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Ibrahim S, Nurmohamed NS, Nierman MC, de Goeij JN, Zuurbier L, van Rooij J, Schonck WAM, de Vries J, Hovingh GK, Reeskamp LF, Stroes ESG. Enhanced identification of familial hypercholesterolemia using central laboratory algorithms. Atherosclerosis 2024; 393:117548. [PMID: 38643673 DOI: 10.1016/j.atherosclerosis.2024.117548] [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: 02/14/2024] [Revised: 03/21/2024] [Accepted: 04/10/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is a highly prevalent genetic disorder resulting in markedly elevated LDL cholesterol levels and premature coronary artery disease. FH underdiagnosis and undertreatment require novel detection methods. This study evaluated the effectiveness of using an LDL cholesterol cut-off ≥99.5th percentile (sex- and age-adjusted) to identify clinical and genetic FH, and investigated underutilization of genetic testing and undertreatment in FH patients. METHODS Individuals with at least one prior LDL cholesterol level ≥99.5th percentile were selected from a laboratory database containing lipid profiles of 590,067 individuals. The study comprised three phases: biochemical validation of hypercholesterolemia, clinical identification of FH, and genetic determination of FH. RESULTS Of 5614 selected subjects, 2088 underwent lipid profile reassessment, of whom 1103 completed the questionnaire (mean age 64.2 ± 12.7 years, 48% male). In these 1103 subjects, mean LDL cholesterol was 4.0 ± 1.4 mmol/l and 722 (65%) received lipid-lowering therapy. FH clinical diagnostic criteria were met by 282 (26%) individuals, of whom 85% had not received guideline-recommended genetic testing and 97% failed to attain LDL cholesterol targets. Of 459 individuals consenting to genetic validation, 13% carried an FH-causing variant, which increased to 19% in clinically diagnosed FH patients. CONCLUSIONS The identification of a substantial number of previously undiagnosed and un(der)treated clinical and genetic FH patients within a central laboratory database highlights the feasibility and clinical potential of this targeted screening strategy; both in identifying new FH patients and in improving treatment in this high-risk population.
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Affiliation(s)
- Shirin Ibrahim
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nick S Nurmohamed
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostic Centers, Amsterdam, the Netherlands
| | - Jim N de Goeij
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Linda Zuurbier
- Department of Human Genetics, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jeroen van Rooij
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Willemijn A M Schonck
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jard de Vries
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Joosten LPT, van Doorn S, van de Ven PM, Köhlen BTG, Nierman MC, Koek HL, Hemels MEW, Huisman MV, Kruip M, Faber LM, Wiersma NM, Buding WF, Fijnheer R, Adriaansen HJ, Roes KC, Hoes AW, Rutten FH, Geersing GJ. Safety of Switching From a Vitamin K Antagonist to a Non-Vitamin K Antagonist Oral Anticoagulant in Frail Older Patients With Atrial Fibrillation: Results of the FRAIL-AF Randomized Controlled Trial. Circulation 2024; 149:279-289. [PMID: 37634130 DOI: 10.1161/circulationaha.123.066485] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND There is ambiguity whether frail patients with atrial fibrillation managed with vitamin K antagonists (VKAs) should be switched to a non-vitamin K oral anticoagulant (NOAC). METHODS We conducted a pragmatic, multicenter, open-label, randomized controlled superiority trial. Older patients with atrial fibrillation living with frailty (≥75 years of age plus a Groningen Frailty Indicator score ≥3) were randomly assigned to switch from international normalized ratio-guided VKA treatment to an NOAC or to continued VKA treatment. Patients with a glomerular filtration rate <30 mL·min-1·1.73 m-2 or with valvular atrial fibrillation were excluded. Follow-up was 12 months. The cause-specific hazard ratio was calculated for occurrence of the primary outcome that was a major or clinically relevant nonmajor bleeding complication, whichever came first, accounting for death as a competing risk. Analyses followed the intention-to-treat principle. Secondary outcomes included thromboembolic events. RESULTS Between January 2018 and June 2022, a total of 2621 patients were screened for eligibility and 1330 patients were randomly assigned (mean age 83 years, median Groningen Frailty Indicator score 4). After randomization, 6 patients in the switch-to-NOAC arm and 1 patient in the continue-with-VKA arm were excluded due to the presence of exclusion criteria, leaving 662 patients switched from a VKA to an NOAC and 661 patients continued VKAs in the intention-to-treat population. After 163 primary outcome events (101 in the switch arm, 62 in the continue arm), the trial was stopped for futility according to a prespecified futility analysis. The hazard ratio for our primary outcome was 1.69 (95% CI, 1.23-2.32). The hazard ratio for thromboembolic events was 1.26 (95% CI, 0.60-2.61). CONCLUSIONS Switching international normalized ratio-guided VKA treatment to an NOAC in frail older patients with atrial fibrillation was associated with more bleeding complications compared with continuing VKA treatment, without an associated reduction in thromboembolic complications. REGISTRATION URL: https://eudract.ema.europa.eu; Unique identifier: 2017-000393-11. URL: https://eudract.ema.europa.eu; Unique identifier: 6721 (FRAIL-AF study).
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Affiliation(s)
- Linda P T Joosten
- Department of Primary Care & Nursing Science (L.P.T.J., S.v.D., B.T.G.K., F.H.R., G.-J.G.), University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht University, The Netherlands
| | - Sander van Doorn
- Department of Primary Care & Nursing Science (L.P.T.J., S.v.D., B.T.G.K., F.H.R., G.-J.G.), University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht University, The Netherlands
| | - Peter M van de Ven
- Department of Data Science & Biostatistics (P.M.v.d.V.), University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht University, The Netherlands
| | - Bart T G Köhlen
- Department of Primary Care & Nursing Science (L.P.T.J., S.v.D., B.T.G.K., F.H.R., G.-J.G.), University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht University, The Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostic Centers, Amsterdam, The Netherlands (M.C.N.,)
| | - Huiberdina L Koek
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, The Netherlands (H.L.K.)
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands (M.E.W.H.)
