Familial hypercholesterolaemia in children and adolescents: gaining decades of life by optimizing detection and treatment

Implementation strategies for improving the care of familial hypercholesterolaemia from the International Atherosclerosis Society: next steps in implementation science and practice

Familial hypercholesterolaemia (FH) is the most common monogenic condition associated with premature atherosclerotic cardiovascular disease. Early detection and initiation of cholesterol lowering therapy combined with lifestyle changes improves the prognosis of patients with FH significantly. The International Atherosclerosis Society (IAS) published a new guidance for implementing best practice in the care of FH. Previous guidelines and position statements seldom provided implementation recommendations. To address this, an implementation science approach was used to generate implementation strategies for the clinical recommendations made. This process entailed the generation by consensus of strong implementation recommendations according to the Expert Recommendations for Implementing Change (ERIC) taxonomy. A total of 80 general and specific implementation recommendations were generated, addressing detection (screening, diagnosis, genetic testing and counselling) and management (risk stratification, treatment of adults or children with heterozygous or homozygous FH, therapy during pregnancy and use of apheresis) of patients with FH. We describe here the IAS guidance core implementation strategies to assist with the adoption of clinical recommendations into routine practice for at-risk patients and families worldwide. We summarise the IAS guidance core implementation strategies as operative statements.

Efficacy and Safety of Inclisiran in Adolescents With Genetically Confirmed Homozygous Familial Hypercholesterolemia: Results From the Double-Blind, Placebo-Controlled Part of the ORION-13 Randomized Trial

BACKGROUND

Homozygous familial hypercholesterolemia (HoFH) is a genetic disease characterized by high levels of low-density lipoprotein cholesterol (LDL-C) present from birth, leading to early-onset and progressive atherosclerotic cardiovascular disease. Early treatment initiation is crucial for cardiovascular risk reduction; however, many patients do not reach LDL-C treatment goals. Inclisiran, a small interfering RNA targeting hepatic PCSK9 (proprotein convertase subtilisin/kexin type 9), is effective and well tolerated in adult patients with hyperlipidemia; however, it has not yet been studied in pediatric patients.

METHODS

Herein we report results of the 1-year, double-blind, placebo-controlled part of the phase 3 study ORION-13 (Study to Evaluate Efficacy and Safety of Inclisiran in Adolescents With Homozygous Familial Hypercholesterolemia) in adolescents with HoFH. This 2-part multicenter study included 13 patients ≥12 to <18 years of age with a genetic diagnosis of HoFH (excluding LDL [low-density lipoprotein] receptor [LDLR] null/null genotypes) and elevated LDL-C levels (>130 mg/dL) on maximally tolerated statin treatment, with or without other lipid-lowering therapies. Eligible patients were randomized 2:1 to receive either 300 mg of inclisiran sodium or placebo, administered on days 1, 90, and 270. The primary end point was the mean percentage change in LDL-C from baseline to day 330.

RESULTS

The mean age of patients was 14.8 years, and mean baseline LDL-C was 272 mg/dL. The placebo-adjusted mean (95% CI) percentage change in LDL-C from baseline to day 330 was -33.3% (-59.2% to -7.3%). Six of 9 (66.7%) inclisiran-treated patients (versus 1 of 4 [25%] on placebo) achieved a >15% reduction in LDL-C, and 5 of 9 (55.6%) inclisiran-treated patients (versus none on placebo) achieved a >20% reduction. The placebo-adjusted mean (95% CI) percentage change in PCSK9 from baseline to day 330 was -60.2% (-79.8% to -40.7%); corresponding changes in apoB (apolipoprotein B), non-high-density lipoprotein cholesterol, and total cholesterol were -23.0%, -32.7%, and -27.8%, respectively. No serious adverse events, treatment discontinuations because of adverse events, or deaths occurred. No new safety findings were reported.

CONCLUSIONS

In a 1-year randomized controlled study (part 1 of ORION-13), inclisiran was effective in lowering LDL-C in adolescents with HoFH and was well tolerated. These results support inclisiran as a potentially useful addition for the treatment of adolescents with HoFH and a minimum of LDLR residual activity.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04659863.

Cascade screening in familial hypercholesterolaemia is associated with earlier statin initiation and fewer cardiovascular events than opportunistic screening

AIMS

The aim of this study is to assess whether the family cascade screening strategy for identifying patients with heterozygous familial hypercholesterolaemia (HeFH) is associated with a reduction in cardiovascular events compared with opportunistic screening strategies.

METHODS AND RESULTS

We retrospectively included 3232 patients, from the French FH registry, REFERCHOL, with a molecular diagnosis. We compared patients according to their screening strategy for HeFH: index cases (opportunistic screening) and cascade screening cases (patients diagnosed by cascade screening) on clinical and biological characteristics. We first compared patients according to screening modality using χ² and Student's t-tests and performed multivariate logistic regression to assess the association between screening strategy and the risk of cardiovascular events. We finally performed the same tests in an age- and sex-matched subpopulation. Compared with index cases (2106 patients), cascade screening cases (1126 patients) started statin use 14 years earlier [18.1 (interquartile range 12.5-29.1) years vs. 31.8 (19.7-42.4) years, P < 0.001] and 8.3% had a cardiovascular event prior to the first visit, vs. 26.5% in the index cases group (P < 0.001). In multivariate logistic regression, the cascade screening was independently associated with 51% less atherosclerotic cardiovascular disease (ASCVD) than the opportunistic screening. Age at statin initiation was also associated with ASCVD, with a higher adjusted odd ratio for higher age categories. In an age- and sex-matched analysis, cascade screening was no longer associated with ASCVD, but age at statin initiation remained.

CONCLUSION

The cascade screening strategy for familial hypercholesterolaemia is associated with 51% fewer cardiovascular events in genetically confirmed heFH probably due to an earlier age at treatment initiation.

Transition of care from childhood/adolescence to adulthood in familial hypercholesterolemia

Familial hypercholesterolemia (FH) is a common genetic disorder with a co-dominant inheritance pattern, characterized by persistently elevated levels of atherogenic low-density lipoprotein cholesterol (LDL-C) and a significantly increased risk of premature atherosclerotic cardiovascular disease. Given that the cardiovascular risk associated with elevated LDL-C begins in early childhood and progresses over time, early identification and long-term management are crucial. Implementing effective screening programs, genetic testing, and timely initiation of lipid-lowering therapy are essential strategies to mitigate future coronary events, improve quality of life, and reduce morbidity and mortality. This document outlines strategies and recommendations to improve early detection, genetic screening, and holistic management of individuals affected by FH, with particular emphasis on facilitating a structured transition from pediatric to adult healthcare services to ensure continuity of care and sustained treatment adherence.

Pediatric Transplant and Cellular Therapy Consortium RESILIENT Conference on Pediatric Chronic Graft-versus-Host Disease Survivorship after Hematopoietic Cell Transplantation: Part III. Long-Term Impact of Chronic Graft-versus-Host Disease on Endocrinologic, Cardiovascular, and Metabolic Outcomes in Survivors of Pediatric Hematopoietic Cell Transplantation

Chronic graft-versus-host disease (cGVHD) has a profound impact on the endocrinologic and cardiovascular health of survivors of transplantation performed in childhood. The impact of cGVHD is long-lasting and contributes to morbidity and early mortality through multiple mechanisms. Organs and tissues may be direct targets of alloreactive donor-derived immune cells. Corticosteroids and other cGVHD-directed therapies influence hormonal actions, alter bone metabolism, and negatively impact cardiometabolic health. Pediatric survivors are particularly vulnerable to the endocrinologic and cardiovascular effects of cGVHD as it develops during periods of intense growth and development, although little is known about the direct contribution to late effects. The Research and Education Toward Solutions for Late Effects to Innovate, Excel, and Nurture after cGVHD (RESILIENT after cGVHD) effort brought together content experts to determine the state of the science, develop clinical recommendations, and propose a research agenda in endocrine, cardiovascular, and metabolic cGVHD survivorship, which are detailed in this report.

Association between statin adherence and arterial stiffness in young adult patients with familial hypercholesterolemia: A cross-sectional study

BACKGROUND

Familial hypercholesterolemia (FH) causes elevated low-density lipoprotein cholesterol (LDL-C) levels, leading to an increased risk for premature atherosclerotic cardiovascular disease (ASCVD). To prevent ASCVD, lipid-lowering therapy (LLT), such as statins, is needed from childhood on, to lower LDL-C levels. Arterial stiffness can serve as a surrogate marker for atherosclerosis. The aim of this study is to determine the association between statin adherence and arterial stiffness in young adults with FH.

METHODS

The cohort for this cross-sectional study originally consisted of 214 children with heterozygous FH who participated in a placebo-controlled trial on the efficacy and safety of pravastatin, and all continued on LLT. After 20 years, these patients were invited for a follow-up visit, including a questionnaire where they reported the percentage of prescribed LLT they had taken over the past month, as well as a 4D flow MRI examination to assess carotid pulse wave velocity (PWV), in m/s.

RESULTS

We included 134 patients with FH (mean (SD) age: 31.7 (3.2) years; 67 (50.0 %) males). A higher adherence (%) to statin therapy was significantly associated with lower PWV (beta [β] -0.003 (95 % confidence interval [CI] -0.007 to -0.000); P = 0.039). After adjustment for potential confounders, this association remained similar (β -0.003 (95 % CI -0.007 to -0.000), P = 0.031).

