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Pavlatos N, Kalra DK. The Role of Lipoprotein(a) in Peripheral Artery Disease. Biomedicines 2024; 12:1229. [PMID: 38927436 PMCID: PMC11200468 DOI: 10.3390/biomedicines12061229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
Lipoprotein(a) is a low-density-lipoprotein-like particle that consists of apolipoprotein(a) bound to apolipoprotein(b). It has emerged as an established causal risk factor for atherosclerotic cardiovascular disease, stroke, and aortic valve stenosis through multifactorial pathogenic mechanisms that include inflammation, atherogenesis, and thrombosis. Despite an estimated 20% of the global population having elevated lipoprotein(a) levels, testing remains underutilized due to poor awareness and a historical lack of effective and safe therapies. Although lipoprotein(a) has a strong association with coronary artery disease and cerebrovascular disease, its relationship with peripheral artery disease is less well established. In this article, we review the epidemiology, biology, and pathogenesis of lipoprotein(a) as it relates to peripheral artery disease. We also discuss emerging treatment options to help mitigate major adverse cardiac and limb events in this population.
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Affiliation(s)
- Nicholas Pavlatos
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA;
| | - Dinesh K. Kalra
- Division of Cardiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
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2
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Kaur G, Abdelrahman K, Berman AN, Biery DW, Shiyovich A, Huck D, Garshick M, Blankstein R, Weber B. Lipoprotein(a): Emerging insights and therapeutics. Am J Prev Cardiol 2024; 18:100641. [PMID: 38646022 PMCID: PMC11033089 DOI: 10.1016/j.ajpc.2024.100641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/08/2024] [Accepted: 02/24/2024] [Indexed: 04/23/2024] Open
Abstract
The strong association between lipoprotein (a) [Lp(a)] and atherosclerotic cardiovascular disease has led to considerations of Lp(a) being a potential target for mitigating residual cardiovascular risk. While approximately 20 % of the population has an Lp(a) level greater than 50 mg/dL, there are no currently available pharmacological lipid-lowering therapies that have demonstrated substantial reduction in Lp(a). Novel therapies to lower Lp(a) include antisense oligonucleotides and small-interfering ribonucleic acid molecules and have shown promising results in phase 2 trials. Phase 3 trials are currently underway and will test the causal relationship between Lp(a) and ASCVD and whether lowering Lp(a) reduces cardiovascular outcomes. In this review, we summarize emerging insights related to Lp(a)'s role as a risk-enhancing factor for ASCVD, association with calcific aortic stenosis, effects of existing therapies on Lp(a) levels, and variations amongst patient populations. The evolving therapeutic landscape of emerging therapeutics is further discussed.
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Affiliation(s)
- Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Adam N. Berman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David W. Biery
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Albert Einstein College of Medicine, New York, NY, USA
| | - Arthur Shiyovich
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Huck
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Ron Blankstein
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brittany Weber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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3
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Koschinsky ML, Stroes ESG, Kronenberg F. Daring to dream: Targeting lipoprotein(a) as a causal and risk-enhancing factor. Pharmacol Res 2023; 194:106843. [PMID: 37406784 DOI: 10.1016/j.phrs.2023.106843] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
Lipoprotein(a) [Lp(a)], a distinct lipoprotein class, has become a major focus for cardiovascular research. This review is written in light of the recent guideline and consensus statements on Lp(a) and focuses on 1) the causal association between Lp(a) and cardiovascular outcomes, 2) the potential mechanisms by which elevated Lp(a) contributes to cardiovascular diseases, 3) the metabolic insights on the production and clearance of Lp(a) and 4) the current and future therapeutic approaches to lower Lp(a) concentrations. The concentrations of Lp(a) are under strict genetic control. There exists a continuous relationship between the Lp(a) concentrations and risk for various endpoints of atherosclerotic cardiovascular disease (ASCVD). One in five people in the Caucasian population is considered to have increased Lp(a) concentrations; the prevalence of elevated Lp(a) is even higher in black populations. This makes Lp(a) a cardiovascular risk factor of major public health relevance. Besides the association between Lp(a) and myocardial infarction, the relationship with aortic valve stenosis has become a major focus of research during the last decade. Genetic studies provided strong support for a causal association between Lp(a) and cardiovascular outcomes: carriers of genetic variants associated with lifelong increased Lp(a) concentration are significantly more frequent in patients with ASCVD. This has triggered the development of drugs that can specifically lower Lp(a) concentrations: mRNA-targeting therapies such as anti-sense oligonucleotide (ASO) therapies and short interfering RNA (siRNA) therapies have opened new avenues to lower Lp(a) concentrations more than 95%. Ongoing Phase II and III clinical trials of these compounds are discussed in this review.
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Affiliation(s)
- Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada; Department of Physiology & Pharmacology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria.
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Maloberti A, Fabbri S, Colombo V, Gualini E, Monticelli M, Daus F, Busti A, Galasso M, De Censi L, Algeri M, Merlini PA, Giannattasio C. Lipoprotein(a): Cardiovascular Disease, Aortic Stenosis and New Therapeutic Option. Int J Mol Sci 2022; 24:ijms24010170. [PMID: 36613613 PMCID: PMC9820656 DOI: 10.3390/ijms24010170] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/23/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Atherosclerosis is a chronic and progressive inflammatory process beginning early in life with late clinical manifestation. This slow pathological trend underlines the importance to early identify high-risk patients and to treat intensively risk factors to prevent the onset and/or the progression of atherosclerotic lesions. In addition to the common Cardiovascular (CV) risk factors, new markers able to increase the risk of CV disease have been identified. Among them, high levels of Lipoprotein(a)-Lp(a)-lead to very high risk of future CV diseases; this relationship has been well demonstrated in epidemiological, mendelian randomization and genome-wide association studies as well as in meta-analyses. Recently, new aspects have been identified, such as its association with aortic stenosis. Although till recent years it has been considered an unmodifiable risk factor, specific drugs have been developed with a strong efficacy in reducing the circulating levels of Lp(a) and their capacity to reduce subsequent CV events is under testing in ongoing trials. In this paper we will review all these aspects: from the synthesis, clearance and measurement of Lp(a), through the findings that examine its association with CV diseases and aortic stenosis to the new therapeutic options that will be available in the next years.
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Affiliation(s)
- Alessandro Maloberti
- Cardiology 4, Cardio Center A. De Gasperis, ASST GOM Niguarda, 20162 Milan, Italy
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
- Correspondence: ; Tel.: +39-02-644-478-55; Fax: +39-02-644-425-66
| | - Saverio Fabbri
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | - Valentina Colombo
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | - Elena Gualini
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | | | - Francesca Daus
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | - Andrea Busti
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | - Michele Galasso
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | - Lorenzo De Censi
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | - Michela Algeri
- Cardiology 4, Cardio Center A. De Gasperis, ASST GOM Niguarda, 20162 Milan, Italy
| | | | - Cristina Giannattasio
- Cardiology 4, Cardio Center A. De Gasperis, ASST GOM Niguarda, 20162 Milan, Italy
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
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Nestel P, Loh WJ, Ward NC, Watts GF. New Horizons: Revival of Lipoprotein (a) as a Risk Factor for Cardiovascular Disease. J Clin Endocrinol Metab 2022; 107:e4281-e4294. [PMID: 36108076 DOI: 10.1210/clinem/dgac541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Indexed: 02/13/2023]
Abstract
The status of lipoprotein (a) [Lp(a)] as a cardiovascular risk factor has been resurrected by advances in genetics. Mendelian randomization studies show a causal link of Lp(a) with coronary artery disease (CAD), peripheral artery disease (PAD), and calcific aortic valve stenosis (CAVS). The genetics of Lp(a) is complex and extends beyond the kringle-IV type 2, as it is also dependent on ancestry. The plasma concentration of Lp(a) is determined by the hepatic production of apolipoprotein(a) [apo(a)] component of Lp(a), supporting the use of nucleic acids that inhibit the messenger RNA (mRNA) gene transcript for apo(a). Analytical barriers to measurement of Lp(a) are being addressed using isoform independent assays and a traceable standard. The association of Lp(a) and atherosclerotic cardiovascular disease is higher for myocardial infarction than PAD and CAVS. Increased risk of type 2 diabetes mellitus associated with low Lp(a) levels is perplexing and requires further investigation. The greatest advancement in Lp(a)-lowering therapies is based on using RNA therapeutics that are now being investigated in clinical trials. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition lowers Lp(a) modestly, but whether cardiovascular benefit is independent of low-density lipoprotein lowering remains unclear. Opportunistic and selective testing for Lp(a) is supported by moderate evidence, with the case for universal screening premature. Modification of behavioral and clinical risk factors may be targeted to mitigate Lp(a)-mediated risk of cardiovascular disease. Clinical practice guidelines have been developed to address gaps in care of high Lp(a), but full implementation awaits the findings of clinical outcome trials using RNA-directed therapies currently underway.
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Affiliation(s)
- Paul Nestel
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Wann Jia Loh
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
- Department of Endocrinology, Changi General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Natalie C Ward
- School of Medicine, University of Western Australia, Perth, Australia
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
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de Boer LM, Wiegman A, Swerdlow DI, Kastelein JJP, Hutten BA. Pharmacotherapy for children with elevated levels of lipoprotein(a): future directions. Expert Opin Pharmacother 2022; 23:1601-1615. [PMID: 36047306 DOI: 10.1080/14656566.2022.2118522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Elevated lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD). With the advent of the antisense oligonucleotides (ASOs) and small interfering RNAs (siRNAs) targeted at LPA, the gene encoding apolipoprotein(a), that are highly effective for lowering Lp(a) levels, this risk factor might be managed in the near future. Given that Lp(a) levels are mostly genetically determined and once elevated, present from early age, we have evaluated future directions for the treatment of children with high Lp(a) levels. AREAS COVERED In the current review, we discuss different pharmacological treatments in clinical development and provide an in-depth overview of the effects of ASOs and siRNAs targeted at LPA. EXPERT OPINION Since high Lp(a) is an important risk factor for ASCVD and given the promising effects of both ASOs and siRNAs targeted at apo(a), there is an urgent need for well-designed prospective studies to assess the impact of elevated Lp(a) in childhood. If the Lp(a)-hypothesis is confirmed in adults, and also in children, the rationale might arise for treating children with high Lp(a) levels. However, we feel that this should be limited to children with the highest cardiovascular risk including familial hypercholesterolemia and potentially pediatric stroke.
