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Delgado-Lista J, Mostaza JM, Arrobas-Velilla T, Blanco-Vaca F, Masana L, Pedro-Botet J, Perez-Martinez P, Civeira F, Cuende-Melero JI, Gomez-Barrado JJ, Lahoz C, Pintó X, Suarez-Tembra M, Lopez-Miranda J, Guijarro C. Consensus on lipoprotein(a) of the Spanish Society of Arteriosclerosis. Literature review and recommendations for clinical practice. Clin Investig Arterioscler 2024:S0214-9168(24)00023-8. [PMID: 38599943 DOI: 10.1016/j.arteri.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/12/2024]
Abstract
The irruption of lipoprotein(a) (Lp(a)) in the study of cardiovascular risk factors is perhaps, together with the discovery and use of proprotein convertase subtilisin/kexin type 9 (iPCSK9) inhibitor drugs, the greatest novelty in the field for decades. Lp(a) concentration (especially very high levels) has an undeniable association with certain cardiovascular complications, such as atherosclerotic vascular disease (AVD) and aortic stenosis. However, there are several current limitations to both establishing epidemiological associations and specific pharmacological treatment. Firstly, the measurement of Lp(a) is highly dependent on the test used, mainly because of the characteristics of the molecule. Secondly, Lp(a) concentration is more than 80% genetically determined, so that, unlike other cardiovascular risk factors, it cannot be regulated by lifestyle changes. Finally, although there are many promising clinical trials with specific drugs to reduce Lp(a), currently only iPCSK9 (limited for use because of its cost) significantly reduces Lp(a). However, and in line with other scientific societies, the SEA considers that, with the aim of increasing knowledge about the contribution of Lp(a) to cardiovascular risk, it is relevant to produce a document containing the current status of the subject, recommendations for the control of global cardiovascular risk in people with elevated Lp(a) and recommendations on the therapeutic approach to patients with elevated Lp(a).
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Affiliation(s)
- Javier Delgado-Lista
- Unidad de Lípidos y Aterosclerosis, Servicio de Medicina Interna, Hospital Universitario Reina Sofía; Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba; IMIBIC, Córdoba; CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, España.
| | - Jose M Mostaza
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid, España
| | - Teresa Arrobas-Velilla
- Sociedad Española de Medicina de Laboratorio (SEQCML), Laboratorio de Bioquímica Clínica, Hospital Universitario Virgen Macarena, Sevilla, España
| | - Francisco Blanco-Vaca
- Departamento de Bioquímica Clínica, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona; Departamento de Bioquímica y Biología Molecular, Universitat Autònoma de Barcelona, 08193 Barcelona; CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, España
| | - Luis Masana
- Unidad de Medicina Vascular y Metabolismo, Hospital Universitari Sant Joan, Universitat Rovira i Virgili, IISPV, CIBERDEM, Reus, Tarragona, España
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Barcelona; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Pablo Perez-Martinez
- Unidad de Lípidos y Aterosclerosis, Servicio de Medicina Interna, Hospital Universitario Reina Sofía; Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba; IMIBIC, Córdoba; CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, España
| | - Fernando Civeira
- Unidad Clínica y de Investigación en Lípidos y Arteriosclerosis, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, IIS Aragón, Universidad de Zaragoza, Zaragoza; CIBER Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, España
| | - Jose I Cuende-Melero
- Consulta de Riesgo Vascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia; Departamento de Medicina, Dermatología y Toxicología, Facultad de Medicina, Universidad de Valladolid, Valladolid, España
| | - Jose J Gomez-Barrado
- Unidad de Cuidados Cardiológicos Agudos y Riesgo Cardiovascular, Servicio de Cardiología, Hospital Universitario San Pedro de Alcántara, Cáceres, España
| | - Carlos Lahoz
- Unidad de Lípidos y Arteriosclerosis, Servicio de Medicina Interna, Hospital La Paz-Carlos III, Madrid, España
| | - Xavier Pintó
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge-Idibell-Universidad de Barcelona-CiberObn, España
| | - Manuel Suarez-Tembra
- Unidad de Lípidos y RCV, Servicio de Medicina Interna, Hospital San Rafael, A Coruña, España
| | - Jose Lopez-Miranda
- Unidad de Lípidos y Aterosclerosis, Servicio de Medicina Interna, Hospital Universitario Reina Sofía; Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba; IMIBIC, Córdoba; CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, España.
| | - Carlos Guijarro
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
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Abstract
Prolonged or excessive exposure to oxidized phospholipids (OxPLs) generates chronic inflammation. OxPLs are present in atherosclerotic lesions and can be detected in plasma on apolipoprotein B (apoB)-containing lipoproteins. When initially conceptualized, OxPL-apoB measurement in plasma was expected to reflect the concentration of minimally oxidized LDL, but, surprisingly, it correlated more strongly with plasma lipoprotein(a) (Lp(a)) levels. Indeed, experimental and clinical studies show that Lp(a) particles carry the largest fraction of OxPLs among apoB-containing lipoproteins. Plasma OxPL-apoB levels provide diagnostic information on the presence and extent of atherosclerosis and improve the prognostication of peripheral artery disease and first and recurrent myocardial infarction and stroke. The addition of OxPL-apoB measurements to traditional cardiovascular risk factors improves risk reclassification, particularly in patients in intermediate risk categories, for whom improving decision-making is most impactful. Moreover, plasma OxPL-apoB levels predict cardiovascular events with similar or greater accuracy than plasma Lp(a) levels, probably because this measurement reflects both the genetics of elevated Lp(a) levels and the generalized or localized oxidation that modifies apoB-containing lipoproteins and leads to inflammation. Plasma OxPL-apoB levels are reduced by Lp(a)-lowering therapy with antisense oligonucleotides and by lipoprotein apheresis, niacin therapy and bariatric surgery. In this Review, we discuss the role of role OxPLs in the pathophysiology of atherosclerosis and Lp(a) atherogenicity, and the use of OxPL-apoB measurement for improving prognosis, risk reclassification and therapeutic interventions.
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Affiliation(s)
- Sotirios Tsimikas
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA.
| | - Joseph L Witztum
- Division of Endocrinology and Metabolism, University of California San Diego, La Jolla, CA, USA
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Orfanos P, Fonseca AF, Hu X, Gautam R, Montgomery G, Studer R, Kaur J, Saxena N, Kaushik N. Burden of elevated lipoprotein(a) among patients with atherosclerotic cardiovascular disease: Evidence from a systematic literature review and feasibility assessment of meta-analysis. PLoS One 2023; 18:e0294250. [PMID: 37983217 PMCID: PMC10659166 DOI: 10.1371/journal.pone.0294250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Elevated lipoprotein(a) [Lp(a)] level is an independent genetic risk factor that increases the risk of atherosclerotic cardiovascular disease (ASCVD) by 2-4 fold. We aimed to report the burden of clinically relevant elevated Lp(a) in secondary prevention ASCVD population as the evaluation of such evidence is lacking. METHODS A systematic literature review (SLR) was conducted using Embase®, MEDLINE®, and MEDLINE® In-Process databases to identify studies reporting burden of elevated Lp(a) levels from January 1, 2010, to March 28, 2022. Full-text, English-language studies including ≥500 participants with ≥1 Lp(a) assessment were included. RESULTS Sixty-one studies reported clinical burden of elevated Lp(a). Of these, 25 observational studies and one clinical trial reported clinical burden of clinically relevant elevated Lp(a) levels. Major clinical outcomes included major adverse cardiovascular event (MACE; n = 20), myocardial infarction (MI; n = 11), revascularization (n = 10), stroke (n = 10), cardiovascular (CV) mortality (n = 9), and all-cause mortality (n = 10). Elevated Lp(a) levels significantly increased the risk of MACE (n = 15) and revascularization (n = 8), while they demonstrated a trend for positive association with remaining CV outcomes. Meta-analysis was not feasible for included studies due to heterogeneity in Lp(a) thresholds, outcome definitions, and patient characteristics. Three studies reported humanistic burden. Patients with elevated Lp(a) levels had higher odds of manifesting cognitive impairment (odds ratio [OR] [95% confidence interval; CI]: 1.62 [1.11-2.37]) and disability related to stroke (OR [95% CI]:1.46 [1.23-1.72)]) (n = 2). Elevated Lp(a) levels negatively correlated with health-related quality of life (R = -0.166, p = 0.014) (n = 1). A single study reported no association between elevated Lp(a) levels and economic burden. CONCLUSIONS This SLR demonstrated a significant association of elevated Lp(a) levels with major CV outcomes and increased humanistic burden in secondary prevention ASCVD population. These results reinforce the need to quantify and manage Lp(a) for CV risk reduction and to perform further studies to characterize the economic burden.
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Affiliation(s)
| | | | - Xingdi Hu
- Value and Access, Novartis Pharmaceutical Corporation, East Hanover, New Jersey, United States of America
| | - Raju Gautam
- Value and Access, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | | | - Rachel Studer
- Value and Access, Novartis Pharma AG, Basel, Switzerland
| | - Japinder Kaur
- Value and Access, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Nehul Saxena
- Value and Access, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Nitin Kaushik
- Value and Access, Novartis Healthcare Pvt. Ltd., Hyderabad, India
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Ma GS, Chiou TT, Wilkinson MJ. Is Lipoprotein(a) Clinically Actionable with Today's Evidence? The Answer is Yes. Curr Cardiol Rep 2023; 25:1175-1187. [PMID: 37632608 PMCID: PMC10651710 DOI: 10.1007/s11886-023-01937-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE OF REVIEW Lipoprotein(a) is an independent risk factor for cardiovascular disease. We review the ongoing shifts in consensus guidelines for the testing and management of Lp(a) and provide insight into whether current evidence suggests that awareness and testing of Lp(a) is clinically actionable. RECENT FINDINGS GWAS and Mendelian randomization studies have established causal links between elevated Lp(a) and forms of CVD, including CAD and calcific aortic valve disease. Testing of Lp(a) identifies patients with similar risk to that of heterozygous FH, enhances risk stratification in patients with borderline/intermediate risk as determined through traditional factors, and facilitates the assessment of inherited CVD risk through cascade screening in patients with known family history of elevated Lp(a). Reductions in Lp(a) through non-targeted therapies including PCSK9 inhibition and lipoprotein apheresis have demonstrated reductions in ASCVD risk that are likely attributable to lowering Lp(a). Targeted therapies to potently lower Lp(a) are in clinical development. Lp(a) is actionable, and can be used to identify high risk patients for primary prevention and their family members through cascade screening, and to guide intensification of therapy in primary and secondary prevention of ASCVD.
