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Taha M, Ibrahim MMM, Sedrak H. Association of epistatic effects of MTHFR, ACE, APOB, and APOE gene polymorphisms with the risk of myocardial infarction and unstable angina in Egyptian patients. Gene 2024; 895:147976. [PMID: 37952748 DOI: 10.1016/j.gene.2023.147976] [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: 09/09/2023] [Revised: 10/29/2023] [Accepted: 11/08/2023] [Indexed: 11/14/2023]
Abstract
Despite remarkable discoveries in the genetic susceptibility of coronary artery disease (CAD), a large part of heritability awaits identification. Epistasis or gene-gene interaction has a profound influence on CAD and might contribute to its missed genetic variability; however, this impact was largely unexplored. Here, we appraised the associations of gene-gene interactions and haplotypes of five polymorphisms, namely methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C, angiotensin converting enzyme (ACE) insertion/deletion (I/D), apolipoprotein B (APOB) R3500Q, and apolipoprotein E (APOE) ε4 with the risk of myocardial infarction (MI) and unstable angina (UA). Gene-environment interactions with traditional risk factors and clinical data were also scrutinized. This study recruited 100 MI, 50 UA patients, and 100 apparently healthy controls. Logistic regression models were employed in association analyses. We remarked that the single locus effect of individual polymorphisms was relatively weak; however, a magnified effect of their combination via gene-gene interaction may predict MI risk after adjustment for multiple comparisons. Only MTHFR C677T, ACE I/D, and APOB R5300Q were associated with the risk of UA, and the ACE I/D-R3500Q interaction posed a decreased UA risk. APOB R3500Q was in strong linkage disequilibrium with MTHFR C677T, ACE I/D, and APE ε4 polymorphisms. The TCDGε3, CADGε4, and TADGε4-C677T-A1298C-ACE I/D-R3500Q-APOE haplotypes were associated with escalating MI risk, while the CDG or CIG-C677T-ACE I/D-R3500Q haplotype was highly protective against UA risk compared to controls. Interestingly, the CADGε4 and CAIGε3 haplotypes were strongly associated with the presence of diabetes and hypertension, respectively in MI patients; both haplotypes stratified patients according to the ECHO results. In UA, the CDG haplotype was negatively associated with the presence of diabetes or dilated heart. Conclusively, our results advocate that a stronger combined effect of polymorphisms in MTHFR, ACE, APOB, and APOE genes via gene-gene and gene-environment interactions might help in risk stratification of MI and UA patients.
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Affiliation(s)
- Mohamed Taha
- Department of Biochemistry, Faculty of Pharmacy, Cairo University, Cairo 11562, Egypt.
| | | | - Heba Sedrak
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Egypt
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2
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Linskey DW, Linskey DC, McLeod HL, Luzum JA. The need to shift pharmacogenetic research from candidate gene to genome-wide association studies. Pharmacogenomics 2021; 22:1143-1150. [PMID: 34608812 DOI: 10.2217/pgs-2021-0108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The primary research approach in pharmacogenetics has been candidate gene association studies (CGAS), but pharmacogenomic genome-wide association studies (GWAS) are becoming more common. We are now at a critical juncture when the results of those two research approaches, CGAS and GWAS, can be compared in pharmacogenetics. We analyzed publicly available databases of pharmacogenetic CGAS and GWAS (i.e., the Pharmacogenomics Knowledgebase [PharmGKB®] and the NHGRI-EBI GWAS catalog) and the vast majority of variants (98%) and genes (94%) discovered in pharmacogenomic GWAS were novel (i.e., not previously studied CGAS). Therefore, pharmacogenetic researchers are not selecting the right candidate genes in the vast majority of CGAS, highlighting a need to shift pharmacogenetic research efforts from CGAS to GWAS.
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Affiliation(s)
- Derek W Linskey
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
| | | | - Howard L McLeod
- Precision Medicine, Geriatric Oncology Consortium, Tampa, FL 33609, USA
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
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3
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Henes JK, Groga-Bada P, Schaeffeler E, Winter S, Hack L, Zdanyte M, Mueller K, Droppa M, Stimpfle F, Gawaz M, Langer H, Schwab M, Geisler T, Rath D. C5 Variant rs10985126 is Associated with Mortality in Patients with Symptomatic Coronary Artery Disease. Pharmgenomics Pers Med 2021; 14:893-903. [PMID: 34321906 PMCID: PMC8312322 DOI: 10.2147/pgpm.s307827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/22/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Complement component 5a (C5a) is a highly potent anaphylatoxin with a variety of pro-inflammatory effects. C5a contributes to progression of atherosclerosis and inhibition of the receptor (C5aR) might offer a therapeutic strategy in this regard. Single nucleotide polymorphisms (SNPs) of the C5 gene may modify protein expression levels and therefore function of C5a and C5aR. This study aimed to examine associations between clinically relevant C5a SNPs and the prognosis of patients with symptomatic coronary artery disease (CAD). Furthermore, we sought to investigate the influence of C5 SNPs on C5aR platelet surface expression and circulating C5a levels. METHODS C5 variants (rs25681, rs17611, rs17216529, rs12237774, rs41258306, and rs10985126) were analyzed in a consecutive cohort of 833 patients suffering from symptomatic coronary artery disease (CAD). Circulating C5a levels were determined in 116 patients whereas C5aR platelet surface expression was measured in 473 CAD patients. Endpoints included all-cause mortality, myocardial infarction (MI), and ischemic stroke (IS). Homozygous carriers (HC) of the minor allele (rs10985126) showed significantly higher all-cause mortality than major allele carriers. While we could not find significant associations between rs10985126 allele frequency and C5aR platelet surfazl ce expression, significantly elevated levels of circulating C5a were found in HC of the minor allele of the respective genotype. rs17216529 allele frequency correlated with the composite combined endpoint and bleeding events. However, since the number of HC of the minor allele of this genotype was low, we cannot draw a robust conclusion about the observed associations. CONCLUSION In this study, we provide evidence for the prognostic relevance of rs10985126 in CAD patients. C5 rs10985126 may serve as a prognostic biomarker for risk stratification in high-risk CAD patients and consequently promote tailored therapies.
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Affiliation(s)
| | - Patrick Groga-Bada
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Elke Schaeffeler
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tuebingen, Tuebingen, Germany
| | - Stefan Winter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tuebingen, Tuebingen, Germany
| | - Luis Hack
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Monika Zdanyte
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Karin Mueller
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Michal Droppa
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Fabian Stimpfle
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Harald Langer
- Department of Cardiology, Angiology and Intensive Care, University Hospital Luebeck, Luebeck, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tuebingen, Tuebingen, Germany
- Department of Clinical Pharmacology, University Hospital Tuebingen, Tuebingen, Germany
- Department of Pharmacy and Biochemistry, University of Tuebingen, Tuebingen, Germany
| | - Tobias Geisler
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Dominik Rath
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
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4
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Razavi MA, Bazzano LA, Nierenberg J, Huang Z, Fernandez C, Razavi AC, Whelton SP, He J, Kelly TN. Advances in Genomics Research of Blood Pressure Responses to Dietary Sodium and Potassium Intakes. Hypertension 2021; 78:4-15. [PMID: 33993724 DOI: 10.1161/hypertensionaha.121.16509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
More than half of US adults have hypertension by 40 years of age and a subsequent increase in atherosclerotic cardiovascular disease risk. Dietary sodium and potassium are intricately linked to the pathophysiology of hypertension. However, blood pressure responses to dietary sodium and potassium, phenomena known as salt and potassium sensitivity of blood pressure, respectively, are heterogenous and normally distributed in the general population. Like blood pressure, salt and potassium sensitivity are complex phenotypes, and previous research has shown that up to 75% of individuals experience a blood pressure change in response to such dietary minerals. Previous research has also implicated both high salt sensitivity and low salt sensitivity (or salt resistance) of blood pressure to an increased risk of hypertension and potentially atherosclerotic cardiovascular disease risk. Given the clinical challenges required to accurately measure the sodium and potassium response phenotypes, genomic characterization of these traits has become of interest for hypertension prevention initiatives on both the individual and population levels. Here, we review advances in human genomics research of blood pressure responses to dietary sodium and potassium by focusing on 3 main areas, including the phenotypic characterization of salt sensitivity and resistance, clinical challenges in diagnosing such phenotypes, and the genomic mechanisms that may help to explain salt and potassium sensitivity and resistance. Through this process, we hope to further underline the value of leveraging genomics and broader multiomics for characterizing the blood pressure response to sodium and potassium to improve precision in lifestyle approaches for primordial and primary atherosclerotic cardiovascular disease prevention.
