[Show abstract][Hide abstract] ABSTRACT: Background:
Ezetimibe lowers plasma levels of low-density lipoprotein (LDL) cholesterol by inhibiting the activity of the Niemann-Pick C1-like 1 (NPC1L1) protein. However, whether such inhibition reduces the risk of coronary heart disease is not known. Human mutations that inactivate a gene encoding a drug target can mimic the action of an inhibitory drug and thus can be used to infer potential effects of that drug.
We sequenced the exons of NPC1L1 in 7364 patients with coronary heart disease and in 14,728 controls without such disease who were of European, African, or South Asian ancestry. We identified carriers of inactivating mutations (nonsense, splice-site, or frameshift mutations). In addition, we genotyped a specific inactivating mutation (p.Arg406X) in 22,590 patients with coronary heart disease and in 68,412 controls. We tested the association between the presence of an inactivating mutation and both plasma lipid levels and the risk of coronary heart disease.
With sequencing, we identified 15 distinct NPC1L1 inactivating mutations; approximately 1 in every 650 persons was a heterozygous carrier for 1 of these mutations. Heterozygous carriers of NPC1L1 inactivating mutations had a mean LDL cholesterol level that was 12 mg per deciliter (0.31 mmol per liter) lower than that in noncarriers (P=0.04). Carrier status was associated with a relative reduction of 53% in the risk of coronary heart disease (odds ratio for carriers, 0.47; 95% confidence interval, 0.25 to 0.87; P=0.008). In total, only 11 of 29,954 patients with coronary heart disease had an inactivating mutation (carrier frequency, 0.04%) in contrast to 71 of 83,140 controls (carrier frequency, 0.09%).
Naturally occurring mutations that disrupt NPC1L1 function were found to be associated with reduced plasma LDL cholesterol levels and a reduced risk of coronary heart disease. (Funded by the National Institutes of Health and others.).
New England Journal of Medicine 11/2014; 371(22):2072-82. DOI:10.1056/NEJMoa1405386 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims:
Percutaneous coronary intervention (PCI) and antithrombotic drugs are the standard therapy for patients with acute coronary syndromes (ACS), but their impact on bleeding and mortality in women has not been adequately investigated.
This was a prospective observational cohort study of ACS patients, who were referred to 6 of the 13 centres belonging to the REgistro regionale AngiopLastiche dell'Emilia-Romagna programme in Emilia-Romagna for coronary angiography and PCI between June 2010 and November 2011. The aim of the study was to verify whether the incidence of Global Registry of Acute Coronary Events-defined in-hospital bleeding after an ACS is significantly higher in women than in men, and to evaluate its impact on short and long-term mortality.
The analysis involved a total of 1686 patients (511 women and 1175 men). The women were older and more frequently affected by hypertension, congestive heart failure and single-vessel disease; however, none of the clinical or procedural variables was significantly different between the sexes after statistical adjustment. There was a significantly higher rate of in-hospital bleeding among the women [8.6 vs. 5.8%; adjusted odds ratio 1.73, 95% confidence interval (CI) 1.19-2.52, P = 0.004], but the adjusted hazard ratio for short and long-term all-cause mortality was not significantly different. After optimal adjustment, bleeding, but not female sex, was identified as a predictor of short-term all-cause mortality (hazard ratio 2.68, 95% CI 1.21-5.93, P = 0.01), but this was not confirmed in the case of long-term mortality (hazard ratio 1.57, 95% CI 0.91-2.71, P = 0.10).
After optimal adjustment for baseline differences, the findings of this contemporary Italian PCI registry study showed that women experience bleeding more frequently, but do not have worse mortality outcomes than men. Bleeding was confirmed as an independent predictor of short-term mortality.
Journal of Cardiovascular Medicine 09/2014; 16(5). DOI:10.2459/JCM.0000000000000174 · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Ischemic heart diseases are the leading cause of morbidity and mortality in developed countries, despite advances in cardiac care over the last few decades. Myocardial infarction is a complex, multifactorial disorder that is thought to be due to interactions between genetic and environmental factors. Recent rapid advances in molecular genetics techniques have identified a number of common genetic variants loosely associated with myocardial infarction, and highly promising, newly designed platforms should identify less common genetic variants with an even greater clinical impact. These discoveries have brought us to a stage at which we need to begin to consider how personalised genomic information should be incorporated into clinical practice in order to benefit individuals and society in general.
