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

2. Clinical Demands for Genetic Testing

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

4. Which genes are responsible?

5. Genome-wide Map - Microsatellites 13 4 5 15 1413 1211 1098 7 6 16 20 21 1817 22 19 2 Resolution: n=400

6. MI locus 14q32 Nat Genet 2002;30:210-214 point LOD 3.9 p= 0.00015 genome wide LOD p< 0.05 1 2 3 4 020406080100120 D14S742D14S128 D14S608 D14S599D14S587D14S588GATA139A07D14S617 D14S592 D14S606D14S143D14S979 D14S1019 D14S267 D14S1426 D14S985 D14S1051 D14S292 D14S1007 LOD cM

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

8. 2007 2006 2005 2000 1992 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!

9. Genome-wide Map - SNPs 13 4 5 15 1413 1211 1098 7 6 16 20 21 1817 22 19 2 resolution: N=1.000.000 1 2 3

10. rs1333049 Better Coverage Chromosome 9p21.3 Gene

11. genome scan - 500,000s SNPs identification of positive regions replication 2.000 affected individuals2.000 healthy individuals 1 22 GWAs – Strategy I

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

13. NEJM 2007; 357: 443-453

14. Association of locus on chromosome 9p21.3 with CAD rs599839 NEJM 2007; 357: 443-453

15. Structure of the chromosome 9 CAD-associated locus T2DM Signal NEJM 2007; 357: 443-453 -Log p-value

16. Association of locus on chromosome 9p21.3 with CAD McPherson R et al. Science 2007;316:1488-1491 Most replicated locus for CAD risk to date

17. Association of locus on chromosome 9p21.3 with CAD Helgadottir A et al. Science 2007; 316:1491-1493 Most replicated locus for CAD risk to date

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

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

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

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

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

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

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

26. rs1333049rs7865618 rs1292136 rs7044859 Haplotype TGGT ACAC Haplotype analysis of the chromosome 9 CAD-associated locus WTCCC Study: Odds ratio1.48 (1.34-1.64) per copy of the ACAC haplotype German MI Study: Odds ratio1.34 (1.12-1.59) per copy of the ACAC haplotype NEJM 2007; 357: 443-453

27. rs1333049 rs7865618 rs1292136 rs7044859 Haplotype analysis of the chromosome 9 CAD-associated locus rs1333049-C allele according to the haplotypic backgrounds

28. Further genomewide results

29. 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 6q25.1rs6922269A (0.25)1.23 (1.15-1.33)2.90x10 -8 0.0023MTHFD1L 2q36.3rs2943634C (0.65)1.21 (1.13-1.30)1.61x10 -7 0.0190­--- 1p13.3rs599839A (0.77)1.29 (1.18-1.40)4.05x10 --9 0.0006PSRC1/ CELRS2 1q41rs17465637C (0.71)1.20 (1.12-1.30)1.27x10 -6 0.1314MIA3 10q11.21rs501120T (0.87)1.33 (1.20-1.48)9.46x10 -8 0.0234CXCL12 15q22.33rs17228212C (0.30)1.21 (1.13-1.30)1.98x10 -7 0.0178SMAD3 NEJM 2007; 357: 443-453

30. 100% 50% 0% Chr 9 Chr 6 Chr 2 Population attributable risk Genomics for risk prediction NEJM 2007; 357: 443-453

31. Novel CAD loci affect risk in both men and women LOCUSSNPODDS RATIO MALE P-VALUE MALE ODDS RATIO FEMALE P-VALUE FEMALE 1p13.3rs5998391.36 (1.16-1.59)1.33x10 -4 1.27 (1.14-1.41)7.61x10 -6 1q41rs174656371.24 (1.12-1.36)1.15x10 -5 1.19 (1.04-1.37)1.24x10 -2 2q36.3rs29436341.20 (1.10-1.32)4.48x10 -5 1.22 (1.07-1.39)2.30x10 -3 6q25.1rs69222691.24 (1.13-1.37)4.56x10 -6 1.23 (1.07-1.41)3.13x10 -3 9p21.3rs13330491.35 (1.24-1.47)7.03x10 -12 1.35 (1.19-1.52)1.90x10 -6 10q11.21rs5011201.30 (1.14-1.48)8.20x10 -5 1.56 (1.27-1.91)1.30x10 -5 15q22.33rs172282121.24 (1.13,1.36)7.68x10 -6 1.16 (1.02-1.33)2.56x10 -2 2117 male cases and 2259 male controls and 684 female cases and 2323 female controls NEJM 2007; 357: 443-453

32. Graphic n=2022 0.2 0.4 0.6 0 Ger MI Fam n=847 P=3.8x10 -6 P=1x10 -4 Chol (mmol/L) per rs599839-allele WTCCC n=2022 1.2 1.4 1.6 1 Ger MI Fam n=847 P=2.1x10 -5 P=3.1x10 -5 MI risk per rs599839-allele NEJM 2007; 357: 443-453 CELSR2 PSRC1 25.7kb 4kb 3.6kb 1 0.8 r 2 0.6 0.4 0.2 0 -35000 -30000 -25000 -20000 -15000 -10000 -5000 0 5000 10000 bp from SNP rs599839 Chromosome 1p13.3 109500k 109510k 109520k 109530k 109540k 0 0.5 1 r 2 rs4970834 rs611917 rs7528419 rs12740374 rs660240 rs658435 rs629301 rs646776 rs17035949 rs602633 rs599839 PSRC1 and CELSR2 genes associate with serum cholesterol and MI risk (in revision)

33. 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)

34. LDL-R locus associates with serum cholesterol and MI risk imputation of the locus 10 -2 top SNPs for MI top SNPs for LDL P. Linsel-Nitschke (unpublished)

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

36. 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

37. 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

38. 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?

39. Mendels threat