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Affiliation(s)
- Lotte M de Boer
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Pediatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert Wiegman
- Department of Pediatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - John J P Kastelein
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Barbara A Hutten
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Patel N, Mittal N, Choubdar PA, Taub PR. Lipoprotein(a)—When to Screen and How to Treat. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00698-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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8
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Lipid Lowering Therapy: An Era Beyond Statins. Curr Probl Cardiol 2022; 47:101342. [DOI: 10.1016/j.cpcardiol.2022.101342] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 12/19/2022]
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9
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Chemello K, Chan DC, Lambert G, Watts GF. Recent advances in demystifying the metabolism of lipoprotein(a). Atherosclerosis 2022; 349:82-91. [DOI: 10.1016/j.atherosclerosis.2022.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/29/2022] [Accepted: 04/01/2022] [Indexed: 12/24/2022]
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10
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Lamina C, Ward NC. Lipoprotein (a) and diabetes mellitus. Atherosclerosis 2022; 349:63-71. [DOI: 10.1016/j.atherosclerosis.2022.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 12/24/2022]
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Tessitore E, Dobretz K, Dhayat NA, Kern I, Ponte B, Pruijm M, Ackermann D, Estoppey S, Burnier M, Martin PY, Vogt B, Vuilleumier N, Bochud M, Mach F, Ehret G. Changes of lipoprotein(a) levels with endogenous steroid hormones. Eur J Clin Invest 2022; 52:e13699. [PMID: 34695230 PMCID: PMC9286445 DOI: 10.1111/eci.13699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 10/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lipoprotein(a) [Lp(a)] is an LDL-like molecule that is likely causal for cardiovascular events and Lp(a) variability has been shown to be mostly of genetic origin. Exogenous hormones (hormone replacement therapy) seem to influence Lp(a) levels, but the impact of endogenous hormone levels on Lp(a) is still unknown. The aim of the study was to assess the effect of endogenous steroid hormone metabolites on Lp(a). METHODS Lipoprotein(a) levels were measured in 1,021 participants from the Swiss Kidney Project on Genes in Hypertension, a family-based, multicentre, population-based prospective cohort study. Endogenous levels of 28 steroid hormone precursors were measured in 24-h urine collections from 883 individuals. Of the participants with Lp(a) data, 1,011 participants had also genotypes available. RESULTS The participants had an average age of 51 years and 53% were female. Median Lp(a) levels were 62 mg/L, and the 90th percentile was 616 mg/L. The prevalence of a Lp(a) elevation ≥700 mg/L was 3.2%. Forty-three per cent of Lp(a) variability was explained respectively by: age (2%, p < .001), LDL-C (1%, p = .001), and two SNPs (39%, p value<2⋅10-16 ). Of the 28 endogenous steroid hormones assessed, androstenetriol, androsterone, 16α-OH-DHEA and estriol were nominatively associated with serum Lp(a) levels in univariable analyses and explained 0.4%-1% of Lp(a) variability, but none of them reached significance in multivariable models. CONCLUSIONS In this contemporary population-based study, the prevalence of a Lp(a) elevation ≥700 mg/L was 3.2%. The effect of endogenous steroid hormone levels of Lp(a) variability was small at best, suggesting a negligible impact on the wide range of Lp(a) variability.
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Affiliation(s)
- Elena Tessitore
- Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Kevin Dobretz
- Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Nasser Abdalla Dhayat
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ilse Kern
- Laboratory Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Belen Ponte
- Nephrology and Hypertension, Geneva University Hospitals, Geneva, Switzerland
| | - Menno Pruijm
- Nephrology, University Hospital Centre Vaudois (CHUV), Lausanne, Switzerland
| | - Daniel Ackermann
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sandrine Estoppey
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Michel Burnier
- Nephrology, University Hospital Centre Vaudois (CHUV), Lausanne, Switzerland
| | - Pierre-Yves Martin
- Nephrology and Hypertension, Geneva University Hospitals, Geneva, Switzerland
| | - Bruno Vogt
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Murielle Bochud
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - François Mach
- Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Georg Ehret
- Cardiology, Geneva University Hospitals, Geneva, Switzerland
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Ying Q, Chan DC, Barrett PHR, Watts GF. Unravelling lipoprotein metabolism with stable isotopes: tracing the flow. Metabolism 2021; 124:154887. [PMID: 34508741 DOI: 10.1016/j.metabol.2021.154887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/16/2021] [Accepted: 09/01/2021] [Indexed: 12/13/2022]
Abstract
Dysregulated lipoprotein metabolism is a major cause of atherosclerotic cardiovascular disease (ASCVD). Use of stable isotope tracers and compartmental modelling have provided deeper understanding of the mechanisms underlying lipid disorders in patients at high risk of ASCVD, including familial hypercholesterolemia (FH), elevated lipoprotein(a) [Lp(a)] and metabolic syndrome (MetS). In patients with FH, deficiency in low-density lipoprotein (LDL) receptor activity not only impairs the catabolism of LDL, but also induces hepatic overproduction and decreases catabolism of triglyceride-rich lipoproteins (TRLs). Patients with elevated Lp(a) are characterized by increased hepatic secretion of Lp(a) particles. Atherogenic dyslipidemia in MetS patients relates to a combination of overproduction of very-low density lipoprotein-apolipoprotein (apo) B-100, decreased catabolism of apoB-100-containing particles, and increased catabolism of high-density lipoprotein-apoA-I particles, as well as to impaired clearance of TRLs in the postprandial state. Kinetic studies show that weight loss, fish oils, statins and fibrates have complementary modes of action that correct atherogenic dyslipidemia. Defining the kinetic mechanisms of action of proprotein convertase subtilisin/kexin type 9 and angiopoietin-like 3 inhibitors on lipid and lipoprotein mechanism in dyslipidemic subjects will further our understanding of these therapies in decreasing the development of ASCVD. "Everything changes but change itself. Everything flows and nothing remains the same... You cannot step twice into the same river, for other waters and yet others go flowing ever on." Heraclitus (c.535- c. 475 BCE).
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Affiliation(s)
- Qidi Ying
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Dick C Chan
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - P Hugh R Barrett
- Faculty of Medicine and Health, University of New England, Armidale, Australia
| | - Gerald F Watts
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia; Lipid Disorders Clinic, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia.
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Naito R, Daida H, Masuda D, Harada-Shiba M, Arai H, Bujo H, Ishibashi S, Koga N, Oikawa S, Yamashita S. Relation of Serum Lipoprotein(a) Levels to Lipoprotein and Apolipoprotein Profiles and Atherosclerotic Diseases in Japanese Patients with Heterozygous Familial Hypercholesterolemia: Familial Hypercholesterolemia Expert Forum (FAME) Study. J Atheroscler Thromb 2021; 29:1188-1200. [PMID: 34456199 PMCID: PMC9371754 DOI: 10.5551/jat.63019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aims: Lipoprotein(a) [Lp(a)] is a plasma lipoprotein consisting of a low-density lipoprotein (LDL)–like particle with apolipoprotein (Apo)(a), attached via a disulfide bond to Apo B100. Previous studies have shown that high Lp(a) levels are associated with an increased risk of cardiovascular disease in patients with familial hypercholesterolemia (FH). To date, limited data are available as to distribution of Lp(a) in FH and associations of Lp(a) with other lipid profiles and cardiovascular disease. Our study aimed to investigate serum Lp(a) levels in relation to other lipid profiles and clinical conditions in the national largest-ever cohort of Japanese FH patients.
Methods: This study is a secondary analysis of the Familial Hypercholesterolemia Expert Forum (FAME) Study that includes a Japanese nationwide cohort of FH patients. In 399 patients under treatment for heterozygous FH who had a baseline measurement of serum Lp(a), the present study examined the distribution of Lp(a) levels and associations of Lp(a) with other lipid profiles and clinical conditions including coronary artery disease (CAD).
Results: The distribution of Lp(a) was skewed to the right with a median of 20.8 mg/dL, showing a log-normal distribution. Serum Apo B and Apo E levels were positively associated with Lp(a) levels. Age-adjusted mean of Apo B was 8.77 mg/dL higher and that of Apo E was 0.39 mg/dL higher in the highest category (40+ mg/dL) of Lp(a) than in the lowest category (<20 mg/dL). LDL-C levels did not show such an association with Lp(a) levels. A tendency towards a positive relationship between Lp(a) and prevalent CAD was observed in men.
Conclusion: Our study demonstrated a distribution pattern of Lp(a) in Japanese FH patients and positive relationships of Lp(a) with Apo B and Apo E levels.
