: 04/10/2021] [Indexed: 12/19/2022] Open
Abstract
Familial hypercholesterolaemia (FH) is a common inherited cause of premature cardiovascular disease, but the majority of patients remain undiagnosed. The aim of this systematic review was to assess the effectiveness of interventions to systematically identify FH in primary care. No randomised, controlled studies were identified; however, three non-randomised intervention studies were eligible for inclusion. All three studies systematically identified FH using reminders (on-screen prompts) in electronic health records. There was insufficient evidence that providing comments on laboratory test results increased the identification of FH using the Dutch Lipid Clinic Network (DLCN) criteria. Similarly, using prompts combined with postal invitation demonstrated no significant increase in definite FH identification using Simon-Broome (SB) criteria; however, the identification of possible FH increased by 25.4% (CI 17.75 to 33.97%). Using on-screen prompts alone demonstrated a small increase of 0.05% (95% CI 0.03 to 0.07%) in identifying definite FH using SB criteria; however, when the intervention was combined with an outreach FH nurse assessment, the result was no significant increase in FH identification using a combination of SB and DLCN criteria. None of the included studies reported adverse effects associated with the interventions. Currently, there is insufficient evidence to determine which is the most effective method of systematically identifying FH in non-specialist settings.
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Affiliation(s)
- Luisa Silva
- Primary Care Stratified Medicine (PRISM) Group, NIHR School of Primary Care Research, University of Nottingham, Nottingham NG7 2RD, UK; (L.S.); (H.A.-H.); (S.W.); (J.K.)
| | - Nadeem Qureshi
- Primary Care Stratified Medicine (PRISM) Group, NIHR School of Primary Care Research, University of Nottingham, Nottingham NG7 2RD, UK; (L.S.); (H.A.-H.); (S.W.); (J.K.)
| | - Hasidah Abdul-Hamid
- Primary Care Stratified Medicine (PRISM) Group, NIHR School of Primary Care Research, University of Nottingham, Nottingham NG7 2RD, UK; (L.S.); (H.A.-H.); (S.W.); (J.K.)
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh 47000, Malaysia
| | - Stephen Weng
- Primary Care Stratified Medicine (PRISM) Group, NIHR School of Primary Care Research, University of Nottingham, Nottingham NG7 2RD, UK; (L.S.); (H.A.-H.); (S.W.); (J.K.)
| | - Joe Kai
- Primary Care Stratified Medicine (PRISM) Group, NIHR School of Primary Care Research, University of Nottingham, Nottingham NG7 2RD, UK; (L.S.); (H.A.-H.); (S.W.); (J.K.)
| | - Jo Leonardi-Bee
- Centre for Evidence Based Healthcare, Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK;
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Zamora A, Paluzie G, García-Vilches J, Alonso Gisbert O, Méndez Martínez AI, Plana N, Rodríguez-Borjabad C, Ibarretxe D, Martín-Urda A, Masana L. Massive data screening is a second opportunity to improve the management of patients with familial hypercholesterolemia phenotype. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2021; 33:138-147. [PMID: 33618913 DOI: 10.1016/j.arteri.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/07/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Familial Hypercholesterolemia (FH) is an autosomal dominant disease with an estimated prevalence between 1/200-250. It is under-treated and underdiagnosed. Massive data screening can increase the detection of patients with FH. METHODS Study population: Residents in the health coverage area (N: 195.000 inhabitants) and with at least one determination of cholesterol linked to low-density lipoproteins (LDL-C) carried out between January 1, 2010 and December 30, 2019. The highest LDL-C values were selected. EXCLUSION CRITERIA nephrotic syndrome, hypothyroidism, Hypothyroid treatment or triglycerides> 400 mg / dL. Seven algorithms suggestive of Familial Hypercholesterolemia Phenotype (HF-P) were analyzed, selecting the most efficient algorithm that could easily be translated into clinical practice. RESULTS Based on 6.264.877 assistances and 288.475 patients, after applying the inclusion-exclusion criteria, 504.316 tests were included, corresponding to 106.382 adults and 10.509 <18 years. The selected algorithm presented a prevalence of 0.62%. 840 patients with HF-P were detected, 55.8% being women and 178 <18 years old, 9.3% had a history of cardiovascular disease (CVD) and 16.4% had died. 65% of the patients in primary prevention had LDL-C values> 130 mg / dL and 83% in secondary prevention values> 70mg / dL. A ratio of 7.64 (1-18) patients with HF-P per analytical requesting physician was obtained. CONCLUSIONS Massive data screening and patient profiling are effective tools and easily applicable in clinical practice for the detection of patients with FH.
