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McPherson R. 2018 George Lyman Duff Memorial Lecture: Genetics and Genomics of Coronary Artery Disease: A Decade of Progress. Arterioscler Thromb Vasc Biol 2019; 39:1925-1937. [PMID: 31462092 PMCID: PMC6766359 DOI: 10.1161/atvbaha.119.311392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent studies have led to a broader understanding of the genetic architecture of coronary artery disease 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 coronary artery disease risk. The tools applied include genome-wide association studies encompassing over 200 000 individuals complemented by bioinformatic approaches including imputation from whole-genome data sets, expression quantitative trait loci analyses, and interrogation of ENCODE (Encyclopedia of DNA Elements), Roadmap Epigenetic Project, and other data sets. Over 160 genome-wide significant loci associated with coronary artery disease risk have been identified using the genome-wide association studies approach, 90% of which are situated in intergenic regions. Here, I will describe, in part, our research over the last decade performed in collaboration with a series of bright trainees and an extensive number of groups and individuals around the world as it applies to our understanding of the genetic basis of this complex disease. These studies include computational approaches to better understand missing heritability and identify causal pathways, experimental approaches, and progress in understanding at the molecular level the function of the multiple risk loci identified and potential applications of these genomic data in clinical medicine and drug discovery.
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Affiliation(s)
- Ruth McPherson
- From the Division of Cardiology, Atherogenomics Laboratory, Ruddy Canadian Cardiovascular Genetics Centre, University of Ottawa Heart Institute, ON, Canada
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2
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Affiliation(s)
- Jacqueline S Dron
- From the Department of Biochemistry (J.S.D., J.L., R.A.H.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Robarts Research Institute (J.S.D., J.L., R.A.H.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Julieta Lazarte
- From the Department of Biochemistry (J.S.D., J.L., R.A.H.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Robarts Research Institute (J.S.D., J.L., R.A.H.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Medicine (J.L., R.A.H.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Robert A Hegele
- From the Department of Biochemistry (J.S.D., J.L., R.A.H.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Robarts Research Institute (J.S.D., J.L., R.A.H.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Medicine (J.L., R.A.H.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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3
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Mytilinaiou M, Kyrou I, Khan M, Grammatopoulos DK, Randeva HS. Familial Hypercholesterolemia: New Horizons for Diagnosis and Effective Management. Front Pharmacol 2018; 9:707. [PMID: 30050433 PMCID: PMC6052892 DOI: 10.3389/fphar.2018.00707] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/12/2018] [Indexed: 12/11/2022] Open
Abstract
Familial hypercholesterolemia (FH) is a common genetic cause of premature cardiovascular disease (CVD). The reported prevalence rates for both heterozygous FH (HeFH) and homozygous FH (HoFH) vary significantly, and this can be attributed, at least in part, to the variable diagnostic criteria used across different populations. Due to lack of consistent data, new global registries and unified guidelines are being formed, which are expected to advance current knowledge and improve the care of FH patients. This review presents a comprehensive overview of the pathophysiology, epidemiology, manifestations, and pharmacological treatment of FH, whilst summarizing the up-to-date relevant recommendations and guidelines. Ongoing research in FH seems promising and novel therapies are expected to be introduced in clinical practice in order to compliment or even substitute current treatment options, aiming for better lipid-lowering effects, fewer side effects, and improved clinical outcomes.
