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Zubirán R, Cruz-Bautista I, Aguilar-Salinas CA. Interaction Between Primary Hyperlipidemias and Type 2 Diabetes: Therapeutic Implications. Diabetes Ther 2024; 15:1979-2000. [PMID: 39080218 PMCID: PMC11330433 DOI: 10.1007/s13300-024-01626-2] [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] [Received: 06/07/2024] [Accepted: 07/10/2024] [Indexed: 08/18/2024] Open
Abstract
There is a gap of knowledge about the clinical and pathophysiological implications resulting from the interaction between primary hyperlipidemias and type 2 diabetes (T2D). Most of the existing evidence comes from sub-analyses of cohorts; scant information derives from randomized clinical trials. The expected clinical implications of T2D in patients with primary hyperlipidemias is an escalation of their already high cardiovascular risk. There is a need to accurately identify patients with this dual burden and to adequately prescribe lipid-lowering therapies, with the current advancements in newer therapeutic options. This review provides an update on the interactions of primary hyperlipidemias, such as familial combined hyperlipidemia, familial hypercholesterolemia, multifactorial chylomicronemia, lipoprotein (a), and type 2 diabetes.
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Affiliation(s)
- Rafael Zubirán
- Lipoprotein Metabolism Laboratory, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ivette Cruz-Bautista
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Carlos A Aguilar-Salinas
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico.
- Dirección de Investigación, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City, Mexico.
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Dimitriadis K, Theofilis P, Iliakis P, Pyrpyris N, Dri E, Sakalidis A, Soulaidopoulos S, Tsioufis P, Fragkoulis C, Chrysohoou C, Tsiachris D, Tsioufis K. Management of dyslipidemia in coronary artery disease: the present and the future. Coron Artery Dis 2024; 35:516-524. [PMID: 38682459 DOI: 10.1097/mca.0000000000001375] [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: 05/01/2024]
Abstract
Coronary artery disease (CAD) remains a leading cause of global morbidity and mortality, necessitating continuous refinement in the management of dyslipidemia, one of its major risk factors, to mitigate cardiovascular risks. Previous studies have proven the critical role of immediate and robust low-density lipoprotein cholesterol (LDL-C) reduction in the aftermath of acute coronary syndrome (ACS). Emphasizing the evidence supporting this approach, we delve into the impact of early intervention on cardiovascular outcomes and propose optimal strategies for achieving rapid LDL-C lowering, while also providing the rationale for early proprotein convertase subtilisin/kexin 9 inhibitor use after an ACS. Given the importance of the residual lipidemic risk, we present an overview of emerging therapeutic avenues poised to reshape dyslipidemia management, such as bempedoic acid, lipoprotein(a) inhibition, ApoC3 modulation, and angiopoietin-like protein 3 targeting. This comprehensive review amalgamates current evidence with future prospects, offering a holistic perspective on the management of dyslipidemia in CAD. By exploring both the urgency for immediate post-ACS LDL-C reduction and the exciting advancements on the horizon, this article provides a roadmap for clinicians navigating the intricate landscape of lipid-lowering therapies in CAD.
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Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens
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Zimerman A, Wiviott SD, Park JG, Murphy SA, Ran X, Bramson CR, Curto M, Ramos V, Jevne A, Kuder JF, Verma S, Wojakowski W, Terra SG, Sabatine MS, Bergmark BA, Marston NA. Reductions in remnant cholesterol and VLDL cholesterol through inhibition of ANGPTL3 protein synthesis: an analysis from the TRANSLATE-TIMI 70 trial. Eur J Prev Cardiol 2024; 31:1216-1223. [PMID: 38484368 DOI: 10.1093/eurjpc/zwae090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/05/2023] [Accepted: 02/29/2024] [Indexed: 08/10/2024]
Abstract
AIMS Remnant cholesterol and very low-density lipoprotein cholesterol (VLDL-C) are increasingly recognized risk factors for atherosclerotic disease with few therapeutic options. Angiopoietin-like 3 (ANGPTL3), a key protein in the metabolism of triglyceride-rich lipoproteins, is a promising target. METHODS AND RESULTS TRANSLATE-TIMI 70 was a double-blind, placebo-controlled randomized trial testing seven dose regimens of vupanorsen, an antisense oligonucleotide against ANGPTL3, in adults with non-HDL-C ≥ 100 mg/dL and triglycerides 150-500 mg/dL. The primary endpoint of this analysis was percentage change in remnant cholesterol (total cholesterol minus directly measured LDL-C minus HDL-C) and VLDL-C (directly measured) over 24 weeks. Two hundred eighty-six patients were enrolled, with a median age of 64 years and 44% female. Median baseline remnant cholesterol and VLDL-C were 42 and 31 mg/dL, respectively (reference: <30 mg/dL). Vupanorsen lowered remnant cholesterol by 42-59% at 24 weeks over placebo (P < 0.001), achieving a median level of 18 mg/dL at the highest dose. Over the same period, VLDL-C was reduced by 52-67% over placebo (P < 0.001), with a median achieved level of 2.5 mg/dL at the highest dose. The effect of vupanorsen on remnant cholesterol and VLDL-C reduction was dose-dependent and directly associated with the degree of ANGPTL3 inhibition: at 90% ANGPTL3 reduction, there was a 61% and 81% decrease in remnant cholesterol and VLDL-C, respectively. CONCLUSION Inhibition of ANGPTL3 protein synthesis significantly lowered remnant cholesterol and VLDL-C in patients with hypertriglyceridaemia. The magnitude of reduction was associated with the degree of ANGPTL3 inhibition. These findings support ANGPTL3 inhibition as a promising target for lowering cholesterol on triglyceride-rich lipoproteins.
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Affiliation(s)
- Andre Zimerman
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | - Xinhui Ran
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | | | | | | | - Alexandra Jevne
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | - Subodh Verma
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Wojtek Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
| | - Nicholas A Marston
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, 7th Floor, 60 Fenwood Road, Boston, MA 02115, USA
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4
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Zhao K, Zeng Z, He Y, Zhao R, Niu J, Sun H, Li S, Dong J, Jing Z, Zhou J. Recent advances in targeted therapy for inflammatory vascular diseases. J Control Release 2024; 372:730-750. [PMID: 38945301 DOI: 10.1016/j.jconrel.2024.06.063] [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: 01/07/2024] [Revised: 06/16/2024] [Accepted: 06/25/2024] [Indexed: 07/02/2024]
Abstract
Vascular diseases constitute a significant contributor to worldwide mortality rates, placing a substantial strain on healthcare systems and socio-economic aspects. They are closely associated with inflammatory responses, as sustained inflammation could impact endothelial function, the release of inflammatory mediators, and platelet activation, thus accelerating the progression of vascular diseases. Consequently, directing therapeutic efforts towards mitigating inflammation represents a crucial approach in the management of vascular diseases. Traditional anti-inflammatory medications may have extensive effects on multiple tissues and organs when absorbed through the bloodstream. Conversely, treatments targeting inflammatory vascular diseases, such as monoclonal antibodies, drug-eluting stents, and nano-drugs, can achieve more precise effects, including precise intervention, minimal non-specific effects, and prolonged efficacy. In addition, personalized therapy is an important development trend in targeted therapy for inflammatory vascular diseases. Leveraging advanced simulation algorithms and clinical trial data, treatment strategies are gradually being personalized based on patients' genetic, biomarker, and clinical profiles. It is expected that the application of precision medicine in the field of vascular diseases will have a broader future. In conclusion, targeting therapies offer enhanced safety and efficacy compared to conventional medications; investigating novel targeting therapies and promoting clinical transformation may be a promising direction in improving the prognosis of patients with inflammatory vascular diseases. This article reviews the pathogenesis of inflammatory vascular diseases and presents a comprehensive overview of the potential for targeted therapies in managing this condition.
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Affiliation(s)
- Kaiwen Zhao
- Department of Vascular Surgery, The First Affiliated Hospital, Naval Medical University, Shanghai, China
| | - Zan Zeng
- Department of Vascular Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Yuzhen He
- Department of Vascular Surgery, The First Affiliated Hospital, Naval Medical University, Shanghai, China
| | - Rong Zhao
- Department of Vascular Surgery, The First Affiliated Hospital, Naval Medical University, Shanghai, China
| | - Jinzhu Niu
- Department of Vascular Surgery, The First Affiliated Hospital, Naval Medical University, Shanghai, China
| | - Huiying Sun
- Department of Vascular Surgery, The First Affiliated Hospital, Naval Medical University, Shanghai, China
| | - Shuangshuang Li
- Department of Vascular Surgery, The First Affiliated Hospital, Naval Medical University, Shanghai, China
| | - Jian Dong
- Department of Vascular Surgery, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zaiping Jing
- Department of Vascular Surgery, The First Affiliated Hospital, Naval Medical University, Shanghai, China
| | - Jian Zhou
- Department of Vascular Surgery, The First Affiliated Hospital, Naval Medical University, Shanghai, China; Department of Vascular Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China; Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Shanghai, China.
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5
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Watts GF, Tamehri Zadeh SS, Chan DC. ANGPTL3 as a therapeutic target for treating homozygous familial hypercholesterolaemia: a shot in the arm for evinacumab. Eur Heart J 2024; 45:2435-2438. [PMID: 38856677 DOI: 10.1093/eurheartj/ehae321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024] Open
Affiliation(s)
- Gerald F Watts
- Medical School, University of Western Australia, GPO Box X2213, Perth, WA 6847, Australia
- Cardiometabolic Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
| | | | - Dick C Chan
- Medical School, University of Western Australia, GPO Box X2213, Perth, WA 6847, Australia
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Rangwala HS, Fatima H, Ali M, Shafiq MA, Rangwala BS, Virwani V, Kumar A, Arsal SA, Raja A, Raja S, Mustafa MS. Evaluating the Effectiveness and Safety of Evinacumab in Treating Hypercholesterolemia and Hypertriglyceridemia: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2024; 24:523-535. [PMID: 38713309 DOI: 10.1007/s40256-024-00649-1] [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] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Cardiovascular disease remains a significant global health concern, with high low-density lipoprotein cholesterol (LDL-C) levels contributing to an increased risk. Familial hypercholesterolemia (FH) further complicates its management, necessitating additional lipid-lowering therapies. Evinacumab, an angiopoietin-like protein 3 monoclonal antibody, has emerged as a potential treatment, particularly for patients with FH, by effectively reducing LDL-C and triglyceride levels. This meta-analysis aimed to evaluate the efficacy and safety of evinacumab across diverse patient populations. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, relevant randomized controlled trials (RCTs) were systematically retrieved from multiple databases until November 24, 2023. The inclusion criteria were studies comparing evinacumab (at doses of 5 and 15 mg) to placebo, with outcomes focusing on lipid levels and adverse events. Standardized protocols were employed for data extraction and quality assessment, and statistical analysis was conducted using RevMan software. RESULTS Four RCTs, involving 270 patients, were included in the analysis. The analysis revealed significant reductions in lipid markers, particularly with the 15-mg dose of evinacumab, including triacylglycerols (standard mean difference [SMD] = -6.09, 95% confidence interval [CI] - 14.53 to 2.36, P = 0.16), total cholesterol (SMD = - 6.20, 95% CI - 11.53 to - 0.88, P = 0.02), high-density lipoprotein cholesterol (SMD = - 0.79, 95% CI - 1.27 to - 0.31, P = 0.001), LDL-C (SMD = - 4.58, 95% CI - 9.13 to - 0.03, P = 0.05), apolipoprotein (Apo) B (SMD = - 4.01, 95% CI - 7.53 to - 0.46, P = 0.03), and Apo C3 (SMD = - 7.67, 95% CI - 12.94 to - 2.41, P = 0.004). Adverse event analysis revealed no significant association, indicating good tolerability. CONCLUSION High-dose evinacumab (15 mg) consistently demonstrated efficacy in reducing cholesterol and other lipid markers, with favorable tolerability. Further research is warranted to comprehensively assess its safety and clinical effectiveness, emphasizing the need for additional data to support its use in managing cardiovascular disease.
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Affiliation(s)
- Hussain Sohail Rangwala
- Department of Medicine, Jinnah Sindh Medical University, Iqbal Shaheed Rd, Karachi, Pakistan.
| | - Hareer Fatima
- Department of Medicine, Jinnah Sindh Medical University, Iqbal Shaheed Rd, Karachi, Pakistan
| | - Mirha Ali
- Department of Medicine, Jinnah Sindh Medical University, Iqbal Shaheed Rd, Karachi, Pakistan
| | - Muhammad Ashir Shafiq
- Department of Medicine, Jinnah Sindh Medical University, Iqbal Shaheed Rd, Karachi, Pakistan
| | | | - Vikash Virwani
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Aashish Kumar
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Syed Ali Arsal
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Adarsh Raja
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Sandesh Raja
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Volgman AS, Koschinsky ML, Mehta A, Rosenson RS. Genetics and Pathophysiological Mechanisms of Lipoprotein(a)-Associated Cardiovascular Risk. J Am Heart Assoc 2024; 13:e033654. [PMID: 38879448 PMCID: PMC11255763 DOI: 10.1161/jaha.123.033654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/19/2024]
Abstract
Elevated lipoprotein(a) is a genetically transmitted codominant trait that is an independent risk driver for cardiovascular disease. Lipoprotein(a) concentration is heavily influenced by genetic factors, including LPA kringle IV-2 domain size, single-nucleotide polymorphisms, and interleukin-1 genotypes. Apolipoprotein(a) is encoded by the LPA gene and contains 10 subtypes with a variable number of copies of kringle -2, resulting in >40 different apolipoprotein(a) isoform sizes. Genetic loci beyond LPA, such as APOE and APOH, have been shown to impact lipoprotein(a) levels. Lipoprotein(a) concentrations are generally 5% to 10% higher in women than men, and there is up to a 3-fold difference in median lipoprotein(a) concentrations between racial and ethnic populations. Nongenetic factors, including menopause, diet, and renal function, may also impact lipoprotein(a) concentration. Lipoprotein(a) levels are also influenced by inflammation since the LPA promoter contains an interleukin-6 response element; interleukin-6 released during the inflammatory response results in transient increases in plasma lipoprotein(a) levels. Screening can identify elevated lipoprotein(a) levels and facilitate intensive risk factor management. Several investigational, RNA-targeted agents have shown promising lipoprotein(a)-lowering effects in clinical studies, and large-scale lipoprotein(a) testing will be fundamental to identifying eligible patients should these agents become available. Lipoprotein(a) testing requires routine, nonfasting blood draws, making it convenient for patients. Herein, we discuss the genetic determinants of lipoprotein(a) levels, explore the pathophysiological mechanisms underlying the association between lipoprotein(a) and cardiovascular disease, and provide practical guidance for lipoprotein(a) testing.
