Physical signs and atherosclerotic cardiovascular disease in familial hypercholesterolemia: the HELLAS-FH Registry

AIMS

Three physical signs, namely tendon xanthomas, corneal arcus and xanthelasma, have been associated with heterozygous familial hypercholesterolemia (heFH). The prevalence and clinical significance of these signs are not well established among contemporary heFH individuals. This study explored the frequency as well as the association of these physical signs with prevalent atherosclerotic cardiovascular disease (ASCVD) in heFH individuals.

METHODS

Data from the Hellenic Familial Hypercholesterolemia Registry were applied for this analysis. The diagnosis of heFH was based on the Dutch Lipid Clinic Network Score. Multivariate logistic regression analysis was conducted to examine the association of heFH-related physical signs with prevalent ASCVD.

RESULTS

Adult patients ( n  = 2156, mean age 50 ± 15 years, 47.7% women) were included in this analysis. Among them, 14.5% had at least one heFH-related physical sign present. The prevalence of corneal arcus before the age of 45 years was 6.6%, tendon xanthomas 5.3%, and xanthelasmas 5.8%. Among physical signs, only the presence of corneal arcus before the age of 45 years was independently associated with the presence of premature coronary artery disease (CAD). No association of any physical sign with total CAD, stroke or peripheral artery disease was found. Patients with physical signs were more likely to receive higher intensity statin therapy and dual lipid-lowering therapy, but only a minority reached optimal lipid targets.

CONCLUSION

The prevalence of physical signs is relatively low in contemporary heFH patients. The presence of corneal arcus before the age of 45 years is independently associated with premature CAD.

Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023

Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.

Obesity and atherosclerotic cardiovascular disease in adults with heterozygous familial hypercholesterolemia: An analysis from HELLAS-FH registry

BACKGROUND

Familial hypercholesterolemia (FH) and obesity are well-established risk factors of atherosclerotic cardiovascular disease (ASCVD). Despite high prevalence, their joint association with ASCVD remains largely unknown.

OBJECTIVE

To investigate the association of obesity with prevalent ASCVD in individuals with heterozygous FH (HeFH) enrolled in the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH).

METHODS

FH diagnosis was based on Dutch Lipid Clinic Network (DLCN) criteria. Adults with at least possible FH diagnosis (DLCN score ≥3) and available body mass index (BMI) values were included. Homozygous FH individuals were excluded.

RESULTS

1655 HeFH adults (mean age 51.0 ± 14.4 years, 48.6% female) were included; 378 (22.8%) and 430 (26.0%) were diagnosed with probable and definite FH, respectively. Furthermore, 371 participants (22.4%) had obesity and 761 (46.0%) were overweight. Prevalence of ASCVD risk factors increased progressively with BMI. Prevalence of coronary artery disease (CAD) was 23.4% (3.2% for stroke and 2.7% for peripheral artery disease, PAD), and increased progressively across BMI groups. After adjusting for traditional ASCVD risk factors and lipid-lowering medication, individuals with obesity had higher odds of established CAD (OR: 1.54, 95% CI: 1.04-2.27, p = 0.036) as well as premature CAD (OR: 1.74, 95% CI: 1.17-2.60, p = 0.009) compared with those with normal BMI. No association was found with stroke or PAD.

CONCLUSIONS

Over half of adults with HeFH have overweight or obesity. Obesity was independently associated with increased prevalence of CAD in this population.

Familial Hypercholesterolemia in the Elderly: An Analysis of Clinical Profile and Atherosclerotic Cardiovascular Disease Burden from the Hellas-FH Registry

BACKGROUND

Familial hypercholesterolemia (FH) carries a high risk of atherosclerotic cardiovascular disease (ASCVD). As the population ages, the age-related influence on clinical characteristics and outcomes becomes increasingly pertinent. This cross-sectional analysis from the HELLAS-FH registry aims to explore potential differences in clinical characteristics, treatment, ASCVD, and goal achievement between those younger and older than 65 years with FH.

RESULTS

A total of 2273 adults with heterozygous FH (51.4% males) were studied. Elderly FH patients (n = 349) had a higher prevalence of ASCVD risk factors, such as hypertension (52.1% vs. 20.9%, p < 0.05) and type 2 diabetes (16.9% vs. 6.0%, p < 0.05), compared to younger patients (n = 1924). They also had a higher prevalence of established ASCVD (38.4% vs. 23.1%, p < 0.001), particularly CAD (33.0% vs. 20.2%, p < 0.001), even after adjusting for major ASCVD risk factors. Elderly patients were more frequently and intensively receiving lipid-lowering treatment than younger ones. Although post-treatment LDL-C levels were lower in elderly than younger patients (125 vs. 146 mg/dL, p < 0.05), both groups had similar attainment of the LDL-C target (3.7% vs. 3.0%).

CONCLUSIONS

Elderly FH patients have a higher prevalence of ASCVD, particularly CAD. Despite more aggressive treatment, the achievement of LDL-C targets remains very poor. These results emphasize the importance of early FH diagnosis and treatment in reducing ASCVD.

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

BACKGROUND

Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies.

METHODS

For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia.

FINDINGS

Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified.

INTERPRETATION

Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life.

FUNDING

Pfizer, Amgen, Merck Sharp & Dohme, Sanofi-Aventis, Daiichi Sankyo, and Regeneron.

Lipoprotein(a), metabolic profile and new-onset type 2 diabetes in patients with familial combined hyperlipidemia: A 9 year follow-up study

BACKGROUND

Lipoprotein(a) [Lp(a)] appears to have an inverse association with the risk of type 2 diabetes mellitus in the general population.

OBJECTIVE

This study aimed to investigate the prognostic role of Lp(a) regarding the development of type 2 diabetes in the special population of subjects with familial combined hyperlipidemia (FCH).

METHODS

This cohort study included 474 patients (mean age 49.7±11.3 years, 64% males) with FCH, without diabetes at baseline who were followed for a mean period of 8.2±6.8 years. At baseline evaluation venous blood samples were obtained for the determination of lipid profile and Lp(a) levels. The endpoint of interest was the development of diabetes.

RESULTS

Patients with increased Lp(a) levels ≥30 mg/dl compared to those with low Lp(a) levels <30 mg/dl had lower levels of triglycerides (238±113 vs 268±129 mg/dl, p = 0.01), greater levels of high-density lipoprotein (HDL) cholesterol (44±10 vs 41±10 mg/dl, p = 0.01) and hypertension in a greater percentage (42% vs 32%, p = 0.03). The incidence of new-onset diabetes during the follow-up period was 10.1% (n = 48). Multiple Cox regression analysis revealed that increased Lp(a) is an independent predictor of lower diabetes incidence (HR 0.39, 95% CI 0.17-0.90, p = 0.02) after adjustment for confounders.