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Affiliation(s)
- Alberto Zamora
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital de Blanes, Corporació de Salut del Maresme i la Selva, Blanes, Girona, España; Grupo de Medicina Traslacional y Ciencias de la Decisión, Departamento de Ciencias Médicas, Facultad de Medicina, Universidad de Girona, Girona, España; Grupo Epidemiología Cardiovascular y Genética. CIBER, Enfermedades Cardiovasculares (CIBERCV), Barcelona, España.
| | - Guillem Paluzie
- Unidad de Información y Documentación Asistencial, Corporació de Salut del Maresme I la Selva, Barcelona, España
| | - Joan García-Vilches
- Departamento de Informática, Corporació de Salut del Maresme i la Selva, Barcelona, España
| | - Oriol Alonso Gisbert
- Servicio de Medicina Interna, Hospital Sant Jaume de Calella, Corporació de Salut del Maresme i la Selva, Barcelona, España
| | - Ana Inés Méndez Martínez
- Servicio de Medicina Interna, Hospital Sant Jaume de Calella, Corporació de Salut del Maresme i la Selva, Barcelona, España
| | - Núria Plana
- Unitat de Medicina Vascular i Metabolisme, Hospital Universitari Sant Joan de Reus, IISPV, Universitat Rovira i Virgili, CIBERDEM, Reus, España
| | - Cèlia Rodríguez-Borjabad
- Unitat de Medicina Vascular i Metabolisme, Hospital Universitari Sant Joan de Reus, IISPV, Universitat Rovira i Virgili, CIBERDEM, Reus, España
| | - Daiana Ibarretxe
- Unitat de Medicina Vascular i Metabolisme, Hospital Universitari Sant Joan de Reus, IISPV, Universitat Rovira i Virgili, CIBERDEM, Reus, España
| | - Anabel Martín-Urda
- Servicio de Medicina Interna, Hospital de Palamòs, Serveis de Salut Integrats Baix Empordà, Girona, España
| | - Luis Masana
- Unitat de Medicina Vascular i Metabolisme, Hospital Universitari Sant Joan de Reus, IISPV, Universitat Rovira i Virgili, CIBERDEM, Reus, España
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Gulizia MM, Maggioni AP, Abrignani MG, Bilato C, Mangiacapra F, Sanchez FA, Piovaccari G, Montagna L, Marini M, De Biasio M, Averna M, Casula M, Colivicchi F, Fabbri G, Lucci D, Zampoleri V, Catapano AL. Prevalence Of familial hypercholeSTerolaemia (FH) in Italian Patients with coronary artERy disease: The POSTER study. Atherosclerosis 2020; 308:32-38. [PMID: 32823190 DOI: 10.1016/j.atherosclerosis.2020.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolaemia (FH) is a powerful risk factor for cardiovascular (CV) events. High levels of low-density lipoprotein cholesterol (LDL-C) since birth are linked to the early onset of atherosclerotic disease. A genetic mutation determining FH is present in about one subject out of 250; FH should be more represented among subjects with a documented diagnosis of coronary artery disease (CAD). The POSTER Study evaluated the prevalence of FH in Italian patients with a recent CAD event. METHODS Eighty-two cardiology centres enrolled patients with a documented CAD event; CV risk profile, drug therapy and biochemical parameters were collected. Dutch Lipid Clinic Network (DLCN) criteria were used to define patients with a potential FH diagnosis (score ≥6); these patients underwent molecular testing for genetic diagnosis of FH. RESULTS Overall, 5415 patients were enrolled and the main index events were myocardial infarction with ST-elevation, non ST-elevation acute coronary syndrome (ACS), or a recent coronary revascularization (34.8%, 37.2%, and 28% respectively). Mean age was 66 ± 11 