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Trinder M, Cermakova L, Ruel I, Baass A, Paquette M, Wang J, Kennedy BA, Hegele RA, Genest J, Brunham LR. Influence of Polygenic Background on the Clinical Presentation of Familial Hypercholesterolemia. Arterioscler Thromb Vasc Biol 2024; 44:1683-1693. [PMID: 38779854 PMCID: PMC11208056 DOI: 10.1161/atvbaha.123.320287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Heterozygous familial hypercholesterolemia (FH) is among the most common genetic conditions worldwide that affects ≈ 1 in 300 individuals. FH is characterized by increased levels of low-density lipoprotein cholesterol (LDL-C) and increased risk of coronary artery disease (CAD), but there is a wide spectrum of severity within the FH population. This variability in expression is incompletely explained by known risk factors. We hypothesized that genome-wide genetic influences, as represented by polygenic risk scores (PRSs) for cardiometabolic traits, would influence the phenotypic severity of FH. METHODS We studied individuals with clinically diagnosed FH (n=1123) from the FH Canada National Registry, as well as individuals with genetically identified FH from the UK Biobank (n=723). For all individuals, we used genome-wide gene array data to calculate PRSs for CAD, LDL-C, lipoprotein(a), and other cardiometabolic traits. We compared the distribution of PRSs in individuals with clinically diagnosed FH, genetically diagnosed FH, and non-FH controls and examined the association of the PRSs with the risk of atherosclerotic cardiovascular disease. RESULTS Individuals with clinically diagnosed FH had higher levels of LDL-C, and the incidence of atherosclerotic cardiovascular disease was higher in individuals with clinically diagnosed compared with genetically identified FH. Individuals with clinically diagnosed FH displayed enrichment for higher PRSs for CAD, LDL-C, and lipoprotein(a) but not for other cardiometabolic risk factors. The CAD PRS was associated with a risk of atherosclerotic cardiovascular disease among individuals with an FH-causing genetic variant. CONCLUSIONS Genetic background, as expressed by genome-wide PRSs for CAD, LDL-C, and lipoprotein(a), influences the phenotypic severity of FH, expanding our understanding of the determinants that contribute to the variable expressivity of FH. A PRS for CAD may aid in risk prediction among individuals with FH.
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Affiliation(s)
- Mark Trinder
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, Canada (M.T., L.C., L.R.B.)
| | - Lubomira Cermakova
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, Canada (M.T., L.C., L.R.B.)
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre, Montreal, Canada (I.R., J.G.)
| | - Alexis Baass
- Montreal Clinical Research Institute, Canada (A.B., M.P.)
| | | | - Jian Wang
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Canada (J.W., B.A.K., R.A.H.)
| | - Brooke A. Kennedy
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Canada (J.W., B.A.K., R.A.H.)
| | - Robert A. Hegele
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Robarts Research Institute, Western University, London, Canada (J.W., B.A.K., R.A.H.)
| | - Jacques Genest
- Research Institute of the McGill University Health Centre, Montreal, Canada (I.R., J.G.)
| | - Liam R. Brunham
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, Canada (M.T., L.C., L.R.B.)
- Departments of Medicine and Medical Genetics, University of British Columbia, Vancouver, Canada (L.R.B.)
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2
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Gao H, Li J, Ma Q, Zhang Q, Li M, Hu X. Causal Associations of Environmental Pollution and Cardiovascular Disease: A Two-Sample Mendelian Randomization Study. Glob Heart 2024; 19:52. [PMID: 38911616 PMCID: PMC11192098 DOI: 10.5334/gh.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/18/2024] [Indexed: 06/25/2024] Open
Abstract
Background There is growing evidence that concentrations of environmental pollutants are previously associated with cardiovascular disease; however, it is unclear whether this association reflects a causal relationship. Methods We utilized a two-sample Mendelian randomization (MR) approach to investigate how environmental pollution affects the likelihood of developing cardiovascular disease. We primarily employed the inverse variance weighted (IVW) method. Additionally, to ensure the robustness of our findings, we conducted several sensitivity analyses using alternative methodologies. These included maximum likelihood, MR-Egger regression, weighted median method and weighted model methods. Results Inverse variance weighted estimates suggested that an SD increase in PM2.5 exposure increased the risk of heart failure (OR = 1.40, 95% CI 1.02-1.93, p = 0.0386). We found that an SD increase in PM10 exposure increased the risk of hypertension (OR = 1.45, 95% CI 1.02-2.05, p = 0.03598) and atrial fibrillation (OR = 1.41, 95% CI 1.03-1.94, p = 0.03461). Exposure to chemical or other fumes in a workplace was found to increase the risk of hypertension (OR = 3.08, 95% CI 1.40-6.78, p = 0.005218), coronary artery disease (OR = 1.81, 95% CI 1.00-3.26, p = 0.04861), coronary heart disease (OR = 3.15, 95% CI 1.21-8.16, p = 0.0183) and myocardial infarction (OR = 3.03, 95% CI 1.13-8.17, p = 0.02802). Conclusion This study reveals the causal relationship between air pollutants and cardiovascular diseases, providing new insights into the protection of cardiovascular diseases.
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Affiliation(s)
- Hui Gao
- Department of Cardiovascular Medicine, The First People’s Hospital of Shangqiu, Shangqiu 476000, China
- Graduate School, Dalian Medical University, Dalian, 116044, China
| | - Jiahai Li
- Department of Cardiovascular Medicine, The First People’s Hospital of Qinzhou, Qinzhou 535000, China
| | - Qiaoli Ma
- Department of Cardiovascular Medicine, Central Hospital of Zibo, Zibo 255000, China
| | - Qinghui Zhang
- Department of Hypertension, Henan Provincial People’s Hospital, Zhengzhou 450000, China
| | - Man Li
- Department of Cardiovascular Medicine, The First People’s Hospital of Shangqiu, Shangqiu 476000, China
| | - Xiaoliang Hu
- Department of Cardiovascular Medicine, The First People’s Hospital of Shangqiu, Shangqiu 476000, China
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3
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Momin MM, Zhou X, Hyppönen E, Benyamin B, Lee SH. Cross-ancestry genetic architecture and prediction for cholesterol traits. Hum Genet 2024; 143:635-648. [PMID: 38536467 DOI: 10.1007/s00439-024-02660-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 02/13/2024] [Indexed: 05/18/2024]
Abstract
While cholesterol is essential, a high level of cholesterol is associated with the risk of cardiovascular diseases. Genome-wide association studies (GWASs) have proven successful in identifying genetic variants that are linked to cholesterol levels, predominantly in white European populations. However, the extent to which genetic effects on cholesterol vary across different ancestries remains largely unexplored. Here, we estimate cross-ancestry genetic correlation to address questions on how genetic effects are shared across ancestries. We find significant genetic heterogeneity between ancestries for cholesterol traits. Furthermore, we demonstrate that single nucleotide polymorphisms (SNPs) with concordant effects across ancestries for cholesterol are more frequently found in regulatory regions compared to other genomic regions. Indeed, the positive genetic covariance between ancestries is mostly driven by the effects of the concordant SNPs, whereas the genetic heterogeneity is attributed to the discordant SNPs. We also show that the predictive ability of the concordant SNPs is significantly higher than the discordant SNPs in the cross-ancestry polygenic prediction. The list of concordant SNPs for cholesterol is available in GWAS Catalog. These findings have relevance for the understanding of shared genetic architecture across ancestries, contributing to the development of clinical strategies for polygenic prediction of cholesterol in cross-ancestral settings.
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Affiliation(s)
- Md Moksedul Momin
- Australian Centre for Precision Health, University of South Australia, Adelaide, SA, 5000, Australia.
- UniSA Allied Health and Human Performance, University of South Australia, Adelaide, SA, 5000, Australia.
- Department of Genetics and Animal Breeding, Faculty of Veterinary Medicine, Chattogram Veterinary and Animal Sciences University (CVASU), Khulshi, Chattogram, 4225, Bangladesh.
- South Australian Health and Medical Research Institute (SAHMRI), University of South Australia, Adelaide, SA, 5000, Australia.
| | - Xuan Zhou
- Australian Centre for Precision Health, University of South Australia, Adelaide, SA, 5000, Australia
- UniSA Allied Health and Human Performance, University of South Australia, Adelaide, SA, 5000, Australia
- South Australian Health and Medical Research Institute (SAHMRI), University of South Australia, Adelaide, SA, 5000, Australia
| | - Elina Hyppönen
- Australian Centre for Precision Health, University of South Australia, Adelaide, SA, 5000, Australia
- South Australian Health and Medical Research Institute (SAHMRI), University of South Australia, Adelaide, SA, 5000, Australia
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Beben Benyamin
- Australian Centre for Precision Health, University of South Australia, Adelaide, SA, 5000, Australia
- UniSA Allied Health and Human Performance, University of South Australia, Adelaide, SA, 5000, Australia
- South Australian Health and Medical Research Institute (SAHMRI), University of South Australia, Adelaide, SA, 5000, Australia
| | - S Hong Lee
- Australian Centre for Precision Health, University of South Australia, Adelaide, SA, 5000, Australia.