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Affiliation(s)
- Ryo Naito
- Department of Cardiovascular Biology and Medicine, Juntendo University
| | - Hiroyuki Daida
- Department of Cardiovascular Biology and Medicine, Juntendo University
| | - Daisaku Masuda
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Mariko Harada-Shiba
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute
| | | | - Hideaki Bujo
- Department of Clinical Laboratory and Experimental Research Medicine, Toho University, Sakura Medical Center
| | - Shun Ishibashi
- Division of Endocrinology and Metabolism, Department of Medicine, Jichi Medical University
| | | | - Shinichi Oikawa
- Director of Diabetes and Lifestyle-related Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA)
| | - Shizuya Yamashita
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine.,Department of Community Medicine, Osaka University Graduate School of Medicine
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14
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Ruscica M, Sirtori CR, Corsini A, Watts GF, Sahebkar A. Lipoprotein(a): Knowns, unknowns and uncertainties. Pharmacol Res 2021; 173:105812. [PMID: 34450317 DOI: 10.1016/j.phrs.2021.105812] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 02/07/2023]
Abstract
Over the last 10 years, there have been advances on several aspects of lipoprotein(a) which are reviewed in the present article. Since the standard immunoassays for measuring lipoprotein(a) are not fully apo(a) isoform-insensitive, the application of an LC-MS/MS method for assaying molar concentrations of lipoprotein(a) has been advocated. Genome wide association, epidemiological, and clinical studies have established high lipoprotein(a) as a causal risk factor for atherosclerotic cardiovascular diseases (ASCVD). However, the relative importance of molar concentration, apo(a) isoform size or variants within the LPA gene is still controversial. Lipoprotein(a)-raising single nucleotide polymorphisms has not been shown to add on value in predicting ASCVD beyond lipoprotein(a) concentrations. Although hyperlipoproteinemia(a) represents an important confounder in the diagnosis of familial hypercholesterolemia (FH), it enhances the risk of ASCVD in these patients. Thus, identification of new cases of hyperlipoproteinemia(a) during cascade testing can increase the identification of high-risk individuals. However, it remains unclear whether FH itself increases lipoprotein(a). The ASCVD risk associated with lipoprotein(a) seems to follow a linear gradient across the distribution, regardless of racial subgroups and other risk factors. The inverse association with the risk of developing type 2 diabetes needs consideration as effective lipoprotein(a) lowering therapies are progressing towards the market. Considering that Mendelian randomization analyses have identified the degree of lipoprotein(a)-lowering that is required to achieve ASCVD benefit, the findings of the ongoing outcome trial with pelacarsen will clarify whether dramatically lowering lipoprotein(a) levels can reduce the risk of ASCVD.
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Affiliation(s)
- Massimiliano Ruscica
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Italy.
| | - Cesare R Sirtori
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia; Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Australia
| | - Amirhossein Sahebkar
- School of Medicine, University of Western Australia, Perth, Australia; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
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15
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Geisler CE, Miller KE, Ghimire S, Renquist BJ. The Role of GPR109a Signaling in Niacin Induced Effects on Fed and Fasted Hepatic Metabolism. Int J Mol Sci 2021; 22:4001. [PMID: 33924461 PMCID: PMC8069761 DOI: 10.3390/ijms22084001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/04/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Signaling through GPR109a, the putative receptor for the endogenous ligand β-OH butyrate, inhibits adipose tissue lipolysis. Niacin, an anti-atherosclerotic drug that can induce insulin resistance, activates GPR109a at nM concentrations. GPR109a is not essential for niacin to improve serum lipid profiles. To better understand the involvement of GPR109a signaling in regulating glucose and lipid metabolism, we treated GPR109a wild-type (+/+) and knockout (-/-) mice with repeated overnight injections of saline or niacin in physiological states characterized by low (ad libitum fed) or high (16 h fasted) concentrations of the endogenous ligand, β-OH butyrate. In the fed state, niacin increased expression of apolipoprotein-A1 mRNA and decreased sterol regulatory element-binding protein 1 mRNA independent of genotype, suggesting a possible GPR109a independent mechanism by which niacin increases high-density lipoprotein (HDL) production and limits transcriptional upregulation of lipogenic genes. Niacin decreased fasting serum non-esterified fatty acid concentrations in both GPR109a +/+ and -/- mice. Independent of GPR109a expression, niacin blunted fast-induced hepatic triglyceride accumulation and peroxisome proliferator-activated receptor α mRNA expression. Although unaffected by niacin treatment, fasting serum HDL concentrations were lower in GPR109a knockout mice. Surprisingly, GPR109a knockout did not affect glucose or lipid homeostasis or hepatic gene expression in either fed or fasted mice. In turn, GPR109a does not appear to be essential for the metabolic response to the fasting ketogenic state or the acute effects of niacin.
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Affiliation(s)
- Caroline E. Geisler
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ 85721, USA; (C.E.G.); (K.E.M.); (S.G.)
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kendra E. Miller
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ 85721, USA; (C.E.G.); (K.E.M.); (S.G.)
| | - Susma Ghimire
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ 85721, USA; (C.E.G.); (K.E.M.); (S.G.)
| | - Benjamin J. Renquist
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ 85721, USA; (C.E.G.); (K.E.M.); (S.G.)
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16
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Ward NC, Vickneswaran S, Watts GF. Lipoprotein (a) and diabetes mellitus: causes and consequences. Curr Opin Endocrinol Diabetes Obes 2021; 28:181-187. [PMID: 33229929 DOI: 10.1097/med.0000000000000597] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review provides an update on the role of lipoprotein (a) [Lp(a)] in diabetes, including its impact as a risk factor as well as its contribution to the development of cardiovascular disease. RECENT FINDINGS Although a specific role for Lp(a) has not yet been conclusively established, it appears to have an inverse association with risk of diabetes. Several population-based studies have demonstrated associations between low levels of Lp(a) and increased risk of type 2 diabetes, but Mendelian randomization studies do not consistently support causality. Conversely, in patients with type 2 diabetes, elevated Lp(a) levels are associated with an increased risk of cardiovascular events. SUMMARY Although Lp(a) contributes to the development of cardiovascular disease in patients with diabetes, few trials have investigated the benefits of reducing Lp(a) within this patient population. Furthermore, guidelines do not specifically address the risk associated with elevated Lp(a) levels. Despite this, Lp(a) should be measured in patients with diabetes and considered when evaluating their overall risk burden.
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Affiliation(s)
- Natalie C Ward
- School of Public Health, Curtin University
- School of Medicine, University of Western Australia
| | | | - Gerald F Watts
- School of Medicine, University of Western Australia
- Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
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17
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Tsimikas S, Moriarty PM, Stroes ES. Emerging RNA Therapeutics to Lower Blood Levels of Lp(a): JACC Focus Seminar 2/4. J Am Coll Cardiol 2021; 77:1576-1589. [PMID: 33766265 DOI: 10.1016/j.jacc.2021.01.051] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/30/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022]
Abstract
Lipoprotein(a) [Lp(a)] has risen to the level of an accepted cardiovascular disease risk factor, but final proof of causality awaits a randomized trial of Lp(a) lowering. Inhibiting apolipoprotein(a) production in the hepatocyte with ribonucleic acid therapeutics has emerged as an elegant and effective solution to reduce plasma Lp(a) levels. Phase 2 clinical trials have shown that the antisense oligonucleotide pelacarsen reduced mean Lp(a) levels by 80%, allowing 98% of subjects to reach on-treatment levels of <125 nmol/l (∼50 mg/dl). The phase 3 Lp(a)HORIZON (Assessing the Impact of Lipoprotein(a) Lowering With TQJ230 on Major Cardiovascular Events in Patients With CVD) outcomes trial is currently enrolling approximately 7,680 patients with history of myocardial infarction, ischemic stroke, and symptomatic peripheral arterial disease and controlled low-density lipoprotein cholesterol to pelacarsen versus placebo. The co-primary endpoints are major adverse cardiovascular events in subjects with Lp(a) >70 mg/dl and >90 mg/dl, in which either of the two being positive will lead to a successful trial. Additional ribonucleic acid-targeted therapies to lower Lp(a) are in preclinical and clinical development. The testing of the Lp(a) hypothesis will provide proof whether Lp(a)-mediated risk can be abolished by potent Lp(a) lowering.
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Affiliation(s)
- Sotirios Tsimikas
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California, USA.
| | - Patrick M Moriarty
- Division of Clinical Pharmacology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Erik S Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
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18
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Liu T, Yoon WS, Lee SR. Recent Updates of Lipoprotein(a) and Cardiovascular Disease. Chonnam Med J 2021; 57:36-43. [PMID: 33537217 PMCID: PMC7840349 DOI: 10.4068/cmj.2021.57.1.36] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022] Open
Abstract
In recent years, epidemiological studies, genome-wide association studies, and Mendelian randomization studies have shown a strong association between increased levels of lipoproteins and increased risks of coronary heart disease and cardiovascular disease (CVD). Although lipoprotein(a) [Lp(a)] was an independent risk factor for ASCVD, the latest international clinical guidelines do not recommend direct reduction of plasma Lp(a) concentrations. The main reason was that there is no effective clinical medicine that directly lowers plasma Lp(a) concentrations. However, recent clinical trials have shown that proprotein convertase subtilisin/kexin-type 9 inhibitors (PCSK9) and second-generation antisense oligonucleotides can effectively reduce plasma Lp(a) levels. This review will present the structure, pathogenicity, prognostic evidences, and recent advances in therapeutic drugs for Lp(a).
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Affiliation(s)
- Taili Liu
- Division of Cardiology, Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Won-Sik Yoon
- Division of Cardiology, Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Sang-Rok Lee
- Division of Cardiology, Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
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19
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Abstract
Familial hypercholesterolemia (FH) is a rare autosomal gene deficiency disease with increased low-density lipoprotein cholesterol, xanthoma, and premature coronary heart disease. Calcified aortic valve disease (CAVD) is prevalent in FH patients, resulting in adverse events and heavy health care burden. Aortic valve calcification is currently considered an active biological process, which shares several common risk factors with atherosclerosis, including aging, hypertension, dyslipidemia, and so on. Unfortunately, the pathogenesis and therapy of CAVD in FH are still controversial. There is no pharmacological intervention recommended to delay the development of CAVD in FH, and the only effective treatment for severe CAVD is aortic valve replacement. In this review, we summarize the detailed description of the pathophysiology, molecular mechanism, risk factors, and treatment of CAVD in FH patients.
