The purpose of this thesis is to examine familial hypercholesterolemia (FH) and emerging pharmacogenomics therapies that propose to lower serum low density lipid (LDL) levels. The search of various data bases resulted in nine research articles being selected for review. Syntheses of the articles suggest emerging phamacogenomic drug therapy can improve treatment outcomes for individuals with a diagnosis of FH. The Human Genome Project (HGP) has had far reaching applications for genomic technologies and pharmacagenomic interventions, tailored to human conditions associated with select genomic traits. Synthesis of nine research articles demonstrate that little is known on the topic and reveals extensive gaps in the evidence. This thesis concludes with implications for nursing education, practice, policy and research along with limitations are noted.

L’excès des particules de LDL dans le sang constitue un facteur de risque majeur dans le développement des maladies cardiovasculaires. Dans ce contexte, nous étudions la protéine PCSK9 qui favorise directement ce facteur de risque. Cette protéine est sécrétée en majorité au niveau du foie par les hépatocytes et possède la capacité de reconnaître et de lier le récepteur LDLR. Le rôle premier de ce dernier est d’éliminer les particules de LDL circulant dans le plasma. Ainsi, lorsque la PCSK9 forme un complexe avec le LDLR et l’amène à la dégradation, la conséquence directe de la diminution des ces récepteurs est une accumulation malsaine des particules LDL dans le plasma. L’importante implication de la PCSK9 dans le métabolisme des lipides nous a menés vers des recherches de caractérisation de cette protéine ainsi que dans l’étude de son mode d’action. La PCSK9 est composée de trois domaines et notre intérêt s’est porté sur l’étude structure-fonction des deux domaines dont la fonction était inconnue, soit le domaine en N-terminal : le prodomaine et de son domaine en C-terminal : CHRD. Le premier article présenté dans cette thèse révèle l’importance d’une région acide (acide aminés 33-58) régulatrice de l’activité de la PCSK9 localisée en N-terminal du prodomaine ainsi que l’effet du pH acide, équivalent à celui des endosomes tardifs, qui accroît la capacité de la PCSK9 à induire la dégradation du LDLR. Le deuxième article dissèque davantage la structure de la PCSK9 et met en lumière la différence des prérequis structurels de la région ‘’Hinge’’ ainsi que du module M2, composant du domaine CHRD, dans la voie intracellulaire et la voie extracellulaire d’activité de la PCSK9. La mutation R434W localisée dans la région ‘’Hinge’’ résulte dans une inhibition totale de l’activité intracellulaire de la PCSK9 tandis que son activité extracellulaire est réduite à ~70%. Contrairement, la perte du module M2 du domaine CHRD est bien tolérée par la PCSK9 lors de son activité intracellulaire mais totalement inhibitrice pour son activité extracellulaire. Le troisième article se distingue en présentant une nouvelle stratégie d’inhibition de l’activité de la PCSK9 en utilisant une chimère composée de la fraction Fc de l’immunoglobuline IgG1 humaine couplée avec le prodomaine de la PCSK9. La protéine fusion Fcpro lie directement la PCSK9, crée un encombrement structurel qui résulte dans une régulation négative l’activité de la PCSK9. En résumé, nous présentons dans cette thèse, trois manuscrits qui apportent une contribution à la connaissance des composantes structurelles de la PCSK9 et leur implication dans le rôle de la protéine en tant que régulateur négatif du LDLR. / Hypercholesterolemia is one of the major risk factors leading to cardiovascular disease. In this context, we focused our study on a protein that directly influences hypercholesterolemia: PCSK9. Since 2003, the coding gene for PCSK9 has been identified as the third locus responsible for familial hypercholesterolemia (FH3). PCSK9 is a protein secreted mostly from the liver by hepatocytes and has the capacity to recognize, bind and direct to degradation the LDLR receptor. The latter is responsible for the elimination the LDL particles from the plasma. The direct consequence of the LDLR degradation induced by PCSK9 is the harmful accumulation of the bad cholesterol in the blood. Since PCSK9 activity has undesirable consequences on lipid metabolism homeostasis, we directed our research to characterize this protein to better understand its mechanism of action. Three domains compose PCSK9 structure and we focused on the ‘’structure-function study’’ of two domains, of which roles were still unknown: the prodomain located at the N-terminal extremity and the CHRD domain at the C-terminus of PCSK9. The first manuscript presented in this thesis brings to light the importance of the acidic N-terminal sequence of the prosegment (amino acids 33-58) and its effect on the activity of PCSK9. It also presents a novel mechanism for fine-tuning the activity of PCSK9, which is enhanced at acidic pHs close to those of late endosomes. The second manuscript dissects further the PCSK9 structure, revealing that the structural requirements of the hinge and the M2 module located in the CHRD domain are not the same for the intracellular and extracellular pathways of PCSK9-induced LDLR degradation. Although the R434W natural mutation in the hinge region is absolutely deleterious for the intracellular activity of PCSK9, it reduces by ~70% the extracellular one. In contrast, the loss of M2 module of the CHRD domain is tolerated for the intracellular activity of PCSK9 but not for the extracellular one. The third manuscript demonstrates for the first time that a chimera containing the prosegment (Fcpro) directly binds PCSK9 and effectively acts as a negative regulator (inhibitor) of its ability to induce LDLR degradation. Our work presents a new strategy to develop such inhibitors by interfering with the structure of PCSK9 and exploiting the properties of the PCSK9 prosegment and the advantage of its fusion to a humanized Fc of IgG1. In summary, the present research data sheds new light on the functional contribution of the prodomain and the CHRD domain of PCSK9.