- UniSA Allied Health and Human Performance, University of South Australia, Adelaide, SA, 5000, Australia.
- South Australian Health and Medical Research Institute (SAHMRI), University of South Australia, Adelaide, SA, 5000, Australia.
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4
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Paquette M, Baass A. Advances in familial hypercholesterolemia. Adv Clin Chem 2024; 119:167-201. [PMID: 38514210 DOI: 10.1016/bs.acc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Familial hypercholesterolemia (FH), a semi-dominant genetic disease affecting more than 25 million people worldwide, is associated with severe hypercholesterolemia and premature atherosclerotic cardiovascular disease. Over the last decade, advances in data analysis, screening, diagnosis and cardiovascular risk stratification has significantly improved our ability to deliver precision medicine for these patients. Furthermore, recent updates on guideline recommendations and new therapeutic approaches have also proven to be highly beneficial. It is anticipated that both ongoing and upcoming clinical trials will offer further insights for the care and treatment of FH patients.
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Affiliation(s)
- Martine Paquette
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, QC, Canada
| | - Alexis Baass
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, QC, Canada; Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, Montreal, QC, Canada.
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5
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Jacob EO, McIntyre AD, Wang J, Hegele RA. Lipoprotein(a) in Familial Hypercholesterolemia. CJC Open 2024; 6:40-46. [PMID: 38313344 PMCID: PMC10837708 DOI: 10.1016/j.cjco.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/25/2023] [Indexed: 02/06/2024] Open
Abstract
Background Low density lipoprotein (LDL) and Lipoprotein (Lp)(a) are proatherogenic apolipoprotein (apo) B-containing members of the non-high-density lipoprotein (non-HDL) family of particles. Elevated plasma levels of LDL cholesterol (C), non-HDL-C, and apo B are defining features of heterozygous familial hypercholesterolemia (HeFH), but reports of elevated plasma Lp(a) concentration are inconsistent. Methods We performed retrospective chart reviews of 256 genetically characterized patients with hypercholesterolemia and 272 control subjects from the Lipid Genetics Clinic at University Hospital in London, Ontario. We evaluated pairwise correlations between plasma levels of Lp(a) and those of LDL-C, non-HDL-C and apo B. Results Mean Lp(a) levels were not different between individuals with hypercholesterolemia and control subjects. No correlations were found between Lp(a) and LDL-C or non-HDL-C levels in controls or patients with hypercholesterolemia; all r values < 0.079 and all P values > 0.193. Borderline weak correlations between Lp(a) and apo B were identified in patients r = 0.103; P = 0.112) and controls (r = 0.175; P = 0.005). Results were similar across genotypic subgroups. Conclusions Lp(a) levels are independent of LDL-C and non-HDL-C; in particular Lp(a) levels are not increased in patients with hypercholesterolemia and molecularly proven HeFH. Apo B was only weakly associated with Lp(a). Elevated Lp(a) does not cause FH in our clinic patients. Genetic variants causing HeFH that raise LDL-C do not affect Lp(a), confirming that these lipoproteins are metabolically distinct. Lp(a) cannot be predicted from LDL-C and must be determined separately to evaluate its amplifying effect on atherosclerotic risk in patients with hypercholesterolemia.
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Affiliation(s)
- Erin O Jacob
- Department of Biochemistry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Adam D McIntyre
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jian Wang
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Robert A Hegele
- Department of Biochemistry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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6
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Watts GF, Gidding SS, Hegele RA, Raal FJ, Sturm AC, Jones LK, Sarkies MN, Al-Rasadi K, Blom DJ, Daccord M, de Ferranti SD, Folco E, Libby P, Mata P, Nawawi HM, Ramaswami U, Ray KK, Stefanutti C, Yamashita S, Pang J, Thompson GR, Santos RD. International Atherosclerosis Society guidance for implementing best practice in the care of familial hypercholesterolaemia. Nat Rev Cardiol 2023; 20:845-869. [PMID: 37322181 DOI: 10.1038/s41569-023-00892-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/17/2023]
Abstract
This contemporary, international, evidence-informed guidance aims to achieve the greatest good for the greatest number of people with familial hypercholesterolaemia (FH) across different countries. FH, a family of monogenic defects in the hepatic LDL clearance pathway, is a preventable cause of premature coronary artery disease and death. Worldwide, 35 million people have FH, but most remain undiagnosed or undertreated. Current FH care is guided by a useful and diverse group of evidence-based guidelines, with some primarily directed at cholesterol management and some that are country-specific. However, none of these guidelines provides a comprehensive overview of FH care that includes both the lifelong components of clinical practice and strategies for implementation. Therefore, a group of international experts systematically developed this guidance to compile clinical strategies from existing evidence-based guidelines for the detection (screening, diagnosis, genetic testing and counselling) and management (risk stratification, treatment of adults or children with heterozygous or homozygous FH, therapy during pregnancy and use of apheresis) of patients with FH, update evidence-informed clinical recommendations, and develop and integrate consensus-based implementation strategies at the patient, provider and health-care system levels, with the aim of maximizing the potential benefit for at-risk patients and their families worldwide.
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Affiliation(s)
- Gerald F Watts
- School of Medicine, University of Western Australia, Perth, WA, Australia.
- Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia.
| | | | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine, Western University, London, ON, Canada
| | - Frederick J Raal
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy C Sturm
- Department of Genomic Health, Geisinger, Danville, PA, USA
- 23andMe, Sunnyvale, CA, USA
| | - Laney K Jones
- Department of Genomic Health, Geisinger, Danville, PA, USA
| | - Mitchell N Sarkies
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Khalid Al-Rasadi
- Medical Research Centre, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Dirk J Blom
- Division of Lipidology and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
| | - Hapizah M Nawawi
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM) and Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
- Specialist Lipid and Coronary Risk Prevention Clinics, Hospital Al-Sultan Abdullah (HASA) and Clinical Training Centre, Puncak Alam and Sungai Buloh Campuses, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Uma Ramaswami
- Royal Free London NHS Foundation Trust, University College London, London, UK
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, UK
| | - Claudia Stefanutti
- Department of Molecular Medicine, Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Regional Centre for Rare Diseases, Immunohematology and Transfusion Medicine, Umberto I Hospital, 'Sapienza' University of Rome, Rome, Italy
| | - Shizuya Yamashita
- Department of Cardiology, Rinku General Medical Center, Osaka, Japan
| | - Jing Pang
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | | | - Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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Ying S, Heung T, Thiruvahindrapuram B, Engchuan W, Yin Y, Blagojevic C, Zhang Z, Hegele RA, Yuen RKC, Bassett AS. Polygenic risk for triglyceride levels in the presence of a high impact rare variant. BMC Med Genomics 2023; 16:281. [PMID: 37940981 PMCID: PMC10634078 DOI: 10.1186/s12920-023-01717-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Elevated triglyceride (TG) levels are a heritable and modifiable risk factor for cardiovascular disease and have well-established associations with common genetic variation captured in a polygenic risk score (PRS). In young adulthood, the 22q11.2 microdeletion conveys a 2-fold increased risk for mild-moderate hypertriglyceridemia. This study aimed to assess the role of the TG-PRS in individuals with this elevated baseline risk for mild-moderate hypertriglyceridemia. METHODS We studied a deeply phenotyped cohort of adults (n = 157, median age 34 years) with a 22q11.2 microdeletion and available genome sequencing, lipid level, and other clinical data. The association between a previously developed TG-PRS and TG levels was assessed using a multivariable regression model adjusting for effects of sex, BMI, and other covariates. We also constructed receiver operating characteristic (ROC) curves using logistic regression models to assess the ability of TG-PRS and significant clinical variables to predict mild-moderate hypertriglyceridemia status. RESULTS The TG-PRS was a significant predictor of TG-levels (p = 1.52E-04), along with male sex and BMI, in a multivariable model (pmodel = 7.26E-05). The effect of TG-PRS appeared to be slightly stronger in individuals with obesity (BMI ≥ 30) (beta = 0.4617) than without (beta = 0.1778), in a model unadjusted for other covariates (p-interaction = 0.045). Among ROC curves constructed, the inclusion of TG-PRS, sex, and BMI as predictor variables produced the greatest area under the curve (0.749) for classifying those with mild-moderate hypertriglyceridemia, achieving an optimal sensitivity and specificity of 0.746 and 0.707, respectively. CONCLUSIONS These results demonstrate that in addition to significant effects of sex and BMI, genome-wide common variation captured in a PRS also contributes to the variable expression of the 22q11.2 microdeletion with respect to elevated TG levels.
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Affiliation(s)
- Shengjie Ying
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Tracy Heung
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
- The Dalglish Family 22Q Clinic, University Health Network, Toronto, ON, Canada
| | | | - Worrawat Engchuan
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Yue Yin
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christina Blagojevic
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Zhaolei Zhang
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, ON, Canada
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Robert A Hegele
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Ryan K C Yuen
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Anne S Bassett
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- The Dalglish Family 22Q Clinic, University Health Network, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital Research Institute and Campbell Family Mental Health Research Institute, Toronto, ON, Canada.