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20
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Rehberger Likozar A, Zavrtanik M, Šebeštjen M. Lipoprotein(a) in atherosclerosis: from pathophysiology to clinical relevance and treatment options. Ann Med 2020; 52:162-177. [PMID: 32453609 PMCID: PMC7877976 DOI: 10.1080/07853890.2020.1775287] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Lipoprotein(a) (Lp(a)) was discovered more than 50 years ago, and a decade later, it was recognized as a risk factor for coronary artery disease. However, it has gained importance only in the past 10 years, with emergence of drugs that can effectively decrease its levels. Lp(a) is a low-density lipoprotein (LDL) with an added apolipoprotein(a) attached to the apolipoprotein B component via a disulphide bond. Circulating levels of Lp(a) are mainly genetically determined. Lp(a) has many functions, which include proatherosclerotic, prothrombotic and pro-inflammatory roles. Here, we review recent data on the role of Lp(a) in the atherosclerotic process, and treatment options for patients with cardiovascular diseases. Currently 'Proprotein convertase subtilisin/kexin type 9' (PCSK9) inhibitors that act through non-specific reduction of Lp(a) are the only drugs that have shown effectiveness in clinical trials, to provide reductions in cardiovascular morbidity and mortality. The effects of PCSK9 inhibitors are not purely through Lp(a) reduction, but also through LDL cholesterol reduction. Finally, we discuss new drugs on the horizon, and gene-based therapies that affect transcription and translation of apolipoprotein(a) mRNA. Clinical trials in patients with high Lp(a) and low LDL cholesterol might tell us whether Lp(a) lowering per se decreases cardiovascular morbidity and mortality.KEY MESSAGESLipoprotein(a) is an important risk factor in patients with cardiovascular diseases.Lipoprotein(a) has many functions, which include proatherosclerotic, prothrombotic and pro-inflammatory roles.Treatment options to lower lipoprotein(a) levels are currently scarce, but new drugs are on the horizon.
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Affiliation(s)
| | - Mark Zavrtanik
- Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Miran Šebeštjen
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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21
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Greco MF, Sirtori CR, Corsini A, Ezhov M, Sampietro T, Ruscica M. Lipoprotein(a) Lowering-From Lipoprotein Apheresis to Antisense Oligonucleotide Approach. J Clin Med 2020; 9:jcm9072103. [PMID: 32635396 PMCID: PMC7408876 DOI: 10.3390/jcm9072103] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 12/11/2022] Open
Abstract
It is well-known that elevated lipoprotein(a)—Lp(a)—levels are associated with a higher risk of cardiovascular (CV) mortality and all-cause mortality, although a standard pharmacotherapeutic approach is still undefined for patients with high CV risk dependent on hyperlipoproteinemia(a). Combined with high Lp(a) levels, familial hypercholesterolemia (FH) leads to a greater CVD risk. In suspected FH patients, the proportion of cases explained by a rise of Lp(a) levels ranges between 5% and 20%. In the absence of a specific pharmacological approach able to lower Lp(a) to the extent required to achieve CV benefits, the most effective strategy today is lipoprotein apheresis (LA). Although limited, a clear effect on Lp(a) is exerted by PCSK9 antagonists, with apparently different mechanisms when given with statins (raised catabolism) or as monotherapy (reduced production). In the era of RNA-based therapies, a new dawn is represented by the use of antisense oligonucleotides APO(a)Lrx, able to reduce Lp(a) from 35% to over 80%, with generally modest injection site reactions. The improved knowledge of Lp(a) atherogenicity and possible prevention will be of benefit for patients with residual CV risk remaining after the most effective available lipid-lowering agents.
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Affiliation(s)
- Maria Francesca Greco
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
| | - Cesare R. Sirtori
- Dyslipidemia Center, A.S.S.T. Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Alberto Corsini
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
- IRCCS Multimedica, 20099 Milan, Italy
| | - Marat Ezhov
- National Medical Research Center of Cardiology of the Ministry of Health, Moscow, Russia;
| | - Tiziana Sampietro
- U.O. Lipoapheresis and Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, 56126 Pisa, Italy;
| | - Massimiliano Ruscica
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
- Correspondence: ; Tel.: +39-0250318220
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22
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Boffa MB, Koschinsky ML. Proprotein convertase subtilisin/kexin type 9 inhibitors and lipoprotein(a)-mediated risk of atherosclerotic cardiovascular disease: more than meets the eye? Curr Opin Lipidol 2019; 30:428-437. [PMID: 31577611 DOI: 10.1097/mol.0000000000000641] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW Evidence continues to mount for elevated lipoprotein(a) [Lp(a)] as a prevalent, independent, and causal risk factor for atherosclerotic cardiovascular disease. However, the effects of existing lipid-lowering therapies on Lp(a) are comparatively modest and are not specific to Lp(a). Consequently, evidence that Lp(a)-lowering confers a cardiovascular benefit is lacking. Large-scale cardiovascular outcome trials (CVOTs) of inhibitory mAbs targeting proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) may address this issue. RECENT FINDINGS Although the ability of PCSK9i to lower Lp(a) by 15-30% is now clear, the mechanisms involved continue to be debated, with in-vitro and in-vivo studies showing effects on Lp(a) clearance (through the LDL receptor or other receptors) and Lp(a)/apolipoprotein(a) biosynthesis in hepatocytes. The FOURIER CVOT showed that patients with higher baseline levels of Lp(a) derived greater benefit from evolocumab and those with the lowest combined achieved Lp(a) and LDL-cholesterol (LDL-C) had the lowest event rate. Meta-analysis of ten phase 3 trials of alirocumab came to qualitatively similar conclusions concerning achieved Lp(a) levels, although an effect independent of LDL-C lowering could not be demonstrated. SUMMARY Although it is not possible to conclude that PCSK9i specifically lower Lp(a)-attributable risk, patients with elevated Lp(a) could derive incremental benefit from PCSK9i therapy.
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Affiliation(s)
| | - Marlys L Koschinsky
- Department of Physiology & Pharmacology
- Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
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23
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Ward NC, Kostner KM, Sullivan DR, Nestel P, Watts GF. Molecular, Population, and Clinical Aspects of Lipoprotein(a): A Bridge Too Far? J Clin Med 2019; 8:E2073. [PMID: 31783529 PMCID: PMC6947201 DOI: 10.3390/jcm8122073] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/16/2022] Open
Abstract
There is now significant evidence to support an independent causal role for lipoprotein(a) (Lp(a)) as a risk factor for atherosclerotic cardiovascular disease. Plasma Lp(a) concentrations are predominantly determined by genetic factors. However, research into Lp(a) has been hampered by incomplete understanding of its metabolism and proatherogeneic properties and by a lack of suitable animal models. Furthermore, a lack of standardized assays to measure Lp(a) and no universal consensus on optimal plasma levels remain significant obstacles. In addition, there are currently no approved specific therapies that target and lower elevated plasma Lp(a), although there are recent but limited clinical outcome data suggesting benefits of such reduction. Despite this, international guidelines now recognize elevated Lp(a) as a risk enhancing factor for risk reclassification. This review summarises the current literature on Lp(a), including its discovery and recognition as an atherosclerotic cardiovascular disease risk factor, attempts to standardise analytical measurement, interpopulation studies, and emerging therapies for lowering elevated Lp(a) levels.
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Affiliation(s)
- Natalie C. Ward
- School of Public Health, Curtin University, Perth 6102, Australia;
- School of Medicine, University of Western Australia, Perth 6009, Australia
| | - Karam M. Kostner
- Department of Cardiology, Mater Hospital, Brisbane 4104, Australia;
- School of Medicine University of Queensland, Brisbane 4072, Australia
| | - David R. Sullivan
- Medical School, The University of Sydney, Sydney 2006, Australia;
- Charles Perkins Centre, The University of Sydney, Sydney 2006, Australia
- Department of Biochemistry, Royal Prince Alfred Hospital, Sydney 2050, Australia
| | - Paul Nestel
- Baker Heart & Diabetes Institute, Melbourne 3004, Australia;
- Department of Cardiology, The Alfred Hospital, Melbourne 3004, Australia
| | - Gerald F. Watts
- School of Medicine, University of Western Australia, Perth 6009, Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth 6000, Australia
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Jones-O'Connor M, Natarajan P. Optimal Non-invasive Strategies to Reduce Recurrent Atherosclerotic Cardiovascular Disease Risk. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:38. [PMID: 31254118 PMCID: PMC6739861 DOI: 10.1007/s11936-019-0741-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) remains the leading cause of death worldwide, with coronary artery disease (CAD) responsible for the vast majority of these deaths. Incidence is increasing in developing countries, and prevalence is increasing globally as populations age. Once CAD is manifest, recurrent event risk remains high. RECENT FINDINGS Multiple therapeutic avenues have had significant recent developments, including diet, low-density lipoprotein cholesterol management, triglycerides, hypoglycemic agents, antiplatelet agents, and oral anticoagulants. Combined approaches involving specific, tailored lifestyle, and pharmacological interventions will provide the most effective strategy for reducing the risk of recurrent CVD events. Here, we review risk prediction and non-invasive non-pharmacologic and pharmacologic approaches to mitigate residual coronary artery disease risk.
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Affiliation(s)
- Maeve Jones-O'Connor
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Pradeep Natarajan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Program in Medical and Population Genetics, Broad Institute of Harvard & MIT, Cambridge, MA, USA.