La proprotéine convertase subtilisine/kexine-9 (PCSK9) a été identifiée comme le troisième locus impliqué dans l’hypercholestérolémie autosome dominante (ADH). Les deux autres gènes impliqués dans l’ADH encodent le récepteur des lipoprotéines de faible densité (LDLR) et l’apolipoprotéine B. La PCSK9 est une convertase qui favorise la dégradation du LDLR dans les hépatocytes et augmente le niveau plasmatique de cholestérol des LDL (LDL-C). Les mutations « gain de fonction » de la PCSK9 sont associées à un phénotype d’hypercholestérolémie familiale, tandis que les variantes « perte de fonction » sont associées à un LDL-C réduit et à un risque coronarien plus faible. Pour élucider le rôle physiologique de la PCSK9, nous avons étudié sa régulation génique. En utilisant le RT-PCR quantitatif dans des hépatocytes humains, nous avons analysé la régulation de PCSK9 sous différentes conditions modulant l’expression des gènes impliqués dans le métabolisme du cholestérol. Nous avons démontré que l’expression de la PCSK9 était induite par les statines de manière dose-dépendante et que cette induction était abolie par le mévalonate. De plus, le promoteur de PCSK9 contenait deux motifs conservés pour la régulation par le cholestérol : le sterol regulatory element (SRE) et un site Sp1. La PCSK9 circule dans le plasma sous des formes mature et clivée par la furine. Grâce à notre anticorps polyclonal, nous avons mis au point un test ELISA mesurant la PCSK9 plasmatique totale. Une étude transversale a évalué les concentrations plasmatiques de PCSK9 chez des sujets sains et hypercholestérolémiques, traités ou non par des statines ou une combinaison statine/ezetimibe. Chez 254 sujets sains, la valeur moyenne de PCSK9 (écart-type) était de 89,5 (31,9) µg/L. La concentration plasmatique de la PCSK9 corrélait avec celle de cholestérol total, du LDL-C, des triglycérides (TG), de la glycémie à jeun, l’âge et l’indice de masse corporelle. Le séquençage de PCSK9 chez des sujets aux extrêmes de la distribution des concentrations de PCSK9 de notre cohorte a révélé la présence d’une nouvelle variation « perte de fonction » : R434W. Chez 200 patients hypercholestérolémiques, la concentration de PCSK9 était plus élevée que chez les sujets sains (P<0,04). Elle a augmenté avec une dose croissante de statine (P<0,001), et a augmenté encore plus suite à l’ajout d’ezetimibe (P<0,001). Chez les patients traités, ceux présentant une hypercholestérolémie familiale (HF; due à une mutation du LDLR) avaient des concentrations plus élevées de PCSK9 que les non-HF (P<0,005), et la réduction de LDL-C corrélait positivement avec la concentration de PCSK9 atteinte de la même manière dans les deux sous-catégories (P<0,02 et P<0,005, respectivement). Par ailleurs, une incubation des cellules HepG2 (hépatocytes) et Caco-2 (entérocytes) avec de l’ezetimibe a provoqué une augmentation de l’ARNm de PCSK9 et de NPC1L1 de 1,5 à 2 fois (P<0,05), mais aucune variation significative de PCSK9 sécrétée n’a été observée, suggérant que ces lignées cellulaires ne sont pas un modèle idéal. Nous avons également mesuré le niveau de PCSK9 chez 1 739 Canadiens-français âgés de 9, 13 et 16 ans. La valeur moyenne (écart-type) de PCSK9 dans cette cohorte était de 84,7 (24,7) µg/L, légèrement plus basse que dans la cohorte d’adultes (89,5 (31,9) µg/L). Chez les garçons, la PCSK9 circulante diminuait avec l’âge, tandis que c’était l’inverse chez les filles. Il y avait des associations positives et significatives entre la PCSK9 et la glycémie à jeun, l’insulinémie, le HOMA-IR, et les paramètres lipidiques (TC, LDL-C, TG, HDL-C, apoAI et apoB). Dans l’analyse multivariée, une hausse de 10% de l’insulinémie à jeun était associée à une augmentation de 1 à 2% de PCSK9. La régulation de PCSK9 est typique de celle d’un gène impliqué dans le métabolisme des lipoprotéines et est probablement la cible du facteur de transcription «sterol regulatory element-binding protein » (SREBP-2). La concentration plasmatique de la PCSK9 est associée avec l’âge, le sexe, et de multiples marqueurs métaboliques chez les enfants et les adultes. La détection de la PCSK9 circulante chez les sujets HF et non-HF signifie que ce test ELISA spécifique à PCSK9 pourrait servir à suivre la réponse à la thérapie chez un grand éventail de sujets. PCSK9 semble être une cible thérapeutique prometteuse dans le traitement de l’hypercholestérolémie et de la maladie cardiovasculaire. / Proprotein convertase subtilisin/kexin type 9 (PCSK9) has been identified as the third locus implicated in autosomal dominant hypercholesterolemia (ADH). The two other known genes implicated in ADH encode the low-density lipoprotein receptor (LDLR) and apolipoprotein B. PCSK9 is a protein convertase that post-translationally promotes the degradation of the LDLR in hepatocytes and increases plasma LDL cholesterol concentration (LDL-C). Heterozygote “gain-of-function” mutations of PCSK9 are associated with the familial hypercholesterolemia phenotype, whereas “loss-of-function” variants are associated with reduced LDL-C concentrations and lower coronary risk. As an approach toward the elucidation of the physiological role(s) of PCSK9, we studied its transcriptional regulation. Using quantitative RT-PCR, we assessed PCSK9 regulation under conditions known to regulate genes involved in cholesterol metabolism in HepG2 cells and in human primary hepatocytes. We found that PCSK9 expression was strongly induced by statins in a dose-dependent manner and that this induction was efficiently reversed by mevalonate. The PCSK9 promoter contains two typical conserved motifs for cholesterol regulation: a sterol regulatory element (SRE) and an Sp1 site. PCSK9 circulates in plasma as mature and furin-cleaved forms. A polyclonal antibody against human PCSK9 was used to develop an ELISA that measures total plasma PCSK9 rather than only the mature form. A cross-sectional study evaluated plasma levels in normal and hypercholesterolemic subjects treated or untreated with statins or statin plus ezetimibe. In 254 healthy subjects, the mean plasma PCSK9 (SD) concentration was 89 (32) µg/L. PCSK9 levels correlated positively with plasma cholesterol, LDL-C, triglycerides, fasting glucose, age and body mass index. Sequencing PCSK9 from subjects at the extremes of PCSK9 plasma distribution revealed a new loss-of-function R434W variant. In 200 hypercholesterolemic patients, circulating PCSK9 was higher than in controls (P<0.04), increased with increasing statin dose (P<0.001), and further increased when ezetimibe was added (P<0.001). In treated patients (n = 139), those with familial hypercholesterolemia (FH; due to LDLR gene mutations) had higher PCSK9 values than non-FH (P<0,005), and LDL-C reduction correlated positively with achieved plasma PCSK9 levels to a similar extent in both subsets (P<0.02 and P<0.005, respectively). However, incubation with ezetimibe of HepG2 (hepatocytes) and Caco-2 (enterocytes) cells caused an increase in PCSK9 and NPC1L1 mRNA of 1.5 to 2-fold (P<0.05), but no significant rise in PCSK9 protein secretion, suggesting that these transformed cells are not an ideal model. We also studied PCSK9 levels in 1,739 French Canadian youth ages 9, 13, and 16 years old. The mean (SD) plasma PCSK9 concentration, measured by ELISA, was 84.7 (24.7) µg/L in the cohort, slightly lower than in the adult cohort (89.5 (31.9) µg/L. In boys, plasma PCSK9 decreased with age, whereas the inverse was true for girls. There were significant positive associations between PCSK9 and fasting glucose, insulin, and HOMA-IR (homeostasis model assessment of insulin resistance). In multivariable analysis, a 10% higher fasting insulin was associated with a 1%-2% higher PCSK9 in both sexes. There were also positive associations between PCSK9 and total cholesterol, LDL-C, and triglycerides, as well as with HDL-C and apolipoproteins A1 and B. PCSK9 regulation is typical of that of the genes implicated in lipoprotein metabolism. In vivo, PCSK9 is probably a target of the transcription factor “sterol response element-binding protein” (SREBP)-2. The PCSK9 plasmatic concentration is associated with age, sex, and multiple metabolic markers in youth and adult samples. The detection of circulating PCSK9 in both FH and non-FH subjects means that this PCSK9 ELISA test could be used to monitor response to therapy in a wide range of patients. PCSK9 seems to be a promising drug target in the treatment of hypercholesterolemia and coronary heart disease.

