[Familial hypercholesterolemia: An under-diagnosed and under-treated disease. Survey of 495 physicians]

Cascade screening in familial hypercholesterolaemia is associated with earlier statin initiation and fewer cardiovascular events than opportunistic screening

AIMS

The aim of this study is to assess whether the family cascade screening strategy for identifying patients with heterozygous familial hypercholesterolaemia (HeFH) is associated with a reduction in cardiovascular events compared with opportunistic screening strategies.

METHODS AND RESULTS

We retrospectively included 3232 patients, from the French FH registry, REFERCHOL, with a molecular diagnosis. We compared patients according to their screening strategy for HeFH: index cases (opportunistic screening) and cascade screening cases (patients diagnosed by cascade screening) on clinical and biological characteristics. We first compared patients according to screening modality using χ² and Student's t-tests and performed multivariate logistic regression to assess the association between screening strategy and the risk of cardiovascular events. We finally performed the same tests in an age- and sex-matched subpopulation. Compared with index cases (2106 patients), cascade screening cases (1126 patients) started statin use 14 years earlier [18.1 (interquartile range 12.5-29.1) years vs. 31.8 (19.7-42.4) years, P < 0.001] and 8.3% had a cardiovascular event prior to the first visit, vs. 26.5% in the index cases group (P < 0.001). In multivariate logistic regression, the cascade screening was independently associated with 51% less atherosclerotic cardiovascular disease (ASCVD) than the opportunistic screening. Age at statin initiation was also associated with ASCVD, with a higher adjusted odd ratio for higher age categories. In an age- and sex-matched analysis, cascade screening was no longer associated with ASCVD, but age at statin initiation remained.

CONCLUSION

The cascade screening strategy for familial hypercholesterolaemia is associated with 51% fewer cardiovascular events in genetically confirmed heFH probably due to an earlier age at treatment initiation.

Mapping of familial hypercholesterolemia and dyslipidemias basic management infrastructure in Pakistan: a cross-sectional study

BACKGROUND

Familial hypercholesterolemia (FH) is an autosomal inherited disorder characterised by elevated low-density lipoprotein cholesterol and premature cardiovascular events. Despite being declared as a public health priority, FH remains highly underdiagnosed, generally due to the lack of awareness and shortcomings in the available infrastructure, particularly in lower income countries.

METHODS

To map the existing infrastructure for the management of FH, a survey was conducted among 128 physicians (cardiologists, paediatricians, endocrinologists, and internal medicine specialists) from different regions of Pakistan.

FINDINGS

The respondents encountered a limited number of adults or children with diagnosed FH. A very small proportion of the population had access to free cholesterol and genetic testing even when indicated by a physician. In general, cascade screening of the relatives was not performed. Uniform diagnostic criteria for FH had not been established even within the same institution or province. The use of statins and ezetimibe in addition to lifestyle changes were the most common recommended treatment option for FH patients. The respondents considered lack of financial resources as a major barrier for the management of FH and stressed on taking relevant measures for a uniform FH screening programs around the country.

INTERPRETATION

National FH screening programmes are not in place worldwide hence FH is commonly undiagnosed, and many individuals are at a high risk for cardiovascular diseases. Timely screening of population for FH requires knowledge about FH among the clinicians and the availability of fundamental infrastructure coupled with sufficient financial resources.

FUNDING

The authors confirm independence from the sponsor. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. FS received funding from Higher Education Commission, Pakistan (Grant 20-15760) and UG received grants from Slovenian Research Agency (J3-2536, P3-0343).

Familial Hypercholesterolemia in the Arabian Gulf Region: Clinical results of the Gulf FH Registry

BACKGROUND AND AIMS

Familial hypercholesterolemia (FH) is a common autosomal dominant disorder that can result in premature atherosclerotic cardiovascular disease (ASCVD). Limited data are available worldwide about the prevalence and management of FH. Here, we aimed to estimate the prevalence and management of patients with FH in five Arabian Gulf countries (Saudi Arabia, Oman, United Arab Emirates, Kuwait, and Bahrain).

METHODS

The multicentre, multinational Gulf FH registry included adults (≥18 years old) recruited from outpatient clinics in 14 tertiary-care centres across five Arabian Gulf countries over the last five years. The Gulf FH registry had four phases: 1- screening, 2- classification based on the Dutch Lipid Clinic Network, 3- genetic testing, and 4- follow-up.

RESULTS

Among 34,366 screened patient records, 3713 patients had suspected FH (mean age: 49±15 years; 52% women) and 306 patients had definite or probable FH. Thus, the estimated FH prevalence was 0.9% (1:112). Treatments included high-intensity statin therapy (34%), ezetimibe (10%), and proprotein convertase subtilisin/kexin type 9 inhibitors (0.4%). Targets for low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol were achieved by 12% and 30%, respectively, of patients at high ASCVD risk, and by 3% and 6%, respectively, of patients at very high ASCVD risk (p <0.001; for both comparisons).

CONCLUSIONS

This snap-shot study was the first to show the high estimated prevalence of FH in the Arabian Gulf region (about 3-fold the estimated prevalence worldwide), and is a "call-to-action" for further confirmation in future population studies. The small proportions of patients that achieved target LDL-C values implied that health care policies need to implement nation-wide screening, raise FH awareness, and improve management strategies for FH.