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25
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Parish S, Hopewell JC, Hill MR, Marcovina S, Valdes-Marquez E, Haynes R, Offer A, Pedersen TR, Baigent C, Collins R, Landray M, Armitage J. Impact of Apolipoprotein(a) Isoform Size on Lipoprotein(a) Lowering in the HPS2-THRIVE Study. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 11:e001696. [PMID: 29449329 PMCID: PMC5841847 DOI: 10.1161/circgen.117.001696] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 12/01/2017] [Indexed: 12/28/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Genetic studies have shown lipoprotein(a) (Lp[a]) to be an important causal risk factor for coronary disease. Apolipoprotein(a) isoform size is the chief determinant of Lp(a) levels, but its impact on the benefits of therapies that lower Lp(a) remains unclear. Methods: HPS2-THRIVE (Heart Protection Study 2–Treatment of HDL to Reduce the Incidence of Vascular Events) is a randomized trial of niacin–laropiprant versus placebo on a background of simvastatin therapy. Plasma Lp(a) levels at baseline and 1 year post-randomization were measured in 3978 participants from the United Kingdom and China. Apolipoprotein(a) isoform size, estimated by the number of kringle IV domains, was measured by agarose gel electrophoresis and the predominantly expressed isoform identified. Results: Allocation to niacin–laropiprant reduced mean Lp(a) by 12 (SE, 1) nmol/L overall and 34 (6) nmol/L in the top quintile by baseline Lp(a) level (Lp[a] ≥128 nmol/L). The mean proportional reduction in Lp(a) with niacin–laropiprant was 31% but varied strongly with predominant apolipoprotein(a) isoform size (PTrend=4×10−29) and was only 18% in the quintile with the highest baseline Lp(a) level and low isoform size. Estimates from genetic studies suggest that these Lp(a) reductions during the short term of the trial might yield proportional reductions in coronary risk of ≈2% overall and 6% in the top quintile by Lp(a) levels. Conclusions: Proportional reductions in Lp(a) were dependent on apolipoprotein(a) isoform size. Taking this into account, the likely benefits of niacin–laropiprant on coronary risk through Lp(a) lowering are small. Novel therapies that reduce high Lp(a) levels by at least 80 nmol/L (≈40%) may be needed to produce worthwhile benefits in people at the highest risk because of Lp(a). Clinical Trial Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT00461630.
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Affiliation(s)
- Sarah Parish
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13.
| | - Jemma C Hopewell
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Michael R Hill
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Santica Marcovina
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Elsa Valdes-Marquez
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Richard Haynes
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Alison Offer
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Terje R Pedersen
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Colin Baigent
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Rory Collins
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Martin Landray
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
| | - Jane Armitage
- From the Medical Research Council Population Health Research Unit (S.P., M.R.H., R.H., C.B., J.A.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (S.P., J.C.H., M.R.H., E.V.-M., R.H., A.O., C.B., R.C., M.L., J.A.), Nuffield Department of Population Health, University of Oxford, United Kingdom; Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.); and Center for Preventive Medicine, University of Oslo, Norway (T.R.P.). A complete list of collaborators in HPS2-THRIVE (Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) is given in reference 13
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Borrelli MJ, Youssef A, Boffa MB, Koschinsky ML. New Frontiers in Lp(a)-Targeted Therapies. Trends Pharmacol Sci 2019; 40:212-225. [PMID: 30732864 DOI: 10.1016/j.tips.2019.01.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 12/13/2022]
Abstract
Interest in lipoprotein (a) [Lp(a)] has exploded over the past decade with the emergence of genetic and epidemiological studies pinpointing elevated levels of this unique lipoprotein as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valve disease (CAVD). This review summarizes the most recent discoveries regarding therapeutic approaches to lower Lp(a) and presents these findings in the context of an emerging, although far from complete, understanding of the biosynthesis and catabolism of Lp(a). Application of Lp(a)-specific lowering agents to outcome trials will be the key to opening this new frontier in the battle against CVD.
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Affiliation(s)
- Matthew J Borrelli
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Amer Youssef
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Michael B Boffa
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; Department of Biochemistry, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Marlys L Koschinsky
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada.
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Boffa MB, Koschinsky ML. Oxidized phospholipids as a unifying theory for lipoprotein(a) and cardiovascular disease. Nat Rev Cardiol 2019; 16:305-318. [DOI: 10.1038/s41569-018-0153-2] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Novel pharmacological targets for calcific aortic valve disease: Prevention and treatments. Pharmacol Res 2018; 136:74-82. [DOI: 10.1016/j.phrs.2018.08.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 12/24/2022]
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Kostner KM, Kostner GM, Wierzbicki AS. Is Lp(a) ready for prime time use in the clinic? A pros-and-cons debate. Atherosclerosis 2018; 274:16-22. [PMID: 29747086 DOI: 10.1016/j.atherosclerosis.2018.04.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/16/2018] [Accepted: 04/25/2018] [Indexed: 12/11/2022]
Abstract
Lipoprotein (a) (Lp(a)) is a cholesterol-rich lipoprotein known since 1963. In spite of extensive research on Lp(a), there are still numerous gaps in our knowledge relating to its function, biosynthesis and catabolism. One reason for this might be that apo(a), the characteristic glycoprotein of Lp(a), is expressed only in primates. Results from experiments using transgenic animals therefore may need verification in humans. Studies on Lp(a) are also handicapped by the great number of isoforms of apo(a) and the heterogeneity of apo(a)-containing fractions in plasma. Quantification of Lp(a) in the clinical laboratory for a long time has not been standardized. Starting from its discovery, reports accumulated that Lp(a) contributed to the risk of cardiovascular disease (CVD), myocardial infarction (MI) and stroke. Early reports were based on case control studies but in the last decades a great deal of prospective studies have been published that highlight the increased risk for CVD and MI in patients with elevated Lp(a). Final answers to the question of whether Lp(a) is ready for wider clinical use will come from intervention studies with novel selective Lp(a) lowering medications that are currently underway. This article expounds arguments for and against this proposition from currently available data.
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Affiliation(s)
- Karam M Kostner
- Department of Cardiology, Mater Hospital and University of Queensland, Brisbane, Australia
| | - Gert M Kostner
- Department of Molecular Biology and Biochemistry, Gottfried Schatz Research Center for Cell Signaling, Medical University of Graz, Austria
| | - Anthony S Wierzbicki
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK.
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Boffa MB, Koschinsky ML. Therapeutic Lowering of Lipoprotein(a). CIRCULATION-GENOMIC AND PRECISION MEDICINE 2018; 11:e002052. [DOI: 10.1161/circgen.118.002052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Michael B. Boffa
- From the Department of Biochemistry (M.B.B.) and Robarts Research Institute (M.L.K.), Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Marlys L. Koschinsky
- From the Department of Biochemistry (M.B.B.) and Robarts Research Institute (M.L.K.), Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
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Scipione CA, Koschinsky ML, Boffa MB. Lipoprotein(a) in clinical practice: New perspectives from basic and translational science. Crit Rev Clin Lab Sci 2017; 55:33-54. [PMID: 29262744 DOI: 10.1080/10408363.2017.1415866] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Elevated plasma concentrations of lipoprotein(a) (Lp(a)) are a causal risk factor for coronary heart disease (CHD) and calcific aortic valve stenosis (CAVS). Genetic, epidemiological and in vitro data provide strong evidence for a pathogenic role for Lp(a) in the progression of atherothrombotic disease. Despite these advancements and a race to develop new Lp(a) lowering therapies, there are still many unanswered and emerging questions about the metabolism and pathophysiology of Lp(a). New studies have drawn attention to Lp(a) as a contributor to novel pathogenic processes, yet the mechanisms underlying the contribution of Lp(a) to CVD remain enigmatic. New therapeutics show promise in lowering plasma Lp(a) levels, although the complete mechanisms of Lp(a) lowering are not fully understood. Specific agents targeted to apolipoprotein(a) (apo(a)), namely antisense oligonucleotide therapy, demonstrate potential to decrease Lp(a) to levels below the 30-50 mg/dL (75-150 nmol/L) CVD risk threshold. This therapeutic approach should aid in assessing the benefit of lowering Lp(a) in a clinical setting.
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Affiliation(s)
- Corey A Scipione
- a Department of Advanced Diagnostics , Toronto General Hospital Research Institute, UHN , Toronto , Canada
| | - Marlys L Koschinsky
- b Robarts Research Institute , Western University , London , Canada.,c Department of Physiology & Pharmacology , Schulich School of Medicine & Dentistry, Western University , London , Canada
| | - Michael B Boffa
- d Department of Biochemistry , Western University , London , Canada
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Boffa MB. Emerging Therapeutic Options for Lowering of Lipoprotein(a): Implications for Prevention of Cardiovascular Disease. Curr Atheroscler Rep 2017; 18:69. [PMID: 27761705 DOI: 10.1007/s11883-016-0622-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Elevated plasma concentrations of lipoprotein(a) (Lp(a)) are an independent and causal risk factor for cardiovascular diseases including coronary artery disease, ischemic stroke, and calcific aortic valve stenosis. This review summarizes the rationale for Lp(a) lowering and surveys relevant clinical trial data using a variety of agents capable of lowering Lp(a). RECENT FINDINGS Contemporary guidelines and recommendations outline populations of patients who should be screened for elevated Lp(a) and who might benefit from Lp(a) lowering. Therapies including drugs and apheresis have been described that lower Lp(a) levels modestly (∼20 %) to dramatically (∼80 %). Existing therapies that lower Lp(a) also have beneficial effects on other aspects of the lipid profile, with the exception of Lp(a)-specific apheresis and an antisense oligonucleotide that targets the mRNA encoding apolipoprotein(a). No clinical trials conducted to date have managed to answer the key question of whether Lp(a) lowering confers a benefit in terms of ameliorating cardiovascular risk, although additional outcome trials of therapies that lower Lp(a) are ongoing. It is more likely, however, that Lp(a)-specific agents will provide the most appropriate approach for addressing this question.