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Affiliation(s)
| | - Marlys L. Koschinsky
- Robarts Research Institute, Schulich School of Medicine and DentistryWestern UniversityLondonONCanada
| | | | - Robert S. Rosenson
- Metabolism and Lipids Program, Mount Sinai Fuster Heart HospitalIcahn School of Medicine at Mount SinaiNew YorkNYUSA
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D'Erasmo L, Bini S, Casula M, Gazzotti M, Bertolini S, Calandra S, Tarugi P, Averna M, Iannuzzo G, Fortunato G, Catapano AL, Arca M. Contemporary lipid-lowering management and risk of cardiovascular events in homozygous familial hypercholesterolaemia: insights from the Italian LIPIGEN Registry. Eur J Prev Cardiol 2024; 31:1038-1047. [PMID: 38374534 DOI: 10.1093/eurjpc/zwae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/21/2024]
Abstract
AIMS The availability of novel lipid-lowering therapies (LLTs) has remarkably changed the clinical management of homozygous familial hypercholesterolaemia (HoFH). The impact of these advances was evaluated in a cohort of 139 HoFH patients followed in a real-world clinical setting. METHODS AND RESULTS The clinical characteristics of 139 HoFH patients, along with information about LLTs and low-density lipoprotein cholesterol (LDL-C) levels at baseline and after a median follow-up of 5 years, were retrospectively retrieved from the records of patients enrolled in the LIPid transport disorders Italian GEnetic Network-Familial Hypercholesterolaemia (LIPIGEN-FH) Registry. The annual rates of major atherosclerotic cardiovascular events (MACE-plus) during follow-up were compared before and after baseline. Additionally, the lifelong survival free from MACE-plus was compared with that of the historical LIPIGEN HoFH cohort. At baseline, LDL-C level was 332 ± 138 mg/dL. During follow-up, the potency of LLTs was enhanced and, at the last visit, 15.8% of patients were taking quadruple therapy. Consistently, LDL-C decreased to an average value of 124 mg/dL corresponding to a 58.3% reduction (Pt < 0.001), with the lowest value (∼90 mg/dL) reached in patients receiving proprotein convertase subtilisin/kexin type 9 inhibitors and lomitapide and/or evinacumab as add-on therapies. The average annual MACE-plus rate in the 5-year follow-up was significantly lower than that observed during the 5 years before baseline visit (21.7 vs. 56.5 per 1000 patients/year; P = 0.0016). CONCLUSION Our findings indicate that the combination of novel and conventional LLTs significantly improved LDL-C control with a signal of better cardiovascular prognosis in HoFH patients. Overall, these results advocate the use of intensive, multidrug LLTs to effectively manage HoFH.
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Affiliation(s)
- Laura D'Erasmo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell'Università 37, Rome 00185, Italy
| | - Simone Bini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell'Università 37, Rome 00185, Italy
| | - Manuela Casula
- IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | | | - Stefano Bertolini
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Sebastiano Calandra
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Patrizia Tarugi
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Maurizio Averna
- Department of Health Promotion, Mother and Child Care, Internal Medicine, University of Palermo, Palermo, Italy
- Medical Specialties 'G. D'Alessandro' (PROMISE), University of Palermo, Palermo, Italy
| | - Gabriella Iannuzzo
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Giuliana Fortunato
- Department of Molecular Medicine and Medical Biotechnology, Federico II University of Naples, Naples, Italy
- CEINGE S.C.a r.l. Advanced Biotechnology, Naples, Italy
| | - Alberico L Catapano
- IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell'Università 37, Rome 00185, Italy
- Internal medicine and metabolic diseases Unit, Azienda Ospedaliero Universitaria Policlinico Umberto I, Rome, Italy
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Mhaimeed O, Burney ZA, Schott SL, Kohli P, Marvel FA, Martin SS. The importance of LDL-C lowering in atherosclerotic cardiovascular disease prevention: Lower for longer is better. Am J Prev Cardiol 2024; 18:100649. [PMID: 38576462 PMCID: PMC10992711 DOI: 10.1016/j.ajpc.2024.100649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/25/2024] [Accepted: 03/09/2024] [Indexed: 04/06/2024] Open
Abstract
Cumulative exposure to low-density lipoprotein cholesterol (LDL-C) is a key driver of atherosclerotic cardiovascular disease (ASCVD) risk. An armamentarium of therapies to achieve robust and sustained reduction in LDL-C can reduce ASCVD risk. The gold standard for LDL-C assessment is ultracentrifugation but in routine clinical practice LDL-C is usually calculated and the most accurate calculation is the Martin/Hopkins equation. For primary prevention, consideration of estimated ASCVD risk frames decision making regarding use of statins and other therapies, and tools such as risk enhancing factors and coronary artery calcium enable tailoring of risk assessment and decision making. In patients with diabetes, lipid lowering therapy is recommended in most patients to reduce ASCVD risk with an opportunity to tailor therapy based on other risk factors. Patients with primary hypercholesterolemia and familial hypercholesterolemia (FH) with baseline LDL-C greater than or equal to 190 mg/dL are at elevated risk, and LDL-C lowering with high-intensity statin therapy is often combined with non-statin therapies to prevent ASCVD. Secondary prevention of ASCVD, including in patients with prior myocardial infarction or stroke, requires intensive lipid lowering therapy and lifestyle modification approaches. There is no established LDL-C level below which benefit ceases or safety concerns arise. When further LDL-C lowering is required beyond lifestyle modifications and statin therapy, additional medications include oral ezetimibe and bempedoic acid, or injectables such as PCSK9 monoclonal antibodies or siRNA therapy. A novel agent that acts independently of hepatic LDL receptors is evinacumab, which is approved for patients with homozygous FH. Other emerging agents are targeted at Lp(a) and CETP. In light of the expanding lipid treatment landscape, this manuscript reviews the importance of early, intensive, and sustained LDL-C-lowering for primary and secondary prevention of ASCVD.
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Affiliation(s)
- Omar Mhaimeed
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Zain A Burney
- Department of Medicine, Cleveland Clinic, Cleveland, OH, United States
| | - Stacey L Schott
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Payal Kohli
- Department of Cardiology, University of Colorado Anschutz, Aurora, CO, United States
- Department of Cardiology, Veterans Affairs Hospital, Aurora, CO, United States
- Cherry Creek Heart, Aurora, CO, United States
- Tegna Broadcasting, MD, United States
| | - Francoise A Marvel
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Seth S Martin
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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10
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Filtz A, Parihar S, Greenberg GS, Park CM, Scotti A, Lorenzatti D, Badimon JJ, Soffer DE, Toth PP, Lavie CJ, Bittner V, Virani SS, Slipczuk L. New approaches to triglyceride reduction: Is there any hope left? Am J Prev Cardiol 2024; 18:100648. [PMID: 38584606 PMCID: PMC10998004 DOI: 10.1016/j.ajpc.2024.100648] [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: 12/17/2023] [Revised: 02/29/2024] [Accepted: 03/09/2024] [Indexed: 04/09/2024] Open
Abstract
Triglycerides play a crucial role in the efficient storage of energy in the body. Mild and moderate hypertriglyceridemia (HTG) is a heterogeneous disorder with significant association with atherosclerotic cardiovascular disease (ASCVD), including myocardial infarction, ischemic stroke, and peripheral artery disease and represents an important component of the residual ASCVD risk in statin treated patients despite optimal low-density lipoprotein cholesterol reduction. Individuals with severe HTG (>1,000 mg/dL) rarely develop atherosclerosis but have an incremental incidence of acute pancreatitis with significant morbidity and mortality. HTG can occur from a combination of genetic (both mono and polygenic) and environmental factors including poor diet, low physical activity, obesity, medications, and diseases like insulin resistance and other endocrine pathologies. HTG represents a potential target for ASCVD risk and pancreatitis risk reduction, however data on ASCVD reduction by treating HTG is still lacking and HTG-associated acute pancreatitis occurs too rarely to effectively demonstrate treatment benefit. In this review, we address the key aspects of HTG pathophysiology and examine the mechanisms and background of current and emerging therapies in the management of HTG.
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Affiliation(s)
- Annalisa Filtz
- Cardiology Division, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Siddhant Parihar
- Cardiology Division, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Garred S Greenberg
- Cardiology Division, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christine M Park
- Cardiology Division, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrea Scotti
- Cardiology Division, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Lorenzatti
- Cardiology Division, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan J Badimon
- Cardiology Department, Hospital General Jaen, Jaen, Spain
- Atherothrombosis Research Unit, Mount Sinai School of Medicine, New York, New York, USA
| | - Daniel E Soffer
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter P Toth
- CGH Medical Center, Sterling, Illinois
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, Louisiana, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, The Aga Khan University, Karachi, Pakistan
- Section of Cardiology, Texas Heart Institute & Baylor College of Medicine, Houston, TX, USA
| | - Leandro Slipczuk
- Cardiology Division, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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11
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Ballantyne CM, Vasas S, Azizad M, Clifton P, Rosenson RS, Chang T, Melquist S, Zhou R, Mushin M, Leeper NJ, Hellawell J, Gaudet D. Plozasiran, an RNA Interference Agent Targeting APOC3, for Mixed Hyperlipidemia. N Engl J Med 2024. [PMID: 38804517 DOI: 10.1056/nejmoa2404143] [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: 05/29/2024]
Abstract
BACKGROUND Persons with mixed hyperlipidemia are at risk for atherosclerotic cardiovascular disease due to an elevated non-high-density lipoprotein (HDL) cholesterol level, which is driven by remnant cholesterol in triglyceride-rich lipoproteins. The metabolism and clearance of triglyceride-rich lipoproteins are down-regulated through apolipoprotein C3 (APOC3)-mediated inhibition of lipoprotein lipase. METHODS We carried out a 48-week, phase 2b, double-blind, randomized, placebo-controlled trial evaluating the safety and efficacy of plozasiran, a hepatocyte-targeted APOC3 small interfering RNA, in patients with mixed hyperlipidemia (i.e., a triglyceride level of 150 to 499 mg per deciliter and either a low-density lipoprotein [LDL] cholesterol level of ≥70 mg per deciliter or a non-HDL cholesterol level of ≥100 mg per deciliter). The participants were assigned in a 3:1 ratio to receive plozasiran or placebo within each of four cohorts. In the first three cohorts, the participants received a subcutaneous injection of plozasiran (10 mg, 25 mg, or 50 mg) or placebo on day 1 and at week 12 (quarterly doses). In the fourth cohort, participants received 50 mg of plozasiran or placebo on day 1 and at week 24 (half-yearly dose). The data from the participants who received placebo were pooled. The primary end point was the percent change in fasting triglyceride level at week 24. RESULTS A total of 353 participants underwent randomization. At week 24, significant reductions in the fasting triglyceride level were observed with plozasiran, with differences, as compared with placebo, in the least-squares mean percent change from baseline of -49.8 percentage points (95% confidence interval [CI], -59.0 to -40.6) with the 10-mg-quarterly dose, -56.0 percentage points (95% CI, -65.1 to -46.8) with the 25-mg-quarterly dose, -62.4 percentage points (95% CI, -71.5 to -53.2) with the 50-mg-quarterly dose, and -44.2 percentage points (95% CI, -53.4 to -35.0) with the 50-mg-half-yearly dose (P<0.001 for all comparisons). Worsening glycemic control was observed in 10% of the participants receiving placebo, 12% of those receiving the 10-mg-quarterly dose, 7% of those receiving the 25-mg-quarterly dose, 20% of those receiving the 50-mg-quarterly dose, and 21% of those receiving the 50-mg-half-yearly dose. CONCLUSIONS In this randomized, controlled trial involving participants with mixed hyperlipidemia, plozasiran, as compared with placebo, significantly reduced triglyceride levels at 24 weeks. A clinical outcomes trial is warranted. (Funded by Arrowhead Pharmaceuticals; MUIR ClinicalTrials.gov number NCT04998201.).
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Affiliation(s)
- Christie M Ballantyne
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Szilard Vasas
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Masoud Azizad
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Peter Clifton
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Robert S Rosenson
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Ting Chang
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Stacey Melquist
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Rong Zhou
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Ma'an Mushin
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Nicholas J Leeper
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Jennifer Hellawell
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
| | - Daniel Gaudet
- From the Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); Borbánya Praxis, Nyíregyháza, Hungary (S.V.); Valley Clinical Trials, Northridge (M.A.), Arrowhead Pharmaceuticals, Pasadena (T.C., S.M., R.Z., M.M., J.H.), and the Stanford School of Medicine, Stanford (N.J.L.) - all in California; the Royal Adelaide Hospital, Adelaide, SA, Australia (P.C.); the Icahn School of Medicine at Mount Sinai, New York (R.S.R.); and the Department of Medicine, Université de Montréal and Ecogene-21, Quebec, QC, Canada (D.G.)