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Affiliation(s)
| | - Lydia A Bazzano
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (L.A.B., Z.H., C.F., A.C.R., J.H., T.N.K.)
| | - Jovia Nierenberg
- Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine (J.N.)
| | - Zhijie Huang
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (L.A.B., Z.H., C.F., A.C.R., J.H., T.N.K.)
| | - Camilo Fernandez
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA (C.F., A.C.R., J.H.).,Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (L.A.B., Z.H., C.F., A.C.R., J.H., T.N.K.)
| | - Alexander C Razavi
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA (C.F., A.C.R., J.H.).,Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (L.A.B., Z.H., C.F., A.C.R., J.H., T.N.K.)
| | - Seamus P Whelton
- The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (S.P.W.)
| | - Jiang He
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA (C.F., A.C.R., J.H.).,Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (L.A.B., Z.H., C.F., A.C.R., J.H., T.N.K.)
| | - Tanika N Kelly
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (L.A.B., Z.H., C.F., A.C.R., J.H., T.N.K.)
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Hynninen Y, Linna M, Vilkkumaa E. Value of genetic testing in the prevention of coronary heart disease events. PLoS One 2019; 14:e0210010. [PMID: 30645616 PMCID: PMC6333335 DOI: 10.1371/journal.pone.0210010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/14/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The health economic evidence about the value and optimal targeting of genetic testing in the prevention of coronary heart disease (CHD) events has remained limited and ambiguous. The objective of this study is to optimize the population-level use and targeting of genetic testing alongside traditional risk factors in the prevention of CHD events and, thereby, to assess the cost-benefit of genetic testing. METHODS AND FINDINGS We compare several strategies for using traditional and genetic testing in the prevention of CHD through statin therapy. The targeting of tests to different patient segments within these strategies is optimized by using a decision-analytic model, in which a patient's estimated risk of CHD is updated based on test results using Bayesian methods. We adopt the perspective of healthcare sector. The data for the model is exceptionally wide and combined from national healthcare registers, the Finnish Institute for Molecular Medicine, and published literature. Our results suggest that targeting genetic testing in an optimal way to those patients about which traditional risk factors do not provide sufficiently accurate information results in the highest expected net benefit. In particular, compared to the use of traditional risk factors only, the optimal use of genetic testing would decrease the expected costs of an average patient aged 45 years or more by 2.54€ in a 10-year follow-up period while maintaining the level of the expected health outcome. Thus, genetic testing is found to be a part of a cost-beneficial testing strategy alongside traditional risk factors. This conclusion is robust to reasonable changes in model inputs. CONCLUSIONS If targeted optimally, the use of genetic testing alongside traditional risk factors is cost-beneficial in the prevention of CHD.
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Affiliation(s)
- Yrjänä Hynninen
- Department of Mathematics and Systems Analysis, School of Science, Aalto University, Espoo, Finland
| | - Miika Linna
- The Institute of Healthcare Engineering, Management, and Architecture, Department of Industrial Engineering and Management, School of Science, Aalto University, Espoo, Finland
| | - Eeva Vilkkumaa
- Department of Information and Service Management, School of Business, Aalto University, Helsinki, Finland
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6
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Arafa S, Abdelsalam S, El-Gilany AH, Mosaad YM, Abdel-Ghaffar A. Endothelial nitric oxide synthase Glu 298 Asp (G894T) and Apolipoprotein E gene polymorphism as possible risk factors for coronary heart disease among Egyptians. Egypt Heart J 2018; 70:393-401. [PMID: 30591762 PMCID: PMC6303524 DOI: 10.1016/j.ehj.2018.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 08/10/2018] [Indexed: 11/17/2022] Open
Abstract
In Egypt, The prevalence of chronic heart disease (CHD) is 8.3%. It is the principal cause of death and is responsible for 22% of total mortality. The age-adjusted mortality rate is 174 per 100,000 of population. There are many studies on traditional risk factors and CHD in Egypt but the study of novel risk factors is deficient. Objectives The aim of the present case control study was to investigate the relation between CHD susceptibility and Endothelial Nitric Oxide Synthase (eNOS) Glu 298 Asp (G894T) and Apolipoprotein E (ApoE) gene polymorphism in a cohort of Egyptian individuals. Methods Genotyping of eNOS (Glu298Asp) and Apo E genes polymorphisms were done using polymerase chain reaction-restriction fragment length polymorphism (PCR–RFLP) method for 100 CHD cases and 100 age and sex matched healthy controls. Results A statistically significant association was observed between GT and TT genotypes of endothelial nitric oxide synthase gene with CHD with OR = 2.03 and 3.5; respectively. Also, carriers of E4 allele and especially E3/E4 genotype were at higher risk of CHD with OR = 3.3 for both. Significant association was also observed between the presence of combined GTE3E4 genotype and CHD with OR = 6.6. Conclusion GT and TT genotypes of endothelial nitric oxide synthase gene, E3/E4 genotype of Apo E gene polymorphism and combined GTE3E4 genotype can be considered risk factors for the development of CHD among Egyptians.
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Affiliation(s)
- Sherif Arafa
- Cardiovascular Medicine, Cardiovascular Department, Mansoura Faculty of Medicine, Mansoura, Egypt
- Corresponding author.
| | - Sherehan Abdelsalam
- Public Health and Preventive Medicine, Public Health & Community Medicine Department, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Abdel-Hady El-Gilany
- Public Health and Preventive Medicine, Public Health & Community Medicine Department, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Youssef Mohamed Mosaad
- Clinical Immunology Unit, Clinical Pathology Department & Mansoura Research Center for Cord Stem Cells (MARC_CSC), Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Adel Abdel-Ghaffar
- Public Health and Preventive Medicine, Public Health & Community Medicine Department, Mansoura Faculty of Medicine, Mansoura, Egypt
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Increased Risk of the APOB rs11279109 Polymorphism for CHD among the Kuwaiti Population. DISEASE MARKERS 2018; 2017:6963437. [PMID: 29362515 PMCID: PMC5737435 DOI: 10.1155/2017/6963437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/04/2017] [Accepted: 10/22/2017] [Indexed: 11/18/2022]
Abstract
Background Coronary heart disease (CHD) is among the leading causes of death in Kuwait. This case-control study investigated the genetic association of APOB rs11279109 with CHD in Kuwaitis. Methods The polymorphism was genotyped in 734 Kuwaiti samples by direct amplification. Statistical analysis with genetic modeling was used to assess its association with CHD. Results A statistically significant association (P < 0.001) between the rs11279109 DD genotype (OR: 2.43, CI: 1.34–4.41) with CHD was observed. A codominant genetic model revealed a 2.69 risk increase (CI: 1.57–4.61) for the DD genotype (P = 0.009) independent of age, sex, BMI, smoking, hypercholesterolemia, and ethnicity suggesting APOB rs11279109 as an indicator for the increased risk of CHD. Conclusion The DD genotype may explain molecular mechanisms that underline increased LDL oxidation leading to arthrosclerosis. The findings emphasize the need to identify genetic markers specific to the CHD patient ethnic group in order to improve prognosis and help in early diagnosis and prevention.