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Affiliation(s)
- Maria Mytilinaiou
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Ioannis Kyrou
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom.,Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry, United Kingdom
| | - Mike Khan
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Dimitris K Grammatopoulos
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Institute of Precision Diagnostics and Translational Medicine, Coventry and Warwickshire Pathology Service, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Harpal S Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom.,Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry, United Kingdom.,Institute of Precision Diagnostics and Translational Medicine, Coventry and Warwickshire Pathology Service, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
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4
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Scicali R, Di Pino A, Ferrara V, Urbano F, Piro S, Rabuazzo AM, Purrello F. New treatment options for lipid-lowering therapy in subjects with type 2 diabetes. Acta Diabetol 2018; 55:209-218. [PMID: 29260404 DOI: 10.1007/s00592-017-1089-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/11/2017] [Indexed: 12/15/2022]
Abstract
Dyslipidemias represent a variety of quantitative and/or qualitative lipoprotein abnormalities. According to etiology, we distinguish primary dyslipidemias with strictly genetic background and secondary ones with their origin in other disease or pathological states. Diabetic dyslipidemia is a type of secondary dyslipidemia and plays an important role in determining the cardiovascular risk of subjects with type 2 diabetes. In these patients, insulin resistance is responsible for overproduction and secretion of atherogenic very low density lipoprotein. In addition, insulin resistance promotes the production of small dense low-density lipoprotein (LDL) and reduces high-density lipoprotein (HDL) production. Cardiovascular disease remains a leading cause of morbidity and mortality in diabetic patients. Previous results support the role for small, dense LDL particles in the etiology of atherosclerosis and their association with coronary artery disease. Moreover, lowering LDL cholesterol reduces the risk of cardiovascular death. Therefore, the European guidelines for the management of dyslipidemias recommend an LDL cholesterol goal < 100 mg/dL in diabetic subjects without cardiovascular events. Moreover, if triglycerides (TG) are elevated (> 400 mg/dL), they recommend a non-HDL cholesterol goal < 130 mg/dL in diabetic individuals without cardiovascular events. Statins are the first line of LDL-lowering therapy in diabetic patients and combined therapy with ezetimibe and statins could be useful in very high cardiovascular risk diabetic subjects. Furthermore, the effect of a fibrate as an add-on treatment to a statin could improve the lipid profile in diabetic individuals with high TG and low HDL cholesterol. Regarding new therapies, recent data from phase III trials show that proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors considerably decrease LDL cholesterol. Thus, they may be useful in diabetic patients with concomitant diseases such as familial dyslipidemia, recurrent cardiovascular events, and elevated LDL cholesterol after second drug administration in addition to maximal statin dose or statin intolerance.
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Affiliation(s)
- Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Viviana Ferrara
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesca Urbano
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Agata Maria Rabuazzo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi Hospital, University of Catania, Via Palermo, 636, 95122, Catania, Italy.
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5
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Clemens KK, Shariff SZ, McArthur E, Hegele RA. Ezetimibe prescriptions in older Canadian adults after an acute myocardial infarction: a population-based cohort study. Lipids Health Dis 2018; 17:8. [PMID: 29310674 PMCID: PMC5759247 DOI: 10.1186/s12944-017-0649-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/21/2017] [Indexed: 11/16/2022] Open
Abstract