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Affiliation(s)
- Gary S Ma
- Division of Cardiovascular Medicine, Department of Medicine, Cardiovascular Institute, UC San Diego Health, Sulpizio Cardiovascular Center, University of California San Diego, 9434 Medical Center Dr, MC 7241, La Jolla, CA, 92037, San Diego, USA
| | - Tommy T Chiou
- Division of Cardiovascular Medicine, Department of Medicine, Cardiovascular Institute, UC San Diego Health, Sulpizio Cardiovascular Center, University of California San Diego, 9434 Medical Center Dr, MC 7241, La Jolla, CA, 92037, San Diego, USA
| | - Michael J Wilkinson
- Division of Cardiovascular Medicine, Department of Medicine, Cardiovascular Institute, UC San Diego Health, Sulpizio Cardiovascular Center, University of California San Diego, 9434 Medical Center Dr, MC 7241, La Jolla, CA, 92037, San Diego, USA.
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Koschinsky ML, Stroes ESG, Kronenberg F. Daring to dream: Targeting lipoprotein(a) as a causal and risk-enhancing factor. Pharmacol Res 2023; 194:106843. [PMID: 37406784 DOI: 10.1016/j.phrs.2023.106843] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
Lipoprotein(a) [Lp(a)], a distinct lipoprotein class, has become a major focus for cardiovascular research. This review is written in light of the recent guideline and consensus statements on Lp(a) and focuses on 1) the causal association between Lp(a) and cardiovascular outcomes, 2) the potential mechanisms by which elevated Lp(a) contributes to cardiovascular diseases, 3) the metabolic insights on the production and clearance of Lp(a) and 4) the current and future therapeutic approaches to lower Lp(a) concentrations. The concentrations of Lp(a) are under strict genetic control. There exists a continuous relationship between the Lp(a) concentrations and risk for various endpoints of atherosclerotic cardiovascular disease (ASCVD). One in five people in the Caucasian population is considered to have increased Lp(a) concentrations; the prevalence of elevated Lp(a) is even higher in black populations. This makes Lp(a) a cardiovascular risk factor of major public health relevance. Besides the association between Lp(a) and myocardial infarction, the relationship with aortic valve stenosis has become a major focus of research during the last decade. Genetic studies provided strong support for a causal association between Lp(a) and cardiovascular outcomes: carriers of genetic variants associated with lifelong increased Lp(a) concentration are significantly more frequent in patients with ASCVD. This has triggered the development of drugs that can specifically lower Lp(a) concentrations: mRNA-targeting therapies such as anti-sense oligonucleotide (ASO) therapies and short interfering RNA (siRNA) therapies have opened new avenues to lower Lp(a) concentrations more than 95%. Ongoing Phase II and III clinical trials of these compounds are discussed in this review.
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Affiliation(s)
- Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada; Department of Physiology & Pharmacology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria.
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Krittanawong C, Maitra NS, El-Sherbini AH, Shah N, Lavie CJ, Shapiro MD, Virani SS. Lipoprotein(a) in clinical practice: A guide for the clinician. Prog Cardiovasc Dis 2023; 79:28-36. [PMID: 37516261 DOI: 10.1016/j.pcad.2023.07.006] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 07/31/2023]
Abstract
Cardiovascular disease (CVD) remains the leading cause of death worldwide. Serum lipoprotein(a) (Lp(a)) has been shown to be an independent and causative risk factor for atherosclerotic CVD and calcific aortic valvular disease. Lp(a) continues to be studied, with emerging insights into the epidemiology of CVD with respect to Lp(a), pathogenic mechanisms of Lp(a) and strategies to mitigate disease. There have been novel insights into genetic polymorphisms of the LPA gene, interactions between concomitant risk factors and Lp(a) based on real-world data, and metabolic pathway targets for Lp(a) reduction. This review highlights these recent advances in our understanding of Lp(a) and discusses management strategies as recommended by cardiovascular professional societies, emerging therapies for lowering Lp(a), and future directions in targeting Lp(a) to reduce CVD.
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Affiliation(s)
- Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY, United States of America.
| | - Neil Sagar Maitra
- Division of Cardiology, Scripps Clinic, La Jolla, CA, United States of America
| | - Adham H El-Sherbini
- Faculty of Health Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Nishant Shah
- Division of Cardiology, Duke Heart Center, Duke University, 2301 Erwin RD, Durham, NC, United States of America
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, United States of America
| | - Michael D Shapiro
- Section on Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America; Center for Prevention of Cardiovascular Disease, Medical Center Boulevard, Winston Salem, NC, United States of America
| | - Salim S Virani
- Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, United States of America; Office of the Vice Provost (Research), The Aga Khan University, Karachi 74800, Pakistan
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Matveyenko A, Pavlyha M, Reyes-Soffer G. Supporting evidence for lipoprotein(a) measurements in clinical practice. Best Pract Res Clin Endocrinol Metab 2023; 37:101746. [PMID: 36828715 PMCID: PMC11014458 DOI: 10.1016/j.beem.2023.101746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
High levels of lipoprotein(a) [Lp(a)] are causal for development of atherosclerotic cardiovascular disease and highly regulated by genetics. Levels are higher in Blacks compared to Whites, and in women compared to men. Lp(a)'s main protein components are apolipoprotein (apo) (a) and apoB100, the latter being the main component of Low-Density Lipoprotein (LDL) particles. Studies have identified Lp(a) to be associated with inflammatory, coagulation and wound healing pathways. Lack of validated and accepted assays to measure Lp(a), risk cutoff values, guidelines for diagnosis, and targeted therapies have added challenges to the field. Scientific efforts are ongoing to address these, including studies evaluating the cardiovascular benefits of decreasing Lp(a) levels with targeted apo(a) lowering treatments. This review will provide a synopsis of evidence-based effects of high Lp(a) on disease presentation, highlight available guidelines and discuss promising therapies in development. We will conclude with current clinical information and future research needs in the field.
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Affiliation(s)
- Anastasiya Matveyenko
- Columbia University College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, P&S 10-501, New York, NY 10032, USA.
| | - Marianna Pavlyha
- Columbia University College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, P&S 10-501, New York, NY 10032, USA.
| | - Gissette Reyes-Soffer
- Columbia University College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, P&S 10-501, New York, NY 10032, USA.
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Schatz U, Schettler VJ, Julius U. State of the Art: Lipoproteinapherese. Dtsch Med Wochenschr 2023; 148:e44-e54. [PMID: 36990113 PMCID: PMC10060055 DOI: 10.1055/a-1516-2761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
Lipoprotein apheresis (LA) is usually a last resort in cardiovascular high-risk patients in the context of secondary prevention after lifestyle measures and maximal pharmacotherapy have failed to prevent the occurrence of new atherosclerotic cardiovascular events (ASCVDE) or to achieve the internationally accepted target values for LDL cholesterol (LDL-C). Patients with homozygous familial hypercholesterolemia (hoFH), in whom myocardial infarctions can occur even in children < 10 years of age without adequate therapy, often owe their survival to LA (used here in primary prevention). Severe hypercholesterolemia (HCH) can often be well controlled with modern potent lipid-lowering agents, including PCSK9 approaches, so that the need for LA has decreased here over the years. In contrast, the number of patients in whom elevation of lipoprotein(a) (Lp(a)) is relevant to atherogenesis is increasing in applications to the apheresis committees of the associations of panel physicians (KV). For this indication, LA is currently the only therapeutic procedure approved by the Federal Joint Committee (G-BA). LA significantly reduces the new occurrence of ASCVDE (comparison with the situation before the start of LA), especially in Lp(a) patients. There are convincing observational studies and a German LA Registry with now 10-year data, but there is no randomized controlled trial. This had been requested by the G-BA in 2008, and a corresponding concept was designed but not accepted by the ethics committee. In addition to the highly effective reduction of atherogenic lipoproteins, many discussed pleiotropic effects of LA itself, the medical rounds and motivating discussions also with the nursing staff, which take place within the weekly LA, certainly contribute to the success of the therapy (steady adjustment of all cardiovascular risk factors, lifestyle measures including smoking cessation, adherence of medication intake). This review article summarizes and discusses the study situation, clinical practical experience as well as the future of LA against the background of the currently rapid development of new pharmacotherapies.
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Parhofer KG. Apheresis: What Should a Clinician Know? Curr Atheroscler Rep 2023; 25:77-83. [PMID: 36701088 PMCID: PMC9947033 DOI: 10.1007/s11883-023-01081-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Apheresis is a treatment option for severe dyslipidemia which has been introduced approximately 40 years ago to clinical practice. This article reviews recent apheresis research progresses, including apheresis for elevated LDL-cholesterol and elevated lipoprotein(a). RECENT FINDINGS While the role of apheresis in treating more common forms of LDL-hypercholesterolemia has been reduced due to the development of new, very potent LDL-lowering drugs, it still plays an important role in treating patients with homozygous familial hypercholesterolemia and patients with severe lipoprotein(a) elevation. One apheresis session can decrease LDL-cholesterol, apoB, and lipoprotein(a) by approximately 65%, which results in a time averaged reduction of 30-50%. Although time-consuming, and expensive regular apheresis is very well tolerated and has been proven safe for decades. Apheresis remains a treatment option for severe dyslipidemia, especially in homozygous familial hypercholesterolemia and elevated lipoprotein(a), if other forms of therapy fail to achieve targets.
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Affiliation(s)
- Klaus G Parhofer
- Medical Department IV - Grosshadern, University Munich, Marchioninistraße 15, 81377, Munich, Germany.
