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Medeiros AM, Alves AC, Miranda B, Chora JR, Bourbon M. Unraveling the genetic background of individuals with a clinical familial hypercholesterolemia phenotype. J Lipid Res 2024; 65:100490. [PMID: 38122934 PMCID: PMC10832474 DOI: 10.1016/j.jlr.2023.100490] [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: 09/01/2023] [Revised: 12/04/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
Familial hypercholesterolemia (FH) is a common genetic disorder of lipid metabolism caused by pathogenic/likely pathogenic variants in LDLR, APOB, and PCSK9 genes. Variants in FH-phenocopy genes (LDLRAP1, APOE, LIPA, ABCG5, and ABCG8), polygenic hypercholesterolemia, and hyperlipoprotein (a) [Lp(a)] can also mimic a clinical FH phenotype. We aim to present a new diagnostic tool to unravel the genetic background of clinical FH phenotype. Biochemical and genetic study was performed in 1,005 individuals with clinical diagnosis of FH, referred to the Portuguese FH Study. A next-generation sequencing panel, covering eight genes and eight SNPs to determine LDL-C polygenic risk score and LPA genetic score, was validated, and used in this study. FH was genetically confirmed in 417 index cases: 408 heterozygotes and 9 homozygotes. Cascade screening increased the identification to 1,000 FH individuals, including 11 homozygotes. FH-negative individuals (phenotype positive and genotype negative) have Lp(a) >50 mg/dl (30%), high polygenic risk score (16%), other monogenic lipid metabolism disorders (1%), and heterozygous pathogenic variants in FH-phenocopy genes (2%). Heterozygous variants of uncertain significance were identified in primary genes (12%) and phenocopy genes (7%). Overall, 42% of our cohort was genetically confirmed with FH. In the remaining individuals, other causes for high LDL-C were identified in 68%. Hyper-Lp(a) or polygenic hypercholesterolemia may be the cause of the clinical FH phenotype in almost half of FH-negative individuals. A small part has pathogenic variants in ABCG5/ABCG8 in heterozygosity that can cause hypercholesterolemia and should be further investigated. This extended next-generation sequencing panel identifies individuals with FH and FH-phenocopies, allowing to personalize each person's treatment according to the affected pathway.
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Affiliation(s)
- Ana Margarida Medeiros
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Ana Catarina Alves
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Beatriz Miranda
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Joana Rita Chora
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Mafalda Bourbon
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal.
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Allevi M, Sarnari S, Giulietti F, Spannella F, Di Pentima C, Sarzani R. Painful and recurring injection site reaction to alirocumab and evolocumab in a young woman with familial hypercholesterolemia and effective therapeutic alternative based on inclisiran: a case report. Front Cardiovasc Med 2023; 10:1181720. [PMID: 37424909 PMCID: PMC10326624 DOI: 10.3389/fcvm.2023.1181720] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
A 28-year-old woman with autosomal dominant familial hypercholesterolemia (FH) with a probable coexistent polygenic contribution causing very high low-density lipoprotein-cholesterol (LDL-C) levels, started therapy with the proprotein convertase subtilisin/kexin type 9-inhibitor (PCSK9i) alirocumab, in addition to high-intensity statin plus ezetimibe. Forty-eight hours after the second injection of alirocumab, the patient developed a painful palpable injection site reaction (ISR) that recurred after the third administration of the drug. Treatment was then switched to evolocumab, another PCSK9i, but the patient had an ISR with similar features. The most conceivable cause of the ISR was a cell-mediated hypersensitivity reaction to polysorbate, an excipient contained in both drugs. Although ISR after PCSK9i administration is usually transient and does not compromise the continuation of treatment, in this case the recurrence of such side effect in an exacerbated way led to treatment withdrawal, with a subsequent re-exposure to increased cardiovascular (CV) risk. As soon as it became available in clinical practice, the patient started treatment with inclisiran, a small interfering RNA targeting hepatic PCSK9 synthesis. No adverse events were reported after inclisiran administration and LDL-C levels decreased significantly, confirming the evidence that this innovative approach to hypercholesterolemia is a safe and effective resource in patients at high CV risk who cannot achieve LDL-C goal with conventional lipid-lowering therapies and antibody-based PCSK9i.