- Department of Cardiology (M.E.W.H.), Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden University, Leiden, The Netherlands (M.V.H.)
| | - Marieke Kruip
- Department of Hematology, Erasmus University Medical Center Rotterdam, Erasmus University, The Netherlands (M.K.)
| | - Laura M Faber
- Department of Thrombosis and Anticoagulation, Starlet Medical Diagnostic Center, Alkmaar, The Netherlands (L.M.F.)
| | - Nynke M Wiersma
- Department of Thrombosis and Anticoagulation, Diagnostic Center Saltro, Utrecht, The Netherlands (N.M.W.)
| | - Wim F Buding
- Patient representative from Dutch Organization for patients using anticoagulant medication, CTD, Leiden, The Netherlands (W.F.B.)
| | - Rob Fijnheer
- Department of Internal Medicine, Meander Hospital, Amersfoort, The Netherlands (B.F.)
| | - Henk J Adriaansen
- Department of Thrombosis and Anticoagulation, Tergooi Medical Center, Hilversum, The Netherlands (H.J.A.)
| | - Kit C Roes
- Department Health Evidence and Biostatistics (K.C.R.), Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Arno W Hoes
- University Medical Center Utrecht, Dean, Board of Directors, Utrecht University, The Netherlands (A.W.H.)
| | - Frans H Rutten
- Department of Primary Care & Nursing Science (L.P.T.J., S.v.D., B.T.G.K., F.H.R., G.-J.G.), University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht University, The Netherlands
| | - Geert-Jan Geersing
- Department of Primary Care & Nursing Science (L.P.T.J., S.v.D., B.T.G.K., F.H.R., G.-J.G.), University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht University, The Netherlands
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Visser C, Yousefi A, Nierman MC, Huisman MV, Gulpen AJW, van Ommen CH, Kruip MJHA. The effect of COVID-19 vaccination on anticoagulation stability in adolescents and young adults using vitamin K antagonists. Thromb Res 2023; 228:121-127. [PMID: 37321159 PMCID: PMC10258126 DOI: 10.1016/j.thromres.2023.06.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/21/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION The European Medicine Agency has authorized COVID-19 vaccination in adolescents and young adults (AYAs) from 12 years onwards. In elderly vitamin K antagonist (VKA) users, COVID-19 vaccination has been associated with an increased risk of supra- and subtherapeutic INRs. Whether this association is also observed in AYAs using VKA is unknown. Our aim was to describe the stability of anticoagulation after COVID-19 vaccination in AYA VKA users. MATERIALS AND METHODS A case-crossover study was performed in a cohort of AYAs (12-30 years) using VKAs. The most recent INR results before vaccination, the reference period, were compared with the most recent INR after the first and, if applicable, second vaccination. Several sensitivity analyses were performed in which we restricted our analysis to stable patients and patients without interacting events. RESULTS 101 AYAs were included, with a median age [IQR] of 25 [7] years, of whom 51.5 % were male and 68.3 % used acenocoumarol. We observed a decrease of 20.8 % in INRs within range after the first vaccination, due to an increase of 16.8 % in supratherapeutic INRs. These results were verified in our sensitivity analyses. No differences were observed after the second vaccination compared to before and after the first vaccination. Complications after vaccination occurred less often than before vaccination (9.0 vs 3.0 bleedings) and were non-severe. CONCLUSIONS the stability of anticoagulation after COVID-19 vaccination was decreased in AYA VKA users. However, the decrease might not be clinically relevant as no increase of complications nor significant dose adjustments were observed.
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Affiliation(s)
- Chantal Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Arjen Yousefi
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostics Centers, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Anouk J W Gulpen
- Department of Internal Medicine, The Elkerliek Hospital, Helmond, the Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands; Thrombosis Service Star-shl, Rotterdam, the Netherlands.
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Nierman MC. Working towards personalized anticoagulation management. Int J Cardiol 2022; 364:102. [PMID: 35675880 DOI: 10.1016/j.ijcard.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostics Centers, Jan Tooropstraat 138, 1061 AD Amsterdam, The Netherlands..
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Visser C, Biedermann JS, Nierman MC, van der Meer FJM, Gulpen AJW, Moors YCF, Cannegieter SC, Lijfering WM, Kruip MJHA. The Immediate Effect of COVID-19 Vaccination on Anticoagulation Control in Patients Using Vitamin K Antagonists. Thromb Haemost 2022; 122:377-385. [PMID: 35245945 PMCID: PMC8899332 DOI: 10.1055/s-0042-1742628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background
In January 2021, the Dutch vaccination program against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was started. Clinical studies have shown that systemic reactions occur in up to 50% of vaccine recipients. Therefore, COVID-19 vaccination could affect anticoagulation control, potentially leading to an increased risk of thrombotic events and bleeding complications.
Aims
This article investigates whether the BNT162b2 vaccine affects anticoagulation control in outpatients using vitamin K antagonists (VKAs).
Methods
A case-crossover study was performed in a cohort of outpatient VKA users from four Dutch anticoagulation clinics who received a BNT162b2 vaccine. International normalized ratio (INR) results and VKA dosages before the first vaccination, the reference period, were compared with those after the first and second vaccination.
Results
A total of 3,148 outpatient VKA users were included, with a mean age (standard deviation) of 86.7 (8.7) years, of whom 43.8% were male, 67.0% used acenocoumarol, and 33.0% phenprocoumon. We observed a decrease of 8.9% of INRs within range in the standard intensity group (target INR 2.0–3.0). There was both an increased risk of supratherapeutic (odds ratio [OR] = 1.34 [95% confidence interval [CI] 1.08–1.67]) and subtherapeutic levels (OR = 1.40 [95% CI 1.08–1.83]) after first vaccination. In the high-intensity group (target INR 2.5–3.5), the risk of a supratherapeutic INR was 2.3 times higher after first vaccination (OR = 2.29 [95% CI 1.22–4.28]) and 3.3 times higher after second vaccination (OR = 3.25 [95% CI 1.06–9.97]).
Conclusion
BNT162b2 was associated with an immediate negative effect on anticoagulation control in patients treated with VKAs, so it is advisable to monitor the INR shortly after vaccination, even in stable patients.