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8
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Berry AS, Jones LK, Sijbrands EJ, Gidding SS, Oetjens MT. Subtyping Severe Hypercholesterolemia by Genetic Determinant to Stratify Risk of Coronary Artery Disease. Arterioscler Thromb Vasc Biol 2023; 43:2058-2067. [PMID: 37589137 PMCID: PMC10538409 DOI: 10.1161/atvbaha.123.319341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/01/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Severe hypercholesterolemia, defined as LDL (low-density lipoprotein) cholesterol (LDL-C) measurement ≥190 mg/dL, is associated with increased risk for coronary artery disease (CAD). Causes of severe hypercholesterolemia include monogenic familial hypercholesterolemia, polygenic hypercholesterolemia, elevated lipoprotein(a) [Lp(a)] hypercholesteremia, polygenic hypercholesterolemia with elevated Lp(a) (two-hit), or nongenetic hypercholesterolemia. The added value of using a genetics approach to stratifying risk of incident CAD among those with severe hypercholesterolemia versus using LDL-C levels alone for risk stratification is not known. METHODS To determine whether risk stratification by genetic cause provided better 10-year incident CAD risk stratification than LDL-C level, a retrospective cohort study comparing incident CAD risk among severe hypercholesterolemia subtypes (genetic and nongenetic causes) was performed among 130 091 UK Biobank participants. Analyses were limited to unrelated, White British or Irish participants with available exome sequencing data. Participants with cardiovascular disease at baseline were excluded from analyses of incident CAD. RESULTS Of 130 091 individuals, 68 416 (52.6%) were women, and the mean (SD) age was 56.7 (8.0) years. Of the cohort, 9.0% met severe hypercholesterolemia criteria. Participants with LDL-C between 210 and 229 mg/dL and LDL-C ≥230 mg/dL showed modest increases in incident CAD risk relative to those with LDL-C between 190 and 209 mg/dL (210-229 mg/dL: hazard ratio [HR], 1.3 [95% CI, 1.1-1.7]; ≥230 mg/dL: HR, 1.3 [95% CI, 1.0-1.7]). In contrast, when risk was stratified by genetic subtype, monogenic familial hypercholesterolemia, elevated Lp(a), and two-hit hypercholesterolemia subtypes had increased rates of incident CAD relative to the nongenetic hypercholesterolemia subtype (monogenic familial hypercholesterolemia: HR, 2.3 [95% CI, 1.4-4.0]; elevated Lp(a): HR, 1.5 [95% CI, 1.2-2.0]; two-hit: HR, 1.9 [95% CI, 1.4-2.6]), while polygenic hypercholesterolemia did not. CONCLUSIONS Genetics-based subtyping for monogenic familial hypercholesterolemia and Lp(a) in those with severe hypercholesterolemia provided better stratification of 10-year incident CAD risk than LDL-C-based stratification.
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Affiliation(s)
| | - Laney K. Jones
- Department of Genomic Health, Geisinger, Danville, PA 17821
- Heart and Vascular Institute, Geisinger, Danville, PA 17821
| | - Eric J. Sijbrands
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, PO-box 2040, 3000 CA Rotterdam, The Netherlands
| | | | - Matthew T. Oetjens
- Autism and Developmental Medicine Institute, Geisinger, Lewisburg, PA 17837
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9
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Lan NSR, Bajaj A, Watts GF, Cuchel M. Recent advances in the management and implementation of care for familial hypercholesterolaemia. Pharmacol Res 2023; 194:106857. [PMID: 37460004 DOI: 10.1016/j.phrs.2023.106857] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023]
Abstract
Familial hypercholesterolaemia (FH) is a common autosomal semi-dominant and highly penetrant disorder of the low-density lipoprotein (LDL) receptor pathway, characterised by lifelong elevated levels of low-density lipoprotein cholesterol (LDL-C) and increased risk of atherosclerotic cardiovascular disease (ASCVD). However, many patients with FH are not diagnosed and do not attain recommended LDL-C goals despite maximally tolerated doses of potent statin and ezetimibe. Over the past decade, several cholesterol-lowering therapies such as those targeting proprotein convertase subtilisin/kexin type 9 (PCSK9) or angiopoietin-like 3 (ANGPTL3) with monoclonal antibody or ribonucleic acid (RNA) approaches have been developed that promise to close the treatment gap. The availability of new therapies with complementary modes of action of lipid metabolism has enabled many patients with FH to attain guideline-recommended LDL-C goals. Emerging therapies for FH include liver-directed gene transfer of the LDLR, vaccines targeting key proteins involved in cholesterol metabolism, and CRISPR-based gene editing of PCSK9 and ANGPTL3, but further clinical trials are required. In this review, current and emerging treatment strategies for lowering LDL-C, and ASCVD risk-stratification, as well as implementation strategies for the care of patients with FH are reviewed.
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Affiliation(s)
- Nick S R Lan
- Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia; School of Medicine, The University of Western Australia, Perth, Australia.
| | - Archna Bajaj
- Division of Translational Medicine & Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gerald F Watts
- Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia; School of Medicine, The University of Western Australia, Perth, Australia
| | - Marina Cuchel
- Division of Translational Medicine & Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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10
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Cuchel M, Raal FJ, Hegele RA, Al-Rasadi K, Arca M, Averna M, Bruckert E, Freiberger T, Gaudet D, Harada-Shiba M, Hudgins LC, Kayikcioglu M, Masana L, Parhofer KG, Roeters van Lennep JE, Santos RD, Stroes ESG, Watts GF, Wiegman A, Stock JK, Tokgözoğlu LS, Catapano AL, Ray KK. 2023 Update on European Atherosclerosis Society Consensus Statement on Homozygous Familial Hypercholesterolaemia: new treatments and clinical guidance. Eur Heart J 2023:7148157. [PMID: 37130090 DOI: 10.1093/eurheartj/ehad197] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/22/2022] [Accepted: 03/16/2023] [Indexed: 05/03/2023] Open
Abstract
This 2023 statement updates clinical guidance for homozygous familial hypercholesterolaemia (HoFH), explains the genetic complexity, and provides pragmatic recommendations to address inequities in HoFH care worldwide. Key strengths include updated criteria for the clinical diagnosis of HoFH and the recommendation to prioritize phenotypic features over genotype. Thus, a low-density lipoprotein cholesterol (LDL-C) >10 mmol/L (>400 mg/dL) is suggestive of HoFH and warrants further evaluation. The statement also provides state-of-the art discussion and guidance to clinicians for interpreting the results of genetic testing and for family planning and pregnancy. Therapeutic decisions are based on the LDL-C level. Combination LDL-C-lowering therapy-both pharmacologic intervention and lipoprotein apheresis (LA)-is foundational. Addition of novel, efficacious therapies (i.e. inhibitors of proprotein convertase subtilisin/kexin type 9, followed by evinacumab and/or lomitapide) offers potential to attain LDL-C goal or reduce the need for LA. To improve HoFH care around the world, the statement recommends the creation of national screening programmes, education to improve awareness, and management guidelines that account for the local realities of care, including access to specialist centres, treatments, and cost. This updated statement provides guidance that is crucial to early diagnosis, better care, and improved cardiovascular health for patients with HoFH worldwide.
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Affiliation(s)
- Marina Cuchel
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 9017 Maloney Building, 3600 Spruce Street, Philadelphia, PA 19104, USA
| | - Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand Parktown, Johannesburg, South Africa
| | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Khalid Al-Rasadi
- Department of Biochemistry, College of Medicine & Health Sciences, Medical Research Center, Sultan Qaboos University, Muscat, Oman
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Maurizio Averna
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialities, University of Palermo, Palermo, Italy
- Istituto di Biofisica, Consiglio Nazionale delle Ricerche, Genova, Italy
| | - Eric Bruckert
- Pitié-Salpêtrière Hospital and Sorbonne University, Cardio metabolic Institute, Paris, France
| | - Tomas Freiberger
- Centre for Cardiovascular Surgery and Transplantation, and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Daniel Gaudet
- Clinical Lipidology and Rare Lipid Disorders Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal, ECOGENE, Clinical and Translational Research Center, and Lipid Clinic, Chicoutimi Hospital, Chicoutimi, Québec, Canada
| | - Mariko Harada-Shiba
- Cardiovascular Center, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Lisa C Hudgins
- Rogosin Institute, Weill Cornell Medical College, New York, NY, USA
| | - Meral Kayikcioglu
- Department of Cardiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Luis Masana
- Vascular Medicine and Metabolism Unit, Research Unit on Lipids and Atherosclerosis, Sant Joan University Hospital, Universitat Rovira i Virgili, IISPV CIBERDEM, Reus, Spain
| | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Ludwigs-Maximilians University Klinikum, Munich, Germany
| | | | - Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
- Academic Research Organization Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerald F Watts
- Medical School, University of Western Australia, and Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
| | - Albert Wiegman
- Department of Pediatrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jane K Stock
- European Atherosclerosis Society, Gothenburg, Sweden
| | - Lale S Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberico L Catapano
- IRCCS MultiMedica, and Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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11
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Choi D, Malick WA, Koenig W, Rader DJ, Rosenson RS. Familial Hypercholesterolemia: Challenges for a High-Risk Population: JACC Focus Seminar 1/3. J Am Coll Cardiol 2023; 81:1621-1632. [PMID: 37076217 DOI: 10.1016/j.jacc.2023.02.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/02/2023] [Indexed: 04/21/2023]
Abstract
The availability of statins, ezetimibe, and PCSK9 inhibitors has significantly improved the prognosis of familial hypercholesterolemia (FH). However, a great number of individuals with FH do not achieve guideline-recommended low-density lipoprotein (LDL) cholesterol levels despite maximal lipid-lowering therapy. Novel therapies that lower LDL independent of LDL receptor activity can help mitigate atherosclerotic cardiovascular disease risk in most homozygous FH and many heterozygous FH patients. However, access to novel therapies remains limited for heterozygous FH patients with persistent elevation of LDL cholesterol despite treatment with multiple classes of cholesterol-lowering therapies. Conduction of cardiovascular outcomes clinical trials in patients with FH can be challenging because of difficulty in recruitment and long periods of follow-up. In the future, the use of validated surrogate measures of atherosclerosis may allow for clinical trials with fewer study participants and shorter duration, thereby expediting access to novel treatments for patients with FH.