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Beaney K, Drenos F, Humphries SE. How close are we to implementing a genetic risk score for coronary heart disease? Expert Rev Mol Diagn 2017; 17:905-915. [DOI: 10.1080/14737159.2017.1368388] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Katherine Beaney
- Centre for Cardiovascular Genetics, BHF Laboratories, Institute of Cardiovascular Science, University College London, London, UK
| | - Fotios Drenos
- Centre for Cardiovascular Genetics, BHF Laboratories, Institute of Cardiovascular Science, University College London, London, UK
- MRC Integrative Epidemiology Unit, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Steve E. Humphries
- Centre for Cardiovascular Genetics, BHF Laboratories, Institute of Cardiovascular Science, University College London, London, UK
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Larifla L, Beaney KE, Foucan L, Bangou J, Michel CT, Martino J, Velayoudom-Cephise FL, Cooper JA, Humphries SE. Influence of Genetic Risk Factors on Coronary Heart Disease Occurrence in Afro-Caribbeans. Can J Cardiol 2016; 32:978-85. [PMID: 26971241 PMCID: PMC4977013 DOI: 10.1016/j.cjca.2016.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 01/08/2016] [Accepted: 01/08/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Despite excessive rates of cardiovascular risk factors such as hypertension, diabetes, and obesity, Afro-Caribbeans have lower mortality rates from coronary heart disease (CHD) than do whites. This study evaluated the association of genetic risk markers previously identified in whites and CHD in Afro-Caribbeans. METHODS We studied 537 Afro-Caribbean individuals (178 CHD cases and 359 controls) who were genotyped for 19 CHD-related single-nucleotide polymorphisms (SNPs). A genetic risk score (GRS) incorporating the 19 SNPs was calculated. These participants were compared with 1360 white individuals from the Second Northwick Park Heart Study. RESULTS In Afro-Caribbeans, patients with CHD had higher rates of hypertension (78.7% vs 30.1%), hypercholesterolemia (52.8% vs 15.0%), and diabetes (53.9% vs 14.8%) and were more often men (64.0% vs 43.7%) and smokers (27.5% vs 13.4%) compared with non-CHD controls (all P < 0.001). The GRS was higher in Afro-Caribbeans with CHD than in those without CHD (13.90 vs 13.17; P < 0.001) and was significantly associated with CHD after adjustment for cardiovascular risk factors, with an odds ratio of 1.40 (95% confidence interval, 1.09-1.80) per standard deviation change. There were significant differences in allelic distributions between the 2 ethnic groups for 14 of the 19 SNPs. The GRS was substantially lower in Afro-Caribbean controls compared with white controls (13.17 vs 16.59; P < 0.001). CONCLUSIONS This study demonstrates that a multilocus GRS composed of 19 SNPs associated with CHD in whites is a strong predictor of the disease in Afro-Caribbeans. The differences in CHD occurrence between Afro-Caribbeans and whites might be a result of significant discrepancies in common gene variant distribution.
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Affiliation(s)
- Laurent Larifla
- Research Group Clinical Epidemiology and Medicine, ECM/L.A.M.I.A EA 4540, University Hospital of Pointe-à-Pitre, University of Antilles, Guadeloupe, France; Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Sciences, University College London, London, United Kingdom; Department of Cardiology, University Hospital of Pointe-à-Pitre, Guadeloupe, France.
| | - Katherine E Beaney
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Lydia Foucan
- Research Group Clinical Epidemiology and Medicine, ECM/L.A.M.I.A EA 4540, University Hospital of Pointe-à-Pitre, University of Antilles, Guadeloupe, France
| | - Jacqueline Bangou
- Research Group Clinical Epidemiology and Medicine, ECM/L.A.M.I.A EA 4540, University Hospital of Pointe-à-Pitre, University of Antilles, Guadeloupe, France
| | - Carl T Michel
- Department of Cardiology, University Hospital of Pointe-à-Pitre, Guadeloupe, France
| | - Jean Martino
- Department of Cardiology, University Hospital of Pointe-à-Pitre, Guadeloupe, France
| | - Fritz-Line Velayoudom-Cephise
- Research Group Clinical Epidemiology and Medicine, ECM/L.A.M.I.A EA 4540, University Hospital of Pointe-à-Pitre, University of Antilles, Guadeloupe, France
| | - Jackie A Cooper
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Steve E Humphries
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Sciences, University College London, London, United Kingdom
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Abstract
Genetic factors contribute importantly to the risk of coronary artery disease (CAD), and in the past decade, there has been major progress in this area. The tools applied include genome-wide association studies encompassing >200,000 individuals complemented by bioinformatic approaches, including 1000 Genomes imputation, expression quantitative trait locus analyses, and interrogation of Encyclopedia of DNA Elements, Roadmap, and other data sets. close to 60 common SNPs (minor allele frequency>0.05) associated with CAD risk and reaching genome-wide significance (P<5 × 10(-8)) have been identified. Furthermore, a total of 202 independent signals in 109 loci have achieved a false discovery rate (q<0.05) and together explain 28% of the estimated heritability of CAD. These data have been used successfully to create genetic risk scores that can improve risk prediction beyond conventional risk factors and identify those individuals who will benefit most from statin therapy. Such information also has important applications in clinical medicine and drug discovery by using a Mendelian randomization approach to interrogate the causal nature of many factors found to associate with CAD risk in epidemiological studies. In contrast to genome-wide association studies, whole-exome sequencing has provided valuable information directly relevant to genes with known roles in plasma lipoprotein metabolism but has, thus far, failed to identify other rare coding variants linked to CAD. Overall, recent studies have led to a broader understanding of the genetic architecture of CAD and demonstrate that it largely derives from the cumulative effect of multiple common risk alleles individually of small effect size rather than rare variants with large effects on CAD risk. Despite this success, there has been limited progress in understanding the function of the novel loci; the majority of which are in noncoding regions of the genome.
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Affiliation(s)
- Ruth McPherson
- From the Department of Medicine, Atherogenomics Laboratory, Division of Cardiology, Ruddy Canadian Cardiovascular Genetics Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); and Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (A.T.-H.).
| | - Anne Tybjaerg-Hansen
- From the Department of Medicine, Atherogenomics Laboratory, Division of Cardiology, Ruddy Canadian Cardiovascular Genetics Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); and Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (A.T.-H.)