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Affiliation(s)
- Michael B Boffa
- Department of Biochemistry, Room 4245A Robarts Research Institute, University of Western Ontario, 1151 Richmond Street North, London, ON, Canada, N6A 5B7.
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Kostner KM, Kostner GM. Lipoprotein (a): a historical appraisal. J Lipid Res 2016; 58:1-14. [PMID: 27821413 DOI: 10.1194/jlr.r071571] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/01/2016] [Indexed: 11/20/2022] Open
Abstract
Initially, lipoprotein (a) [Lp(a)] was believed to be a genetic variant of lipoprotein (Lp)-B. Because its lipid moiety is almost identical to LDL, Lp(a) has been deliberately considered to be highly atherogenic. Lp(a) was detected in 1963 by Kare Berg, and individuals who were positive for this factor were called Lpa+ Lpa+ individuals were found more frequently in patients with coronary heart disease than in controls. After the introduction of quantitative methods for monitoring of Lp(a), it became apparent that Lp(a), in fact, is present in all individuals, yet to a greatly variable extent. The genetics of Lp(a) had been a mystery for a long time until Gerd Utermann discovered that apo(a) is expressed by a variety of alleles, giving rise to a unique size heterogeneity. This size heterogeneity, as well as countless mutations, is responsible for the great variability in plasma Lp(a) concentrations. Initially, we proposed to evaluate the risk of myocardial infarction at a cut-off for Lp(a) of 30-50 mg/dl, a value that still is adopted in numerous epidemiological studies. Due to new therapies that lower Lp(a) levels, there is renewed interest and still rising research activity in Lp(a). Despite all these activities, numerous gaps exist in our knowledge, especially as far as the function and metabolism of this fascinating Lp are concerned.
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Affiliation(s)
- Karam M Kostner
- Department of Cardiology, Mater Hospital and University of Queensland, Brisbane, 4101 Queensland, Australia
| | - Gert M Kostner
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, A-8010 Graz, Austria
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Effect of therapeutic interventions on oxidized phospholipids on apolipoprotein B100 and lipoprotein(a). J Clin Lipidol 2016; 10:594-603. [DOI: 10.1016/j.jacl.2016.01.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/31/2015] [Accepted: 01/26/2016] [Indexed: 11/20/2022]
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Tsimikas S. Lipoprotein(a): novel target and emergence of novel therapies to lower cardiovascular disease risk. Curr Opin Endocrinol Diabetes Obes 2016; 23:157-64. [PMID: 26825471 PMCID: PMC5061509 DOI: 10.1097/med.0000000000000237] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This article summarizes recent observations on the role of lipoprotein(a) [Lp(a)] as a risk factor mediating cardiovascular disease. RECENT FINDINGS Lp(a) is a highly prevalent cardiovascular risk factor, with levels above 30 mg/dl affecting 20-30% of the global population. Up until now, no specific therapies have been developed to lower Lp(a) levels. Three major levels of evidence support the notion that elevated Lp(a) levels are a causal, independent, genetic risk factor for cardiovascular disease: epidemiologic studies and meta-analyses, genome-wide association studies and Mendelian randomization studies. Recent studies also have noted that individuals with low levels of Lp(a) are associated with a higher risk of incident type 2 diabetes mellitus, and conversely individuals with high levels have a lower risk, but this association does not appear to be causal. Novel therapies to lower Lp(a) include PCSK9 inhibitors and antisense oligonucleotides directly preventing translation of apolipoprotein(a) mRNA. SUMMARY With this robust and expanding clinical database, a reawakening of interest in Lp(a) as clinical risk factor is taking place. Trials are underway with novel drugs that substantially lower Lp(a) and may reduce its contribution to cardiovascular disease.
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Affiliation(s)
- Sotirios Tsimikas
- Vascular Medicine Program, Sulpizio Cardiovascular Center, University of California San Diego School of Medicine, La Jolla, California, USA
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36
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van Capelleveen JC, van der Valk FM, Stroes ESG. Current therapies for lowering lipoprotein (a). J Lipid Res 2015; 57:1612-8. [PMID: 26637277 DOI: 10.1194/jlr.r053066] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Indexed: 01/21/2023] Open
Abstract
Lipoprotein (a) [Lp(a)] is a human plasma lipoprotein with unique structural and functional characteristics. Lp(a) is an assembly of two components: a central core with apoB and an additional glycoprotein, called apo(a). Ever since the strong association between elevated levels of Lp(a) and an increased risk for CVD was recognized, interest in the therapeutic modulation of Lp(a) levels has increased. Here, the past and present therapies aiming to lower Lp(a) levels will be reviewed, demonstrating that these agents have had varying degrees of success. The next challenge will be to prove that Lp(a) lowering also leads to cardiovascular benefit in patients with elevated Lp(a) levels. Therefore, highly specific and potent Lp(a)-lowering strategies are awaited urgently.
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Affiliation(s)
| | - Fleur M van der Valk
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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Ooi EM, Watts GF, Chan DC, Pang J, Tenneti VS, Hamilton SJ, McCormick SP, Marcovina SM, Barrett PHR. Effects of extended-release niacin on the postprandial metabolism of Lp(a) and ApoB-100-containing lipoproteins in statin-treated men with type 2 diabetes mellitus. Arterioscler Thromb Vasc Biol 2015; 35:2686-93. [PMID: 26515419 DOI: 10.1161/atvbaha.115.306136] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 10/20/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The effects of extended-release niacin (ERN; 1-2 g/d) on the metabolism of lipoprotein(a) (Lp(a)) and apolipoprotein (apo) B-100-containing lipoproteins were investigated in 11 statin-treated white men with type 2 diabetes mellitus in a randomized, crossover trial of 12-weeks duration. APPROACH AND RESULTS The kinetics of Lp(a) and very low-density lipoprotein (VLDL), intermediate-density lipoprotein, and low-density lipoprotein (LDL) apoB-100 were determined following a standardized oral fat load (87% fat) using intravenous administration of D3-leucine, gas chromatography-mass spectrometry, and compartmental modeling. ERN significantly decreased fasting plasma total cholesterol, LDL cholesterol, and triglyceride concentrations. These effects were achieved without significant changes in body weight or insulin resistance. ERN significantly decreased plasma Lp(a) concentration (-26.5%) and the production rates of apo(a) (-41.5%) and Lp(a)-apoB-100 (-32.1%); the effect was greater in individuals with elevated Lp(a) concentration. ERN significantly decreased VLDL (-58.7%), intermediate-density lipoprotein (-33.6%), and LDL (-18.3%) apoB-100 concentrations and the corresponding production rates (VLDL, -49.8%; intermediate-density lipoprotein, -44.7%; LDL, -46.1%). The number of VLDL apoB-100 particles secreted increased in response to the oral fat load. Despite this, total VLDL apoB-100 production over the 10-hour postprandial period was significantly decreased with ERN (-21.9%). CONCLUSIONS In statin-treated men with type 2 diabetes mellitus, ERN decreased plasma Lp(a) concentrations by decreasing the production of apo(a) and Lp(a)-apoB-100. ERN also decreased the concentrations of apoB-100-containing lipoproteins by decreasing VLDL production and the transport of these particles down the VLDL to LDL cascade. Our study provides further mechanistic insights into the lipid-regulating effects of ERN.
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Affiliation(s)
- Esther M Ooi
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.)
| | - Gerald F Watts
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.)
| | - Dick C Chan
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.)
| | - Jing Pang
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.)
| | - Vijay S Tenneti
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.)
| | - Sandra J Hamilton
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.)
| | - Sally P McCormick
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.)
| | - Santica M Marcovina
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.)
| | - P Hugh R Barrett
- From the Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (E.M.O., G.F.W., D.C.C., J.P., V.S.T., P.H.R.B.); Lipid Disorders Clinic, Cardiometabolic Service, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia (G.F.W.); Western Australian Centre for Rural Health, University of Western Australia, Geraldton, Australia (S.J.H.); Department of Biochemistry, University of Otago, Dunedin, New Zealand (S.P.M.); Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle (S.M.M.); and Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, Australia (P.H.R.B.).
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Croyal M, Ouguerram K, Passard M, Ferchaud-Roucher V, Chétiveaux M, Billon-Crossouard S, de Gouville AC, Lambert G, Krempf M, Nobécourt E. Effects of Extended-Release Nicotinic Acid on Apolipoprotein (a) Kinetics in Hypertriglyceridemic Patients. Arterioscler Thromb Vasc Biol 2015; 35:2042-7. [PMID: 26160958 DOI: 10.1161/atvbaha.115.305835] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 06/24/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the mechanisms by which extended-release nicotinic acid reduces circulating lipoprotein (a) concentrations in hypertriglyceridemic patients. APPROACH AND RESULTS Eight nondiabetic, obese male subjects (aged 48±12 years; body mass index, 31.2±1.8 kg/m(2)) with hypertriglyceridemia (triglycerides, 226±78 mg/dL) were enrolled in an 8 week, double blind, placebo-controlled cross-over study. At the end of each treatment phase, fasted subjects received a 10 µmol/L per kg bolus injection of [5,5,5-(2)H3]-l-Leucine immediately followed by constant infusion of [5,5,5-(2)H3]-l-Leucine (10 µmol L(-1) kg(-1) h(-1)) for 14 hours, and blood samples were collected. A liquid chromatography-tandem mass spectrometry method was used to study apolipoprotein (a) (Apo(a)) kinetics. The fractional catabolic rate of Apo(a) was calculated with a single compartmental model using the apolipoprotein B100 (ApoB100) containing very low density lipoprotein tracer enrichment as a precursor pool. Extended-release nicotinic acid decreased plasma triglycerides (-46%; P=0.023), raised high-density lipoprotein cholesterol (+20%; P=0.008), and decreased Apo(a) plasma concentrations (-20%; P=0.008). Extended-release nicotinic acid also decreased ApoB100 (22%; P=0.008) and proprotein convertase subtilisin/kexin type 9 (PCSK9, -29%; P=0.008) plasma concentrations. Apo(a) fractional catabolic rate and production rates were decreased by 37% (0.58±0.28 versus 0.36±0.19 pool/d; P=0.008) and 50% (1.4±0.8 versus 0.7±0.4 nmol/kg per day; P=0.008), respectively. CONCLUSIONS Extended-release nicotinic acid treatment decreased Apo(a) plasma concentrations by 20%, production rates by 50%, and catabolism by 37%. ApoB100 and PCSK9 concentrations were also decreased by treatment, but no correlation was found with Apo(a) kinetic parameters.