Les maladies cardiovasculaires (MCV) sont les principales causes de mortalité et de morbidité à travers le monde. En Amérique du Nord, on estime à 90 millions le nombre d’individus ayant une ou plusieurs MCV, à près de 1 million le nombre de décès reliés par année et à 525 milliards de dollars les coûts directs et indirects en 2010. En collaboration avec l’équipe du Dre. Boileau, notre laboratoire a récemment identifié, le troisième locus impliqué dans l’hypercholestérolémie familiale. Une étude publiée dans le New Engl J Med a révélé que l’absence de la convertase PCSK9 réduit de 88% le risque de MCV, corrélé à une forte réduction du taux de cholestérol plasmatique (LDL-C). Il fut démontré que PCSK9 lie directement le récepteur aux lipoprotéines de faible densité (LDLR) et, par un mécanisme méconnu, favorise sa dégradation dans les endosomes/lysosomes provoquant ainsi une accumulation des particules LDL-C dans le plasma. Dans cet ouvrage, nous nous sommes intéressés à trois aspects bien distincts : [1] Quels sont les cibles de PCSK9 ? [2] Quelle voie du trafic cellulaire est impliquée dans la dégradation du LDLR par PCSK9 ? [3] Comment peut-on inhiber la fonction de PCSK9 ? [1] Nous avons démontré que PCSK9 induit la dégradation du LDLR de même que les récepteurs ApoER2 et VLDLR. Ces deux membres de la famille du LDLR (fortes homologies) sont impliqués notamment dans le métabolisme des lipides et de la mise en place de structures neuronales. De plus, nous avons remarqué que la présence de ces récepteurs favorise l’attachement cellulaire de PCSK9 et ce, indépendamment de la présence du LDLR. Cette étude a ouvert pour la première fois le spectre d’action de PCSK9 sur d’autres protéines membranaires. [2] PCSK9 étant une protéine de la voie sécrétoire, nous avons ensuite évalué l’apport des différentes voies du trafic cellulaire, soit extra- ou intracellulaire, impliquées dans la dégradation du LDLR. À l’aide de milieux conditionnées dérivés d’hépatocytes primaires, nous avons d’abord démontré que le niveau extracellulaire de PCSK9 endogène n’a pas une grande influence sur la dégradation intracellulaire du LDLR, lorsqu’incubés sur des hépatocytes provenant de souris déficientes en PCSK9 (Pcsk9-/-). Par analyses de tri cellulaire (FACS), nous avons ensuite remarqué que la surexpression de PCSK9 diminue localement les niveaux de LDLR avec peu d’effet sur les cellules voisines. Lorsque nous avons bloqué l’endocytose du LDLR dans les cellules HepG2 (lignée de cellules hépatiques pour l’étude endogène de PCSK9), nous n’avons dénoté aucun changement des niveaux protéiques du récepteur. Par contre, nous avons pu démontrer que PCSK9 favorise la dégradation du LDLR par l’intermédiaire d’une voie intracellulaire. En effet l’interruption du trafic vésiculaire entre le réseau trans-Golgien (RTG) et les endosomes (interférence à l’ARN contre les chaînes légères de clathrine ; siCLCs) prévient la dégradation du LDLR de manière PCSK9-dépendante. [3] Par immunobuvardage d’affinité, nous avons identifié que la protéine Annexine A2 (AnxA2) interagit spécifiquement avec le domaine C-terminal de PCSK9, important pour son action sur le LDLR. Plus spécifiquement, nous avons cartographié le domaine R1 (acides aminés 34 à 108) comme étant responsable de l’interaction PCSK9AnxA2 qui, jusqu’à présent, n’avait aucune fonction propre. Finalement, nous avons démontré que l’ajout d’AnxA2 prévient la dégradation du LDLR induite par PCSK9. En somme, nos travaux ont pu identifier que d’autres membres de la famille du LDLR, soit ApoER2 et VLDLR, sont sensibles à la présence de PCSK9. De plus, nous avons mis en évidence que l’intégrité du trafic intracellulaire est critique à l’action de PCSK9 sur le LDLR et ce, de manière endogène. Finalement, nous avons identifié l’Annexine A2 comme unique inhibiteur naturel pouvant interférer avec la dégradation du LDLR par PCSK9. Il est indéniable que PCSK9 soit une cible de premier choix pour contrer l’hypercholestérolémie afin de prévenir le développement de MCV. Cet ouvrage apporte donc des apports considérables dans notre compréhension des voies cellulaires impliquées, des cibles affectées et ouvre directement la porte à une approche thérapeutique à fort potentiel. / Cardiovascular disease (CVD) is the primary cause of death and morbidity worldwide, claiming about 900 000 lives yearly in North America alone. A high level of circulating LDL-cholesterol is a major risk factor positively correlated with premature development of complex CVD mainly due to a rapid buildup of lipid deposition in the arteries. In collaboration with Dre Boileau, we recently discovered that the convertase PCSK9 is the third locus of familial hypercholesterolemia. A study published in the New Eng J Med revealed that the absence of PCSK9 reduces the risk of CVD by ~88%, resulting from a strong reduction of cholesterol in the bloodstream (LDL-C). It has been shown that PCSK9 directly binds the low-density lipoprotein receptor (LDLR) and by an unknown mechanism, reroutes it towards degradation in late endosomes/lysosomes, resulting in the accumulation of LDL-C particles in plasma. In this thesis, we addressed three different aspects of PCSK9 biology: [1] What are the targets of PCSK9? [2] Which cellular trafficking components are involved in PCSK9-induced LDLR degradation? [3] How can we inhibit the function of PCSK9? [1] We first demonstrated that PCSK9 induces the degradation of the LDLR and two of its closest family members. These include the very-low-density-lipoprotein receptor (VLDLR) and apolipoprotein E receptor 2 (ApoER2) implicated in neuronal development and lipid metabolism. In addition, we demonstrated that these receptors enhance the cellular association of PCSK9 independently of the presence of the LDLR. This study represents the first evidence that PCSK9 could target other proteins for degradation, reinforcing its role as a key regulator of some members of the LDLR family. [2] Since PCSK9 is a secreted protein, we decided to investigate the contributions of both the intra- and extracellular trafficking pathways in LDLR degradation. Using conditioned media derived from mice primary hepatocytes, we showed that endogenously secreted PCSK9 was not able to influence LDLR levels of PCSK9-deficient primary hepatocytes (Pcsk9-/-). By flow cytometry (FACS), we observed that overexpression of the gain-of-function PCSK9-D374Y, but not wild type PCSK9, decreases cell surface LDLR on adjacent cells suggesting that its spectrum of action is local. We also noticed that blockade of endocytosis in HepG2 cells (commonly used to study endogenous LDLR degradation