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Luo F, Das A, Khetarpal SA, Fang Z, Zelniker TA, Rosenson RS, Qamar A. ANGPTL3 inhibition, dyslipidemia, and cardiovascular diseases. Trends Cardiovasc Med 2024; 34:215-222. [PMID: 36746257 DOI: 10.1016/j.tcm.2023.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 02/07/2023]
Abstract
Optimal management of low-density lipoprotein cholesterol (LDL-C) is a central tenet in the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). However, significant residual cardiovascular risk remains despite achieving guideline-directed LDL-C levels, in part due to mixed hyperlipidemia with elevated fasting and non-fasting triglyceride-rich lipoprotein levels. Advances in human genetics have identified angiopoietin-like 3 (ANGPTL3) as a promising therapeutic target to lower cardiovascular risk. Evidence accrued from genetic epidemiological studies demonstrate that ANGPTL3 loss of function is strongly associated with lowering of circulating LDL-C, triglyceride-rich lipoproteins and concurrent risk reduction in development of coronary artery disease. Pharmacological inhibition of ANGPTL3 with monoclonal antibodies, antisense oligonucleotides and gene editing are in development with early studies showing their safety and efficacy in lowering in both, LDL-C and TGs, circumventing a key limitation of previous therapies. Monoclonal antibodies targeting ANGPTL3 are approved for clinical use in homozygous familial hypercholesteremia in USA and Europe. Although promising, future studies focusing on long-term beneficial effect in reducing cardiovascular events with inhibition of ANGPTL3 are warranted.
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Affiliation(s)
- Fei Luo
- Department of Cardiovascular Medicine, Research Institute of Blood Lipid and Atherosclerosis, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Avash Das
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Sumeet A Khetarpal
- Division of Cardiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Zhenfei Fang
- Department of Cardiovascular Medicine, Research Institute of Blood Lipid and Atherosclerosis, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Thomas A Zelniker
- Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Austria
| | - Robert S Rosenson
- Metabolism and Lipids Unit, Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josee and Henry R Kravis Center for Cardiovascular Health, Mount Sinai Icahn School of Medicine, New York, NY, United States
| | - Arman Qamar
- Section of Interventional Cardiology & Vascular Medicine, NorthShore University Health System, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Evanston, IL, United States.
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13
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Landfors F, Henneman P, Chorell E, Nilsson SK, Kersten S. Drug-target Mendelian randomization analysis supports lowering plasma ANGPTL3, ANGPTL4, and APOC3 levels as strategies for reducing cardiovascular disease risk. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae035. [PMID: 38895109 PMCID: PMC11182694 DOI: 10.1093/ehjopen/oeae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/30/2024] [Accepted: 04/26/2024] [Indexed: 06/21/2024]
Abstract
Aims APOC3, ANGPTL3, and ANGPTL4 are circulating proteins that are actively pursued as pharmacological targets to treat dyslipidaemia and reduce the risk of atherosclerotic cardiovascular disease. Here, we used human genetic data to compare the predicted therapeutic and adverse effects of APOC3, ANGPTL3, and ANGPTL4 inactivation. Methods and results We conducted drug-target Mendelian randomization analyses using variants in proximity to the genes associated with circulating protein levels to compare APOC3, ANGPTL3, and ANGPTL4 as drug targets. We obtained exposure and outcome data from large-scale genome-wide association studies and used generalized least squares to correct for linkage disequilibrium-related correlation. We evaluated five primary cardiometabolic endpoints and screened for potential side effects across 694 disease-related endpoints, 43 clinical laboratory tests, and 11 internal organ MRI measurements. Genetically lowering circulating ANGPTL4 levels reduced the odds of coronary artery disease (CAD) [odds ratio, 0.57 per s.d. protein (95% CI 0.47-0.70)] and Type 2 diabetes (T2D) [odds ratio, 0.73 per s.d. protein (95% CI 0.57-0.94)]. Genetically lowering circulating APOC3 levels also reduced the odds of CAD [odds ratio, 0.90 per s.d. protein (95% CI 0.82-0.99)]. Genetically lowered ANGPTL3 levels via common variants were not associated with CAD. However, meta-analysis of protein-truncating variants revealed that ANGPTL3 inactivation protected against CAD (odds ratio, 0.71 per allele [95%CI, 0.58-0.85]). Analysis of lowered ANGPTL3, ANGPTL4, and APOC3 levels did not identify important safety concerns. Conclusion Human genetic evidence suggests that therapies aimed at reducing circulating levels of ANGPTL3, ANGPTL4, and APOC3 reduce the risk of CAD. ANGPTL4 lowering may also reduce the risk of T2D.
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Affiliation(s)
- Fredrik Landfors
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, B41, Norrlands universitetssjukhus, S-901 87 Umeå, Sweden
- Lipigon Pharmaceuticals AB, Tvistevägen 48C, S-907 36 Umeå, Sweden
| | - Peter Henneman
- Department of Human Genetics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Elin Chorell
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, B41, Norrlands universitetssjukhus, S-901 87 Umeå, Sweden
| | - Stefan K Nilsson
- Lipigon Pharmaceuticals AB, Tvistevägen 48C, S-907 36 Umeå, Sweden
- Department of Medical Biosciences, Umeå University, B41, Norrlands universitetssjukhus, S-901 87 Umeå, Sweden
| | - Sander Kersten
- Nutrition, Metabolism, and Genomics group, Division of Human Nutrition and Health, Wageningen University, 6708WE Wageningen, the Netherlands
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA
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Qureshi Z, Khanzada M, Safi A, Fatima E, Altaf F, Vittorio TJ. Hypercholesterolemia: a literature review on management using tafolecimab: a novel member of PCSK9 monoclonal antibodies. Ann Med Surg (Lond) 2024; 86:2818-2827. [PMID: 38694324 PMCID: PMC11060207 DOI: 10.1097/ms9.0000000000001945] [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: 12/05/2023] [Accepted: 03/02/2024] [Indexed: 05/04/2024] Open
Abstract
Background Cardiovascular diseases (CVD) persist as the leading cause of mortality globally, with atherosclerotic cardiovascular disease (ASCVD), including hypercholesterolaemia, being a significant contributor. Hyperlipidemia management includes various lipid-lowering drugs, including statins, Bempedoic acid, inclisiran, Lomitapide, ANGPTL3 inhibitors, and PCSK9 inhibitors. Statins have traditionally dominated lipid management therapies; however, a subset of patients remains unresponsive or intolerant to this therapy, necessitating novel therapeutic approaches. Tafolecimab, a promising and novel PCSK9 monoclonal antibody, demonstrated significant LDL-C reduction and a favourable safety profile in clinical trials. Objective This review aimed to discuss the role and efficacy of Tafolecimab in the management of hypercholesterolaemia. Methods The authors searched online databases, including PubMed, Scopus, and Embase, for articles related to talofecimab. Discussion The efficacy of Tafolecimab in diverse patient populations, including those with comorbid conditions and various lipid disorders, has been explored. Ongoing trials, such as CREDIT-1, CREDIT-2, and CREDIT-4, have provided valuable insights into Tafolecimab's potential as a lipid-lowering agent. Moreover, the drug's extended dosing interval may enhance patient compliance and reduce treatment costs. It has also been found that Tafolecimab has more affinity for PCSK9 and a longer duration of LDL-C reduction than other monoclonal antibody drugs such as evolocumab. Thus, this review focuses on Tafolecimab, a novel PCSK9 monoclonal antibody, its mechanism of action, clinical trial outcomes, safety profile, and potential role in hypercholesterolaemia management. Despite its assuring potential, the long-term impact of Tafolecimab on cardiovascular outcomes remains to be fully elucidated, necessitating further research. Regulatory authorities like the FDA and EMA should also evaluate Tafolecimab's risks and benefits. Conclusion In conclusion, Tafolecimab shows potential as an innovative therapeutic option for hypercholesterolaemia, particularly in patients with specific risk factors, but warrants additional research.
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Affiliation(s)
- Zaheer Qureshi
- The Frank H. Netter M.D. School of Medicine at Quinnipiac University, Bridgeport, CT
| | - Mikail Khanzada
- Department of Internal Medicine, Lahore Medical & Dental College
| | - Adnan Safi
- Department of Medicine, Lahore General Hospital
| | - Eeshal Fatima
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Faryal Altaf
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai/BronxCare Health System
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Pawlos A, Khoury E, Gaudet D. Emerging therapies for refractory hypercholesterolemia: a narrative review. Future Cardiol 2024; 20:317-334. [PMID: 38985520 PMCID: PMC11318688 DOI: 10.1080/14796678.2024.2367860] [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: 01/03/2024] [Accepted: 06/11/2024] [Indexed: 07/12/2024] Open
Abstract
Refractory hypercholesterolemia (RH) is characterized by the failure of patients to achieve therapeutic targets for low-density lipoprotein-cholesterol (LDL-C) despite receiving maximal tolerable doses of standard lipid-lowering treatments. It predominantly impacts individuals with familial hypercholesterolemia (FH), thereby elevating the risk of cardiovascular complications. The prevalence of RH is now recognized to be substantially greater than previously thought. This review provides a comprehensive insight into current and emerging therapies for RH patients, including groundbreaking genetic-based therapeutic approaches. The review places emphasis on the dependency of therapies on low-density lipoprotein receptors (LDLRs) and highlights the critical role of considering LDLR activity in RH patients for individualization of the treatment.
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Affiliation(s)
- Agnieszka Pawlos
- Department of Internal Diseases & Clinical Pharmacology, Laboratory of Tissue Immunopharmacology, Medical University of Lodz, Kniaziewicza 1/5, 91-347, Lodz, Poland
| | - Etienne Khoury
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada
| | - Daniel Gaudet
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada
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Abdulla A, Shalaby M, Kumfa P, Raja M, Allencherril J, Sharifeh TA. Updates on Non-Statin LDL-Lowering Therapy. Curr Cardiol Rep 2024; 26:221-231. [PMID: 38436784 DOI: 10.1007/s11886-024-02028-3] [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] [Accepted: 02/06/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE OF REVIEW There is ample evidence of the benefits and safety of low-density lipoprotein (LDL)-lowering therapies in the prevention of atherosclerotic cardiovascular disease. While statins remain the first-line agent for LDL reduction, several new therapies are now available. This narrative review provides an overview of currently available non-statin LDL-lowering agents, specifically mechanisms of action and data on efficacy and safety. It also discusses recommendations on their use in clinical practice. RECENT FINDINGS Ezetimibe, PCSK9 inhibitors, and bempedoic acid have proven safe and efficacious in reducing cardiovascular events in large randomized controlled trials. Inclisiran is a promising agent that suppresses PCSK9 mRNA translation and is currently under investigation in a large clinical outcomes randomized controlled trial assessing its effect on clinical outcomes. Expert consensus advocates for lower LDL targets in higher risk patients and escalation to or a combination of non-statin therapies as needed to achieve these goals.
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Affiliation(s)
- Amer Abdulla
- , 301 University Blvd., JSA 5.106G, Galveston, TX, 77555-0553, USA.
| | - Mostafa Shalaby
- , 301 University Blvd., JSA 5.106G, Galveston, TX, 77555-0553, USA
| | - Paul Kumfa
- , 301 University Blvd., JSA 5.106G, Galveston, TX, 77555-0553, USA
| | - Muhammad Raja
- , 301 University Blvd., JSA 5.106G, Galveston, TX, 77555-0553, USA
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Reijman MD, Kusters DM, Wiegman A. Current and emerging monoclonal antibodies for treating familial hypercholesterolemia in children. Expert Opin Biol Ther 2024; 24:243-249. [PMID: 38501269 DOI: 10.1080/14712598.2024.2330948] [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: 11/03/2023] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Heterozygous familial hypercholesterolemia (HeFH) is a common genetic disorder caused by pathogenic variants in the LDL-C metabolism. Lifelong exposure to elevated LDL-C levels leads to a high risk of premature cardiovascular disease. To reduce that risk, children with HeFH should be identified and treated with lipid-lowering therapy. The cornerstone consists of statins and ezetimibe, but not in all patients this lowers the LDL-C levels to treatment targets. For these patients, more intensive lipid-lowering therapy is needed. AREAS COVERED In this review, we provide an overview of the monoclonal antibodies which are currently available or being tested for treating HeFH in childhood. EXPERT OPINION Monoclonal antibodies that inhibit PCSK9 are first in line lipid-lowering treatment options if oral statin and ezetimibe therapy are insufficient, due to intolerance or very high baseline LDL-C levels. Both evolocumab and alirocumab have been shown to be safe and effective in children with HeFH. For children, evolocumab has been registered from the age of 10 years old and alirocumab from the age of 8 years old. The costs of these new agents are much higher than oral therapy, which makes it important to only use them in a selected patient population.
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Affiliation(s)
- M Doortje Reijman
- Department of Pediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - D Meeike Kusters
- Department of Pediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Albert Wiegman
- Department of Pediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Liu S, Ke J, Feng X, Wang Z, Wang X, Yang L, Zhao D. The Effect of Canagliflozin on High-Density Lipoprotein Cholesterol and Angiopoietin-Like Protein 3 in Type 2 Diabetes Mellitus. J Diabetes Res 2024; 2024:2431441. [PMID: 38577301 PMCID: PMC10994702 DOI: 10.1155/2024/2431441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 01/12/2024] [Accepted: 02/28/2024] [Indexed: 04/06/2024] Open
Abstract
Background Diabetes mellitus is often accompanied by dyslipidemia. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, as a novel therapeutic agent for the treatment of type 2 diabetes mellitus (T2DM), have been reported to exert effects on lipid, while the results remain controversial. This study is aimed at exploring the effect of SGLT2 inhibitor canagliflozin on lipid profile. Methods This study was a single-center, open-label, nonrandomized, prospective study. Metformin (500 mg three times per day) or canagliflozin (100 mg, once daily) was administered for 12 weeks. Fasting blood samples were collected before and 12 weeks after treatment. Serum lipid profile levels and angiopoietin-like protein 3 (ANGPTL3) were determined. In animal experiment, C57BL/6 J mice were divided into three groups including control, STZ + HFD, and STZ + HFD + canagliflozin. Lipid profile and plasma ANGPTL3 level were measured after 12 week's treatment. Moreover, the expression of ANGPTL3 was detected in the liver tissues. Results There was a decreased trend in low-density lipoprotein cholesterol (LDL-c) and triglycerides (TG) after canagliflozin treatment, while canagliflozin significantly increased high-density lipoprotein cholesterol (HDL-c) level and decreased plasma ANGPTL3 level. In addition, the expression of ANGPTL3 in liver tissues decreased obviously in diabetic mice with canagliflozin treatment. Conclusions Canagliflozin increases HDL-c level and suppresses ANGPTL3 expression in patients with T2DM and diabetic mice. The reduction of ANGPTL3 may contribute to the increase of HDL-c. However, the specific mechanism needs further research. This trial is registered with ChiCTR1900021231.