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Affiliation(s)
- Daein Choi
- Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Waqas A Malick
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany; Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Daniel J Rader
- Departments of Medicine and Genetics and the Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert S Rosenson
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/DrRSRosenson
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12
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Clarke SL. Does low-density lipoprotein fully explain atherosclerotic risk in familial hypercholesterolemia? Curr Opin Lipidol 2023; 34:52-58. [PMID: 36853849 PMCID: PMC9994798 DOI: 10.1097/mol.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW Familial hypercholesterolemia (FH) is a monogenic disorder of elevated low-density lipoprotein cholesterol (LDL-C) from birth leading to increased risk for atherosclerotic cardiovascular disease. However, not all carriers of FH variants display an FH phenotype. Despite this fact, FH variants confer increased risk for atherosclerotic disease in population cohorts. An important question to consider is whether measurements of LDL-C can fully account for this risk. RECENT FINDINGS The atherosclerotic risk associated with FH variants is independent of observed adult LDL-C levels. Modeling adult longitudinal LDL-C accounts for more of this risk compared to using a single measurement. Still, even when adjusting for observed longitudinal LDL-C in adult cohorts, FH variant carriers are at increased risk for coronary artery disease. Genetic analyses, observational studies, and clinical trials all suggest that cumulative LDL-C is a critical driver of cardiovascular risk that may not be fully appreciated by routine LDL-C measurements in adulthood. As such, FH variants confer risk independent of adult LDL-C because these variants increase cumulative LDL-C exposure starting from birth. SUMMARY Both research and clinical practice focus on LDL-C measurements in adults, but measurements during adulthood do not reflect lifelong cumulative exposure to LDL-C. Genetic assessments may compliment clinical assessments by better identifying patients who have experienced greater longitudinal LDL-C exposure.
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Affiliation(s)
- Shoa L. Clarke
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, California, USA
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13
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Genetic Heterogeneity of Familial Hypercholesterolemia: Repercussions for Molecular Diagnosis. Int J Mol Sci 2023; 24:ijms24043224. [PMID: 36834635 PMCID: PMC9961636 DOI: 10.3390/ijms24043224] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
Genetics of Familial Hypercholesterolemia (FH) is ascribable to pathogenic variants in genes encoding proteins leading to an impaired LDL uptake by the LDL receptor (LDLR). Two forms of the disease are possible, heterozygous (HeFH) and homozygous (HoFH), caused by one or two pathogenic variants, respectively, in the three main genes that are responsible for the autosomal dominant disease: LDLR, APOB and PCSK9 genes. The HeFH is the most common genetic disease in humans, being the prevalence about 1:300. Variants in the LDLRAP1 gene causes FH with a recessive inheritance and a specific APOE variant was described as causative of FH, contributing to increase FH genetic heterogeneity. In addition, variants in genes causing other dyslipidemias showing phenotypes overlapping with FH may mimic FH in patients without causative variants (FH-phenocopies; ABCG5, ABCG8, CYP27A1 and LIPA genes) or act as phenotype modifiers in patients with a pathogenic variant in a causative gene. The presence of several common variants was also considered a genetic basis of FH and several polygenic risk scores (PRS) have been described. The presence of a variant in modifier genes or high PRS in HeFH further exacerbates the phenotype, partially justifying its variability among patients. This review aims to report the updates on the genetic and molecular bases of FH with their implication for molecular diagnosis.
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Abstract
Atherosclerotic cardiovascular disease is the leading cause of death globally. Despite its important risk of premature atherosclerosis and cardiovascular disease, familial hypercholesterolemia (FH) is still largely underdiagnosed worldwide. It is one of the most frequently inherited diseases due to mutations, for autosomal dominant forms, in either of the LDLR, APOB, and PCSK9 genes or possibly a few mutations in the APOE gene and, for the rare autosomal forms, in the LDLRAP1 gene. The discovery of the genes implicated in the disease has largely helped to improve the diagnosis and treatment of FH from the LDLR by Brown and Goldstein, as well as the introduction of statins, to PCSK9 discovery in FH by Abifadel et al., and the very rapid availability of PCSK9 inhibitors. In the last two decades, major progress has been made in clinical and genetic diagnostic tools and the therapeutic arsenal against FH. Improving prevention, diagnosis, and treatment and making them more accessible to all patients will help reduce the lifelong burden of the disease.
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Affiliation(s)
- Marianne Abifadel
- UMR1148, Inserm, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, F-75018 Paris, France.,Laboratory of Biochemistry and Molecular Therapeutics (LBTM), Faculty of Pharmacy, Pôle Technologie-Santé, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Catherine Boileau
- UMR1148, Inserm, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, F-75018 Paris, France.,Département de Génétique, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
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15
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Pan-Lizcano R, Mariñas-Pardo L, Núñez L, Rebollal-Leal F, López-Vázquez D, Pereira A, Molina-Nieto A, Calviño R, Vázquez-Rodríguez JM, Hermida-Prieto M. Rare Variants in Genes of the Cholesterol Pathway Are Present in 60% of Patients with Acute Myocardial Infarction. Int J Mol Sci 2022; 23:ijms232416127. [PMID: 36555767 PMCID: PMC9786046 DOI: 10.3390/ijms232416127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Acute myocardial infarction (AMI) is a pandemic in which conventional risk factors are inadequate to detect who is at risk early in the asymptomatic stage. Although gene variants in genes related to cholesterol, which may increase the risk of AMI, have been identified, no studies have systematically screened the genes involved in this pathway. In this study, we included 105 patients diagnosed with AMI with an elevation of the ST segment (STEMI) and treated with primary percutaneous coronary intervention (PPCI). Using next-generation sequencing, we examined the presence of rare variants in 40 genes proposed to be involved in lipid metabolism and we found that 60% of AMI patients had a rare variant in the genes involved in the cholesterol pathway. Our data show the importance of considering the wide scope of the cholesterol pathway in order to assess the genetic risk related to AMI.
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Affiliation(s)
- Ricardo Pan-Lizcano
- Grupo de Investigación en Cardiología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), GRINCAR-Universidade da Coruña (UDC), 15006 A Coruña, Spain
| | - Luis Mariñas-Pardo
- Facultad de Ciencias de la Salud, Universidad Internacional de Valencia (VIU), 46002 Valencia, Spain
| | - Lucía Núñez
- Grupo de Investigación en Cardiología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), GRINCAR-Universidade da Coruña (UDC), 15006 A Coruña, Spain
- Departamento de Ciencias de la Salud, GRINCAR Research Group, Universidade da Coruña, 15403 A Coruña, Spain
- Correspondence: ; Tel.: +34-981-178-150
| | - Fernando Rebollal-Leal
- Servicio de Cardiología, Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña (UDC), 15006 A Coruña, Spain
| | - Domingo López-Vázquez
- Servicio de Cardiología, Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña (UDC), 15006 A Coruña, Spain
| | - Ana Pereira
- Servicio de Cardiología, Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña (UDC), 15006 A Coruña, Spain
| | - Aranzazu Molina-Nieto
- Servicio de Cardiología, Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña (UDC), 15006 A Coruña, Spain
| | - Ramón Calviño
- Servicio de Cardiología, Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña (UDC), 15006 A Coruña, Spain
- CIBERCV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Jose Manuel Vázquez-Rodríguez
- Servicio de Cardiología, Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña (UDC), 15006 A Coruña, Spain
- CIBERCV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Manuel Hermida-Prieto
- Grupo de Investigación en Cardiología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC-SERGAS), GRINCAR-Universidade da Coruña (UDC), 15006 A Coruña, Spain
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16
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Vanhoye X, Bardel C, Rimbert A, Moulin P, Rollat-Farnier PA, Muntaner M, Marmontel O, Dumont S, Charrière S, Cornélis F, Ducluzeau PH, Fonteille A, Nobecourt E, Peretti N, Schillo F, Wargny M, Cariou B, Meirhaeghe A, Di Filippo M. A new 165-SNP low-density lipoprotein cholesterol polygenic risk score based on next generation sequencing outperforms previously published scores in routine diagnostics of familial hypercholesterolemia. Transl Res 2022; 255:119-127. [PMID: 36528340 DOI: 10.1016/j.trsl.2022.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 11/14/2022] [Accepted: 12/09/2022] [Indexed: 12/16/2022]
Abstract
Genetic diagnosis of familial hypercholesterolemia (FH) remains unexplained in 30 to 70% of patients after exclusion of monogenic disease. There is now a growing evidence that a polygenic burden significantly modulates LDL-cholesterol (LDL-c) concentrations. Several LDL-c polygenic risk scores (PRS) have been set up. However, the balance between their diagnosis performance and their practical use in routine practice is not clearly established. Consequently, we set up new PRS based on our routine panel for sequencing and compared their diagnostic performance with previously-published PRS. After a meta-analysis, four new PRS including 165 to 1633 SNP were setup using different softwares. They were established using two French control cohorts (MONA LISA n=1082 and FranceGenRef n=856). Then the explained LDL-c variance and the ability of each PRS to discriminate monogenic negative FH patients (M-) versus healthy controls were compared with 4 previously-described PRS in 785 unrelated FH patients. Between all PRS, the 165-SNP PRS developed with PLINK showed the best LDL-c explained variance (adjusted R²=0.19) and the best diagnosis abilities (AUROC=0.77, 95%CI=0.74-0.79): it significantly outperformed all the previously-published PRS (p<1 × 10-4). By using a cut-off at the 75th percentile, 61% of M- patients exhibited a polygenic hypercholesterolemia with the 165-SNP PRS versus 48% with the previously published 12-SNP PRS (p =3.3 × 10-6). These results were replicated using the UK biobank. This new 165-SNP PRS, usable in routine diagnosis, exhibits better diagnosis abilities for a polygenic hypercholesterolemia diagnosis. It would be a valuable tool to optimize referral for whole genome sequencing.