by PCSK9) does not affect total LDLR protein levels. In contrast, disruption of the intracellular trafficking between the trans-Golgi network (TGN) and endosomes (siRNAs against clathrin light chains; CLCs) prevented LDLR degradation in a PCSK9-specific manner. [3] By Far Western blotting, we identified that Annexin A2 (AnxA2) specifically interacts with the C-terminal domain of PCSK9, which is crucial for its function in LDLR degradation. Moreover, we determined that the R1 domain (amino acids 34 to 108) is responsible for the PCSK9AnxA2 interaction, which confers a new function for this protein. Finally, we showed that addition of AnxA2 prevents PCSK9-induced LDLR degradation. In summary, this work allowed us to identify that PCSK9 induces the degradation of the LDLR and its closest family members, ApoER2 and VLDLR. We also highlighted that the integrity of the intracellular trafficking pathway is crucial for endogenous PCSK9-induced LDLR degradation. Furthermore, we discovered that AnxA2 is a unique, natural inhibitor capable of interfering with the action of PCSK9 in LDLR degradation. It is undeniable that PCSK9 is a genetically validated target to reduce circulating LDL-cholesterol and prevent CVD. This thesis brings forth important contributions in our understanding of the cellular pathways involved and opens the door for novel therapeutic approaches.

L’excès des particules de LDL dans le sang constitue un facteur de risque majeur dans le développement des maladies cardiovasculaires. Dans ce contexte, nous étudions la protéine PCSK9 qui favorise directement ce facteur de risque. Cette protéine est sécrétée en majorité au niveau du foie par les hépatocytes et possède la capacité de reconnaître et de lier le récepteur LDLR. Le rôle premier de ce dernier est d’éliminer les particules de LDL circulant dans le plasma. Ainsi, lorsque la PCSK9 forme un complexe avec le LDLR et l’amène à la dégradation, la conséquence directe de la diminution des ces récepteurs est une accumulation malsaine des particules LDL dans le plasma. L’importante implication de la PCSK9 dans le métabolisme des lipides nous a menés vers des recherches de caractérisation de cette protéine ainsi que dans l’étude de son mode d’action. La PCSK9 est composée de trois domaines et notre intérêt s’est porté sur l’étude structure-fonction des deux domaines dont la fonction était inconnue, soit le domaine en N-terminal : le prodomaine et de son domaine en C-terminal : CHRD. Le premier article présenté dans cette thèse révèle l’importance d’une région acide (acide aminés 33-58) régulatrice de l’activité de la PCSK9 localisée en N-terminal du prodomaine ainsi que l’effet du pH acide, équivalent à celui des endosomes tardifs, qui accroît la capacité de la PCSK9 à induire la dégradation du LDLR. Le deuxième article dissèque davantage la structure de la PCSK9 et met en lumière la différence des prérequis structurels de la région ‘’Hinge’’ ainsi que du module M2, composant du domaine CHRD, dans la voie intracellulaire et la voie extracellulaire d’activité de la PCSK9. La mutation R434W localisée dans la région ‘’Hinge’’ résulte dans une inhibition totale de l’activité intracellulaire de la PCSK9 tandis que son activité extracellulaire est réduite à ~70%. Contrairement, la perte du module M2 du domaine CHRD est bien tolérée par la PCSK9 lors de son activité intracellulaire mais totalement inhibitrice pour son activité extracellulaire. Le troisième article se distingue en présentant une nouvelle stratégie d’inhibition de l’activité de la PCSK9 en utilisant une chimère composée de la fraction Fc de l’immunoglobuline IgG1 humaine couplée avec le prodomaine de la PCSK9. La protéine fusion Fcpro lie directement la PCSK9, crée un encombrement structurel qui résulte dans une régulation négative l’activité de la PCSK9. En résumé, nous présentons dans cette thèse, trois manuscrits qui apportent une contribution à la connaissance des composantes structurelles de la PCSK9 et leur implication dans le rôle de la protéine en tant que régulateur négatif du LDLR. / Hypercholesterolemia is one of the major risk factors leading to cardiovascular disease. In this context, we focused our study on a protein that directly influences hypercholesterolemia: PCSK9. Since 2003, the coding gene for PCSK9 has been identified as the third locus responsible for familial hypercholesterolemia (FH3). PCSK9 is a protein secreted mostly from the liver by hepatocytes and has the capacity to recognize, bind and direct to degradation the LDLR receptor. The latter is responsible for the elimination the LDL particles from the plasma. The direct consequence of the LDLR degradation induced by PCSK9 is the harmful accumulation of the bad cholesterol in the blood. Since PCSK9 activity has undesirable consequences on lipid metabolism homeostasis, we directed our research to characterize this protein to better understand its mechanism of action. Three domains compose PCSK9 structure and we focused on the ‘’structure-function study’’ of two domains, of which roles were still unknown: the prodomain located at the N-terminal extremity and the CHRD domain at the C-terminus of PCSK9. The first manuscript presented in this thesis brings to light the importance of the acidic N-terminal sequence of the prosegment (amino acids 33-58) and its effect on the activity of PCSK9. It also presents a novel mechanism for fine-tuning the activity of PCSK9, which is enhanced at acidic pHs close to those of late endosomes. The second manuscript dissects further the PCSK9 structure, revealing that the structural requirements of the hinge and the M2 module located in the CHRD domain are not the same for the intracellular and extracellular pathways of PCSK9-induced LDLR degradation. Although the R434W natural mutation in the hinge region is absolutely deleterious for the intracellular activity of PCSK9, it reduces by ~70% the extracellular one. In contrast, the loss of M2 module of the CHRD domain is tolerated for the intracellular activity of PCSK9 but not for the extracellular one. The third manuscript demonstrates for the first time that a chimera containing the prosegment (Fcpro) directly binds PCSK9 and effectively acts as a negative regulator (inhibitor) of its ability to induce LDLR degradation. Our work presents a new strategy to develop such inhibitors by interfering with the structure of PCSK9 and exploiting the properties of the PCSK9 prosegment and the advantage of its fusion to a humanized Fc of IgG1. In summary, the present research data sheds new light on the functional contribution of the prodomain and the CHRD domain of PCSK9.