Background The utility of ezetimibe in preventing cardiovascular outcomes remains controversial. To guide future assessments of the effectiveness of ezetimibe in routine care, we evaluated how this medication has been prescribed to high-risk older adults in Ontario, Canada. Methods Using linked healthcare databases, we carried out a population-based cohort study of older adults who were discharged from hospital following an acute myocardial infarction from 2005 until 2014. We ascertained the rate of ezetimibe initiation within 6 months of their discharge. We also examined the characteristics of new ezetimibe prescriptions, as well as the predictors for receiving the therapy. Results Seventy one thousand one hundred twenty five older adults were hospitalized for an acute myocardial infarction between 2005 and 2014 (mean age 78.36 ± 7.71 years, 45.8% women). Only 1230 (1.7%) patients were newly prescribed ezetimibe within 6 months of their hospital discharge. The median duration of continuous use of ezetimibe was 1.2 years (IQR 0.3–3.5 years). Ezetimibe was prescribed more often to patients living in rural areas, with a history of coronary artery disease, on high-potency statins, and, with evidence of healthcare follow-up after hospital discharge. Prescriptions were less common in men, older patients, those living in long-term care facilities, those with a history of congestive heart failure, and those who were hospitalized for a myocardial infarction in more recent years. Conclusions Real-world drug effectiveness studies can help to complement the findings of randomized controlled trials. In our region however, only a small proportion of high-risk older adults received a prescription for ezetimibe following a myocardial infarction. Clinical and research implications are discussed. Electronic supplementary material The online version of this article (10.1186/s12944-017-0649-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristin K Clemens
- St. Joseph's Health Care London, PO BOX 5777, STN B, London, ON, N6A 4V2, Canada. .,Department of Medicine, Division of Endocrinology, Western University, London, ON, Canada. .,Institute for Clinical Evaluative Sciences, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada. .,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
| | | | - Eric McArthur
- Institute for Clinical Evaluative Sciences, ON, Canada
| | - Robert A Hegele
- St. Joseph's Health Care London, PO BOX 5777, STN B, London, ON, N6A 4V2, Canada.,Robarts Research Institute, 100 Perth Drive, London, ON, N6K 5K8, Canada
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6
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Silverstein RL. Atherothrombosis. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00144-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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7
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Wang LR, Hegele RA. Genetics for the Identification of Lipid Targets Beyond PCSK9. Can J Cardiol 2017; 33:334-342. [DOI: 10.1016/j.cjca.2016.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/06/2016] [Accepted: 11/07/2016] [Indexed: 12/21/2022] Open
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8
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Hoe E, Hegele RA. Lipid Management in Diabetes with a Focus on Emerging Therapies. Can J Diabetes 2016; 39 Suppl 5:S183-90. [PMID: 26653256 DOI: 10.1016/j.jcjd.2015.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/07/2015] [Accepted: 09/17/2015] [Indexed: 11/18/2022]
Abstract
We reviewed the current and potential future management of dyslipidemia in patients with diabetes, with a focus on reduction of risk for macrovascular disease. We considered novel dyslipidemia therapies, in particular, inhibitors of proprotein convertase subtilisin kexin 9 (PCSK9), which have been approved in Canada for reducing low-density lipoprotein (LDL) cholesterol in certain patient groups. We searched for English-language randomized clinical trials (RCTs) of lipid-lowering modalities, mainly since 2012, that included patients with diabetes. The results from some RCTs may have future impacts on the approach to patients with diabetes. In particular, ezetimibe added to statins in the context of acute coronary syndromes seems to have particular benefits in patients with diabetes. Also, patients with diabetes show no differences, so far, from patients without diabetes with respect to efficacy of PCSK9 inhibitors in LDL cholesterol reduction and also in the frequency of adverse effects. RCTs of clinical outcomes with PCSK9 inhibitors performed exclusively in patients with diabetes are desirable, but approval of these agents for use in Canada has occurred before the availability of such results. Clinicians will have to gauge whether certain subjects with diabetes might benefit from this therapy, such as those with superimposed familial dyslipidemia, those with recurrent cardiovascular events and recalcitrant LDL cholesterol levels despite maximally tolerated statin therapy and those with high cardiovascular risk who cannot tolerate any dose of statins.