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Niiranen TJ, Vasan RS. Epidemiology of cardiovascular disease: recent novel outlooks on risk factors and clinical approaches. Expert Rev Cardiovasc Ther 2016; 14:855-69. [PMID: 27057779 DOI: 10.1080/14779072.2016.1176528] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Cardiovascular (CVD) risk assessment with traditional risk factors (age, sex, blood pressure, lipids, smoking and diabetes) has remained relatively invariant over the past decades despite some inaccuracies associated with this approach. However, the search for novel, robust and cost-effective risk markers of CVD risk is ongoing. AREAS COVERED A large share of the major developments in CVD risk prediction during the past five years has been made in large-scale biomarker discovery and the so called 'omics' - the rapidly growing fields of genomics, transcriptomics, epigenetics and metabolomics. This review focuses on how these new technologies are helping drive primary CVD risk estimation forward in recent years, and speculates on how they could be utilized more effectively for discovering novel risk factors in the future. Expert commentary: The search for new CVD risk factors is currently undergoing a significant revolution as the simple relationship between single risk factors and disease will have to be replaced by models that strive to integrate the whole field of omics into medicine.
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Affiliation(s)
- Teemu J Niiranen
- a National Heart, Blood and Lung Institute's and Boston University's Framingham Heart Study , Framingham , MA , USA
| | - Ramachandran S Vasan
- a National Heart, Blood and Lung Institute's and Boston University's Framingham Heart Study , Framingham , MA , USA
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12
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Calcagno C, Mulder WJM, Nahrendorf M, Fayad ZA. Systems Biology and Noninvasive Imaging of Atherosclerosis. Arterioscler Thromb Vasc Biol 2016; 36:e1-8. [PMID: 26819466 PMCID: PMC4861402 DOI: 10.1161/atvbaha.115.306350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Claudia Calcagno
- From the Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY (C.C., W.J.M.M., Z.A.F.); Department of Medical Biochemistry, Academic Medical Center, Amsterdam, The Netherlands (W.J.M.M.); and Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.N.).
| | - Willem J M Mulder
- From the Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY (C.C., W.J.M.M., Z.A.F.); Department of Medical Biochemistry, Academic Medical Center, Amsterdam, The Netherlands (W.J.M.M.); and Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.N.)
| | - Matthias Nahrendorf
- From the Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY (C.C., W.J.M.M., Z.A.F.); Department of Medical Biochemistry, Academic Medical Center, Amsterdam, The Netherlands (W.J.M.M.); and Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.N.)
| | - Zahi A Fayad
- From the Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY (C.C., W.J.M.M., Z.A.F.); Department of Medical Biochemistry, Academic Medical Center, Amsterdam, The Netherlands (W.J.M.M.); and Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.N.)
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Beaney KE, Cooper JA, Ullah Shahid S, Ahmed W, Qamar R, Drenos F, Crockard MA, Humphries SE. Clinical Utility of a Coronary Heart Disease Risk Prediction Gene Score in UK Healthy Middle Aged Men and in the Pakistani Population. PLoS One 2015; 10:e0130754. [PMID: 26133560 PMCID: PMC4489836 DOI: 10.1371/journal.pone.0130754] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 05/22/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Numerous risk prediction algorithms based on conventional risk factors for Coronary Heart Disease (CHD) are available but provide only modest discrimination. The inclusion of genetic information may improve clinical utility. METHODS We tested the use of two gene scores (GS) in the prospective second Northwick Park Heart Study (NPHSII) of 2775 healthy UK men (284 cases), and Pakistani case-control studies from Islamabad/Rawalpindi (321 cases/228 controls) and Lahore (414 cases/219 controls). The 19-SNP GS included SNPs in loci identified by GWAS and candidate gene studies, while the 13-SNP GS only included SNPs in loci identified by the CARDIoGRAMplusC4D consortium. RESULTS In NPHSII, the mean of both gene scores was higher in those who went on to develop CHD over 13.5 years of follow-up (19-SNP p=0.01, 13-SNP p=7x10-3). In combination with the Framingham algorithm the GSs appeared to show improvement in discrimination (increase in area under the ROC curve, 19-SNP p=0.48, 13-SNP p=0.82) and risk classification (net reclassification improvement (NRI), 19-SNP p=0.28, 13-SNP p=0.42) compared to the Framingham algorithm alone, but these were not statistically significant. When considering only individuals who moved up a risk category with inclusion of the GS, the improvement in risk classification was statistically significant (19-SNP p=0.01, 13-SNP p=0.04). In the Pakistani samples, risk allele frequencies were significantly lower compared to NPHSII for 13/19 SNPs. In the Islamabad study, the mean gene score was higher in cases than controls only for the 13-SNP GS (2.24 v 2.34, p=0.04). There was no association with CHD and either score in the Lahore study. CONCLUSION The performance of both GSs showed potential clinical utility in European men but much less utility in subjects from Pakistan, suggesting that a different set of risk loci or SNPs may be required for risk prediction in the South Asian population.
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Affiliation(s)
- Katherine E. Beaney
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Science, University College London, University Street, London, United Kingdom
| | - Jackie A. Cooper
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Science, University College London, University Street, London, United Kingdom
| | - Saleem Ullah Shahid
- Department of Microbiology and Molecular Genetics, New Campus, University of the Punjab, Lahore, Pakistan
| | - Waqas Ahmed
- Department of Microbiology, University of Haripur, Haripur, Pakistan
| | - Raheel Qamar
- COMSATS Institute of Information Technology, Park Road, Chak Shahzad, Islamabad, Pakistan
| | - Fotios Drenos
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Science, University College London, University Street, London, United Kingdom
- Integrative Epidemiology Unit, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Martin A. Crockard
- Molecular Diagnostics Group, Randox Laboratories Ltd, Crumlin, United Kingdom
| | - Steve E. Humphries
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Science, University College London, University Street, London, United Kingdom
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Máchal J, Pávková-Goldbergová M, Hlinomaz O, Groch L, Vašků A. Patients with chronic three-vessel disease in a 15-year follow-up study: genetic and non-genetic predictors of survival. Medicine (Baltimore) 2014; 93:e278. [PMID: 25526459 PMCID: PMC4603099 DOI: 10.1097/md.0000000000000278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Genetic and non-genetic predictors of 15-year survival in patients with chronic three-vessel disease (3VD) were investigated. Coronary angiography was performed on 810 subjects with symptoms of stable ischemic heart disease in 1998. The patients with 3VD were genotyped for 23 candidate polymorphisms covering the PPAR-RXR pathway, matrix metalloproteinase-2, renin-angiotensin-aldosterone system, endothelin-1, cytokine genes, MTHFR and APO E variants. Fifteen-year survival data were obtained from the national insurance registry. All data were available in the case of 150 patients with 3VD. Statistical analysis used stepwise Cox regression with dominant, recessive, or additive mode of genetic expression. Involved variables included age, sex, BMI, blood pressure, diabetes, ejection fraction, left main stenosis, previously diagnosed coronary stenosis, myocardial infarction in personal history, and coronary bypass along with polymorphisms pre-selected by log-rank tests. Out of the 23 polymorphisms, four were included in the model construction. SNP in the IL-6 gene rs1800795 (-174 G/C) has been found to be a significant predictor of survival. This SNP was in a linkage disequilibrium with rs1800797 (-597 G/A) in the same gene (D'=1.0), which was also found to constitute a significant predictor of survival when rs1800795 was not included in the model construction. Age, increased BMI, diabetes, low EF, and left main stenosis were also significant predictors in all models. Age, increased BMI, diabetes, low ejection fraction, left main stenosis, and genetic variation in the IL-6 promoter were established as significant independent risk factors for the survival of patients with three-vessel disease.