Hábitos de vida saudáveis e uma dieta balanceada aliados ao alto consumo de frutas e vegetais, estão associados à prevenção de doenças e à manutenção da saúde. A maçã possui em sua composição compostos bioativos que podem agir na prevenção e no controle das dislipidemias. Tendo em vista a preocupação da Saúde Pública em encontrar uma fonte alternativa na redução das doenças cardiovasculares, esse trabalho teve como objetivo analisar a composição química da maçã, variedade Gala, e estudar os efeitos do seu consumo no ganho de peso, consumo alimentar, níveis sanguíneos de colesterol total, HDL-C, LDL-C, triglicerídeos, colesterol hepático e colesterol excretado em ratos Wistar hipercolesterolêmicos. Foram utilizados 6 animais em cada grupo de tratamento (controle, 5%, 15% e 25% de maçã na dieta) durante 30 e 60 dias. Foi observado neste estudo, quanto a composição centesimal da maçã, que uma maçã (200g), é capaz de fornecer 14,5% das recomendações de fibras totais e 55% de vitamina C, além de quantidades consideráveis de compostos fenólicos (0,38g/100g em base fresca) e tanino (0,16g/100g em base fresca). No ensaio biológico, os animais de ambos os tempos, apresentaram uma redução não significativa no ganho de peso e no consumo de dieta com o aumento das concentrações de maçã. Ao final de 30 dias, todas as dietas proporcionaram uma redução significativa (p &#8804; 0,05) nos níveis de triglicerídeos comparativamente ao grupo controle e não significativa com relação aos níveis de HDL-C. As dietas com 15% e 25% de maçã mostraram reduções significativas nos níveis sanguíneos de colesterol total e LDL-C e um aumento no teor de colesterol excretado em relação ao grupo controle. A dieta com 25% de maçã promoveu uma redução significativa nos níveis de colesterol hepático em comparação ao grupo controle. Aos 60 dias, os níveis sanguíneos de colesterol total, LDL-C, HDL-C e triglicerídeos de ratos alimentados com as dietas 5%, 15% e 25% de maçã foram semelhantes ao grupo controle.A partir desses resultados, pode-se concluir que a maçã Gala é um potente alimento no controle dirigido das dislipidemias em ratos. Uma dieta rica em verduras, legumes e frutas, inclusive a maçã, associado a um estilo de vida saudável, ao longo do tempo, podem ser considerados fundamentais na prevenção e redução do risco de doenças, principalmente as cardiovasculares. / Healthy life habits and an equilibrate diet, associated with a high fruit and vegetable intake, are joined with the prevention of diseases and health maintenance. The apple has in its composition bioactives compounds that can help in the prevention and control of hyperlipidemia. With the worry of Public Health to find an alternative source in the reduction of the cardiovasculars diseases, the objective of this work was to analyse the chemical composition of the Gala apple and to study the effects of its consumption in the gain of weigh, food intake, seric levels of total cholesterol, HDL-C, LDL-C, triglycerides, hepatic cholesterol and feces cholesterol in hypercholesterolemics Wistar rats. Six animals were distributed in each treatments (control, 5%, 15% and 25% apple diet) during 30 and 60 days. This study showed that one apple (200g) can provide 14,5% of the total fiber and 55% of the vitamin C within the recommendation, besides considerable quantities of phenolic compounds (0,38 g/100g wet weigh) and tannins (0,16 g/100g wet weigh). In the biological assay all the animals showed a non significative reduction in the gain of weigh and food intake with the increase of apple concentrations in the diets. At the end of 30 days, all the diets provided a significative reduction in the levels of tryglicerides comparable to the control group and non significative in relation to HDL-C levels. The 15% and 25% apple diets showed significatives reductions in the seric levels of total cholesterol and LDL-C and an increase in the level of feces cholesterol in relation to the control group. The 25% apple diet provided a significative reduction in the hepatic cholesterol levels comparable to the control group. After 60 days, the seric levels of total cholesterol, LDL-C, HDL-C and tryglicerides in rats fed with 5%, 15% and 25% apple diets were alike to the control group. These results confirm the importance of the Gala apple in the rats hyperlipidemia control. A diet rich in vegetables and fruits, including apple, associated with a healthy life habits, along the time, can be considered in the prevention and reduction against the risk of disease, mainly, the cardiovascular ones.