CONCLUSIONS

The results of our study suggest that higher adherence to statin therapy is associated with less arterial stiffness, thereby reducing the risk for ASCVD compared to lower levels of adherence. These findings highlight the importance of adherence to LLT in patients with FH.

Statin-associated rhabdomyolysis: an exemplary case report and a mini-review of therapeutic management

Background

Familial hypercholesterolemia (FH) is a genetic disorder that significantly increases low-density lipoprotein cholesterol (LDL-C) levels. Statins are commonly prescribed to minors to improve overall cardiovascular outcomes. Despite their well-documented efficacy in lowering lipid levels, statins can cause adverse side effects, including myopathy and, in rare cases, rhabdomyolysis.

Case Description

A 17-year-old male adolescent presented with acute muscle pain in both arms. The patient had a history of FH and was undergoing treatment with rosuvastatin. Laboratory results revealed a marked elevation in creatine kinase (CK), myoglobin, cystatin C, and hepatic enzymes. Urinalysis did not show any abnormalities. Given the suspicion of statin-associated rhabdomyolysis, rosuvastatin was promptly discontinued. Further, the patient was administered intravenous fluids (3 L/m2/day) for renal protection. Nine days after admission, levels of CK, myoglobin, and creatinine returned to normal. Hepatic enzymes and cystatin C remained elevated. The patient was advised to discontinue statin therapy for a total of 6 weeks. For further treatment, the patient was referred to a pediatric lipid clinic.

Conclusions

While the use of statins is generally safe, rare side effects including rhabdomyolysis must be detected and therapy promptly initiated to prevent long-term health effects. Patients that experienced statin-associated rhabdomyolysis should be monitored closely and referred to a pediatric lipid clinic for further treatment.

[Role of genetics in precision medicine of coronary artery disease]

Coronary artery disease (CAD) develops multifactorially through an interplay of lifestyle, environmental and genetic factors. Smoking, hypertension, hyperlipidemia, obesity and diabetes mellitus are modifiable risk factors for CAD. In addition, both rare mutations and multiple frequently occurring genetic variants can cause CAD, whereby the heritability of CAD is ca. 50%. Genetic diagnostics enable the early identification of affected children and adults and, based on a greatly increased cardiovascular risk, initiation of preventive treatment. In recent years, genome-wide association studies have identified hundreds of significant variants that together greatly increase the risk of CAD. In the general population the many frequently occurring risk alleles in combination with modifiable risk factors result in a widespread genetic predisposition to CAD. Their relevance arises in the context of an integrative risk assessment, whereby the additional genetic risk can be calculated by polygenic risk scores (PRS), which provide a hazard ratio that can be multiplied with the clinically determined risk. This overview article discusses the diagnostic principles of rare and frequent genetic causes of CAD as well as their implications in the precision treatment of the disease.

Implementation science and genetic testing for familial hypercholesterolemia

PURPOSE OF REVIEW

Familial hypercholesterolemia is a treatable genetic disorder of cholesterol metabolism. Genetic testing is the most specific method for diagnosing familial hypercholesterolemia, but it remains underutilized. Implementation science aims to bridge the gap between evidence and practice and, thereby, support improved familial hypercholesterolemia care. This review presents the current evidence on the use of implementation science to improve the use of genetic testing for familial hypercholesterolemia.

RECENT FINDINGS

Recent research has focused on developing implementation strategies to improve the use of genetic testing, particularly cascade testing of at-risk blood relatives of known familial hypercholesterolemia cases. Stakeholder informed strategies aimed at improving communication between families and detection of familial hypercholesterolemia in primary care have been developed and implemented. Findings demonstrate implementation science methods can help remove barriers and improve the uptake of cascade genetic testing.

SUMMARY

Significant gaps in familial hypercholesterolemia care emphasize the importance of practical and realistic approaches to improve the detection of this preventable cause of premature heart disease, and recent efforts using implementation science have shown some promising results. More implementation science studies are needed that address the considerable gaps in familial hypercholesterolemia care, including the underutilization of genetic testing, so that all individuals receive the best clinical care.

Fiber in the Treatment of Dyslipidemia in Pediatric Patients

Dietary fiber is present in many food categories (fruits, cereals, vegetables, legumes), and is considered a beneficial component of adult and children's diets. It is now well-established that dietary intervention is the first line of treatment for childhood dyslipidemia, both as a curative intervention (Familial Hyperchylomicronemia Syndrome, Sitosterolemia) and as an appropriate lifestyle aimed at improving the lipid profile in dyslipidemia, which is associated with early atherosclerosis and an increased risk of cardiovascular disease in adulthood (Familial Hypercholesterolemia, overweight- and obesity-related dyslipidemia). In this paper, we reviewed the main consensus documents to determine the current indications for its use in children and adolescents, and analyzed the few specific papers on the subject in the literature to assess how fiber is currently used in the treatment of pediatric dyslipidemia, what precautions should be taken, and what the main benefits of fiber are on the lipid profile and cardiovascular risk.

Ages at coronary heart disease and death in familial hypercholesterolaemia: a Danish nationwide study spanning 44 years

BACKGROUND AND AIMS

Familial hypercholesterolaemia leads to lifelong elevated low-density lipoprotein cholesterol with increased risk of coronary heart disease and pre-mature death. It is unknown whether the prognosis for individuals with familial hypercholesterolaemia has improved over the past four decades as registration of this condition has been limited worldwide. However, in Danish nationwide registries, modified ICD coding has allowed such registration since 1978. This study tested the hypothesis that age at death and coronary heart disease has improved from 1978 to 2021 in individuals with vs. those without familial hypercholesterolaemia.

METHODS

From nationwide registries, all Danish residents were included in a retrospective cohort study. Inclusion and follow-up were from 1978 to 2021. Individuals diagnosed with familial hypercholesterolaemia were identified, and trends over time were examined for age at death and age at coronary heart disease.

RESULTS

During follow-up for those with (n = 10 199) and without (n = 9 174 926) familial hypercholesterolaemia, 27% and 27% died and 34% and 9% experienced coronary heart disease. Age at death was 22 years younger in 1978 (P < .001) but similar in 2021 (P = .16) in individuals with vs. without familial hypercholesterolaemia. Although the corresponding age at coronary heart disease was 20 years younger in 1978 (P < .001), it was still 7 years younger in 2021 (P < .001) in individuals with vs. without familial hypercholesterolaemia. These results were similar in women and men and in a 1:100 matched analysis by sex, ethnicity, and time of birth.

CONCLUSIONS

Nationwide from 1978 to 2021 in Denmark, normalization of age at death but not age at coronary heart disease was observed for individuals diagnosed with familial hypercholesterolaemia.

Dyslipidaemia among children and adolescents in Pakistan: a five-year retrospective cohort study based on laboratory data

BACKGROUND

Dyslipidaemia is a significant risk factor for cardiovascular diseases, which can manifest early in life. Despite its importance, the prevalence of dyslipidaemia in the paediatric population of Pakistan remains poorly understood. This study uses laboratory data to determine the prevalence of dyslipidaemia and lipid testing practices among Pakistani children and adolescents.

METHODS

This retrospective cohort study analysed the laboratory data from children and adolescents, aged up to 19 years, who underwent lipid testing. The data was obtained from two centres with collection points all over Pakistan for five years (March 2019-March 2024). Logistic regression models were used to assess relationships between demographic factors (age, sex and regions/provinces) and lipid profile parameters.

RESULTS

Over five years, 9,787 children and adolescents with a mean age of 13.8 ± 5.1 years underwent lipid testing. Boys accounted for 59.7% of those tested compared to 40.3% of girls (p = 0.09). Most tests were conducted in Punjab (81.2%), with minimal representation from Balochistan (0.5%) and Gilgit Baltistan (0.3%). Among tested children and adolescents, 33.3% had elevated total cholesterol, 25.4% high low-density lipoprotein cholesterol, 46.6% low high-density lipoprotein cholesterol, 48.0% abnormal non- high-density lipoprotein cholesterol and 41.7% hypertriglyceridemia. Compared to boys, girls had significantly lower odds of abnormal high-density lipoprotein cholesterol (Odds Ratio 0.556, 95% CI 0.511-0.607, p < 0.001) and triglyceride levels (Odds Ratio 0.702, 95% CI 0.642-0.767, p < 0.001).

CONCLUSION

This study highlights a high prevalence of dyslipidaemia among Pakistani children, with boys more affected than girls. The study also highlights a gender-based inequality in lipid testing where girls appear to be less frequently tested compared to boys.

Evaluation of glycemic status and subclinical atherosclerosis in familial hypercholesterolemia subjects with or without LDL receptor mutation

BACKGROUND

Familial hypercholesterolemia (FH) is a genetic condition characterized by elevated LDL-C and increased cardiovascular risk. Beyond LDL-C levels, the impact of genotype on glucose homeostasis has not been well evaluated. We aimed to evaluate the impact of genotype on glycemic status and on atherosclerotic injury in FH subjects.

