The Molecular and Clinical Heterogeneity of FH G.Kees Hovingh MD PhD AMC, Amsterdam, the Netherlands g.k.hovingh@amc.uva.nl

Disclaimer Dr. Kees Hovingh is consultant and speaker for biotech as well as pharmaceutical companies that develop molecules that influence lipoprotein metabolism, including Regeneron, Pfizer, MSD, Sanofi, Amgen, Roche and Genzyme Kees Hovingh is head of the Clinical Trial Unit of the department of Vascular Medicine at the AMC, Amsterdam, and PI for clinical trials in dyslipidemia conducted with i.e. Amgen, Sanofi, Lilly, Novartis, Kowa, Genzyme, Cerenis, Pfizer, Astra. The department receives the honoraria and investigator fees.

FH, the traditional picture...

The same genotype may lead to extremely different phenotypes

And people might look alike while not sharing the genotype.. 8

FH diagnosis Clinical diagnosis Simon Broome Dutch Lipid Criteria clinical +, mutation - Simon Broome Dutch Lipid Criteria Clinical diagnosis Molecular diagnosis clinical -, mutation +

FH; “one disease?” EAS-consensus Clinical diagnosis patient: treat LDL-C family: “monitor LDL-C” clinical +, mutation - patient: treat LDL-C family: mutation test consider to treat LDLC Clinical diagnosis clinical +, mutation + Molecular diagnosis EAS-consensus patient: monitor LDL-C family: monitor LDL-C clinical -, mutation + Intervention is based on LDL-C, not on genetic result Nordestgaard B et al Eur H J 2013;34:3478

Range of LDL-C in heFH? Besseling, Hovingh, work in progress

HoADH in the Netherlands + 2 null alleles No compound heterozygous or homozygous patients for PCSK9 mutations were detected. Rural area… 1 null allele, 1 defective 2 defective alleles

HoADH in the Netherlands No compound heterozygous or homozygous patients for PCSK9 mutations were detected. Rural area…

Clinical Heterogeneity in daily life, outpatient clinic setting august 2015....

Clinical Heterogeneity in daily life, outpatient clinic setting august 2015.... referal letter: “DC, please analyze CVD risk in mother of 9 year old boy with FH seen @ my outpatient clinic, best Bert Wiegman (BTW; I ordered lab for her, she’ll bring it)”

LDL-C 9mmol/L AMI age 51 LDL-C 3 mmol/L LDL-C 6.5 mmol/L

Genetic analysis would help in this family LDL-C 9mmol/L AMI age 51 APOB truncation?? LDL-C 3 mmol/L Genetic analysis would help in this family LDL-C 6.5 mmol/L

FH; a matter of selection bias? LDL-C 9mmol/L AMI age 51 LDL-C 6 mmol/L LDL-C 3 mmol/L

Is the FH phenotype (LDL-C and CVD) attenuated with increasing distance-to- index?

NO mutation: cascade stops in this branch Data - collection FH screening program in the Netherlands (‘94 - ‘14) Genetic cascade approach Questionnaire and blood sample (lipids since ‘04) Index Subject for FH 1) Medical information 2) DNA Analysis NO mutation: cascade stops in this branch Mutation + approach 1st degree relatives etc

Degrees of distance-to-index Study population Degrees of distance-to-index 1 2 3 4 5 6 No. (%) 7,512 (41.9%) 3,887 (21.7%) 1,493 (8.3%) 456 (2.5%) 38 (0.2%) 3 (0%) Men * 3,568 (47.5%) 1,866 (48%) 735 (49.2%) 232 (50.9%) 22 (57.9%) 1 (33.3%) Age in age † 40.9 (20.5) 33.1 (21.6) 26 (17.1) 17 (13,0) 16.7 (9.7) 8.9 (2.6) Year of screening § 2006 [2003 - 2009] 2007 [2004 - 2010] 2009 [2006 - 2011] 2008 [2005 - 2011] 2001 [2001 - 2007] Body mass index in kg/m2 † 23.8 (5) 22.6 (5.3) 21.8 (5.2) 19.6 (4.8) 20.1 (5.4) 18.7 (5.7) Smokers 1,969 (26.2%) 920 (23.7%) 306 (20.5%) 56 (12.3%) 9 (23.7%) 0 (0%) Alcohol use 3,388 (45.1%) 1,633 (42%) 566 (37.9%) 100 (21.9%) 17 (44.7%) CVD in medical history *‡ 759 (10.1%) 285 (7.3%) 36 (2.4%) 1 (0.2%) Hypertension * 812 (10.8%) 304 (7.8%) 54 (3.6%) 8 (1.8%) * no. (%); † mean (SE); ‡ Defined as MI, CABG, PTCA, CVA or angina; § median [IQR]

Description heterozygous FH Degrees of distance-to-index 1 2 3 4 5 6 Diabetes * 223 (3%) 84 (2.2%) 21 (1.4%) 1 (0.2%) 0 (0%) Statin user * 2,997 (39.9%) 1,050 (27%) 265 (17.7%) 31 (6.8%) User of other LLT * 802 (10.7%) 240 (6.2%) 57 (3.8%) 9 (2%) Lipid profiles (mg/dL) LDL-C † 211 (80) 199 (75) 189 (72) 177 (65) 190 (77) 168 (152) HDL-C † 46 (14) 46 (38,67) 53 (0.32) 41 (16) Triglycerides § 99 [67- 148] 95 [66 - 142] 92 [63 - 133] 88 [59 - 133] 90 [58 - 123] 134 [104 - 190] * no. (%); † mean (SE); § median [IQR] LLT: lipid lowering therapy

heFH; clinical diverse

CVD incidence in heterozygous FH

Does genetics matter? Huijgen, Eur H J 2012 3(18):2325-30

Does genetics matter? No !!!

Another benefit of genetic analysis in FH The new PCSK9?? if we do not sequence; we will not get to this! clinical +, mutation - Clinical diagnosis Molecular diagnosis clinical -, mutation +

“with every success it gets harder to find the next one” ??? PCSK9 APOB LDLR “with every success it gets harder to find the next one”

Conclusion 1) FH; a diverse disease: LDL-C is the driver, not genetics 2) No “devaluation” of phenotype in families: CVD risk and LDL-C 3) Genetics do help! 4) without molecular biology: no novel insights!