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Affiliation(s)
- Mikaël Croyal
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
| | - Khadija Ouguerram
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
| | - Maxime Passard
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
| | - Véronique Ferchaud-Roucher
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
| | - Maud Chétiveaux
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
| | - Stéphanie Billon-Crossouard
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
| | - Anne-Charlotte de Gouville
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
| | - Gilles Lambert
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
| | - Michel Krempf
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.).
| | - Estelle Nobécourt
- From the CRNH, West Human Nutrition Research Center, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K., E.N.); UMR 1280 PhAN Laboratory, National Institute of Agronomic Research, INRA, CHU Hôtel Dieu, HNB1, Nantes, France (M.C., K.O., M.P., V.F.-R., S.B.-C., G.L., M.K.); University of Nantes and Medical School, Nantes, France (M.C., K.O., M.P., M.C., S.B.-C., G.L., M.K., E.N.); GlaxoSmithKline, Les Ulis, France (A.-C.d.G.); and Endocrinology and Nutrition Department, G and R Laennec Hospital, Bd Jacques Monod, Nantes, France (M.K., E.N.)
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Cooper DL, Murrell DE, Roane DS, Harirforoosh S. Effects of formulation design on niacin therapeutics: mechanism of action, metabolism, and drug delivery. Int J Pharm 2015; 490:55-64. [PMID: 25987211 DOI: 10.1016/j.ijpharm.2015.05.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 05/10/2015] [Accepted: 05/11/2015] [Indexed: 12/27/2022]
Abstract
Niacin is a highly effective, lipid regulating drug associated with a number of metabolically induced side effects such as prostaglandin (PG) mediated flushing and hepatic toxicity. In an attempt to reduce the development of these adverse effects, scientists have investigated differing methods of niacin delivery designed to control drug release and alter metabolism. However, despite successful formulation of various orally based capsule and tablet delivery systems, patient adherence to niacin therapy is still compromised by adverse events such as PG-induced flushing. While the primary advantage of orally dosed formulations is ease of use, alternative delivery options such as transdermal delivery or polymeric micro/nanoparticle encapsulation for oral administration have shown promise in niacin reformulation. However, the effectiveness of these alternative delivery options in reducing inimical effects of niacin and maintaining drug efficacy is still largely unknown and requires more in-depth investigation. In this paper, we present an overview of niacin applications, its metabolic pathways, and current drug delivery formulations. Focus is placed on oral immediate, sustained, and extended release niacin delivery as well as combined statin and/or prostaglandin antagonist niacin formulation. We also examine and discuss current findings involving transdermal niacin formulations and polymeric micro/nanoparticle encapsulated niacin delivery.
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Affiliation(s)
- Dustin L Cooper
- Department of Pharmaceutical Sciences, Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, United States
| | - Derek E Murrell
- Department of Pharmaceutical Sciences, Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, United States
| | - David S Roane
- Department of Pharmaceutical Sciences, Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, United States
| | - Sam Harirforoosh
- Department of Pharmaceutical Sciences, Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, United States.
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Abstract
Niacin is an important vitamin (B3) that can be used in gram doses to positively modify pathogenetically relevant lipid disorders: elevated LDL cholesterol, elevated non-HDL cholesterol, elevated triglycerides, elevated lipoprotein(a), and reduced HDL cholesterol. This review reports the latest published findings with respect to niacin's mechanisms of action on these lipids and its anti-inflammatory and anti-atherosclerotic effects. In the pre-statin era, niacin was shown to have beneficial effects on cardiovascular end-points; but in recent years, two major studies performed in patients whose LDL cholesterol levels had been optimized by a statin therapy did not demonstrate an additional significant effect on these end-points in the groups where niacin was administered. Both studies have several drawbacks that suggest that they are not representative for other patients. Thus, niacin still plays a role either as an additive to a statin or as a substitute for a statin in statin-intolerant patients. Moreover, patients with elevated triglyceride and low HDL cholesterol levels and patients with elevated lipoprotein(a) concentrations will possibly benefit from niacin, although currently the study evidence for these indications is rather poor. Niacin may be useful for compliant patients, however possible side effects (flushing, liver damage) and contraindications should be taken into consideration.
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Affiliation(s)
- Ulrich Julius
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany. Fetscherstr. 74, 01307 Dresden (Germany).,Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany. Fetscherstr. 74, 01307 Dresden (Germany)
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Knowles JW, Xie W, Zhang Z, Chennamsetty I, Assimes TL, Paananen J, Hansson O, Pankow J, Goodarzi MO, Carcamo-Orive I, Morris AP, Chen YDI, Mäkinen VP, Ganna A, Mahajan A, Guo X, Abbasi F, Greenawalt DM, Lum P, Molony C, Lind L, Lindgren C, Raffel LJ, Tsao PS, Schadt EE, Rotter JI, Sinaiko A, Reaven G, Yang X, Hsiung CA, Groop L, Cordell HJ, Laakso M, Hao K, Ingelsson E, Frayling TM, Weedon MN, Walker M, Quertermous T. Identification and validation of N-acetyltransferase 2 as an insulin sensitivity gene. J Clin Invest 2015; 125:1739-51. [PMID: 25798622 DOI: 10.1172/jci74692] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 02/05/2015] [Indexed: 11/17/2022] Open
Abstract
Decreased insulin sensitivity, also referred to as insulin resistance (IR), is a fundamental abnormality in patients with type 2 diabetes and a risk factor for cardiovascular disease. While IR predisposition is heritable, the genetic basis remains largely unknown. The GENEticS of Insulin Sensitivity consortium conducted a genome-wide association study (GWAS) for direct measures of insulin sensitivity, such as euglycemic clamp or insulin suppression test, in 2,764 European individuals, with replication in an additional 2,860 individuals. The presence of a nonsynonymous variant of N-acetyltransferase 2 (NAT2) [rs1208 (803A>G, K268R)] was strongly associated with decreased insulin sensitivity that was independent of BMI. The rs1208 "A" allele was nominally associated with IR-related traits, including increased fasting glucose, hemoglobin A1C, total and LDL cholesterol, triglycerides, and coronary artery disease. NAT2 acetylates arylamine and hydrazine drugs and carcinogens, but predicted acetylator NAT2 phenotypes were not associated with insulin sensitivity. In a murine adipocyte cell line, silencing of NAT2 ortholog Nat1 decreased insulin-mediated glucose uptake, increased basal and isoproterenol-stimulated lipolysis, and decreased adipocyte differentiation, while Nat1 overexpression produced opposite effects. Nat1-deficient mice had elevations in fasting blood glucose, insulin, and triglycerides and decreased insulin sensitivity, as measured by glucose and insulin tolerance tests, with intermediate effects in Nat1 heterozygote mice. Our results support a role for NAT2 in insulin sensitivity.
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Boffa MB, Koschinsky ML. Update on lipoprotein(a) as a cardiovascular risk factor and mediator. Curr Atheroscler Rep 2014; 15:360. [PMID: 23990263 DOI: 10.1007/s11883-013-0360-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Recent genetic studies have put the spotlight back onto lipoprotein(a) [Lp(a)] as a causal risk factor for coronary heart disease. However, there remain significant gaps in our knowledge with respect to how the Lp(a) particle is assembled, the route of its catabolism, and the mechanism(s) of Lp(a) pathogenicity. It has long been speculated that the effects of Lp(a) in the vasculature can be attributed to both its low-density lipoprotein moiety and the unique apolipoprotein(a) component, which is strikingly similar to the kringle-containing fibrinolytic zymogen plasminogen. However, the ability of Lp(a) to modulate either purely thrombotic or purely atherothrombotic processes in vivo remains unclear. The presence of oxidized phospholipid on Lp(a) may underlie many of the proatherosclerotic effects of Lp(a) that have been identified both in cell models and in animal models, and provides a possible avenue for identifying therapeutics aimed at mitigating the effects of Lp(a) in the vasculature. However, the beneficial effects of targeted Lp(a) therapeutics, designed to either lower Lp(a) concentrations or interfere with its effects, on cardiovascular outcomes remains to be determined.
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Affiliation(s)
- Michael B Boffa
- Department of Chemistry & Biochemistry, University of Windsor, 401 Sunset Avenue, Windsor, ON, Canada.