CONCLUSION

Among subjects with FCH those with higher Lp(a) levels have lower risk for the development of type 2 diabetes. Moreover, the presence of increased Lp(a) seems to differentiate the expression of metabolic syndrome characteristics in patients with FCH, as increased Lp(a) is related to lower levels of triglycerides, greater prevalence of hypertension and higher levels of HDL cholesterol.

Comparative performance of equations to estimate low-density lipoprotein cholesterol levels and cardiovascular disease incidence: The ATTICA study (2002-2022)

Accurate estimation of low-density lipoprotein cholesterol (LDL-C) is important for monitoring cardiovascular disease (CVD) risk and guiding lipid-lowering therapy. This study aimed to evaluate the magnitude of discordance of LDL-C levels calculated by different equations and its effect on CVD incidence. The study sample consisted of 2354 CVD-free individuals (49% males, mean age 45 ± 14 years); 1600 were re-evaluated at 10 years and 1570 at 20 years. LDL-C was estimated using the Friedewald, Martin/Hopkins, and Sampson equations. Participants were categorized as discordant if estimated LDL-C was below the CVD-risk specific cut-off for one equation and equal/above for its comparator. The Friedewald and Martin/Hopkins equations presented a similar performance in estimating LDL-C; however, both yielded lower values compared to the Sampson. In all pairwise comparisons, differences were more pronounced at lower LDL-C levels, while the Friedewald equation significantly underestimated LDL-C in hypertriglyceridemic participants. Discordance was evident in 11% of the study population, and more specifically 6%, 22%, and 20% for Friedewald versus Martin/Hopkins, Friedewald versus Sampson and Martin/Hopkins versus Sampson equations, respectively. Among discordant participants, median (1st, 3rd quartile) difference in LDL-C was -4.35 (-10.1, 1.95), -10.6 (-12.3, -9.53) and -11.3 (-11.9, -10.6) mg/dL for Friedewald versus Martin/Hopkins, Friedewald versus Sampson and Martin/Hopkins versus Sampson equations, respectively. The 10- and 20-year CVD survival model that included LDL-C values of the Martin-Hopkins equation outperformed the predictive ability of those based on the Friedewald or Sampson equations. Significant differences in estimated LDL-C exist among equations, which may result in LDL-C underestimation and undertreatment.

Long-term prognostic value of LDL-C, HDL-C, lp(a) and TG levels on cardiovascular disease incidence, by body weight status, dietary habits and lipid-lowering treatment: the ATTICA epidemiological cohort study (2002-2012)

BACKGROUND

The link between blood lipids and cardiovascular disease (CVD) is complex. Our aim was to assess the differential effect of blood lipids on CVD risk according to age, sex, body weight, diet quality, use of lipid-lowering drugs and presence of hypercholesterolemia.

METHODS

In this secondary analysis of the ATTICA prospective cohort study, serum blood lipids, i.e., total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and liproprotein(a) [Lp(a)], and sociodemographic, anthropometric, lifestyle and clinical parameters were evaluated at baseline (2001/2002) in 2020 CVD-free men and women. CVD incidence was recorded at the 10-year follow-up (2011/2012).

RESULTS

All blood lipids assessed were univariately related to CVD risk; however, associations remained significant only for HDL-C and TG in multivariate models adjusted for age, sex, body mass index, smoking, Mediterranean Diet Score, physical activity, presence of hypercholesterolemia, hypertension and diabetes mellitus, use of lipid-lowering drugs, and family history of CVD [RR per 1 mg/dL (95% CI): 0.983 (0.967, 1.000) and 1.002 (1.001, 1.003), respectively]. In stratified analyses, TC and LDL-C predicted CVD risk in younger subjects, normal-weight subjects, and those not on lipid-lowering drugs, while HDL-C and TG were significant predictors in older subjects, those with low adherence to the Mediterranean diet, and hypercholesterolemic subjects; a significant effect on CVD risk was also observed for TG in males, overweight participants and lipid-lowering medication users and for Lp(a) in older subjects and females (all p ≤ 0.050).

CONCLUSIONS

The impact of blood lipids on CVD risk differs according to several biological, lifestyle and clinical parameters.

Correlation of lipoprotein(a) with parameters of lipid profile and other cardiovascular risk factors in patients with familial combined hyperlipidemia

Background

According to previous studies, Familial Combined Hyperlipidemia (FCH) is related to metabolic syndrome. However, it is unclear whether the presence of increased Lipoprotein (a) [Lp (a)] modifies the characteristics of metabolic syndrome in patients with FCH. Thus, the aim of our study was to identify and compare the components of metabolic syndrome in patients with FCH according to their Lp (a) levels.

Methods

We enrolled 906 patients (592 males, mean age 49±11 years) who fulfilled the FCH criteria, from the outpatient lipid clinic of our hospital.Venous blood samples were obtained for the determination of plasma glucose and lipid profile [i.e., total cholesterol, triglycerides (TG), low and high-lipoprotein cholesterol, (LDL, HDL)], as well as levels of Lp (a). Moreover, information was obtained regarding demographic characteristics and blood pressure (BP) levels. Diagnosis of hypertension was based on BP levels≥140/90 mmHg and metabolic syndrome was defined according to ATP III criteria.

Results

In the total population of 906 patients with FCH, 58% (n=524) had metabolic syndrome. We identified a negative correlation between levels of Lp (a) and TG (r=−0.07, p=0.03) and a positive correlation between levels of Lp (a) and HDL (r=0.08, p=0.02). Also, there was a trend towards a negative correlation between levels of Lp (a) and waist circumference (r=−0.6, p=0.06). Moreover, the group of patients with increased Lp (a) levels (≥30mg/dl, n=289, 32%) compared to those with low Lp (a) levels (&lt;30mg/dl, n=616, 68%)had hypertension in a greater percentage (44% vs 36%, p=0.02), lower levels of TG (278±146 vs 302±172 mg/dl, p=0.04), higher levels of HDL (42±11 vs 39±9 mg/dl, p=0.01) and increased levels of LDL (193±55 vs 185±53 mg/dl, p=0.05), while there was no difference in glucose levels (104±24 vs 102±20 mg/dl, p=0.18). In multiple logistic regression analysis increased Lp (a) levels were independent determinants of lower triglycerides levels (&lt;150mg/dl) (OR 0.59, 95% CI 0.36–0.95), after adjustment for confounding factors.

Conclusions

In patients with FCH, increased Lp (a) is related to lower levels of triglycerides, higher levels of HDL, lower waist circumference levels and increased prevalence of hypertension. Thus, it seems that Lp (a) differentiates the expression of metabolic syndrome characteristics in patients with Familial Combined Hyperlipidemia.

Funding Acknowledgement

Type of funding sources: None.

Visceral adipose tissue phenotype and hypoadiponectinemia are associated with aortic Fluorine-18 fluorodeoxyglucose uptake in patients with familial dyslipidemias

BACKGROUND

The role of adipose tissue (AT) in arterial inflammation in familial dyslipidaemias is poorly studied. We investigated the relationship between AT and arterial inflammation in patients with heterozygous familial hypercholesterolemia (heFH) and familial combined hyperlipidemia (FCH).