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Affiliation(s)
- Massimiliano Allevi
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Silvia Sarnari
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | | | - Francesco Spannella
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | | | - Riccardo Sarzani
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
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Massini G, Capra N, Buganza R, Nyffenegger A, de Sanctis L, Guardamagna O. Mediterranean Dietary Treatment in Hyperlipidemic Children: Should It Be an Option? Nutrients 2022; 14:1344. [PMID: 35405957 DOI: 10.3390/nu14071344] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Diet is considered the cornerstone of lipid management in hyperlipidemic children but evidence to demonstrate the effects of nutrient benefits on the lipid profile is limited. AIM The aim of this study is to evaluate the impact of the Mediterranean diet on low-density lipoprotein (LDL-C) and non-high density lipoprotein (HDL-C) decrease in primary hyperlipidemia affected children and in the achievement of therapeutical target levels. METHODS A retrospective cohort study was used, recruiting n = 223 children (10.05 ± 3.26 mean age years) with familial hypercholesterolemia (FH) (n = 61, 27%) and polygenic hypercholesterolemia (PH) (n =162, 73%). Secondary hyperlipidemias were excluded. Based on LDL-C and non-HDL-C decrease, participants were divided into two groups, named the Responder Group and Non-Responder Group. Participants and their families underwent dietary education by an expert nutritionist and were asked to fill in a weekly diary to be delivered at visits. Dietary indications were in line with daily caloric requirement, daily food quality and quantity intakes typical of the Mediterranean diet. These include carbohydrates, extra virgin olive oil, yoghurt and milk derivatives, fish and vegetable proteins, fresh seasonal vegetables and fresh fruits. Nuts or almonds were also recommended. The advice to limit intakes of meat, in particular red meat, and caution against junk food and sugar added food and beverages was provided. At medical visits, carried out at baseline (T0) and 6 months later (T1), children underwent anthropometric measurements and blood collection. Standard kits and methods were applied for lipid analysis. Statistical methods were performed by SAS version 9.4 (SAS Institute, Cary, NC, USA). Signed informed consent was given by parents according to the Declaration of Helsinki and the study was approved by the Local Committee. RESULTS The Responder Group (n = 156/223, 70%) included 45 FH and 111 PH children, while the Non-Responder Group (n = 67/223, 30%) included 16 FH and 51 PH children. The Responder Group showed total cholesterol (TC), LDL-C and non-HDL-C median percentage decreases of 9.45, 13.51 and 10.90, respectively. These statistically significant changes (p ≤ 0.0001) were similar in the FH and PH subgroups but just PH subjects reached the LDL-C and non-HDL-C target, which fell below 130 mg/dL and 145 mg/dL, respectively. Saturated fatty acids (SFAs) were the main dietary parameter that distinguished between the Responder Group and the Non-Responder Group (p = 0.014). Positive correlations were found at T1 between dietary total lipids, SFAs and cholesterol with serum LDL-C, non-HDL-C and TC variations. These latter serum parameters had an inverse correlation with dietary carbohydrate at T1. Among macronutrients, SFAs were finally demonstrated to be the predictor of serum lipids variation at T1. CONCLUSIONS The dietary intervention with a Mediterranean diet in children with primary hyperlipidemia significantly improves the lipid profile both in FH and PH subgroups and allows target levels of LDL-C and non-HDL-C in PH subjects to be reached. Responsiveness benefits should be primarily attributed to the reduction in SFAs, but changes in dietary lipids, cholesterol and carbohydrate intake may also play a role. In contrast, the Non-Responder Group showed a worsening of lipid profile regarding the unchanged diet.