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Affiliation(s)
- Jan Máchal
- From the Department of Pathophysiology, Faculty of Medicine, Masaryk University Brno, Czech Republic (JM, MPG, AV); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (JM, LG, OH); and First Department of Internal Medicine - Cardioangiology, St. Anne's University Hospital, Brno, Czech Republic (OH, LG)
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Saracyn M, Płoski R, Niemczyk S. Contemporary role of medical genetics in internal medicine. Arch Med Sci 2013; 9:594-600. [PMID: 24049516 PMCID: PMC3776171 DOI: 10.5114/aoms.2013.34988] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 02/21/2012] [Accepted: 03/11/2012] [Indexed: 01/10/2023] Open
Abstract
Molecular biology and medical genetics, one of the most dynamically developing fields of medicine, nowadays is also a base for development of basic and clinical research in internal medicine. Understanding of crucial genetic pathomechanisms of many common diseases was possible due to the newest and modern molecular methods and tools. Moreover, development of genetics also made possible the discovery and understanding of the pathogenesis of many different diseases. However, not so long ago, we discovered precise pathomechanisms leading from damage of a single gene to a related pathological phenotype. Now, we have just started to explain molecular mechanisms of complex, multifactorial diseases. To achieve these goals, we need permanent development of genetic tests, genomics and proteomics. After fulfilling these conditions, we will get a chance to implement all molecular and genetic hopes, particularly their practical application in the clinic.
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Affiliation(s)
- Marek Saracyn
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Health Services, Warsaw, Poland
| | - Rafał Płoski
- Department of Medical Genetics, Medical University of Warsaw, Poland
| | - Stanisław Niemczyk
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Health Services, Warsaw, Poland
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Mayr M, Zampetaki A, Willeit P, Willeit J, Kiechl S. MicroRNAs within the continuum of postgenomics biomarker discovery. Arterioscler Thromb Vasc Biol 2013; 33:206-14. [PMID: 23325478 DOI: 10.1161/atvbaha.112.300141] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The postgenomic shift in paradigm from reductionism to systems-wide network inference has increased recognition that cardiovascular diseases are not simply determined by the genome but arise from an interaction and dynamic dysregulation of gene regulatory networks, proteins, and metabolic alterations. The advent of postgenomic technologies promises to interrogate these complex pathophysiological perturbations by applying concepts of systemic relationships to biomarker discovery. A multibiomarker panel consisting of biomarkers capturing different levels of information (eg, microRNAs to assess endothelial and platelet activation, molecular lipid species to profile metabolic status, and proteolytic degradation products to assess vascular integrity) could outperform inflammatory biomarkers without vascular specificity in their ability of predicting cardiovascular risk. As atherosclerosis develops over decades, different biomarkers may be required for different stages of disease. Thus far, there is no simple blood test to directly assess the health of blood vessels or identify vulnerable patients. We discuss strategies for biomarker discovery using post genomics technologies, with a particular focus on circulating microRNAs. The aim is to reveal distinctive cardiovascular phenotypes and identify biomarker signatures that complement the Framingham risk scores in clinical decision-making and in a stratified medicine approach for early preventive treatment of disease.
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Affiliation(s)
- Manuel Mayr
- King's British Heart Foundation Centre, King's College London, 125 Coldharbour Lane, London SE5 9NU, United Kingdom.
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Abstract
BACKGROUND Coronary heart disease (CHD) is a leading cause of death worldwide, yet many areas of its pathogenesis remain unknown or poorly understood, leaving potential for novel preventive and therapeutic interventions. Recent major advances in genomic science and technology have opened new avenues of investigation in the pathogenesis of CHD, some of which are leading to clinical translation. SOURCES OF DATA The published literature in CHD genetics has burgeoned in the last 5 years with the reporting of genome-wide association studies (GWASs) and many other findings. AREAS OF AGREEMENT Identification of many genetic variants with small effects on CHD risk has been a common finding. These have included several predicted loci, such as those involved in conventional CHD risk factors (e.g. plasma lipids) and many novel loci, where their mechanism of action is unclear. The need for large, collaborative approaches to research has also become clear and is now an accepted modus operandi. AREAS OF CONTROVERSY The clinical utility of novel GWAS findings remains uncertain. In particular, the relative contribution of common variants of modest effect and rare variants of larger effects to risk of CHD or response to drugs is unclear. GROWING POINTS As a greater number of larger GWASs are conducted in CHD and its related phenotypes, much effort is being made to find translational applications for their findings. Therapeutics, prediction and pathology are major areas of research endeavour.
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Affiliation(s)
- Daniel I Swerdlow
- Genetic Epidemiology Group, Department of Epidemiology and Public Health, UCL Institute of Epidemiology and Health Care, University College London, UK
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Coronary heart disease diagnosis by artificial neural networks including genetic polymorphisms and clinical parameters. J Cardiol 2012; 59:190-4. [DOI: 10.1016/j.jjcc.2011.11.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 11/21/2011] [Indexed: 11/20/2022]
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El-Bab MF, Shawky N, Al-Sisi A, Akhtar M. Retinopathy and risk factors in diabetic patients from Al-Madinah Al-Munawarah in the Kingdom of Saudi Arabia. Clin Ophthalmol 2012; 6:269-76. [PMID: 22368446 PMCID: PMC3284208 DOI: 10.2147/opth.s27363] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Diabetes mellitus is accompanied by chronic and dangerous microvascular changes affecting most body systems, especially the eye, leading to diabetic retinopathy. Diabetic retinopathy without appropriate management is emerging as one of the leading causes of blindness. Therefore, it is necessary to improve the early diagnosis of diabetic retinopathy, reduce the risk of blindness, and identify relevant risk factors. Methods This descriptive study was designed to estimate the prevalence of retinopathy and its staging in diabetic patients attending the diabetes clinic at King Fahd Hospital in Al-Madinah Al-Munawarah, Kingdom of Saudi Arabia, from 2008 to 2010. Patients completed a questionnaire, underwent a full medical assessment carried out by the treating clinicians, and were examined for evidence of diabetic retinopathy using standard ophthalmic outpatient instruments. Results In total, 690 randomly selected diabetic patients of mean age 46.10 ± 11.85 (range 16–88) years were included, comprising 395 men (57.2%) of mean age 46.50 ± 11.31 years and 295 women (42.8%) of mean age 45.55 ± 12.53 years. The mean duration of diabetes mellitus was 11.91 ± 7.92 years in the women and 14.42 ± 8.20 years in the men, and the mean total duration of known diabetes mellitus was 13.35 ± 8.17 years. Glycated hemoglobin was higher in men (8.53% ± 1.81%) than in women (7.73% ± 1.84%), and this difference was statistically significant (P ≤ 0.0001). Of the 690 diabetic patients, 249 (36.1%) had retinopathy. Mild nonproliferative diabetic retinopathy was present in 13.6% of patients, being of moderate grade in 8% and of severe grade in 8.1%. A further 6.4% had proliferative diabetic retinopathy. Conclusion Regular screening to detect diabetic retinopathy is strongly recommended because early detection has the best chance of preventing retinal complications.