METHODS AND RESULTS

A total of 40 patients (20 heFH/20 FCH) and a subgroup of 20 of non-heFH/FCH patients were enrolled. Participants underwent blood sampling for serum adipokine measurements and Fluorine-18 fluorodeoxyglucose (18F-FDG) PET/CT imaging. Abdominal visceral (VAT) and subcutaneous (SAT) AT volumes and AT and abdominal aorta 18F-FDG uptake were quantified. FCH patients had increased VAT (pANOVA = 0.004) and SAT volumes (pANOVA = 0.003), lower VAT metabolic activity (pANOVA = 0.0047), and lower adiponectin levels (pANOVA = 0.007) compared to heFH or the control group. Log(Serum adiponectin) levels were correlated with aortic TBR (b = - 0.118, P = 0.038). In mediation analysis, VAT volume was the major determinant of circulating adiponectin, an effect partly mediated via VAT TBR. Clustering of the population of heFH/FCH by VAT volume/TBR and serum adiponectin identified two distinct patient clusters with significant differences in aortic TBR levels (2.11 ± 0.06 vs 1.89 ± 0.05, P= 0.012).

CONCLUSIONS

VAT phenotype (increased VAT volume and/or high VAT TBR) and hypoadiponectinemia may account for the observed differences in arterial inflammation levels between heFH and FCH patients.

Association between lipoprotein(a) concentrations and atherosclerotic cardiovascular disease risk in patients with familial hypercholesterolemia: an analysis from the HELLAS-FH

AIMS

Lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD) in the general population. However, such a role in patients with familial hypercholesterolemia (FH) is less documented. The purpose of this study was to evaluate the association between Lp(a) concentrations and ASCVD prevalence in adult patients with FH.

METHODS

This was a cross-sectional study from the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH). Patients were categorized into 3 tertiles according to Lp(a) levels.

RESULTS

A total of 541 adult patients (249 males) with possible/probable/definite FH heterozygous FH (HeFH) were included (mean age 48.5 ± 15.0 years at registration, 40.8 ± 15.9 years at diagnosis). Median (interquartile range) Lp(a) concentrations in the 1st, 2nd and 3rd Lp(a) tertile were 6.4 (3.0-9.7), 22.4 (16.0-29.1) and 77.0 (55.0-102.0) mg/dL, respectively. There was no difference in lipid profile across Lp(a) tertiles. The overall prevalence of ASCVD was 9.4% in the first, 16.1% in the second and 20.6% in the third tertile (p = 0.012 among tertiles). This was also the case for premature ASCVD, with prevalence rates of 8.5, 13.4 and 19.8%, respectively (p = 0.010 among tertiles). A trend for increasing prevalence of coronary artery disease (8.3, 12.2 and 16.1%, respectively; p = 0.076 among tertiles) was also observed. No difference in the prevalence of stroke and peripheral artery disease was found across tertiles.

CONCLUSIONS

Elevated Lp(a) concentrations are significantly associated with increased prevalence of ASCVD in patients with possible/probable/definite HeFH.

LDL cholesterol target achievement in heterozygous familial hypercholesterolemia patients according to 2019 ESC/EAS lipid guidelines: Implications for newer lipid-lowering treatments

BACKGROUND

The 2019 European guidelines (ESC/EAS) for the treatment of dyslipidaemias recommend more aggressive targets for low-density lipoprotein cholesterol (LDL-C) in patients with familial hypercholesterolemia (FH). Current lipid-lowering treatment is often inadequate to achieve these targets.

METHODS

Data from the HELLAS-FH registry were analysed to assess achievement of LDL-C targets in adults with FH based on the 2019 ESC/EAS guidelines. In patients who had not achieved LDL-C target, the maximally reduced LDL-C value was calculated after theoretical switch to rosuvastatin/ezetimibe 40/10 mg/day. The percentage of patients who remained candidates for proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) was then calculated.

RESULTS

Patients (n = 1694, mean age 50.8 ± 14.7 years) had LDL-C levels 242 ± 71 mg/dL (6.3 ± 1.8 mmol/L) at diagnosis. Most treated patients were receiving statins (97.5%) and about half were on additional ezetimibe (47.5%). Based on the 2019 ESC/EAS guidelines the percentage of patients achieving LDL-C goals was only 2.7%. Following theoretical up titration to rosuvastatin/ezetimibe 40/10 mg, LDL-C target achievement rate would increase to 5.9%. In this scenario, most patients (55.9%) would be eligible for PCSK9i treatment. Following theoretical administration of a PCSK9i, LDL-C target achievement rate would rise to 57.6%. However, 42.4% of patients would still be eligible for further LDL-C lowering treatment.

CONCLUSIONS

Most FH patients do not reach new LDL-C targets even if on maximum intensity statin/ezetimibe treatment. In this case, more than half of FH patients are candidates for PCSK9i therapy and a considerable proportion may still require additional LDL-C lowering.

Global perspective of familial hypercholesterolaemia: a cross-sectional study from the EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC)

BACKGROUND

The European Atherosclerosis Society Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry provides a platform for the global surveillance of familial hypercholesterolaemia through harmonisation and pooling of multinational data. In this study, we aimed to characterise the adult population with heterozygous familial hypercholesterolaemia and described how it is detected and managed globally.

METHODS

Using FHSC global registry data, we did a cross-sectional assessment of adults (aged 18 years or older) with a clinical or genetic diagnosis of probable or definite heterozygous familial hypercholesterolaemia at the time they were entered into the registries. Data were assessed overall and by WHO regions, sex, and index versus non-index cases.

FINDINGS

Of the 61 612 individuals in the registry, 42 167 adults (21 999 [53·6%] women) from 56 countries were included in the study. Of these, 31 798 (75·4%) were diagnosed with the Dutch Lipid Clinic Network criteria, and 35 490 (84·2%) were from the WHO region of Europe. Median age of participants at entry in the registry was 46·2 years (IQR 34·3-58·0); median age at diagnosis of familial hypercholesterolaemia was 44·4 years (32·5-56·5), with 40·2% of participants younger than 40 years when diagnosed. Prevalence of cardiovascular risk factors increased progressively with age and varied by WHO region. Prevalence of coronary disease was 17·4% (2·1% for stroke and 5·2% for peripheral artery disease), increasing with concentrations of untreated LDL cholesterol, and was about two times lower in women than in men. Among patients receiving lipid-lowering medications, 16 803 (81·1%) were receiving statins and 3691 (21·2%) were on combination therapy, with greater use of more potent lipid-lowering medication in men than in women. Median LDL cholesterol was 5·43 mmol/L (IQR 4·32-6·72) among patients not taking lipid-lowering medications and 4·23 mmol/L (3·20-5·66) among those taking them. Among patients taking lipid-lowering medications, 2·7% had LDL cholesterol lower than 1·8 mmol/L; the use of combination therapy, particularly with three drugs and with proprotein convertase subtilisin-kexin type 9 inhibitors, was associated with a higher proportion and greater odds of having LDL cholesterol lower than 1·8 mmol/L. Compared with index cases, patients who were non-index cases were younger, with lower LDL cholesterol and lower prevalence of cardiovascular risk factors and cardiovascular diseases (all p<0·001).