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MESH Headings
- Combined Modality Therapy/adverse effects
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/therapy
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/therapy
- Drug Therapy, Combination/adverse effects
- Drug Therapy, Combination/trends
- Drugs, Investigational/adverse effects
- Drugs, Investigational/therapeutic use
- Dyslipidemias/complications
- Dyslipidemias/prevention & control
- Humans
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/adverse effects
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use
- Hypolipidemic Agents/adverse effects
- Hypolipidemic Agents/therapeutic use
- Practice Guidelines as Topic
- Precision Medicine
- Proprotein Convertase 9
- Proprotein Convertases/antagonists & inhibitors
- Proprotein Convertases/metabolism
- Randomized Controlled Trials as Topic
- Serine Endopeptidases/metabolism
- Serine Proteinase Inhibitors/adverse effects
- Serine Proteinase Inhibitors/therapeutic use
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9
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Ballantyne CM, Bays HE, Philip S, Doyle RT, Braeckman RA, Stirtan WG, Soni PN, Juliano RA. Icosapent ethyl (eicosapentaenoic acid ethyl ester): Effects on remnant-like particle cholesterol from the MARINE and ANCHOR studies. Atherosclerosis 2016; 253:81-87. [PMID: 27596132 DOI: 10.1016/j.atherosclerosis.2016.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/09/2016] [Accepted: 08/17/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Remnant-like particle cholesterol (RLP-C) is atherogenic and may increase atherosclerotic cardiovascular disease risk. Icosapent ethyl is a high-purity prescription eicosapentaenoic acid ethyl ester (approved as an adjunct to diet to reduce triglyceride [TG] levels in adult patients with TGs ≥500 mg/dL [≥5.65 mmol/L] at 4 g/day). In the MARINE and ANCHOR studies, icosapent ethyl reduced TG and other atherogenic lipid parameter levels without increasing low-density lipoprotein cholesterol (LDL-C) levels. This exploratory analysis evaluated the effects of icosapent ethyl on calculated and directly measured RLP-C. METHODS MARINE (TGs ≥500 and ≤2000 mg/dL [≥5.65 mmol/L and ≤22.6 mmol/L]) and ANCHOR (TGs ≥200 and <500 mg/dL [≥2.26 and <5.65 mmol/L] despite statin-controlled LDL-C) were phase 3, 12-week, double-blind studies that randomized adult patients to icosapent ethyl 4 g/day, 2 g/day, or placebo. This analysis assessed median percent change from baseline to study end in directly measured (immunoseparation assay) RLP-C levels (MARINE, n = 218; ANCHOR, n = 252) and calculated RLP-C levels in the full populations. RESULTS Icosapent ethyl 4 g/day significantly reduced directly measured RLP-C levels -29.8% (p = 0.004) in MARINE and -25.8% (p = 0.0001) in ANCHOR versus placebo, and also reduced directly measured RLP-C levels to a greater extent in subgroups with higher versus lower baseline TG levels, in patients receiving statins versus no statins (MARINE), and in patients receiving medium/higher-intensity versus lower-intensity statins (ANCHOR). Strong correlations were found between calculated and directly measured RLP-C for baseline, end-of-treatment, and percent change values in ANCHOR and MARINE (0.73-0.92; p < 0.0001 for all). CONCLUSIONS Icosapent ethyl 4 g/day significantly reduced calculated and directly measured RLP-C levels versus placebo in patients with elevated TG levels from the MARINE and ANCHOR studies.
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Affiliation(s)
- Christie M Ballantyne
- Baylor College of Medicine and the Houston Methodist DeBakey Heart and Vascular Center, 6565 Fannin St. MSA 601, Houston, TX 77030, USA.
| | - Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, Louisville, KY, USA
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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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11
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Tragante V, Asselbergs FW, Swerdlow DI, Palmer TM, Moore JH, de Bakker PIW, Keating BJ, Holmes MV. Harnessing publicly available genetic data to prioritize lipid modifying therapeutic targets for prevention of coronary heart disease based on dysglycemic risk. Hum Genet 2016; 135:453-467. [PMID: 26946290 PMCID: PMC4835528 DOI: 10.1007/s00439-016-1647-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/07/2016] [Indexed: 01/14/2023]
Abstract
Therapeutic interventions that lower LDL-cholesterol effectively reduce the risk of coronary artery disease (CAD). However, statins, the most widely prescribed LDL-cholesterol lowering drugs, increase diabetes risk. We used genome-wide association study (GWAS) data in the public domain to investigate the relationship of LDL-C and diabetes and identify loci encoding potential drug targets for LDL-cholesterol modification without causing dysglycemia. We obtained summary-level GWAS data for LDL-C from GLGC, glycemic traits from MAGIC, diabetes from DIAGRAM and CAD from CARDIoGRAMplusC4D consortia. Mendelian randomization analyses identified a one standard deviation (SD) increase in LDL-C caused an increased risk of CAD (odds ratio [OR] 1.63 (95 % confidence interval [CI] 1.55, 1.71), which was not influenced by removing SNPs associated with diabetes. LDL-C/CAD-associated SNPs showed consistent effect directions (binomial P = 6.85 × 10−5). Conversely, a 1-SD increase in LDL-C was causally protective of diabetes (OR 0.86; 95 % CI 0.81, 0.91), however LDL-cholesterol/diabetes-associated SNPs did not show consistent effect directions (binomial P = 0.15). HMGCR, our positive control, associated with LDL-C, CAD and a glycemic composite (derived from GWAS meta-analysis of four glycemic traits and diabetes). In contrast, PCSK9, APOB, LPA, CETP, PLG, NPC1L1 and ALDH2 were identified as “druggable” loci that alter LDL-C and risk of CAD without displaying associations with dysglycemia. In conclusion, LDL-C increases the risk of CAD and the relationship is independent of any association of LDL-C with diabetes. Loci that encode targets of emerging LDL-C lowering drugs do not associate with dysglycemia, and this provides provisional evidence that new LDL-C lowering drugs (such as PCSK9 inhibitors) may not influence risk of diabetes.