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Vinod M, Chennamsetty I, Colin S, Belloy L, De Paoli F, Schaider H, Graier WF, Frank S, Kratky D, Staels B, Chinetti-Gbaguidi G, Kostner GM. miR-206 controls LXRα expression and promotes LXR-mediated cholesterol efflux in macrophages. Biochim Biophys Acta Mol Cell Biol Lipids 2014; 1841:827-35. [PMID: 24603323 PMCID: PMC3996726 DOI: 10.1016/j.bbalip.2014.02.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/13/2014] [Accepted: 02/24/2014] [Indexed: 01/16/2023]
Abstract
Liver X receptors (LXRα and LXRβ) are key transcription factors in cholesterol metabolism that regulate cholesterol biosynthesis/efflux and bile acid metabolism/excretion in the liver and numerous organs. In macrophages, LXR signaling modulates cholesterol handling and the inflammatory response, pathways involved in atherosclerosis. Since regulatory pathways of LXR transcription control are well understood, in the present study we aimed at identifying post-transcriptional regulators of LXR activity. MicroRNAs (miRs) are such post-transcriptional regulators of genes that in the canonical pathway mediate mRNA inactivation. In silico analysis identified miR-206 as a putative regulator of LXRα but not LXRβ. Indeed, as recently shown, we found that miR-206 represses LXRα activity and expression of LXRα and its target genes in hepatic cells. Interestingly, miR-206 regulates LXRα differently in macrophages. Stably overexpressing miR-206 in THP-1 human macrophages revealed an up-regulation and miR-206 knockdown led to a down-regulation of LXRα and its target genes. In support of these results, bone marrow-derived macrophages (BMDMs) from miR-206 KO mice also exhibited lower expression of LXRα target genes. The physiological relevance of these findings was proven by gain- and loss-of-function of miR-206; overexpression of miR-206 enhanced cholesterol efflux in human macrophages and knocking out miR-206 decreased cholesterol efflux from MPMs. Moreover, we show that miR-206 expression in macrophages is repressed by LXRα activation, while oxidized LDL and inflammatory stimuli profoundly induced miR-206 expression. We therefore propose a feed-back loop between miR-206 and LXRα that might be part of an LXR auto-regulatory mechanism to fine tune LXR activity. Functional differences of miR-206 in the liver and macrophages In the liver, miR-206 suppresses LXRα expression and signaling. In macrophages, miR-206 increases LXRα abundance and promotes cholesterol efflux. In macrophages, LXRα activation represses miR-206 expression. In macrophages, pro-inflammatory stimuli increase miR-206 expression.
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Affiliation(s)
- Manjula Vinod
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria
| | | | - Sophie Colin
- Université Lille 2, F-59000 Lille, France; Inserm, U1011, F-59000 Lille, France; Institut Pasteur de Lille, F-59019 Lille, France; European Genomic Institute for Diabetes (EGID), FR 3508, F-59000 Lille, France
| | - Loic Belloy
- Université Lille 2, F-59000 Lille, France; Inserm, U1011, F-59000 Lille, France; Institut Pasteur de Lille, F-59019 Lille, France; European Genomic Institute for Diabetes (EGID), FR 3508, F-59000 Lille, France
| | - Federica De Paoli
- Université Lille 2, F-59000 Lille, France; Inserm, U1011, F-59000 Lille, France; Institut Pasteur de Lille, F-59019 Lille, France; European Genomic Institute for Diabetes (EGID), FR 3508, F-59000 Lille, France
| | - Helmut Schaider
- Translation Research Institute, University of Queensland, Brisbane, Australia
| | - Wolfgang F Graier
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria
| | - Saša Frank
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria
| | - Dagmar Kratky
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria
| | - Bart Staels
- Université Lille 2, F-59000 Lille, France; Inserm, U1011, F-59000 Lille, France; Institut Pasteur de Lille, F-59019 Lille, France; European Genomic Institute for Diabetes (EGID), FR 3508, F-59000 Lille, France
| | - Giulia Chinetti-Gbaguidi
- Université Lille 2, F-59000 Lille, France; Inserm, U1011, F-59000 Lille, France; Institut Pasteur de Lille, F-59019 Lille, France; European Genomic Institute for Diabetes (EGID), FR 3508, F-59000 Lille, France
| | - Gerhard M Kostner
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria.
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Cenarro A, Puzo J, Ferrando J, Mateo-Gallego R, Bea AM, Calmarza P, Jarauta E, Civeira F. Effect of Nicotinic acid/Laropiprant in the lipoprotein(a) concentration with regard to baseline lipoprotein(a) concentration and LPA genotype. Metabolism 2014; 63:365-71. [PMID: 24333007 DOI: 10.1016/j.metabol.2013.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 10/30/2013] [Accepted: 10/30/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Lipoprotein(a) [Lp(a)] is a lipoprotein in which apolipoproteinB-100 is linked to apolipoprotein(a) [apo(a)]. Significant variation in Lp(a) concentration is specific to LPA gene, which codes for apo(a). Nicotinic acid (NA) is used for treatment of dyslipidemias, and the lowering effect of NA on Lp(a) has been previously reported. OBJECTIVE To evaluate the Lp(a) lowering effect of 1g/20mg and 2g/40mgday of Nicotinic acid/Laropiprant in subjects with different baseline Lp(a) concentrations and depending on the LPA genotype. METHODS In an open-label, 10-week study, 1g/20mgday of NA/Laropiprant for 4weeks followed by 6weeks of 2g/40mgday conducted at 3 centers in Spain, 82 subjects were enrolled. Patients were studied at baseline and at the end of both treatment periods and were enrolled in three groups: normal Lp(a) (<50mg/dL), high Lp(a) (50-120mg/dL) and very high Lp(a) (>120mg/dL). The LPA genetic polymorphism was analyzed by a real-time PCR. RESULTS There was a significant difference in LPA genotypes among Lp(a) concentration groups and an inverse and significant correlation between baseline Lp(a) concentration and LPA genotype was found (R=-0.372, p<0.001). There were a significant decrease in total cholesterol, triglycerides, LDL cholesterol, apo B and Lp(a), and a significant increase in HDL cholesterol after NA/Laropiprant treatment, without changes in BMI. However, there were no statistical differences in percentage variation of analyzed variables depending on LPA genotype. CONCLUSION LPA genotype is a major determinant of Lp(a) baseline concentration. However, the lipid lowering effect of NA is not related to LPA genotype.
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Affiliation(s)
- Ana Cenarro
- Lipid Unit and Laboratorio de Investigación Molecular, Hospital Universitario Miguel Servet, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - José Puzo
- Lipid Unit, Hospital San Jorge, Huesca, Spain
| | - Juan Ferrando
- Lipid Unit, Hospital Royo Villanova, Zaragoza, Spain
| | - Rocío Mateo-Gallego
- Lipid Unit and Laboratorio de Investigación Molecular, Hospital Universitario Miguel Servet, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Ana M Bea
- Lipid Unit and Laboratorio de Investigación Molecular, Hospital Universitario Miguel Servet, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Pilar Calmarza
- Biochemistry Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Estíbaliz Jarauta
- Lipid Unit and Laboratorio de Investigación Molecular, Hospital Universitario Miguel Servet, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Fernando Civeira
- Lipid Unit and Laboratorio de Investigación Molecular, Hospital Universitario Miguel Servet, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain.
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Pang J, Chan DC, Watts GF. Critical review of non-statin treatments for dyslipoproteinemia. Expert Rev Cardiovasc Ther 2014; 12:359-71. [DOI: 10.1586/14779072.2014.888312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Recently published epidemiological and genetic studies strongly suggest a causal relationship of elevated concentrations of lipoprotein (a) [Lp(a)] with cardiovascular disease (CVD), independent of low-density lipoproteins (LDLs), reduced high density lipoproteins (HDL), and other traditional CVD risk factors. The atherogenicity of Lp(a) at a molecular and cellular level is caused by interference with the fibrinolytic system, the affinity to secretory phospholipase A2, the interaction with extracellular matrix glycoproteins, and the binding to scavenger receptors on macrophages. Lipoprotein (a) plasma concentrations correlate significantly with the synthetic rate of apo(a) and recent studies demonstrate that apo(a) expression is inhibited by ligands for farnesoid X receptor. Numerous gaps in our knowledge on Lp(a) function, biosynthesis, and the site of catabolism still exist. Nevertheless, new classes of therapeutic agents that have a significant Lp(a)-lowering effect such as apoB antisense oligonucleotides, microsomal triglyceride transfer protein inhibitors, cholesterol ester transfer protein inhibitors, and PCSK-9 inhibitors are currently in trials. Consensus reports of scientific societies are still prudent in recommending the measurement of Lp(a) routinely for assessing CVD risk. This is mainly caused by the lack of definite intervention studies demonstrating that lowering Lp(a) reduces hard CVD endpoints, a lack of effective medications for lowering Lp(a), the highly variable Lp(a) concentrations among different ethnic groups and the challenges associated with Lp(a) measurement. Here, we present our view on when to measure Lp(a) and how to deal with elevated Lp(a) levels in moderate and high-risk individuals.
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Affiliation(s)
- Karam M Kostner
- Associate Professor of Medicine, Mater Hospital, University of Queensland, St Lucia, QLD, Australia
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Abstract
Plasma lipoprotein(a) [Lp(a)] is a quantitative genetic trait with a very broad and skewed distribution, which is largely controlled by genetic variants at the LPA locus on chromosome 6q27. Based on genetic evidence provided by studies conducted over the last two decades, Lp(a) is currently considered to be the strongest genetic risk factor for coronary heart disease (CHD). The copy number variation of kringle IV in the LPA gene has been strongly associated with both Lp(a) levels in plasma and risk of CHD, thereby fulfilling the main criterion for causality in a Mendelian randomization approach. Alleles with a low kringle IV copy number that together have a population frequency of 25-35% are associated with a doubling of the relative risk for outcomes, which is exceptional in the field of complex genetic phenotypes. The recently identified binding of oxidized phospholipids to Lp(a) is considered as one of the possible mechanisms that may explain the pathogenicity of Lp(a). Drugs that have been shown to lower Lp(a) have pleiotropic effects on other CHD risk factors, and an improvement of cardiovascular endpoints is up to now lacking. However, it has been established in a proof of principle study that lowering of very high Lp(a) by apheresis in high-risk patients with already maximally reduced low-density lipoprotein cholesterol levels can dramatically reduce major coronary events.
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Affiliation(s)
- F Kronenberg
- Division of Genetic Epidemiology, Innsbruck Medical University, Innsbruck, Austria
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