Os transportadores de membrana do tipo ATP Binding Cassette (ABC) e solute carriers (SLC) regulam a homeostase intracelular de fármacos, modificando a biodisponibilidade e possivelmente a eficácia terapêutica. A variabilidade na resposta a hipolipemiantes, como as vastatinas, tem sido associada a vários fatores genéticos e ambientais. Com a finalidade de avaliarmos os mecanismos de regulação da expressão dos transportadores pela atorvastatina, a expressão de RNAm de transportadores ABC (ABCB1, ABCG2 e ABCC2) e SLC (SLCO1B1, SLCO2B1 e SLC22A1) foi avaliada por RT-PCRq em células mononucleares do sangue periférico (CMSP) de 18 indivíduos normolipidêmicos (NL) e 22 pacientes hipercolesterolêmicos (HC) tratados com atorvastatina (10mg/dia/4 semanas). A possível associação entre o polimorfismo ABCB1 C3435T e a expressão de RNAm também foi avaliada. Os estudos in vitro foram realizados com as células das linhagens HepG2 e Caco-2. Foram avaliados os efeitos da atorvastatina na ativação de fatores de transcrição (NF-kappaB, NF-Y, c-jun, SP-1 e PXR) por ensaio de mobilidade eletroforética retardada em gel de poliacrilamida (EMSA) e na meia-vida do RNAm do gene ABCB1 por RT-PCRq, e a expressão e atividade funcional da proteína ABCB1 por Western blot, imunohistoquimica e citometria de fluxo. A proteina ABCB1 foi localizada por imunohistoquimica na membrana apical do canalículo biliar das celulas HepG2 e na membrana apical das Caco-2. O tratamento das células HepG2 com atorvastatina causou redução da expressão de RNAm do gene ABCB1 e aumento na expressão dos genes ABCG2 e ABCC2. Esses efeitos foram dose e tempo dependentes. O tratamento com atorvastatina das células Caco-2 não modificou a expressão dos transportadores de efluxo após 30 a 120 min. Nas células HepG2, as concentrações de 10 e 20 M de atorvastatina causaram diminuição da expressão de ABCB1 (0 &#181;M: 1,00 ± 0,06; 10 &#181;M: 0,69 ± 0,25, p< 0,05; 20 &#181;M: 0,69 ± 0,06, p< 0,05). A atividade da ABCB1, avaliada pelo efluxo de Rh123, mostrou-se estar reduzida em 41% nas células HepG2, após tratamento com atorvastatina 20 &#181;M. Embora a diminuição da expressão do ABCB1 não tenha sido decorrente de uma menor ativação transcricional, avaliada indiretamente por EMSA, estudos de mecanismos de regulação pós-transcricionais, revelaram que a atorvastatina diminui a estabilidade de RNAm do gene ABCB1. Esse resultado parece estar de acordo com o ocorrido nas CMSP, já que o tratamento com atorvastatina diminuiu a expressão de RNAm do gene ABCB1 nos indivíduos HC. Essa modulação, no entanto não está associada à presença do polimorfismo ABCB1 C3435T. Em relação aos transportadores de captação, a expressão do SLC22A1 nas células Caco-2 diminui após tratamento com atorvastatina por 30 min e não foi modificada nas células HepG2. Já o gene SLCO2B1 encontrou-se muito aumentado após 24 h de tratamento nas células HepG2. Estudos in vivo nas CMSP, mostrou que a expressão de mRNA basal dos transportadores nos HC foi 10 vezes maior que nos NL e diminuiu após tratamento com atorvastatina nos HC. Com os resultados obtidos podemos sugerir que diferenças no efeito da atorvastatina nos tipos celulares podem ser em decorrência da expressão tecido-específica de fatores de transcrição. No modelo de hepatócito, HepG2, a atorvastatina é um inibidor do transporte mediado pela ABCB1 e é capaz de diminuir a síntese e a função da ABCB1, via aumento da degradação de RNAm do gene ABCB1. Em conseqüência ocorre uma redução do efluxo pelo sistema biliar, causando aumento da concentração intracelular. Ainda, podemos concluir que em CMSP o colesterol pode ser o responsável pela modulação dos genes dos transportadores de membrana e que isso pode implicar em diferenças na eficácia da atorvastatina. / Specific membrane transporters have a significant impact on drug absorption and disposition. Most of them belong to two super-families, ABC (ATP-binding cassette) and SLC (solute-linked carrier). Statins are important therapeutic agents in the management of hypercholesterolemia, and considerable inter-individual variation exists in response to its therapy. The effects of atorvastatin expression of efflux (ABCG2 and ABCC2) and uptake (SLCO1B1, SLCO2B1 and SLC22A1) drug transporters were investigated by qPCR in Caco-2 and HepG2 cell lines and in peripheral blood mononuclear cells (PBMCs) of eighteen normolipidemic (NL) and twenty two hypercholesterolemic (HC) individuals treated with atorvastatin (10mg/day/4 weeks). The possible involvement of ABCB1 C3435T polymorphism in ABCB1 mRNA expression was also evaluated. In vitro studies with the cell lines HepG2 and Caco-2 were also performed. The effect of atorvastatin on the activation of the promoter of ABCB1 by transcription factors (NF-kappaB, NF-Y, c-jun, SP-1, and PXR) was evaluated by electrophoretic mobility shift assay (EMSA), and ABCB1 mRNA half-life were measured by PCRq. The expression and functional activity of ABCB1 were investigated by Western blot, imunohistochemistry and flow cytometry. Immunohystochemical analysis revealed that ABCB1 is located at the apical membrane of the bile canaliculi in HepG2, and in apical membrane of Caco-2 cells. Atorvastatin treatment of HepG2 cells caused a decreased in ABCB1 and an increase in ABCC2 and ABCG2 transcript levels. These effects were time and dose-dependent. Treatment of Caco-2 cells did not present any differences in efflux transporters mRNA levels. Treatment of HepG2 cells with 10 and 20 M atorvastatin caused a reduction on ABCB1 expression (0 &#181;M: 1,00 ± 0,06; 10 &#181;M: 0,69 ± 0,25, p< 0,05; 20 &#181;M: 0,69 ± 0,06, p< 0,05), and a 41% decrease in ABCB1-mediated efflux of Rhodamine123 (p < 0.01). Although reduced ABCB1 mRNA expression was not due to any repressor protein suppressing ABCB1 promoter activation, mRNA stability studies revealed that mRNA stability of ABCB1 was markedly decreased by atorvastatin treatment (2h versus 7h for control). In agrrement with these results, in PBMCs of HC individuals, atorvastatin treatment also reduced ABCB1 mRNA expression. However, the down-regulation was not associated with the presence of 3435T allele. For the uptake transporters, atorvastatin decreased SLC22A1 transcript levels after 30min-treatment and it was not regulated in HepG2. On the other hand, SLCO2B1 was up-regulated after 24h-treatment of HepG2 cells. In vivo studies with PBMCs revealed that during hypercholesterolemia all the drug transporters analyzed were increased almost 10-fold (p< 0.05), and after atorvastatin therapy the efflux and uptake transporters transcript levels were all down-regulated. These findings suggest that atorvastatin exhibits differential effects on mRNA expression of drug transporters depending on the cell type, which may be related to tissue-specific expression of transcription factors. Atorvastatin leads to decreased ABCB1 function and synthesis in HepG2 cells by increasing degradation of ABCB1 mRNA. Therefore, inhibition of ABCB1 may reduce atorvastatin elimination via bile, increasing its cellular concentrations. We also may suggest that in PBMCs cholesterol modulates mRNA expression of drug transporters, and this may contribute to the variability of response to atorvastatin.