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Affiliation(s)
- Vinicius Tragante
- Department of Heart and Lungs, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Heart and Lungs, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands. .,Institute of Cardiovascular Science, University College London, 222 Euston Road, London, NW1 2DA, UK. .,Durrer Center for Cardiogenetic Research, ICIN-Netherlands Heart Institute, Utrecht, The Netherlands.
| | - Daniel I Swerdlow
- Institute of Cardiovascular Science, University College London, 222 Euston Road, London, NW1 2DA, UK.,Department of Medicine, Imperial College London, Du Cane Road, London, W12 0NN, UK
| | - Tom M Palmer
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Jason H Moore
- Department of Biostatistics and Epidemiology, Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA, 19104-6021, USA
| | - Paul I W de Bakker
- Department of Medical Genetics, Center for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Brendan J Keating
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Michael V Holmes
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA. .,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA. .,Clinical Trials Services Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, Richard Doll Building, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK.
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12
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Abstract
BACKGROUND/OBJECTIVES Epidemiological, diet-based, and some interventional outcomes studies suggest that polyunsaturated omega-3 fatty acids (OM3FAs), specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), confer cardiovascular protection in some patient populations. This review examines the historical context of OM3FAs in cardiovascular disease and future perspectives on the place of OM3FA products in reducing cardiovascular risk. METHODS Relevant articles were identified via PubMed/Medline and Google Scholar searches through 2015 and through reference lists of selected publications. Articles determined by the authors to be relevant to the topic of this review were included. RESULTS Review of the identified articles indicated that inconsistent results among interventional outcomes studies have been attributed to use of low doses of OM3FAs, patient cohorts with non-elevated triglyceride (TG) levels, differential use of concomitant statin therapy, and study designs with insufficient statistical power. Several prescription OM3FA products are now approved as an adjunct to diet to reduce TG levels in adults with severe (≥500 mg/dL) hypertriglyceridemia. Most formulations contain both EPA and DHA; one formulation contains purified EPA. In randomized controlled trials, these products significantly reduced TG levels in patients with very high TG levels (≥500 mg/dL [≥13.0 mmol/L]) and in statin-treated patients with high TG levels (200-499 mg/dL [5.2-12.9 mmol/L]). The DHA-containing products raised LDL-C levels in these studies, whereas the EPA-only product had no effect on LDL-C, suggesting that all OM3FA prescription products are not therapeutically equivalent. Besides lowering TG levels, OM3FAs (particularly EPA) exert anti-inflammatory effects and may slow multiple atherogenic processes. Two well designed interventional outcomes studies (REDUCE-IT and STRENGTH) are evaluating prescription-strength, high-dose OM3FAs (4 g/day) in statin-treated patients with persistently high TG levels. CONCLUSIONS The results of the ongoing prescription-strength, high-dose OM3FA interventional trials will help define the potential role of OM3FAs in addressing residual cardiovascular risk despite statin therapy.