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Affiliation(s)
- Xavier Vanhoye
- Service de Biochimie et de Biologie Moléculaire, Laboratoire de Biologie Médicale MultiSites, Hospices Civils de Lyon, Bron, France
| | - Claire Bardel
- Laboratoire de Biométrie et Biologie Evolutive UMR 5558, Université de Lyon, Université Lyon 1, CNRS, Villeurbanne, France; Plateforme de séquençage NGS HCL, Cellule bio-informatique, Hospices Civils de Lyon, Lyon, France
| | - Antoine Rimbert
- Institut du thorax, Nantes Université, CHU Nantes, CNRS, Inserm, Nantes, France
| | - Philippe Moulin
- Fédération d'endocrinologie, maladies métaboliques, diabète et nutrition, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Laboratoire CarMen, INSERM U1060, INRAE U1397, Oullins, France
| | | | - Manon Muntaner
- Institut Pasteur de Lille, U1167 - RID-AGE - Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, Univ. Lille, INSERM, Centre Hospitalo-Universitaire Lille, Lille, France
| | - Oriane Marmontel
- Service de Biochimie et de Biologie Moléculaire, Laboratoire de Biologie Médicale MultiSites, Hospices Civils de Lyon, Bron, France; Laboratoire CarMen, INSERM U1060, INRAE U1397, Oullins, France
| | - Sabrina Dumont
- Service de Biochimie et de Biologie Moléculaire, Laboratoire de Biologie Médicale MultiSites, Hospices Civils de Lyon, Bron, France
| | - Sybil Charrière
- Fédération d'endocrinologie, maladies métaboliques, diabète et nutrition, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Laboratoire CarMen, INSERM U1060, INRAE U1397, Oullins, France
| | - François Cornélis
- Génétique - Oncogénétique Adulte - Prévention, Centre Hospitalo-Universitaire et Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Pierre Henri Ducluzeau
- Unité d'endocrinologie, Centre Hospitalo-Universitaire Bretonneau, Université de Tours, Tours, France
| | - Annie Fonteille
- Infectiologie, Médecine Interne, Médecine des voyages, Centre Hospitalier d'Annecy Genevois, Epagny Metz-Tessy, Annecy, France
| | - Estelle Nobecourt
- Service d'Endocrinologie, Diabète et Nutrition et Centre d'Investigation Clinique - Epidémiologie Clinique (CIC-EC) U1410 INSERM, Centre Hospitalo-Universitaire de la Réunion, Saint-Pierre, La Réunion, France
| | - Noël Peretti
- Laboratoire CarMen, INSERM U1060, INRAE U1397, Oullins, France; Service de Gastroentérologie Hépatologie et Nutrition Pédiatrique, GHE, Hospices Civils de Lyon, Lyon, France
| | - Franck Schillo
- Service de Diabétologie-Endocrinologie-Nutrition, Centre Hospitalo-Universitaire Jean Minjoz Besançon France
| | - Matthieu Wargny
- Institut du thorax, Nantes Université, CHU Nantes, CNRS, Inserm, Nantes, France
| | - Bertrand Cariou
- Institut du thorax, Nantes Université, CHU Nantes, CNRS, Inserm, Nantes, France
| | - Aline Meirhaeghe
- Institut Pasteur de Lille, U1167 - RID-AGE - Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, Univ. Lille, INSERM, Centre Hospitalo-Universitaire Lille, Lille, France
| | - Mathilde Di Filippo
- Service de Biochimie et de Biologie Moléculaire, Laboratoire de Biologie Médicale MultiSites, Hospices Civils de Lyon, Bron, France; Laboratoire CarMen, INSERM U1060, INRAE U1397, Oullins, France.
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17
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Deshotels MR, Hadley TD, Roth M, Agha AM, Pulipati VP, Nugent AK, Virani SS, Nambi V, Moriarty PM, Davidson MH, Ballantyne CM. Genetic Testing for Hypertriglyceridemia in Academic Lipid Clinics: Implications for Precision Medicine-Brief Report. Arterioscler Thromb Vasc Biol 2022; 42:1461-1467. [PMID: 36325899 DOI: 10.1161/atvbaha.122.318445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Severe hypertriglyceridemia is often caused by variants in genes of triglyceride metabolism. These variants include rare, heterozygous pathogenic variants (PVs), or multiple common, small-effect single nucleotide polymorphisms that can be quantified using a polygenic risk score (PRS). The role of genetic testing to examine PVs and PRS in predicting risk for pancreatitis and severity of hypertriglyceridemia is unknown. METHODS We examined the relationship of PVs and PRSs associated with hypertriglyceridemia with the highest recorded plasma triglyceride level and risk for acute pancreatitis in 363 patients from 3 academic lipid clinics who underwent genetic testing (GBinsight's Dyslipidemia Comprehensive Panel). Categories of hypertriglyceridemia included: normal triglyceride (<200 mg/dL), moderate (200-499 mg/dL), severe (500-999 mg/dL), or very severe (≥1000 mg/dL). RESULTS PVs and high PRSs were identified in 37 (10%) and 59 (16%) individuals, respectively. Patients with both had increased risk for very severe hypertriglyceridemia compared with those with neither genetic risk factor. Risk for acute pancreatitis was also increased in individuals with both genetic risk factors (odds ratio, 5.1 [P=0.02] after controlling for age, race, sex, body mass index, and highest triglyceride level), but not in individuals with PV or high PRS alone. CONCLUSIONS The presence of both PV and high PRS significantly increased risk for very severe hypertriglyceridemia and acute pancreatitis, whereas PV or PRS alone only modestly increased risk. Genetic testing may help identify patients with hypertriglyceridemia who have the greatest risk for developing pancreatitis and may derive the greatest benefit from novel triglyceride-lowering therapies.
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Affiliation(s)
- Matthew R Deshotels
- Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (M.R.D., T.D.H., A.M.A., S.S.V., V.N., C.M.B.)
| | - Trevor D Hadley
- Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (M.R.D., T.D.H., A.M.A., S.S.V., V.N., C.M.B.)
| | | | - Ali M Agha
- Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (M.R.D., T.D.H., A.M.A., S.S.V., V.N., C.M.B.)
| | - Vishnu Priya Pulipati
- Section of Cardiology, Department of Medicine, University of Chicago, IL (V.P.P., M.H.D.)
| | - Anne K Nugent
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City (A.K.N., P.M.M.)
| | - Salim S Virani
- Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX (S.S.V., V.N.)
| | - Vijay Nambi
- Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX (S.S.V., V.N.)
| | - Patrick M Moriarty
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City (A.K.N., P.M.M.)
| | - Michael H Davidson
- Section of Cardiology, Department of Medicine, University of Chicago, IL (V.P.P., M.H.D.)
| | - Christie M Ballantyne
- Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (M.R.D., T.D.H., A.M.A., S.S.V., V.N., C.M.B.)