INTERPRETATION

Familial hypercholesterolaemia is diagnosed late. Guideline-recommended LDL cholesterol concentrations are infrequently achieved with single-drug therapy. Cardiovascular risk factors and presence of coronary disease were lower among non-index cases, who were diagnosed earlier. Earlier detection and greater use of combination therapies are required to reduce the global burden of familial hypercholesterolaemia.

FUNDING

Pfizer, Amgen, Merck Sharp & Dohme, Sanofi-Aventis, Daiichi Sankyo, and Regeneron.

Carotid Artery Temperature Reduction with Statin Therapy in Patients with Familial Hyperlipidemia Syndromes

Background: Microwave radiometry (MWR) assesses non-invasive carotid artery temperatures reflecting inflammation. In the present study, we aimed to investigate the impact of hypolipidemic therapy either with simvastatin or with combination simvastatin plus ezetimibe on carotid artery temperatures of patients with familial hyperlipidemia syndromes (FHS). Methods: Consecutive patients with diagnosis of either familial heterozygous hypercholesterolemia (heFH) or familial combined hyperlipidemia (FCH) were included in the study. Patients were assigned to either simvastatin 40 mg or simvastatin 40 mg plus ezetimibe 10 mg, according to the discretion of the physician. FHS patients who refused statin therapy were used as a control group. Common carotid intima-media thickness (ccIMT) was measured and ΔΤ (maximum-minimum) temperature measurements were performed across each carotid during MWR evaluation. RESULTS: In total, 115 patients were included in the study. Of them, 40 patients received simvastatin (19 heFH and 21 FCH), 41 simvastatin + ezetimibe (31 heFH and 10 FCH), and 34 (21 heFH and 13 FCH) no statin. Carotid artery temperatures were significantly reduced at 6 months in FH patients who received hypolipidemic treatment (0.83 ± 0.34 versus 0.63 ± 0.24 °C, p = 0.004 for simvastatin, 1.00 ± 0.38 versus 0.69 ± 0.23 °C, p < 0.001 for simvastatin + ezetimibe), but no change was recorded in controls (0.72 ± 0.26 versus 0.70 ± 0.26 °C, p = 0.86). Conclusions: Hypolipidemic therapy reduced carotid temperatures in FHS patients.

Coronary artery disease and familial hypercholesterolaemia patients' eligibility for PCSK-9 inhibitors: who is to benefit from lower ldl thresholds?

Purpose

High and very high cardiovascular risk patients are usually possible candidates for PCSK-9 inhibitors. Coronary artery disease (CAD) and Familial Hypercholesterolaemia (FH) patients belong to this group by definition, according to 2019 recent dyslipidaemia guidelines. The real contribution of each group to potential eligibility for PCSK-9 is to be investigated.

Methods

We enrolled 1892 inpatients prospectively for 12 months, diagnosed either with chronic CAD or with acute coronary syndrome (ACS). In order to test eligibility for PCSK-9 inhibitors, three different LDL thresholds were used in our model for very high and high risk groups: 55mg/dl and 70mg/dl, 70mg/dl and 100mg/dl, 100mg/dl and 130mg/dl, as recommended by the 2019 and 2016 ESC/EAS Guidelines for Dyslipidaemia and the National Health Care system, respectively. A proprietary software was developed and eligibility was determined by using patient clinical information and different criteria. Dutch Lipid Clinic Network criteria were used to determine heterozygous FH population.

Results

The eligible percentage for the three classifications was 18.6%, 7.7% and 1.8%, in the total CAD population respectively. Definite/ probable FH percentages among our population were 4.8%, 3.4%, 1.4%, respectively. Solely CAD eligible population was 13.8%, 4.3% and 0.4% respectively. The increase of the eligible percentages toward more recent guidelines was mostly attributed to the increasing number of coronary patients who become eligible as our criteria become stricter while the percentage of the eligible CAD/FH population only slightly increases.

Conclusions

FH is a significant cardiovascular risk factor but stricter criteria and LDL thresholds, favour solely CAD patients. Using real-world data and an adjustable model, we provide a realistic estimation of PCSK-9 eligibility among CAD patients.

Funding Acknowledgement

Type of funding sources: None. Subgroup analysis of eligible population

Prevalence of Non-coronary Heart Disease in Patients with Familial Hypercholesterolemia: An Analysis from the HELLAS-FH

AIMS

Despite the established link between familial hypercholesterolemia (FH) and increased risk of coronary heart disease (CHD), its association with other common atherosclerotic and metabolic diseases has not been extensively studied. The aim of this study was to report the prevalence of peripheral arterial disease (PAD) [i.e., common carotid artery disease (CCAD) and lower extremity arterial disease (LEAD)], aortic valve stenosis, chronic kidney disease (CKD) and non-alcoholic fatty liver disease (NAFLD) in patients with FH.

MATERIALS & METHODS

This was a cross-sectional study retrieving data from the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH).

RESULTS

A total of 1,633 adult patients (850 males) with heterozygous FH (HeFH) were included (mean age 51.3±14.6 years at registration and 44.3±15.9 years at diagnosis). Any common carotid artery stenosis (CCAS) was diagnosed in 124 out of 569 patients with available related data (21.8%), while the prevalence of CCAD (defined as a CCAS ≥50%) was 4.2%. The median (interquartile range - IQR) CCAS was 30% (20-40), whereas the median (IQR) carotid intima-media thickness (CIMT) was 0.7 (0.1-1.4) mm. LEAD was reported in 44 patients (prevalence 2.7%). The prevalence of aortic valve stenosis and CKD was 2.0% and 6.4%, respectively. NAFLD was present in 24% of study participants.

CONCLUSION

HeFH is associated with a relatively high prevalence of any CCAS and CCAD. The prevalence of LEAD, CKD and aortic valve stenosis was relatively low, whereas the prevalence of NAFLD was similar to that of the general population.

The new LDL-C target &lt;55 mg/dL is achieved by less than 40% of very high risk patients with familial hypercholesterolaemia despite receiving PCSK9 inhibitors: real world data

Background

The recently published ESC/EAS guidelines for the management of dyslipidaemias have lowered the low-density lipoprotein cholesterol (LDL-C) target in the very high risk patients below 55 mg/dL.

Purpose

To examine how achievable is this target in very high risk patients receiving a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) on top of lipid-lowering treatment (LLT).

