Objective: Familial hypercholesterolemia (FH) is traditionally defined as a monogenic disease characterized by severely elevated LDL-C (low-density lipoprotein cholesterol) levels. In practice, FH is ...commonly a clinical diagnosis without confirmation of a causative mutation. In this study, we sought to characterize and compare monogenic and clinically defined FH in a large sample of Icelanders.
Approach and Results: We whole-genome sequenced 49 962 Icelanders and imputed the identified variants into an overall sample of 166 281 chip-genotyped Icelanders. We identified 20 FH mutations in LDLR, APOB, and PCSK9 with combined prevalence of 1 in 836. Monogenic FH was associated with severely elevated LDL-C levels and increased risk of premature coronary disease, aortic valve stenosis, and high burden of coronary atherosclerosis. We used a modified version of the Dutch Lipid Clinic Network criteria to screen for the clinical FH phenotype among living adult participants (N=79 058). Clinical FH was found in 2.2% of participants, of whom only 5.2% had monogenic FH. Mutation-negative clinical FH has a strong polygenic basis. Both individuals with monogenic FH and individuals with mutation-negative clinical FH were markedly undertreated with cholesterol-lowering medications and only a minority attained an LDL-C target of <2.6 mmol/L (<100 mg/dL; 11.0% and 24.9%, respectively) or <1.8 mmol/L (<70 mg/dL; 0.0% and 5.2%, respectively), as recommended for primary prevention by European Society of Cardiology/European Atherosclerosis Society cholesterol guidelines.
Conclusions: Clinically defined FH is a relatively common phenotype that is explained by monogenic FH in only a minority of cases. Both monogenic and clinical FH confer high cardiovascular risk but are markedly undertreated.
Abstract
Aims
To explore whether variability in dietary cholesterol and phytosterol absorption impacts the risk of coronary artery disease (CAD) using as instruments sequence variants in the ABCG5/8 ...genes, key regulators of intestinal absorption of dietary sterols.
Methods and results
We examined the effects of ABCG5/8 variants on non-high-density lipoprotein (non-HDL) cholesterol (N up to 610 532) and phytosterol levels (N = 3039) and the risk of CAD in Iceland, Denmark, and the UK Biobank (105 490 cases and 844 025 controls). We used genetic scores for non-HDL cholesterol to determine whether ABCG5/8 variants confer greater risk of CAD than predicted by their effect on non-HDL cholesterol. We identified nine rare ABCG5/8 coding variants with substantial impact on non-HDL cholesterol. Carriers have elevated phytosterol levels and are at increased risk of CAD. Consistent with impact on ABCG5/8 transporter function in hepatocytes, eight rare ABCG5/8 variants associate with gallstones. A genetic score of ABCG5/8 variants predicting 1 mmol/L increase in non-HDL cholesterol associates with two-fold increase in CAD risk odds ratio (OR) = 2.01, 95% confidence interval (CI) 1.75–2.31, P = 9.8 × 10−23 compared with a 54% increase in CAD risk (OR = 1.54, 95% CI 1.49–1.59, P = 1.1 × 10−154) associated with a score of other non-HDL cholesterol variants predicting the same increase in non-HDL cholesterol (P for difference in effects = 2.4 × 10−4).
Conclusions
Genetic variation in cholesterol absorption affects levels of circulating non-HDL cholesterol and risk of CAD. Our results indicate that both dietary cholesterol and phytosterols contribute directly to atherogenesis.
•We investigated mercury health risks in the Baltic, Greater North Sea and North Atlantic.•23% of the marine mammals had Hg-concentrations in the High & Severe Risk Category.•The corresponding ...percentages for birds, fish and bivalves were 2.7, 25 and 8.0%•The estimated risk for Baltic populations was not higher that the bordering waters.•Baltic Sea has improved with respect to mercury exposure over the last decades.
A wide range of species, including marine mammals, seabirds, birds of prey, fish and bivalves, were investigated for potential population health risks resulting from contemporary (post 2000) mercury (Hg) exposure, using novel risk thresholds based on literature and de novo contamination data. The main geographic focus is on the Baltic Sea, while data from the same species in adjacent waters, such as the Greater North Sea and North Atlantic, were included for comparative purposes. For marine mammals, 23% of the groups, each composing individuals of a specific sex and maturity from the same species in a specific study region, showed Hg-concentrations within the High Risk Category (HRC) and Severe Risk Category (SRC). The corresponding percentages for seabirds, fish and bivalves were 2.7%, 25% and 8.0%, respectively, although fish and bivalves were not represented in the SRC. Juveniles from all species showed to be at no or low risk. In comparison to the same species in the adjacent waters, i.e. the Greater North Sea and the North Atlantic, the estimated risk for Baltic populations is not considerably higher. These findings suggest that over the past few decades the Baltic Sea has improved considerably with respect to presenting Hg exposure to its local species, while it does still carry a legacy of elevated Hg levels resulting from high neighbouring industrial and agricultural activity and slow water turnover regime.
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