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18
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Paquette M, Carrié A, Bernard S, Cariou B, Hegele RA, Genest J, Trinder M, Brunham LR, Béliard S, Baass A. Effect of the LDL receptor mutation type on incident major adverse cardiovascular events in familial hypercholesterolaemia. Eur J Prev Cardiol 2022; 29:2125-2131. [PMID: 36047048 DOI: 10.1093/eurjpc/zwac188] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/04/2022] [Accepted: 08/24/2022] [Indexed: 01/11/2023]
Abstract
AIMS Patients with familial hypercholesterolaemia (FH) are at increased risk of cardiovascular disease (CVD) due to extremely high circulating LDL cholesterol (LDL-C) concentrations. Our objective was to study the effect of the type of LDL receptor (LDLR) mutation on the incidence of major adverse cardiovascular events (MACEs). METHODS AND RESULTS This was a multinational prospective cohort study, which included patients with heterozygous FH aged 18-65 years, without a prior history of CVD, and carrying a pathogenic or likely pathogenic variant in the LDLR gene. A total of 2131 patients (20 535person-years of follow-up) were included in the study, including 1234 subjects carrying a defective mutation in the LDLR and 897 subjects carrying a null mutation. During the follow-up, a first MACE occurred in 79 cases (6%) in the defective group and in 111 cases (12%) in the null group. The mean baseline LDL-C concentration was 17% higher in the null group than in the defective group (7.90 vs. 6.73 mmoL/L, P < 0.0001). In a Cox regression model corrected for traditional cardiovascular risk factors, the presence of a null mutation was associated with a hazard ratio of 2.09 (1.44-3.05), P = 0.0001. CONCLUSION Carriers of a null mutation have an independent ∼2-fold increased risk of incident MACE compared with patients carrying a defective mutation. This study highlights the importance of genetic screening in FH in order to improve patient care.
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Affiliation(s)
- Martine Paquette
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, 110 avenue des Pins Ouest, Montreal, QC H2W 1R7, Canada
| | - Alain Carrié
- Department of Biochemistry, Obesity and Dyslipidemia Genetics Unit, Hôpital de La Pitié-Salpêtrière, Sorbonne University, Inserm, Institute of Cardiometabolism and Nutrition (ICAN), UMR_S1166, APHP, ICAN, 47-83 boulevard de l'hôpital, 75013 Paris, France
| | - Sophie Bernard
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, 110 avenue des Pins Ouest, Montreal, QC H2W 1R7, Canada
- Department of Medicine, Division of Endocrinology, Université de Montreal, Pavillon Roger-Gaudry, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4, Canada
| | - Bertrand Cariou
- Nantes Université, CHU Nantes, CNRS, Inserm, l'institut du thorax, 8 Quai Moncousu, F-44000 Nantes, France
| | - Robert A Hegele
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON N6A 5C1, Canada
- Robarts Research Institute, Western University, 100 Perth Dr, London, ON N6A 5K8, Canada
| | - Jacques Genest
- Research Institute of the McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Mark Trinder
- Department of Medicine, Faculty of Medicine, University of British Columbia, Centre for Heart and Lung Innovation, University of British Columbia, 1081 Burrard St Room 166, Vancouver, BC V6Z 1Y6, Canada
| | - Liam R Brunham
- Department of Medicine, Faculty of Medicine, University of British Columbia, Centre for Heart and Lung Innovation, University of British Columbia, 1081 Burrard St Room 166, Vancouver, BC V6Z 1Y6, Canada
| | - Sophie Béliard
- Department of Nutrition, Metabolic Diseases, Endocrinology, Aix Marseille University, INSERM, INRAE, C2VN, La Conception Hospital, 27 Bd Jean Moulin, 13005 Marseille, France
| | - Alexis Baass
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, 110 avenue des Pins Ouest, Montreal, QC H2W 1R7, Canada
- Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, 3605 Rue de la Montagne, Montreal, QC H3G 2M1, Canada
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19
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New Trends and Therapies for Familial Hypercholesterolemia. J Clin Med 2022; 11:jcm11226638. [PMID: 36431115 PMCID: PMC9696955 DOI: 10.3390/jcm11226638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/26/2022] [Accepted: 11/05/2022] [Indexed: 11/12/2022] Open
Abstract
Familial hypercholesterolemia (FH) is associated with an elevated risk of atherosclerosis. The finding of monogenic defects indicates higher atherosclerotic risk in comparison with hypercholesterolemia of other etiologies. However, in heterozygous FH, cardiovascular risk is heterogeneous and depends not only on high cholesterol levels but also on the presence of other biomarkers and genes. The development of atherosclerosis risk scores specific for heterozygous FH and the use of subclinical coronary atherosclerosis imaging help with identifying higher-risk individuals who may benefit from further cholesterol lowering with PCSK9 inhibitors. There is no question about the extreme high risk in homozygous FH, and intensive LDL-cholesterol-lowering therapy must be started as soon as possible. These patients have gained life free of events in comparison with the past, but a high atherosclerosis residual risk persists. Furthermore, there is also the issue of aortic and supra-aortic valve disease development. Newer therapies such as inhibitors of microsomal transfer protein and angiopoietin-like protein 3 have opened the possibility of LDL-cholesterol normalization in homozygous FH and may provide an alternative to lipoprotein apheresis for these patients. Gene-based therapies may provide more definite solutions for lowering high LDL cholesterol and consequent atherosclerosis risk for people with FH.
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20
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Monogenic Versus Polygenic Forms of Hypercholesterolemia and Cardiovascular Risk: Are There Any Differences? Curr Atheroscler Rep 2022; 24:419-426. [PMID: 35386091 DOI: 10.1007/s11883-022-01018-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Common DNA variants with small effects work together to create susceptibility to polygenic hypercholesterolemia. Some clinicians wonder whether patients with polygenic hypercholesterolemia have less severe clinical features compared to patients with monogenic familial hypercholesterolemia (FH) caused by rare deleterious variants. RECENT FINDINGS Studies performed in cohorts of patients with both monogenic and polygenic hypercholesterolemia have assessed lipid levels, non-invasive markers of atherosclerosis, and clinical end points, including major adverse cardiovascular events. The totality of data suggests a gradient across genotypes. Specifically, individuals with polygenic hypercholesterolemia have deleterious phenotypes that are intermediate in severity between those in patients with monogenic hypercholesterolemia and in control subjects. Although clinical variables in patients with polygenic hypercholesterolemia are less severe than in those with monogenic hypercholesterolemia, cardiovascular risk is still very high in these patients compared to controls. Patients with polygenic hypercholesterolemia must be treated assertively.
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21
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Brunham LR, Trinder M. Polygenic risk scores for the diagnosis and management of dyslipidemia. Curr Opin Endocrinol Diabetes Obes 2022; 29:95-100. [PMID: 35034034 DOI: 10.1097/med.0000000000000708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review current progress in the use of polygenic risk scores for lipid traits and their use in the diagnosis and treatment of lipid disorders. RECENT FINDINGS Inherited lipid disorders, including those causing extremes of low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, or triglycerides were initially identified as monogenic traits, in which a single rare variant with large effect size is responsible for the phenotype. More recently, a polygenic basis for many lipid traits has also been identified. Patients with polygenic dyslipidemia can be identified through the use of polygenic risk scores (PRSs), which collapse information from a handful to several million genetic variants into a single metric. SUMMARY PRSs for lipid traits may aid in the identification of the genetic basis for the lipid phenotype in individual patients, may provide additional information regarding the risk of cardiovascular disease, and could help in guiding therapeutic decision making.
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Affiliation(s)
- Liam R Brunham
- Centre for Heart Lung Innovation
- Department of Medicine
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
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22
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Mszar R, Webb GB, Kulkarni VT, Ahmad Z, Soffer D. Genetic Lipid Disorders Associated with Atherosclerotic Cardiovascular Disease: Molecular Basis to Clinical Diagnosis and Epidemiologic Burden. Med Clin North Am 2022; 106:325-348. [PMID: 35227434 DOI: 10.1016/j.mcna.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Genetic lipid disorders, ranging from common dyslipidemias such as familial hypercholesterolemia, lipoprotein (a), and familial combined hyperlipidemia to rare disorders including familial chylomicronemia syndrome and inherited hypoalphalipoproteinemias (ie, Tangier and fish eye diseases), affect millions of individuals in the United States and tens of millions around the world and are often undiagnosed in the general population. Clinicians should take into consideration the potential of inherited lipid disorders or syndromes when severe derangements in lipid parameters are observed. Patients' combined genotype and phenotype should be evaluated in conjunction with a host of environmental factors impacting their risk of atherosclerotic cardiovascular disease.
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Affiliation(s)
- Reed Mszar
- Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Gayley B Webb
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vivek T Kulkarni
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Zahid Ahmad
- Division of Nutrition and Metabolic Disease, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Daniel Soffer
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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23
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Peng JJ, Saleh N, Roston TM, Kramer A, Cermakova L, Mancini GJ, Fordyce CB, Brunham LR. The design and rationale of the Advancing Cardiac Care Unit-based Rapid Assessment and Treatment of hypErcholesterolemia (ACCURATE) study. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100097. [PMID: 38560068 PMCID: PMC10978219 DOI: 10.1016/j.ahjo.2022.100097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 04/04/2024]
Abstract
Familial hypercholesterolemia (FH) is an inherited condition characterized by elevated low-density lipoprotein cholesterol (LDL-C) levels and premature atherosclerotic cardiovascular disease (ASCVD). Despite being the most common inherited cardiovascular disorder, it is still highly underdiagnosed and undertreated worldwide. We designed the Advancing Cardiac Care Unit-based Rapid Assessment and Treatment of hypErcholesterolemia (ACCURATE) study to test the hypothesis that opportunistic genetic testing for FH among patients hospitalized for acute coronary syndrome (ACS) will increase the diagnosis of FH and improve patient outcomes. ACCURATE is a non-randomized, controlled trial of patients <60 years old admitted to an acute cardiac unit with ACS and elevated LDL-C levels. The first cohort will consist of a control group of patients presenting with ACS who will be treated according to usual standard-of-care. The second cohort will consist of patients presenting with ACS in whom research-based genetic testing for FH will be performed during hospitalization and the results returned to the treating physicians. The primary endpoint will be the number of patients with a new diagnosis of FH. The secondary endpoints will be the proportion of patients who undergo intensification of lipid-lowering therapy, the lowest LDL-C level achieved, and the proportion of patients reaching guideline recommended lipid targets in the 12 months after the index ACS. To our knowledge, ACCURATE represents the first clinical trial of genetic testing for FH in the acute cardiac care setting and is expected to help identify optimal approaches to increase the diagnosis and treatment of FH.