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Affiliation(s)
- Simo Liu
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jing Ke
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Feng
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zongwei Wang
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xin Wang
- Institute of Medical Genomics, Biomedical Sciences College, Shandong First Medical University, Taian, Shandong, China
| | - Longyan Yang
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Dong Zhao
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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19
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Rosenson RS, Rader DJ, Ali S, Banerjee P, McGinniss J, Pordy R. Evinacumab Reduces Triglyceride-Rich Lipoproteins in Patients with Hyperlipidemia: A Post-Hoc Analysis of Three Randomized Clinical Trials. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07567-z. [PMID: 38446275 DOI: 10.1007/s10557-024-07567-z] [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: 02/24/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Natural selection (Mendelian randomization) studies support a causal relationship between elevated triglyceride-rich lipoproteins (TRLs) and atherosclerotic cardiovascular disease (ASCVD). This post-hoc analysis assessed the efficacy of evinacumab in reducing TRLs in patient cohorts from three separate clinical trials with evinacumab. METHODS Patients with homozygous familial hypercholesterolemia (HoFH) and low-density lipoprotein cholesterol (LDL-C) ≥ 70 mg/dL were enrolled in a phase III trial (R1500-CL-1629; NCT03399786). Patients diagnosed with refractory hypercholesterolemia, with LDL-C ≥ 70 mg/dL or ≥ 100 mg/dL for those with or without ASCVD, respectively, were enrolled in a phase II trial (R1500-CL-1643; NCT03175367). Patients with severe hypertriglyceridemia (fasting TGs ≥ 500 mg/dL) were enrolled in a phase II trial (R1500-HTG-1522; NCT03452228). Patients received evinacumab intravenously (5 or 15 mg/kg) every 4 weeks, or subcutaneously (300 or 450 mg) every week or every 2 weeks. Efficacy outcomes included change in TRLs (calculated as total cholesterol minus high-density lipoprotein cholesterol minus LDL-C) and other lipid parameters from baseline to 12, 16, or 24 weeks for trial 1522, 1643, and 1629, respectively. RESULTS At baseline, TRL levels were higher for patients with severe hypertriglyceridemia entering the 1522 trial vs. other cohorts. Reductions in TRLs were observed across all studies with evinacumab, with > 50% reduction from baseline observed at the highest doses evaluated in patients with HoFH or refractory hypercholesterolemia. Within all three trials, evinacumab was generally well tolerated. CONCLUSIONS Despite limitations in direct comparisons between study groups, these data indicate that TRL levels could be a future target for lipid-lowering therapies.
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Affiliation(s)
- Robert S Rosenson
- Metabolism and Lipids Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - Daniel J Rader
- Department of Genetics and Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Shazia Ali
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, New York, NY, 10591, USA
| | - Poulabi Banerjee
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, New York, NY, 10591, USA
| | - Jennifer McGinniss
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, New York, NY, 10591, USA
| | - Robert Pordy
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, New York, NY, 10591, USA
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20
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Paquette M, Baass A. Advances in familial hypercholesterolemia. Adv Clin Chem 2024; 119:167-201. [PMID: 38514210 DOI: 10.1016/bs.acc.2024.02.004] [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] [Indexed: 03/23/2024]
Abstract
Familial hypercholesterolemia (FH), a semi-dominant genetic disease affecting more than 25 million people worldwide, is associated with severe hypercholesterolemia and premature atherosclerotic cardiovascular disease. Over the last decade, advances in data analysis, screening, diagnosis and cardiovascular risk stratification has significantly improved our ability to deliver precision medicine for these patients. Furthermore, recent updates on guideline recommendations and new therapeutic approaches have also proven to be highly beneficial. It is anticipated that both ongoing and upcoming clinical trials will offer further insights for the care and treatment of FH patients.
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Affiliation(s)
- Martine Paquette
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, QC, Canada
| | - Alexis Baass
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, QC, Canada; Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, Montreal, QC, Canada.
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21
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Zimerman A, Wiviott SD, Park JG, Murphy SA, Ran X, Bramson CR, Curto M, Ramos V, Jevne A, Kuder JF, Verma S, Wojakowski W, Terra SG, Sabatine MS, Bergmark BA, Marston NA. Hepatic fat changes with antisense oligonucleotide therapy targeting ANGPTL3. J Clin Lipidol 2024; 18:e261-e268. [PMID: 38158248 DOI: 10.1016/j.jacl.2023.12.001] [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: 10/30/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Angiopoietin-like protein 3 (ANGPTL3) is a novel therapeutic target for hyperlipidemia. Vupanorsen, an antisense oligonucleotide targeting ANGPTL3, reduced triglycerides up to 57% in a phase 2b trial, but caused dose-dependent increases in hepatic fat fraction (HFF). OBJECTIVE To determine the degree of HFF progression with escalating doses of vupanorsen, differential HFF increases in key patient subgroups, and the correlation between changes in HFF and liver enzymes. METHODS TRANSLATE-TIMI 70 was a randomized, placebo-controlled trial testing 7 dosing regimens of vupanorsen in 286 adults with hyperlipidemia. A total of 227 patients had HFF measured at baseline and 24 weeks and were included in this analysis. RESULTS The median HFF at baseline was 8.5%. Vupanorsen led to dose-dependent relative increases in HFF of up to 76% at 24 weeks (p < 0.001), corresponding to an absolute increase of up to 7.0% at the highest dose (p < 0.001). Increases in HFF were numerically greater in patients who had elevated baseline HFF, body mass index, triglycerides, or diabetes. Vupanorsen also increased liver enzymes in a dose-dependent manner, and changes in HFF were moderately positively correlated with changes in aspartate transaminase (AST) (rho = 0.49, p < 0.001) and alanine transaminase (ALT) (rho = 0.50, p < 0.001). CONCLUSION Vupanorsen, an inhibitor of ANGPTL3 protein synthesis, caused dose-dependent increases in HFF. Increases in HFF were only moderately correlated with elevations in AST and ALT, suggesting that liver enzymes are an imperfect indicator to detect increases in hepatic fat. These results highlight the need to monitor HFF in clinical trials of therapies targeting intracellular ANGPTL3 inhibition, especially those that are targeted to the liver.
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Affiliation(s)
- Andre Zimerman
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Xinhui Ran
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Candace R Bramson
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Madelyn Curto
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Vesper Ramos
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Alexandra Jevne
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Subodh Verma
- Department of Surgery, University of Toronto, Toronto, Canada (Dr. Verma)
| | | | - Steven G Terra
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Nicholas A Marston
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston).
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22
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Gobeil É, Bourgault J, Mitchell PL, Houessou U, Gagnon E, Girard A, Paulin A, Manikpurage HD, Côté V, Couture C, Marceau S, Bossé Y, Thériault S, Mathieu P, Vohl MC, Tchernof A, Arsenault BJ. Genetic inhibition of angiopoietin-like protein-3, lipids, and cardiometabolic risk. Eur Heart J 2024; 45:707-721. [PMID: 38243829 PMCID: PMC10906986 DOI: 10.1093/eurheartj/ehad845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/16/2023] [Accepted: 12/07/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND AND AIMS RNA-based, antibody-based, and genome editing-based therapies are currently under investigation to determine if the inhibition of angiopoietin-like protein-3 (ANGPTL3) could reduce lipoprotein-lipid levels and atherosclerotic cardiovascular disease (ASCVD) risk. Mendelian randomisation (MR) was used to determine whether genetic variations influencing ANGPTL3 liver gene expression, blood levels, and protein structure could causally influence triglyceride and apolipoprotein B (apoB) levels as well as coronary artery disease (CAD), ischaemic stroke (IS), and other cardiometabolic diseases. METHODS RNA sequencing of 246 explanted liver samples and genome-wide genotyping was performed to identify single-nucleotide polymorphisms (SNPs) associated with liver expression of ANGPTL3. Genome-wide summary statistics of plasma protein levels of ANGPTL3 from the deCODE study (n = 35 359) were used. A total of 647 carriers of ANGPTL3 protein-truncating variants (PTVs) associated with lower plasma triglyceride levels were identified in the UK Biobank. Two-sample MR using SNPs that influence ANGPTL3 liver expression or ANGPTL3 plasma protein levels as exposure and cardiometabolic diseases as outcomes was performed (CAD, IS, heart failure, non-alcoholic fatty liver disease, acute pancreatitis, and type 2 diabetes). The impact of rare PTVs influencing plasma triglyceride levels on apoB levels and CAD was also investigated in the UK Biobank. RESULTS In two-sample MR studies, common genetic variants influencing ANGPTL3 hepatic or blood expression levels of ANGPTL3 had a very strong effect on plasma triglyceride levels, a more modest effect on low-density lipoprotein cholesterol, a weaker effect on apoB levels, and no effect on CAD or other cardiometabolic diseases. In the UK Biobank, the carriers of rare ANGPTL3 PTVs providing lifelong reductions in median plasma triglyceride levels [-0.37 (interquartile range 0.41) mmol/L] had slightly lower apoB levels (-0.06 ± 0.32 g/L) and similar CAD event rates compared with non-carriers (10.2% vs. 10.9% in carriers vs. non-carriers, P = .60). CONCLUSIONS PTVs influencing ANGPTL3 protein structure as well as common genetic variants influencing ANGPTL3 hepatic expression and/or blood protein levels exhibit a strong effect on circulating plasma triglyceride levels, a weak effect on circulating apoB levels, and no effect on ASCVD. Near-complete inhibition of ANGPTL3 function in patients with very elevated apoB levels may be required to reduce ASCVD risk.
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Affiliation(s)
- Émilie Gobeil
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Jérôme Bourgault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Patricia L Mitchell
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Ursula Houessou
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Eloi Gagnon
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Arnaud Girard
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Audrey Paulin
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Hasanga D Manikpurage
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Valérie Côté
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Christian Couture
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Simon Marceau
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, Canada
| | - Yohan Bossé
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, Québec, Canada
| | - Sébastien Thériault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
- Department of Molecular Biology, Medical Biochemistry and Pathology, Faculty of Medicine, Université Laval, Québec, Canada
| | - Patrick Mathieu
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, Canada
| | - Marie-Claude Vohl
- School of Nutrition, Université Laval, Québec, Canada
- Centre Nutrition, santé et société, Institut sur la nutrition et les aliments fonctionnels, Université Laval, Québec, Canada
| | - André Tchernof
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
- School of Nutrition, Université Laval, Québec, Canada
| | - Benoit J Arsenault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, 2725 chemin Ste-Foy, Québec, QC G1V 4G5, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, 2325 Rue de l'Université, Québec, QC G1V 0A6, Canada
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23
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White RT, Sankey KH, Nawarskas JJ. Evinacumab-dgnb (Evkeeza-REGN1500), A Novel Lipid-Lowering Therapy for Homozygous Familial Hypercholesterolemia. Cardiol Rev 2024; 32:180-185. [PMID: 37071085 DOI: 10.1097/crd.0000000000000522] [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: 04/19/2023]
Abstract
Chronically elevated low-density lipoprotein (LDL) has harmful effects on the vasculature including increased vasoconstriction and the formation of plaques which may rupture, causing coronary heart disease and stroke. In patients with familial hypercholesterolemia, adequate reduction of LDL is especially challenging. Although HMG-CoA reductase inhibitors (statins) are the mainstays for LDL lowering, other treatments such as proprotein convertase subtilisin/kexin type 9 inhibitors, bempedoic acid, incliseran, lomitapide, and apheresis have been employed in an effort to achieve adequate LDL reduction in these patients. Despite these available therapies, many patients with familial hypercholesterolemia do not meet the LDL targets suggested in current guidelines. Evinacumab is a novel lipid-lowering therapy that exerts its LDL-lowering effect through inhibition of angiopoietin-like protein 3 (ANGPTL3). ANGPTL3 inhibits the breakdown of triglyceride-rich lipoproteins, such as very low-density lipoprotein and chylomicrons. By inhibiting ANGPTL3, evinacumab allows these lipoproteins to be degraded, ultimately leading to reductions in LDL, high-density lipoprotein, and triglycerides. Clinical trials have demonstrated evinacumab to be safe and effective in reducing LDL. However, data are lacking regarding its potential to reduce risk of atherosclerotic cardiovascular disease. Evinacumab is generally well tolerated with the primary adverse effects comprising infusion reactions, nasopharyngitis, influenza-like illness, dizziness, rhinorrhea, and nausea. While evinacumab is an interesting therapy, until it is proven to reduce cardiovascular events, its high cost leaves its anticipated role in therapy somewhat ambiguous. In the meantime, it may be a useful therapy for those with homozygous familial hypercholesterolemia.
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Affiliation(s)
- Raechel T White
- From the Department of Pharmacy Practice and Administrative sciences, College of Pharmacy, University of New Mexico Health Science Center, Albuquerque, NM
| | | | - James J Nawarskas
- From the Department of Pharmacy Practice and Administrative sciences, College of Pharmacy, University of New Mexico Health Science Center, Albuquerque, NM
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24
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Sawhney JPS, Madan K. Familial hypercholesterolemia. Indian Heart J 2024; 76 Suppl 1:S108-S112. [PMID: 38599725 PMCID: PMC11019323 DOI: 10.1016/j.ihj.2023.12.002] [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: 12/02/2023] [Indexed: 04/12/2024] Open
Abstract
Familial hypercholesterolemia is a common genetic disorder of autosomal inheritance associated with elevated LDL-cholesterol. It is estimated to affect 1:250 individuals in general population roughly estimated to be 5 million in India. The prevalence of FH is higher in young CAD patients (<55 years in men; <60 years in women). FH is underdiagnosed and undertreated. Screening during childhood and Cascade screening of family members of known FH patients is of utmost importance in order to prevent the burden of CAD. Early identification of FH patients and early initiation of the lifelong lipid lowering therapy is the most effective strategy for managing FH. FH management includes pharmaceutical agents (statins and non statin drugs) and lifestyle modification. Inspite of maximum dose of statin with or without Ezetimibe, if target levels of LDL-C are not achieved, Bempedoic acid, proprotein convertase subtilisin/kexin type 9 (PCSK9) Inhibitors/Inclisiran can be added.