[Show abstract][Hide abstract] ABSTRACT: The antiplatelet drug clopidogrel is a commonly prescribed therapy in patients with acute coronary syndrome. However, its clinical efficacy is hampered by a wide inter-patient response variability, with over 30% of patients treated with this drug experiencing an inadequate antiplatelet response. There are growing evidences that clopidogrel response variability is associated with cytochrome P450 (CYP) enzyme genetic polymorphisms, primarily CYP2C19 which is responsible for the conversion of clopidogrel into its active metabolite. All of the CYP2C19 polymorphism data suggest that carriers of allele 2 or 17 are at greater risk of ischemic or bleeding events, particularly in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Yet, CYP2C19 status explains only 12% of clopidogrel response variability, indicating that genetic variants other than CYP2C19 might be important. Clopidogrel undergoes intestinal efflux via P-glycoprotein, encoded by the ABCB1 gene. The C3435T polymorphism in this gene affects the bioavailability of clopidogrel, however, its effects on clinical outcomes are inconclusive. Similarly, a polymorphism in the gene encoding PON1, a rate-limiting enzyme for clopidogrel bioactivation, also affects the response to clopidogrel. Among nongenetic factors, an adverse drug interaction between proton pump inhibitors and clopidogrel is often reported, but evidence is inconclusive. A genetic test to identify potential responders to clopidogrel might be useful. However, the use of such tests is currently limited because they focus mainly on CYP2C19 loss-of-function alleles, and there is no empirical evidence yet for genotype-guided clopidogrel therapy.
Journal of Cardiovascular Medicine 12/2013; 14 Suppl 1:S1-7. DOI:10.2459/JCM.0b013e328364bb04 · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Left ventricular-right atrial communications, known collectively as the Gerbode defect, are rare types of ventricular septal defects. Acquired forms of this defect have been described as a complication of cardiac surgery, bacterial endocarditis, chest trauma, or myocardial infarction. Diagnosis of this rare defect is challenging, but can be confirmed with echocardiography or cardiac magnetic resonance imaging. Until 6 years ago, these communications were corrected only surgically, often with relatively high mortality. However, few case reports of transcatheter closures of the defects have recently been reported with excellent results. We describe a 69-year-old patient with left ventricular-right atrial communication secondary to mitral valve surgery. The diagnosis was made by transesophageal and real-time three-dimensional echocardiography. The defect was closed percutaneously using an Amplatzer device. At follow-up, there was no residual flow and the patient improved clinically.
Giornale italiano di cardiologia (2006) 04/2013; 14(4):283-5. DOI:10.1714/1257.13885
[Show abstract][Hide abstract] ABSTRACT: Bivalirudin is a direct thrombin inhibitor that has been approved for use in patients with or at risk for heparin-induced thrombocytopenia undergoing percutaneous coronary intervention. The efficacy of bivalirudin has been well documented in the setting of percutaneous coronary intervention, but there are only few data on its use in chronic dialysis-dependent patients. Bivalirudin is mainly eliminated enzymatically (80%) and to a lesser extent renally (20%). Nevertheless, in patients with chronic kidney disease a substantial increase in coagulation time and bleeding complications has been reported. Therefore, dosage adjustments may be necessary in patients with renal impairment. Dosing and monitoring recommendations in dialysis patients have not yet been established. We describe the case of a 77-year-old man with non-ST-elevation acute coronary syndrome complicated by heparin-induced thrombocytopenia and acute renal failure requiring dialysis treatment. During percutaneous coronary intervention, anticoagulant therapy with bivalirudin was administered at non-standard doses, though already documented in the literature.
Giornale italiano di cardiologia (2006) 02/2013; 14(2):141-4. DOI:10.1714/1218.13528
[Show abstract][Hide abstract] ABSTRACT: More women die every year from cardiovascular disease than men from any other cause. Several fundamental variations have been reported in the mechanisms underlying coronary artery disease, which suggest that its genetic basis varies by gender. Such differences are not limited to gonadal hormones and can be seen in the physiology of atherosclerosis, including plaque components, endothelial function and hemostasis. It is possible to speculate that genetic factors are different in men and women and probably involve biological pathways that have not yet been identified. To date, studies performed by means of the candidate gene approach have identified several genetic variants associated with coronary artery disease in women. However, these scientific data have not been translated into clinical practice. It has recently become possible to search for common gene variants that affect the susceptibility to myocardial infarction on the basis of our knowledge of common single nucleotide polymorphisms and haplotypes across the human genome using genome-wide genotyping technologies. Currently more than 20 gene regions have been associated with ischemic heart disease using this approach. However, so far we do not know several genetic variants differently associated with risk of ischemic heart disease in men and women. A challenge for the near future will therefore be to identify genetic variants that maximally differentiate males from females, and also to identify possible relationships between genes and environment and genes and hormones in both sexes.