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Jarauta E, Bea-Sanz AM, Marco-Benedi V, Lamiquiz-Moneo I. Genetics of Hypercholesterolemia: Comparison Between Familial Hypercholesterolemia and Hypercholesterolemia Nonrelated to LDL Receptor. Front Genet 2020; 11:554931. [PMID: 33343620 PMCID: PMC7744656 DOI: 10.3389/fgene.2020.554931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/28/2020] [Indexed: 01/04/2023] Open
Abstract
Severe hypercholesterolemia (HC) is defined as an elevation of total cholesterol (TC) due to the increase in LDL cholesterol (LDL-C) >95th percentile or 190 mg/dl. The high values of LDL-C, especially when it is maintained over time, is considered a risk factor for the development of atherosclerotic cardiovascular disease (ASCVD), mostly expressed as ischemic heart disease (IHD). One of the best characterized forms of severe HC, familial hypercholesterolemia (FH), is caused by the presence of a major variant in one gene (LDLR, APOB, PCSK9, or ApoE), with an autosomal codominant pattern of inheritance, causing an extreme elevation of LDL-C and early IHD. Nevertheless, an important proportion of serious HC cases, denominated polygenic hypercholesterolemia (PH), may be attributed to the small additive effect of a number of single nucleotide variants (SNVs), located along the whole genome. The diagnosis, prevalence, and cardiovascular risk associated with PH has not been fully established at the moment. Cascade screening to detect a specific genetic defect is advised in all first- and second-degree relatives of subjects with FH. Conversely, in the rest of cases of HC, it is only advised to screen high values of LDL-C in first-degree relatives since there is not a consensus for the genetic diagnosis of PH. FH is associated with the highest cardiovascular risk, followed by PH and other forms of HC. Early detection and initiation of high-intensity lipid-lowering treatment is proposed in all subjects with severe HC for the primary prevention of ASCVD, with an objective of LDL-C <100 mg/dl or a decrease of at least 50%. A more aggressive reduction in LDL-C is necessary in HC subjects who associate personal history of ASCVD or other cardiovascular risk factors.
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Affiliation(s)
- Estíbaliz Jarauta
- Hospital Universitario Miguel Servet, Instituto de Investigacion Sanitaria Aragon (IIS Aragn), Zaragoza, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Psychiatry a Dermatology, Universidad de Zaragoza, Zaragoza, Spain
| | - Ana Ma Bea-Sanz
- Hospital Universitario Miguel Servet, Instituto de Investigacion Sanitaria Aragon (IIS Aragn), Zaragoza, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Victoria Marco-Benedi
- Hospital Universitario Miguel Servet, Instituto de Investigacion Sanitaria Aragon (IIS Aragn), Zaragoza, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Itziar Lamiquiz-Moneo
- Hospital Universitario Miguel Servet, Instituto de Investigacion Sanitaria Aragon (IIS Aragn), Zaragoza, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Psychiatry a Dermatology, Universidad de Zaragoza, Zaragoza, Spain
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Blinc L, Mlinaric M, Battelino T, Groselj U. High-Sensitivity C-Reactive Protein and Carotid Intima Media Thickness as Markers of Subclinical Inflammation and Atherosclerosis in Pediatric Patients with Hypercholesterolemia. Molecules 2020; 25:E5118. [PMID: 33158028 PMCID: PMC7663751 DOI: 10.3390/molecules25215118] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022] Open
Abstract
Hypercholesterolemia is a major cause of atherosclerosis development and premature cardiovascular disease (CVD). It leads to inflammation, which further accelerates atherosclerosis progression. Familial hypercholesterolemia (FH) is an autosomal dominant disorder characterized by elevated serum LDL-c from birth, due to a disease-causing variant in one of the causative genes (LDLR, APOB, PCSK9). In polygenic hypercholesterolemia (PH), the disease-causing genetic variant is absent; it is likely the cumulative result of multiple single nucleotide polymorphisms in LDL metabolism-related genes and other factors, such as lifestyle and environment. In high risk groups, such as patients with FH, an effective primary prevention of CVD must begin in childhood. High-sensitivity C-reactive protein (hsCRP) and carotid intima media thickness (cIMT) are two potential minimally invasive correlates of inflammation and subclinical atherosclerosis progression. hsCRP and cIMT have been shown to be significantly increased in patients with FH and PH relative to healthy controls, with some studies yielding conflicting results. In this review, we aim to summarize current knowledge and recent findings regarding the applicability of hsCRP and cIMT as markers of low-grade inflammation and subclinical atherosclerosis, focusing especially on children and adolescents with hypercholesterolemia.
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Affiliation(s)
- Lana Blinc
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (L.B.); (T.B.)
| | - Matej Mlinaric
- University Children’s Hospital, University Medical Center Ljubljana, Bohoriceva ulica 20, 1000 Ljubljana, Slovenia;
| | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (L.B.); (T.B.)
- University Children’s Hospital, University Medical Center Ljubljana, Bohoriceva ulica 20, 1000 Ljubljana, Slovenia;
| | - Urh Groselj
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (L.B.); (T.B.)