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Affiliation(s)
- Laurence S Sperling
- a a Emory University School of Medicine and Rollins School of Public Health at Emory University , Atlanta , GA , USA
| | - John R Nelson
- b b UCSF School of Medicine, Fresno-Medicine Residency Program-Volunteer , Fresno , CA , USA
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13
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Hegele RA, Gidding SS, Ginsberg HN, McPherson R, Raal FJ, Rader DJ, Robinson JG, Welty FK. Nonstatin Low-Density Lipoprotein-Lowering Therapy and Cardiovascular Risk Reduction-Statement From ATVB Council. Arterioscler Thromb Vasc Biol 2015; 35:2269-80. [PMID: 26376908 DOI: 10.1161/atvbaha.115.306442] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 08/28/2015] [Indexed: 12/15/2022]
Abstract
Pharmacological reduction of low-density lipoprotein (LDL) cholesterol using statin drugs is foundational therapy to reduce cardiovascular disease (CVD) risk. Here, we consider the place of nonstatin therapies that also reduce LDL cholesterol in prevention of CVD. Among conventional nonstatins, placebo-controlled randomized clinical trials showed that bile acid sequestrants, niacin, and fibrates given as monotherapy each reduce CVD end points. From trials in which patients' LDL cholesterol was already well controlled on a statin, adding ezetimibe incrementally reduced CVD end points, whereas adding a fibrate or niacin showed no incremental benefit. Among emerging nonstatins, monoclonal antibodies against proprotein convertase subtilisin kexin type 9 added to a statin and given for ≤78 weeks showed preliminary evidence of reductions in CVD outcomes. Although these promising early findings contributed to the recent approval of these agents in Europe and in North America, much larger and longer duration outcomes studies are ongoing for definitive proof of CVD benefits. Other nonstatin agents recently approved in the United States include lomitapide and mipomersen, which both act via distinctive LDL receptor independent mechanisms to substantially reduce LDL cholesterol in homozygous familial hypercholesterolemia. We also address some unanswered questions, including measuring alternative biochemical variables to LDL cholesterol, evidence for treating children with monitoring of subclinical atherosclerosis, and potential risks of extremely low LDL cholesterol. As evidence for benefit in CVD prevention accumulates, we anticipate that clinical practice will shift toward more assertive LDL-lowering treatment, using both statins and nonstatins initiated earlier in appropriately selected patients.
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Affiliation(s)
- Robert A Hegele
- From the Department of Medicine, Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada (R.A.H.); Nemours Cardiac Center, A. I. duPont Hospital for Children, Wilmington, DE (S.S.G.); Irving Institute for Clinical and Translational Research, Department of Medicine, Columbia University, New York, NY (H.N.G.); Department of Medicine and Biochemistry, Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa (F.J.R); Department of Genetics (D.J.R.) and Division of Translational Medicine and Human Genetics, Department of Medicine (D.J.R.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Department of Epidemiology and Medicine, University of Iowa, Iowa City (J.G.R.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.K.W.).
| | - Samuel S Gidding
- From the Department of Medicine, Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada (R.A.H.); Nemours Cardiac Center, A. I. duPont Hospital for Children, Wilmington, DE (S.S.G.); Irving Institute for Clinical and Translational Research, Department of Medicine, Columbia University, New York, NY (H.N.G.); Department of Medicine and Biochemistry, Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa (F.J.R); Department of Genetics (D.J.R.) and Division of Translational Medicine and Human Genetics, Department of Medicine (D.J.R.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Department of Epidemiology and Medicine, University of Iowa, Iowa City (J.G.R.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.K.W.)