Giornale italiano di cardiologia (2006) 06/2012; 13(6):386-95. DOI:10.1714/1073.11755
[Show abstract][Hide abstract] ABSTRACT: The major clinical complication of statins is a variety of muscle complaints ranging from myalgia to rhabdomyolysis. There is growing evidence that carriers of genetic polymorphisms in the enzymes and transporters implicated in statin disposition, particularly the SLCO1B1 gene, are at increased risk of myotoxicity. Our objective is to report on two cases of statin-induced myopathy occurring in a family with two patients who are carriers of the loss of function SLCO1B1 genetic variant and to briefly review the related literature.
Patient 1, a 48-year-old man with history of coronary artery disease, experienced rapidly evolving muscle pain and weakness of the extremities during treatment with atorvastatin 40 mg. Patient 2, a 65-year-old man, father of patient 1, had symptoms similar to those of his son after 2 weeks' treatment with the same statin. Atorvastatin was stopped in both cases, and symptoms resolved. On the basis of family relationship between the two patients, it was possible to hypothesize a genetic basis for the myopathy. Genotyping showed the patients to be carriers of the rs4363657 polymorphism of SLCO1B1 gene.
The two cases reported here and the brief literature review emphasize the impact of genetic factors on the risk of myopathy with statins. Although genotyping all patients before initiating therapy is not recommended at present, pharmacogenetic testing may be useful for new patients who have a family history of statin-induced myopathy.
Journal of Clinical Pharmacy and Therapeutics 05/2012; 37(5):604-6. DOI:10.1111/j.1365-2710.2012.01337.x · 1.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The antiplatelet agent clopidogrel is an effective drug for the prevention of thrombotic events in patients with acute coronary syndrome and in those undergoing percutaneous coronary intervention with the deployment of a coronary stent. However, it has been reported that, despite adequate treatment, about 30% of patients continue to show the high degree of platelet reactivity that is central to the development of atherothrombotic complications and poorer clinical outcomes. Up to 13% of those taking clopidogrel experience a recurrent ischemic event during the first year after acute coronary syndrome, 1-3% experience subacute stent thrombosis after percutaneous coronary intervention probably due to a poor drug response, and about 1.5% experience major bleeding mainly due to an enhanced response. Recent research findings have highlighted the role of genetic variations in determining antiplatelet response variability, and this has aroused interest in genotyping all thienopyridine-eligible patients in order to identify those who would be at increased risk of harm if treated with clopidogrel. However, it remains to be determined whether this information is necessary or sufficient for risk stratification. Only when there are clinical data to support the hypothesis that genotype-guided therapy reduces the rate of ischemic and bleeding events will it be possible to justify the use of genetic testing in all potential patients. When that happens, genotype-guided antiplatelet therapy will also be available in the field of cardiovascular medicine.
Giornale italiano di cardiologia (2006) 10/2011; 12(10):686-9. DOI:10.1714/945.10356
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to test whether the 9p21.3 variant rs1333040 influences the occurrence of new cardiovascular events and coronary atherosclerosis progression after early-onset myocardial infarction.
9p21.3 genetic variants are associated with ischemic heart disease, but it is not known whether they influence prognosis after an acute coronary event.
Within the Italian Genetic Study of Early-onset Myocardial Infarction, we genotyped rs1333040 in 1,508 patients hospitalized for a first myocardial infarction before the age of 45 years who underwent coronary angiography without index event coronary revascularization. They were followed up for major cardiovascular events and angiographic coronary atherosclerosis progression.
Over 16,599 person-years, there were 683 cardiovascular events and 492 primary endpoints: 77 cardiovascular deaths, 223 reoccurrences of myocardial infarction, and 383 coronary artery revascularizations. The rs1333040 genotype had a significant influence (p = 0.01) on the primary endpoint, with an adjusted hazard ratio of 1.19 (95% confidence interval [CI]: 1.08 to 1.37) for heterozygous carriers and 1.41 (95% CI: 1.06 to 1.87) for homozygous carriers. Analysis of the individual components of the primary endpoints provided no significant evidence that the rs1333040 genotype influenced the hazard of cardiovascular death (p = 0.24) or the reoccurrence of myocardial infarction (p = 0.57), but did provide significant evidence that it influenced on the hazard of coronary revascularization, with adjusted heterozygous and homozygous ratios of 1.38 (95% CI: 1.17 to 1.63) and 1.90 (95% CI: 1.36 to 2.65) (p = 0.00015), respectively. It also significantly influenced the angiographic endpoint of coronary atherosclerosis progression (p = 0.002).
In early-onset myocardial infarction, the 9p21.3 variant rs1333040 affects the progression of coronary atherosclerosis and the probability of coronary artery revascularization during long-term follow-up.
Journal of the American College of Cardiology 07/2011; 58(4):426-34. DOI:10.1016/j.jacc.2010.11.075 · 16.50 Impact Factor