International Atherosclerosis Society guidance for implementing best practice in the care of familial hypercholesterolaemia

This contemporary, international, evidence-informed guidance aims to achieve the greatest good for the greatest number of people with familial hypercholesterolaemia (FH) across different countries. FH, a family of monogenic defects in the hepatic LDL clearance pathway, is a preventable cause of premature coronary artery disease and death. Worldwide, 35 million people have FH, but most remain undiagnosed or undertreated. Current FH care is guided by a useful and diverse group of evidence-based guidelines, with some primarily directed at cholesterol management and some that are country-specific. However, none of these guidelines provides a comprehensive overview of FH care that includes both the lifelong components of clinical practice and strategies for implementation. Therefore, a group of international experts systematically developed this guidance to compile clinical strategies from existing evidence-based guidelines for the detection (screening, diagnosis, genetic testing and counselling) and management (risk stratification, treatment of adults or children with heterozygous or homozygous FH, therapy during pregnancy and use of apheresis) of patients with FH, update evidence-informed clinical recommendations, and develop and integrate consensus-based implementation strategies at the patient, provider and health-care system levels, with the aim of maximizing the potential benefit for at-risk patients and their families worldwide.

Web discussions on cardiovascular diseases: assessing the impact of COVID-19 pandemic. An Italian prospective analysis

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Non-conditioning grant from Sanofi Italia.

Background.

Awareness and risk knowledge are the first steps along the complex journey leading to effective primordial, primary and secondary cardiovascular disease (CVD) prevention. Interactions among people significantly influence awareness and personal beliefs and favour behavioral changes. Given the increased use of Internet to search information and share experiences on health, Web and social media represent innovative health-information-gathering sources, facilitating interactions and information exchanges able to influence health-related behaviour.

Purpose.

This study is based on a longitudinal Web listening analysis approach, aimed at analyzing and comparing Web discussions collected before the COVID-19 pandemic (February 2018–February 2020) with those occurred during the first pandemic wave in Italy (March–July 2020).

Methods.

A preliminary analysis of the data indexed by prominent search engines (i.e., Google) was performed, followed by a systematic process of data collection. Automated data identification was analyzed using data mining techniques, machine learning and Natural Language Processing (NLP) algorithms. This analysis was integrated by a qualitative analysis.

Results.

In Italy, over the entire study timeframe, Web conversations associated to health topics were primarily focused on vaccines and tumors, and discussions on CVDs (about 235,000 conversations) were only at the 5th place. The main topics of the conversations concerned symptoms (25%), treatments (18%), causes of disease (14%), quality of life (13%). Conversations on prevention were marginal (only 5%). During the pandemic timeframe discussion topics were focused on the growing COVID-19 risk for people with CV comorbidities, the risk linked to CVD therapies and the difficulties and delays in accessing hospitals.  Over 80% of patients were not satisfied about their caring experience and such dissatisfaction grew stronger during the pandemic. In this period, anxiety, frustration, fear and depression were the mainly mentioned feelings. A good relationship with physicians (empathy, understanding) was mentioned by patients as a key factor of a positive caring experience.

Conclusions.

The limited attention to CVDs and their prevention registered through the conversations on the Web is not consistent with the epidemiological relevance of such diseases in terms of health risks and mortality. Given the crucial role of Web interactions in influencing beliefs and health-related behaviours, this study highlights the urgency to promote novel prevention strategies and to engage people leveraging digital channels and social media. The COVID-19 pandemic worsened the quality of relationship and contact with physicians. Such evidence underlines further the need to develop novel models of patient management - even remotely (digital tools, telemedicine), to encourage citizen/patient involvement and empowerment.