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Wang H, Zheng H, Meng P, Cao X, Liu J, Zhang T, Zuo H, Wang Z. Relationship between lipoprotein(a) and colorectal cancer among inpatients: a retrospective study. Front Oncol 2023; 13:1181508. [PMID: 37213310 PMCID: PMC10196502 DOI: 10.3389/fonc.2023.1181508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 04/24/2023] [Indexed: 05/23/2023] Open
Abstract
The present study was to explore the association between lipoprotein(a) [Lp(a)] and colorectal cancer (CRC) among inpatients. This study included 2822 participants (393 cases vs. 2429 controls) between April 2015 and June 2022. Logistic regression models, smooth curve fitting, and sensitivity analyses were performed to investigate the relationship between Lp(a) and CRC. Compared with the lower Lp(a) quantile 1 (<79.6 mg/L), the adjusted odds ratios (ORs) in quantile 2 (79.6-145.0 mg/L), quantile 3 (146.0-299.0 mg/L), and quantile 4 (≥300.0 mg/L) were 1.41 (95% confidence interval [CI]: 0.95-2.09), 1.54 (95% CI: 1.04-2.27), 1.84 (95% CI: 1.25-2.7), respectively. A linear relationship between lipoprotein(a) and CRC was observed. The finding that Lp(a) has a positive association with CRC supports the "common soil" hypothesis of cardiovascular disease (CVD) and CRC.
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Affiliation(s)
- Huijie Wang
- Department of Endoscopy, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, China
| | - Huanwei Zheng
- Department of Gastroenterology, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, China
- *Correspondence: Huanwei Zheng,
| | - Ping Meng
- Department of Gastroenterology, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, China
| | - Xu Cao
- Department of Endoscopy, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, China
| | - Jinli Liu
- Department of Endoscopy, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, China
| | - Teng Zhang
- Institute of Traditional Chinese Medicine, North China University of Science and Technology, Tangshan, China
| | - Haiying Zuo
- Graduate School, Hebei North University, Zhangjiakou, China
| | - Zhichao Wang
- Graduate School, Hebei North University, Zhangjiakou, China
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Pei J, Liu C, Yang Z, Lai Y, Zhang S, Guan T, Shen Y. Association of KATP variants with CMD and RAP in CAD patients with increased serum lipoprotein(a) levels. J Clin Endocrinol Metab 2022; 108:1061-1074. [PMID: 36469795 DOI: 10.1210/clinem/dgac709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Refractory angina pectoris (RAP) is a specific subtype of coronary artery disease (CAD). Lipoprotein(a) [Lp(a)] and its induced coronary microvascular dysfunction (CMD) play an important role in pathogenesis of RAP, but its metabolism was mostly genetically determined. ATP-sensitive potassium channels (KATP) is involved in lipid metabolism and microvascular homeostasis, and becomes a promising target for the management of Lp(a) and its related RAP. OBJECTIVE To investigate associations of KATP variants with hyperlipoprotein(a)emia, CMD and RAP in CAD patients. DESIGN, PATIENTS, SETTINGS A total of 1,148 newly diagnosed CAD patients were prospectively selected, and divided into control [Lp(a) < 180 mg/dL] and case [Lp(a) ≥ 180 mg/dL, hyperlipoprotein(a)emia] group. METHODS 9 KATP variants were genotyped by MassARRAY system. The expression profile of exosome-derived microRNAs (exo-miRs) was identified by next-generation sequencing, and the expression levels of differentially expressed exo-miRs were evaluated by qRT-PCR in verification cohort. RESULTS Three KATP variants were associated with increased risk of hyperlipoprotein(a)emia in CAD patients as follows: rs2285676 (AA + GA genotype, adjusted OR = 1.44, 95% CI: 1.10-1.88, P = 0.008), rs1799858 (CC genotype, adjusted OR = 1.33, 95% CI: 1.03-1.73, P = 0.030), and rs141294036 (CC genotype, adjusted OR = 1.43, 95% CI: 1.10-1.87, P = 0.008). Only rs141294036 was associated with increased risk of CMD (CC genotype, adjusted OR = 1.62, 95% CI: 1.23-2.13, P = 0.001), and further with increased RAP risk (CC genotype, adjusted HR = 2.05, 95% CI: 1.22-3.43, P = 0.007) after median follow-up of 50.6-months. Between the two genotypes of rs141294036, 152 exo-miRs were significantly differentially expressed, only 10 exo-miRs (miR-7110-3p, miR-548az-5p, miR-214-3p, let-7i-5p, miR-218-5p, miR-128-3p, miR-378i, miR-625-3p, miR-128-1-5p and miR-3187-3p) were further confirmed in RAP patients with hyperlipoprotein(a)emia and CMD. CONCLUSION KATP rs141294036 may serve a potential genetic marker for hyperlipoprotein(a)emia, CMD and RAP in CAD patients.
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Affiliation(s)
- Jingxian Pei
- Department of Cardiology, the second affiliated hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Cheng Liu
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou 510180, China
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou 510180, China
| | - Zhengxia Yang
- Department of Electronic Business, School of Economics and Finance, South China University of Technology, Guangzhou 510006, China
| | - Yanxian Lai
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou 510180, China
| | - Shenghui Zhang
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou 510180, China
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510180, China
| | - Tianwang Guan
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou 510180, China
| | - Yan Shen
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou 510180, China
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12
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Schettler VJJ, Schettler E. Beyond cholesterol-pleiotropic effects of lipoprotein apheresis. Ther Apher Dial 2022; 26 Suppl 1:35-40. [PMID: 36468323 DOI: 10.1111/1744-9987.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 03/21/2022] [Accepted: 04/15/2022] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease is a leading cause of mortality worldwide, which is caused mainly by atherosclerosis, a chronic inflammatory disease of blood vessels. Therefore, atherosclerosis represents a complex disorder, which induces damage or imbalance on different levels: for example, genes, cytokines, lipoproteins, cells, vessels, and organs. Lipoprotein apheresis (LA) is a well-established extracorporeal treatment of severe hyperlipoproteinemia. In addition, LA may have simultaneously crucial effects on many other atherogenic factors during the treatments, for example, as vascular inflammation, rheology, mobilization of adult stem cells and gene expressions in blood or endothelial cells, which will be discussed in this short review. In addition, stable microRNAs besides tissues also appear in extracellular compartments, for example, vessels, involved in atherosclerotic processes, were found to be reduced by LA treatments. In summary, LA represents a complex therapeutic procedure, that provides an ideal tool for the treatment of complex disorders such as atherosclerosis.
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Affiliation(s)
| | - Elke Schettler
- BRAVE - Benefit for Research on Arterial Hypertension, Dyslipidemia and Vascular Risk and Education e.V., Göttingen, Germany
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13
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Li J, Ma C, Zhao D, Yan X, Li J, Ma C, Zhao D, Yan X, Ye P, Chen H, Li Y, Yuan Z, Zhang R, Zhao S, Lu G, Liang C, Dong Y, Chen Z, Peng D, Tang Y, Wang F, Zhou Z, Sun Y, Liu J, Guo Y, Yuan H, Wu N, Zhu Y. Lipoprotein(a) and Cardiovascular Disease in Chinese Population. JACC: Asia 2022; 2:653-665. [PMID: 36444328 PMCID: PMC9700018 DOI: 10.1016/j.jacasi.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022]
Abstract
Elevated concentration of lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease, including coronary artery disease, stroke, peripheral artery disease, and so on. Emerging data suggest that Lp(a) contributes to the increased risk for cardiovascular events even in the setting of effective reduction of plasma low-density lipoprotein cholesterol. Nevertheless, puzzling issues exist covering potential genetic factors, Lp(a) assay, possible individuals for analysis, a cutoff point of increased risk, and clinical interventions. In the Chinese population, Lp(a) exhibited a distinctive prevalence and regulated various cardiovascular diseases in specific ways. Hence, it is valuable to clarify the role of Lp(a) in cardiovascular diseases and explore prevention and control measures for the increase in Lp(a) prevalence in the Chinese population. This Beijing Heart Society experts' scientific statement will present the detailed knowledge concerning Lp(a)-related studies combined with Chinese population observations to provide the key points of reference.
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14
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de Boer LM, Wiegman A, Swerdlow DI, Kastelein JJP, Hutten BA. Pharmacotherapy for children with elevated levels of lipoprotein(a): future directions. Expert Opin Pharmacother 2022; 23:1601-1615. [PMID: 36047306 DOI: 10.1080/14656566.2022.2118522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Elevated lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD). With the advent of the antisense oligonucleotides (ASOs) and small interfering RNAs (siRNAs) targeted at LPA, the gene encoding apolipoprotein(a), that are highly effective for lowering Lp(a) levels, this risk factor might be managed in the near future. Given that Lp(a) levels are mostly genetically determined and once elevated, present from early age, we have evaluated future directions for the treatment of children with high Lp(a) levels. AREAS COVERED In the current review, we discuss different pharmacological treatments in clinical development and provide an in-depth overview of the effects of ASOs and siRNAs targeted at LPA. EXPERT OPINION Since high Lp(a) is an important risk factor for ASCVD and given the promising effects of both ASOs and siRNAs targeted at apo(a), there is an urgent need for well-designed prospective studies to assess the impact of elevated Lp(a) in childhood. If the Lp(a)-hypothesis is confirmed in adults, and also in children, the rationale might arise for treating children with high Lp(a) levels. However, we feel that this should be limited to children with the highest cardiovascular risk including familial hypercholesterolemia and potentially pediatric stroke.
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Affiliation(s)
- Lotte M de Boer
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Pediatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert Wiegman
- Department of Pediatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - John J P Kastelein
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Barbara A Hutten
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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15
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Wilson DP, Jacobson TA, Jones PH, Koschinsky ML, McNeal CJ, Nordestgaard BG, Orringer CE. Use of Lipoprotein(a) in clinical practice: A biomarker whose time has come. A scientific statement from the National Lipid Association. J Clin Lipidol 2022; 16:e77-e95. [PMID: 36068139 DOI: 10.1016/j.jacl.2022.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Lipoprotein(a) [Lp(a)] is a well-recognized, independent risk factor for atherosclerotic cardiovascular disease, with elevated levels estimated to be prevalent in 20% of the population. Observational and genetic evidence strongly support a causal relationship between high plasma concentrations of Lp(a) and increased risk of atherosclerotic cardiovascular disease-related events, such as myocardial infarction and stroke, and valvular aortic stenosis. In this scientific statement, we review an array of evidence-based considerations for testing of Lp(a) in clinical practice and the utilization of Lp(a) levels to inform treatment strategies in primary and secondary prevention.