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Affiliation(s)
- Chantal Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joseph S Biedermann
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostics Centers, Amsterdam, The Netherlands
| | - Felix J M van der Meer
- Department of Internal Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anouk J W Gulpen
- Department of Internal Medicine, Elkerliek Hospital, Helmond, The Netherlands
| | - Yvonne C F Moors
- Department of Internal Medicine, Elkerliek Hospital, Helmond, The Netherlands
| | - Suzanne C Cannegieter
- Department of Internal Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Kennisinstituut van de Federatie Medisch Specialisten, Utrecht, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.,Thrombosis Service Star-shl, Rotterdam, The Netherlands
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Toorop MMA, Chen Q, Kruip MJHA, van der Meer FJM, Nierman MC, Faber L, Goede L, Cannegieter SC, Lijfering WM. Switching from vitamin K antagonists to direct oral anticoagulants in non-valvular atrial fibrillation patients: Does low time in therapeutic range affect persistence? J Thromb Haemost 2022; 20:339-352. [PMID: 34779140 PMCID: PMC9299168 DOI: 10.1111/jth.15592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 06/17/2021] [Revised: 10/20/2021] [Accepted: 11/10/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Non-valvular atrial fibrillation (NVAF) patients are advised to switch from a vitamin K antagonist (VKA) to direct oral anticoagulant (DOAC) when time in therapeutic range (TTR) is low. OBJECTIVE To examine if pre-switch TTR determines persistence patterns in NVAF patients who are switched from a VKA to DOAC. PATIENTS/METHODS Adult NVAF patients from three Dutch anticoagulation clinics who were newly switched from a VKA to DOAC between July 1, 2013 and September 30, 2018 were stratified by pre-switch TTR levels. DOAC prescription records were examined to determine persistence patterns according to a 100-day prescription gap. Cumulative incidences of non-persistence to DOAC were estimated using the cumulative incidence competing risk method. The association of pre-switch TTR levels with DOAC non-persistence was evaluated by Cox regression models. RESULTS A total of 3696 NVAF patients were included, of whom 690 (18.7%) had a pre-switch TTR ≤ 45%. After switching from VKA to DOAC, 14.0% (95% confidence interval [CI] 11.3-17.0%) of the patients with a pre-switch TTR ≤ 45% became non-persistent to DOAC within 1 year, while 9.8% (95% CI 8.7-11.0%) did in those with a pre-switch TTR > 45%. In a multivariable model, a pre-switch TTR ≤ 45% was associated with a higher risk of non-persistence to DOAC (adjusted hazard ratio 1.55, 95% CI 1.22-1.97). Results were similar when using other cut-off points (60% or 70%) to define a low TTR. CONCLUSION NVAF patients switching from VKA to DOAC due to a low pre-switch TTR saw a worse persistence pattern to DOAC after the switch compared to patients with a high pre-switch TTR.
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Affiliation(s)
- Myrthe M. A. Toorop
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Qingui Chen
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Marieke J. H. A. Kruip
- Department of HaematologyErasmus MCErasmus University Medical CenterRotterdamthe Netherlands
- Thrombosis Service Star‐shlRotterdamthe Netherlands
| | | | | | - Laura Faber
- Department of MedicineRed Cross HospitalBeverwijkthe Netherlands
| | - Lies Goede
- Thrombosis Service of Utrecht (Saltro)Utrechtthe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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Toorop MMA, van Rein N, Nierman MC, Vermaas HW, Huisman MV, van der Meer FJM, Cannegieter SC, Lijfering WM. Inter- and intra-individual concentrations of direct oral anticoagulants: The KIDOAC study. J Thromb Haemost 2022; 20:92-103. [PMID: 34664401 PMCID: PMC9297950 DOI: 10.1111/jth.15563] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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] [Received: 08/09/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) do not require concentration monitoring. However, whether DOAC concentrations are stable and their variation between and within patients is not well studied. METHODS Patients on vitamin K antagonists (VKA) who switched to rivaroxaban, apixaban, or dabigatran were included between 2018 and 2020. Blood was drawn at DOAC trough and peak concentrations at week 0, 2, and 8. Plasma drug concentrations were determined by anti-factor Xa concentrations (rivaroxaban, apixaban) or diluted thrombin time (dabigatran). Inter- and intra-individual variability was assessed by calculating the coefficient of variation (CV). Linear regression models were employed to evaluate associations between DOAC trough concentrations and previous VKA dosage, creatinine clearance, and body mass index (BMI). RESULTS One hundred fifty-two patients were included, of whom 96 (63%) were male and with a mean age of 73.9 ± 8.4 years. For the inter-individual variability, the CV ranged between 48% and 81% for trough values and between 25% and 69% for peak values among patients using the recommended DOAC dose. Intra-individual variability was substantially lower, as here the CV ranged between 18% and 33% for trough values and between 15% and 29% for peak values among patients using the recommended DOAC dose. Previous VKA dosage and creatinine clearance were inversely associated with DOAC trough concentrations. No association was found between BMI and DOAC trough concentrations. CONCLUSION Inter-individual variability of DOAC concentrations was higher than intra-individual variability. Lower previous VKA dosage and creatinine clearance were associated with higher DOAC trough concentrations. These findings support further study into an optimal target range, in which the risks of both bleeding and thrombosis are minimal.
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Affiliation(s)
- Myrthe M. A. Toorop
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Nienke van Rein
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenthe Netherlands
| | | | - Helga W. Vermaas
- Thrombosis Service of the Hague (LabWest)The Haguethe Netherlands
| | - Menno V. Huisman
- Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | | | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Kennisinstituut van de Federatie Medisch SpecialistenUtrechtthe Netherlands
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Camilleri E, van Rein N, van der Meer FJM, Nierman MC, Lijfering WM, Cannegieter SC. Stability of vitamin K antagonist anticoagulation after COVID-19 diagnosis. Res Pract Thromb Haemost 2021; 5:e12597. [PMID: 34667920 PMCID: PMC8511881 DOI: 10.1002/rth2.12597] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 07/14/2021] [Revised: 07/14/2021] [Accepted: 08/02/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Coagulopathy has been reported in severely ill patients with coronavirus disease 2019 (COVID-19). It is unclear whether outpatients with COVID-19 who are treated with vitamin K antagonists (VKAs) have unstable anticoagulation. OBJECTIVE To assess the stability of VKA therapy in patients with COVID-19 through a case-crossover study. METHODS Between February and July 2020, we included patients who tested positive for COVID-19 from two anticoagulant clinics in the Netherlands. We collected international normalized ratios (INRs) determined between 26 weeks before infection and 12 weeks after. Time in therapeutic range (TTR) and the variance growth rate (VGR) were calculated within patients. RESULTS Fifty-one patients with COVID-19 (mean age, 84 years) were included, of whom 15 (29%) were men. Mean TTR in the 26 weeks before COVID-19 was 80% (95% confidence interval [CI], 75-85) compared to 59% (95% CI, 51-68) in the 6 weeks after infection. Mean TTR difference was -23% (95% CI, -32 to -14) with a time above therapeutic range of 38% (95% CI, 30-47) in the 6 weeks after infection. The TTR rose again to 79% (95% CI, 69-89) between 6 and 12 weeks after infection. Also, VGR increased, with a mean increase of 4.8 (95% CI, 2.1-7.5) in the 6 weeks after infection. In the 26 weeks before infection, we registered 19 of 641 (3%) of INR ≥5.0 compared with 35 of 247 (14%) in the 6 weeks after (risk ratio, 4.4; 95% CI, 2.7-7.3). CONCLUSIONS COVID-19 is associated with a strong decrease in TTR and in therapeutic stability in patients taking VKAs. Additional monitoring in these patients is advised to maximize therapeutic stability.