Die autosomal-dominant vererbte Familiäre Hypercholesterinämie ist durch eine exzessive Erhöhung der LDL-Serumcholesterinspiegel gekennzeichnet und bedingt aufgrund einer prämaturen Atherosklerose den frühzeitigen Tod der Patienten. Da ursächlich ein defekter LDL-Rezeptor (LDL-R) zugrundeliegt, der durch Mutationen im Bereich des LDL-R-Gens hervorgerufen wird, kommt der Gentherapie als potentieller Behandlungsmöglichkeit ein besonderer Stellenwert zu. Diese Arbeit untersuchte den Einfluß einer Virusdosiseskalation auf Cholesterinsenkung und Langzeitexpression im adenoviral vermittelten LDL-R-Gentransferversuch im Kaninchenmodell. Hierfür wurden 7 Watanabe Heritable Hyperlipidemic Kaninchen, welche an einer vergleichbaren kongenitalen Hypercholesterinämie durch einen LDL-R-Defekt leiden, mit unterschiedlichen Dosierungen eines Adenovirus des Serotyps 5 therapiert, der die Gensequenz für den humanen LDL-R enthielt. Vor und nach Therapie wurden Bestimmungen der Serumcholesterinkonzentrationen und LDL-Stoffwechselkinetiken mit 125I-LDL sowie semiquantitative szintigraphische Auswertungen durch 111In-LDL-Scans durchgeführt. Hierbei mußte festgestellt werden, dass die adenoviral vermittelte transgene Expression des LDL-R durch die Bestimmung des Serumcholesterins nicht korrekt wiedergegeben wird. Denn zum einen konnte bei der Bestimmung des Serumcholesterins ein dosisabhängiger Effekt beobachtet werden, dieser zeigte sich bei den Stoffwechselkinetiken mit 125I-LDL und bei den Scanuntersuchungen mit 111-In-LDL jedoch nicht. Zum anderen kam es innerhalb von 12-18 Tagen nach Gentransfer zu einem Wiedererreichen der Serumcholesterinausgangswerte, wohingegen die in vivo-Stoffwechselkinetiken eine erhöhte Abbaurate radiomarkierter LDL und die Szintigraphie eine LDL-R-Expression über die gesamte Dauer des Experimentes von 120 Tagen belegten. / Familial hypercholesterolemia is an autosomal dominantly inherited disease characterized by an exzessive elevation of serum LDL cholesterol which leads to premature atherosclerosis and an early death of the patients. As the reason is a defective LDL receptor (LDLR) caused by mutations in the gene encoding LDLR, gene therapy plays an increasingly important role as a treatment possibility. This paper examined the influence of an escalation of the virus dose on the cholestorol reduction and long-term expression in the adenovirally mediated LDLR gene therapy experiment using a rabbit animal model. To facilitate this 7 Watanabe Heritable Hyperlipidemic rabbits, suffering from an equivalent congenital hypercholesterolemia due to a LDLR defect, were treated with different doses of a serotype 5 adenovirus which contained the gene sequence of the human LDLR. Pre and post gene therapy measurements of the serum cholesterol levels and kinetics of LDL metabolism with 125I-LDL were performed, as well as semiquantitative scintigraphic analysis of 111In-LDL scans. The finding was that the adenovirally mediated transgene expression of the LDLR was not correctly reflected by the measurement of the serum cholesterol levels. This was because of a dose dependant effect concerning the measurements of the serum LDL cholesterol levels, which did not appear regarding the kinetics of LDL metabolism with 125I-LDL and the scans with 111In-LDL. Moreover, the serum cholesterol levels reached their initial value within 12-18 days post gene transfer whilst the in vivo-kinetics of LDL metabolism showed an increased catabolic rate of radiolabeled LDL and the scintigraphy indicated a LDLR expression for the whole period of the experiment lasting 120 days.

A hipercolesterolemia familiar (HF) é uma alteração de origem genética comum que pode se manifestar clinicamente desde o nascimento e provoca um aumento nos níveis plasmáticos de LDL-colesterol (LDL-c), xantomas e doença coronária prematura. Sua detecção e tratamento precoce reduzem a morbidade e mortalidade coronária. A identificação e rastreamento em cascata familiar usando níveis de LDL-c e detecção genética é a estratégia mais aconselhável e rentável para descoberta de novos casos. O tratamento crônico com estatinas reduz o risco cardiovascular da população em geral, contudo, estudos clínicos com estatinas revelam risco cardiovascular residual mesmo após correção das concentrações de LDL-c. Com o surgimento de novas drogas e mais recentemente um inibidor da enzima pró-proteína convertase subtilisina/kexina tipo 9 (PCSK9), este estudo enfatizou na investigação específica para aqueles acometidos com defeitos genéticos nessa enzima, por ser de frequência ainda mais rara e pouco estudada, necessitando de melhor investigação na população em estudo a fim de rastrear a ocorrência de mutações patológicas na PCSK9. O objetivo desse estudo foi identificar e caracterizar mutações e/ou deleções patológicas no gene PCSK9 em pacientes com Hipercolesterolemia Familiar provenientes do Hospital das Clínicas de Ribeirão Preto da FMRP/USP selecionados para o teste genético. Foi feito o rastreamento de mutações pelo método Hight Resolution Melting (HRM), de forma prática, rápida e eficiente, onde mutações detectadas foram seqüenciadas. Foram identificadas 7 mutações não patogênicas, caracterizando que a população estudada não apresenta Hipercolesterolemia Familiar associada a mutações no gene PCSK9, fato que não exclui o diagnóstico por outros defeitos genéticas associados a doença. / Familial hypercholesterolemia (FH) is an alteration of common genetic origin that can manifest clinically from birth and which causes an increase in the LDL-cholesterol plasma levels (LDL-c), xanthomas and premature coronary disease. Its early detection and treatment reduce morbidity and coronary mortality. The identification and tracking in familial cascade using levels of LDL-c and genetic detection is the most advisable and profitable strategy to find new cases. The chronic treatment with statins reduces the cardiovascular risk in the population in general. However, clinic studies on statins show a residual cardiovascular risk even after the correction of LDL-c concentrations. With the appearance of new drugs and, more recently, of a proprotein convertase subtilisin/kexin type 9 enzyme inhibitor (PCSK9), this study highlighted the specific investigation for those stricken by genetic defects in this enzyme, once it is even rarer and understudied and needs further investigation in the study\'s population aiming at tracking the occurrence of a pathological mutation in the PCSK9. This study aimed at identifying and characterizing mutations and/or pathological deletions in the PCSK9 gene in patients with Familial Hypercholesterolemia from the RPMS/USP Ribeirão Preto Clinical Hospital which were selected for the genetic test. We performed the mutation tracking by using the High Resolution Melting (HRM) method in a practical, fast and efficient way, where the mutations detected were sequenced. We identified 7 non-pathogenic mutations, showing that the population studied does not present Familial Hypercholesterolemia associated to mutations in the PCSK9 gene, which doesn\'t exclude the diagnosis by other genetic defects associated to the disease.