Methods

The cohort comprised 158 patients who attended the lipid clinic of 3 hospitals in Greece and started treatment with PCSK9i. Patients were requested to attend the lipid clinic 3 months after the initiation of PCSK9i.

Results

Ninety percent of patients had heterozygous familial hypercholesterolaemia (heFH) and 75% had cardiovascular disease (CVD). One hundred forty patients were classified as very high risk because they had either cardiovascular disease (CVD) or heFH with an additional risk factor for whom a target &lt;55 mg/dL is currently recommended. Of those very high risk patients, 105 (75%) were given PCSK9i due to failure to achieve LDL-C targets despite maximum LLT (high intensity statin at maximum tolerated dose + ezetimibe) while in the rest of cases the indication was statin intolerance. The mean reduction of LDL-C at 3 months was 56.2%. Among 105 very high risk patients (all had heFH), LDL-C below 55 mg/dL was achieved by 37.1% while the previously LDL-C target &lt;70 mg/dL was achieved by 60% (Figure 1).

Conclusions

The new LDL-C target &lt;55 mg/dL is achieved by &lt;40% of very high risk patients with heFH despite receiving triple LLT, i.e. PCSK9i + statin + ezetimibe. This therapeutic gap suggests that there is still need for more effective LLT in very high risk heFH patients to maximize their clinical benefit.

Figure 1

Funding Acknowledgement

Type of funding source: None

Carotid artery temperature reduction with statin therapy in patients with familial hyperlipidemia syndromes

Background

Familial hypercholesterolemia (FH) syndromes constitute an important risk factor for premature atherosclerosis. Microwave radiometry (MWR) assess non-invasively carotid artery temperatures reflecting inflammation. Recent data support that statin therapy, that constitutes the cornerstone for the treatment of FH, reduces systemic inflammation.

Purpose

To investigate the impact of statin therapy either with simvastatin or with combination simvastatin plus ezetimibe on carotid artery temperatures.

Methods

Consecutive patients with diagnosis of either heterozygous hypercholesterolemia (hFH) or combined hyperlipidemia (FCH) not under statin therapy for at least 6 months were included in the study. FH pts were assigned to either simvastatin 40 mg or simvastatin 40 mg plus ezetimibe 10mg according to the discretion of the physician. FH patients who refused statin therapy were used as control group for the assessment of statins effect. In all subjects, common carotid intima-media thickness (ccIMT) was measured in the last 2 cm of the far wall of both common carotids close to the carotid bifurcation and ΔT (maximum-minimum) temperature measurements were performed across each carotid during MWR evaluation. Examinations were performed at baseline and after 6 months. Blood's lipid profile was also obtained in all patients.

Results

In total 115 patients were included in the study. Of them 40 patients received simvastatin (19 hFH and 11 FCH), 41 simvastatin + ezetimibe (31hFH and 10 FCH) and 34 (21 hFH and 13 FCH) no statin. There was no difference at baseline in ccIMT and ΔT measurements between hFH and FCH patients (0.10±0.03 vs 0.10±0.02, p=0.74 and 0.88±0.38 vs 0.84±0.32, p=0.52, respectively). Patients who refused statin therapy did not show any reduction in ccIMT and ΔT measurements between baseline and follow up (ccIMT: 0.10±0.02 vs 0.09±0.02, p=0.06 and ΔT: 0.72±0.26 vs 0.70±0.26). In contrast, there was a significant reduction in ccIMT and ΔT for patients under both simvastatin (0.10±0.03 vs 0.09±0.01, p=0.004 for ccIMT and 0.83±0.34 vs 0.63±0.24, p=0.04 for ΔT) and simvastatin + ezetimibe therapy (0.11±0.03 vs 0.09±0.02, p&lt;0.001 and 1.00±0.38 vs 0.69±0.23, p&lt;0.001 for ΔT). Patients under combination therapy reduced more significantly their carotid artery temperatures compared to patients under simvastatin monotherapy or patients without statin (−0.31±0.46 vs −0.2±0.40 vs −0.01±0.37, ANOVA p=0.04, Figure 1).

Conclusions

Both simvastatin and simvastatin + ezetimibe therapy among the beneficial effect on IMT, reduced carotid wall inflammation in FH pts.

Figure 1

Funding Acknowledgement

Type of funding source: None

Combined effect of cigarette smoking and prediabetes on structural and functional changes of large arteries

Purpose

Smoking is a major risk factor for cardiovascular disease and prediabetes is associated with excess risks for adverse cardiovascular outcomes and death. Aim of this study was to explore whether smoking and prediabetes exert a synergistic unfavourable effect on functional and structural parameters of large arteries.

Methods

We measured carotid-femoral pulse wave velocity (cfPWV), augmentation index (AIx) and carotid intima media thickness (cIMT) in 407 individuals without known atherosclerotic disease (mean age: 52±8 years) categorized into four age-matched groups according to glucose metabolic and smoking status: Smokers with diabetes (n=68), Smokers with prediabetes (n=87), Non-smokers with prediabetes (n=98) and Non- smokers with normal fasting blood glucose (FBG) (n=154). Prediabetes was defined as impaired fasting glucose (100–125 mg/dL), impaired glucose tolerance (2-hour glucose level of 140–199 mg/dL during an oral glucose tolerance test), or glycosylated hemoglobin (HbA1c) level of 5.7% to 6.4%. High sensitivity C-reactive protein (hsCRP) was measured in all patients.

Results

Systolic pressure, pulse pressure were increased and hsCRP levels were higher in smokers with diabetes compared to the three other groups (overall P&lt;0.05, P&lt;0.01 and P&lt;0.05, respectively, ANOVA). The cumulative tobacco exposure (measured in pack-years) was similar between smokers with diabetes and smokers with prediabetes (45 pack-years). Figure 1 shows cfPWV, AIx and cIMT of the four groups. Interestingly, smokers with diabetes and smokers with prediabetes have similar mean cfPWV and cIMT and significantly higher values compared to non-smokers with prediabetes and non-smokers with normal FBG. The associations remained statistically significant even after adjusting for systolic pressure and hsCRP level. AIx was not different between the four study groups.

Conclusion

The combination of prediabetes and smoking is associated with higher cfPWV and cIMT values compared to prediabetes alone. The smokers with impaired glucose regulation have functional and structural alterations of large arteries similar to that of smokers with established diabetes. Considering the risk for developing prediabetes in relation to smoking status and the number of cigarettes smoked daily and the independent predictive value of assessing vascular changes in large arteries, the present findings may have important clinical and prognostic implications.

Figure 1. Smoking, prediabetes and vascular changes

Funding Acknowledgement

Type of funding source: None

A predictive model of pcsk-9 inhibitors eligibility in coronary and dyslipidemic patients

Purpose

Dyslipidemia is a major cardiovascular risk factor and treatment is mostly based on statins and ezetimibe. PCSK-9 inhibitors are monoclonal antibodies that reduce LDL-c levels and have shown significant reduction of cardiovascular risk in high risk patients. Data regarding potential eligibility for PCSK-9, is limited especially when referring to the recent guidelines.