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Affiliation(s)
- Eleonora Camilleri
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Nienke van Rein
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of PharmacyAmsterdam University Medical Centers – Location AMC, University of AmsterdamAmsterdamThe Netherlands
| | - Felix J. M. van der Meer
- Anticoagulation Clinic LeidenLeidenThe Netherlands
- Department of Internal Medicine, Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Melchior C. Nierman
- Department of Thrombosis and AnticoagulationAtalmedial Medical Diagnostics CentersAmsterdamThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal Medicine, Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal Medicine, Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
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Toorop MMA, van Rein N, Nierman MC, Vermaas HW, Huisman MV, van der Meer FJM, Cannegieter SC, Lijfering WM. Switching from vitamin K antagonists to direct oral anticoagulants: Treatment satisfaction and patient concerns. J Thromb Haemost 2020; 18:1390-1397. [PMID: 32170987 PMCID: PMC7318134 DOI: 10.1111/jth.14793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/14/2020] [Accepted: 03/10/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Since direct oral anticoagulants (DOACs) have been introduced for treatment and prevention of thromboembolic diseases, patients on vitamin K antagonists (VKA) have to decide whether to remain on VKA or switch to DOAC. The goal of this study was to evaluate treatment satisfaction, preferences, and concerns among those who already have switched from VKA to DOAC. METHODS A questionnaire was sent to 2920 former patients of three anticoagulation clinics in the Netherlands, who switched from VKA to DOAC (2016-2017). Questions concerned demographics, treatment satisfaction, concerns, perspectives on antidotes, and monitoring. To identify predictors for being concerned about adverse events, logistic regression was used to estimate crude- and adjusted (age and sex) odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS One thousand, three hundred ninety-nine questionnaires (response rate 48%) were used for analysis. DOAC treatment satisfaction was high (mean 8.8 of a maximum 10-point score). A quarter of patients expressed concerns about adverse events. Predictors for being concerned were age < 60 years (vs age > 75 years, OR 4.1, 95% CI 2.6-6.4), female sex (OR 1.3, 95% CI 1.0-1.6), and high education (OR 1.6, 95% CI 1.2-2.2). Fifty-nine percent of all patients indicated antidote availability as important, 73% would be willing to participate in DOAC monitoring. CONCLUSIONS DOAC treatment satisfaction was high. A substantial number of patients expressed concerns about adverse events, especially women, patients aged < 60 years, or highly educated patients. Our findings among patients who already had switched to DOAC may assist in the process of shared decision-making when switching a patient from VKA to DOAC is considered.
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Affiliation(s)
- Myrthe M. A. Toorop
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Nienke van Rein
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
- Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | | | - Helga W. Vermaas
- Thrombosis Service of the Hague (LabWest)The HagueThe Netherlands
| | - Menno V. Huisman
- Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | | | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
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Toorop MMA, van Rein N, Nierman MC, Vermaas HW, Huisman MV, van der Meer FJM, Cannegieter SC, Lijfering WM. Self-reported therapy adherence and predictors for nonadherence in patients who switched from vitamin K antagonists to direct oral anticoagulants. Res Pract Thromb Haemost 2020; 4:586-593. [PMID: 32548557 PMCID: PMC7292652 DOI: 10.1002/rth2.12316] [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: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Many patients who used vitamin K antagonists (VKAs) for long-term prevention of thromboembolism are now actively switched to a direct oral anticoagulant (DOAC). Strict adherence to a DOAC is crucial for its success. However, therapy adherence and clinical factors that predict nonadherence are currently not well studied among patients who switched from a VKA to a DOAC. METHODS A questionnaire was developed and sent to 2920 former patients of 3 anticoagulation clinics in the Netherlands, who switched from a VKA to a DOAC between January 2016 and December 2017. Questions concerned demographics, treatment persistence, adherence, and the occurrence of bleeding or thromboembolic events on DOACs. To identify predictors for nonadherence, logistic regression models were used to estimate crude and age/sex-adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS A total of 1399 questionnaires (response rate 48%) were used for analysis. DOAC treatment persistence (94%) and adherence (86%) rates were high. Several predictors of nonadherence were identified, including young age (OR, 5.9; 95% CI, 3.6-9.8 for <60 years compared to >75 years), low consultation frequency with a specialist (OR, 1.6; 95% CI, 1.1-2.2), a history of minor bleeding on DOACs (OR, 1.9; 95% CI, 1.3-2.8), and a twice-daily dosing regimen (OR, 1.9; 95% CI, 1.3-2.6). CONCLUSIONS Self-reported treatment persistence and adherence were high in our study population, and several predictors of nonadherence were identified. Factors that can be influenced (low consult frequency with medical specialist, daily dosing regimen) may be used to improve therapy adherence.
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Affiliation(s)
- Myrthe M. A. Toorop
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | | | - Helga W. Vermaas
- Thrombosis Service of the Hague (LabWest)The HagueThe Netherlands
| | - Menno V. Huisman
- Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | | | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
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Joosten LPT, van Doorn S, Hoes AW, Nierman MC, Wiersma NM, Koek HL, Hemels MEW, Huisman MV, Roes KC, van den Bor RM, Buding WF, Rutten FH, Geersing GJ. Safety of switching from vitamin K antagonist to non-vitamin K antagonist oral anticoagulant in frail elderly with atrial fibrillation: rationale and design of the FRAIL-AF randomised controlled trial. BMJ Open 2019; 9:e032488. [PMID: 31888928 PMCID: PMC6937027 DOI: 10.1136/bmjopen-2019-032488] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Clinical guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF). Frail elderly were under-represented in the landmark NOAC-trials, leaving a knowledge gap on the optimal anticoagulant management (VKA or NOAC) in this increasing population. The aim of the Frail-AF (FRAIL-AF) study is to assess whether switching from international normalised ratio (INR)-guided VKA-management to a NOAC-based treatment strategy compared with continuing VKA-management is safe in frail elderly patients with AF. METHODS AND ANALYSIS The FRAIL-AF study is a pragmatic, multicentre, open-label, randomised controlled clinical trial. Frail elderly (age ≥75 years plus a Groningen Frailty Indicator score ≥3) who receive VKA-treatment for AF in the absence of a mechanical heart valve or severe mitral valve stenosis will be randomised to switch to a NOAC-based treatment strategy or to continue INR-guided VKA-management. Patients with severe renal impairment (estimated glomerular filtration rate <30 mL/min/1.73 m2) will be excluded from randomisation. Based on existing trial evidence in non-frail patients, we will aim to explore whether NOAC-treatment is superior to VKA-therapy in reducing major or clinically relevant non-major bleeding events. Secondary outcomes include minor bleeding, the composite of ischaemic and haemorrhagic stroke, health-related quality of life and cost-effectiveness. The follow-up period for all subjects is 12 months. ETHICS AND DISSEMINATION The protocol was approved by the Medical Research Ethics Committee of the University Medical Center Utrecht, the Netherlands and by the Central Committee on Research Involving Human Subjects, the Netherlands. All patients are asked written informed consent. Results are expected in 2022 and will be disseminated through peer-reviewed journals as well as presentations at national and international conferences. TRIAL REGISTRATION NUMBER EudraCT: 2017-000393-11; The Netherlands Trial Registry: 6721 (FRAIL-AF study).
