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Familial hypercholesterolaemia

Abstract

Familial hypercholesterolaemia is a common inherited disorder characterized by abnormally elevated serum levels of low-density lipoprotein (LDL) cholesterol from birth, which in time can lead to cardiovascular disease (CVD). Most cases are caused by autosomal dominant mutations in LDLR, which encodes the LDL receptor, although mutations in other genes coding for proteins involved in cholesterol metabolism or LDLR function and processing, such as APOB and PCSK9, can also be causative, although less frequently. Several sets of diagnostic criteria for familial hypercholesterolaemia are available; common diagnostic features are an elevated LDL cholesterol level and a family history of hypercholesterolaemia or (premature) CVD. DNA-based methods to identify the underlying genetic defect are desirable but not essential for diagnosis. Cascade screening can contribute to early diagnosis of the disease in family members of an affected individual, which is crucial because familial hypercholesterolaemia can be asymptomatic for decades. Clinical severity depends on the nature of the gene that harbours the causative mutation, among other factors, and is further modulated by the type of mutation. Lifelong LDL cholesterol-lowering treatment substantially improves CVD-free survival and longevity. Statins are the first-line therapy, but additional drugs, such as ezetimibe, bile acid sequestrants, PCSK9 inhibitors and other emerging therapies, are often required.

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Figure 1: Survival rates of patients with familial hypercholesterolaemia.
Figure 2: Basic pathways in LDL particle synthesis and LDLR-mediated uptake.
Figure 3: Tendinous xanthomas on the hands and Achilles tendon in patients with heterozygous familial hypercholesterolaemia.
Figure 4: Arcus cornealis and xanthelasmata in patients with heterozygous familial hypercholesterolaemia.
Figure 5: Basic schematic procedure of clinical cascade screening.
Figure 6: Severe familial hypercholesterolaemia criteria and treatment goals according to the International Atherosclerosis Society expert panel*.

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Contributions

Introduction (J.C.D. and R.A.H.); Epidemiology (A.S.W.); Mechanisms/pathophysiology (R.A.H. and J.C.D.); Diagnosis, screening and prevention (R.A.H., R.D.S. and J.C.D.); Management (A.S.W., R.A.H. and S.S.G.); Quality of life (S.S.G. and M.H.-S.); Outlook (M.H.-S. and R.A.H.); Overview of the Primer (J.C.D. and R.A.H).

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Correspondence to Joep C. Defesche or Robert A. Hegele.

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Competing interests

S.S.G. acts as a consultant for RegenXbio. M.H.-S. acts as a consultant for Aegerion, receives research funding from Amgen, Astellas, Sanofi and MSD and has received speaker fees from Amgen, Astellas, Astra Zeneca, Sanofi, Boehringer Ingelheim, Otsuka and Daiichi-Sankyo. R.A.H. acts as a consultant for and is on the advisory board of Acasti, Aegerion, Amgen, Boston Heart Diagnostics, Cerenis, Medpace, Pfizer, Regeneron, Sanofi and Valeant. R.S.D. acts as a consultant for Amgen, Biolab, Boehringer Ingelheim, Eli Lilly, Merck, NovoNordisk, Pfizer and Sanofi/Regeneron and has received speaker fees from Amgen, Astra Zeneca and Sanofi/Regeneron. J.C.D. and A.S.W. declare no competing interests.

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Defesche, J., Gidding, S., Harada-Shiba, M. et al. Familial hypercholesterolaemia. Nat Rev Dis Primers 3, 17093 (2017). https://doi.org/10.1038/nrdp.2017.93

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