years, men were 78%; about 40% were already treated with statins, proportion that increased after the acute event (96.5%). Based on the DLCN score, the prevalence of potential FH was 5.1%, 0.9% of them had a diagnosis of definite FH (score >8). These patients were younger than patients with a score <6 (56 ± 10 vs 66 ± 11, p < 0.001), and LDL-C levels were in most of them (~87%) >190 mg/dL. FH was genetically confirmed in 42 subjects (15.9%); genetic diagnosis was defined as not conclusive for FH in 63 patients (23.9%). Finally, in 159 subjects (60.2%) no pathogenic mutations in the tested genes were identified, defining them as negative for monogenic familial hypercholesterolemia. CONCLUSIONS Results underscore a relatively high prevalence of potential FH in patients with a recent CAD event. Therefore, an early identification of these subjects may help improve the management of their high CV risk and, by cascade screening, identify possible FH relatives.
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Affiliation(s)
- Michele Massimo Gulizia
- Cardiology Division, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi" Catania, Italy; Heart Care Foundation, Florence, Italy.
| | - Aldo P Maggioni
- ANMCO Research Center of the Heart Care Foundation, Florence, Italy.
| | | | - Claudio Bilato
- Division of Cardiology, West Vicenza General Hospitals, Arzignano, Italy
| | | | | | | | - Laura Montagna
- Cardiology Department, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, Orbassano, Italy
| | - Marco Marini
- Cardiology Department, Riuniti Hospital, Ancona, Italy
| | - Marzia De Biasio
- Cardiology Department, Santa Maria Della Misericordia Hospital, Udine, Italy
| | - Maurizio Averna
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | | | - Gianna Fabbri
- ANMCO Research Center of the Heart Care Foundation, Florence, Italy
| | - Donata Lucci
- ANMCO Research Center of the Heart Care Foundation, Florence, Italy
| | - Veronica Zampoleri
- Department of Excellence of Pharmacological and Biomolecular Sciences (DisFeB), University of Milan, Milan, Italy; SISA Centre, Bassini Hospital, Cinisello Balsamo, Italy
| | - Alberico L Catapano
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy; Department of Excellence of Pharmacological and Biomolecular Sciences (DisFeB), University of Milan, Milan, Italy
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12
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Hu P, Dharmayat KI, Stevens CA, Sharabiani MT, Jones RS, Watts GF, Genest J, Ray KK, Vallejo-Vaz AJ. Prevalence of Familial Hypercholesterolemia Among the General Population and Patients With Atherosclerotic Cardiovascular Disease. Circulation 2020; 141:1742-1759. [DOI: 10.1161/circulationaha.119.044795] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background:
Contemporary studies suggest that familial hypercholesterolemia (FH) is more frequent than previously reported and increasingly recognized as affecting individuals of all ethnicities and across many regions of the world. Precise estimation of its global prevalence and prevalence across World Health Organization regions is needed to inform policies aiming at early detection and atherosclerotic cardiovascular disease (ASCVD) prevention. The present study aims to provide a comprehensive assessment and more reliable estimation of the prevalence of FH than hitherto possible in the general population (GP) and among patients with ASCVD.