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Affiliation(s)
- Linda P T Joosten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostics Centers, Amsterdam, The Netherlands
| | - Nynke M Wiersma
- Department of Thrombosis and Anticoagulation, Diagnostic Center Saltro, Utrecht, The Netherlands
| | - Huiberdina L Koek
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Kit C Roes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rutger M van den Bor
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wim F Buding
- Member of the Dutch Organisation for patients using anticoagulant medication, CTD Nederland, Leiden, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Nieuwkerk PT, Nierman MC, Vissers MN, Locadia M, Greggers-Peusch P, Knape LP, Kastelein JJ, Sprangers MA, de Haes HC, Stroes ES. Intervention to improve adherence to lipid-lowering medication and lipid-levels in patients with an increased cardiovascular risk. Am J Cardiol 2012; 110:666-72. [PMID: 22621795 DOI: 10.1016/j.amjcard.2012.04.045] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 04/26/2012] [Accepted: 04/26/2012] [Indexed: 11/25/2022]
Abstract
Low levels of statin adherence may compromise treatment outcomes. The aim of this study was to investigate whether nurse-led cardiovascular risk-factor counseling could improve statin adherence and lipid levels without increasing patients' anxiety. Patients with indications for statin therapy for primary or secondary prevention of cardiovascular disease were randomly assigned to receive routine care or extended care (EC) at baseline and at months 3, 9, and 18. Patients in the EC group received a personalized risk-factor passport, showing modifiable and unmodifiable individual risk factors and a graphical presentation of their calculated absolute 10-year cardiovascular disease risk as well as the target risk that could be reached if all modifiable risk factors were optimally treated. Lipid levels were assessed at each visit. Carotid intima-media thickness was measured at baseline and at month 18. Adherence, anxiety, quality of life, symptoms, and smoking status were assessed using a self-administered questionnaire at each visit. A total of 201 patients were included in the study. Statin adherence was significantly higher (p <0.01) and anxiety was significantly lower (p <0.01) in the EC group than in the routine care group. Low-density lipoprotein cholesterol was statistically significantly lower in the EC group than in the routine group (2.66 vs 3.00 mmol/L, respectively, p = 0.024) in primary prevention patients only. Intima-media thickness improved significantly from baseline (p <0.01) in all patients, irrespective of group assignment. In conclusion, cardiovascular risk-factor counseling resulted in improved lipid profiles in primary prevention patients and higher levels of adherence to statins and lower levels of anxiety in all patients.
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13
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Stroes ES, Nierman MC, Meulenberg JJ, Franssen R, Twisk J, Henny CP, Maas MM, Zwinderman AH, Ross C, Aronica E, High KA, Levi MM, Hayden MR, Kastelein JJ, Kuivenhoven JA. Intramuscular administration of AAV1-lipoprotein lipase S447X lowers triglycerides in lipoprotein lipase-deficient patients. Arterioscler Thromb Vasc Biol 2008; 28:2303-4. [PMID: 18802015 DOI: 10.1161/atvbaha.108.175620] [Citation(s) in RCA: 168] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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van der Graaf A, Nierman MC, Firth JC, Wolmarans KH, Marais AD, de Groot E. Efficacy and safety of fluvastatin in children and adolescents with heterozygous familial hypercholesterolaemia. Acta Paediatr 2006; 95:1461-6. [PMID: 17062478 DOI: 10.1080/08035250600702602] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIM To assess whether early initiation of statin therapy for heterozygous familial hypercholesterolaemia favourably affects lipid profiles or vascular morphological changes. METHODS Children and adolescents aged 10-16 y with heterozygous familial hypercholesterolaemia were administered fluvastatin (80 mg/d) for 2 y in a single-arm two-centre study. Carotid B-mode intima-media thickness (IMT) and M-mode arterial wall stiffness (beta) were recorded. Eighty of the 85 enrolled subjects completed the trial. RESULTS The median decrease in low-density lipoprotein (LDL) cholesterol from baseline at last study visit was 33.9%; median decreases in total cholesterol, triglycerides and apolipoprotein B were 27.1%, 5.3% and 24.2%, respectively; the median increase in high-density lipoprotein (HDL) cholesterol was 5.3%. Changes in carotid arterial wall thickness and stiffness versus baseline were fractional and statistically non-significant (delta IMT -0.005 mm, 95% CI -0.018 to +0.007 mm, n=83; and delta beta = 0.017, 95% CI -0.219 to +0.253, n=79). Adverse events, all non-serious, were reported by 58 subjects (68.2%); four were suspected to be drug-related. Change in hormone levels and sexual maturation were appropriate for this age group. CONCLUSION Fluvastatin lowered LDL cholesterol, total cholesterol and apolipoprotein B levels effectively over a prolonged period in children and adolescents with heterozygous familial hypercholesterolaemia. Carotid IMT and wall stiffness remained largely unchanged.