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Affiliation(s)
- Don P Wilson
- Department of Pediatric Endocrinology and Diabetes, Cook Children''s Medical Center, Fort Worth, TX, USA.
| | - Terry A Jacobson
- Department of Medicine, Lipid Clinic and Cardiovascular Risk Reduction Program, Emory University, Atlanta, GA, USA
| | - Peter H Jones
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine, Baylor Scott & White Health, Temple, TX, USA
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Carl E Orringer
- Division of Cardiology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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16
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Patel N, Mittal N, Choubdar PA, Taub PR. Lipoprotein(a)—When to Screen and How to Treat. Curr Cardiovasc Risk Rep 2022. [DOI: 10.1007/s12170-022-00698-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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17
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Schwartz GG, Ballantyne CM. Existing and emerging strategies to lower Lipoprotein(a). Atherosclerosis 2022; 349:110-122. [DOI: 10.1016/j.atherosclerosis.2022.04.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 04/13/2022] [Accepted: 04/16/2022] [Indexed: 12/24/2022]
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18
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Sbrana F, Dal Pino B, Aquaro GD, Bigazzi F, Vergaro G, Sampietro T. Lipoprotein(a) apheresis restores coronary microcirculation in refractory angina. Rev Port Cardiol 2022; 41:437-439. [DOI: 10.1016/j.repc.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 11/25/2022] Open
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19
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Korneva VA, Kuznetsova TY, Julius U. Modern Approaches to Lower Lipoprotein(a) Concentrations and Consequences for Cardiovascular Diseases. Biomedicines 2021; 9:biomedicines9091271. [PMID: 34572458 PMCID: PMC8469722 DOI: 10.3390/biomedicines9091271] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/09/2021] [Accepted: 09/15/2021] [Indexed: 12/11/2022] Open
Abstract
Lipoprotein(a) (Lp(a)) is a low density lipoprotein particle that is associated with poor cardiovascular prognosis due to pro-atherogenic, pro-thrombotic, pro-inflammatory and pro-oxidative properties. Traditional lipid-lowering therapy does not provide a sufficient Lp(a) reduction. For PCSK9 inhibitors a small reduction of Lp(a) levels could be shown, which was associated with a reduction in cardiovascular events, independently of the effect on LDL cholesterol. Another option is inclisiran, for which no outcome data are available yet. Lipoprotein apheresis acutely and in the long run decreases Lp(a) levels and effectively improves cardiovascular prognosis in high-risk patients who cannot be satisfactorily treated with drugs. New drugs inhibiting the synthesis of apolipoprotein(a) (an antisense oligonucleotide (Pelacarsen) and two siRNA drugs) are studied. Unlike LDL-cholesterol, for Lp(a) no target value has been defined up to now. This overview presents data of modern capabilities of cardiovascular risk reduction by lowering Lp(a) level.
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Affiliation(s)
- Victoria A. Korneva
- Department of Faculty Therapy, Petrozavodsk State University, Lenin Ave. 33, 185000 Petrozavodsk, Russia;
- Correspondence:
| | | | - Ulrich Julius
- Lipidology and Lipoprotein Apheresis Center, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany;
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20
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Ruscica M, Sirtori CR, Corsini A, Watts GF, Sahebkar A. Lipoprotein(a): Knowns, unknowns and uncertainties. Pharmacol Res 2021; 173:105812. [PMID: 34450317 DOI: 10.1016/j.phrs.2021.105812] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 02/07/2023]
Abstract
Over the last 10 years, there have been advances on several aspects of lipoprotein(a) which are reviewed in the present article. Since the standard immunoassays for measuring lipoprotein(a) are not fully apo(a) isoform-insensitive, the application of an LC-MS/MS method for assaying molar concentrations of lipoprotein(a) has been advocated. Genome wide association, epidemiological, and clinical studies have established high lipoprotein(a) as a causal risk factor for atherosclerotic cardiovascular diseases (ASCVD). However, the relative importance of molar concentration, apo(a) isoform size or variants within the LPA gene is still controversial. Lipoprotein(a)-raising single nucleotide polymorphisms has not been shown to add on value in predicting ASCVD beyond lipoprotein(a) concentrations. Although hyperlipoproteinemia(a) represents an important confounder in the diagnosis of familial hypercholesterolemia (FH), it enhances the risk of ASCVD in these patients. Thus, identification of new cases of hyperlipoproteinemia(a) during cascade testing can increase the identification of high-risk individuals. However, it remains unclear whether FH itself increases lipoprotein(a). The ASCVD risk associated with lipoprotein(a) seems to follow a linear gradient across the distribution, regardless of racial subgroups and other risk factors. The inverse association with the risk of developing type 2 diabetes needs consideration as effective lipoprotein(a) lowering therapies are progressing towards the market. Considering that Mendelian randomization analyses have identified the degree of lipoprotein(a)-lowering that is required to achieve ASCVD benefit, the findings of the ongoing outcome trial with pelacarsen will clarify whether dramatically lowering lipoprotein(a) levels can reduce the risk of ASCVD.
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Affiliation(s)
- Massimiliano Ruscica
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Italy.
| | - Cesare R Sirtori
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia; Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Australia
| | - Amirhossein Sahebkar
- School of Medicine, University of Western Australia, Perth, Australia; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
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21
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Parthymos I, Kostapanos MS, Mikhailidis DP, Florentin M. Lipoprotein (a) as a treatment target for cardiovascular disease prevention and related therapeutic strategies: a critical overview. Eur J Prev Cardiol 2021; 29:739-755. [PMID: 34389859 DOI: 10.1093/eurjpc/zwab052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/30/2020] [Accepted: 03/15/2021] [Indexed: 12/21/2022]
Abstract
Advances in several fields of cardiovascular (CV) medicine have produced new treatments (e.g. to treat dyslipidaemia) that have proven efficacy in terms of reducing deaths and providing a better quality of life. However, the burden of CV disease (CVD) remains high. Thus, there is a need to search for new treatment targets. Lipoprotein (a) [Lp(a)] has emerged as a potential novel target since there is evidence that it contributes to CVD events. In this narrative review, we present the current evidence of the potential causal relationship between Lp(a) and CVD and discuss the likely magnitude of Lp(a) lowering required to produce a clinical benefit. We also consider current and investigational treatments targeting Lp(a), along with the potential cost of these interventions.
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Affiliation(s)
- Ioannis Parthymos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina 45110, Greece
| | - Michael S Kostapanos
- Department of General Medicine, Lipid Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London NW3 2QG, UK
| | - Matilda Florentin
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina 45110, Greece
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22
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Abstract
Lipoprotein(a) [Lp(a)] is an atherogenic lipoprotein with a strong genetic regulation. Up to 90% of the concentrations are explained by a single gene, the LPA gene. The concentrations show a several-hundred-fold interindividual variability ranging from less than 0.1 mg/dL to more than 300 mg/dL. Lp(a) plasma concentrations above 30 mg/dL and even more above 50 mg/dL are associated with an increased risk for cardiovascular disease including myocardial infarction, stroke, aortic valve stenosis, heart failure, peripheral arterial disease, and all-cause mortality. Since concentrations above 50 mg/dL are observed in roughly 20% of the Caucasian population and in an even higher frequency in African-American and Asian-Indian ethnicities, it can be assumed that Lp(a) is one of the most important genetically determined risk factors for cardiovascular disease.Carriers of genetic variants that are associated with high Lp(a) concentrations have a markedly increased risk for cardiovascular events. Studies that used these genetic variants as a genetic instrument to support a causal role for Lp(a) as a cardiovascular risk factor are called Mendelian randomization studies. The principle of this type of studies has been introduced and tested for the first time ever with Lp(a) and its genetic determinants.There are currently no approved pharmacologic therapies that specifically target Lp(a) concentrations. However, some therapies that target primarily LDL cholesterol have also an influence on Lp(a) concentrations. These are mainly PCSK9 inhibitors that lower LDL cholesterol by 60% and Lp(a) by 25-30%. Furthermore, lipoprotein apheresis lowers both, Lp(a) and LDL cholesterol, by about 60-70%. Some sophisticated study designs and statistical analyses provided support that lowering Lp(a) by these therapies also lowers cardiovascular events on top of the effect caused by lowering LDL cholesterol, although this was not the main target of the therapy. Currently, new therapies targeting RNA such as antisense oligonucleotides (ASO) or small interfering RNA (siRNA) against apolipoprotein(a), the main protein of the Lp(a) particle, are under examination and lower Lp(a) concentrations up to 90%. Since these therapies specifically lower Lp(a) concentrations without influencing other lipoproteins, they will serve the last piece of the puzzle whether a decrease of Lp(a) results also in a decrease of cardiovascular events.
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23
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Davies A, Fox K, Galassi AR, Banai S, Ylä-Herttuala S, Lüscher TF. Management of refractory angina: an update. Eur Heart J 2021; 42:269-283. [PMID: 33367764 DOI: 10.1093/eurheartj/ehaa820] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/17/2020] [Accepted: 10/03/2020] [Indexed: 12/15/2022] Open
Abstract
Despite the use of anti-anginal drugs and/or percutaneous coronary interventions (PCI) or coronary artery bypass grafting, the proportion of patients with coronary artery disease who have daily or weekly angina ranges from 2% to 24%. Refractory angina refers to long-lasting symptoms (for >3 months) due to established reversible ischaemia, which cannot be controlled by escalating medical therapy with the use of 2nd- and 3rd-line pharmacological agents, bypass grafting, or stenting. While there is uncertain prognostic benefit, the treatment of refractory angina is important to improve the quality of life of the patients affected. This review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. The symptomatic and prognostic impact of advanced and novel revascularization strategies such as chronic total occlusion PCI, transmyocardial laser revascularization, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation are also covered and recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes discussed. Finally, the potential clinical use of current angiogenetic and stem cell therapies in reducing ischaemia and/or pain is evaluated.