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Affiliation(s)
- Mohamed F El-Bab
- Department of Physiology, Faculty of Medicine, Suez Canal University, Ismailia
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Ndiaye NC, Azimi Nehzad M, El Shamieh S, Stathopoulou MG, Visvikis-Siest S. Cardiovascular diseases and genome-wide association studies. Clin Chim Acta 2011; 412:1697-701. [DOI: 10.1016/j.cca.2011.05.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 05/31/2011] [Accepted: 05/31/2011] [Indexed: 12/27/2022]
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Waller K, Kujala UM, Kaprio J, Koskenvuo M, Rantanen T. Effect of physical activity on health in twins: a 30-yr longitudinal study. Med Sci Sports Exerc 2011; 42:658-64. [PMID: 19952836 DOI: 10.1249/mss.0b013e3181bdeea3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The aim of this study was to investigate whether persistent leisure-time physical activity, adjusted for genetic liability and childhood experiences, protects against chronic diseases, early signs of disability, and loss of life satisfaction. METHODS From 5663 healthy adult twin pairs, we identified 146 pairs who were discordant for both intensity and volume of leisure physical activity in 1975 and 1981. Of them, both members of 95 pairs were alive and participated in our follow-up study in 2005 when chronic diseases (such as diabetes, cardiovascular disease, and osteoarthritis), life satisfaction, and disability were assessed by a structured telephone interview. The mean age of the participants was 58 yr (range = 47-79 yr) in 2005. Paired tests were used in the analyses. RESULTS At the end of follow-up, the active cotwins had a decreased risk of reporting at least one chronic diseases, whereas active monozygotic (MZ) twins had two or more chronic diseases significantly less often than their inactive cotwins (odds ratio [OR] = 0.14, P = 0.031). Overall, the risk for type 2 diabetes or glucose intolerance (OR = 0.09, P = 0.022) and elevated blood pressure (OR = 0.46, P = 0.039) was decreased among the active cotwins. These effects were seen clearly among dizygotic twins but not always among small number of monozygotic twins. The active cotwins reported greater life satisfaction (P = 0.047) and tended to be less likely to be hospitalized (P = 0.065), although active cotwins had somewhat more sports-related injuries (OR = 1.9, P = 0.051) than inactive cotwins. Studied disability variables did not differ between the active and the inactive cotwins. CONCLUSIONS Physical activity reduces the risk for chronic diseases and helps in maintaining life satisfaction. However, genetic factors may play a role in this association because some findings emerged more clearly among dizygotic than monozygotic twins discordant for physical activity.
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Affiliation(s)
- Katja Waller
- Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland.
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Holmes MV, Harrison S, Talmud PJ, Hingorani AD, Humphries SE. Utility of genetic determinants of lipids and cardiovascular events in assessing risk. Nat Rev Cardiol 2011; 8:207-21. [PMID: 21321562 DOI: 10.1038/nrcardio.2011.6] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The prevention of coronary heart disease (CHD) is a major public-health goal, but disease architecture is such that a larger proportion of clinical events occur among the average majority than among the high-risk minority--the prevention paradox. Genetic findings over the past few years have resulted in the reopening of the old debate on whether an individualized or a population-based approach to prevention is preferable. Genetic testing is an attractive tool for CHD risk prediction because it is a low-cost, high-fidelity technology with multiplex capability. Moreover, by contrast with nongenetic markers, genotype is invariant and determined from conception, which eliminates biological variability and makes prediction from early life possible. Mindful of the prevention paradox, this Review examines the potential applications and challenges of using genetic information for predicting CHD, focusing on lipid risk factors and drawing on experience in the evaluation of nongenetic risk factors as screening tests for CHD. Many of the issues we discuss hold true for any late-onset common disease with modifiable risk factors and proven preventative strategies.
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Affiliation(s)
- Michael V Holmes
- Genetic Epidemiology Group, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
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23
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Use of genomic profiling to assess risk for cardiovascular disease and identify individualized prevention strategies—A targeted evidence-based review. Genet Med 2010; 12:772-84. [DOI: 10.1097/gim.0b013e3181f8728d] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Lack of replication in polymorphisms reported to be associated with atrial fibrillation. Heart Rhythm 2010; 8:403-9. [PMID: 21056700 DOI: 10.1016/j.hrthm.2010.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 11/01/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia and has a substantial heritable component. Numerous associations between single nucleotide polymorphisms (SNPs) and AF have been described, but few have been replicated. OBJECTIVE We sought to systematically replicate SNPs that are reported to be associated with AF in two large study samples of European descent. METHODS We searched PubMed for studies reporting associations between SNPs and AF published before July 1, 2007. SNPs were genotyped in two independent case-control samples from Germany and the United States. Associations between SNPs and AF were assessed using logistic regression models adjusting for age, sex, and hypertension. A meta-analysis of the results from the two studies was performed. RESULTS We identified 21 SNPs and the angiotensin-converting enzyme insertion/deletion polymorphism that were reported to be associated with AF in the literature. Nine of these genetic variants were not represented on common genome-wide SNP arrays. We successfully genotyped 21 of these 22 variants in 2,145 cases with AF from the German Competence Network for Atrial Fibrillation and 4,073 controls from the KORA S4 study and 16 variants in 790 cases and 1,330 controls from the Massachusetts General Hospital. None of the SNPs replicated in independent populations with AF. CONCLUSION Our results suggest that previously reported associations to AF were likely false positives and highlight the need for systematic replication of genetic associations in large, independent cohorts to accurately detect variants associated with disease.
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Sudomoina MA, Sukhinina TS, Barsova RM, Favorov AV, Sakhnovich RM, Titov BV, Matveeva NA, Rybalkin IN, Vlasik TN, Ochs MF, Ruda MY, Favorova O. Complex analysis of association of inflammation gene polymorphisms with myocardial infarction. Mol Biol 2010. [DOI: 10.1134/s0026893310030088] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Pestana CI, Torres A, Blanco S, Rojas MJ, Méndez C, López JL, de Bosch NB, Porco A. Factor V Leiden and the risk of venous thrombosis, myocardial infarction, and stroke: a case-control study in Venezuela. Genet Test Mol Biomarkers 2009; 13:537-42. [PMID: 19604111 DOI: 10.1089/gtmb.2008.0100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The most common genetic defect associated with deep vein thrombosis (DVT) is a mutation in the Factor V gene (G1691A), known as Factor V Leiden (FVL). We investigated the genotypes for FVL in 571 individuals in Venezuela: 208 patients with DVT, 175 patients with acute myocardial infarction, 54 patients with stroke, and 134 control subjects. Our results showed in the population analyzed here that the FVL was associated with a fourfold increase in the risk for DVT (odds ratio, 4.24; 95% confidence interval, 1.35-14.79); particularly, women carriers showed a 6.5-fold increase in the risk for DVT. No relation was observed between the presence of FVL and the risk for acute myocardial infarction or stroke. In conclusion, a clear association between the FVL mutation and DVT was observed in the population analyzed in Venezuela. These results are in agreement with those found in other populations with different ethnic backgrounds.
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Affiliation(s)
- Carolina I Pestana
- Laboratorio de Genética Molecular Humana B, Departamento de Biología Celular, Universidad Simón Bolívar, Caracas, Venezuela
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Sanderson SC, Humphries SE, Hubbart C, Hughes E, Jarvis MJ, Wardle J. Psychological and behavioural impact of genetic testing smokers for lung cancer risk: a phase II exploratory trial. J Health Psychol 2008; 13:481-94. [PMID: 18420756 DOI: 10.1177/1359105308088519] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The behavioural and psychological impact of genetic testing for lung cancer susceptibility was examined among smokers (N = 61) who were randomly allocated to a GSTM1 genetic testing group (with GSTM1-missing or GSTM1-present result) or no-test control group. The GSTM1-missing (higher risk) group reported greater motivation to quit smoking, and both genetic testing groups reported lower depression than the control group at one-week follow-up (p < .05 for all). Differences were not significant at two months follow-up. This study indicates the feasibility of much-needed research into the risks and benefits for individuals of emerging lifestyle-related genetic susceptibility tests.
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Affiliation(s)
- Saskia C Sanderson
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, University College London, London, UK.
