Individualized Treatment for Patients With Familial Hypercholesterolemia

Stratification in Heterozygous Familial Hypercholesterolemia: Imaging, Biomarkers, and Genetic Testing

PURPOSE OF REVIEW

Heterozygous familial hypercholesterolemia (HeFH) is the most common monogenic autosomal dominant disorder. However, the condition is often underdiagnosed and undertreated. The objective of this review is to provide an update on the risk stratification in patients with HeFH, incorporating new cardiovascular imaging techniques, various biomarkers, and genetic studies.

RECENT FINDINGS

The diagnosis of HeFH places patients in a high cardiovascular risk category due to the increased incidence of premature atherosclerotic cardiovascular disease. However, the level of risk varies significantly among different individuals with HeFH. Achieving an optimal stratification of cardiovascular risk is crucial for establishing appropriate and accurate treatment and management strategies. Different new tools such as risk scores have emerged in recent years, aiding physicians in assessing the risk stratification for HeFH using imaging, biomarkers, and genetics. This review emphasizes that not all patients with HeFH face the same cardiovascular risk. By utilizing different assessment tools, we can identify those who require more intensive monitoring, follow-up, and treatment.

A randomized trial of genotype-guided perindopril use

OBJECTIVE

Cough caused by angiotensin-converting enzyme inhibitors (ACEIs) limits their clinical application and cardiovascular benefits. This randomized trial investigated whether genotype-guided perindopril use could reduce drug-related cough in 20 to 79-year-old individuals with hypertension.

METHODS

After screening 120 patients and randomization, 68 were assigned to genotyping ( n  = 41) and control ( n  = 27) groups. NELL1 p.Arg382Trp (rs8176786) and intron (rs10766756) genotype information was used to subdivide the genotyping group into high-risk and low-risk subgroups with at least one or no risk alleles for ACEI-related cough, respectively. The high-risk subgroup received candesartan (8 mg/day) for 6 weeks, whereas the low-risk subgroup received perindopril (4 mg/day). The control group, which was not genotyped, received perindopril (4 mg/day). The primary outcome variables were cough and moderate/severe cough; the secondary outcome variable was any adverse event.

RESULTS

During the 6-week period, the risk of cough was lower in the genotyping group than in the control group [five (12.2%) and nine (33.3%) participants, respectively; hazard ratio: 0.25; log-rank P  = 0.017]. The moderate/severe cough risk was also lower in the genotyping group [one (2.4%) and five (18.5%) participants, respectively; hazard ratio: 0.12; log-rank P  = 0.025]. Differences in cough (hazard ratio: 0.56; log-rank P  = 0.32) and moderate/severe cough risk (hazard ratio: 0.26; log-rank P  = 0.19) between the low-risk and control groups were not significant. The risk of total adverse events was similar between any two groups.

CONCLUSION

Cough risk was lower during genotype-guided treatment than during conventional treatment. These results support the utility of NELL1 variant data in clinical decision making to personalize renin-angiotensin system blocker therapy use.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT05535595 (retrospectively registered at September 7, 2022).

Coronary artery calcium among patients with heterozygous familial hypercholesterolaemia

Aims

We aimed to determine if coronary artery calcium (CAC) is associated with cardiovascular disease (CVD) events, defined as CVD-related death, unstable angina, myocardial infarction, or staged revascularization among patients with heterozygous familial hypercholesterolaemia (HeFH) under primary prevention settings.

Methods and results

Data of patients with FH admitted to Kanazawa University Hospital between 2000 and 2020, who underwent CAC measurement and were followed up (n = 622, male = 306, mean age = 54 years), were retrospectively reviewed. Risk factors for CVD events were determined using the Cox proportional hazard model. The median follow-up duration was 13.2 years (interquartile range: 9.8-18.4 years). We observed 132 CVD events during the follow-up period. The event rate per 1000 person-years for CAC scores of 0 [n = 283 (45.5%)], 1-100 [n = 260 (41.8%)], and >100 [n = 79 (12.7%)] was 1.2, 17.0, and 78.8, respectively. Log (CAC score + 1) was a significant predictor of the occurrence of CVD events (hazard ratio: 3.24; 95% confidence interval: 1.68-4.80; P < 0.0001) in the multivariate Cox regression analysis, independent of other factors. The risk discrimination of CVD events was enhanced by adding CAC information to other conventional risk factors (C-statistics: 0.833-0.934; P < 0.0001).

Conclusion

The CAC score helps in further risk stratification in patients with HeFH.

Impact of Severe Hypercholesterolemia on Cardiovascular Risk in Individuals With or Without Diabetes Mellitus

Objective

The aim of the current study was to investigate whether the impact of low-density lipoprotein-cholesterol (LDL-C) levels on cardiovascular risk is different between individuals with severe hypercholesterolemia and diabetes mellitus (DM) and those without DM.

Methods

This study used the database of a National Health Insurance Service cohort of Korea. Among individuals who underwent health check-up, 2,261,332 were included and categorized into 3 groups with severe hypercholesterolemia, >260, 225–259, and 190–224 mg/dL groups, and a control group (<160 mg/dL). Risks of composite events (myocardial infarction [MI], coronary revascularization, and ischemic stroke) and total mortality were analyzed, according to the presence of DM.

Results

Of the study population, 5.2% had DM. During median follow-up of 6.1 years, the rates of composite events (/1,000 person-year) in non-DM and DM subjects were up to 5.66 and 8.92, respectively. Adjusted hazard ratios (aHRs) of the composite events ranged up to 3.11 and 1.44 in non-DM and DM groups, respectively (p<0.0001 between LDL-C categories in both groups). Dependency of aHR on LDL-C levels was more prominent in the non-DM group. aHRs of MI and coronary revascularization showed similar tendency to the composite events. Although aHRs of ischemic stroke (p<0.0001) and total mortality (p=0.002) were different according to LDL-C categories in the non-DM group, these relations were not observed in DM group.

Conclusion

Although individuals with severe hypercholesterolemia had high cardiovascular risk when DM was present, the impact of LDL-C on the risk was attenuated in this population.