Prof. Dr. H. Schunkert Medizinische Klinik II UK S-H Campus Lübeck Genome-wide association for myocardial infarction

Clinical Demands for Genetic Testing

Myocardial infarction Genes Calcification/ Remodeling/ Plaque formation Hyperlipidemia ? Genes environment Hypertensionsmoking Hypercoagulation Inflammation/ Endothelial dysfunction Diab. mell. Clin Res Cardiol. 2007;96:1-7

Which genes are responsible?

Genome-wide Map - Microsatellites Resolution: n=400

MI locus 14q32 Nat Genet 2002;30: point LOD 3.9 p= genome wide LOD p< D14S742D14S128 D14S608 D14S599D14S587D14S588GATA139A07D14S617 D14S592 D14S606D14S143D14S979 D14S1019 D14S267 D14S1426 D14S985 D14S1051 D14S292 D14S1007 LOD cM

linkage-Scans for atherosclerosis genetic hot spots for CAD Clin Res Cardiol 2007; 96:1–7

candidate gene- polymorphisms genome-wide linkage analysis 10k-SNP Chip LOD black box : myocardial infarction 500k-SNP Chip 1000k-SNP Chip the key: a chip!

Genome-wide Map - SNPs resolution: N=

rs Better Coverage Chromosome 9p21.3 Gene

genome scan - 500,000s SNPs identification of positive regions replication affected individuals2.000 healthy individuals 1 22 GWAs – Strategy I

GWAs – Strategy II 2000 cases 3200 controls 1988 cases 3000 controls

NEJM 2007; 357:

Association of locus on chromosome 9p21.3 with CAD rs NEJM 2007; 357:

Structure of the chromosome 9 CAD-associated locus T2DM Signal NEJM 2007; 357: Log p-value

Association of locus on chromosome 9p21.3 with CAD McPherson R et al. Science 2007;316: Most replicated locus for CAD risk to date

Association of locus on chromosome 9p21.3 with CAD Helgadottir A et al. Science 2007; 316: Most replicated locus for CAD risk to date

SNPs with triple replication across 3 GWAs 13 out of 16 SNPs with triple replication are located at 9p21 ! (Circulation Suppl 2007)

Replicated association between chromosome 9p21.3 and MI risk (in revision)

Broadbend et al (Procardis) Hum Mol Gen 2008 (in press) Replicated association between chromosome 9p21.3 and MI risk

Broadbend et al (Procardis) Hum Mol Gen 2008 (in press) Replicated association between chromosome 9p21.3 and MI risk

Broadbend et al (Procardis) Hum Mol Gen 2008 (in press) Replicated association between chromosome 9p21.3 and MI risk

Helgadottir et al (deCode) Nat Genet 2008 (in press)

Replicated association between chromosome 9p21.3 and MI risk in Korea Shen et al ATVB 2008;28; in press n=294 n=611

rs rs rs rs Haplotype TGGT ACAC Haplotype analysis of the chromosome 9 CAD-associated locus WTCCC Study: Odds ratio1.48 ( ) per copy of the ACAC haplotype German MI Study: Odds ratio1.34 ( ) per copy of the ACAC haplotype NEJM 2007; 357:

rs rs rs rs Haplotype analysis of the chromosome 9 CAD-associated locus rs C allele according to the haplotypic backgrounds

Further genomewide results

Other loci strongly associated with CAD identified from joint analysis of the WTCCC Study and German MI Study LOCUSSNPRISK ALLELE AND FREQUENCY ODDS RATIO PER COPY OF RISK ALLELE P-VALUEFPRPGENES 6q25.1rs A (0.25)1.23 ( )2.90x MTHFD1L 2q36.3rs C (0.65)1.21 ( )1.61x ­--- 1p13.3rs599839A (0.77)1.29 ( )4.05x PSRC1/ CELRS2 1q41rs C (0.71)1.20 ( )1.27x MIA3 10q11.21rs501120T (0.87)1.33 ( )9.46x CXCL12 15q22.33rs C (0.30)1.21 ( )1.98x SMAD3 NEJM 2007; 357:

100% 50% 0% Chr 9 Chr 6 Chr 2 Population attributable risk Genomics for risk prediction NEJM 2007; 357:

Novel CAD loci affect risk in both men and women LOCUSSNPODDS RATIO MALE P-VALUE MALE ODDS RATIO FEMALE P-VALUE FEMALE 1p13.3rs ( )1.33x ( )7.61x q41rs ( )1.15x ( )1.24x q36.3rs ( )4.48x ( )2.30x q25.1rs ( )4.56x ( )3.13x p21.3rs ( )7.03x ( )1.90x q11.21rs ( )8.20x ( )1.30x q22.33rs (1.13,1.36)7.68x ( )2.56x male cases and 2259 male controls and 684 female cases and 2323 female controls NEJM 2007; 357:

Graphic n= Ger MI Fam n=847 P=3.8x10 -6 P=1x10 -4 Chol (mmol/L) per rs allele WTCCC n= Ger MI Fam n=847 P=2.1x10 -5 P=3.1x10 -5 MI risk per rs allele NEJM 2007; 357: CELSR2 PSRC1 25.7kb 4kb 3.6kb r bp from SNP rs Chromosome 1p k k k k k r 2 rs rs rs rs rs rs rs rs rs rs rs PSRC1 and CELSR2 genes associate with serum cholesterol and MI risk (in revision)

4 SNPs associate with MI GWA German MI Family Study 4 SNPs associate with LDL GWA MONICA/KORA Study LDL-R locus associates with serum cholesterol and MI risk P. Linsel-Nitschke (unpublished)

LDL-R locus associates with serum cholesterol and MI risk imputation of the locus top SNPs for MI top SNPs for LDL P. Linsel-Nitschke (unpublished)

Myocardial infarction Chrom 9p21 Plaque formation Hyperlipidemia PCSK9Chrom 19p13 Chrom 1p13 Vascular defect

Genetic score for MI risk 20 risk alleles 400 risk alleles 80 risk alleles 40 risk alleles Ortlepp et al Euro J Intern Med 2002; 13:485 MI patientscontrols 10 genes = 20 alleles

Genetic score for MI risk 20 risk alleles 400 risk alleles 80 risk alleles 40 risk alleles Ortlepp et al Euro J Intern Med 2002; 13:485

molecular genetics of myocardial infarction yesterday pos. family hx : important risk factor (predictor) for CAD today (missed) opportunities for prevention tomorrow individual genetic risk prediction?

Mendels threat