Methods

Eligibility was calculated using a proprietary adjustable software, which stores data and patient information and thus by using different criteria it can determine potential candidates for PCSK-9 inhibitors. For this purpose, 2000 patients were enrolled prospectively. Our study population was comprised of inpatients diagnosed either with acute coronary syndromes (ACS) or with chronic coronary disease (cCAD) and outpatients from Lipids' Clinic (OLC) (n=407, n=1087, n=506, respectively). In order to test eligibility, three different LDL thresholds were used in our model for high and very high risk groups: a) 70mg/dl and 55mg/dl, respectively, as recommended by the recently updated 2019 ESC/EAS Guidelines for Dyslipidaemia b) 100mg/dl and 70mg/dl, respectively, as recommended by the 2016 ESC/EAS Guidelines for Dyslipidaemias and c) 130mg/dl and 100mg/dl respectively, as mandated by our National Health Care system but also applicable in other countries.

Results

The eligible percentages for the three thresholds were 18.85%, 9.75% and 2.15%, in the total population (TP) respectively and it varied according to clinical status. Subgroup analysis of eligible population revealed the trends in each group (Figure 1). The increase toward more recent guidelines was mostly attributed to the increasing number of coronary patients who become eligible as our criteria become stricter.

Conclusions

Our predictive model provides a realistic estimation of PCSK-9 inhibitors potential eligibility in coronary and dyslipidaemic patients and thus it can become a useful tool for the use of PCSK-9 in health care systems.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen Hellas LTD

PCSK9 inhibitors in clinical practice: Novel directions and new experiences

BACKGROUND

In randomized clinical trials, proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) effectively reduce low-density lipoprotein-cholesterol (LDL-C) with a favorable tolerability and safety profile. Our purpose is to provide real-world data regarding the indications, efficacy and safety of PCSK9i.

METHODS

The cohort comprised 141 patients who attended the lipid clinic of 3 hospitals in Greece and started using PCSK9i. Patients were requested to attend the lipid clinic at 3 months and at 1 year.

RESULTS

Ninety percent of patients had heterozygous familial hypercholesterolaemia (heFH) and 75% had cardiovascular disease (CVD). A PCSK9i [evolocumab 140 mg/2 weeks (n = 82), alirocumab 75 mg/2 weeks (n = 46) and alirocumab 150 mg/2 weeks (n = 13)] was prescribed due to failure to achieve LDL-C targets despite maximum lipid-lowering therapy (LLT) in 75% of patients, while in the remaining cases, the indication was statin intolerance. The mean reduction of LDL-C at 3 months was 56.2% and remained constant at 12 months (55.8% reduction from baseline). LDL-C target was achieved by 68.1% of patients at 3 months. "Totally" intolerant to statins patients (unable to tolerate any statin dose, n = 23) showed the lowest LDL-C reduction (47.7%). Side effects attributed to treatment were reported by 14 patients (10%). The total number of patients who stopped PCSK9i at 1 year was 14 (10%) but only 2 (1.4%) discontinued treatment because of side effects (myalgias).

CONCLUSIONS

Our real-world results of PCSK9i showed comparable efficacy and tolerability to those reported in clinical trials and highlighted the value of treatment with PCSK9i heFH patients not achieving LDL-C targets despite maximum LLT and high or very high risk statin intolerant patients.

P4467PCSK9 and Lp(a) levels of children born after assisted reproduction technologies: results from a pilot study

Background

Since the introduction of Assisted Reproduction Technologies (ART) in clinical practice several studies have addressed concerns regarding the long-term health of the offspring and have revealed indications of an adverse cardiovascular/cardiometabolic outcome. Proprotein convertase subtilisin/kexin type 9 (PCSK9) and lipoprotein (a) (Lp[a]) levels have been associated with cardiovascular risk.

Purpose

To investigate PCSK9 and Lp(a) levels of children born after ART compared with naturally conceived (NC) controls.

Methods

In this case-control study, 73 sex- and age-matched children (mean age 98±35 months) of ART (intracytoplasmic sperm injection [ICSI]: n=33, classic in vitro fertilization [IVF]: n=40) and 73 NC children were assessed. Blood lipid profile, including PCSK9 and Lp(a) levels, was measured. Children were grouped according to age (<8 years, 8–10 years, ≥10 years).

Results

In the univariate model of the overall population, circulating PCSK9 levels were related to total cholesterol (r=0.186, P=0.025), LDL-C (r=0.180, P=0.029) and SBP (r=0.199, P=0.021). Similarly, circulating Lp(a) levels were related to age (r=0.269, P=0.001), apoB (r=0.214, P=0.01), birth weight (r=−0.183, P=0.037), height (r=0.263, P=0.001), waist-to-hip ratio (r=−0.350, P<0.001), HOMA-IR (r=0.319, P<0.001), insulin (r=0.316, P<0.001), and hsCRP (ρ=0.241, P=0.018). No significant differences were observed regarding lipid biomarkers between ART and NC children. (p=0.515 for PCSK9 and p=0.277 for Lp(a) values). It is noteworthy that a significant interaction was found between age groups and conception method (P<0.001) showing that PCSK9 levels increase with age in ART children, while they decline with age in NC offspring (Figure 1). IVF children showed higher levels of adjusted mean Lp(a) than ICSI (13.5 vs. 6.8 mg/dl, P=0.010) and NC children (12.3 vs. 8.3 mg/dl, P=0.048).

Mean LogPCSK9 concentrations with the st

Conclusions

PCSK9 and Lp(a) levels did not differ between ART and NC children. Nonetheless, PCSK9 levels increase with age in ART children indicating a gradual deterioration of lipidemic profile that could lead to increased cardiovascular risk. Moreover, our results imply that ART method may be of importance given that classic IVF is associated with higher levels of Lp(a). The impact of the method of conception on PCSK9 and Lp(a) values should be validated in larger patient series.

P6261Aortic stiffness and carotid intima thickness in hypercholesterolemic males with erectile dysfunction: relation to smoking status and statin therapy

Purpose

Aim of the study was to examine possible differentiation of aortic stiffness and carotid atherosclerosis among hypercholesterolemic patients with erectile dysfunction (ED) according to smoking status and statin therapy.

Methods

We measured carotid intima-media thickness (cIMT) and carotid-femoral pulse wave velocity (cfPWV) in three age-matched groups of ED patients with a moderate cardiovascular risk (SCORE) and low-density lipoprotein cholesterol (LDL-C) level greater than or equal to 100 mg/dL: Smokers not receiving statin therapy (n=106), Smokers actively under statin treatment for at least three months with no dose adjustment for a minimum of six weeks (n=59) and Non-smokers not receiving statin therapy (n=97). The severity of ED was evaluated with measurements of penile peak velocity (PSV) 20 min after the intracavernous injection of prostaglandin E1 (20 μg).