Methods:
We performed a systematic review and meta-analysis including studies reporting on the prevalence of heterozygous FH in the GP or among those with ASCVD. Studies reporting gene founder effects and focused on homozygous FH were excluded. The search was conducted through Medline, Embase, Cochrane, and Global Health, without time or language restrictions. A random-effects model was applied to estimate the overall pooled prevalence of FH in the general and ASCVD populations separately and by World Health Organization regions.
Results:
From 3225 articles, 42 studies from the GP and 20 from populations with ASCVD were eligible, reporting on 7 297 363 individuals/24 636 cases of FH and 48 158 patients/2827 cases of FH, respectively. More than 60% of the studies were from Europe. Use of the Dutch Lipid Clinic Network criteria was the commonest diagnostic method. Within the GP, the overall pooled prevalence of FH was 1:311 (95% CI, 1:250–1:397; similar between children [1:364] and adults [1:303],
P
=0.60; across World Health Organization regions where data were available,
P
=0.29; and between population-based and electronic health records–based studies,
P
=0.82). Studies with ≤10 000 participants reported a higher prevalence (1:200–289) compared with larger cohorts (1:365–407;
P
<0.001). The pooled prevalence among those with ASCVD was 18-fold higher than in the GP (1:17 [95% CI, 1:12–1:24]), driven mainly by coronary artery disease (1:16; [95% CI, 1:12–1:23]). Between-study heterogeneity was large (
I
2
>95%). Tests assessing bias were nonsignificant (
P
>0.3).
Conclusions:
With an overall prevalence of 1:311, FH is among the commonest genetic disorders in the GP, similarly present across different regions of the world, and is more frequent among those with ASCVD. The present results support the advocacy for the institution of public health policies, including screening programs, to identify FH early and to prevent its global burden.
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Affiliation(s)
- Pengwei Hu
- Imperial Center for Cardiovascular Disease Prevention (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V.), Imperial College London, UK
- Department of Primary Care and Public Health (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V., M.T.A.S.), Imperial College London, UK
- Department of Health Service, Logistics University of People’s Armed Police Force, Tianjin, China (P.H.)
| | - Kanika I. Dharmayat
- Imperial Center for Cardiovascular Disease Prevention (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V.), Imperial College London, UK
- Department of Primary Care and Public Health (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V., M.T.A.S.), Imperial College London, UK
| | - Christophe A.T. Stevens
- Imperial Center for Cardiovascular Disease Prevention (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V.), Imperial College London, UK
- Department of Primary Care and Public Health (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V., M.T.A.S.), Imperial College London, UK
| | - Mansour T.A. Sharabiani
- Department of Primary Care and Public Health (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V., M.T.A.S.), Imperial College London, UK
| | - Rebecca S. Jones
- School of Public Health, and Charing Cross Campus Library (R.S.J.), Imperial College London, UK
| | - Gerald F. Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth (G.F.W.)
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Australia (G.F.W.)
| | - Jacques Genest
- McGill University Health Center, Montreal, QC, Canada (J.G.)
| | - Kausik K. Ray
- Imperial Center for Cardiovascular Disease Prevention (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V.), Imperial College London, UK
- Department of Primary Care and Public Health (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V., M.T.A.S.), Imperial College London, UK
| | - Antonio J. Vallejo-Vaz
- Imperial Center for Cardiovascular Disease Prevention (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V.), Imperial College London, UK
- Department of Primary Care and Public Health (P.H., K.I.D., C.A.T.S., K.K.R., A.J.V.-V., M.T.A.S.), Imperial College London, UK
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13
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Elis A, Leventer-Roberts M, Bachrach A, Lieberman N, Durst R, Knobler H, Balicer R. The characteristics of patients with possible familial hypercholesterolemia-screening a large payer/provider healthcare delivery system. QJM 2020; 113:411-417. [PMID: 31883017 DOI: 10.1093/qjmed/hcz327] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/24/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is an under-diagnosed condition. AIM We applied standard laboratory criteria across a large longitudinal electronic medical record database to describe cross-sectional population with possible FH. METHODS A cross-sectional study of Clalit Health Services members. Subjects who met the General Population MED-PED laboratory criteria, excluding: age <10 years, documentation of thyroid, liver, biliary or autoimmune diseases, a history of chronic kidney disease stage 3 or greater, the presence of urine protein >300 mg/l, HDL-C>80 mg/dl, active malignancy or pregnancy at the time of testing were considered possible FH. Demographic and clinical characteristics are described at time of diagnosis and at a single index date following diagnosis to estimate the burden on the healthcare system. The patient population is also compared to the general population. RESULTS The study cohort included 12 494 subjects with out of over 4.5 million members of Clalit Health Services. The estimated prevalence of FH in Israel was found to be 1:285. These patients are notably positive for, and have a family history of, cardiovascular disease and risk factors. For most of them the LDL-C levels are not controlled, and only a quarter of them are medically treated. CONCLUSIONS By using the modified MED-PED criteria in a large electronic database, patients with possible FH can be identified enabling early intervention and treatment.