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Affiliation(s)
- Junran J. Peng
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Navid Saleh
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas M. Roston
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Adam Kramer
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lubomira Cermakova
- Healthy Heart Program Prevention Clinic, St. Paul's Hospital, Vancouver, Canada
| | - G.B. John Mancini
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christopher B. Fordyce
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation & Outcomes Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Liam R. Brunham
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
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24
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Polygenic risk scores for cardiovascular disease prediction in the clinical practice: Are we there? Atherosclerosis 2021; 340:46-47. [PMID: 34895918 DOI: 10.1016/j.atherosclerosis.2021.11.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 12/12/2022]
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25
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Abstract
PURPOSE OF REVIEW The present review summarizes different polygenic risk scores associated with hypercholesterolemia applied to cohorts with a genetic diagnosis of familial hypercholesterolemia (FH). RECENT FINDINGS Several single-nucleotide polymorphisms associated with increased levels of LDL-C or Lp(a) have been genotyped in population cohorts with FH phenotype, to identify the cause of hypercholesterolemia in mutation negative individuals. In different studies, a large proportion of individuals without a monogenic causative variant (in low density lipoprotein receptor gene (LDLR), apolipoprotein B gene (APOB) or proprotein convertase subtilisin/kexin type 9 gene (PCSK9 genes) was considered to have a hypercholesterolemia with a polygenic basis. The heterogeneity in the phenotype of monogenic FH may also be explained by polygenic contributions to LDL-C. The elevated LDL-C genetic risk score (GRS) has been associated with increased risk of atherosclerotic cardiovascular disease in individuals with monogenic FH. Moreover, a poorer response to lipid lowering therapy has been associated with monogenic FH when compared to a polygenic basis. The reason why Lp(a) concentrations are raised in individuals with clinical FH is unclear, but it could be caused by a genetic variation in Lipoprotein(A) gene as a polygenic contribution. SUMMARY Polygenic risk scores have revealed to be important tools to define the cause of hypercholesterolemia in FH mutation-negative individuals and should be included in FH diagnosis strategies, although there is still space for more specific LDL-C GRS to be developed. The use of GRS may be used to refine cardiovascular risk prediction in FH patients and could lead to a personalized approach to therapy. The identification of the genetic status of an individual with FH phenotype (monogenic or polygenic) may have implications on their risk stratification, cascade screening of relatives, disease management and therapeutic measures.
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Affiliation(s)
- Ana Margarida Medeiros
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge
- BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Mafalda Bourbon
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge
- BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
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26
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Futema M, Taylor-Beadling A, Williams M, Humphries SE. Genetic testing for familial hypercholesterolemia-past, present, and future. J Lipid Res 2021; 62:100139. [PMID: 34666015 PMCID: PMC8572866 DOI: 10.1016/j.jlr.2021.100139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 01/01/2023] Open
Abstract
In the early 1980s, the Nobel Prize winning cellular and molecular work of Mike Brown and Joe Goldstein led to the identification of the LDL receptor gene as the first gene where mutations cause the familial hypercholesterolemia (FH) phenotype. We now know that autosomal dominant monogenic FH can be caused by pathogenic variants of three additional genes (APOB/PCSK9/APOE) and that the plasma LDL-C concentration and risk of premature coronary heart disease differs according to the specific locus and associated molecular cause. It is now possible to use next-generation sequencing to sequence all exons of all four genes, processing 96 patient samples in one sequencing run, increasing the speed of test results, and reducing costs. This has resulted in the identification of not only many novel FH-causing variants but also some variants of unknown significance, which require further evidence to classify as pathogenic or benign. The identification of the FH-causing variant in an index case can be used as an unambiguous and rapid test for other family members. An FH-causing variant can be found in 20-40% of patients with the FH phenotype, and we now appreciate that in the majority of patients without a monogenic cause, a polygenic etiology for their phenotype is highly likely. Compared with those with a monogenic cause, these patients have significantly lower risk of future coronary heart disease. The use of these molecular genetic diagnostic methods in the characterization of FH is a prime example of the utility of precision or personalized medicine.
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Affiliation(s)
- Marta Futema
- Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London, United Kingdom; Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Alison Taylor-Beadling
- Regional Molecular Genetics Laboratory, Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - Steve E Humphries
- Institute of Cardiovascular Science, University College London, London, United Kingdom.
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27
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Awan ZA, Rashidi OM, Al-Shehri BA, Jamil K, Elango R, Al-Aama JY, Hegele RA, Banaganapalli B, Shaik NA. Saudi Familial Hypercholesterolemia Patients With Rare LDLR Stop Gain Variant Showed Variable Clinical Phenotype and Resistance to Multiple Drug Regimen. Front Med (Lausanne) 2021; 8:694668. [PMID: 34249980 PMCID: PMC8267156 DOI: 10.3389/fmed.2021.694668] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022] Open
Abstract
Familial hypercholesterolemia (FH), a well-known lipid disease caused by inherited genetic defects in cholesterol uptake and metabolism is underdiagnosed in many countries including Saudi Arabia. The present study aims to identify the molecular basis of severe clinical manifestations of FH patients from unrelated Saudi consanguineous families. Two Saudi families with multiple FH patients fulfilling the combined FH diagnostic criteria of Simon Broome Register, and the Dutch Lipid Clinic Network (DLCN) were recruited. LipidSeq, a targeted resequencing panel for monogenic dyslipidemias, was used to identify causative pathogenic mutation in these two families and in 92 unrelated FH cases. Twelve FH patients from two unrelated families were sharing a very rare, pathogenic and founder LDLR stop gain mutation i.e., c.2027delG (p.Gly676Alafs*33) in both the homozygous or heterozygous states, but not in unrelated patients. Based on the variant zygosity, a marked phenotypic heterogeneity in terms of LDL-C levels, clinical presentations and resistance to anti-lipid treatment regimen (ACE inhibitors, β-blockers, ezetimibe, statins) of the FH patients was observed. This loss-of-function mutation is predicted to alter the free energy dynamics of the transcribed RNA, leading to its instability. Protein structural mapping has predicted that this non-sense mutation eliminates key functional domains in LDLR, which are essential for the receptor recycling and LDL particle binding. In conclusion, by combining genetics and structural bioinformatics approaches, this study identified and characterized a very rare FH causative LDLR pathogenic variant determining both clinical presentation and resistance to anti-lipid drug treatment.
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Affiliation(s)
- Zuhier Ahmed Awan
- Department of Clinical Biochemistry, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Genetics, Al Borg Medical Laboratories, Jeddah, Saudi Arabia
| | - Omran M Rashidi
- Department of Clinical Biochemistry, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bandar Ali Al-Shehri
- Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Kaiser Jamil
- Department of Genetics, Bhagwan Mahavir Medical Research Center (BMMRC), Hyderabad, India
| | - Ramu Elango
- Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jumana Y Al-Aama
- Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Robert A Hegele
- Departments of Medicine and Biochemistry, Schulich School of Medicine and Dentistry, Robarts Research Institute, Western University, London, ON, Canada
| | - Babajan Banaganapalli
- Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Noor A Shaik
- Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
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28
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Paquette M, Fantino M, Bernard S, Baass A. Paternal inheritance predicts earlier cardiovascular event onset in patients with familial hypercholesterolemia. Atherosclerosis 2021; 329:9-13. [PMID: 34157652 DOI: 10.1016/j.atherosclerosis.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 05/20/2021] [Accepted: 06/08/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is a genetic disease, with an autosomal codominant inheritance, predisposing to premature atherosclerotic cardiovascular disease (ASCVD). Paternal or maternal inheritance of the FH-causing mutation may affect the FH phenotype in offspring, but the effect of the genetic transmission on cardiovascular disease risk remains to be established. The aim of the present study is to compare the incidence of cardiovascular events between patients with maternal vs paternal inheritance of familial hypercholesterolemia. METHODS We prospectively studied 725 genetically-confirmed FH patients (33,805 person-years), including 268 with maternal inheritance and 321 with paternal inheritance of the mutation. ASCVD was defined as angina, myocardial infarction, coronary angioplasty, coronary bypass surgery, claudication, peripheral angioplasty, peripheral arterial surgery, transient ischemic attack, stroke, carotid endarterectomy and CV death. Cox-proportional hazard models and Kaplan-Meier analysis were used to compare the two groups. RESULTS Before 50 years of age, paternal inheritance of FH was associated with a 1.5-fold increased risk for ASCVD, as compared to maternal inheritance (HR 1.59, 95% CI 1.11-2.28, p = 0.01). This association remained significant after adjusting for confounding factors (HR 1.49, 95% CI 1.00-2.23, p = 0.05). The age of first ASCVD event was also significantly lower in the paternal inheritance group (42 years) than in the maternal inheritance group (46 years), p = 0.02. CONCLUSIONS This study suggests that paternal inheritance of the FH-causing mutation was associated with an earlier cardiovascular event onset compared to maternal inheritance. The mechanisms behind these findings remain to be established.