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Affiliation(s)
- J P S Sawhney
- Dharma Vira Heart Center, Sir Ganga Ram Hospital, New Delhi 110060, India.
| | - Kushal Madan
- Dharma Vira Heart Center, Sir Ganga Ram Hospital, New Delhi 110060, India.
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25
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Davis JD, Bravo Padros M, Conrado DJ, Ganguly S, Guan X, Hassan HE, Hazra A, Irvin SC, Jayachandran P, Kosloski MP, Lin KJ, Mukherjee K, Paccaly A, Papachristos A, Partridge MA, Prabhu S, Visich J, Welf ES, Xu X, Zhao A, Zhu M. Subcutaneous Administration of Monoclonal Antibodies: Pharmacology, Delivery, Immunogenicity, and Learnings From Applications to Clinical Development. Clin Pharmacol Ther 2024; 115:422-439. [PMID: 38093583 DOI: 10.1002/cpt.3150] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
Subcutaneous (s.c.) administration of monoclonal antibodies (mAbs) can reduce treatment burden for patients and healthcare systems compared with intravenous (i.v.) infusion through shorter administration times, made possible by convenient, patient-centric devices. A deeper understanding of clinical pharmacology principles related to efficacy and safety of s.c.-administered mAbs over the past decade has streamlined s.c. product development. This review presents learnings from key constituents of the s.c. mAb development pathway, including pharmacology, administration variables, immunogenicity, and delivery devices. Restricted mAb transportation through the hypodermis explains their incomplete absorption at a relatively slow rate (pharmacokinetic (PK)) and may impact mAb-cellular interactions and/or onset and magnitude of physiological responses (pharmacodynamic). Injection volumes, formulation, rate and site of injection, and needle attributes may affect PKs and the occurrence/severity of adverse events like injection-site reactions or pain, with important consequences for treatment adherence. A review of immunogenicity data for numerous compounds reveals that incidence of anti-drug antibodies (ADAs) is generally comparable across i.v. and s.c. routes, and complementary factors including response magnitude (ADA titer), persistence over time, and neutralizing antibody presence are needed to assess clinical impact. Finally, four case studies showcase how s.c. biologics have been clinically developed: (i) by implementation of i.v./s.c. bridging strategies to streamline PD-1/PD-L1 inhibitor development, (ii) through co-development with i.v. presentations for anti-severe acute respiratory syndrome-coronavirus 2 antibodies to support rapid deployment of both formulations, (iii) as the lead route for bispecific T cell engagers (BTCEs) to mitigate BTCE-mediated cytokine release syndrome, and (iv) for pediatric patients in the case of dupilumab.
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Affiliation(s)
- John D Davis
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | | | | | - Samit Ganguly
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Xiaowen Guan
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Hazem E Hassan
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Anasuya Hazra
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Susan C Irvin
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | | | | | - Kuan-Ju Lin
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | | | - Anne Paccaly
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | | | | | - Saileta Prabhu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | | | - Erik S Welf
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Xiaoying Xu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - An Zhao
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Min Zhu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
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Hegele RA. Inhibiting angiopoietin-like protein 3: clear skies or clouds on the horizon? Eur Heart J 2024; 45:722-724. [PMID: 38366820 PMCID: PMC10906984 DOI: 10.1093/eurheartj/ehae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Affiliation(s)
- Robert A Hegele
- Department of Medicine and Robarts Research Institute, Western University, 4288A-1151 Richmond Street North, London, Ontario N6A 5B7, Canada
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27
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Wu NQ, Li ZF, Lu MY, Li JJ. Monoclonal antibodies for dyslipidemia in adults: a focus on vulnerable patients groups. Expert Opin Biol Ther 2024:1-13. [PMID: 38375817 DOI: 10.1080/14712598.2024.2321374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/15/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION Dyslipidemia significantly contributes to atherosclerotic cardiovascular disease (ASCVD). Patients with lipid-rich vulnerable plaques are particularly susceptible to cardiovascular complications. Despite available lipid-lowering therapies (LLTs), challenges in effective lipid management remain. AREAS COVERED This article reviews monoclonal antibody (mAb) therapy in dyslipidemia, particularly focusing on vulnerable plaques and patients. We have reviewed the definitions of vulnerable plaques and patients, outlined the efficacy of traditional LLTs, and discussed in-depth the mAbs targeting PCSK9. We extensively discuss the potential mechanisms, intracoronary imaging, and clinical evidence of PCSK9mAbs in vulnerable plaques and patients. A brief overview of promising mAbs targeting other targets such as ANGPTL3 is also provided. EXPERT OPINION Research consistently supports the potential of mAb therapies in treating adult dyslipidemia, particularly in vulnerable patients. PCSK9mAbs are effective in regulating lipid parameters, such as LDL-C and Lp(a), and exhibit anti-inflammatory and anti-thrombotic properties. These antibodies also maintain endothelial and smooth muscle health, contributing to the stabilization of vulnerable plaques and reduction in adverse cardiovascular events. Future research aims to further understand PCSK9 and other targets like ANGPTL3, focusing on vulnerable groups. Overall, mAbs are emerging as a promising and superior approach in dyslipidemia management and cardiovascular disease prevention.
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Affiliation(s)
- Na-Qiong Wu
- Cardiometabolic Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Zhi-Fan Li
- Cardiometabolic Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Meng-Ying Lu
- Cardiometabolic Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jian-Jun Li
- Cardiometabolic Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
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Agnello F, Ingala S, Laterra G, Scalia L, Barbanti M. Novel and Emerging LDL-C Lowering Strategies: A New Era of Dyslipidemia Management. J Clin Med 2024; 13:1251. [PMID: 38592091 PMCID: PMC10931739 DOI: 10.3390/jcm13051251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/09/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) represents a major global health challenge, significantly contributing to mortality rates. This chronic inflammatory condition affecting blood vessels is intricately linked to hypercholesterolemia, with elevated levels of low-density lipoprotein cholesterol (LDL-C) recognized as a central and modifiable risk factor. The effectiveness of lipid-lowering therapy (LLT) in mitigating ASCVD risk is well established, with studies revealing a substantial reduction in major ischemic events correlating with LDL-C reduction. While statins, often combined with ezetimibe, remain fundamental in dyslipidemia management, a significant proportion of patients on statin therapy continue to experience cardiovascular events. Recent pharmacological advancements, driven by a deeper understanding of atherogenesis, have unveiled novel therapeutic targets and potent drugs. Notably, agents like bempedoic acid and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (evolocumab, alirocumab, inclisiran) have emerged as effective options to intensify LLT and achieve LDL-C goals, addressing limitations associated with statins, such as myopathy. Molecular insights into alternative pathways have spurred the investigation of emerging agents, offering promising perspectives for novel medications with efficacy comparable to established treatments, associated with advantages in cost and administration. This review provides a comprehensive overview of the evolving landscape of lipid-lowering strategies, highlighting the progress made in addressing ASCVD risk and the potential of upcoming therapies to further optimize cardiovascular prevention.
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Affiliation(s)
- Federica Agnello
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
| | - Salvatore Ingala
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
| | - Giulia Laterra
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
| | - Lorenzo Scalia
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
| | - Marco Barbanti
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
- Faculty of Medicine and Surgery, Università degli Studi di Enna “Kore”, 94100 Enna, Italy
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Sherratt SCR, Mason RP, Libby P, Steg PG, Bhatt DL. Do patients benefit from omega-3 fatty acids? Cardiovasc Res 2024; 119:2884-2901. [PMID: 38252923 PMCID: PMC10874279 DOI: 10.1093/cvr/cvad188] [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: 05/01/2023] [Revised: 08/11/2023] [Accepted: 09/26/2023] [Indexed: 01/24/2024] Open
Abstract
Omega-3 fatty acids (O3FAs) possess beneficial properties for cardiovascular (CV) health and elevated O3FA levels are associated with lower incident risk for CV disease (CVD.) Yet, treatment of at-risk patients with various O3FA formulations has produced disparate results in large, well-controlled and well-conducted clinical trials. Prescription formulations and fish oil supplements containing low-dose mixtures of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have routinely failed to prevent CV events in primary and secondary prevention settings when added to contemporary care, as shown most recently in the STRENGTH and OMEMI trials. However, as observed in JELIS, REDUCE-IT, and RESPECT-EPA, EPA-only formulations significantly reduce CVD events in high-risk patients. The CV mechanism of action of EPA, while certainly multifaceted, does not depend solely on reductions of circulating lipids, including triglycerides (TG) and LDL, and event reduction appears related to achieved EPA levels suggesting that the particular chemical and biological properties of EPA, as compared to DHA and other O3FAs, may contribute to its distinct clinical efficacy. In vitro and in vivo studies have shown different effects of EPA compared with DHA alone or EPA/DHA combination treatments, on atherosclerotic plaque morphology, LDL and membrane oxidation, cholesterol distribution, membrane lipid dynamics, glucose homeostasis, endothelial function, and downstream lipid metabolite function. These findings indicate that prescription-grade, EPA-only formulations provide greater benefit than other O3FAs formulations tested. This review summarizes the clinical findings associated with various O3FA formulations, their efficacy in treating CV disease, and their underlying mechanisms of action.
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Affiliation(s)
- Samuel C R Sherratt
- Department of Molecular, Cellular, and Biomedical Sciences, University of New Hampshire, Durham, NH, USA
- Elucida Research LLC, Beverly, MA, USA
| | - R Preston Mason
- Elucida Research LLC, Beverly, MA, USA
- Department of Medicine, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Libby
- Department of Medicine, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ph Gabriel Steg
- Université Paris-Cité, INSERM_UMR1148/LVTS, FACT (French Alliance for Cardiovascular Trials), Assistance Publique–Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, NewYork 10029-5674, NY, USA
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30
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Kim KA, Kim NJ, Choo EH. The effect of fibrates on lowering low-density lipoprotein cholesterol and cardiovascular risk reduction: a systemic review and meta-analysis. Eur J Prev Cardiol 2024; 31:291-301. [PMID: 37855457 DOI: 10.1093/eurjpc/zwad331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/14/2023] [Accepted: 10/17/2023] [Indexed: 10/20/2023]
Abstract
AIMS The effect of fibrate treatment on cardiovascular risk is inconsistent. This meta-analysis aimed to assess the effect of fibrates on major adverse cardiovascular outcome (MACE) reduction. METHODS AND RESULTS PubMed, Embase, and Cochrane library databases were searched up to February 2023 for randomized controlled trials comparing fibrate therapy against placebo and reporting cardiovascular outcomes and lipid profile changes. The primary outcome was the clinical outcomes of each trial that most closely corresponding to MACE, a composite of cardiovascular death, acute myocardial infarction, stroke, and coronary revascularization. A pre-specified meta-regression analysis to examine the relationship between the changes in lipid levels after fibrate treatment and the risk of MACE was also performed. Twelve trials were selected for final analysis, with 25 781 patients and 2741 MACEs in the fibrate group and 27 450 patients and 3754 MACEs in the control group. Overall, fibrate therapy was associated with decreased risk of MACE [RR 0.87, 95% confidence interval (CI) 0.81-0.94] with moderate heterogeneity (I2 = 47%). In meta-regression analysis, each 1 mmol/L reduction in low-density lipoprotein cholesterol (LDL-C) after fibrate treatment reduced MACE (RR 0.71, 95% CI 0.49-0.94, P = 0.01), while triglyceride level changes did not show a significant association (RR per 1mmol/L reduction 0.96, 95% CI 0.53-1.40, P = 0.86). A sensitivity analysis with the composite outcome of cardiovascular death or acute myocardial infarction produced similar results. CONCLUSION Treatment with fibrates was associated with decreased risk of MACE. The reduction in MACE risk with fibrate therapy appears to be attributable to LDL-C reduction rather than a decrease in triglyceride levels.
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Affiliation(s)
- Kyung An Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St.Mary's Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Na Jin Kim
- Medical Library, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St.Mary's Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
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Mormone A, Tortorella G, Esposito F, Caturano A, Marrone A, Cozzolino D, Galiero R, Marfella R, Sasso FC, Rinaldi L. Advances in Pharmacological Approaches for Managing Hypercholesterolemia: A Comprehensive Overview of Novel Treatments. Biomedicines 2024; 12:432. [PMID: 38398034 PMCID: PMC10887105 DOI: 10.3390/biomedicines12020432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Hypercholesterolemia plays a crucial role in the formation of lipid plaques, particularly with elevated low-density lipoprotein (LDL-C) levels, which are linked to increased risks of cardiovascular disease, cerebrovascular disease, and peripheral arterial disease. Controlling blood cholesterol values, specifically reducing LDL-C, is widely recognized as a key modifiable risk factor for decreasing the morbidity and mortality associated with cardiovascular diseases. Historically, statins, by inhibiting the enzyme β-hydroxy β-methylglutaryl-coenzyme A (HMG)-CoA reductase, have been among the most effective drugs. However, newer non-statin agents have since been introduced into hypercholesterolemia therapy, providing a viable alternative with a favorable cost-benefit ratio. This paper aims to delve into the latest therapies, shedding light on their mechanisms of action and therapeutic benefits.