Reducing the Clinical and Public Health Burden of Familial Hypercholesterolemia: A Global Call to Action

Importance

Familial hypercholesterolemia (FH) is an underdiagnosed and undertreated genetic disorder that leads to premature morbidity and mortality due to atherosclerotic cardiovascular disease. Familial hypercholesterolemia affects 1 in 200 to 250 people around the world of every race and ethnicity. The lack of general awareness of FH among the public and medical community has resulted in only 10% of the FH population being diagnosed and adequately treated. The World Health Organization recognized FH as a public health priority in 1998 during a consultation meeting in Geneva, Switzerland. The World Health Organization report highlighted 11 recommendations to address FH worldwide, from diagnosis and treatment to family screening and education. Research since the 1998 report has increased understanding and awareness of FH, particularly in specialty areas, such as cardiology and lipidology. However, in the past 20 years, there has been little progress in implementing the 11 recommendations to prevent premature atherosclerotic cardiovascular disease in an entire generation of families with FH.

Observations

In 2018, the Familial Hypercholesterolemia Foundation and the World Heart Federation convened the international FH community to update the 11 recommendations. Two meetings were held: one at the 2018 FH Foundation Global Summit and the other during the 2018 World Congress of Cardiology and Cardiovascular Health. Each meeting served as a platform for the FH community to examine the original recommendations, assess the gaps, and provide commentary on the revised recommendations. The Global Call to Action on Familial Hypercholesterolemia thus represents individuals with FH, advocacy leaders, scientific experts, policy makers, and the original authors of the 1998 World Health Organization report. Attendees from 40 countries brought perspectives on FH from low-, middle-, and high-income regions. Tables listing country-specific government support for FH care, existing country-specific and international FH scientific statements and guidelines, country-specific and international FH registries, and known FH advocacy organizations around the world were created.

Conclusions and Relevance

By adopting the 9 updated public policy recommendations created for this document, covering awareness; advocacy; screening, testing, and diagnosis; treatment; family-based care; registries; research; and cost and value, individual countries have the opportunity to prevent atherosclerotic heart disease in their citizens carrying a gene associated with FH and, likely, all those with severe hypercholesterolemia as well.

Gaps in beliefs and practice in dyslipidaemia management in Japan, Germany, Colombia and the Philippines: insights from a web-based physician survey

BACKGROUND

Implementing evidence-based management of dyslipidaemia is a challenge worldwide.

OBJECTIVES

To understand physician beliefs and behaviour and identify uncertainties in dyslipidaemia management across four world regions.

METHODS

Web-based survey of 1758 physicians in Japan, Germany, Colombia and the Philippines who were selected randomly from existing databases. Key inclusion criteria were 1) for cardiologists and diabetes/endocrinology specialists: ≥50 dyslipidaemia patients examined in the last month; 2) for specialists in neurology/neurosurgery/stroke medicine: ≥50 dyslipidaemia patients and ≥ 20 patients with a history of ischaemic stroke examined in the last month; and 3) for specialists in nephrology and general medicine: based at centres with ≥20 beds and ≥ 50 dyslipidaemia patients examined in the last month. The self-report survey covered dyslipidaemia management, target low-density lipoprotein cholesterol (LDL-C) levels in different patient groups, and statin safety. All physicians gave voluntary consent and all data were anonymised. Analysis was solely descriptive.

RESULTS

The survey highlighted key areas of uncertainty in dyslipidaemia management in the four countries. These related to LDL-C targets in different patient groups, the safety of low LDL-C levels, the safety of statins, especially for effects on cognitive, renal and hepatic function and for haemorrhagic stroke risk, and lipid management strategies in patients with chronic kidney disease, including those with concomitant hypertriglyceridaemia.

CONCLUSIONS

This survey of physicians in Japan, Germany, Colombia and the Philippines has identified key gaps in knowledge about dyslipidaemia management. These relate to the safety of low LDL-C levels, the safety of statins, and lipid management of chronic kidney disease. The findings from this survey highlight the need for further education to improve the implementation of guideline recommendations for dyslipidaemia management.