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Morgan TM, Xiao L, Lyons P, Kassebaum B, Krumholz HM, Spertus JA. Investigation of 89 candidate gene variants for effects on all-cause mortality following acute coronary syndrome. BMC MEDICAL GENETICS 2008; 9:66. [PMID: 18620593 PMCID: PMC2483267 DOI: 10.1186/1471-2350-9-66] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Accepted: 07/12/2008] [Indexed: 11/10/2022]
Abstract
Background Many candidate genes have been reported to be risk factors for acute coronary syndrome (ACS), but their impact on clinical prognosis following ACS is unknown. Methods We examined the association of putative genetic risk factors with 3-year post-ACS mortality in 811 ACS survivors at university-affiliated hospitals in Kansas City, Missouri. Through a systematic literature search, we first identified genetic variants reported as susceptibility factors for atherosclerosis or ACS. Restricting our analysis to whites, so as to avoid confounding from racial admixture, we genotyped ACS cases for 89 genetic variants in 72 genes, and performed individual Kaplan-Meier survival analyses. We then performed Cox regression to create multivariate risk prediction models that further minimized potential confounding. Results Of 89 variants tested, 16 were potentially associated with mortality (P < 0.1 for all), of which 6 were significantly associated (P < 0.05) with mortality following ACS. While these findings are not more than what would be expected by chance (P = 0.28), even after Bonferroni correction and adjustment for traditional cardiac risk factors, the IRS1 972Arg variant association (P = 0.001) retained borderline statistical significance (P < 0.1). Conclusion With the possible exception of IRS1, we conclude that multiple candidate genes were not associated with post-ACS mortality in our patient cohort. Because of power limitations, the 16 gene variants with P values < 0.1 may warrant further study. Our data do not support the hypothesis that the remaining 73 genes have substantial, clinically significant association with mortality after an ACS.
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Affiliation(s)
- Thomas M Morgan
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Humphries SE, Yiannakouris N, Talmud PJ. Cardiovascular disease risk prediction using genetic information (gene scores): is it really informative? Curr Opin Lipidol 2008; 19:128-32. [PMID: 18388692 DOI: 10.1097/mol.0b013e3282f5283e] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW DNA-based tests for assessment of genetic predisposition to coronary heart disease need to provide information over and above that of conventional risk factors. The efficacy of selected 'candidate' gene loci in risk algorithms, to improve the predictive accuracy for coronary heart disease, remains to be demonstrated. RECENT FINDINGS Although many candidate genes for coronary heart disease have been tested, the optimal set of risk genotypes has yet to be identified. There is only a relatively modest risk to be expected in association with any single genotype, published estimates are in the range of 1.12-1.73. Thus the risk associated with any one genotype is modest, but, in combination, selected genotypes may be associated with a clinically significant risk. Since the allele frequency for many of these variants is high, many individuals will carry several 'risk alleles'. A small number of selected single nucleotide polymorphisms should complement the conventional risk factors to identify high-risk individuals in whom correction of 'modifiable risk factors' through lifestyle interventions or medication would be most beneficial. SUMMARY As our understanding of how genetic variation impacts on common diseases advances, the novel loci identified by genome-wide association scans associated with disease risk will rapidly improve these risk algorithms.
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Affiliation(s)
- Steve E Humphries
- Division of Cardiovascular Genetics, British Heart Foundation Laboratories, Department of Medicine, Royal Free and UCL Medical School, London, UK.
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Abstract
PURPOSE Because multiple genetic variants influence risk for coronary heart disease, we combined multiple variants that had been associated with coronary heart disease in several studies into a genetic risk score and asked whether a high genetic risk score would be significantly associated with coronary heart disease after accounting for traditional risk factors. METHODS We considered five variants that were associated with coronary heart disease in two studies and confirmed in the Atherosclerosis Risk in Communities study: rs20455 (KIF6), rs3900940 (MYH15), rs7439293 (PALLD), rs2298566 (SNX19), and rs1010 (VAMP8). We calculated a genetic risk score for each Atherosclerosis Risk in Communities study participant and estimated the hazard ratio for incident coronary heart disease of a high genetic risk score (compared with not-high) in Cox models that adjusted for traditional risk factors during a median of 13 years of follow-up. RESULTS For white participants with a high genetic risk score (4% of the 9129 whites), compared with those without a high genetic risk score, the hazard ratio for incident coronary heart disease was 1.57 (95% confidence interval 1.21-2.04; P = 0.001). Internal validation using bootstrap samples estimated that a hazard ratio of 1.43 could be expected in external populations. CONCLUSIONS After adjusting for traditional risk factors, those with a high genetic risk score had a 57% increased risk of incident coronary heart disease in the Atherosclerosis Risk in Communities study.
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Thompson A, Drenos F, Hafez H, Humphries S. Candidate Gene Association Studies in Abdominal Aortic Aneurysm Disease: A Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2008; 35:19-30. [DOI: 10.1016/j.ejvs.2007.07.022] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 07/04/2007] [Indexed: 10/22/2022]
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32
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Guías de práctica clínica sobre prevención de la enfermedad cardiovascular: versión resumida. Rev Esp Cardiol 2008. [DOI: 10.1157/13114961] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Rouse RL, Boudreaux MJ, Penn AL. In utero environmental tobacco smoke exposure alters gene expression in lungs of adult BALB/c mice. ENVIRONMENTAL HEALTH PERSPECTIVES 2007; 115:1757-1766. [PMID: 18087596 PMCID: PMC2137099 DOI: 10.1289/ehp.10358] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Accepted: 09/19/2007] [Indexed: 05/25/2023]
Abstract
BACKGROUND In utero environmental tobacco smoke (ETS) exposure exacerbates initial lung responses of adult mice to ovalbumin (OVA), a common allergen in rodent models of allergic asthma. OBJECTIVE We tested the hypothesis that in utero ETS exposure alters expression of genes (including asthma-related and inflammatory genes) in the lungs of adult mice and that this differential expression is reflected in differential respiratory and immune responses to nontobacco allergens. METHODS Using Affymetrix Mouse Genome 430 2.0 arrays, we examined gene expression changes in lungs of BALB/c mice exposed to ETS in utero, OVA, or saline aerosol at weeks 7-8, and OVA sensitization and challenge at weeks 11-15. Data sets were filtered by transcript p-value (< or = 0.05), false discovery rate (< or = 0.05), and fold change (> or = 1.5). Differential expression of selected genes was confirmed by polymerase chain reaction (PCR). RESULTS Genes differentially expressed as a result of in utero ETS exposure are involved in regulation of biological processes (immune response, cell proliferation, apoptosis, cell metabolism) through altered cytoskeleton, adhesion, transcription, and enzyme molecules. A number of genes prominent in lung inflammation were differentially expressed on PCR but did not pass selection criteria for microarray, including arginase (Arg1), chitinases (Chia, Chi3l3, Chi3l4), eotaxins (Ccl11, Ccl24), small proline-rich protein 2a (Sprr2a), and cytokines (Il4, Il6, Il10, Il13, Tnfa) . CONCLUSION The differential lung gene expression reported here is consistent with previously reported functional changes in lungs of mice exposed in utero to ETS and as adults to the nontobacco allergen OVA.