METHODS

We conducted a cross-sectional study on 322 FH subjects not on lipid-lowering therapy and without history of cardiovascular disease. Biochemical and genetic analyses as well as vascular profile assessment were obtained from all subjects. The study population was divided into two groups according to genotype: LDL receptor (LDLR) group and non-LDLR (NLDLR) group.

RESULTS

The LDLR group exhibited a higher prevalence of low glycemic status (LGS) than the NLDLR group (44.1% vs. 26%, p < 0.01), whereas a high glycemic status (HGS) was more prevalent in the NLDLR group compared with LDLR group (74% vs. 55.9%, p < 0.01). The NLDLR group exhibited a higher prevalence of peripheral atherosclerotic plaques than the LDLR group (93.4% vs. 73%, p < 0.05), while coronary artery calcification (CAC) presence was more prevalent in the LDLR group compared with the NLDLR group (74.7% vs. 48%, p < 0.01). In a secondary analysis the study population was stratified into three groups based on LDLR genotype: NLDLR, LDLR defective, LDLR null groups. The prevalence of LGS progressively increased from the NLDLR to the LDLR null group, while HGS showed an inverse trend (p for trend < 0.05). Peripheral atherosclerotic plaque prevalence decreased from the NLDLR to the LDLR null group (p for trend < 0.05), while CAC prevalence increased progressively in the three groups (p for trend < 0.01). Logistic regression analysis showed that FH groups with an LDLR mutation were inversely associated with HGS (p for both < 0.01) and the LDLR null group exhibited the strongest association.

CONCLUSIONS

FH subjects with NLDLR mutations exhibited a worse glycemic profile, while null LDLR mutations showed the strongest inverse association with HGS. The integrations of genetic, lipid and glucose data could be useful to better identify the metabolic profile and the atherosclerosis distribution in FH subjects.

RESEARCH INSIGHTS

WHAT IS CURRENTLY KNOWN ABOUT THIS TOPIC?: Familial hypercholesterolemia (FH) is characterized by elevated LDL-C levels. LDLR null mutations protected pancreatic β-cells from cholesterol accumulation. NGS has improved FH diagnosis by analysis of all genes implicated in the lipid disorder. WHAT IS THE KEY RESEARCH QUESTION?: What is the impact of FH genotype (monogenic with or without LDLR mutation/polygenic) on glycemic status? WHAT IS NEW?: FH population was characterized by a heterogeneous glycemic profile according to LDLR mutation. LDL-C and plasma glucose could modulate the distribution of subclinical atherosclerosis. HOW MIGHT THIS STUDYINFLUENCE CLINICAL PRACTICE?: Genetic, lipid, glucose data could better identify the metabolic and atherosclerotic profiles in FH.

Population Pharmacokinetics and Exposure-Response Modeling for Evinacumab in Children, Adolescents, and Adults With Homozygous Familial Hypercholesterolemia

Evinacumab, an angiopoietin-like 3 (ANGPTL3) inhibitor, significantly reduces low-density lipoprotein cholesterol (LDL-C), independent of low-density lipoprotein receptor, in patients with homozygous familial hypercholesterolemia (HoFH). A population pharmacokinetic (PK)/pharmacodynamic (PD) model was previously developed to characterize evinacumab exposure and LDL-C response in adolescents and adults. In this analysis, the PK/PD model was refined to include children aged 5 to < 12 years and to characterize the lipoprotein apheresis effect on LDL-C reduction. The PK of evinacumab was characterized by a two-compartment model with parallel linear and non-linear elimination. Linear disposition parameters were allometrically scaled by body weight. Baseline ANGPTL3 concentrations and disease status (non-HoFH vs. HoFH) influenced the maximum target-mediated rate of elimination but had a minimal effect on evinacumab exposures at 15 mg/kg intravenous doses every 4 weeks across weight/age groups. In patients with HoFH, the LDL-C reduction was adequately described by an indirect response model in which evinacumab inhibits the formation of LDL-C and that includes a secondary elimination process quantifying the lipoprotein apheresis effect. Older age was associated with a decrease in baseline LDL-C. An increase in body weight was associated with a reduction in the maximum inhibitory effect of evinacumab. Model-based simulations showed that while evinacumab exposure is reduced with decreasing age/body weight, younger patients are predicted to have a comparable or greater magnitude of LDL-C reduction than older patients at a dose of 15 mg/kg. Overall, the model adequately predicted the evinacumab exposure and LDL-C reduction in children, adolescents, and adults with HoFH, aligning with clinically relevant observations.

Comparison of Model-Predicted and Observed Evinacumab Pharmacokinetics and Efficacy in Children Aged < 5 Years With Homozygous Familial Hypercholesterolemia

Evinacumab, an angiopoietin-like 3 inhibitor, significantly reduces low-density lipoprotein cholesterol (LDL-C) in patients with homozygous familial hypercholesterolemia (HoFH). Herein, we report pharmacokinetic and efficacy analyses of evinacumab in < 5-year-old patients with HoFH. Population pharmacometric models characterizing evinacumab exposure and LDL-C response accounting for lipoprotein apheresis effect in ≥ 5-year-old patients were adapted for growth and maturation to predict and compare evinacumab and LDL-C concentrations across age/weight groups in virtual ≥ 6-month-old patients receiving 15 mg/kg evinacumab intravenous (iv) infusions every 4 weeks (q4w). As expected from allometric theory, weight-based dosing resulted in decreasing evinacumab exposures with declining body weight. Consistent with trends observed in > 5-year-old patients, the predicted percent change from LDL-C baseline (%∆LDL-C) was generally comparable or even higher in < 5-year-old patients (63.0%-68.5%) than in 5- to < 18-year-old patients (61.3%-67.8%) or adults (51.7%), with the predicted percentages of patients achieving %∆LDL-C > 50% also higher in < 5-year-old patients (82.0%-86.9%) versus 5- to < 18-year-old patients (72.0%-84.5%) and adults (54.8%). Through a managed access program, six 1- to < 5-year-old patients received between 5 and 23 iv infusions of 15 mg/kg evinacumab q4w. Rapid and clinically meaningful LDL-C reductions were observed, with %∆LDL-C at the last reported dose ranging from 41.3% to 77.3%. Based on the actual patient dosing and plasmapheresis history, model-predicted evinacumab and LDL-C concentrations were comparable to the observed data collected in the managed access program. Overall, this analysis provides evidence for the use of evinacumab 15 mg/kg iv q4w dosing regimen in 6-month-old to 5-year-old patients.

Sex-Based Disparities in Index Cases of Familial Hypercholesterolemia in Vietnam: A Cross-Sectional Study

Background and Aims

Familial hypercholesterolemia (FH) is a substantial contributor to the development of atherosclerotic cardiovascular disease. Therefore, the primary focus of our study was to examine sex-based disparities in clinical signs, atherosclerotic status, lipid profiles, and treatment intensity among patients with FH from Vietnam.

Methods

This retrospective cross-sectional report analyzed the clinical profiles of 110 patients with FH from the Vietnam Familial Hypercholesterolemia (VINAFH) registry.

Results

Among these patients, 47 (42.7%) were females, and 48 (43.6%) had mutant FH. Women were diagnosed with FH at a significantly later age than men. However, smoking and clinical signs suggestive of FH were observed more frequently in males than in females. Male patients exhibited a higher prevalence of premature coronary artery disease than females. No significant differences in plasma total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels were observed between sexes. In males, the areas under the curve (AUC) for plasma LDL-C levels were 0.83, with a cut-off value of 6.11 mmol/L (sensitivity, 79.4%; specificity, 89.7%). In females, the AUC for plasma LDL-C levels was 0.72, with a cut-off value of 6.9 mmol/L (sensitivity, 57.1%; specificity, 93.9%). Statins were prescribed to most patients (93.6%), with a higher proportion of men than women receiving high-intensity statin therapy.

Conclusion

Our findings suggested that in Vietnam, FH is diagnosed later in women, whereas men are more likely to smoke and have atherosclerotic cardiovascular disease. Treatment intensity in female patients with FH was lower than that in male patients, despite statin prescription.

Cascade Screening in Adolescents with Lipid Disorders Suggestive of Familial Hypercholesterolemia: Findings from the ERICA Study in Curitiba

BACKGROUND

Familial hypercholesterolemia (FH) is a common genetic cause of premature coronary heart disease due to prolonged exposure to high levels of LDL cholesterol (LDL-C). Its prevalence in the heterozygous form ranges from 1:200 to 1:500, and early diagnosis is fundamental for treatment and risk reduction. Cascade screening is recommended upon the identification of index cases.

OBJECTIVES

To assess the prevalence of lipid disorders suggestive of FH in students aged 12 to 17 years participating in the ERICA study in Curitiba and to determine the prevalence of FH based on clinical and laboratory criteria in these adolescents and their first-degree relatives undergoing cascade screening.

METHODS

Using data from the ERICA study, adolescents with LDL-C levels > 160 mg/dL or non-HDL cholesterol > 190 mg/dL were identified, along with their first-degree relatives. The clinical diagnosis of the study participants was based on the DUTCH MedPed criteria. Statistical significance was defined as P < 0.05.

RESULTS

Eleven adolescents with lipid disorders suggestive of FH were identified among the 2,383 evaluated (1:216). Of these, 7 students and 15 first-degree relatives were assessed. None of the adolescents had a diagnosis of possible FH confirmed by the clinical score. However, 3 family members (20%) were diagnosed with possible/probable FH.