Results

The groups of untreated smokers and non-smokers had similar mean LDL-C level. The mean LDL-C of patients under statin therapy was lower, however the differences with the level of the untreated patients was not statistically significant. Overall 33 (56%) of the patients under statin therapy reached their LDL-C goal. Body mass index and the prevalence of hypertension were not different between the three groups. The PSV was significantly lower in smokers with or without therapy compared to that of non-smokers, denoting significant influence of smoking status on the smaller in size penile arteries and consequently, a unfavorable effect on erectile function. Figure illustrates the differences in cfPWV (left plot) and cIMT (right plot) mean (±SE) values between the three groups. Smokers not receiving statin therapy had significantly higher cfPWV compared to the other groups while smokers under statin therapy had no different cfPWV than that of non-smokers not receiving therapy. The cIMT values were not different between the three groups.

Smoking, statins and vascular changes

Conclusions

Smokers ED patients receiving statin therapy exhibited similar atherosclerotic burden compared to untreated hypercholesterolemic individuals, however, the cfPWV was significantly lower, possibly because of the known pleiotropic effects of these drugs on the aortic elastic properties. Although the cross-sectional design precludes drawing conclusions of causal relationships, the findings of this study have important clinical implications given the harmful effect of both hypercholesterolemia and smoking in men suffering from ED and the higher risk for future cardiovascular events that ED confers.

P6136Intense daily cigarette smoking accelerates vascular damage of smokers with a moderate cumulative tobacco smoke exposure

Purpose

Coronary artery disease death has been associated with increased cigarette smoking intensity. Aim of the study is to investigate the impact of cigarette smoking intensity on vascular function and structure changes among male smokers with similar age at starting smoking and moderate cumulative tobacco smoke exposure.

Methods

Indices of vascular function and structure including carotid-femoral pulse wave velocity (PWV), brachial flow-mediated dilation (bFMD), carotid intima media thickness (cIMT) and microvascular damage (penile vasculature) were measured in 118 smokers consuming up to 1 pack (20 cigarettes)/day and 58 patients smoking >1 pack (20 cigarettes)/day. The two groups had a similar mean cigarette smoking exposure (32 pack/years). Microvascular damage was examined by measuring penile peak systolic velocity (PSV) with a dynamic penile color Doppler ultrasonography after intracavernous injection of prostanglandin E1. Lower PSV values indicate severe penile vascular disease.

Results

The individuals smoking more than 1 pack/day were 10 years younger than smokers consuming up to 1 pack/day, however systolic, diastolic blood pressure, body-mass index, fasting blood glucose levels, lipid profile, C-reactive protein and total testosterone concentration were similar between the two groups. Figure shows mean bFMD, penile PSV, PWV and cIMT of the two groups. Interestingly, despite the similar cumulative smoking exposure between the two groups, the younger in age individuals with the intense cigarette smoking history had significantly lower mean bFMD and penile PSV (all P<0.05) and similar PWV and cIMT compared to the mean values of older subjects smoking up to 1 pack/day.

Smoking intensity and vascular changes

Conclusions

Intense daily smoking accelerates damage of large arteries and significantly impairs microvascular and systemic endothelial function. Considering the predictive value of vascular biomarkers, the findings of this study imply the possibility that baseline daily smoking intensity could be a better summary measure of smoking-related cardiovascular risk among young heavy smokers, relative to total pack-years of smoking.

P5324Children with familial hypercholesterolemia: lipid profile, treatment and evaluation of different formulas for calculating low-density lipoprotein cholesterol: an analysis from the HELLAS-FH registry

Introduction

There is limited data on cardiometabolic characteristics and treatment of underage patients with familial hypercholesterolemia (FH). Accurate estimation of low-density lipoprotein cholesterol is essential to tailor hypolipidemic treatment.

Purpose

To report lipid profile and current treatment of underage patients with FH in Greece as recorded in the HELLAS-FH registry. Also, to compare the Friedewald with the Martin/Hopkins equation, (which provides a customized estimation of VLDL-C) and the Dahlen's formula [(which adjusts the LDL-C measurements for the amount of cholesterol in Lp(a)].

Methods

Underage patients with FH were evaluated. Lipid profile, current treatment regimen as well as LDL-C levels as assessed with different formulas were evaluated.

Results

A total of 191 children were included (51.0% boys, 11.0±3.5 years old). Children at baseline had mean LDL-C as calculated by the Friedewald equation (LDL-CF) 233±65 mg/dL and median Lp(a) 15.3 (IQR 8–51) mg/dL. A total of 59.2% of subjects were receiving hypolipidemic treatment, mainly statins (29.4%) and sterols/stanols (25.5%). Children on hypolipidemic therapy had mean LDL-CF 183±98 mg/dL with 22.1% achieving an LDL-C≤130 mg/dL. When LDL-C was calculated based on the Martin-Hopkins equation (LDL-CM/H) respective values were 180±58 mg/dL and 24.8%. When LDL-C was corrected for Lp(a) [= LDL-CM/H − (Lp(a) * 0.30)], LDL-C was 174±105 mg/dL with 33.3% of patients within the LDL-C target.

Conclusions

Nearly two-thirds of children were receiving some kind of hypolipidemic treatment at the time of registration. For those on treatment, LDL-C goal is achieved by one in five, which rises to 1 in 3 when LDL-C is corrected for Lp(a) levels.

P5302Significant correlation of visceral adiposity and adipocytokines with arterial inflammation in genetic dyslipidaemias

Background

The adipose tissue is now established as a major regulator of cardiovascular status, mediated by the secretion of several bioactive molecules, including adipocytokines. Individuals with genetic dyslipidaemias of either familial combined hyperlipidemia (FCH) or heterozygous familial hypercholesterolemia (heFH) subtype are characterized by accelerated atherosclerosis. Nonetheless, limited data exists on the relationship between adiposity and arterial inflammation, a marker of cardiovascular risk, in this setting.

Purpose

To investigate the relationship between adiposity indices and arterial inflammation evaluated by 18F fluorodeoxyglycose positron emission tomography (PET/CT) in patients with hereditary lipid metabolism disorders.

Methods

Consecutive patients with either FCH or heFH, free of statin therapy, and normolipidaemic individuals underwent PET/CT imaging. Arterial FDG uptake was estimated as the average value of target-to-background ratio (TBR) within aortic and carotid wall. Volumes of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were measured from CT images between the proximal (cephalic) end of the L1 and distal (caudal) end of the L3 vertebrae by selecting all voxels with attenuation between −190 and −30 Hounsfield Units (HU). Serum adiponectin and leptin levels were measured with ELISA by available commercial kits. For comparisons with arterial TBR, adiponectin and leptin concentrations above and below the 25th percentile, were stratified as high and low, respectively.

