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Research questions testing strategy for familial high cholesterol

Current testing strategies for the families of patients with familial hypercholesterolemia (FH) may not be an efficient use of health resources, suggest results published in The Lancet.

Researchers at the Centre for Cardiovascular Genetics have discovered that a substantial proportion of individuals with a clinical diagnosis of FH inherit a combination of small-effect changes in several genes (polygenic) rather than a large-effect mutation in a single gene (monogenic).

These findings have implications for the majority of national guidelines, including those of the National Institute for Health and Clinical Excellence (NICE), on family screening for FH. It is currently advocated that relatives of all individuals with a clinical diagnosis of FH are tested.

FH is an inherited condition, in which the level of low-density lipoprotein (LDL) cholesterol or “bad cholesterol” in the blood is higher than normal from birth. The condition can be discovered during routine health check.

Professor Steve Humphries, Chief Executive Officer of the BRC-supported UCL Genetics Institute and his team suggest the current screening strategy should be restricted to FH patients with a known autosomal dominant mutation, as such screening is likely to have little value if patients inherit their condition in a polygenic fashion. He explained:

“Cascade [family] testing of the roughly 40 per cent of patients with a clinical diagnosis of FH and an identifiable causative mutation would eliminate staff and screening costs associated with screening relatives of the remaining 60 per cent of patients without an identifiable mutation.

“This is very likely to be more cost-effective, but proving this will require a more detailed analysis,"

FH is one of the most common inherited disorders affecting over 12 million people worldwide (1 in 500 of the general population). If untreated, it can result in five to eight times greater risk of early coronary heart disease (CHD). Identification of patients with FH needs to be improved because at least 75 per cent of cases remain undetected, untreated, or improperly treated, despite good evidence that early detection and treatment with statins can significantly improve life expectancy.

DNA-based cascade screening to identify other family members with FH, who would benefit from treatment, has been recommended by NICE on the presumption of a monogenic inheritance of the disorder, where first-degree relatives would have a 50:50 chance of having the condition. However, 60 per cent of people with clinically suspected FH have no identifiable mutation in any of the three genes (LDLR, APOB, or PCSK9) known to cause FH. Professor Humphries said:

“The current study was designed to investigate whether individuals who inherit many small-effect, LDL-cholesterol raising sequence differences in a wide range of genes might have received a clinical diagnosis of FH, which would influence the efficacy of any cascade screening programme since the odds of finding relatives with grossly elevated LDL-C in such cases would be less than the expected 50 per cent."

Recent genetic studies have identified many common genetic variants associated with a small increment in LDL-C levels. Genotyping for 12 of these single nucleotide polymorphisms (SNPs) was done on blood samples from 321 mutation-negative UK patients with FH, as well as 319 UK patients with FH with a known mutation, and 3,020 healthy individuals (controls) from the UK Whitehall II study.

Each participant was assigned a weighted LDL-C-raising gene score based on the number of risk-associated gene copies inherited. The results were validated by repeating the analysis in a sample of over 700 patients with FH from Belgium.

The findings showed that clinically suspected, but mutation negative FH, was associated with inheritance of a greater than average number of small-effect LDL-C-raising sequence differences.

Professor Humphries says: “We propose that the clinical diagnosis of FH should be restricted to those in whom a mutation can be identified, whereas those with no detected mutation should be given the clinical diagnosis of polygenic hypercholesterolaemia.

“Both groups of patients will need statin therapy, but the cost effectiveness of FH cascade testing will differ depending on whether or not there is a polygenic or a single mutation cause.”