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Affiliation(s)
- Anouk van der Graaf
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, The Netherlands
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15
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Nierman MC, Peter J, Khoo KL, Defesche JC. Lipoprotein lipase gene analyses in one Turkish family and three different Chinese families with severe hypertriglyceridaemia: one novel and several established mutations. J Inherit Metab Dis 2006; 29:686. [PMID: 16972177 DOI: 10.1007/s10545-006-0310-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Revised: 04/12/2006] [Accepted: 06/19/2006] [Indexed: 10/24/2022]
Abstract
Lipoprotein lipase (LPL, triacylglycerol acylhydrolase; EC 3.1.1.3) deficiency (OMIM 238600) is an autosomal recessive inherited condition caused by mutations in the LPL gene, either in a homozygous or in a compound heterozygous state, leading to loss of lipolytic activity and resulting in severe hypertriglyceridaemia and subsequent risk for developing pancreatitis. Numerous LPL gene mutations leading to loss of catalytic function have been described. In this present study, we describe full clinical, biochemical and molecular analyses of severe hypertriglyceridaemic individuals in one Turkish and three Chinese families. We established one novel mutation (delCT1312-1313), a new combination of mutations (S193R and I194T) and four previously reported mutations (L252R, L252V, S193R and I194T) of the LPL gene and report phenotypes for these and four previously described mutations. Finally, we show that two patients homozygous for the LPL gene delCT1312-1313 mutations are characterized by absence of LPL activity that coincides with absence of LPL protein.
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Affiliation(s)
- Melchior C Nierman
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, The Netherlands, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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16
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Nierman MC, Rip J, Kuivenhoven JA, Sakai N, Kastelein JJP, de Sain-van der Velden MGM, Stroes ESG, Prinsen BHCMT. Enhanced apoB48 metabolism in lipoprotein lipase X447 homozygotes. Atherosclerosis 2006; 194:446-51. [PMID: 16989840 DOI: 10.1016/j.atherosclerosis.2006.08.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2006] [Revised: 08/15/2006] [Accepted: 08/22/2006] [Indexed: 11/16/2022]
Abstract
RATIONALE Lipoprotein lipase (LPL) X447 homozygotes are characterized by enhanced conversion of TRL apoB100. Here, we set out to investigate whether this LPL variant is also associated with enhanced apoB48 clearance. Therefore, we evaluated apoB48 kinetics in X447 homozygotes in the fed state by infusion of isotope L-[1-(13)C]-valine and subsequent compartmental modeling. METHODS AND RESULTS ApoB48 metabolism was assessed in five X447 homozygotes (X/X genotype) and five S447 homozygotes (S/S genotype). Subjects were continuously fed and received infusion of stable isotope L-[1-(13)C]-valine. Results were analyzed by SAAM II modeling. Fasting (2.4-fold, p=0.02) as well as non-fasting (1.6-fold, p=0.09) apoB48 concentration was increased in the X447 homozygotes compared to S447 homozygotes. In addition, the X447 homozygotes exhibited a 1.7-fold higher apoB48 poolsize (p=0.04). Interestingly, apoB48 fractional catabolic rate (FCR) was 1.9-fold higher (p=0.007) and apoB48 synthesis was more than two-fold higher (p=0.006) in the X447 homozygotes compared to S447 homozygotes. CONCLUSION In the present study, we show that X447 homozygotes exhibit enhanced apoB48 clearance. Previously, these homozygotes were shown to present with enhanced apoB100 TRL conversion. Combined, this LPLS447X gain of function variant affects apoB48 as well as apoB100 TRL metabolism.
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Affiliation(s)
- Melchior C Nierman
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Schaap FG, Nierman MC, Berbée JFP, Hattori H, Talmud PJ, Vaessen SFC, Rensen PCN, Chamuleau RAFM, Kuivenhoven JA, Groen AK. Evidence for a complex relationship between apoA-V and apoC-III in patients with severe hypertriglyceridemia. J Lipid Res 2006; 47:2333-9. [PMID: 16861622 DOI: 10.1194/jlr.m500533-jlr200] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The relevance of apolipoprotein A-V (apoA-V) for human lipid homeostasis is underscored by genetic association studies and the identification of truncation-causing mutations in the APOA5 gene as a cause of type V hyperlipidemia, compatible with an LPL-activating role of apoA-V. An inverse correlation between plasma apoA-V and triglyceride (TG) levels has been surmised from animal data. Recent studies in human subjects using (semi)quantitative immunoassays, however, do not provide unambiguous support for such a relationship. Here, we used a novel, validated ELISA to measure plasma apoA-V levels in patients (n = 28) with hypertriglyceridemia (HTG; 1.8-78.7 mmol TG/l) and normolipidemic controls (n = 42). Unexpectedly, plasma apoA-V levels were markedly increased in the HTG subjects compared with controls (1,987 vs. 258 ng/ml; P < 0.001). In the HTG group, apoA-V and TG were positively correlated (r = +0.44, P = 0.02). In addition, we noted an increased level of the LPL-inhibitory protein apoC-III in the HTG group (45.8 vs. 10.6 mg/dl in controls; P < 0.001). The correlation between apoA-V and TG levels in the HTG group disappeared (partial r = +0.09, P = 0.65) when controlling for apoC-III levels. In contrast, apoC-III and TG remained positively correlated in this group when controlling for apoA-V (partial r = +0.43, P = 0.025). Our findings suggest that in HTG patients, increased TG levels are accompanied by high plasma levels of apoA-V and apoC-III, apolipoproteins with opposite modes of action. This study provides evidence for a complex interaction between apoA-V and apoC-III in patients with severe HTG.
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Affiliation(s)
- Frank G Schaap
- Academic Medical Center Liver Center, 1105 BK Amsterdam, The Netherlands.
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Rip J, Nierman MC, Ross CJ, Jukema JW, Hayden MR, Kastelein JJP, Stroes ESG, Kuivenhoven JA. Lipoprotein lipase S447X: a naturally occurring gain-of-function mutation. Arterioscler Thromb Vasc Biol 2006; 26:1236-45. [PMID: 16574898 DOI: 10.1161/01.atv.0000219283.10832.43] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lipoprotein lipase (LPL) hydrolyzes triglycerides in the circulation and promotes the hepatic uptake of remnant lipoproteins. Since the gene was cloned in 1989, more than 100 LPL gene mutations have been identified, the majority of which cause loss of enzymatic function. In contrast to this, the naturally occurring LPL(S447X) variant is associated with increased lipolytic function and an anti-atherogenic lipid profile and can therefore be regarded as a gain-of-function mutation. This notion combined with the facts that 20% of the general population carries this prematurely truncated LPL and that it may protect against cardiovascular disease has led to extensive clinical and basic research into this frequent LPL mutant. It is only until recently that we begin to understand the molecular mechanisms that underlie the beneficial effects associated with LPL(S447X). This review summarizes the current literature on this interesting LPL variant.