| | - Henry N Ginsberg
- From the Department of Medicine, Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada (R.A.H.); Nemours Cardiac Center, A. I. duPont Hospital for Children, Wilmington, DE (S.S.G.); Irving Institute for Clinical and Translational Research, Department of Medicine, Columbia University, New York, NY (H.N.G.); Department of Medicine and Biochemistry, Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa (F.J.R); Department of Genetics (D.J.R.) and Division of Translational Medicine and Human Genetics, Department of Medicine (D.J.R.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Department of Epidemiology and Medicine, University of Iowa, Iowa City (J.G.R.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.K.W.)
| | - Ruth McPherson
- From the Department of Medicine, Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada (R.A.H.); Nemours Cardiac Center, A. I. duPont Hospital for Children, Wilmington, DE (S.S.G.); Irving Institute for Clinical and Translational Research, Department of Medicine, Columbia University, New York, NY (H.N.G.); Department of Medicine and Biochemistry, Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa (F.J.R); Department of Genetics (D.J.R.) and Division of Translational Medicine and Human Genetics, Department of Medicine (D.J.R.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Department of Epidemiology and Medicine, University of Iowa, Iowa City (J.G.R.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.K.W.)
| | - Frederick J Raal
- From the Department of Medicine, Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada (R.A.H.); Nemours Cardiac Center, A. I. duPont Hospital for Children, Wilmington, DE (S.S.G.); Irving Institute for Clinical and Translational Research, Department of Medicine, Columbia University, New York, NY (H.N.G.); Department of Medicine and Biochemistry, Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa (F.J.R); Department of Genetics (D.J.R.) and Division of Translational Medicine and Human Genetics, Department of Medicine (D.J.R.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Department of Epidemiology and Medicine, University of Iowa, Iowa City (J.G.R.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.K.W.)
| | - Daniel J Rader
- From the Department of Medicine, Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada (R.A.H.); Nemours Cardiac Center, A. I. duPont Hospital for Children, Wilmington, DE (S.S.G.); Irving Institute for Clinical and Translational Research, Department of Medicine, Columbia University, New York, NY (H.N.G.); Department of Medicine and Biochemistry, Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa (F.J.R); Department of Genetics (D.J.R.) and Division of Translational Medicine and Human Genetics, Department of Medicine (D.J.R.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Department of Epidemiology and Medicine, University of Iowa, Iowa City (J.G.R.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.K.W.)
| | - Jennifer G Robinson
- From the Department of Medicine, Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada (R.A.H.); Nemours Cardiac Center, A. I. duPont Hospital for Children, Wilmington, DE (S.S.G.); Irving Institute for Clinical and Translational Research, Department of Medicine, Columbia University, New York, NY (H.N.G.); Department of Medicine and Biochemistry, Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa (F.J.R); Department of Genetics (D.J.R.) and Division of Translational Medicine and Human Genetics, Department of Medicine (D.J.R.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Department of Epidemiology and Medicine, University of Iowa, Iowa City (J.G.R.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.K.W.)
| | - Francine K Welty
- From the Department of Medicine, Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada (R.A.H.); Nemours Cardiac Center, A. I. duPont Hospital for Children, Wilmington, DE (S.S.G.); Irving Institute for Clinical and Translational Research, Department of Medicine, Columbia University, New York, NY (H.N.G.); Department of Medicine and Biochemistry, Atherogenomics Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (R.M.); Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa (F.J.R); Department of Genetics (D.J.R.) and Division of Translational Medicine and Human Genetics, Department of Medicine (D.J.R.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Department of Epidemiology and Medicine, University of Iowa, Iowa City (J.G.R.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.K.W.)
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Borow KM, Nelson JR, Mason RP. Biologic plausibility, cellular effects, and molecular mechanisms of eicosapentaenoic acid (EPA) in atherosclerosis. Atherosclerosis 2015; 242:357-66. [DOI: 10.1016/j.atherosclerosis.2015.07.035] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/06/2015] [Accepted: 07/20/2015] [Indexed: 01/08/2023]
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15
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Gryn SE, Hegele RA. Ezetimibe plus simvastatin for the treatment of hypercholesterolemia. Expert Opin Pharmacother 2015; 16:1255-62. [DOI: 10.1517/14656566.2015.1041504] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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