A case of premature and recurrent myocardial infarction associated with ABCA.1 gene mutation

Coronary heart disease (CHD) is the most important cause of cardiovascular death and when premature, it affects the most productive population of the community. Premature CHD usually has a specific etiology, which on diagnosis, might help in the secondary prevention in that individual. We report a case of young adult with recurrent myocardial infarction, who on evaluation had mildly reduced HDL and Protein C levels with elevated serum homocysteine. Clinical exome identified a possibly pathogenic variant of ABCA1 gene, associated with Tangier disease.

Lysosomal acid lipase deficiency - early diagnosis is the key

Lysosomal acid lipase deficiency (LAL-D) is an ultra-rare lysosomal storage disease that may present from infancy to late adulthood depending on residual enzyme activity. While the severe form manifests as a rapidly progressive disease with near universal mortality within the first 6 months of life, milder forms frequently go undiagnosed for prolonged periods and typically present with progressive fatty liver disease, enlarged spleen, atherogenic dyslipidemia and premature atherosclerosis. The adult variant of LAL-D is typically diagnosed late or even overlooked due to the unspecific nature of the presenting symptoms, which are similar to common changes observed in the context of the metabolic syndrome. This review is aimed at delineating clinically useful scenarios in which pediatric or adult medicine clinicians should be aware of LAL-D as a differential diagnosis for selected patients. This is particularly relevant as a potentially life-saving enzyme replacement therapy has become available and the diagnosis can easily be ruled out or confirmed using a dried blood spot test.

Managing dyslipidaemia in type 2 diabetes mellitus

Glucose-control has a modest beneficial effect on cardiovascular outcomes in patients with type 2 diabetes mellitus. Thus, managing other atherogenic risk factors including hypertriglyceridemia, low HDL-cholesterol and moderately elevated LDL-cholesterol levels with increased small dense LDL-cholesterol fraction, is crucial. Insulin resistance is a key pathophysiologic factor in this population. Treatment starts with lifestyle modifications, but current best programmes have not translated into positive cardiovascular outcomes. Lowering LDL-cholesterol with statins is currently the main treatment strategy, but significant residual risk remains. Attempts to elevate HDL-cholesterol and to reduce triglycerides levels, with niacin or fibrates have not improved cardiovascular prognosis, but addition of ezetimibe, or fibrates in specific patients subgroups, have shown modest benefit. Some glucose-lowering medications and bariatric surgery may also improve diabetic dyslipidemia. Results of three major cardiovascular outcome trials evaluating the effect of lowering LDL-cholesterol with PCSK9 inhibitors in large cohorts that include thousands of diabetic patients are pending.

Low High-Density Lipoprotein and Risk of Myocardial Infarction

Low HDL is an independent risk factor for myocardial infarction. This paper reviews our current understanding of HDL, HDL structure and function, HDL subclasses, the relationship of low HDL with myocardial infarction, HDL targeted therapy, and clinical trials and studies. Furthermore potential new agents, such as alirocumab (praluent) and evolocumab (repatha) are discussed.