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Affiliation(s)
- Allan Davies
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK
| | - Kim Fox
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK
| | | | - Shmuel Banai
- Slezak Super Centre for Cardiac Research, Tel Aviv University, Tel Aviv, Israel.,Tel Aviv Medical Centre, Tel Aviv, Israel
| | | | - Thomas F Lüscher
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK.,University of Zurich, Center for Molecular Cardiology, University of Zurich, Switzerland
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24
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Gallone G, Armeni P, Verheye S, Agostoni P, Timmers L, Campo G, Ielasi A, Sgura F, Tarantini G, Rosseel L, Zivelonghi C, Leenders G, Stella P, Tebaldi M, Tespili M, D'Amico G, Baldetti L, Ponticelli F, Colombo A, Giannini F. Cost-effectiveness of the coronary sinus Reducer and its impact on the healthcare burden of refractory angina patients. Eur Heart J Qual Care Clin Outcomes 2021; 6:32-40. [PMID: 31124556 DOI: 10.1093/ehjqcco/qcz027] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 05/01/2019] [Accepted: 05/17/2019] [Indexed: 11/13/2022]
Abstract
AIMS The coronary sinus Reducer is a percutaneous device proven to improve angina symptoms in refractory angina (RA). We evaluated its potential cost-effectiveness and impact on the healthcare resource use. METHODS AND RESULTS Angina-related healthcare resource usage and quality-of-life data were collected for 215 consecutive RA patients undergoing Reducer implantation in Belgium, the Netherlands, and Italy. Costs were assessed from each country's healthcare system perspective. Data from the date of RA diagnosis to Reducer implantation [Standard-of-Care (SoC)-period] and from Reducer implantation to follow-up (Reducer-period) were compared: during Reducer-period, a significant reduction in angina-driven hospitalizations, outpatient visits, coronary angiograms, and percutaneous coronary interventions per patient-year was observed, translating into significantly reduced costs per patient-year. To assess cost-effectiveness, costs and utilities of 1-year SoC were compared with those of 1-year Reducer-period. Assumptions on Reducer efficacy duration were further explored with modelled projections. Reducer was associated with higher quality-adjusted life years (QALYs: 0.665 vs. 0.580, P < 0.001) and incremental costs, yielding incremental cost-effectiveness ratios (ICERs) of 53 197, 34 948, 63 146 €/QALY gained in Belgium, the Netherlands, and Italy, respectively. Under both the assumptions of 2 and 3 years Reducer effect duration with a 30%-year efficacy decrease, the device yielded ICERs in the range of 1977-20 796 €/QALY gained. CONCLUSION In patients with RA, Reducer device decreases healthcare resource use and related costs. In a limited 1-year timeframe, Reducer is consistently cost-effective according to a range of cost-effectiveness thresholds. Under the explored assumptions, the device yields cost-effectiveness ratios suggesting high value from all the considered perspectives.
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Affiliation(s)
- Guglielmo Gallone
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizio Armeni
- SDA Bocconi School of Management and CERGAS (Centre for Research on Social and Healthcare Management), Bocconi University, Milan, Italy
| | - Stefan Verheye
- Cardiovascular Center, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | | | - Leo Timmers
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S: Health Science Foundation, Cotignola, Italy
| | - Alfonso Ielasi
- Division of Cardiology, ASST Bergamo Est, "Bolognini" Hospital, Seriate, Italy
| | - Fabio Sgura
- Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center, Milan, Italy
| | - Giuseppe Tarantini
- Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Modena, Italy.,Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Liesbeth Rosseel
- Cardiovascular Center, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Carlo Zivelonghi
- Department of Cardiology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Geert Leenders
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pieter Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S: Health Science Foundation, Cotignola, Italy
| | - Maurizio Tespili
- Division of Cardiology, ASST Bergamo Est, "Bolognini" Hospital, Seriate, Italy
| | - Gianpiero D'Amico
- Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Modena, Italy.,Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Luca Baldetti
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ponticelli
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Maria Cecilia Hospital, GVM Care & Research, E.S: Health Science Foundation, Cotignola, Italy
| | - Francesco Giannini
- Maria Cecilia Hospital, GVM Care & Research, E.S: Health Science Foundation, Cotignola, Italy
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Khan TZ, Hartley A, Haskard D, Caga-Anan M, Pennell DJ, Collins P, Barbir M, Khamis R. Oxidised LDL and Anti-Oxidised LDL Antibodies Are Reduced by Lipoprotein Apheresis in a Randomised Controlled Trial on Patients with Refractory Angina and Elevated Lipoprotein(a). Antioxidants (Basel) 2021; 10:antiox10010132. [PMID: 33477712 PMCID: PMC7831935 DOI: 10.3390/antiox10010132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/23/2020] [Accepted: 01/13/2021] [Indexed: 11/16/2022] Open
Abstract
Aims: An abundance of epidemiological evidence demonstrates that elevated lipoprotein(a) (Lp(a)) represents a significant contributing risk factor towards the development of cardiovascular disease. In particular, raised Lp(a) may play a mechanistic role in patients with refractory angina. Studies have also shown a correlation between oxidised LDL (oxLDL) levels and atherosclerotic burden as well as rates of cardiovascular events. Antibodies against oxLDL (anti-oxLDL) are involved in the removal of oxLDL. Lipoprotein apheresis (LA), which removes lipoproteins using extra-corporeal processes, is an established means of reducing Lp(a), and thereby reduces cardiovascular events. The aim of this study was to investigate the effect of LA on oxLDL and anti-oxLDL levels amongst those with refractory angina in the context of raised Lp(a). Methods: We performed a sub-study within a randomised controlled crossover trial involving 20 patients with refractory angina and raised Lp(a) > 500 mg/L, comparing the effect of three months of blinded weekly LA or sham, followed by crossover to the opposite study arm. We utilized enzyme-linked immunosorbent assays (ELISA) to quantify oxLDL and IgG/ IgM anti-oxLDL antibody levels at baseline and following three months of active LA or sham sessions. Results: Following three months of LA, there was a 30% reduction in oxLDL from 0.37 ± 0.06 to 0.26 ± 0.04 with a mean drop of -0.11 units (U) (95% CI -0.13, -0.09) compared to no significant change with sham therapy (p < 0.0001 between treatment arms). LA also led to a 22% reduction in levels of IgG and IgM anti-oxLDL, again with no significant change demonstrated during sham (p = 0.0036 and p = 0.012, respectively, between treatment arms). Conclusion: Amongst patients with refractory angina in the context of elevated Lp(a), LA significantly lowers levels of oxLDL and anti-oxLDL antibodies, representing potential mechanisms by which LA yields symptomatic and prognostic benefits in this patient cohort.
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Affiliation(s)
- Tina Z. Khan
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Cale Street, London SW3 6LY, UK; (T.Z.K.); (D.J.P.); (P.C.)
- Royal Brompton and & Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK;
| | - Adam Hartley
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, Du Cane Road, London W12 0NN, UK; (A.H.); (D.H.); (M.C.-A.)
| | - Dorian Haskard
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, Du Cane Road, London W12 0NN, UK; (A.H.); (D.H.); (M.C.-A.)
| | - Mikhail Caga-Anan
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, Du Cane Road, London W12 0NN, UK; (A.H.); (D.H.); (M.C.-A.)
| | - Dudley J. Pennell
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Cale Street, London SW3 6LY, UK; (T.Z.K.); (D.J.P.); (P.C.)
- Royal Brompton and & Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK;
| | - Peter Collins
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Cale Street, London SW3 6LY, UK; (T.Z.K.); (D.J.P.); (P.C.)
- Royal Brompton and & Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK;
| | - Mahmoud Barbir
- Royal Brompton and & Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK;
- Cardiology Department, Harefield Hospital, Hill End Road, Harefield UB9 6JH, UK
| | - Ramzi Khamis
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, Du Cane Road, London W12 0NN, UK; (A.H.); (D.H.); (M.C.-A.)
- Correspondence:
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Abstract
PURPOSE OF REVIEW Genetic, epidemiological, and translational data indicate that Lipoprotein (a) [Lp(a)] is likely in the causal pathway for atherosclerotic cardiovascular diseases as well as calcification of the aortic valves. RECENT FINDINGS Lp(a) is structurally similar to low-density lipoprotein, but in addition to apolipoprotein B-100, it has a glycoprotein apolipoprotein(a) [apo(a)], which is attached to the apolipoprotein B-100. Several distinctive properties of Lp(a) can be attributed to the presence of apo(a). This review discusses the current state of literature on pathophysiological and clinical aspects of Lp(a). After five decades of research, the understanding of Lp(a) structure, biochemistry, and pathophysiology of its cardiovascular manifestations still remains less than fully understood. Universally, Lp(a) elevation may be the most predominant monogenetic lipid disorder with approximate prevalence of Lp(a)>50 mg/dL among estimated >1.4 billion people. This makes a compelling rationale for diagnosing and managing Lp(a)-mediated risk. In addition to discussing various cardiovascular phenotypes of Lp(a) and associated morbidity, we also outline current and emerging therapies aimed at identifying a definitive treatment for elevated Lp(a) levels.
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Affiliation(s)
- Anum Saeed
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Sina Kinoush
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Salim S. Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX USA
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 USA
- Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, TX USA
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27
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Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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29
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Moriarty PM, Gorby LK, Stroes ES, Kastelein JP, Davidson M, Tsimikas S. Lipoprotein(a) and Its Potential Association with Thrombosis and Inflammation in COVID-19: a Testable Hypothesis. Curr Atheroscler Rep 2020; 22:48. [PMID: 32710255 PMCID: PMC7381416 DOI: 10.1007/s11883-020-00867-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [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] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The COVID-19 pandemic has infected over > 11 million as of today people worldwide and is associated with significant cardiovascular manifestations, particularly in subjects with preexisting comorbidities and cardiovascular risk factors. Recently, a predisposition for arterial and venous thromboses has been reported in COVID-19 infection. We hypothesize that besides conventional risk factors, subjects with elevated lipoprotein(a) (Lp(a)) may have a particularly high risk of developing cardiovascular complications. RECENT FINDINGS The Lp(a) molecule has the propensity for inhibiting endogenous fibrinolysis through its apolipoprotein(a) component and for enhancing proinflammatory effects such as through its content of oxidized phospholipids. The LPA gene contains an interleukin-6 (IL-6) response element that may induce an acute phase-type increase in Lp(a) levels following a cytokine storm from COVID-19. Thus, subjects with either baseline elevated Lp(a) or those who have an increase following COVID-19 infection, or both, may be at very high risk of developing thromboses. Elevated Lp(a) may also lead to acute destabilization of preexisting but quiescent atherosclerotic plaques, which might induce acute myocardial infarction and stroke. Ongoing studies with IL-6 antagonists may be informative in understanding this relationship, and registries are being initiated to measure Lp(a) in subjects infected with COVID-19. If indeed an association is suggestive of being causal, consideration can be given to systematic testing of Lp(a) and prophylactic systemic anticoagulation in infected inpatients. Therapeutic lipid apheresis and pharmacotherapy for the reduction of Lp(a) levels may minimize thrombogenic potential and proinflammatory effects. We propose studies to test the hypothesis that Lp(a) may contribute to cardiovascular complications of COVID-19.