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Affiliation(s)
- Andrea Mormone
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
| | - Giovanni Tortorella
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
| | - Francesca Esposito
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
- Department of Experimental Medicine, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy
| | - Aldo Marrone
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
| | - Domenico Cozzolino
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
| | - Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (A.M.); (G.T.); (F.E.); (A.C.); (A.M.); (D.C.); (R.G.); (R.M.); (F.C.S.)
| | - Luca Rinaldi
- Department of Medicine and Health Sciences “Vincenzo Tiberio”, Università degli Studi del Molise, 86100 Campobasso, Italy
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Burks KH, Xie Y, Gildea M, Jung IH, Mukherjee S, Lee P, Pudupakkam U, Wagoner R, Patel V, Santana K, Alisio A, Goldberg IJ, Finck BN, Fisher EA, Davidson NO, Stitziel NO. ANGPTL3 deficiency impairs lipoprotein production and produces adaptive changes in hepatic lipid metabolism. J Lipid Res 2024; 65:100500. [PMID: 38219820 PMCID: PMC10875267 DOI: 10.1016/j.jlr.2024.100500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/16/2024] Open
Abstract
Angiopoietin-like protein 3 (ANGPTL3) is a hepatically secreted protein and therapeutic target for reducing plasma triglyceride-rich lipoproteins and low-density lipoprotein (LDL) cholesterol. Although ANGPTL3 modulates the metabolism of circulating lipoproteins, its role in triglyceride-rich lipoprotein assembly and secretion remains unknown. CRISPR-associated protein 9 (CRISPR/Cas9) was used to target ANGPTL3 in HepG2 cells (ANGPTL3-/-) whereupon we observed ∼50% reduction of apolipoprotein B100 (ApoB100) secretion, accompanied by an increase in ApoB100 early presecretory degradation via a predominantly lysosomal mechanism. Despite defective particle secretion in ANGPTL3-/- cells, targeted lipidomic analysis did not reveal neutral lipid accumulation in ANGPTL3-/- cells; rather ANGPTL3-/- cells demonstrated decreased secretion of newly synthesized triglycerides and increased fatty acid oxidation. Furthermore, RNA sequencing demonstrated significantly altered expression of key lipid metabolism genes, including targets of peroxisome proliferator-activated receptor α, consistent with decreased lipid anabolism and increased lipid catabolism. In contrast, CRISPR/Cas9 LDL receptor (LDLR) deletion in ANGPTL3-/- cells did not result in a secretion defect at baseline, but proteasomal inhibition strongly induced compensatory late presecretory degradation of ApoB100 and impaired its secretion. Additionally, these ANGPTL3-/-;LDLR-/- cells rescued the deficient LDL clearance of LDLR-/- cells. In summary, ANGPTL3 deficiency in the presence of functional LDLR leads to the production of fewer lipoprotein particles due to early presecretory defects in particle assembly that are associated with adaptive changes in intrahepatic lipid metabolism. In contrast, when LDLR is absent, ANGPTL3 deficiency is associated with late presecretory regulation of ApoB100 degradation without impaired secretion. Our findings therefore suggest an unanticipated intrahepatic role for ANGPTL3, whose function varies with LDLR status.
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Affiliation(s)
- Kendall H Burks
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Yan Xie
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Michael Gildea
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - In-Hyuk Jung
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Sandip Mukherjee
- Division of Nutritional Science and Obesity Medicine, Department of Medicine, Center for Human Nutrition, Washington University School of Medicine, Saint Louis, MO, USA
| | - Paul Lee
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Upasana Pudupakkam
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ryan Wagoner
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ved Patel
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Katherine Santana
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Arturo Alisio
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ira J Goldberg
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Brian N Finck
- Division of Nutritional Science and Obesity Medicine, Department of Medicine, Center for Human Nutrition, Washington University School of Medicine, Saint Louis, MO, USA
| | - Edward A Fisher
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Nicholas O Davidson
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA.
| | - Nathan O Stitziel
- Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA; Department of Genetics, Washington University School of Medicine, Saint Louis, MO, USA.
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Chen J, Fang Z, Luo Q, Wang X, Warda M, Das A, Oldoni F, Luo F. Unlocking the mysteries of VLDL: exploring its production, intracellular trafficking, and metabolism as therapeutic targets. Lipids Health Dis 2024; 23:14. [PMID: 38216994 PMCID: PMC10785355 DOI: 10.1186/s12944-023-01993-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/26/2023] [Indexed: 01/14/2024] Open
Abstract
Reducing circulating lipid levels is the centerpiece of strategies for preventing and treating atherosclerotic cardiovascular disease (ASCVD). Despite many available lipid-lowering medications, a substantial residual cardiovascular risk remains. Current clinical guidelines focus on plasma levels of low-density lipoprotein (LDL). Recent attention has been given to very low-density lipoprotein (VLDL), the precursor to LDL, and its role in the development of coronary atherosclerosis. Preclinical investigations have revealed that interventions targeting VLDL production or promoting VLDL metabolism, independent of the LDL receptor, can potentially decrease cholesterol levels and provide therapeutic benefits. Currently, methods, such as mipomersen, lomitapide, and ANGPTL3 inhibitors, are used to reduce plasma cholesterol and triglyceride levels by regulating the lipidation, secretion, and metabolism of VLDL. Targeting VLDL represents an avenue for new lipid-lowering strategies. Interventions aimed at reducing VLDL production or enhancing VLDL metabolism, independent of the LDL receptor, hold promise for lowering cholesterol levels and providing therapeutic benefits beyond LDL in the management of ASCVD.
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Affiliation(s)
- Jingfei Chen
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Research Institute of Blood Lipid and Atherosclerosis, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China
| | - Zhenfei Fang
- Research Institute of Blood Lipid and Atherosclerosis, the Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China
| | - Qin Luo
- Research Institute of Blood Lipid and Atherosclerosis, the Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China
| | - Xiao Wang
- State Key Laboratory of Membrane Biology, Peking University, Beijing, 100871, China
| | - Mohamad Warda
- Department of Biochemistry and Molecular Biology, Faculty of Veterinary Medicine, Cairo University, Giza, 12211, Egypt
- Department of Physiology, Faculty of Veterinary Medicine, Ataturk University, Erzurum, 25240, Turkey
| | - Avash Das
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215-5400, USA
| | - Federico Oldoni
- Department of Molecular Genetics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fei Luo
- Research Institute of Blood Lipid and Atherosclerosis, the Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
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Zhang P, Wang K, Hu T, Xu M, You X, Chen M, Tang X, Hu H, Jiang Y, Zhao W, Tan S. A novel fully human anti-NT-ANGPTL3 antibody from phage display library exhibits potent ApoB, TG, and LDL-C lowering activities in hyperlipidemia mice. FASEB J 2024; 38:e23399. [PMID: 38174870 DOI: 10.1096/fj.202301564rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024]
Abstract
Dyslipidemia is characterized by elevated plasma levels of low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and TG-rich lipoprotein (TGRLs) in circulation, and is closely associated with the incidence and development of cardiovascular disease. Angiopoietin-like protein 3 (ANGPTL3) deficiency has been identified as a cause of familial combined hypolipidemia in humans, which allows it to be an important therapeutic target for reducing plasma lipids. Here, we report the discovery and characterization of a novel fully human antibody F1519-D95aA against N-terminal ANGPTL3 (NT-ANGPTL3), which potently inhibits NT-ANGPTL3 with a KD as low as 9.21 nM. In hyperlipidemic mice, F1519-D95aA shows higher apolipoprotein B (ApoB) and TG-lowering, and similar LDL-C reducing activity as compared to positive control Evinacumab (56.50% vs 26.01% decrease in serum ApoB levels, 30.84% vs 25.28% decrease in serum TG levels, 23.32% vs 22.52% decrease in serum LDLC levels, relative to vehicle group). Molecular docking and binding energy calculations reveal that the F1519-D95aA-ANGPTL3 complex (10 hydrogen bonds, -65.51 kcal/mol) is more stable than the Evinacumab-ANGPTL3 complex (4 hydrogen bonds, -63.76 kcal/mol). Importantly, F1519-D95aA binds to ANGPTL3 with different residues in ANGPTL3 from Evinacumab, suggesting that F1519-D95aA may be useful for the treatment of patients resistant to Evinacumab. In conclusion, F1519-D95aA is a novel fully human anti-NT-ANGPTL3 antibody with potent plasma ApoB, TG, and LDL-C lowering activities, which can potentially serve as a therapeutic agent for hyperlipidemia and relevant cardiovascular diseases.
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Affiliation(s)
- Panpan Zhang
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Ke Wang
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Tuo Hu
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Menglong Xu
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Xiangyan You
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Manman Chen
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Xuan Tang
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Huajing Hu
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Yiwei Jiang
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Wenfeng Zhao
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
| | - Shuhua Tan
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing, PR China
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Tomlinson B, Wu QY, Zhong YM, Li YH. Advances in Dyslipidaemia Treatments: Focusing on ApoC3 and ANGPTL3 Inhibitors. J Lipid Atheroscler 2024; 13:2-20. [PMID: 38299167 PMCID: PMC10825570 DOI: 10.12997/jla.2024.13.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/23/2023] [Accepted: 10/09/2023] [Indexed: 02/02/2024] Open
Abstract
Apolipoprotein C3 (apoC3) and angiopoietin-like protein 3 (ANGPTL3) inhibit lipolysis by lipoprotein lipase and may influence the secretion and uptake of various lipoproteins. Genetic studies show that depletion of these proteins is associated with improved lipid profiles and reduced cardiovascular events so it was anticipated that drugs which mimic the effects of loss-of-function mutations would be useful lipid treatments. ANGPTL3 inhibitors were initially developed as a treatment for severe hypertriglyceridaemia including familial chylomicronaemia syndrome (FCS), which is usually not adequately controlled with currently available drugs. However, it was found ANGPTL3 inhibitors were also effective in reducing low-density lipoprotein cholesterol (LDL-C) and they were studied in patients with homozygous familial hypercholesterolaemia (FH). Evinacumab targets ANGPTL3 and reduced LDL-C by about 50% in patients with homozygous FH and it has been approved for that indication. The antisense oligonucleotide (ASO) vupanorsen targeting ANGPTL3 was less effective in reducing LDL-C in patients with moderate hypertriglyceridaemia and its development has been discontinued but the small interfering RNA (siRNA) ARO-ANG3 is being investigated in Phase 2 studies. ApoC3 can be inhibited by the ASO volanesorsen, which reduced triglycerides by >70% in patients with FCS and it was approved for FCS in Europe but not in the United States because of concerns about thrombocytopaenia. Olezarsen is an N-acetylgalactosamine-conjugated ASO targeting apoC3 which appears as effective as volanesorsen without the risk of thrombocytopaenia and is undergoing Phase 3 trials. ARO-APOC3 is an siRNA targeting apoC3 that is currently being investigated in Phase 3 studies.
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Affiliation(s)
- Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macau, China
| | - Qian-yan Wu
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yi-ming Zhong
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yan-hong Li
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
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Lauzière A, Brisson D, Tremblay G, Bédard S, Khoury E, Gaudet D. Comparison of the burden of familial hypercholesterolemia between two cohorts of French Canadians hospitalized 25 years apart for coronary heart disease. J Clin Lipidol 2024; 18:e90-e96. [PMID: 38030518 DOI: 10.1016/j.jacl.2023.10.008] [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: 06/06/2023] [Revised: 09/25/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is associated with lifelong elevated plasma concentrations of low-density lipoprotein cholesterol (LDL-C) and high risk of premature coronary heart disease (CHD). Clinical recommendations and treatments have emerged to facilitate the management of FH patients. Their impact on the burden of FH is however not well documented. OBJECTIVE To compare the burden of FH between patients hospitalized for a CHD event 25 years apart in the French-Canadian founder population. METHODS Lipid profiles, cardiovascular risk factors, treatments and FH status of 2,029 patients consecutively hospitalized for an acute CHD event between 2017 and 2022 (2022 Cohort) were compared to those of 2,506 patients with angiographically-confirmed CHD who were admitted between 1995 and 1998 (1998 Cohort). RESULTS At the time of admission, 24.6 % of CHD patients had LDL-C levels >5.0 mmol/L in 1998 compared to 1.4 % in 2022, and FH was diagnosed in 9.6 % of patients in the 1998 cohort compared to 5.5 % in 2022 (p<0.001). FH patients hospitalized for a CHD event were older in 2022 than in 1998 (p <0.001). The prevalence of premature CHD requiring a hospitalization significantly decreased from 1998 to 2022 (64.3% vs. 44.1 %, p<0.001). At the moment of admission, 18.2 % of FH patients had LDL-C concentration <2.0 mmol/L in 2022 vs 0 % in 1998 (p <0.001). CONCLUSIONS Over 25 years, FH patients tend to be older and contribute to a lower proportion of hospitalizations for CHD in the French-Canadian founder population. Despite significant improvement in diagnosis and treatment, FH management remains however sub-optimal.
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Affiliation(s)
- Alex Lauzière
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada; Lipid Clinic, Chicoutimi Hospital, Chicoutimi, Canada
| | - Diane Brisson
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada
| | | | - Sophie Bédard
- Lipid Clinic, Chicoutimi Hospital, Chicoutimi, Canada
| | - Etienne Khoury
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada
| | - Daniel Gaudet
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada; Lipid Clinic, Chicoutimi Hospital, Chicoutimi, Canada.
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Danilov A, Frishman WH, Aronow WS. Antihyperlipidemic Treatment Options in Statin Resistance and Intolerance. Cardiol Rev 2024; 32:51-56. [PMID: 36305712 DOI: 10.1097/crd.0000000000000498] [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: 11/26/2022]
Abstract
Cardiovascular disease is the global leading cause of death and hypercholesterolemia is implicated as one of its top contributors. Moreover, there is growing recognition that lower low-density lipoprotein cholesterol levels offer greater protection against cardiovascular disease. Statins are the first-line lipid-lowering agents for both primary and secondary prevention of cardiovascular disease in patients with hypercholesterolemia. However, statin resistance and intolerance lead to undertreatment in patients who would likely derive the most benefit from antihyperlipidemic drugs. Several non-statin therapies are increasingly prescribed to such patients, most commonly ezetimibe and the PCSK9 monoclonal antibodies, but numerous other options have been developed in recent years and investigations into new therapies are ongoing. The use of these non-statin therapies requires the clinician to take a highly personalized approach to cholesterol reduction in complex patients. In this review, we describe current non-statin options for statin-resistant and statin-intolerant patients in addition to areas of active research.