CONCLUSION

Although the clinical score application did not confirm any cases among adolescents with lipid disorders suggestive of FH, indicating a limitation of the diagnostic method in this population, cascade screening identified potential cases in first-degree relatives.

Assessment of Low-density Lipoprotein Cholesterol Levels and Non-invasive Vascular Health in School-aged Children: A Study in Ogasa District, Shizuoka Prefecture

AIM

The present study assessed low-density lipoprotein cholesterol (LDL-C) levels in school-aged children from the Ogasa District of Shizuoka Prefecture and evaluated the utility of non-invasive vascular tests, namely flow-mediated dilation (FMD) and intima-media thickness (IMT), in pediatric patients with familial hypercholesterolemia (FH).

METHOD

We analyzed the lipid test results of 8,568 students screened for prevention of lifestyle-related diseases and 78 children under 15 years old with cholesterol levels exceeding 220 mg/dL who visited Chutoen General Medical Center. We examined the LDL-C distribution from school-age screenings and conducted FMD and IMT assessments on those meeting the 2022 Pediatric FH Guidelines criteria.

RESULTS

Among the screened students, 186 (2.2%) exhibited LDL-C levels above 140 mg/dL, including 123 fourth-graders (2.8%) and 63 first-year junior high students (1.5%). The mean LDL-C level across all students was 90.0 mg/dL (standard deviation: 21.3 mg/dL), with the 95th percentile at approximately 125.0 mg/dL. Of the 78 children who visited the hospital, 65 met the FH diagnostic criteria. In children ≥ 10 years old, no significant IMT differences were observed between the Definitive and Probable FH groups and the Possible FH group; however, a significant difference in the FMD percentage was noted between these groups (9.9% [8.1%-11.9%] vs. 14.2% [11.6%-16.3%], P=0.003).

CONCLUSIONS

Our findings highlight the LDL-C distribution in FH screening and suggest a potential reduction in FMD in pediatric FH patients ≥ 10 years old. These results emphasize the importance of initiating pharmacological interventions in school-aged children to maintain optimal LDL-C levels for lifelong cardiovascular health.

Nutrition and dietary interventions for treatment and management of familial hypercholesterolaemia in children and adolescents: A systematic review

AIMS

Familial hypercholesterolaemia (FH) is a common inherited metabolic disease caused by mutations of genes involved in low-density cholesterol (LDL-C) catabolism. The accumulation of LDL-C increases the risk of early atherosclerosis and premature coronary artery disease. The aim of this systematic review was to investigate the impact of dietary interventions to lower total cholesterol (TC) and LDL-C in FH children not on medication.

DATA SYNTHESIS

We searched three databases to March 2024 to identify randomised-controlled trials (RCTs), crossover and non-randomised observational studies of dietary interventions conducted in children and adolescents, 2-<19 years, with FH and measuring TC and LDL-C pre- and post-intervention. Twenty-eight studies were found, testing interventions with modified percent of energy from fat, change in type of fat consumed, functional foods e.g., plant sterols, fibre and modification of specific nutrients. 8 studies using plant sterols (1.21 ± 0.13-2.76 ± 0.15g/day) demonstrated significant LDL-C reductions ranging from 10 to 18 % compared to control groups. Modifying fat content using rapeseed oil (59 % monounsaturated fat @15g/day) showed a 7 % reduction in LDL-C. 7 studies of functional foods showed reductions in LDL -C ranging from 4 % (calcium carbonate) to 27.5 % after consumption of pulverized blueberry tea with 32 mg/kg anthocyanins. 6 studies of dietary counselling interventions reported reductions in LDL-C from 3 to 22 %.

CONCLUSIONS

The addition of plant sterols had a significant cholesterol-lowering effect for children with FH from age 5. Additional studies are needed to investigate the efficacy of all other dietary interventions.

REGISTRY NUMBER

PROSPERO (CRD42023392111).

Diagnosis and Screening Strategies for Detection of Familial Hypercholesterolaemia in Children and Adolescents in Italy: A Survey from the LIPIGEN Paediatric Group

BACKGROUND

Awareness, diagnosis, and treatment of familial hypercholesterolemia (FH) starting from childhood are a cornerstone of cardiovascular disease prevention. The LIPIGEN Paediatric Group, a network of specialised centres for the diagnosis and management of familial genetic dyslipidemia, is an active part of this mission.

MATERIALS AND METHODS

This is the second exploratory survey organised within the LIPIGEN (LIpid transPort disorders Italian GEnetic Network) paediatric centres. A digital questionnaire consisting of 16 questions was proposed to the principal investigators of 35 LIPIGEN centres in September 2023. We analysed the main FH screening strategies implemented in Italy, which are the referral characteristics to the lipid clinics and clinical and biochemical criteria considered to diagnose FH in paediatric patients.

RESULTS

Centres frequently reported conducting cascade screening (88.6%) and reverse screening (57.1%), whereas 28.6% of respondents indicated using selective screening and only 5.7% reported employing child-parent screening. We documented a detailed biochemical characterisation of paediatric patients (62.9% of respondents usually perform full lipoprotein profile and 80% determine lipoprotein(a) for each patient) and a high percentage of genetic analysis (82.9%). We have also highlighted a quite low awareness of FH as a genetic condition involving paediatric patients among primary care paediatricians and general practitioners.

CONCLUSIONS

The results of our survey show that specialised lipid centres usually have good diagnostic competence when dealing with paediatric patients with hypercholesterolemia. However, FH awareness and the importance of early diagnosis and treatment initiation in childhood still need to be further improved.

Incidental diagnosis of familial hypercholesterolaemia in a mother-daughter pair: the underdiagnosis of the disease highlighting the need for universal screening

Familial hypercholesterolaemia (FH) is a common yet underdiagnosed genetic disorder of low-density lipoprotein metabolism leading to premature cardiovascular disease. Most FH individuals are only diagnosed later in their adulthood, missing the critical window for pre-emptive treatment. The absence of clinical manifestations until adulthood and poor awareness by medical and general communities contribute to this unmet clinical need. This case report describes a mother-daughter pair diagnosed with FH after hypercholesterolaemia was incidentally detected in the daughter during an evaluation for obesity. This underscores the importance of increasing awareness among primary care physicians about the clinically silent nature of FH. As the first point of contact for patients, they play a vital role in identifying potential FH cases during routine clinical encounters. Simultaneously, efforts should focus on developing a cost-effective universal screening programme.

Efficacy and safety of statins, ezetimibe and statins-ezetimibe therapies for children and adolescents with heterozygous familial hypercholesterolaemia: Systematic review, pairwise and network meta-analyses of randomised controlled trials

BACKGROUND AND AIMS

Statins, ezetimibe and statins-ezetimibe combination therapy are recommended lipid-lowering therapies (LLTs) in children with heterozygous familial hypercholesterolaemia (HeFH). However, their relative effectiveness is not well understood. We aimed to compare the safety and efficacy of these therapies using direct and indirect comparisons.

METHODS

We conducted systematic review, pairwise and network meta-analyses (NMAs) of randomised-controlled trials (RCTs) of statins, ezetimibe and statins-ezetimibe combination therapy in people <18 years with HeFH. Comprehensive bibliographic searches were conducted in December 2022, and a Medline update in January 2024. NMA models accounted for drug class, statin type and dosage.

RESULTS

Thirteen RCTs were included (n = 1649, median age 13 years, follow-up 6 weeks-2 years). All LLTs reduced low-density lipoprotein cholesterol (LDL-C) and total cholesterol; statins led to increases in high-density lipoprotein cholesterol and reductions in triglycerides. Statins reduced LDL-C by 33.61 % against placebo (95 % CI 27.58 to 39.63, I2 = 83 %). Adding ezetimibe to statins reduced LDL-C by an additional 15.85 % (95 % CI 11.91 to 19.79). NMAs showed intermediate-dose statins reduced LDL-C by an additional 4.77 % compared with lower-doses statins (95 % CrI -11.22 to 1.05); higher-dose statins and intermediate-dose statins + ezetimibe may be similarly effective and are probably superior to ezetimibe, intermediate-and lower-dose statins. There was no evidence of differences in maturation, safety or tolerability between LLTs and placebo.

CONCLUSIONS

Statins, ezetimibe and statins-ezetimibe are all effective treatments for children with HeFH, but the magnitude of LDL-C reductions varies and may depend on treatment dosage and combination. No safety or tolerability issues were found. Longer-term safety and effectiveness are uncertain.

PCSK9 in metabolism and diseases

PCSK9 is a serine protease that regulates plasma levels of low-density lipoprotein (LDL) and cholesterol by mediating the endolysosomal degradation of LDL receptor (LDLR) in the liver. When PCSK9 functions unchecked, it leads to increased degradation of LDLR, resulting in elevated circulatory levels of LDL and cholesterol. This dysregulation contributes to lipid and cholesterol metabolism abnormalities, foam cell formation, and the development of various diseases, including cardiovascular disease (CVD), viral infections, cancer, and sepsis. Emerging clinical and experimental evidence highlights an imperative role for PCSK9 in metabolic anomalies such as hypercholesterolemia and hyperlipidemia, as well as inflammation, and disturbances in mitochondrial homeostasis. Moreover, metabolic hormones - including insulin, glucagon, adipokines, natriuretic peptides, and sex steroids - regulate the expression and circulatory levels of PCSK9, thus influencing cardiovascular and metabolic functions. In this comprehensive review, we aim to elucidate the regulatory role of PCSK9 in lipid and cholesterol metabolism, pathophysiology of diseases such as CVD, infections, cancer, and sepsis, as well as its pharmaceutical and non-pharmaceutical targeting for therapeutic management of these conditions.