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Affiliation(s)
- Patrick M Moriarty
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Lauryn K Gorby
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Erik S Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - John P Kastelein
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael Davidson
- Lipid Clinic, The University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Sotirios Tsimikas
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA.
- Vascular Medicine Program, Sulpizio Cardiovascular Center, University of California San Diego, 9500 Gilman Drive, BSB 1080, La Jolla, CA, 92093-0682, USA.
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30
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Greco MF, Sirtori CR, Corsini A, Ezhov M, Sampietro T, Ruscica M. Lipoprotein(a) Lowering-From Lipoprotein Apheresis to Antisense Oligonucleotide Approach. J Clin Med 2020; 9:jcm9072103. [PMID: 32635396 PMCID: PMC7408876 DOI: 10.3390/jcm9072103] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 12/11/2022] Open
Abstract
It is well-known that elevated lipoprotein(a)—Lp(a)—levels are associated with a higher risk of cardiovascular (CV) mortality and all-cause mortality, although a standard pharmacotherapeutic approach is still undefined for patients with high CV risk dependent on hyperlipoproteinemia(a). Combined with high Lp(a) levels, familial hypercholesterolemia (FH) leads to a greater CVD risk. In suspected FH patients, the proportion of cases explained by a rise of Lp(a) levels ranges between 5% and 20%. In the absence of a specific pharmacological approach able to lower Lp(a) to the extent required to achieve CV benefits, the most effective strategy today is lipoprotein apheresis (LA). Although limited, a clear effect on Lp(a) is exerted by PCSK9 antagonists, with apparently different mechanisms when given with statins (raised catabolism) or as monotherapy (reduced production). In the era of RNA-based therapies, a new dawn is represented by the use of antisense oligonucleotides APO(a)Lrx, able to reduce Lp(a) from 35% to over 80%, with generally modest injection site reactions. The improved knowledge of Lp(a) atherogenicity and possible prevention will be of benefit for patients with residual CV risk remaining after the most effective available lipid-lowering agents.
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Affiliation(s)
- Maria Francesca Greco
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
| | - Cesare R. Sirtori
- Dyslipidemia Center, A.S.S.T. Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Alberto Corsini
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
- IRCCS Multimedica, 20099 Milan, Italy
| | - Marat Ezhov
- National Medical Research Center of Cardiology of the Ministry of Health, Moscow, Russia;
| | - Tiziana Sampietro
- U.O. Lipoapheresis and Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, 56126 Pisa, Italy;
| | - Massimiliano Ruscica
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
- Correspondence: ; Tel.: +39-0250318220
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Wu MF, Xu KZ, Guo YG, Yu J, Wu Y, Lin LM. Lipoprotein(a) and Atherosclerotic Cardiovascular Disease: Current Understanding and Future Perspectives. Cardiovasc Drugs Ther 2019; 33:739-48. [PMID: 31655942 DOI: 10.1007/s10557-019-06906-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To review current knowledge of elevated lipoprotein(a) [Lp(a)] levels in relation to atherosclerotic cardiovascular disease (ASCVD) and discuss their potential use as biomarkers and therapeutic approaches in clinical practice. METHODS We summarized the current understanding and recent advances in the structure, metabolism, atherogenic mechanisms, standardized laboratory measurement, recommended screening populations, and prognostic value of Lp(a), with a special focus on the current potential treatment approaches for hyperlipoprotein(a)emia in patients with ASCVD. RESULTS Lp(a) is composed of LDL-like particle and characteristic apolipoprotein(a) [apo(a)] connected by a disulfide bond. Substantial evidence shows that elevated plasma Lp(a) level is a heritable, independent, and possibly causal risk factor for ASCVD through its proatherogenic, proinflammatory, and potentially prothrombotic properties. Current guidelines recommend Lp(a) measurement for patients with an intermediate-high risk of ASCVD, familial hypercholesterolemia, a family history of early ASCVD or elevated Lp(a), and progressive ASCVD despite receiving optimal therapy. Traditional Lp(a)-lowering approaches such as niacin, PCSK9 inhibitors, mipomersen, lomitapide, and lipoprotein apheresis were associated with a non-specific and limited reduction of Lp(a), intolerable side effects, invasive procedure, and high expense. The phase 2 randomized controlled trial of antisense oligonucleotide against the apo(a) encoding gene LPA mRNA showed that IONIS-APO(a)-LRX could specifically reduce the level of Lp(a) by 90% with good tolerance, which may become a promising candidate for the prevention and treatment of ASCVD in the future. CONCLUSIONS It is reasonable to measure Lp(a) levels to reclassify ASCVD risk and manage individuals with elevated Lp(a) to further reduce the residual risk of ASCVD, especially with IONIS-APO(a)-LRX.
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Julius U, Tselmin S, Schatz U, Fischer S, Birkenfeld AL, Bornstein SR. Actual situation of lipoprotein apheresis in patients with elevated lipoprotein(a) levels. ATHEROSCLEROSIS SUPP 2020; 40:1-7. [PMID: 31818437 DOI: 10.1016/j.atherosclerosissup.2019.08.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
An elevation of lipoprotein(a) (Lp(a)) is an internationally recognized atherogenic risk factor, documented in epidemiological studies, in studies with Mendelian randomization and in genome-wide association studies (GWAS). At present, no drug is available to effectively reduce its concentration. In Germany, an elevation of Lp(a) associated with progressive cardiovascular diseases is officially recognized as an indication for a lipoprotein apheresis (LA). The number of patients who were treated with LA with this abnormality was steadily increasing in the years 2013-2016 - the official data are reported. In all new patients, who started to be treated at our LA center in 2017 (n = 20) the increased Lp(a) was a main indication for extracorporeal therapy, though some of them also showed clearly elevated LDL cholesterol (LDL-C) concentrations despite being treated with a maximal tolerated lipid-lowering drug therapy. A diabetes mellitus was seen in 5 patients. The higher was the Lp(a) level before the first LA session, the higher was the cardiovascular risk. Lp(a) concentrations measured before LA sessions were usually about 20% lower than those before the start of the LA therapy. Acutely, Lp(a) levels were reduced by about 70%. Following LA sessions the Lp(a) levels increased and in the majority reach pre-session concentrations after one week. Thus a weekly interval is best for the patients, but a few may need two sessions per week to stop the progress of atherosclerosis. The interval mean values were about 39% lower than previous levels. Several papers had been published showing a higher efficiency of LA therapy on the incidence of cardiovascular events in patients with high Lp(a) values when comparing with hypercholesterolemic patients with normal Lp(a) concentrations. Russian specific anti-Lp(a) columns positively affected coronary atherosclerosis. PCSK9 inhibitors reduce Lp(a) concentrations in many patients and in this way have a positive impact on cardiovascular outcomes. In the future, an antisense oligonucleotide against apolipoprotein(a) may be an alternative therapeutic option, provided a clear-cut reduction of cardiovascular events will be demonstrated.
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Affiliation(s)
- Ulrich Julius
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Sergey Tselmin
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
| | - Ulrike Schatz
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
| | - Sabine Fischer
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
| | - Andreas L Birkenfeld
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
| | - Stefan R Bornstein
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
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33
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Affiliation(s)
- Andrew E Arai
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Li-Yueh Hsu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
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34
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Golledge J, Rowbotham S, Velu R, Quigley F, Jenkins J, Bourke M, Bourke B, Thanigaimani S, Chan DC, Watts GF. Association of Serum Lipoprotein (a) With the Requirement for a Peripheral Artery Operation and the Incidence of Major Adverse Cardiovascular Events in People With Peripheral Artery Disease. J Am Heart Assoc 2020; 9:e015355. [PMID: 32172653 PMCID: PMC7335512 DOI: 10.1161/jaha.119.015355] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The aim of this study was to assess the relationship between serum lipoprotein (a) (Lp[a]) concentration and the requirement for peripheral artery disease (PAD) operations or incidence of major adverse cardiovascular events. Methods and Results A total of 1472 people with PAD presenting with intermittent claudication (n=355), abdominal aortic aneurysm (n=989) or critical limb ischemia (n=128) were prospectively recruited from 4 outpatient clinics in Australia. Lp(a) was measured in serum samples collected at recruitment using an immunoassay. Participants were followed for a median (interquartile range) of 2.4 (0.1-6.1) years to record requirement for any PAD operation, defined to include any open or endovascular PAD intervention (lower limb peripheral revascularization, abdominal aortic aneurysm repair, other aneurysm repair, or carotid artery revascularization). Myocardial infarctions, strokes, and deaths were also recorded. The association of Lp(a) with events was assessed using Cox proportional hazard analysis adjusting for traditional risk factors. Participants with Lp(a) ≥30 mg/dL had a greater requirement for any PAD operation (hazard ratio, 1.20, 95% CI, 1.02-1.41) and lower limb peripheral revascularization alone (hazard ratio 1.33, 95% CI, 1.06-1.66) but no increased risk of major adverse cardiovascular events or all-cause mortality. Lp(a) ≥50 mg/dL and a 40 mg/dL increase in Lp(a) were also associated with an increased risk of lower limb peripheral revascularization alone but not with other outcomes. Conclusions In participants with PAD referred for hospital management those with high Lp(a) had greater requirement for lower limb peripheral revascularization but Lp(a) was not consistently associated with other clinical events.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Department of Vascular and Endovascular Surgery Townsville University Hospital Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Sophie Rowbotham
- Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The University of Queensland UQ Centre for Clinical Research Herston Queensland Australia
| | - Ramesh Velu
- The Department of Vascular and Endovascular Surgery Townsville University Hospital Townsville Queensland Australia
| | | | - Jason Jenkins
- Department of Vascular Surgery The Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - Michael Bourke
- Gosford Vascular Services Gosford New South Wales Australia
| | - Bernie Bourke
- Gosford Vascular Services Gosford New South Wales Australia
| | - Shivshankar Thanigaimani
- Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Dick C Chan
- School of Medicine Faculty of Health and Medical Sciences University of Western Australia Perth Australia
| | - Gerald F Watts
- School of Medicine Faculty of Health and Medical Sciences University of Western Australia Perth Australia.,Lipid Disorders Clinic Department of Cardiology Royal Perth Hospital Perth Australia
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35
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Bornstein SR, Voit-Bak K, Rosenthal P, Tselmin S, Julius U, Schatz U, Boehm BO, Thuret S, Kempermann G, Reichmann H, Chrousos GP, Licinio J, Wong ML, Schally AV, Straube R. Extracorporeal apheresis therapy for Alzheimer disease-targeting lipids, stress, and inflammation. Mol Psychiatry 2020; 25:275-82. [PMID: 31595035 DOI: 10.1038/s41380-019-0542-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 02/06/2023]
Abstract
Current therapeutic approaches to Alzheimer disease (AD) remain disappointing and, hence, there is an urgent need for effective treatments. Here, we provide a perspective review on the emerging role of "metabolic inflammation" and stress as a key factor in the pathogenesis of AD and propose a novel rationale for correction of metabolic inflammation, increase resilience and potentially slow-down or halt the progression of the neurodegenerative process. Based on recent evidence and observations of an early pilot trial, we posit a potential use of extracorporeal apheresis in the prevention and treatment of AD. Apolipoprotein E, lipoprotein(a), oxidized LDL (low density lipoprotein)'s and large LDL particles, as well as other proinflammatory lipids and stress hormones such as cortisol, have been recognized as key factors in amyloid plaque formation and aggravation of AD. Extracorporeal lipoprotein apheresis systems employ well-established, powerful methods to provide an acute, reliable 60-80% reduction in the circulating concentration of these lipid classes and reduce acute cortisol levels. Following a double-membrane extracorporeal apheresis in patients with AD, there was a significant reduction of proinflammatory lipids, circulating cytokines, immune complexes, proinflammatory metals and toxic chaperones in patients with AD. On the basis of the above, we suggest designing clinical trials to assess the promising potential of such "cerebropheresis" treatment in patients with AD and, possibly, other neurodegenerative diseases.