Introdução: A Hipercolesterolemia Familiar (HF) é uma doença genética caracterizada clinicamente por elevados níveis de lipoproteína de baixa densidade (LDL-C) na corrente sanguínea desde a infância. Indivíduos que apresentam HF podem desenvolver doença aterosclerótica ainda em idade jovem. Os principais preditores de risco no desenvolvimento da doença cardiovascular (DCV) nesses indivíduos após entrarem em um programa de rastreamento genético não são conhecidos na nossa população. Além disso, a HF é subdiagnosticada e subtratada mundialmente e o rastreamento genético em cascata dos familiares tem sido mundialmente avaliado como o método diagnóstico mais custo. Contudo, a efetividade do rastreamento genético em cascata é dependente dos critérios clínicos de entrada do primeiro indivíduo da família e não há um consenso de qual critério apresenta a melhor acurácia para detecção de uma mutação. Objetivos: Identificar os fatores determinantes para ocorrência de eventos cardiovasculares (CV) em todos os indivíduos da coorte e avaliar o critério clínico para detecção de uma variante genética patogênica para HF, no primeiro indivíduo da família, após serem inseridos em um programa de rastreamento genético em cascata.Métodos: Estudo de coorte prospectiva aberta dos pacientes que foram inseridos no programa de rastreamento genético em cascata para HF. A população do estudo é definida como caso índice (CI), o primeiro da família a ser identificado clinicamente e encaminhado para o teste genético, e os familiares, que são os parentes de 1º grau do CI em que foi encontrada uma alteração genética. Todos os indivíduos são inseridos na coorte no momento em que recebem o laudo genético (tempo zero, T0). Um ano depois do T0 é realizado o primeiro contato telefônico, ou seja, primeiro ano de seguimento (T1) Resultados: No T1, o total de 818 indivíduos foi incluído, sendo verificados 47 eventos CV, sendo 14 (29,7%) fatais. Para o CI, o único fator independente associado ao aumento do risco de eventos CV no T1 foi a presença de arco corneano (OR: 9,39; IC 95%: 2,46-35,82). Para os familiares com uma mutação positiva os fatores associados ao aumento do risco de eventos CV foram diabetes mellitus (OR: 7,97; IC 95%: 2,07-30,66) e consumo de tabaco (OR: 3,70; IC 95%: 1,09-12,50). Na análise do melhor critério clínico para detecção de uma mutação patogênica no CI os valores de LDL-C >= 230 mg/dL tiveram a melhor relação entre sensibilidade e especificidade. Na análise da curva ROC o escore Dutch Lipid Clinic Network (DLCN) apresentou melhor desempenho do que o LDL-C para identificar uma mutação, a área sob a curva ROC foi 0,744 (IC 95%: 0,704-0,784) e 0,730 (IC 95%: 0,687-0,774), respectivamente, p = 0, 014. Conclusão: Em um ano de seguimento essa coorte identificou uma alta incidência de eventos CV após a entrada em um programa de rastreamento genético em cascata e os preditores dos eventos CV diferem entre CI e familiares. Esses resultados podem contribuir para o desenvolvimento de ações preventivas nesse grupo altamente susceptível de indivíduos. Além disso, devido a importância da detecção da mutação para um diagnóstico definitivo de HF e a importância da cascata ser custo efetiva o estudo identificou que o critério único do LDL-C >= 230 mg/dl é viável para indicar o CI para o teste genético / Introduction: Familial Hypercholesterolemia (FH) is a genetic disease characterized clinically by high levels of low density lipoprotein (LDL-C) in the bloodstream since childhood. Individuals with FH can develop atherosclerotic disease at a young age. The main predictors of cardiovascular disease (CVD) risk in these individuals after entering a genetic screening program are not known in our population. In addition, FH is underdiagnosed and undertreated worldwide and cascaded genetic screening of family members has been evaluated globally as the most cost effective for the diagnosis of FH. However, the effectiveness of cascading genetic screening is dependent on the clinical entry criteria of the first individual in the family and there is no consensus as to which criterion shows the best accuracy for detecting a mutation. Objectives: To identify the determinant factors for cardiovascular (CV) events in all individuals in the cohort and to evaluate the clinical criteria for detecting a genetic variant pathogenic to FH in the first individual of the family after being inserted into a genetic screening program in cascade. Methods: Open prospective cohort study of patients who were enrolled in the cascade genetic screening program for FH. The study population is defined as index case (IC), the first of the family to be clinically identified and referred to the genetic test, and relatives, who are the first-degree relatives of the IC in which a genetic alteration was found. All individuals are inserted into the cohort at the moment they receive the genetic report (time zero, T0). The first follow-up telephone contact is made one year after T0 (first year of follow-up, T1). Results: In T1, a total of 818 subjects were included, and 47 CV events were verified, of which 14 (29.7%) were fatal. For IC, the only factor independently associated with the increased risk of CV events in T1 was the presence of a corneal arch (OR: 9.39; 95% CI: 2.46-35.82). For relatives with positive mutation, factors associated with increased risk of CV events were diabetes mellitus (OR: 7.97; 95% CI: 2.07-30.66) and tobacco consumption (OR: 3.70; 95% CI: 1.09-12.50). In the analysis of the best clinical criteria for the detection of a pathogenic mutation in the IC, the LDL-C values >= 230 mg/dL had the best relationship between sensitivity and specificity. In the ROC curve analysis, the Dutch Lipid Clinic Network (DLCN) score performed better than LDL-C to identify a mutation, the area under the ROC curve was 0.744 (95% CI: 0.704-0.784) and 0.730 (CI 95 %: 0.687-0.774), respectively, p = 0.014. Conclusion: At one year follow-up this cohort identified a high incidence of CV events following entry into a cascade genetic screening program and the predictors of CV events differ between IC and family members. These results may contribute to the development of preventive actions in this group highly susceptible to individuals. In addition, because of the importance of detecting the mutation for a definitive diagnosis of HF and the importance of the cascade being cost effective, the study identified that the single LDL-C criterion >= 230 mg / dl is feasible to indicate IC for the genetic test