Importance of Genotype-Phenotype Correlation in the Population Screening of Familial Hypercholesterolemia

A 43-year-old male presented to our clinic with a complaint of multiple swellings on the extensor tendons of the elbows, ankles, and feet. On examination, he was found to have tendon xanthomas and xanthelasmas, and arcus lipoidosis. Investigations showed a low-density lipoprotein (LDL) level of 214 mg/dl. He had been on statins for a decade. His pretreatment LDL was 226 mg/dl. His genetic workup showed a homozygous variant in exon 9 of the low-density lipoprotein receptor (LDLR) gene of chromosome 19 and was classified as having homozygous familial hypercholesterolemia. His treatment was intensified to the maximum tolerated dosage of statin and ezetimibe but LDL was far above the acceptable limit, so he was planned for monthly injections of proprotein convertase subtilisin/kexin type 9 protein (PCSK9) inhibitor, evolocumab. Primary care physicians should have a keen eye on correlating the clinical and biochemical parameters of the patient with a genetic mutation analysis so as to not miss out on diseases with a rare occurrence such as homozygous familial hypercholesterolemia (HoFH) since early and optimal treatment with appropriate lipid-lowering therapies (LLT) is warranted to reduce the morbidity and mortality of patients. One should also increase awareness in the population for family planning due to increased maternal risk of atherosclerotic cardiovascular disease (ASCVD) during pregnancy, and also that children born to this population will have obligate heterozygous familial hypercholesterolemia (HeFH).

Clinical reality and challenges with familial hypercholesterolemia patients' management. 2024 results from the Regional Center for Rare Diseases (RCRD) Registry in Poland

BACKGROUND

Despite advancements in early diagnosis and effective medications in last decade, most heterozygous familial hypercholesterolemia (heFH) patients still fail to achieve their low-density lipoprotein cholesterol (LDL-C) goals and remain at residual cardiovascular disease risk. We present recent data from the regional FH registry in Poland, highlighting the challenges and real-life clinical management of FH patients.

METHODS

The registry is held at the Regional Centre for Rare Diseases, founded in 2016, at the 2nd largest, supraregional hospital in Poland, where >80 different rare diseases in patients from all over Poland are diagnosed and treated, including phenotypically or genetically diagnosed FH patients. Our analysis focused on both children and adult FH patients, excluding those treated with inclisiran due to a small sample size (n = 5).

RESULTS

We studied 173 consecutive heFH patients, median age for adult population was 40 years (range: 27-57), of whom 56.14 % were women. Among the population, 82.1 % were adults (n = 142), and 31 were children (17.92 %; median age 9 (8-13), females 58.16 %). Children exhibited lower total cholesterol and triglyceride levels compared to adults, with no significant differences in LDL-C and high-density lipoprotein cholesterol (HDL-C) levels. Molecular diagnosis in the whole population revealed that 76.6 % had an LDL receptor (LDLR) mutation, while 23.4 % had an apolipoprotein B (APOB) mutation. Risk assessment categorized patients into high (70.7 %), very high (22.1 %), and extremely high (7.1 %) risk groups. Triple therapy achieved treatment goals in 61.76 % of adults and 70.97 % of children. At baseline, 36.62 % of adult patients were not using statins. High-intensity statin therapy combined with ezetimibe was initiated for the remaining patients. Only 3.33 % of patients avoided statins due to complete intolerance. Ezetimibe was used in 57.27 % of patients (mostly in combination therapy), and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were prescribed for 28.17 % FH patients. In adults receiving statin and ezetimibe therapy, median achieved LDL-C was 141 mg/dl (107-184). For triple therapy, median achieved LDL-C was 52.5 mg/dL (32-86.5). Overall median achieved LDL-C in the study population was 99.5 mg/dl (57.5-145.4). PCSK9 inhibitors reduced LDL-C by 165.6 mg/dl. Combination therapy did not significantly alter baseline lipoprotein(a) (Lp(a)) levels (p = 0.134), and PCSK9 inhibitors led to a mean Lp(a) reduction of 18.66 mg/dl (45 % reduction; p = 0.013). Multivariable regression analysis identified key factors for achieving LDL-C targets in FH patients: DLCN total score, DLCN category, ezetimibe use, and PCSK9 inhibitors.

CONCLUSIONS

In Poland, FH patients are often diagnosed too late (usually over 40 years of age), and many still do not reach their LDL-C goals. Combination LLT double or triple therapy significantly increases the likelihood of achieving LDL-C targets - even up to fivefold. Therefore, unrestricted access to PCSK9 inhibitors for all FH patients is crucial, without the current limitations imposed by drug reimbursement programs like B101.

Rapid lipid-lowering response in two cases of autosomal recessive hypercholesterolemia

BACKGROUND

Autosomal recessive hypercholesterolemia (ARH) is an ultrarare dyslipidemia caused by variants in the LDLRAP1 gene. Clinically, this condition is indistinguishable from other homozygous familial hypercholesterolemia (HoFH).

CASE

We present the cases of 2 siblings diagnosed with ARH caused by LDLRAP1 gene c.617-14C > A splicing homozygous variant. Over a 5-year treatment period, the older sibling experienced an 81% reduction in low-density lipoprotein cholesterol (LDL-C) levels with the maximal dose of pitavastatin plus ezetimibe, while the younger sibling achieved a 75% reduction. After three sessions, the older brother no longer required LDL apheresis, and the sibling never had LDL apheresis.

CONCLUSION

Our findings demonstrate a rapid and significant response to lipid-lowering therapy (LLT) in patients with ARH caused by c.617-14C > A splicing VUS variant, a condition that mimics HoFH at diagnosis. Long-term follow-up studies in large pediatric cohorts of ARH patients treated with pitavastatin plus ezetimibe from childhood are necessary to better define the risk of cardiovascular disease (CVD) development.

Impact of Genetic Testing and Sex Differences among Patients with Familial Hypercholesterolemia: The Hokuriku-plus Familial Hypercholesterolemia Registry Study

AIM

We aimed to clarify the degree and factors associated with low-density lipoprotein (LDL)-cholesterol treatment target attainment among patients with heterozygous familial hypercholesterolemia (HeFH) using the Hokuriku-plus FH registry.

METHODS

The Hokuriku-plus FH registry (UMIN000038210) was a prospective, observational, multicenter cohort study that enrolled consecutive patients with FH who fulfilled the clinical criteria for FH in Japan from 37 participating hospitals, mostly in the Hokuriku region, from April 2020 to March 2024. This registry collects data on clinical parameters, including lipid levels, physical findings, genetic background, and clinical events. In total, 431 patients were enrolled, and the median followup period was 3.1 years. We assessed the degree and factors associated with LDL-cholesterol treatment target attainment among patients with HeFH using the Hokuriku-plus FH registry.

RESULTS

Among the 431 patients, sufficient data were collected from 386 patients. Logistic regression analysis revealed that male sex (odds ratio [OR] = 2.16, 95% confidence interval [CI]: 1.14-3.18, p＜0.001) and genetic testing (OR = 1.68, 95% CI: 1.10-2.26, p＜0.001) were significantly associated with LDL-cholesterol treatment target attainment. In fact, female patients were less likely to attain LDL-cholesterol treatment target than male patients (24.0% vs. 38.1%, p＜0.001), and patients who did not undergo genetic testing were less likely to attain LDL-cholesterol treatment target than those who underwent genetic testing (24.5% vs. 37.1%, p＜0.001).

CONCLUSION

Sex bias and masked genetic status are significant barriers to the clinical management of patients with HeFH.

Universal screening for familial hypercholesterolaemia: how can we maximise benefits and minimise potential harm for children and their families?

PURPOSE OF REVIEW

Universal Screening programmes to identify subjects with familial hypercholesterolaemia (FH) have been the subject of much recent interest. However, any screening programme can cause harm as well as having potential benefits. Here we review recent papers using different ages and strategies to identify subjects with FH, and examine to what extent the publications provide quantitative or qualitative evidence of benefit or harm to children and adults.

RECENT FINDINGS

Three studies have been published over the last 2 years where Universal Screening for FH has been carried out in infancy, at the time of routine vaccinations, or at preschool age. Next-generation sequencing of all known FH-causing genes has been used to determine the proportion of screened individuals, who have total or low-density lipoprotein cholesterol (LDL-C) concentrations above a predetermined threshold (such as >95th percentile), with genetically confirmed FH.

SUMMARY

While we fully support the concept of Universal Screening for FH, which appears feasible and of potential clinical utility at all of the different ages examined, there is little data to document potential benefit or how to mitigate potential harms. Future study protocols should include collection of such data to strengthen the case of roll out of Universal Screening programmes.