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Affiliation(s)
| | - William H Frishman
- Department of Medicine, New York Medical College, and Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Medicine, New York Medical College, and Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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Jiang S, Ren Z, Yang Y, Liu Q, Zhou S, Xiao Y. The GPIHBP1-LPL complex and its role in plasma triglyceride metabolism: Insights into chylomicronemia. Biomed Pharmacother 2023; 169:115874. [PMID: 37951027 DOI: 10.1016/j.biopha.2023.115874] [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: 09/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/13/2023] Open
Abstract
GPIHBP1 is a protein found in the endothelial cells of capillaries that is anchored by glycosylphosphatidylinositol and binds to high-density lipoproteins. GPIHBP1 attaches to lipoprotein lipase (LPL), subsequently carrying the enzyme and anchoring it to the capillary lumen. Enabling lipid metabolism is essential for the marginalization of lipoproteins alongside capillaries. Studies underscore the significance of GPIHBP1 in transporting, stabilizing, and aiding in the marginalization of LPL. The intricate interplay between GPIHBP1 and LPL has provided novel insights into chylomicronemia in recent years. Mutations hindering the formation or reducing the efficiency of the GPIHBP1-LPL complex are central to the onset of chylomicronemia. This review delves into the structural nuances of the GPIHBP1-LPL interaction, the consequences of mutations in the complex leading to chylomicronemia, and cutting-edge advancements in chylomicronemia treatment.
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Affiliation(s)
- Shali Jiang
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, PR China; Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, PR China
| | - Zhuoqun Ren
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, PR China; Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, PR China
| | - Yutao Yang
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, PR China; Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, PR China
| | - Qiming Liu
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, PR China
| | - Shenghua Zhou
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, PR China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, PR China.
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Ma J, Zhao K, Zhu Y, Xu W, Huang J, Wei X, Zhao Z. Bibliometric analysis of monoclonal antibodies for atherosclerosis. Hum Vaccin Immunother 2023; 19:2266926. [PMID: 37905896 PMCID: PMC10760398 DOI: 10.1080/21645515.2023.2266926] [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: 05/18/2023] [Accepted: 10/01/2023] [Indexed: 11/02/2023] Open
Abstract
Atherosclerosis (AS) is a prevalent cardiovascular disease that greatly increases mortality in the aging population and imposes a heavy burden on global healthcare systems. The purpose of this study is to examine the research structure and current trends of monoclonal antibodies (mAbs) against AS from a bibliometric perspective, since the development of these drugs is currently booming. This study collected articles and reviews on mAbs against AS from the Web of Science Core Collection, spanning from 2003 to 2022. Biblioshiny was utilized to analyze and visualize the characteristics of countries, regions, authors, institutions, and journals included in this collection. We used VOS viewer to illustrate the frequency of country co-occurrence, and CiteSpace to visualize co-cited reference, keywords co-occurrence, keywords citation bursts, keywords clustering and timeline plots. The study included 1325 publications, with the United States emerging as a leading contributor to the field. ATHEROSCLEROSIS, CIRCULATION and ARTERIOSCLEROSISTHROMBOSIS AND VASCULAR BIOLOGY are core journals that publish high-quality literature on the latest advances in the field. Noteworthy authors with numerous high-quality publications include Witztum JL and Tsimikas S. Currently, lipid metabolism and inflammation are the main research areas of interest in this field. The mAbs against AS is an evolving field, and ongoing research continues to advance our understanding. This paper provides a comprehensive overview of the current state of knowledge in this area, highlighting two primary research directions: inflammation and lipid metabolism. Additionally, the paper identifies emerging research hotspots, which will provide researchers with useful insights to guide future investigations and anticipate research directions.
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Affiliation(s)
- Jiqing Ma
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Kaiwen Zhao
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yalin Zhu
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
- Department of Anesthesiology, Naval Hospital of Eastern Theater, Zhoushan, China
| | - Wen Xu
- Department of Anesthesiology, Naval Hospital of Eastern Theater, Zhoushan, China
| | - Jie Huang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaolong Wei
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
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Srivastava RAK. New opportunities in the management and treatment of refractory hypercholesterolemia using in vivo CRISPR-mediated genome/base editing. Nutr Metab Cardiovasc Dis 2023; 33:2317-2325. [PMID: 37805309 DOI: 10.1016/j.numecd.2023.08.010] [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: 05/18/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 10/09/2023]
Abstract
AIMS Refractory hypercholesterolemia (RH), caused primarily by the loss-of-function mutation of LDL receptor (LDLR) gene seen in HoFH and HeFH patients, remains a major risk factor for atherosclerotic cardiovascular disease (ASCVD). Statin and ezetimibe combination therapy lower circulating LDL by 30% in HoFH patients. PCSK9 mAB, being an LDLR-dependent therapy, is not effective in HoFH, but lowers LDL by 25% in HeFH patients. A maximum reduction of 50% was noted in HoFH patients treated with ANGPTL3 mAB, which was not enough to achieve therapeutic goal of LDL. Therefore, new approaches are warranted to offer hopes to individuals intolerant to higher dose statins and not able to achieve recommended LDL level. DATA SYNTHESIS New approaches to lower LDL include gene therapy and gene editing. AAV-based gene therapy has shown encouraging results in animal models. Using CRISPR/Cas9-mediated genome/base editing, gain of function and loss of function have been successfully done in animal models. Recent progress in the refinement of genome/base editing has overcome the issues of off-target mutagenesis with ∼1% mutagenesis in case of PCSK9 and almost no off-target mutagenesis in inactivating ANGPTL3 in animal models showing 50% reduction in cholesterol. Current approaches using CRISPR-Cas9 genome/base editing targeting LDLR-dependent and LDLR-independent pathways are underway. CONCLUSIONS The new information on gain of LDLR function and inactivation of ANGPTL3 together with developments in genome/base editing technology to overcome off-target insertion and deletion mutagenesis offer hope to refractory hypercholesterolemic individuals who are at a higher risk of developing ASCVD.
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Thorin E, Labbé P, Lambert M, Mury P, Dagher O, Miquel G, Thorin-Trescases N. Angiopoietin-Like Proteins: Cardiovascular Biology and Therapeutic Targeting for the Prevention of Cardiovascular Diseases. Can J Cardiol 2023; 39:1736-1756. [PMID: 37295611 DOI: 10.1016/j.cjca.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
Despite the best pharmacologic tools available, cardiovascular diseases (CVDs) remain a major cause of morbidity and mortality in developed countries. After 2 decades of research, new therapeutic targets, such as angiopoietin-like proteins (ANGPTLs), are emerging. ANGPTLs belong to a family of 8 members, from ANGPTL1 to ANGPTL8; they have structural homology with angiopoietins and are secreted in the circulation. ANGPTLs display a multitude of physiological and pathologic functions; they contribute to inflammation, angiogenesis, cell death, senescence, hematopoiesis, and play a role in repair, maintenance, and tissue homeostasis. ANGPTLs-particularly the triad ANGPTL3, 4, and 8-have an established role in lipid metabolism through the regulation of triacylglycerol trafficking according to the nutritional status. Some ANGPTLs also contribute to glucose metabolism. Therefore, dysregulation in ANGPTL expression associated with abnormal circulating levels are linked to a plethora of CVD and metabolic disorders including atherosclerosis, heart diseases, diabetes, but also obesity and cancers. Because ANGPTLs bind to different receptors according to the cell type, antagonists are therapeutically inadequate. Recently, direct inhibitors of ANGPTLs, mainly ANGPTL3, have been developed, and specific monoclonal antibodies and antisense oligonucleotides are currently being tested in clinical trials. The aim of the current review is to provide an up-to-date preclinical and clinical overview on the function of the 8 members of the ANGPTL family in the cardiovascular system, their contribution to CVD, and the therapeutic potential of manipulating some of them.
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Affiliation(s)
- Eric Thorin
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada; Faculty of Medicine, Department of Pharmacology, Université de Montréal, Montréal, Québec, Canada; Faculty of Medicine, Department of Surgery, Université de Montréal, Montréal, Québec, Canada.
| | - Pauline Labbé
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Mélanie Lambert
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada; Faculty of Medicine, Department of Pharmacology, Université de Montréal, Montréal, Québec, Canada
| | - Pauline Mury
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada; Faculty of Medicine, Department of Pharmacology, Université de Montréal, Montréal, Québec, Canada
| | - Olina Dagher
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada; Faculty of Medicine, Department of Surgery, Université de Montréal, Montréal, Québec, Canada; Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Géraldine Miquel
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
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Li Y, Zhang Y, Zhang Y, Lin T, Gao Y, Cai Y, Zhou C, Yang L, Liu B, Dong S, Jiang Y. Optimization of the proportions of advantageous components in the hypolipidemic "bioequivalent substance system" of Jiang-Zhi-Ning and its mechanism of action. PHARMACEUTICAL BIOLOGY 2023; 61:1374-1386. [PMID: 37655554 PMCID: PMC10478595 DOI: 10.1080/13880209.2023.2243999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 06/06/2023] [Accepted: 07/29/2023] [Indexed: 09/01/2023]
Abstract
CONTEXT Jiang-Zhi-Ning (JZN), a traditional Chinese medicinal formula, is used to treat hyperlipidemia in clinics. OBJECTIVE To screen the hypolipidemic "bioequivalent substance system (BSS)" of JZN and elucidate the potential hypolipidemic mechanism. MATERIALS AND METHODS In vitro, the TG content in HepG2 cells was determined after the intervention of the combination of advantageous components (CAC) by uniform design. In vivo, hyperlipidemia models were established by Triton WR-1339 (400 mg/kg; i.p.) in male ICR mice, and corresponding treatments were administered via oral administration once. The mice were divided into 12 groups (n = 5): control, hyperlipidemic model, simvastatin (positive control, 20 mg/kg), gradient doses of JZN granules (2, 4 and 8 g/kg) and the hypolipidemic effective extraction (HEE) of JZN (120, 240 and 480 mg/kg) and CAC groups (20, 40 and 160 mg/kg). Serum TC, TG, LDL-C and HDL-C were performed after 24 h. Transcriptomics and qRT-PCR technology were used to explore the mechanism of the "BSS" of JZN. RESULTS In vitro, the ratio of CAC was determined. CAC could reduce the TG content in HepG2 cells (77.21%). Compared with the model group, the high dose of CAC could markedly decrease the levels of TC (61.86%), TG (105.54%) and LDL-C (39.38%) and increase the level of HDL-C (232.67%). CAC was proved to be the "BSS". Transcriptomics and qRT-PCR analysis revealed CAC regulated non-alcoholic fatty liver disease, bile secretion, PPAR and adipocytokine signalling pathway. DISCUSSION AND CONCLUSIONS These findings provided new feasible ideas and methods for the elucidation of the pharmacodynamic material basis.
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Affiliation(s)
- Yumiao Li
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yan Zhang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yu Zhang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Tianfeng Lin
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yanyan Gao
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yuan Cai
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Chang Zhou
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Leyi Yang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Bin Liu
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
- The Key Research Laboratory of "Exploring Effective Substance in Classic and Famous Prescriptions of Traditional Chinese Medicine". The State Administration of Traditional Chinese Medicine of the People’s Republic of China, Beijing, China
| | - Shifen Dong
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yanyan Jiang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
- The Key Research Laboratory of "Exploring Effective Substance in Classic and Famous Prescriptions of Traditional Chinese Medicine". The State Administration of Traditional Chinese Medicine of the People’s Republic of China, Beijing, China
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Abstract
PURPOSE OF REVIEW The aim of this study was to discuss the potential mechanisms and implications of the opposing liver safety results from recent angiopoietin-like 3 (ANGPTL3) inhibition studies. RECENT FINDINGS The clinical development of vupanorsen, a N-acetylgalactosamine (GalNAc) antisense targeting hepatic ANGPTL3, was recently discontinued due to a significant signal of liver transaminase increase. Vupanorsen elicited a dose-dependent increase in hepatic fat fraction up to 75%, whereas the small interfering RNA (siRNA) ARO-ANG3, has reported preliminary evidence of a dose-dependent decrease in hepatic fat fraction up to 30%. SUMMARY ANGPTL3 inhibition is an attractive therapeutic target to reduce all apoB-containing lipoproteins. The discrepancy in liver signal results between the antisense and siRNA approach may be explained by the level of target inhibition. An alternative explanation may relate to off-target effects of vupanorsen, which have a molecule- and/or platform-specific origin. For intrahepatic strategies, highly potent ANGPTL3 inhibition will for now require special attention for liver safety.
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Affiliation(s)
- Reindert F Oostveen
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Pirillo A, Catapano AL. How to Handle Elevated Triglycerides: Life after PROMINENT. Curr Atheroscler Rep 2023; 25:921-929. [PMID: 38114852 DOI: 10.1007/s11883-023-01175-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW Hypertriglyceridaemia (HTG) is a common condition characterised by elevated levels of plasma triglycerides (TG), which are transported in the blood mainly by TG-rich lipoproteins (TRL). Elevated TG levels (150-400 mg/dL) are associated with increased cardiovascular risk. Severe HTG (>880 mg/dL) is associated with a risk of acute pancreatitis only. Randomised clinical trials investigating the clinical benefit of TG-lowering drugs in patients with elevated TG levels have provided conflicting results. RECENT FINDINGS Elevated TG levels are only one marker of altered lipid/lipoprotein metabolism and indeed reflect altered concentrations of one or more classes or subfractions of TRL, which in turn may have a different association with CV risk. Fibrates, the drugs most commonly used to treat HTG, provide cardiovascular benefits to only a specific subgroup of patients. The lack of clinical benefit from pemafibrate has emphasised the concept that lowering TG levels is not sufficient to reduce the CV risk unless it is accompanied by a reduction in the number of circulating atherogenic lipoproteins, which can be assessed by determining apolipoprotein B levels. Treatment with omega-3 fatty acids was also ineffective in reducing CV risk, with the exception of icosapent ethyl, which, however, appears to have beneficial effects beyond lipids. New drugs are currently being developed that aim to lower TG levels by targeting apolipoprotein C-III or angiopoietin-like-3, both of which are involved in the metabolism of TGs. TG reduction can be achieved by various drugs, but most of them are ineffective in reducing CV risk. The results of outcome studies on new TG-lowering drugs will clarify whether lowering apoB levels is critical to achieve clinical benefit.