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Affiliation(s)
- A Elis
- Department of Internal Medicine, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | | | | | - N Lieberman
- Medical Policy Division, Clalit Health Services, Tel Aviv, Israel
| | - R Durst
- The Center for Research Prevention and Treatment of Atherosclerosis, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - H Knobler
- The Institute of Diabetes, Endocrinology, and Metabolism, Kaplan Medical Center, Rehovot, Israel
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14
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McGowan MP, Hosseini Dehkordi SH, Moriarty PM, Duell PB. Diagnosis and Treatment of Heterozygous Familial Hypercholesterolemia. J Am Heart Assoc 2019; 8:e013225. [PMID: 31838973 PMCID: PMC6951065 DOI: 10.1161/jaha.119.013225] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | | | | | - P. Barton Duell
- Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
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15
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Overview of the current status of familial hypercholesterolaemia care in over 60 countries - The EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC). Atherosclerosis 2019; 277:234-255. [PMID: 30270054 DOI: 10.1016/j.atherosclerosis.2018.08.051] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS Management of familial hypercholesterolaemia (FH) may vary across different settings due to factors related to population characteristics, practice, resources and/or policies. We conducted a survey among the worldwide network of EAS FHSC Lead Investigators to provide an overview of FH status in different countries. METHODS Lead Investigators from countries formally involved in the EAS FHSC by mid-May 2018 were invited to provide a brief report on FH status in their countries, including available information, programmes, initiatives, and management. RESULTS 63 countries provided reports. Data on FH prevalence are lacking in most countries. Where available, data tend to align with recent estimates, suggesting a higher frequency than that traditionally considered. Low rates of FH detection are reported across all regions. National registries and education programmes to improve FH awareness/knowledge are a recognised priority, but funding is often lacking. In most countries, diagnosis primarily relies on the Dutch Lipid Clinics Network criteria. Although available in many countries, genetic testing is not widely implemented (frequent cost issues). There are only a few national official government programmes for FH. Under-treatment is an issue. FH therapy is not universally reimbursed. PCSK9-inhibitors are available in ∼2/3 countries. Lipoprotein-apheresis is offered in ∼60% countries, although access is limited. CONCLUSIONS FH is a recognised public health concern. Management varies widely across countries, with overall suboptimal identification and under-treatment. Efforts and initiatives to improve FH knowledge and management are underway, including development of national registries, but support, particularly from health authorities, and better funding are greatly needed.