Managing Dyslipidemia in Children: Current Approaches and the Potential of Artificial Intelligence

Dyslipidemia is abnormal lipid and lipoprotein levels in the blood, influenced mainly by genetics, lifestyle, and environmental factors. The management of lipid levels in children involves early screening, nonpharmacological interventions such as lifestyle modifications and dietary changes, nutraceuticals, and pharmacological treatments, including drug therapy. However, the prevalence of dyslipidemia in the pediatric population is increasing, particularly among obese children, which is a significant risk factor for cardiovascular complications. This narrative review analyzes current literature on the management of dyslipidemia in children and explores the potential of artificial intelligence (AI) to improve screening, diagnosis, and treatment outcomes. A comprehensive literature search was conducted using Google Scholar and PubMed databases, focusing primarily on the application of AI in managing dyslipidemia. AI has been beneficial in managing lipid disorders, including lipid profile analysis, obesity assessments, and familial hypercholesterolemia screening. Deep learning models, machine learning algorithms, and artificial neural networks have improved diagnostic accuracy and treatment efficacy. While most studies are done in the adult population, the promising results suggest further exploring AI management of dyslipidemia in children.

Association of magnesium intake with predicted atherosclerotic lesions and cardiovascular risk in young adults based on PDAY score: a cross-sectional study

BACKGROUND

Magnesium deficiency has been shown to accelerate atherosclerosis. We hypothesized that dietary magnesium intake at a young age is associated with future atherosclerotic lesions and cardiovascular risk in a large, nationally representative cohort of U.S. adults.

METHODS

We included U.S. adults aged 20 to 34 years old from the National Health and Nutrition Examination Survey (NHANES) 2007 to 2018, a population-based cross-sectional study. Dietary magnesium intake was assessed using 24-hour diet recalls. Atherosclerotic lesions in the young adult population were predicted by the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) score that was based on age, sex, smoking status, lipids, blood pressure, and obesity. Information on cardiovascular disease (CVD) risk factors including hypertension, non-HDL-C dyslipidemia, and diabetes was also collected. We used multivariable logistic analysis models to test the association between magnesium intake levels and the PDAY score and CVD risk factors, respectively, after adjusting for several potential confounding factors.

RESULTS

7,244 eligible participants were included in the analysis. The magnesium intake level was classified into three categories based on the tertile distribution in the population (i.e., ≤ 224, 225-340, and ≥ 341 mg/day). Compared with the lowest tertile, the multivariable-adjusted odds ratio (OR) and 95% confidence interval (95% CI) for the PDAY score were 0.83 (95% CI, 0.72 to 0.96) and 0.60 (95% CI, 0.49 to 0.74) in the second and the third tertiles of magnesium intake, respectively (P value for trend < 0.001), and there was a negative dose-response relationship (test for trend P value < 0.001). In addition, the highest dietary magnesium intake was significantly inverse associated with non-HDL-C dyslipidemia compared with the lowest magnesium intake (OR = 0.65; 95% CI, 0.46 to 0.91).

CONCLUSIONS

Dietary magnesium intake is inversely associated with the risk of future cardiovascular events assessed by the PDAY score and non-HDL-C dyslipidemia in young adulthood years.

Targeted NGS Revealed Pathogenic Mutation in a 13-Year-Old Patient with Homozygous Familial Hypercholesterolemia: A Case Report

Familial hypercholesterolemia is an autosomal hereditary disease defined by an increased level of low-density lipoprotein cholesterol (LDL-C), which predisposes significant risks for premature cardiovascular disorders. We present a family trio study: proband, a 13-year-old Kazakh girl with homozygous familial hypercholesterolemia (HoFH) and her parents. HoFH is much more rare and severe than a heterozygous form of the disorder. HoFH patients generally present with LDL-C levels exceeding 13 mmol/L, resulting in early and life-threatening cardiovascular events within the first decades of life. In cases of neglected treatment, young patients have a risk of death from coronary diseases before the age of 30. The aim of this research was to identify genetic mutations in the affected patient and her parents. Genetic testing was necessary due to highly elevated LDL-C levels and the presence of multiple xanthomas. Targeted next-generation sequencing (NGS) was performed in this study using the Illumina TruSight cardio panel, which targets 174 genes related to cardiac disorders. The girl was diagnosed with HoFH based on the results of genetic testing. A biallelic mutation was observed in exon 3 of the low-density lipoprotein receptor (LDLR): c. 295 G>A (p.Glu99Lys). Sanger sequencing confirmed that the mutant gene was inherited from both parents. After confirming the genetic diagnosis of HoFH, the patient was treated with LDL apheresis and statins. This case report is the first study of HoFH in a pediatric patient from the Central Asian region. Globally, it emphasizes the need for increased clinical awareness among healthcare providers, as early detection and intervention are important for improving outcomes, particularly in pediatric patients with this rare genetic disorder.

The therapeutic effect of liver transplantation in 14 children with homozygous familial hypercholesterolemia: A prospective cohort: Liver transplant for familial hypercholesterolemia

OBJECTIVES

Homozygous familial hypercholesterolemia (HoFH) is characterized by elevated low-density lipoprotein cholesterol (LDL-C) and early-onset cardiovascular disease. To assess the therapeutic effects of liver transplantation (LT) on HoFH patients, we observed and analyzed the outcomes of HoFH children after LT.

STUDY DESIGN

This prospective cohort study included all LT candidates under 18 years old diagnosed with HoFH at Ren Ji Hospital between November 2017 and July 2021. The patients were followed until October 2023. They were treated according to the standard protocol at our center. We collected data on changes in lipid profiles, clinical manifestations, and cardiovascular complications at different time points, and recorded postoperative recipient and graft survival.

RESULTS

Fourteen HoFH patients with a median age of 7 (2-12) years were included. Preoperatively, xanthomas and arcus corneas occurred in 14 and 3 patients, respectively, with 10 patients showing mild cardiovascular disease. All patients underwent LT. Recipient and graft survival rates were 100% over a median follow-up duration of 35 (27-71) months. Median LDL-C levels dropped from 11.83 (7.99-26.14) mmol/L preoperatively to 2.3 (1.49-3.39) mmol/L postoperative at the last measurement. Thirteen patients discontinued lipid-lowering treatment after LT, while only one patient resumed statins 6 months post-operation. Xanthomas and arcus corneas significantly improved. Cardiovascular complications regressed in five patients, with no progression observed in the others.

CONCLUSIONS

LT is a safe and effective treatment for severe HoFH patients beyond lipid-lowering control. Early LT improves prognosis and quality of life while minimizing the risk of cardiovascular complications.

Efficacy and Safety of Evolocumab and Alirocumab as PCSK9 Inhibitors in Pediatric Patients with Familial Hypercholesterolemia: A Systematic Review and Meta-Analysis

Background and Objectives: The proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors evolocumab and alirocumab are recently developed promising drugs used for treatment of familial hypercholesterolemia (FH). This systematic review and meta-analysis aimed to thoroughly evaluate the efficacy and safety of evolocumab and alirocumab among pediatric patients with FH. Materials and Methods: A comprehensive search was conducted in PubMed, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and ClinicalTrials.gov from inception through July 2024 to identify primary interventional studies among pediatric patients with FH. Meta-analyses were performed if appropriate. Statistics were analyzed using Review Manager version 5.4 and Stata version 16.0. Results: Fourteen articles reporting nine unique studies were included. There were three randomized controlled trials (RCTs) assessing evolocumab or alirocumab involving a total of 320 pediatric patients, one cross-over trial and five single-arm or observational studies. Pooled results showed significant efficacy of evolocumab/alirocumab in reducing low-density lipoprotein cholesterol (LDL-C) (weighted mean difference [WMD]: -37.92%, 95% confidence interval [CI]: -43.06% to -32.78%; I2 = 0.0%, p = 0.60), apolipoprotein B (WMD: -33.67%, 95% CI: -38.12% to -29.22%; I2 = 0.0%, p = 0.71), and also lipoprotein(a) (WMD: -16.94%, 95% CI: -26.20% to -7.69%; I2 = 0.0%, p = 0.71) among pediatric patients with FH. The efficacies of evolocumab/alirocumab on LDL-C reduction within pediatric patients with heterozygous FH (HeFH) were consistent between studies, whereas in patients with homozygous FH (HoFH), it varied dramatically. Pediatric patients with the null/null variant may respond to the treatment. PCSK9 inhibitors were generally well tolerated within most pediatric patients, in line with previous studies among adult populations. Conclusions: The PCSK9 inhibitors evolocumab/alirocumab significantly reduced LDL-C and some other lipid parameters, such as apolipoprotein B, in pediatric patients with HeFH. These drugs may be appropriate as a potential therapy for pediatric patients with HoFH who cannot achieve LDL-C targets with other treatments. Evolocumab/alirocumab was generally well tolerated in the pediatric population.

Long-term effectiveness and safety of lomitapide in patients with homozygous familial hypercholesterolemia: an observational case series

BACKGROUND

We assessed long-term real-world effectiveness and safety of lomitapide in patients with homozygous familial hypercholesterolemia (HoFH).