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36
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Affiliation(s)
- Sotirios Tsimikas
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California.
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37
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Berent T, Berent R, Sinzinger H. Lipoprotein apheresis - Shortening of treatment intervals reduces cardiovascular events: Case reports. ATHEROSCLEROSIS SUPP 2019; 40:125-130. [PMID: 31818444 DOI: 10.1016/j.atherosclerosissup.2019.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Lipoprotein (Lp-) apheresis is a life-long therapy, usually performed in weekly intervals. In some cases, however, atherosclerotic disease progresses despite adequate therapy with weekly Lp-apheresis and maximal lipid lowering medication. In an attempt to improve the effectiveness of therapy, we temporarily shortened treatment intervals of Lp-apheresis in patients with elevated lipoprotein(a) (Lp(a)) and further progression of coronary atherosclerosis despite weekly Lp-apheresis and maximal lipid lowering medication. METHODS We illustrate three case reports of patients with elevated Lp(a), who underwent regular weekly Lp-apheresis treatment for secondary prevention. The intensified treatment protocol contained three therapies in two weeks (alternating 2 per week and 1 per week). RESULTS The shortening of treatment intervals achieved a stabilization of atherosclerotic disease in case 1. After a total of 68 therapies in 52 weeks (1.31 sessions/week) the elective coronary angiography revealed excellent long-term results. In case 2, the intensified treatment protocol is still ongoing. The patient reported a decrease in angina pectoris and an increase in exercise capacity since the beginning of more frequent therapy sessions. In some cases, as it is shown in case 3, a fast decision for shortening the treatment intervals is necessary. CONCLUSIONS The intensified treatment regimen resulted in an improvement in clinical symptoms and no further progression of atherosclerosis. In conclusion, shorter therapeutic Lp-apheresis intervals, at least temporarily, should be considered in patients who suffer from clinical and/or angiographic progression of atherosclerosis, despite maximal lipid lowering medication and weekly Lp-apheresis.
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Affiliation(s)
- Theresa Berent
- Athos Institute, Institute for Diagnosis and Treatment of Lipid Disorders, Vienna, Austria.
| | - Robert Berent
- Center for Cardiovascular Rehabilitation, HerzReha, Bad Ischl, Austria
| | - Helmut Sinzinger
- Athos Institute, Institute for Diagnosis and Treatment of Lipid Disorders, Vienna, Austria; Sigmund Freud University, Department of Lipid Metabolism, Faculty of Medicine, Vienna, Austria
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Schettler VJJ, Neumann CL, Peter C, Zimmermann T, Julius U, Hohenstein B, Roeseler E, Heigl F, Grützmacher P, Blume H, Klingel R, Vogt A. Lipoprotein apheresis is an optimal therapeutic option to reduce increased Lp(a) levels. Clin Res Cardiol Suppl 2019; 14:33-38. [PMID: 30838552 DOI: 10.1007/s11789-019-00094-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Lipoprotein(a) (Lp(a)) is a genetic risk factor for cardiovascular disease (CVD) and is associated with the induction and sustaining of atherosclerotic cardiovascular diseases (ASCVD). Since 2008 Lp(a) along with progressive CVD has been approved as an indication for regular lipoprotein apheresis (LA) in Germany. The German Lipoprotein Apheresis Registry (GLAR) has been initiated to provide statistical evidence for the assessment of extracorporeal procedures to treat dyslipidemia for both LDL-cholesterol (LDL-C) and Lp(a). The GLAR now allows prospective investigations over a 5-year period about annual incidence rates of cardiovascular events. Here Lp(a) patients (LDL-C < 100 mg/dl; Lp(a) > 60 mg/dl or >120 nmol/l) showed the same reduction of major coronary (83%) and non-coronary events (63%) as had been formerly shown in the Pro(a)LiFe study. However, Lp(a) is not only an apolipoprotein(a) (apo(a)) and LDL-C containing particle, which is covalently bound to a LDL-C core by a disulphide bridge. The composition of this particle, inter alia containing oxidized phospholipids, gives pro-atherosclerotic, pro-inflammatory, and pro-thrombotic properties, inducing atherosclerotic processes mainly in the arterial wall. However, recent investigations have shown that a reduction of inflammatory settings without LDL-C or Lp(a) reduction may reduce ASCVD events. Lipoprotein apheresis (LA) could not only reduce LDL-C and Lp(a) in parallel, but also different inflammatory and coagulation parameters. In summary lipoprotein apheresis is not only anti-atherosclerotic, but also anti-inflammatory and anti-thrombotic and therefore an ideal treatment option with respect to the shown reduction of major adverse coronary events (MACE) and major adverse non-coronary events (MANCE) by reducing Lp(a) levels.
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Affiliation(s)
- V J J Schettler
- Center of Nephrology Göttingen GbR, An der Lutter 24, 37075, Göttingen, Germany.
| | - C L Neumann
- BRAVE-Benefit for Research on Arterial Hypertension, Dyslipidemia and Vascular Risk and Education e. V, Göttingen, Germany
| | - C Peter
- BioArtProducts GmbH (B.A.P.), Rostock, Germany
| | | | - U Julius
- Extracorporeal Treatment and Apheresis Center, Department of Internal Medicine III, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - B Hohenstein
- Extracorporeal Treatment and Apheresis Center, Department of Internal Medicine III, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - E Roeseler
- Center for Nephrology, Hypertension, and Metabolic Diseases, Hanover, Germany
| | - F Heigl
- Medical Care Centre Kempten-Allgäu, Kempten, Germany
| | - P Grützmacher
- Department of Medicine II for Nephrology, Hypertension and Vascular Risks, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - H Blume
- Scientific Institute for Nephrology (WiNe), Düsseldorf, Germany
| | - R Klingel
- Apheresis Research Institute, Stadtwaldgürtel 77, 50935, Cologne, Germany
| | - A Vogt
- Medizinische Klinik und Poliklinik 4, Universität München, Munich, Germany
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Cegla J, Neely RG, France M, Ferns G, Byrne CD, Halcox J, Datta D, Capps N, Shoulders C, Qureshi N, Rees A, Main L, Cramb R, Viljoen A, Payne J, Soran H. HEART UK consensus statement on Lipoprotein(a): A call to action. Atherosclerosis 2019; 291:62-70. [DOI: 10.1016/j.atherosclerosis.2019.10.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 12/24/2022]
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Abstract
Several new or emerging drugs for dyslipidemia owe their existence, in part, to human genetic evidence, such as observations in families with rare genetic disorders or in Mendelian randomization studies. Much effort has been directed to agents that reduce LDL (low-density lipoprotein) cholesterol, triglyceride, and Lp[a] (lipoprotein[a]), with some sustained programs on agents to raise HDL (high-density lipoprotein) cholesterol. Lomitapide, mipomersen, AAV8.TBG.hLDLR, inclisiran, bempedoic acid, and gemcabene primarily target LDL cholesterol. Alipogene tiparvovec, pradigastat, and volanesorsen primarily target elevated triglycerides, whereas evinacumab and IONIS-ANGPTL3-LRx target both LDL cholesterol and triglyceride. IONIS-APO(a)-LRx targets Lp(a).
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Affiliation(s)
- Robert A Hegele
- From the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (R.A.H.)
| | - Sotirios Tsimikas
- Sulpizio Cardiovascular Center, Vascular Medicine Program, University of California San Diego, La Jolla (S.T.)
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 740] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Labudovic D, Kostovska I, Tosheska Trajkovska K, Cekovska S, Brezovska Kavrakova J, Topuzovska S. Lipoprotein(a) – Link between Atherogenesis and Thrombosis. Prague Med Rep 2019; 120:39-51. [DOI: 10.14712/23362936.2019.9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Lipoprotein(a) – Lp(a) – is an independent risk factor for cardiovascular disease (CVD). Indeed, individuals with plasma concentrations of Lp(a) > 200 mg/l carry an increased risk of developing CVD. Circulating levels of Lp(a) are remarkably resistant to common lipid lowering therapies, currently available treatment for reduction of Lp(a) is plasma apheresis, which is costly and labour intensive. The Lp(a) molecule is composed of two parts: LDL/apoB-100 core and glycoprotein, apolipoprotein(a) – Apo(a), both of them can interact with components of the coagulation cascade, inflammatory pathways and blood vessel cells (smooth muscle cells and endothelial cells). Therefore, it is very important to determine the molecular pathways by which Lp(a) affect the vascular system in order to design therapeutics for targeting the Lp(a) cellular effects. This paper summarises the cellular effects and molecular mechanisms by which Lp(a) participate in atherogenesis, thrombogenesis, inflammation and development of cardiovascular diseases.