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Affiliation(s)
| | | | - Arthur L. Penn
- Address correspondence to A. Penn, Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Skip Bertman Dr., Baton Rouge, LA 70803 USA. Telephone: (225) 578-9760. Fax: (225) 578-9895. E-mail:
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Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R, Dallongeville J, De Backer G, Ebrahim S, Gjelsvik B, Herrmann-Lingen C, Hoes A, Humphries S, Knapton M, Perk J, Priori SG, Pyorala K, Reiner Z, Ruilope L, Sans-Menendez S, Op Reimer WS, Weissberg P, Wood D, Yarnell J, Zamorano JL, Walma E, Fitzgerald T, Cooney MT, Dudina A, Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Funck-Brentano C, Filippatos G, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL, Altiner A, Bonora E, Durrington PN, Fagard R, Giampaoli S, Hemingway H, Hakansson J, Kjeldsen SE, Larsen ML, Mancia G, Manolis AJ, Orth-Gomer K, Pedersen T, Rayner M, Ryden L, Sammut M, Schneiderman N, Stalenhoef AF, Tokgözoglu L, Wiklund O, Zampelas A. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). ACTA ACUST UNITED AC 2007; 14 Suppl 2:E1-40. [PMID: 17726406 DOI: 10.1097/01.hjr.0000277984.31558.c4] [Citation(s) in RCA: 259] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Other experts who contributed to parts of the guidelines: Edmond Walma, Schoonhoven (The Netherlands), Tony Fitzgerald, Dublin (Ireland), Marie Therese Cooney, Dublin (Ireland), Alexandra Dudina, Dublin (Ireland) European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG):, Alec Vahanian (Chairperson) (France), John Camm (UK), Raffaele De Caterina (Italy), Veronica Dean (France), Kenneth Dickstein (Norway), Christian Funck-Brentano (France), Gerasimos Filippatos (Greece), Irene Hellemans (The Netherlands), Steen Dalby Kristensen (Denmark), Keith McGregor (France), Udo Sechtem (Germany), Sigmund Silber (Germany), Michal Tendera (Poland), Petr Widimsky (Czech Republic), José Luis Zamorano (Spain) Document reviewers: Irene Hellemans (CPG Review Coordinator) (The Netherlands), Attila Altiner (Germany), Enzo Bonora (Italy), Paul N. Durrington (UK), Robert Fagard (Belgium), Simona Giampaoli(Italy), Harry Hemingway (UK), Jan Hakansson (Sweden), Sverre Erik Kjeldsen (Norway), Mogens Lytken Larsen (Denmark), Giuseppe Mancia (Italy), Athanasios J. Manolis (Greece), Kristina Orth-Gomer (Sweden), Terje Pedersen (Norway), Mike Rayner (UK), Lars Ryden (Sweden), Mario Sammut (Malta), Neil Schneiderman (USA), Anton F. Stalenhoef (The Netherlands), Lale Tokgözoglu (Turkey), Olov Wiklund (Sweden), Antonis Zampelas (Greece)
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Affiliation(s)
- Ian Graham
- Department of Cardiology, The Adelaide and Meath Hospital, Tallaght, Doublin, Ireland.
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Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R, Dallongeville J, De Backer G, Ebrahim S, Gjelsvik B, Herrmann-Lingen C, Hoes A, Humphries S, Knapton M, Perk J, Priori SG, Pyorala K, Reiner Z, Ruilope L, Sans-Menendez S, Op Reimer WS, Weissberg P, Wood D, Yarnell J, Zamorano JL. European guidelines on cardiovascular disease prevention in clinical practice: Executive summary. Atherosclerosis 2007; 194:1-45. [PMID: 17880983 DOI: 10.1016/j.atherosclerosis.2007.08.024] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Ian Graham
- Department of Cardiology, The Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland.
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Miller DT, Ridker PM, Libby P, Kwiatkowski DJ. Atherosclerosis: the path from genomics to therapeutics. J Am Coll Cardiol 2007; 49:1589-1599. [PMID: 17433948 DOI: 10.1016/j.jacc.2006.12.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Revised: 10/30/2006] [Accepted: 12/04/2006] [Indexed: 01/19/2023]
Abstract
Recent rapid advances in genomic tools and techniques hold great promise for transforming the practice of cardiovascular medicine. Resources including the Human Genome Project and the International HapMap project, major technological advances in high-throughput genotyping and methods of statistical analysis, and methods for high-throughput gene expression and small molecule profiling allow researchers to confront issues that will fundamentally change the practice of cardiovascular medicine during the 21st century. Genomic, proteomic, and metabolomic studies of complex cardiovascular diseases such as atherosclerosis will bridge epidemiology and basic biology, and promise increased understanding of cardiovascular disease processes. Genetic approaches applied to atherosclerosis will continue to identify genes and pathways involved in the predisposition to and pathophysiology of atherosclerosis. Gene expression profiling refines our understanding of the dynamic nature of the atherosclerotic vascular wall and promises discovery and validation of targets for therapeutic intervention. Opportunities to translate genetic, genomic, proteomic, and metabolomic information into cardiovascular clinical practice have never been greater, but their fruition requires validation in large independent cohorts, achieved only through collaborative effort. Their continued success will depend on ongoing cooperation within the cardiovascular research community.
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Affiliation(s)
- David T Miller
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts; Donald W. Reynolds Cardiovascular Clinical Research Center on Atherosclerosis at Brigham and Women's Hospital and the Harvard Medical School, Boston, Massachusetts
| | - Paul M Ridker
- Division of Preventive Medicine and Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, Massachusetts; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Donald W. Reynolds Cardiovascular Clinical Research Center on Atherosclerosis at Brigham and Women's Hospital and the Harvard Medical School, Boston, Massachusetts
| | - Peter Libby
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Donald W. Reynolds Cardiovascular Clinical Research Center on Atherosclerosis at Brigham and Women's Hospital and the Harvard Medical School, Boston, Massachusetts..
| | - David J Kwiatkowski
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts; Donald W. Reynolds Cardiovascular Clinical Research Center on Atherosclerosis at Brigham and Women's Hospital and the Harvard Medical School, Boston, Massachusetts
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Drenos F, Whittaker JC, Humphries SE. The use of meta-analysis risk estimates for candidate genes in combination to predict coronary heart disease risk. Ann Hum Genet 2007; 71:611-9. [PMID: 17403027 DOI: 10.1111/j.1469-1809.2007.00359.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although the risk for coronary heart disease (CHD) associated with single SNPs is modest it has been suggested that, in combination, several common risk-associated alleles could lead to a substantially better heart disease risk prediction. We have modelled this using 10 SNPs in ten candidate genes (APOB, NOS3, APOE, ACE, SERPINE1, MTHFR, ITGA2B, PON 1, LPL, and CETP) and their predicted summary risk estimates from meta-analysis. Based on published allele frequencies, approximately 29% of the general population would be expected to carry less than three risk alleles, approximately 55% would carry 3 or 4 risk alleles, 4% would have 6 and 1% 7 or more risk alleles. Compared to the mean of those with 3 or 4 risk associated genotypes, those with 6 and 7-or-more alleles have a significantly higher risk odds ratio (OR) of CHD (mean OR (95% Confidence Intervals), 1.70 (1.14 to 2.55); and 4.51 (2.89 to 7.04) respectively), while compared to those in the lowest decile of risk, those in the highest decile have a CHD odds ratio in the range of 3.05 (2.24 to 4.14). Taking into account age and the risk alleles carried, the mean 10 year probability for developing CHD for a 55 year old man was calculated to be 15% (8.6% to 24.8%), with nearly 1 in 5 having more than 20% risk. Whether this particular group of 10 SNPs will improve the accuracy of CHD predictions over the combination of classical risk factors in clinical use requires further experimental evidence.
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Affiliation(s)
- F Drenos
- Centre for Cardiovascular Genetics, Dept. of Medicine, British Heart Foundation Laboratories, Rayne Building, Royal Free and University College Medical School, London WC1E 6JF, UK.
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