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Björnsson E, Thorgeirsson G, Helgadóttir A, Thorleifsson G, Sveinbjörnsson G, Kristmundsdóttir S, Jónsson H, Jónasdóttir A, Jónasdóttir Á, Sigurðsson Á, Guðnason T, Ólafsson Í, Sigurðsson EL, Sigurðardóttir Ó, Viðarsson B, Baldvinsson M, Bjarnason R, Danielsen R, Matthíasson SE, Thórarinsson BL, Grétarsdóttir S, Steinthórsdóttir V, Halldórsson BV, Andersen K, Arnar DO, Jónsdóttir I, Guðbjartsson DF, Hólm H, Thorsteinsdóttir U, Sulem P, Stefánsson K. Large-Scale Screening for Monogenic and Clinically Defined Familial Hypercholesterolemia in Iceland. Arterioscler Thromb Vasc Biol 2021; 41:2616-2628. [PMID: 34407635 PMCID: PMC8454500 DOI: 10.1161/atvbaha.120.315904] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 08/02/2021] [Indexed: 01/07/2023]
Abstract
Objective: Familial hypercholesterolemia (FH) is traditionally defined as a monogenic disease characterized by severely elevated LDL-C (low-density lipoprotein cholesterol) levels. In practice, FH is commonly a clinical diagnosis without confirmation of a causative mutation. In this study, we sought to characterize and compare monogenic and clinically defined FH in a large sample of Icelanders. Approach and Results: We whole-genome sequenced 49 962 Icelanders and imputed the identified variants into an overall sample of 166 281 chip-genotyped Icelanders. We identified 20 FH mutations in LDLR, APOB, and PCSK9 with combined prevalence of 1 in 836. Monogenic FH was associated with severely elevated LDL-C levels and increased risk of premature coronary disease, aortic valve stenosis, and high burden of coronary atherosclerosis. We used a modified version of the Dutch Lipid Clinic Network criteria to screen for the clinical FH phenotype among living adult participants (N=79 058). Clinical FH was found in 2.2% of participants, of whom only 5.2% had monogenic FH. Mutation-negative clinical FH has a strong polygenic basis. Both individuals with monogenic FH and individuals with mutation-negative clinical FH were markedly undertreated with cholesterol-lowering medications and only a minority attained an LDL-C target of <2.6 mmol/L (<100 mg/dL; 11.0% and 24.9%, respectively) or <1.8 mmol/L (<70 mg/dL; 0.0% and 5.2%, respectively), as recommended for primary prevention by European Society of Cardiology/European Atherosclerosis Society cholesterol guidelines. Conclusions: Clinically defined FH is a relatively common phenotype that is explained by monogenic FH in only a minority of cases. Both monogenic and clinical FH confer high cardiovascular risk but are markedly undertreated.
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Affiliation(s)
- Eythór Björnsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
- Faculty of Medicine, University of Iceland, Reykjavík (E.B., E.L.S., R.B., K.A., D.O.A., I.J., U.T., K.S.)
- Department of Internal Medicine (E.B.), Landspítali-The National University Hospital of Iceland, Reykjavík
| | - Guðmundur Thorgeirsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
- Division of Cardiology, Department of Internal Medicine (G. Thorgeirsson, R.D., K.A., D.O.A.), Landspítali-The National University Hospital of Iceland, Reykjavík
| | - Anna Helgadóttir
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Guðmar Thorleifsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Garðar Sveinbjörnsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Snaedís Kristmundsdóttir
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Hákon Jónsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Aðalbjörg Jónasdóttir
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Áslaug Jónasdóttir
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Ásgeir Sigurðsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | | | - Ísleifur Ólafsson
- Department of Clinical Biochemistry (I.O.), Landspítali-The National University Hospital of Iceland, Reykjavík
| | - Emil L. Sigurðsson
- Faculty of Medicine, University of Iceland, Reykjavík (E.B., E.L.S., R.B., K.A., D.O.A., I.J., U.T., K.S.)
- Development Centre for the Primary Care, Reykjavík, Iceland (E.L.S.)
| | | | - Brynjar Viðarsson
- Department of Hematology (B.V.), Landspítali-The National University Hospital of Iceland, Reykjavík
- The Laboratory in Mjódd, Reykjavík, Iceland (B.V.)
| | | | - Ragnar Bjarnason
- Faculty of Medicine, University of Iceland, Reykjavík (E.B., E.L.S., R.B., K.A., D.O.A., I.J., U.T., K.S.)
- Children’s Medical Center (R.B.), Landspítali-The National University Hospital of Iceland, Reykjavík
| | - Ragnar Danielsen
- Division of Cardiology, Department of Internal Medicine (G. Thorgeirsson, R.D., K.A., D.O.A.), Landspítali-The National University Hospital of Iceland, Reykjavík
| | | | - Björn L. Thórarinsson
- Department of Neurology (B.L.T.), Landspítali-The National University Hospital of Iceland, Reykjavík
| | - Sólveig Grétarsdóttir
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Valgerður Steinthórsdóttir
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Bjarni V. Halldórsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Karl Andersen
- Faculty of Medicine, University of Iceland, Reykjavík (E.B., E.L.S., R.B., K.A., D.O.A., I.J., U.T., K.S.)
- Division of Cardiology, Department of Internal Medicine (G. Thorgeirsson, R.D., K.A., D.O.A.), Landspítali-The National University Hospital of Iceland, Reykjavík
| | - Davíð O. Arnar
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
- Faculty of Medicine, University of Iceland, Reykjavík (E.B., E.L.S., R.B., K.A., D.O.A., I.J., U.T., K.S.)
- Division of Cardiology, Department of Internal Medicine (G. Thorgeirsson, R.D., K.A., D.O.A.), Landspítali-The National University Hospital of Iceland, Reykjavík
| | - Ingileif Jónsdóttir
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
- Faculty of Medicine, University of Iceland, Reykjavík (E.B., E.L.S., R.B., K.A., D.O.A., I.J., U.T., K.S.)
| | - Daníel F. Guðbjartsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
- School of Engineering and Natural Sciences, University of Iceland, Reykjavík (D.F.G.)
| | - Hilma Hólm
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Unnur Thorsteinsdóttir
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
- Faculty of Medicine, University of Iceland, Reykjavík (E.B., E.L.S., R.B., K.A., D.O.A., I.J., U.T., K.S.)
| | - Patrick Sulem
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
| | - Kári Stefánsson
- deCODE genetics/Amgen, Inc, Reykjavík, Iceland (E.B., G. Thorgeirsson, A.H., G. Thorleifsson, G.S., S.K., H.J., Aðalbjörg Jónasdóttir, Áslaug Jónasdóttir, A.S., S.G., V.S., B.V.H., D.O.A., I.J., D.F.G., H.H., U.T., P.S., K.S.)
- Faculty of Medicine, University of Iceland, Reykjavík (E.B., E.L.S., R.B., K.A., D.O.A., I.J., U.T., K.S.)
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