METHODS

Retrospective case series of six patients with HoFH treated with lomitapide in an Italian clinic. Changes in low-density lipoprotein cholesterol (LDL-C) during lomitapide treatment were assessed. The effect on LDL-C of PCSK9 inhibitors, apheresis and lomitapide was evaluated. Additionally, high-density lipoprotein cholesterol (HDL-C), gastrointestinal tolerability, hepatic steatosis/elasticity, transaminases, and cardiovascular events and symptoms were assessed.

RESULTS

Median age at HoFH clinical and molecular diagnoses was 25 (range 2-49) and 40 (29-71) years, respectively. Five (83.3%) had prior cardiovascular events. One patient received apheresis, which was subsequently discontinued. All patients received PCSK9 inhibitors but discontinued due to minimal effectiveness. Median (range) age at lomitapide initiation was 44 (28-73) years, with a median 47 (18-85) months' treatment (mean dose 17.5 [5-40] mg/day). Mean (SD) baseline LDL-C was 263.2 (148.1) mg/dL, which decreased by 80% at nadir (52.8 [19.2] mg/dL) and 69% at last follow-up (81.3 [30.5] mg/dL). Four patients (66.7%) achieved LDL-C < 70 mg/dL sometime during follow-up, all of whom also achieved LDL-C < 55 mg/dL. Adverse events (AEs) were generally mild to moderate, hepatic steatosis was either absent or mild/moderate and hepatic elasticity remained normal in all but two patients (> 70 years old). All patients with reported cardiovascular symptoms had improvements in symptoms, and all patients reported stabilization or regression of intima-media thickness and atheromatous plaques.

CONCLUSIONS

These long-term, real-world data demonstrate that lomitapide substantially reduced LDL-C for up to seven years. Most patients achieved LDL-C goal at some point, consistent with published Phase III trial and real-world evidence data. No patient discontinued lomitapide treatment. Further long-term follow-up in a larger patient population will be important to determine cardiovascular and other outcomes.

The LDL cumulative exposure hypothesis: evidence and practical applications

The trapping of LDL and other apolipoprotein B-containing lipoproteins within the artery wall causes atherosclerosis. As more LDL becomes trapped within the artery wall over time, the atherosclerotic plaque burden gradually increases, raising the risk of an acute cardiovascular event. Therefore, the biological effect of LDL on the risk of atherosclerotic cardiovascular disease (ASCVD) depends on both the magnitude and duration of exposure. Maintaining low levels of LDL-cholesterol (LDL-C) over time decreases the number of LDL particles trapped within the artery wall, slows the progression of atherosclerosis and, by delaying the age at which mature atherosclerotic plaques develop, substantially reduces the lifetime risk of ASCVD events. Summing LDL-C measurements over time to calculate cumulative exposure to LDL generates a unique biomarker that captures both the magnitude and duration of exposure, which facilitates the estimation of the absolute risk of having an acute cardiovascular event at any point in time. Titrating LDL-C lowering to keep cumulative exposure to LDL below the threshold at which acute cardiovascular events occur can effectively prevent ASCVD. In this Review, we provide the first comprehensive overview of how the LDL cumulative exposure hypothesis can guide the prevention of ASCVD. We also discuss the benefits of maintaining lower LDL-C levels over time and how this knowledge can be used to inform clinical practice guidelines as well as to design novel primary prevention trials and ASCVD prevention programmes.

The Importance of Genetic Testing for Familial Hypercholesterolemia: A Pediatric Pilot Study

Background and Objectives: Familial hypercholesterolemia (FH) is a genetic disease that is massively underdiagnosed worldwide. Affected patients are at high risk of cardiovascular events at young ages. Early intervention in childhood could help prevent heart attacks and cerebral strokes in these patients. Materials and Methods: We conducted an interventional study including 10 patients that previously underwent genetic testing for familial hypercholesterolemia. These patients received lifestyle and diet recommendations that they followed for a year before being reevaluated. Results: Patients with negative genetic testing were able to achieve lower levels in their lipid panel values compared to the patients with positive genetic testing, with lifestyle changes alone. LDL-cholesterol levels decreased by 18.5% in patients without FH while patients genetically confirmed with FH failed to achieve lower LDL-cholesterol levels without medication. Conclusions: Genetic testing for FH is not always part of screening algorithms for FH. Some studies even advise against it. Our study proved the importance of genetic testing for FH when suspecting this disorder and choosing the treatment course for patients.

Exome wide association study for blood lipids in 1,158,017 individuals from diverse populations

Rare coding alleles play crucial roles in the molecular diagnosis of genetic diseases. However, the systemic identification of these alleles has been challenging due to their scarcity in the general population. Here, we discovered and characterized rare coding alleles contributing to genetic dyslipidemia, a principal risk for coronary artery disease, among over a million individuals combining three large contemporary genetic datasets (the Million Veteran Program, n = 634,535, UK Biobank, n = 431,178, and the All of Us Research Program, n = 92,304) totaling 1,158,017 multi-ancestral individuals. Unlike previous rare variant studies in lipids, this study included 238,243 individuals (20.6%) from non-European-like populations. Testing 2,997,401 rare coding variants from diverse backgrounds, we identified 800 exome-wide significant associations across 209 genes including 176 predicted loss of function and 624 missense variants. Among these exome-wide associations, 130 associations were driven by non-European-like populations. Associated alleles are highly enriched in functional variant classes, showed significant additive and recessive associations, exhibited similar effects across populations, and resolved pathogenicity for variants enriched in African or South-Asian populations. Furthermore, we identified 5 lipid-related genes associated with coronary artery disease (RORC, CFAP65, GTF2E2, PLCB3, and ZNF117). Among them, RORC is a potentially novel therapeutic target through the down regulation of LDLC by its silencing. This study provides resources and insights for understanding causal mechanisms, quantifying the expressivity of rare coding alleles, and identifying novel drug targets across diverse populations.

Brazilian Guideline for Exercise Testing in Children and Adolescents - 2024

CLASSES OF RECOMMENDATION

LEVELS OF EVIDENCE

Time-Restricted Feeding Reduces Atherosclerosis in LDLR KO Mice but Not in ApoE Knockout Mice

BACKGROUND

Dyslipidemia increases cardiovascular disease risk, the leading cause of death worldwide. Under time-restricted feeding (TRF), wherein food intake is restricted to a consistent window of <12 hours, weight gain, glucose intolerance, inflammation, dyslipidemia, and hypercholesterolemia are all reduced in mice fed an obesogenic diet. LDLR (low-density lipoprotein receptor) mutations are a major cause of familial hypercholesterolemia and early-onset cardiovascular disease.

METHODS

We subjected benchmark preclinical models, mice lacking LDLR-knockout or ApoE knockout to ad libitum feeding of an isocaloric atherogenic diet either ad libitum or 9 hours TRF for up to 13 weeks and assessed disease development, mechanism, and global changes in hepatic gene expression and plasma lipids. In a regression model, a subset of LDLR-knockout mice were ad libitum fed and then subject to TRF.

RESULTS

TRF could significantly attenuate weight gain, hypercholesterolemia, and atherosclerosis in mice lacking the LDLR-knockout mice under experimental conditions of both prevention and regression. In LDLR-knockout mice, increased hepatic expression of genes mediating β-oxidation during fasting is associated with reduced VLDL (very-low-density lipoprotein) secretion and lipid accumulation. Additionally, increased sterol catabolism coupled with fecal loss of cholesterol and bile acids contributes to the atheroprotective effect of TRF. Finally, TRF alone or combined with a cholesterol-free diet can reduce atherosclerosis in LDLR-knockout mice. However, mice lacking ApoE, which is an important protein for hepatic lipoprotein reuptake do not respond to TRF.

CONCLUSIONS

In a preclinical animal model, TRF is effective in both the prevention and regression of atherosclerosis in LDLR knockout mice. The results suggest TRF alone or in combination with a low-cholesterol diet can be a lifestyle intervention for reducing cardiovascular disease risk in humans.

Cardiovascular Risk Estimation and Stratification Among Individuals with Hypercholesterolemia

PURPOSE OF THE REVIEW

This review aims to assess the variability in considering hypercholesterolemia for cardiovascular risk stratification in the general population. Recent literature on the integration of hypercholesterolemia into clinical risk scores and its interaction with other risk factors will be explored.

RECENT FINDINGS

The impact of hypercholesterolemia on risk estimation varies among different cardiovascular risk calculators. Elevated lipid levels during early life stages contribute to atherosclerotic plaque development, influencing disease severity despite later treatment initiation. The interplay between low-density lipoprotein cholesterol (LDLc), inflammatory markers and non-LDL lipid parameters enhances cardiovascular risk stratification. Studies have also examined the role of coronary artery calcium (CAC) score as a negative risk marker in populations with severe hypercholesterolemia. Furthermore, polygenic risk scores (PRS) may aid in diagnosing non-monogenic hypercholesterolemia, refining cardiovascular risk stratification and guiding lipid-lowering therapy strategies. Understanding the heterogeneity in risk estimation and the role of emerging biomarkers and imaging techniques is crucial for optimizing cardiovascular risk prediction and guiding personalized treatment strategies in individuals with hypercholesterolemia.