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Affiliation(s)
- Angela Pirillo
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Alberico L Catapano
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy.
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.
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Larouche M, Khoury E, Brisson D, Gaudet D. Inhibition of Angiopoietin-Like Protein 3 or 3/8 Complex and ApoC-III in Severe Hypertriglyceridemia. Curr Atheroscler Rep 2023; 25:1101-1111. [PMID: 38095804 DOI: 10.1007/s11883-023-01179-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE OF REVIEW The role of the inhibition of ANGPTL3 in severe or refractory hypercholesterolemia is well documented, less in severe hyperTG. This review focuses on the preclinical and clinical development of ApoC-III inhibitors and ANGPTL3, 4, and 3/8 complex inhibitors for the treatment of severe or refractory forms of hypertriglyceridemia to prevent cardiovascular disease or other morbidities. RECENT FINDINGS APOC3 and ANGPTL3 became targets for drug development following the identification of naturally occurring loss of function variants in families with a favorable lipid profile and low cardiovascular risk. The inhibition of ANGPTL3 covers a broad spectrum of lipid disorders from severe hypercholesterolemia to severe hypertriglyceridemia, while the inhibition of ApoC-III can treat hypertriglyceridemia regardless of the severity. Preclinical and clinical data suggest that ApoC-III inhibitors, ANGPTL3 inhibitors, and inhibitors of the ANGPTL3/8 complex that is formed postprandially are highly effective for the treatment of severe or refractory hypertriglyceridemia. Inhibition of ANGPTL3 or the ANGPTL3/8 complex upregulates LPL and facilitates the hydrolysis and clearance of triglyceride-rich lipoproteins (TRL) (LPL-dependent mechanisms), whereas ApoC-III inhibitors contribute to the management and clearance of TRL through both LPL-dependent and LPL-independent mechanisms making it possible to successfully lower TG in subjects completely lacking LPL (familial chylomicronemia syndrome). Most of these agents are biologicals including monoclonal antibodies (mAb), antisense nucleotides (ASO), small interfering RNA (siRNA), or CRISPR-cas gene editing strategies.
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Affiliation(s)
- Miriam Larouche
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada
| | - Etienne Khoury
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada
| | - Diane Brisson
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada
| | - Daniel Gaudet
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada.
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Gill PK, Hegele RA. New Biological Therapies for Low-Density Lipoprotein Cholesterol. Can J Cardiol 2023; 39:1913-1930. [PMID: 37562541 DOI: 10.1016/j.cjca.2023.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023] Open
Abstract
Depressed low-density lipoprotein cholesterol concentration protects against atherosclerotic cardiovascular disease. Natural hypocholesterolemia states can have a monogenic etiology, caused by pathogenic loss of function variants in the PCSK9, ANGPTL3, MTTP, or APOB genes. In this focused review, we discuss development and clinical use of several new therapeutics that inhibit these gene products to target elevated levels of low-density lipoprotein cholesterol. In particular, inhibitors of proprotein convertase subtilisin kexin type 9 (PCSK9) have notably affected clinical practice, followed recently by inhibition of angiopoietin-like 3 (ANGPTL3). Currently used in the clinic are alirocumab and evolocumab, two anti-PCSK9 monoclonal antibodies, inclisiran, a small interfering RNA that prevents PCSK9 translation, evinacumab, an anti-ANGPTL3 monoclonal antibody, and lomitapide, a small-molecule inhibitor of microsomal triglyceride transfer protein. Additional therapies are in preclinical or clinical trial stages of development. These consist of other monoclonal antibodies, antisense oligonucleotides, small-molecule inhibitors, mimetic peptides, adnectins, vaccines, and gene-editing therapies. Vaccines and gene-editing therapies in particular hold great potential to confer active long-term attenuation or provide single-treatment life-long knock-down of PCSK9 or ANGPTL3 activity. Biologic therapies inspired by monogenic hypocholesterolemia states are becoming valuable tools to help protect against atherosclerotic cardiovascular disease.
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Affiliation(s)
- Praneet K Gill
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Robert A Hegele
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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Wojtasińska A, Kućmierz J, Tokarek J, Dybiec J, Rodzeń A, Młynarska E, Rysz J, Franczyk B. New Insights into Cardiovascular Diseases Treatment Based on Molecular Targets. Int J Mol Sci 2023; 24:16735. [PMID: 38069058 PMCID: PMC10706703 DOI: 10.3390/ijms242316735] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
Cardiovascular diseases (CVDs) which consist of ischemic heart disease, stroke, heart failure, peripheral arterial disease, and several other cardiac and vascular conditions are one of the most common causes of death worldwide and often co-occur with diabetes mellitus and lipid disorders which worsens the prognosis and becomes a therapeutic challenge. Due to the increasing number of patients with CVDs, we need to search for new risk factors and pathophysiological changes to create new strategies for preventing, diagnosing, and treating not only CVDs but also comorbidities like diabetes mellitus and lipid disorders. As increasing amount of patients suffering from CVDs, there are many therapies which focus on new molecular targets like proprotein convertase subtilisin/kexin type 9 (PCSK9), angiopoietin-like protein 3, ATP-citrate lyase, or new technologies such as siRNA in treatment of dyslipidemia or sodium-glucose co-transporter-2 and glucagon-like peptide-1 in treatment of diabetes mellitus. Both SGLT-2 inhibitors and GLP-1 receptor agonists are used in the treatment of diabetes, however, they proved to have a beneficial effect in CVDs as well. Moreover, a significant amount of evidence has shown that exosomes seem to be associated with myocardial ischaemia and that exosome levels correlate with the severity of myocardial injury. In our work, we would like to focus on the above mechanisms. The knowledge of them allows for the appearance of new strategies of treatment among patients with CVDs.
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Affiliation(s)
- Armanda Wojtasińska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Kućmierz
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Julita Tokarek
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jill Dybiec
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Anna Rodzeń
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
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Michaud L, Sharedalal P, Seplowe M, Rosenzveig A, Frishman WH, Aronow WS. Hyperlipidemia in Children and Adolescents. Cardiol Rev 2023; 31:330-335. [PMID: 35700367 DOI: 10.1097/crd.0000000000000465] [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: 11/26/2022]
Abstract
While coronary artery disease (CAD) is thought to be a disease of adulthood, atherosclerosis can originate in childhood and adolescence. There is a paucity of randomized controlled treatment trials regarding dyslipidemia among the younger population. However, it is apparent that childhood dyslipidemia is associated with an earlier onset of CAD. Most recent guidelines by the American College of Cardiology (ACC) and American Heart Association (AHA) focus on lifestyle modification and lifetime risk of atherosclerotic disease, as well as adequate screening measures. Genetic factors, environmental contributors such as pollution, obesity linked to poor nutrition, and sedentary lifestyles are shown to be associated with increased lipid levels and early CAD among children and adolescents. Familial hyperlipidemia is one of the most prevalent genetic diseases and can affect 1 in 250 individuals. A multimodal treatment plan is most effective for children and adolescents with dyslipidemia including lifestyle changes (a modified diet and moderate physical activity) and pharmacologic intervention. The mainstay of pharmacologic treatment for childhood dyslipidemia is similar to that of adults. Statins are the most widely used medications. Newer medications have proven integral in treatment for genetic dyslipidemias including evolocumab and evinacumab.
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Affiliation(s)
- Liana Michaud
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Parija Sharedalal
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Matthew Seplowe
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | | | - William H Frishman
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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Rosenson RS, Burgess LJ, Ebenbichler CF, Baum SJ, Stroes ESG, Ali S, Khilla N, McGinniss J, Gaudet D, Pordy R. Longer-Term Efficacy and Safety of Evinacumab in Patients With Refractory Hypercholesterolemia. JAMA Cardiol 2023; 8:1070-1076. [PMID: 37703006 PMCID: PMC10500429 DOI: 10.1001/jamacardio.2023.2921] [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] [Received: 11/22/2022] [Accepted: 07/20/2023] [Indexed: 09/14/2023]
Abstract
Importance Patients with refractory hypercholesterolemia who do not achieve their guideline-defined low-density lipoprotein cholesterol (LDL-C) thresholds despite treatment with maximally tolerated combinations of lipid-lowering therapies (LLTs) have an increased risk of atherosclerotic cardiovascular disease (ASCVD). Objective To evaluate longer-term efficacy and safety of evinacumab in patients with refractory hypercholesterolemia. Design, Setting, and Participants This randomized clinical trial included a 2-week screening period followed by a 16-week double-blind treatment period (DBTP) for subcutaneous regimens (evinacumab, 450 mg, once weekly [QW]; evinacumab, 300 mg, QW; evinacumab, 300 mg, every 2 weeks; or placebo QW) or a 24-week DBTP for intravenous regimens (evinacumab, 15 mg/kg, every 4 weeks [Q4W]; evinacumab, 5 mg/kg, Q4W; or placebo Q4W); a 48-week open-label treatment period (OLTP) for intravenous treatment only; and a 24-week follow-up period. Patients from 85 sites across 20 countries were recruited for the study; patients with primary hypercholesterolemia (defined as heterozygous familial hypercholesterolemia or established clinical ASCVD without familial hypercholesterolemia) who entered the 48-week OLTP were included. In addition, the patients' hypercholesterolemia was refractory to maximally tolerated LLTs. Interventions All patients entering the OLTP received evinacumab, 15 mg/kg, intravenously Q4W. Main Outcomes and Measures Efficacy outcomes included change in LDL-C level and other lipid/lipoprotein parameters from baseline to week 72 (end of the OLTP). Safety outcomes included assessment of treatment-emergent adverse events (TEAEs). Results A total of 96 patients (mean [SD] age, 54.4 [11.3] years; 52 female [54.2%]) entered the OLTP, of whom 88 (91.7%) completed the OLTP. Mean (SD) baseline LDL-C level was 145.9 (55.2) mg/dL. At week 72, evinacumab, 15 mg/kg, reduced mean (SD) LDL-C level from baseline by 45.5% (28.7%) in the overall cohort. Evinacumab, 15 mg/kg, reduced mean (SD) apolipoprotein B (38.0% [22.1%]), non-high density lipoprotein cholesterol (48.4% [23.2%]), total cholesterol (42.6% [17.5%]), and median (IQR) fasting triglyceride (57.2% [65.4%-44.4%]) levels at week 72 from baseline in the overall cohort. TEAEs occurred in 78 of 96 patients (81.3%). Serious TEAEs occurred in 9 of 96 patients (9.4%); all were considered unrelated to study treatment. Conclusions and Relevance In patients with refractory hypercholesterolemia, evinacumab provided sustained reductions in LDL-C level and was generally well tolerated. Trial Registration ClinicalTrials.gov Identifier: NCT03175367.
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Affiliation(s)
- Robert S. Rosenson
- Metabolism and Lipids Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lesley J. Burgess
- TREAD Research Centre, Cardiology Unit, Department of Internal Medicine, Stellenbosch University and Tygerberg Hospital, Parow, South Africa
| | | | - Seth J. Baum
- Excel Medical Clinical Trials and Department of Integrated Medical Sciences, Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Erik S. G. Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Shazia Ali
- Regeneron Pharmaceuticals Inc, Tarrytown, New York
| | - Nagwa Khilla
- Regeneron Pharmaceuticals Inc, Tarrytown, New York
| | | | - Daniel Gaudet
- Clinical Lipidology and Rare Lipid Disorders Unit, Department of Medicine, Université de Montréal Community Gene Medicine Center, and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Québec, Canada
| | - Robert Pordy
- Regeneron Pharmaceuticals Inc, Tarrytown, New York
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50
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Raschi E, Casula M, Cicero AFG, Corsini A, Borghi C, Catapano A. Beyond statins: New pharmacological targets to decrease LDL-cholesterol and cardiovascular events. Pharmacol Ther 2023; 250:108507. [PMID: 37567512 DOI: 10.1016/j.pharmthera.2023.108507] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023]
Abstract
The pharmacological treatment of dyslipidemia, a major modifiable risk factor for developing atherosclerotic cardiovascular disease (ASCVD), remains a debated and controversial issue, not only in terms of the most appropriate therapeutic range for lipid levels, but also with regard to the optimal strategy and sequence approach (stepwise vs upstream therapy). Current treatment guidelines for the management of dyslipidemia focus on the intensity of low-density lipoprotein cholesterol (LDL-C) reduction, stratified according to risk for developing ASCVD. Beyond statins and ezetimibe, different medications targeting LDL-C have been recently approved by regulatory agencies with potential innovative mechanisms of action, including proprotein convertase subtilisin/kexin type 9 modulators (monoclonal antibodies such as evolocumab and alirocumab; small interfering RNA molecules such as inclisiran), ATP-citrate lyase inhibitors (bempedoic acid), angiopoietin-like 3 inhibitors (evinacumab), and microsomal triglyceride transfer protein inhibitors (lomitapide). An understanding of their pharmacological aspects, benefit-risk profile, including impact on hard cardiovascular endpoints beyond LDL-C reduction, and potential advantages from the patient perspective (e.g., adherence) - the focus of this evidence-based review - is crucial for practitioners across medical specialties to minimize therapeutic inertia and support clinical practice.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Arrigo F G Cicero
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
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