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Affiliation(s)
- Jaap Rip
- Department of Vascular Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands
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Rip J, Nierman MC, Sierts JA, Petersen W, Van den Oever K, Van Raalte D, Ross CJD, Hayden MR, Bakker AC, Dijkhuizen P, Hermens WT, Twisk J, Stroes E, Kastelein JJP, Kuivenhoven JA, Meulenberg JM. Gene therapy for lipoprotein lipase deficiency: working toward clinical application. Hum Gene Ther 2006; 16:1276-86. [PMID: 16259561 DOI: 10.1089/hum.2005.16.1276] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Lipoprotein lipase (LPL) deficiency causes hypertriglyceridemia and recurrent, potentially life-threatening pancreatitis. There currently is no adequate treatment for this disease. Previously, we showed that intramuscular administration of an adeno-associated virus serotype 1 (AAV1) vector encoding the human LPL(S447X) variant cDNA (AAV1-LPL(S447X)) normalized the dyslipidemia of LPL-/- mice for more than 1 year. In preparation for a clinical trial, we evaluated the safety and biodistribution of AAV1-LPL(S447X) in wild-type mice and fully characterized six LPL-deficient patients. Toxicological analysis in mice showed that intramuscular administration was well tolerated. Acute inflammatory response markers were transiently increased, and anti- AAV1 antibodies were generated. Histological analyses indicated a dose-dependent reversible spleen hyperplasia, and myositis at the injection sites. Biodistribution data showed short-term vector leakage from injection sites into the circulation, followed by liver-mediated clearance. Persistence of vector DNA was limited to the injected muscle and draining lymph nodes, and spread to reproductive organs was limited. Characterization of LPL-deficient patients showed that all patients presented with hypertriglyceridemia and recurrent pancreatitis. LPL catalytic activity was absent, but LPL protein levels were 20-100% of normal. Myoblasts derived from skeletal muscle biopsies of these patients were efficiently transduced by AAV1-LPL(S447X) and secreted active LPL. These data support the initiation of a clinical trial in LPL-deficient patients, for which regulatory approval has been granted.
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Affiliation(s)
- Jaap Rip
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Monraats PS, Rana JS, Nierman MC, Pires NMM, Zwinderman AH, Kastelein JJP, Kuivenhoven JA, de Maat MPM, Rittersma SZH, Schepers A, Doevendans PAF, de Winter RJ, Tio RA, Frants RR, Quax PHA, van der Laarse A, van der Wall EE, Jukema JW. Lipoprotein lipase gene polymorphisms and the risk of target vessel revascularization after percutaneous coronary intervention. J Am Coll Cardiol 2005; 46:1093-100. [PMID: 16168296 DOI: 10.1016/j.jacc.2005.05.071] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2005] [Revised: 05/20/2005] [Accepted: 05/24/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to identify polymorphisms in genes that predispose to restenosis. BACKGROUND Variations in the lipoprotein lipase (LPL) gene have been implicated in a number of pathophysiologic conditions associated with coronary heart disease. The present study examines the impact of polymorphisms in the LPL gene on restenosis (defined by target vessel revascularization [TVR]) in a large patient population undergoing percutaneous coronary intervention (PCI). A mouse model for restenosis was used to further investigate LPL's role in restenosis. METHODS The GENetic DEterminants of Restenosis (GENDER) project is a multicenter, prospective study design that enrolled 3,104 consecutive patients after successful PCI. These patients were genotyped for four different LPL gene polymorphisms. In apolipoprotein E (ApoE)*3-Leiden transgenic mice, arterial messenger ribonucleic acid (mRNA) was used to assess LPL expression during a cuff-induced restenotic process. RESULTS Using multivariable analysis, carriers of the 447Ter allele of the LPL enzyme showed a lower risk of TVR compared with 447Ser homozygotes (p = 0.005). In the mouse model, LPL mRNA levels were increased 40-fold compared with control arteries at 6 h after cuff placement. CONCLUSIONS The LPL C/G polymorphism (Ser447Ter), resulting in a truncation of the two C-terminal amino acids of the mature LPL protein, appears to be an important protective factor for TVR in humans. The role of LPL in this process was further established in a mouse model, where LPL expression was very strongly up-regulated in the target arterial wall, suggesting a contribution of this lipolytic enzyme to restenosis. Possibly, LPL Ser447Ter genotyping may lead to better risk stratification and tailored therapy in the prevention of restenosis after PCI.
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Affiliation(s)
- Pascalle S Monraats
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Rip J, Nierman MC, Wareham NJ, Luben R, Bingham SA, Day NE, van Miert JNI, Hutten BA, Kastelein JJP, Kuivenhoven JA, Khaw KT, Boekholdt SM. Serum lipoprotein lipase concentration and risk for future coronary artery disease: the EPIC-Norfolk prospective population study. Arterioscler Thromb Vasc Biol 2005; 26:637-42. [PMID: 16373616 DOI: 10.1161/01.atv.0000201038.47949.56] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [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] [Indexed: 01/23/2023]
Abstract
BACKGROUND Lipoprotein lipase (LPL) is associated with coronary artery disease (CAD) risk, but prospective population data are lacking. This is mainly because of the need for cumbersome heparin injections, which are necessary for LPL measurements. Recent retrospective studies, however, indicate that LPL concentration can be reliably measured in serum that enabled evaluation of the prospective association between LPL and future CAD. METHODS AND RESULTS LPL concentration was determined in serum samples of men and women in the EPIC-Norfolk population cohort who developed fatal or nonfatal CAD during 7 years of follow-up. For each case (n=1006), 2 controls, matched for age, sex, and enrollment time, were identified. Serum LPL concentration was lower in cases compared with controls (median and interquartile range: 61 [43-85] versus 66 [46-92] ng/mL; P<0.0001). Those in the highest LPL concentration quartile had a 34% lower risk for future CAD compared with those in the lowest quartile (odds ratio [OR] 0.66; confidence interval [CI], 0.53 to 0.83; P<0.0001). This effect remained significant after adjustment for blood pressure, diabetes, smoking, body mass index, and low-density lipoprotein (LDL) cholesterol (OR, 0.77; CI, 0.60-0.99; P=0.02). As expected from LPL biology, additional adjustments for either high-density lipoprotein cholesterol (HDL-C) or triglyceride (TG) levels rendered loss of statistical significance. Of interest, serum LPL concentration was positively linear correlated with HDL and LDL size. CONCLUSIONS Reduced levels of serum LPL are associated with an increased risk for future CAD. The data suggest that high LPL concentrations may be atheroprotective through decreasing TG levels and increasing HDL-C levels.