- University Children’s Hospital, University Medical Center Ljubljana, Bohoriceva ulica 20, 1000 Ljubljana, Slovenia;
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Mickiewicz A, Futema M, Ćwiklinska A, Kuchta A, Jankowski M, Kaszubowski M, Chmara M, Wasąg B, Fijałkowski M, Jaguszewski M, Humphries SE, Gruchała M. Higher Responsiveness to Rosuvastatin in Polygenic versus Monogenic Hypercholesterolaemia: A Propensity Score Analysis. Life (Basel) 2020; 10:E73. [PMID: 32443900 PMCID: PMC7281142 DOI: 10.3390/life10050073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 04/22/2020] [Revised: 05/14/2020] [Accepted: 05/16/2020] [Indexed: 12/14/2022] Open
Abstract
Background: The monogenic defect in familial hypercholesterolemia (FH) is detected in ∼40% of cases. The majority of mutation-negative patients have a polygenic cause of high LDL-cholesterol (LDL-C). We sought to investigate whether the underlying monogenic or polygenic defect is associated with the response to rosuvastatin. METHODS FH Individuals were tested for mutations in LDLR and APOB genes. A previously established LDL-C-specific polygenic risk score (PRS) was used to examine the possibility of polygenic hypercholesterolemia in mutation-negative patients. All of the patients received rosuvastatin and they were followed for 8 ± 2 months. A propensity score analysis was performed to evaluate the variables associated with the response to treatment. RESULTS Monogenic subjects had higher mean (±SD) baseline LDL-C when compared to polygenic (7.6 ± 1.5 mmol/L vs. 6.2 ± 1.2 mmol/L; p < 0.001). Adjusted model showed a lower percentage of change in LDL-C after rosuvastatin treatment in monogenic patients vs. polygenic subjects (45.9% vs. 55.4%, p < 0.001). The probability of achieving LDL-C targets in monogenic FH was lower than in polygenic subjects (0.075 vs. 0.245, p = 0.004). Polygenic patients were more likely to achieve LDL-C goals, as compared to those monogenic (OR 3.28; 95% CI: 1.23-8.72). CONCLUSION Our findings indicate an essentially higher responsiveness to rosuvastatin in FH patients with a polygenic cause, as compared to those carrying monogenic mutations.
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Affiliation(s)
- Agnieszka Mickiewicz
- Department of Cardiology I, Medical University of Gdansk, Dębinki 7, 80-211 Gdańsk, Poland; (M.F.); (M.J.); (M.G.)
| | - Marta Futema
- Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK;
| | - Agnieszka Ćwiklinska
- Department of Clinical Chemistry, Medical University of Gdansk, Dębinki 7, 80-211 Gdańsk, Poland; (A.Ć.); (A.K.); (M.J.)
| | - Agnieszka Kuchta
- Department of Clinical Chemistry, Medical University of Gdansk, Dębinki 7, 80-211 Gdańsk, Poland; (A.Ć.); (A.K.); (M.J.)
| | - Maciej Jankowski
- Department of Clinical Chemistry, Medical University of Gdansk, Dębinki 7, 80-211 Gdańsk, Poland; (A.Ć.); (A.K.); (M.J.)
| | - Mariusz Kaszubowski
- Institute of Statistics, Department of Economic Sciences, Faculty of Management and Economics, Gdansk University of Technology, 80-233 Gdańsk, Poland;
| | - Magdalena Chmara
- Department of Biology and Genetics, Medical University of Gdansk, Dębinki 1, 80-211 Gdańsk, Poland; (M.C.); (B.W.)
| | - Bartosz Wasąg
- Department of Biology and Genetics, Medical University of Gdansk, Dębinki 1, 80-211 Gdańsk, Poland; (M.C.); (B.W.)
| | - Marcin Fijałkowski
- Department of Cardiology I, Medical University of Gdansk, Dębinki 7, 80-211 Gdańsk, Poland; (M.F.); (M.J.); (M.G.)
| | - Miłosz Jaguszewski
- Department of Cardiology I, Medical University of Gdansk, Dębinki 7, 80-211 Gdańsk, Poland; (M.F.); (M.J.); (M.G.)
| | - Steve E. Humphries
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Institute of Cardiovascular Science, the Rayne Building University College London, London WC1E 6JF, UK;
| | - Marcin Gruchała
- Department of Cardiology I, Medical University of Gdansk, Dębinki 7, 80-211 Gdańsk, Poland; (M.F.); (M.J.); (M.G.)
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