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Affiliation(s)
- Martine Paquette
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Québec, Canada.
| | - Manon Fantino
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Québec, Canada
| | - Sophie Bernard
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Québec, Canada; Department of Medicine, Division of Endocrinology, Université de Montreal, Québec, Canada
| | - Alexis Baass
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Québec, Canada; Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, Québec, Canada.
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29
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Abstract
PURPOSE OF REVIEW Current methods to assess genetic risk of familial hypercholesterolemia and coronary artery disease (CAD) focus on testing monogenic mutations in well known genes. Here we review recent developments in polygenic risk scores (PRSs) for LDL cholesterol and for CAD, and how they may add to current risk prediction algorithms. RECENT FINDINGS PRSs can identify 10-20 times as many individuals at high polygenic risk compared with monogenic mutations, and PRSs can modulate the effect of a monogenic variant on risk. Current risk factor prediction tools for prevention of CAD incompletely capture polygenic susceptibility, and PRSs may identify subgroups of patients who are likely to benefit more from lipid-lowering therapy. Finally, PRSs can be quantified already at birth, long before other risk factors used to predict CAD, and before clinical manifestations of disease. SUMMARY PRSs for CAD may soon be incorporated into clinical practice. Therefore, there is an urgent need to establish both analytical and clinical reporting standards for PRSs, and for validating scores in different ethnicities. Thresholds for intervention need to be established for PRSs and integrated into established risk scores. Training programs are needed for clinical staff to learn to communicate polygenic risk in a comprehensive way to the patient.
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Affiliation(s)
- Mette Christoffersen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital
| | - Anne Tybjærg-Hansen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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30
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Polygenic risk scores for low-density lipoprotein cholesterol and familial hypercholesterolemia. J Hum Genet 2021; 66:1079-1087. [PMID: 33967275 DOI: 10.1038/s10038-021-00929-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 12/19/2022]
Abstract
Familial hypercholesterolemia (FH) is an autosomal dominant monogenic disorder characterized by elevated levels of low-density lipoprotein cholesterol (LDL-C) and an increased risk of premature coronary artery disease (CAD). Recently, it has been shown that a high polygenic risk score (PRS) could be an independent risk factor for CAD in FH patients of European ancestry. However, it is uncertain whether PRS is also useful for risk stratification of FH patients in East Asia. We recruited and genotyped clinically diagnosed FH (CDFH) patients from the Kanazawa University Mendelian Disease FH registry and controls from the Shikamachi Health Improvement Practice genome cohort in Japan. We calculated PRS from 3.6 million variants of each participant (imputed from the 1000 Genome phase 3 Asian dataset) for LDL-C (PRSLDLC) using a genome-wide association study summary statistic from the BioBank Japan Project. We assessed the association of PRSLDLC with LDL-C and CAD among and within monogenic FH, mutation negative CDFH, and controls. We tested a total of 1223 participants (376 FH patients, including 173 with monogenic FH and 203 with mutation negative CDFH, and 847 controls) for the analyses. PRSLDLC was significantly higher in mutation negative CDFH patients than in controls (p = 3.1 × 10-13). PRSLDLC was also significantly linked to LDL-C in controls (p trend = 3.6 × 10-4) but not in FH patients. Moreover, we could not detect any association between PRSLDLC and CAD in any of the groups. In conclusion, mutation negative CDFH patients demonstrated significantly higher PRSLDLC than controls. However, PRSLDLC may have little additional effect on LDL-C and CAD among FH patients.
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Trinder M, Brunham LR. Polygenic scores for dyslipidemia: the emerging genomic model of plasma lipoprotein trait inheritance. Curr Opin Lipidol 2021; 32:103-111. [PMID: 33395106 DOI: 10.1097/mol.0000000000000737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Contemporary polygenic scores, which summarize the cumulative contribution of millions of common single-nucleotide variants to a phenotypic trait, can have effects comparable to monogenic mutations. This review focuses on the emerging use of 'genome-wide' polygenic scores for plasma lipoproteins to define the etiology of clinical dyslipidemia, modify the severity of monogenic disease, and inform therapeutic options. RECENT FINDINGS Polygenic scores for low-density lipoprotein cholesterol (LDL-C), triglycerides, and high-density lipoprotein cholesterol are associated with severe hypercholesterolemia, hypertriglyceridemia, or hypoalphalipoproteinemia, respectively. These polygenic scores for LDL-C or triglycerides associate with risk of incident coronary artery disease (CAD) independent of polygenic scores designed specifically for CAD and may identify individuals that benefit most from lipid-lowering medication. Additionally, the severity of hypercholesterolemia and CAD associated with familial hypercholesterolemia-a common monogenic disorder-is modified by these polygenic factors. The current focus of polygenic scores for dyslipidemia is to design predictive polygenic scores for diverse populations and determining how these polygenic scores could be implemented and standardized for use in the clinic. SUMMARY Polygenic scores have shown early promise for the management of dyslipidemias, but several challenges need to be addressed before widespread clinical implementation to ensure that potential benefits are robust and reproducible, equitable, and cost-effective.
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Affiliation(s)
- Mark Trinder
- Centre for Heart Lung Innovation, University of British Columbia
- Experimental Medicine Program, University of British Columbia
| | - Liam R Brunham
- Centre for Heart Lung Innovation, University of British Columbia
- Experimental Medicine Program, University of British Columbia
- Department of Medicine, University of British Columbia
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
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Cupido AJ, Tromp TR, Hovingh GK. The clinical applicability of polygenic risk scores for LDL-cholesterol: considerations, current evidence and future perspectives. Curr Opin Lipidol 2021; 32:112-116. [PMID: 33560669 PMCID: PMC7984749 DOI: 10.1097/mol.0000000000000741] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The current review describes the development, clinical relevance and potential caveats of polygenic risk scores (PRS) for LDL cholesterol (LDL-C). RECENT FINDINGS In recent years, a large number of common variants have been shown to have a small effect on LDL-C levels. The aggregate effect of all of these variants on LDL-C levels can be captured in a PRS and an elevated number of LDL-C increasing common variants is considered to be a cause of high LDL-C levels in patients with familial hypercholesterolemia (FH) without a large effect, rare mutation. PRS do not only serve as a tool in diagnostics, but are also helpful in cardiovascular disease (CVD) risk prediction. Moreover, PRS modulate CVD risk even in patients without a monogenic FH. However, future larger scale PRS directly aimed at CVD risk may serve as more sensitive tools to identify individuals with severely increased CVD risk. SUMMARY LDL-C PRS help explain part of hypercholesterolemia in a proportion of dyslipidemic patients that do not have monogenic FH. Nevertheless, the CVD risk conferred by current PRS does not appear to match that of monogenic FH. LDL-C PRS are currently not widely used in clinical care.
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Affiliation(s)
- Arjen J Cupido
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
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Tomlinson B, Patil NG, Fok M, Lam CWK. Role of PCSK9 Inhibitors in Patients with Familial Hypercholesterolemia. Endocrinol Metab (Seoul) 2021; 36:279-295. [PMID: 33866776 PMCID: PMC8090480 DOI: 10.3803/enm.2021.964] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
Patients with familial hypercholesterolemia (FH) are at high or very high risk for cardiovascular disease. Those with heterozygous FH (HeFH) often do not reach low-density lipoprotein cholesterol (LDL-C) targets with statin and ezetimibe therapy, and those with homozygous FH (HoFH) usually require additional lipid-modifying therapies. Drugs that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9) offer a novel approach to reduce LDL-C. The monoclonal antibodies, alirocumab and evolocumab, given by subcutaneous injection every 2 or 4 weeks produce reductions in LDL-C of 50% to 60% in patients with HeFH, allowing many of them to achieve their LDL-C goals. Patients with HoFH show a reduced and more variable LDL-C response, which appears to depend on residual LDL receptor activity, and those with receptor-negative mutations may show no response. Inclisiran is a long-acting small interfering RNA therapeutic agent that inhibits the synthesis of PCSK9. Subcutaneous doses of 300 mg can reduce LDL-C by more than 50% for at least 6 months and the responses in HeFH and HoFH patients are similar to those achieved with monoclonal antibodies. These PCSK9 inhibitors are generally well tolerated and they provide a new opportunity for effective treatment for the majority of patients with FH.
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Affiliation(s)
- Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macau, China
| | | | - Manson Fok
- Faculty of Medicine, Macau University of Science and Technology, Macau, China
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