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Affiliation(s)
- Jaap Rip
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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Nierman MC, Prinsen BHCMT, Rip J, Veldman RJ, Kuivenhoven JA, Kastelein JJP, de Sain-van der Velden MGM, Stroes ESG. Enhanced Conversion of Triglyceride-Rich Lipoproteins and Increased Low-Density Lipoprotein Removal in LPLS447X Carriers. Arterioscler Thromb Vasc Biol 2005; 25:2410-5. [PMID: 16195478 DOI: 10.1161/01.atv.0000188506.79946.ce] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Lipoprotein lipase (LPL) exerts 2 principal actions, comprising enzymatic hydrolysis of triglyceride-rich lipoproteins (TRLs) and nonenzymatic ligand capacity for enhancing lipoprotein removal. The common LPLS447X variant has been associated with cardiovascular protection, for which the mechanism is unknown. We therefore evaluated enzymatic and nonenzymatic consequences of this LPL variant on TRL metabolism. METHODS AND RESULTS TRL apolipoprotein B100 (apoB100) metabolism was determined in 5 homozygous LPLS447X carriers and 5 controls. Subjects were continuously fed and received infusion of stable isotope l-[1-(13C)]-valine. Results were analyzed by SAAMII modeling. Also, preheparin and postheparin LPL concentration and activity were measured. Compared with controls, carriers presented increased very low-density lipoprotein 1 (VLDL1) to VLDL2 apoB100 flux (P=0.04), increased VLDL2 to intermediate-density lipoprotein (IDL) apoB100 flux (P=0.02), increased IDL to low-density lipoprotein (LDL) apoB100 flux (P=0.049), as well as an increased LDL clearance (P=0.04). Additionally, IDL apoB100 synthesis was attenuated (P=0.05). Preheparin LPL concentration was 4-fold higher compared with controls (P=0.01), and a correlation was observed between preheparin LPL concentration and LDL clearance (r2=0.92; P=0.01). CONCLUSIONS Enhanced TRL conversion and enhanced LDL removal combined with increased preheparin LPL concentration suggest increased enzymatic consequences as well as increased nonenzymatic consequences of LPL in LPLS447X carriers, which might both contribute to the cardiovascular benefit of this LPL variant.
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Affiliation(s)
- Melchior C Nierman
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
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Nierman MC, Rip J, Kuivenhoven JA, van Raalte DH, Hutten BA, Sakai N, Kastelein JJP, Stroes ESG. Carriers of the frequent lipoprotein lipase S447X variant exhibit enhanced postprandial apoprotein B-48 clearance. Metabolism 2005; 54:1499-503. [PMID: 16253639 DOI: 10.1016/j.metabol.2005.05.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Accepted: 05/16/2005] [Indexed: 11/17/2022]
Abstract
The frequent lipoprotein lipase S447X variant (LPLS447X) is firmly associated with a lower incidence of cardiovascular disease, the mechanisms for which remain to be established. To further unravel these beneficial effects, we studied the consequences of LPLS447X heterozygosity on LPL mass and activity, as well as on the postprandial lipoprotein profile. Fifteen male heterozygous LPLS447X carriers and 15 matched control subjects received an oral fat load (30 g/m(2)). Lipid parameters were evaluated at baseline and 2, 3, 4, and 6 hours after fat loading. LPL concentration and activity were analyzed, and endothelial function was evaluated noninvasively as flow-mediated dilation of the brachial artery. Although baseline apoprotein B-48 (apoB48) levels were similar, the rise in apoB48 was attenuated in LPLS447X carriers with 25% lower peak values compared with controls (P=.04). In conjunction, LPLS447X carriers were characterized by a 2.4-fold increase in pre-heparin LPL mass (P<.0001). The decrease in postprandial flow-mediated dilation was comparable in both groups. LPLS447X carriers exhibit enhanced apoB48 clearance with concomitant increase in pre-heparin LPL mass, without changes in LPL activity. This combination might suggest a role for increased ligand action of LPL in LPLS447X carriers contributing to the cardiovascular protection in carriers of this mutation.
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Affiliation(s)
- Melchior C Nierman
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Rip J, Nierman MC, Sierts JA, Petersen W, Den Oever KV, Raalte DV, Ross CJ, Hayden MR, Bakker AC, Dijkhuizen P, Hermens WT, Twisk J, Stroes E, Kastelein JJP, Kuivenhoven JA, Meulenberg JM. Gene Therapy for Lipoprotein Lipase Deficiency: Working Toward Clinical Application. Hum Gene Ther 2005. [DOI: 10.1089/hum.2005.16.ft-138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Nierman MC, Rip J, Twisk J, Meulenberg JJM, Kastelein JJP, Stroes ESG, Kuivenhoven JA. Gene therapy for genetic lipoprotein lipase deficiency: from promise to practice. Neth J Med 2005; 63:14-9. [PMID: 15719847] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Lipoprotein lipase (LPL) deficiency is a rare, hereditary disorder of lipoprotein metabolism characterised by severely increased triglyceride levels, and associated with an increased risk for pancreatitis. Since no adequate treatment modality is available for this disorder, we set out to develop an LPL gene therapy protocol. This paper focuses on the clinical presentation of LPL deficiency, summarises the preclinical investigations in animal models and describes the rationale to evaluate gene therapy for this monogenetic disorder of lipid metabolism in humans.
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Affiliation(s)
- M C Nierman
- Department of Vascular Medicine (G1-113), Academic Medical Centre, University of Amsterdam, The Netherlands
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Abstract
Advances in our understanding of the ways in which the traditional cardiovascular risk factors, including standard lipid (eg, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol) and nonlipid (eg, hypertension) risk factors, interact to initiate atherosclerosis and promote the development of cardiovascular disease have enhanced our ability to assess risk in the individual patient. In addition, the ongoing identification and understanding of so-called novel risk factors may further improve our ability to predict future risk when these are included along with the classic risk factors in assessing the global risk profile. This review briefly summarizes the evidence that some newer risk factors, including impaired fasting glucose, triglycerides and triglyceride-rich lipoprotein remnants, lipoprotein(a), homocysteine, and high-sensitivity C-reactive protein, contribute to an increased risk of coronary and cardiovascular diseases.
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Affiliation(s)
- Jean-Charles Fruchart
- Departement de Recherche sur les Lipoproteines et l'Atherosclerose,Pasteur de Lille, Inserm U545 et Faculté de Pharmacie, Université du Droit et de la Santé de Lille 2, Lille, France.
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