Familial hypercholesterolemia care by Dutch pediatricians-mind the gaps

PURPOSE

Familial hypercholesterolemia (FH) leads to elevated low-density lipoprotein cholesterol levels, which increases the risk of premature atherosclerotic cardiovascular disease (ASCVD). Since the first functional and morphologic changes of the arterial wall occur in childhood, treatment should start early in childhood to mitigate the elevated risk of ASCVD. Pediatricians play an important role in the detection and care of children with FH. In this study, we aim to explore potential gaps in FH care amongst Dutch pediatricians, in order to enhance their knowledge and awareness of detecting and treating children with FH.

METHODS

An anonymous online survey, deployed using Google Forms, including 26 closed and semi-closed questions on FH care in children was distributed by the Dutch Association of Pediatrics via a newsletter to which the majority of the practicing Dutch pediatricians subscribe. In addition, we requested that the pediatric departments of all Dutch hospitals in the Netherlands distribute this survey personally among their employed pediatricians. Respondents were instructed to answer the questions without any help or use of online resources.

RESULTS

Between September 1st, 2023 and November 1st, 2023, 158 (an estimated 11% response rate) Dutch pediatricians completed the survey. They reported a median (IQR) of 15.0 (6.0-22.0) years of experience as a pediatrician, and 34 (21.5%) were working in academic hospitals. The majority (76.6%) of pediatricians correctly identified a typical FH lipid profile but 68 (43.0%) underestimated the true prevalence of FH (1:300). Underestimation and unawareness of the increased risk of FH patients for ASCVD were reported by 37.3% and 25.9% of pediatricians, respectively. Although 70.9% of the pediatricians correctly defined FH, only 67 (42.4%) selected statins and ezetimibe to treat severe hypercholesterolemia.

CONCLUSIONS

The results of this study suggest significant gaps in knowledge and awareness of FH in children among Dutch pediatricians. FH care in children needs improvement through educational and training initiatives to mitigate the life-long risk of ASCVD from early life.

WHAT IS KNOWN

• Familial hypercholesterolemia (FH) leads to elevated LDL-cholesterol levels, which increases the risk of premature atherosclerotic cardiovascular disease (ASCVD). • The process of atherosclerosis starts in childhood • Pediatricians play an important role in the detection and treatment of children with FH.

WHAT IS NEW

• Our results highlight significant gaps in care for children with FH amongst pediatricians and this may lead to suboptimal detection and treatment. • FH care in children needs improvement by educational initiatives to ultimately prevent ASCVD in adulthood.

Lipoprotein(a) in children and adolescents with genetically confirmed familial hypercholesterolemia followed up at a specialized lipid clinic

Background and aim

Many children with an FH mutation also exhibit elevated lipoprotein(a) levels, which is an independent risk factor for atherosclerotic cardiovascular disease. Studies have reported higher levels of lipoprotein(a) in adult and middle-aged women than men. There is limited knowledge on the concentration and change of lipoprotein(a) levels in children with genetic FH, and therefore we investigated sex-differences in lipoprotein(a) level and change in lipoprotein(a) in girls and boys with genetically confirmed FH.

Methods

Medical records were reviewed retrospectively in 438 subjects with heterozygous FH that started follow-up below the age of 19 years at the Lipid Clinic, Oslo University Hospital in Norway, and of these we included 386 subjects with at least one Lp(a) measurement.

Results

Mean (SD) age at baseline was 13.8 (7.3) years and the age was similar between sexes. Girls had a higher lipoprotein(a) level than boys at baseline: median (25-75 percentile) 223 (108-487) vs. 154 (78-360) mg/L, respectively (p < 0.01). From baseline to follow-up measurement (mean [SD] 8.9 [6.1] years apart), the mean (95 % CI) absolute and percentage change in Lp(a) level in girls was 151.4 (54.9-247.8) mg/L and 44.8 (16.4-73.1) %, respectively, and in boys it was 66.8 (22.9-110.8) mg/L and 50.5 (8.8-92.3) %, respectively (both p > 0.05).

Conclusions

We found an increase in Lp(a) levels in children with genetic FH with age, and higher levels in girls than boys, which could impact risk assessment and future ASCVD. Further research is needed to elucidate whether subjects with FH could benefit from lipoprotein(a)-lowering therapies that are under current investigations.

Lipoprotein(a) in Children and Adolescents: Risk or Causal Factor for Cardiovascular Disease? A Narrative Review

The evaluation of serum Lp(a) values in childhood and adolescence has been widely debated, and in the last few years, many authors have tried to better define Lp(a) role in atherosclerosis pathogenesis, starting from childhood. In our narrative review, we have evaluated the main historical stages of Lp(a) studies in childhood, trying to focus on pathogenic mechanisms linked to elevated serum Lp(a) values, starting from ischemic stroke and vascular damage, and to its possible direct involvement in premature atherosclerosis from childhood onwards. Historic manuscripts on Lp(a) in pediatric patients have mainly focused on serum Lp(a) values and increased stroke risk. More recently, many studies have evaluated Lp(a) as a coronary vascular disease (CVD) risk factor starting from childhood, especially related to a positive family history of premature CVD. Finally, only a few studies evaluated the role of Lp(a) in premature atherosclerotic processes and endothelial and vascular damage in pediatric patients. Lastly, we have hypothesized a future perspective, with the hope that plasma Lp(a) levels will be treated with a tailored pharmacologic approach, and Lp(a) will become a precocious therapeutic target to control the atherosclerotic pathways from the first years of life.

Adverse events associated with inclisiran: a real-world disproportionality analysis based on the FAERS database

BACKGROUND

Randomized clinical trials have reported some safety profiles in inclisiran, but adverse events in real-world remain insufficient. We aim to evaluate the safety of inclisiran in real-world by collecting the data from the FDA Adverse Event Reporting System database.

METHODS

Disproportionality analysis was performed by utilizing both Frequency method and Bayesian method to mine adverse event signals of inclisiran. A positive signal was deemed significant when adverse event met the criteria of the aforementioned methods simultaneously.

RESULTS

We gathered a total of 2309 adverse event reports. Among these cases, adverse events were more common in females and ≥ 65 years age group. After data analysis, 51 positive signals from 11 system organ classes were identified, involving "Musculoskeletal and connective tissue disorders," "General disorders and administration site conditions," "Gastrointestinal disorders," etc. At the preferred term level, the top three frequently reported adverse events were arthralgia, injection site pain and myalgia. We also found some uncommon but significantly strong adverse event signals (bladder discomfort and sinus pain) which should be taken prudently.

CONCLUSIONS

In this study, we analyzed the real-world adverse events of inclisiran more comprehensively and reported some new adverse events, hoping that can offer more safety information for clinical medication.

Consensus document on diagnosis and management of familial hypercholesterolemia from the Italian Society for the Study of Atherosclerosis (SISA)

AIMS

Familial Hypercholesterolemia (FH) is a genetic disorder of lipoprotein metabolism that causes an increased risk of premature atherosclerotic cardiovascular disease (ASCVD). Although early diagnosis and treatment of FH can significantly improve the cardiovascular prognosis, this disorder is underdiagnosed and undertreated. For these reasons the Italian Society for the Study of Atherosclerosis (SISA) assembled a Consensus Panel with the task to provide guidelines for FH diagnosis and treatment.

DATA SYNTHESIS

Our guidelines include: i) an overview of the genetic complexity of FH and the role of candidate genes involved in LDL metabolism; ii) the prevalence of FH in the population; iii) the clinical criteria adopted for the diagnosis of FH; iv) the screening for ASCVD and the role of cardiovascular imaging techniques; v) the role of molecular diagnosis in establishing the genetic bases of the disorder; vi) the current therapeutic options in both heterozygous and homozygous FH. Treatment strategies and targets are currently based on low-density lipoprotein cholesterol (LDL-C) levels, as the prognosis of FH largely depends on the magnitude of LDL-C reduction achieved by lipid-lowering therapies. Statins with or without ezetimibe are the mainstay of treatment. Addition of novel medications like PCSK9 inhibitors, ANGPTL3 inhibitors or lomitapide in homozygous FH results in a further reduction of LDL-C levels. LDL apheresis is indicated in FH patients with inadequate response to cholesterol-lowering therapies.

CONCLUSION

FH is a common, treatable genetic disorder and, although our understanding of this disease has improved, many challenges still remain with regard to its identification and management.

The Role of Reverse Cascade Screening in Children with Familial Hypercholesterolemia: A Literature Review and Analysis

PURPOSE OF REVIEW

Familial Hypercholesterolemia (FH) is a common genetic disorder characterized by lifelong elevation of severely elevated plasma low-density lipoprotein cholesterol. Atherosclerotic cardiovascular disease (ASCVD) risk accelerates after age 20. Early diagnosis allows for treatment of children with FH and creates an opportunity to identify affected relatives through reverse cascade screening (RCS). Historically, cascade screening has had little impact on identifying individuals with FH.

RECENT FINDINGS

Universal cholesterol screening (UCS) to identify youth with FH, beginning at 9-11 years-of-age, is currently recommended in the U.S. The European Atherosclerosis Society has called for UCS worldwide, emphasizing the need for educational programs to increase awareness amongst healthcare professions. Underdiagnoses and undertreatment of FH remain high. Improved rates of UCS and a systematic approach to RCS are needed. The absence of a coordinated RCS program limits the benefits of UCS. Further research is needed to identify barriers to cholesterol screening in youth.