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16
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Lan NSR, Martin AC, Brett T, Watts GF, Bell DA. Improving the detection of familial hypercholesterolaemia. Pathology 2018; 51:213-221. [PMID: 30579649 DOI: 10.1016/j.pathol.2018.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 02/03/2023]
Abstract
Familial hypercholesterolaemia (FH) is a dominantly inherited disorder of low-density lipoprotein (LDL) catabolism, which if untreated causes lifelong elevated LDL-cholesterol (LDL-c), accelerated atherosclerosis and premature cardiovascular disease. Recent evidence suggests the prevalence of heterozygous FH is ∼1:220, making FH the most common autosomal dominant condition. Lowering LDL-c with statin and lifestyle therapy reduces the risk of cardiovascular events. Furthermore, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors significantly lower LDL-c in addition to statin therapy, and early outcome data suggest improved vascular outcomes with these agents in FH patients in addition to statins. However, the vast majority of people with FH still remain undiagnosed. The onus is on clinicians to identify kindreds with FH, as PCSK9 inhibitors, although expensive, are funded for patients with FH in Australia. Multiple strategies for detecting FH have been proposed. The detection of index cases can be achieved through applying electronic screening tools to general practice databases, universal screening of children during immunisation, and targeted screening of patients with premature cardiovascular disease. Advances in genomic technology have decreased costs of genetic testing, improved the understanding of the pathogenesis of FH and facilitated cascade screening. However, awareness of FH amongst clinicians and the general public still requires optimisation. This review outlines recent advances in FH detection, including emerging strategies and challenges for the next decade.
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Affiliation(s)
- Nick S R Lan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Andrew C Martin
- Department of General Paediatrics, Perth Children's Hospital, Nedlands, WA, Australia
| | - Tom Brett
- Department of General Practice and Primary Health Care Research, School of Medicine, The University of Notre Dame Australia, Fremantle, WA, Australia
| | - Gerald F Watts
- Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, Crawley, WA, Australia; Department of Cardiology, Lipid Disorders Clinic, Cardiometabolic Service, Royal Perth Hospital, Perth, WA, Australia
| | - Damon A Bell
- Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, Crawley, WA, Australia; Department of Cardiology, Lipid Disorders Clinic, Cardiometabolic Service, Royal Perth Hospital, Perth, WA, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, WA, Australia; Department of Clinical Biochemistry, Australian Clinical Laboratories, Perth, WA, Australia.
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17
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Vallejo-Vaz AJ, Ray KK. Epidemiology of familial hypercholesterolaemia: Community and clinical. Atherosclerosis 2018; 277:289-297. [DOI: 10.1016/j.atherosclerosis.2018.06.855] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/06/2018] [Accepted: 06/14/2018] [Indexed: 01/10/2023]
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18
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Mytilinaiou M, Kyrou I, Khan M, Grammatopoulos DK, Randeva HS. Familial Hypercholesterolemia: New Horizons for Diagnosis and Effective Management. Front Pharmacol 2018; 9:707. [PMID: 30050433 PMCID: PMC6052892 DOI: 10.3389/fphar.2018.00707] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/12/2018] [Indexed: 12/11/2022] Open
Abstract
Familial hypercholesterolemia (FH) is a common genetic cause of premature cardiovascular disease (CVD). The reported prevalence rates for both heterozygous FH (HeFH) and homozygous FH (HoFH) vary significantly, and this can be attributed, at least in part, to the variable diagnostic criteria used across different populations. Due to lack of consistent data, new global registries and unified guidelines are being formed, which are expected to advance current knowledge and improve the care of FH patients. This review presents a comprehensive overview of the pathophysiology, epidemiology, manifestations, and pharmacological treatment of FH, whilst summarizing the up-to-date relevant recommendations and guidelines. Ongoing research in FH seems promising and novel therapies are expected to be introduced in clinical practice in order to compliment or even substitute current treatment options, aiming for better lipid-lowering effects, fewer side effects, and improved clinical outcomes.
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Affiliation(s)
- Maria Mytilinaiou
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Ioannis Kyrou
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom.,Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry, United Kingdom
| | - Mike Khan
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Dimitris K Grammatopoulos
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Institute of Precision Diagnostics and Translational Medicine, Coventry and Warwickshire Pathology Service, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Harpal S Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom.,Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry, United Kingdom.,Institute of Precision Diagnostics and Translational Medicine, Coventry and Warwickshire Pathology Service, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
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