Results

In total, 60 individuals (20 FCH, 20 heFH and 20 controls) were included. A modest but significant correlation between SAT volume and arterial TBR (R=0.386, p=0.004) was detected. This relationship did not remain significant after controlling for VAT volume (p=0.303). A strong correlation between VAT volume and arterial TBR (R=0.621, p=0.001) was observed. This relationship remained significant after controlling for SAT volume (R=0.541, p<0.001). Arterial TBR values were higher in individuals with low plasma adiponectin levels (p=0.010). In addition, patients with higher leptin levels exhibited increased arterial FDG uptake compared to subjects with low serum leptin concentrations (p=0.05)

Conclusions

Abdominal adipose tissue imaging markers and serum adipocytokines correlate with arterial inflammation as assessed by PET/CT in patients with familial dyslipidaemias highlighting the role of abdominal adipose tissue for atherosclerosis progression in this population.

P730Decreased adiponectin levels and FDG uptake in visceral adipose tissue in familial combined hyperlipidemia compared to heterozygous familial hypercholesterolemia and normolipidemics

Background

Adipose tissue regulates energy balance and glucose homeostasis via the secretion of circulating molecules, termed adipokines, such as leptin and adiponectin. Excess adiposity and adipose tissue dysfunction have been involved in the pathogenesis of dyslipidemias. Positron emission tomography/computed tomography (PET/CT) with F-18-Fluorodeoxyglycose (FDG) has been used for the assessment of adiposity.

Purpose

To compare abdominal adipose tissue function assessed by FDG uptake with serum indices, such as plasma adipokines' levels in individuals with different subtypes of dyslipidemia and normolipidemics.

Methods

Seventy individuals (mean age 44±13 years, range 21–75, 43 men) with a clinical diagnosis of either heterozygous familial hypercholesterolemia (heFH) (n=38) or familial combined hyperlipidemia (FCH) (n=32), not under statins for at least one year, and 20 age and sex matched controls, were enrolled. Visceral (VAT) and subcutaneous adipose tissue metabolic activity (SAT) was assessed with FDG-PET/CT imaging and was quantified by calculating the target-to-background ratios (TBR) in consecutive axial fat images between the proximal (cephalic) end of the L1 and distal (caudal) end of the L3 vertebrae by dividing the average of the mean standard uptake value (SUV) to the mean SUV of the vena cava. Leptin and adiponectin were measured in all the subjects.

Results

There was no significant difference of plasma leptin values between FCH, heFH and non dyslipidemics subjects (p=0.204). FCH had reduced adiponectin values compared to heFH patients and controls [median 5.7 IQR (3.9–7.6) vs. 13.1 (9.2–23.3) vs. 10.9 (6.1–19.1) μg/mL, respectively, p<0.001]. There was no difference in FDG uptake in subcutaneous adipocytes (SATTBR) between FCH, heFH and controls (p=0.161). In contrast, patients with FCH had reduced VATTBR values compared to heFH patients and controls (0.63±0.14 versus 0.81±0.17 versus 0.86±0.28, p=0.005). This difference remained significant even after adjustment for age, sex and cardiovascular risk factors (b=-0.428, p=0.001, adjusted R2=0.219). SATTBR was inversely correlated to leptin levels (r=−0.484, p<0.001), while no significant association was observed with adiponectin values (p=0.167). No significant associations were observed between VATTBR and either serum leptin (p=0.066) or adiponectin levels (p=0.254).

Conclusions

Visceral adipose tissue FDG uptake is reduced in patients with FCH compared to those with heFH and normolipidemics. In addition, serum adiponectin levels are lower in patients with FCH. These findings highlight the different pathophysiological role of visceral fat function in the two most common types of familial dyslipidemia and suggest that visceral fat could be an attractive target for the treatment of FCH.

P5321The association of Lp(a) levels and cardiovascular disease in adult patients with familial hypercholesterolemia: analysis from the HELLAS-FH registry

Introduction

Familial hypercholesterolemia (FH) as well as elevated Lp(a) levels are both associated with increased cardiovascular disease (CVD) risk. There are limited data on the association of Lp(a) levels with CVD in FH Patients.

Purpose

To evaluate the association between Lp(a) levels and CVD in adult FH patients included in the HELLAS-FH registry in Greece.

Methods

Adult patients with FH and measured Lp(a) levels were included in this analysis. Demographics, CVD prevalence and lipid profile were evaluated.

Results

A total of 337 patients were evaluated (46% male, 48.3±15.4 years old). The median [IQR] of Lp(a) at baseline was 22.6 (9.7–56.2) mg/dL. Patients were categorized into 4 different groups according to the Lp(a) levels quartiles. There was no gender or age difference between the 4 groups. Moreover, all groups had similar smoking status, hypertension, body mass index and type 2 diabetes prevalence. There was no significant difference between groups regarding baseline and on treatment lipid profile. We observed a significant positive association between Lp(a) quartile and coronary artery disease (CAD) prevalence (p=0.004). Patients in the highest vs lowest quartile had greater CAD prevalence (21.7% vs 7%, p=0.006). No association was observed between Lp(a) quartile and the prevalence of cerebrovascular disease or peripheral artery disease.

Conclusions

Elevated Lp(a) levels have a positive correlation with CAD in patients with FH.

Visceral adiposity index outperforms common anthropometric indices in predicting 10-year diabetes risk: Results from the ATTICA study

BACKGROUND

Visceral adiposity index (VAI) is a novel marker of visceral adipose tissue accumulation and dysfunction. The study aim was to explore the association of VAI with the 10-year type 2 diabetes mellitus (T2DM) incidence in apparently healthy individuals and compare its T2DM predictive ability against common anthropometric indices.

METHODS

In 2001 to 2002, the ATTICA study (Greece) recruited a random sample of 1514 and 1528 CVD-free men (18-87 years old) and women (18-89 years old), respectively. Sociodemographic, lifestyle, clinical, and biochemical characteristics of participants were measured at baseline, and the 10-year follow-up was performed during 2011 to 2012. After excluding participants with diabetes at baseline and participants without complete follow-up information regarding diabetes status and/or baseline VAI values, the working sample consisted of 1049 participants. In this sample, the predictive value of baseline VAI value was studied in relation to 10-year diabetes incidence.

RESULTS

One hundred thirty-three incident cases of diabetes were documented (10-year incidence: 12.7%). In the fully adjusted model, VAI significantly increased diabetes risk by 22% (OR per 1-unit increase =1.22; 95%CI, 1.09-1.37). Markers of oxidative stress and inflammation were found to, at least partly, mediate this relationship. Also, a moderating effect of menstruation status was revealed among women. VAI showed the highest predictive ability and contributed the most, along with waist-to-height ratio, to the correct classification of participants who developed diabetes.

CONCLUSIONS

The present findings suggest that VAI may be a useful index for predicting long-term diabetes development and may exhibit better predictive ability to commonly used anthropometric indices.