Perspective: Improving Nutritional Guidelines for Sustainable Health Policies: Current Status and Perspectives

A large body of evidence supports the notion that incorrect or insufficient nutrition contributes to disease development. A pivotal goal is thus to understand what exactly is appropriate and what is inappropriate in food ingestion and the consequent nutritional status and health. The effective application of these concepts requires the translation of scientific information into practical approaches that have a tangible and measurable impact at both individual and population levels. The agenda for the future is expected to support available methodology in nutrition research to personalize guideline recommendations, properly grading the quality of the available evidence, promoting adherence to the well-established evidence hierarchy in nutrition, and enhancing strategies for appropriate vetting and transparent reporting that will solidify the recommendations for health promotion. The final goal is to build a constructive coalition among scientists, policy makers, and communication professionals for sustainable health and nutritional policies. Currently, a strong rationale and available data support a personalized dietary approach according to personal variables, including sex and age, circulating metabolic biomarkers, food quality and intake frequency, lifestyle variables such as physical activity, and environmental variables including one's microbiome profile. There is a strong and urgent need to develop a successful commitment among all the stakeholders to define novel and sustainable approaches toward the management of the health value of nutrition at individual and population levels. Moving forward requires adherence to well-established principles of evidence evaluation as well as identification of effective tools to obtain better quality evidence. Much remains to be done in the near future.

2017 Position Paper of the Italian Society for Cardiovascular Prevention (SIPREC) for an Updated Clinical Management of Hypercholesterolemia and Cardiovascular Risk: Executive Document

The benefits achieved by implementing cardiovascular prevention strategies in terms of reduced incidence of atherosclerotic diseases and mortality are accepted, worldwide. In particular, the clinical management of hypercholesterolemia has a fundamental role for all preventive strategies, both in primary and secondary prevention, at each stage of cardiovascular risk. Since the net clinical benefit of lipid-lowering therapy largely depends on baseline individual cardiovascular risk profile, the assessment of individual risk is essential to establish type and intensity of both preventive and therapeutic strategies. Thus, the real challenge in a setting of clinical practice is not only to identify whom to treat among individuals at low-to-moderate risk, but mostly how much and how long to treat high or very-high risk patients. This manuscript, which reflects concepts and positions that have been published in a more extensive document of the Italian Society for Cardiovascular Prevention (SIPREC), deals with the diagnostic and therapeutic management of patients with dyslipidaemia, with an evidence-based approach adapted and updated from recent guidelines of the European Society of Cardiology and very recent results of randomized clinical trials. The purpose is to suggest a multidimensional and integrated actions aimed at eliminating or minimizing the impact of cardiovascular diseases and their related disabilities and mortality in patients with hypercholesterolemia.

Defining severe familial hypercholesterolaemia and the implications for clinical management: a consensus statement from the International Atherosclerosis Society Severe Familial Hypercholesterolemia Panel

Familial hypercholesterolaemia is common in individuals who had a myocardial infarction at a young age. As many as one in 200 people could have heterozygous familial hypercholesterolaemia, and up to one in 300 000 individuals could be homozygous. The phenotypes of heterozygous and homozygous familial hypercholesterolaemia overlap considerably; the response to treatment is also heterogeneous. In this Review, we aim to define a phenotype for severe familial hypercholesterolaemia and identify people at highest risk for cardiovascular disease, based on the concentration of LDL cholesterol in blood and individuals' responsiveness to conventional lipid-lowering treatment. We assess the importance of molecular characterisation and define the role of other cardiovascular risk factors and advanced subclinical coronary atherosclerosis in risk stratification. Individuals with severe familial hypercholesterolaemia might benefit in particular from early and more aggressive cholesterol-lowering treatment (eg, with PCSK9 inhibitors). In addition to better tailored therapy, more precise characterisation of individuals with severe familial hypercholesterolaemia could improve resource use.

SAP97 interacts with Kv1.5 in heterologous expression systems

PDZ domain-containing proteins such as SAP97 and ZO-1 have been implicated in the targeting and clustering of ion channels. We have explored the interactions of these polypeptides with a cardiac voltage-gated potassium channel. Immunocytochemistry in cardiac myocytes revealed colocalization of SAP97 and Kv1.5, both at the intercalated disks and the lateral membranes. Transient transfection experiments in COS-7 cells revealed that SAP97 and Kv1.5 polypeptides formed perinuclear clustered complexes that could be coimmunoprecipitated. Mutation of the three COOH-terminal amino acid residues of Kv1.5 (T-D-L to A-A-A) abolished these interactions. Whereas in most COS-7 cells the SAP97-Kv1.5 complexes were retained in the ER, functional analyses in Xenopus oocytes showed that Kv1.5-encoded outward potassium currents were augmented by coexpression with SAP97. By contrast, cotransfected ZO-1 and Kv1.5 polypeptides in COS-7 cells could not be coprecipitated nor did the coinjection of ZO-1 augment the Kv1.5-encoded currents in oocytes. Collectively, our results suggest that SAP97 may play an important role in the modulation of Kv1.5 channel function in cardiac myocytes.