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Khan TZ, Gorog DA, Arachchillage DJ, Ahnström J, Rhodes S, Donovan J, Banya W, Pottle A, Barbir M, Pennell DJ. Impact of lipoprotein apheresis on thrombotic parameters in patients with refractory angina and raised lipoprotein(a): Findings from a randomized controlled cross-over trial. J Clin Lipidol 2019; 13:788-796. [DOI: 10.1016/j.jacl.2019.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 12/29/2022]
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Tsimikas S, Fazio S, Ferdinand KC, Ginsberg HN, Koschinsky ML, Marcovina SM, Moriarty PM, Rader DJ, Remaley AT, Reyes-Soffer G, Santos RD, Thanassoulis G, Witztum JL, Danthi S, Olive M, Liu L. NHLBI Working Group Recommendations to Reduce Lipoprotein(a)-Mediated Risk of Cardiovascular Disease and Aortic Stenosis. J Am Coll Cardiol 2019; 71:177-192. [PMID: 29325642 DOI: 10.1016/j.jacc.2017.11.014] [Citation(s) in RCA: 303] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 12/16/2022]
Abstract
Pathophysiological, epidemiological, and genetic studies provide strong evidence that lipoprotein(a) [Lp(a)] is a causal mediator of cardiovascular disease (CVD) and calcific aortic valve disease (CAVD). Specific therapies to address Lp(a)-mediated CVD and CAVD are in clinical development. Due to knowledge gaps, the National Heart, Lung, and Blood Institute organized a working group that identified challenges in fully understanding the role of Lp(a) in CVD/CAVD. These included the lack of research funding, inadequate experimental models, lack of globally standardized Lp(a) assays, and inadequate understanding of the mechanisms underlying current drug therapies on Lp(a) levels. Specific recommendations were provided to facilitate basic, mechanistic, preclinical, and clinical research on Lp(a); foster collaborative research and resource sharing; leverage expertise of different groups and centers with complementary skills; and use existing National Heart, Lung, and Blood Institute resources. Concerted efforts to understand Lp(a) pathophysiology, together with diagnostic and therapeutic advances, are required to reduce Lp(a)-mediated risk of CVD and CAVD.
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Affiliation(s)
- Sotirios Tsimikas
- Vascular Medicine Program, Sulpizio Cardiovascular Center, Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California.
| | - Sergio Fazio
- Oregon Health & Science University, Portland, Oregon
| | | | - Henry N Ginsberg
- College of Physicians and Surgeons, Columbia University, New York, New York
| | - Marlys L Koschinsky
- Robarts Research Institute and Department of Physiology & Pharmacology Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | | | | | - Daniel J Rader
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan T Remaley
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Raul D Santos
- Heart Institute (InCor) University of Sao Paulo Medical School Hospital and Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Joseph L Witztum
- Division of Endocrinology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Simhan Danthi
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michelle Olive
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Lijuan Liu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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Wilson DP, Jacobson TA, Jones PH, Koschinsky ML, Mcneal CJ, Nordestgaard BG, Orringer CE. Use of Lipoprotein(a) in clinical practice: A biomarker whose time has come. A scientific statement from the National Lipid Association. J Clin Lipidol 2019; 13:374-92. [DOI: 10.1016/j.jacl.2019.04.010] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 12/24/2022]
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Khantalin I, Blanchard V, Viallet N, Lambert G. Recurrent coronary syndromes in a patient with isolated very-high lipoprotein (a) and the prothrombin genetic variant rs1799963 (G20210A): a case report. Eur Heart J Case Rep 2019; 3:ytz019. [PMID: 31020261 PMCID: PMC6439380 DOI: 10.1093/ehjcr/ytz019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/07/2019] [Indexed: 12/24/2022]
Abstract
Background Elevated lipoprotein (a) [Lp(a)] is an under-diagnosed genetically inherited risk factor for coronary heart disease (CHD) and calcific aortic valve stenosis. Premature myocardial infarction (MI) could stem from the association between elevated Lp(a) and other non-traditional cardiovascular risk factors. Case summary Here, we report a male patient with extremely high Lp(a) plasma levels [610 nmol/L (244 mg/dL); normal <75 nmol/L (<30 mg/dL)] associated with the prothrombin genetic variant rs1799963 (G20210A) and no other CHD risk factor. At the age of 32, he suffered recurrent episodes of MI treated by coronary angioplasty and drug eluting stents. The patient who was initially prescribed antiplatelet therapy, beta-blockers, and statins, has subsequently been treated by lipoprotein apheresis every fortnight for 43 months. He has never experienced any recurrent episode of angina or chest pain since. Discussion The rare association between extremely elevated circulating Lp(a) levels and prothrombotic genetic variants of coagulation factors appears to be a deadly combination that can only be adequately treated by antiplatelet therapy and lipoprotein apheresis.
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Affiliation(s)
- Ilya Khantalin
- Université de La Réunion, Inserm, UMR 1188 DéTROI, Plateforme CYROI, 2 Rue Maxime Rivière, Sainte-Clotilde, France.,CHU de La Réunion, Service de Chirurgie Vasculaire, Allée des Topazes, Saint-Denis, France
| | - Valentin Blanchard
- Université de La Réunion, Inserm, UMR 1188 DéTROI, Plateforme CYROI, 2 Rue Maxime Rivière, Sainte-Clotilde, France
| | - Nicolas Viallet
- CHU de La Réunion, Service de Néphrologie, Allée des Topazes, Saint-Denis, France
| | - Gilles Lambert
- Université de La Réunion, Inserm, UMR 1188 DéTROI, Plateforme CYROI, 2 Rue Maxime Rivière, Sainte-Clotilde, France
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Boffa MB, Stranges S, Klar N, Moriarty PM, Watts GF, Koschinsky ML. Lipoprotein(a) and secondary prevention of atherothrombotic events: A critical appraisal. J Clin Lipidol 2018; 12:1358-66. [DOI: 10.1016/j.jacl.2018.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/16/2018] [Accepted: 08/29/2018] [Indexed: 12/24/2022]
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Khan TZ, de Silva R. Is there a role for invasive assessment of the coronary microcirculation in patients with unobstructed epicardial coronary arteries in clinical practice? Int J Cardiol 2018; 267:46-47. [DOI: 10.1016/j.ijcard.2018.05.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 10/16/2022]
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Abstract
BACKGROUND Therapeutic apheresis is a term used to describe a group of treatments where blood components are separated in real time, and one component is removed, exchanged, and/or treated to remove pathogenic substances from the circulation. Plasma exchange, which removed all plasma components, and lipid apheresis which selectively removes lipoproteins from circulation, have both been used to treat atherosclerotic vascular diseases. METHODS To review the literature regarding the application of therapeutic apheresis for atherosclerotic vascular diseases. RESULTS Primarily lipid apheresis is used to treat atherosclerotic vascular diseases, particularly familial hypercholesterolemia, lipoprotein (a) hyperlipoproteinemia and peripheral vascular diseases. Lipid apheresis can be used as first line or second line treatment with a strong evidenced-based recommendation. Its use has decreased atherosclerotic events. CONCLUSION Lipid apheresis is an important therapy for the treatment of familial hypercholesterolemia, lipoprotein (a) hyperlipoproteinemia and peripheral vascular diseases. Lipid apheresis does more than remove low-density lipoproteins and other lipoproteins but also decreases inflammatory markers and improves blood flow.
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Affiliation(s)
| | - Beth H Shaz
- New York Blood Center, New York, New York, USA
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Wu MD, Moccetti F, Brown E, Davidson BP, Atkinson T, Belcik JT, Giraud G, Duell PB, Fazio S, Tavori H, Tsimikas S, Lindner JR. Lipoprotein Apheresis Acutely Reverses Coronary Microvascular Dysfunction in Patients With Severe Hypercholesterolemia. JACC Cardiovasc Imaging 2019; 12:1430-40. [PMID: 29909101 DOI: 10.1016/j.jcmg.2018.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/23/2018] [Accepted: 05/01/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVES This study evaluated whether lipoprotein apheresis produces immediate changes in resting perfusion in subjects with severe hypercholesterolemia, and whether there is a difference in the response between peripheral and coronary microcirculations. BACKGROUND Lipoprotein apheresis is used in patients with severe hypercholesterolemia to reduce plasma levels of low-density lipoprotein cholesterol. METHODS Quantitative contrast-enhanced ultrasound perfusion imaging of the myocardium at rest and skeletal muscle at rest and during calibrated contractile exercise was performed before and immediately after lipoprotein apheresis in 8 subjects with severe hypercholesterolemia, 7 of whom had a diagnosis of familial hypercholesterolemia. Myocardial perfusion imaging was also performed in 14 normal control subjects. Changes in myocardial work and left ventricular function were assessed by echocardiography. Ex vivo ovine coronary and femoral artery ring tension assays were assessed in the presence of pre- and post-apheresis plasma. RESULTS Apheresis acutely decreased low-density lipoprotein cholesterol (234.9 ± 103.2 mg/dl vs. 67.1 ± 49.5 mg/dl; p < 0.01) and oxidized phospholipid on apolipoprotein B-100 (60.2 ± 55.2 nmol/l vs. 47.0 ± 24.5 nmol/l; p = 0.01), and acutely increased resting myocardial perfusion (55.1 [95% confidence interval: 77.2 to 73.1] IU/s vs. 135 [95% confidence interval: 81.2 to 189.6] IU/s; p = 0.01), without changes in myocardial work. Myocardial longitudinal strain improved in those subjects with reduced pre-apheresis function. Skeletal muscle perfusion at rest and during contractile exercise was unchanged by apheresis. Acetylcholine-mediated dilation of ex vivo ovine coronary but not femoral arteries was impaired in pre-apheresis plasma and was completely reversed in post-apheresis plasma. CONCLUSIONS Lipoprotein apheresis produces an immediate improvement in coronary microvascular function, which increases myocardial perfusion and normalizes endothelial-dependent vasodilation. These changes are not observed in the periphery. (Acute Microvascular Changes With LDL Apheresis; NCT02388633).
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