Sucrose-phosphate synthase from Synechocystis sp. strain PCC 6803: identification of the spsA gene and characterization of the enzyme expressed in Escherichia coli

The first identification and characterization of a prokaryotic gene (spsA) encoding sucrose-phosphate synthase (SPS) is reported for Synechocystis sp. strain PCC 6803, a unicellular non-nitrogen-fixing cyanobacterium. Comparisons of the deduced amino acid sequence and some relevant biochemical properties of the enzyme with those of plant SPSs revealed important differences in the N-terminal and UDP-glucose binding site regions, substrate specificities, molecular masses, subunit compositions, and regulatory properties.

A cellular model for long QT syndrome. Trapping of heteromultimeric complexes consisting of truncated Kv1.1 potassium channel polypeptides and native Kv1.4 and Kv1.5 channels in the endoplasmic reticulum

We demonstrated that overexpression of a cRNA encoding a truncated potassium channel polypeptide that contains the NH2 terminus and the first transmembrane segment (Kv1.1N206Tag) abolished the expression of Kv1.1 and Kv1.5 outward currents in Xenopus oocytes (Babila, T., Moscucci, A., Wang, H., Weaver, F. E. & Koren, G. (1994) Neuron 12, 615-626). Recently, we showed that expression of Kv1.1N206Tag in the heart of transgenic mice resulted in the creation of mice with prolongation of the surface electrocardiogram's QT interval (London, B., Han, X., Folco, E. & Koren, G. (1996) Biophys. J. 70, A2601). To study the dominant negative mechanism of Kv1.1N206Tag, we overexpressed it in GH3 cells, a pituitary cell line expressing Kv1. 5 and Kv1.4. RNase protection analysis comparing the steady-state levels of native Kv1.5 and Kv1.1N206Tag transcripts revealed an excess of Kv1.1N206Tag transcript. Immunoprecipitation analysis using 12CA5 monoclonal antibody detected a 25-kDa polypeptide in the transfected cells. The half-life of Kv1.1N206Tag was 2.6 h. Subcellular fractionation of cell lysates labeled with [35S]methionine revealed that Kv1.1N206Tag polypeptide is detectable in the particulate (membranous) fraction, but not in the soluble (cytosol) fraction. A series of double immunoprecipitations with 12CA5 and polyclonal antibodies against Kv1.5 and Kv1.4 revealed that Kv1.1N206Tag forms heteromultimeric complexes with the native Kv1.4 and Kv1.5 polypeptides. The steady-state levels of Kv1.5 were not affected by the overexpression of Kv1.1N206Tag. Immunofluorescence colocalization and confocal microscopy analyses revealed that Kv1.1N206TagFlag did not reach the plasma membrane, and its distribution pattern was characteristic to that of a resident endoplasmic reticulum polypeptide. Our observations establish that the negative effect of Kv1.1N206Tag is mediated by the formation of heteromultimeric complexes with the native channels and by the retention of these complexes in the endoplasmic reticulum.

GH3 cell-specific expression of Kv1.5 gene. Regulation by a silencer containing a dinucleotide repetitive element

A silencer element (Kv1.5 repressor element; KRE) was characterized by deletion analyses in the promoter of Kv1.5, a voltage-gated potassium channel. The silencer element selectively decreases expression of Kv1.5- and thymidine kinase-chloramphenicol acetyl-transferase reporter gene constructs in cell lines that do not express Kv1.5 polypeptide. It contains a dinucleotide repetitive element (poly(GT)19(GA)1(CA)15(GA)16), and self-associates spontaneously in vitro to form complexes with slow electrophoretic mobility. Deletion of the repetitive element abolished self-association in vitro and the silencing activity in transient transfection experiments in vivo. Electromobility gel shift assays of KRE with GH3 cells nuclear extracts detected the formation of a unique DNA-protein complex, which was not detectable in Chinese hamster ovary and COS-7 cells. This complex does not react with an antibody against nonhistone high mobility group 1 protein, which binds KRE in gel retardation assays. These observations establish that a dinucleotide tandem repeat sequence, capable of self-association, forms part of a cell-specific silencer element in a mammalian gene.

Molecular characterization of a novel rabbit interleukin-8 receptor isotype

Interleukin-8 (IL-8) mediates the transendothelial migration and activation of neutrophils to the site of inflammation. Two human IL-8 receptor isotype (A and B) and one rabbit IL-8 receptor isotype (A) cDNAs have been previously cloned and characterized on the basis of their pharmacological profile. Human and rabbit IL-8 receptor subtype A binds IL-8 and structurally related peptide melanoma growth-stimulating activity (MGSA) and neutrophil-activating peptide-2 (NAP-2) according to the following affinity binding profile: IL-8 >>> MGSA > NAP-2, whereas the human IL-8 receptor subtype B profile is IL-8 = MGSA > NAP-2 (LaRosa, G., Thomas, K. M., Kaufmann, M., Mark, R., White, M., Taylor, L., Gray, G., Witt, D., and Navarro, J. (1992) J. Biol. Chem. 267, 25402-25406). In this study, we isolated a cDNA clone (5B1a) from a rabbit neutrophil library encoding a G-protein-coupled receptor of the interleukin-8 receptor family. The 5B1a clone encodes a 358-amino acid protein exhibiting 80% amino acid identity to the human IL-8 receptor B, 74% to the rabbit IL-8 receptor A, and 73% to the human IL-8 receptor A. Tissue distribution by Northern blot analysis reveals that the 5B1a mRNA is expressed preferentially in neutrophils. In contrast to previously described IL-8 receptors, the 5B1a receptor exhibited specific 125I-IL-8 binding with a novel affinity binding profile of IL-8 >> NAP-2 > MGSA. The corresponding apparent Ki values for IL-8, NAP-2, and MGSA were 4, 120, and 320 nM, respectively. IL-8 induced intracellular calcium mobilization and desensitization in Chinese hamster ovary cells stably transfected with 5B1a, indicating that this cDNA encodes a functional IL-8 receptor. Sequence analysis of the 5B1a protein with other IL-8 receptor subtypes within the framework of their pharmacological profile reveals putative structural motifs that may correspond to the ligand binding site of the IL-8 receptor.

The transcription of a mammalian voltage-gated potassium channel is regulated by cAMP in a cell-specific manner

The transcript of Kv1.5, a Shaker-like delayed rectifier K+ channel cloned in our laboratory, is regulated in both tissue and developmentally specific manners. In this study we characterized the 5'-flanking region of the Kv1.5 gene. The gene lacks a canonical TATA box, has several transcription start sites, and the 5'-noncoding sequence is intronless. A cAMP response element (CRE) consensus signal was identified in the 5'-noncoding region. cAMP regulates the expression of Kv1.5 gene in a cell-specific manner. In primary cardiac cells, cAMP induces a 6-fold increase in the steady state levels of Kv1.5 transcript. However, in GH3 cells cAMP induces a 5-6-fold decrease in steady state levels of Kv1.5 transcript. The half-life of Kv1.5 transcript is 37 min and is not affected by cAMP. Nuclear run-on experiments show that in GH3 cells, cAMP reduces the transcription rate of Kv1.5 gene. Transient transfection assays using 5'-deletion mutations of Kv1.5 5'-flanking sequences revealed that the CRE located at +636 can confer the cAMP inducibility to Kv1.5 reporter gene constructs and binds to CRE-binding protein (CREB) and CRE modulator protein (CREM) in electromobility gel shift assays. Furthermore, KCl-induced depolarization can increase the steady state levels of Kv1.5 transcript in primary atrial cells and decrease it in GH3 cells. We conclude that cAMP and depolarization play an important role in regulating K+ channel expression and thus may induce long term effects on the pattern of electrical activity of excitable cells.