Genome Wide and Candidate Gene Studies in Cardiovascular Disease

Martin HersbergerDivision of Clinical Chemistry and Biochemistry

Global Risk Assessment for Cardiovascular Events in the Asymptomatic

Patient

Der Score dient der Schätzung des kardiovaskulären Gesamtrisikos für Männer und postmenopausale Frauen (inkl. Diabetiker Typ 1 ohne Endorganschäden), soweit sie nicht direkt den Risikokategorien «Sehr hohes Risiko»oder «Hohes Risiko» zugeordnet werden. Für prämenopausale Frauen ist der ermittelte Risikowert rund 4-mal zu hoch, so dass er korrigiert werden muss (dividiert durch 4).

Risk

for m

yoca

rdial

infar

ction

Strategies for the Prevention of Heart Disease

Intensivelife style change± drugs

10-20 % / 10 yearsIntermediary(15%)

Intensive, and global reduction ofrisk factors

>20 % / 10 yearsHigh(7.5%)

Life style change& control

<10 % / 10 yearsLow(77.5%)

Risk Intervention

ESC/EAS(high risk)

64.6

77.9

17.5

96.8

77.0

25.0

ATP III

34.5

91.1

21.9

95.1

87.3

10.6

ITF / IAS

35.7

94.5

32.0

95.3

90.5

7.5

Sensitivity (%)

Specificity (%)

Positive predictive value (%)

Negative predictive value (%)

Diagnostic efficacy (%)

Prevalence of treatmentrequiring persons (%)

Comparison of Methods for the Estimation of Global Coronary Risk in Middle Aged Men

Relative Risk for Death from CHD in Twinswhen One‘s Twin Died from Premature CHD

(N Engl J Med. 1994 Apr 14;330(15):1041-6)

Females Males Monozygotic twins

RR = 15 (n = 4012)

RR = 8.1 (N = 3298)

Dizygotic twins

RR = 2.6 (n = 7730)

RR = 3.8 (N = 5964)

Heritability of CHD Risk Factors inTwin Studies

(Heart 2013;99:373–375)

89Lp(a)

75Diabetes I & II52-55Physical activity74-83BMI48-53Blood pressure

66-77Total cholesterol51-69Triglycerides69-77LDL-C

69HDL-CHeritability (%)CAD risk factor

Number of Publications InvestigatingPolymorphisms Associated with CHD and MI

0

100200

300400

500

600700

80019

69

1976

1980

1983

1986

1989

1992

1995

1998

2001

2004

2007

2010

Meta-Analyses of PolymorphismsAssociated with CHD

(Atherosclerosis. 2009 Dec;207(2):492-5 / Circulation. 2001 Dec 18;104(25):3063-8 / Circulation. 2005 Jan 25;111(3):278-87 / Ann Intern Med. 2004 Jul 20;141(2):137-47 / Circulation. 2004 Mar 23;109(11):1359-65 / Heart. 2004 Jan;90(1):82-6 / Thromb Haemost. 1998 Dec;80(6):1029-30 )

1.30.12eNOS Glu298Asp

0.80.18CX3CR1 (fractalkine)

0.80.22COX2 G-765C

1.20.224G/5G PAI1

0.80.42CETP TaqIB

1.40.26Apo E4

1.20.47LDLR ins/del

1.10.04Factor V Leiden R506Q

1.20.02G20210A prothrombinOR for CHDFrequencyPolymorphism

ApoE is Associated with CAD Risk in a Meta-Analysis (n = 48‘457)

(Ann Intern Med. 2004 Jul 20;141(2):137-47)

0.98

1.42

0.9 8

1

0.5 1.5

Relative Risk

E4+

E2+

E3E3

E4+ genotype frequency: 26%

CHD Risk by ApoE Genotype and Smoking in theNorthwick Park Heart Study II (n=3052)

(Lancet (2001) 358: 115-119)

1.68

1.18

3.17

1

0 1 2 3 4 5

Relative Risk

E4+ [163/21]E2+ [98/5]E3E3 [367/5]

Smokers

Never smoked [727/32]

Genetic Risk Estimate Including 5 Functional SNPs to Predict CHD in the Northwick Park Heart

Study II (n=3052)(Clin Chem. 2007 Jan;53(1):8-16)

A set of 5 common SNPs with genotype frequencies >10% was used for this geneticrisk score (UCP2, APOE, LPL, and APOA4 )

∙ Conventional risk factors◆ Genetic risk factors

Combination showed significantimprovement over the CRF score

Additional imoprovement whengene-environment interactionsincluded

Meta-Analysis Genetic Risk Estimate to Predict CHD

(Ann Hum Genet. 2007 Sep;71(Pt 5):611-9)

Distribution in the Population OR for # of Risk Genotypes

A set of 10 common SNPs with meta-analysis risk estimates and genotypefrequencies >10% was used for this genetic risk score

(APOB, NOS3, APOE, ACE, PAI1, MTHFR, ITGA2B, PON1, LPL, and CETP)

GWAS for Cardiovascular Disease(Trends in Genetics June 2012, Vol. 28, No. 6)

Myocardial infarction Heart faillure

GWAS Identified Loci for CAD/MI with a Role in Lipipoprotein Metabolism

(Can J Cardiol. 2013 Jan;29(1):23-9)

LDL-CAPOE1.17 (1.08-1.28)0.18rs442063819q13

LDL-CLDLR1.18 (1.11-1.25)0.89rs651172019p13

LDL-C, BPSH2B31.07 (1.04-1.10)0.44rs318450412q24

APOC3

APOA1 Triglycerides, HDL-C

APOA5

1.13 (1.06-1.16)0.13rs96418411q23

TriglyceridesTRIB11.06 (1.03-1.10)0.53rs173215158q24

Lipoprotein (a)LPA1.68 (1.43-1.98)0.07rs104558726q26

Lipoprotein (a)LPA1.51 (1.33-1.70)0.02rs37892206q25.3

ABCG8 LDL-C

ABCG5

1.07 (1.04-1.11)0.32rs42993762p21

LDL-CSORT11.11 (1.08-1.15)0.78rs5998391p13

LDL-CPCSK91.08 (1.05-1.11)0.82rs112065101p32.3

Associatedlipoproteinphenotype

Genes of interestOR per risk allele mean (CI)Risk allele

freqLead SNPLocus

SORT1 and TRIB1 May be Involved in VLDL-Lipoprotein Secretion from the Liver

(J Lipid Res. 2011 Nov;52(11):1885-926)

GWAS Identified Loci for CAD/MI Associated with Risk Factors or Related Phenotypes

(Can J Cardiol. 2013 Jan;29(1):23-9)

Proliferative response to vascular injuryADAMTS71.08 (1.06-1.10)0.57rs382580715q25

Type IV collagen chain of basement membraneCOL4A1/A21.07 (1.05-1.09)0.44rs477314413q34

NT5C2

CNNM2Blood pressure,Intracranial aneurysms

CYP17A1

1.12 (1.08-1.16)0.89rs1241340910q24

Endothelial functionLIPA1.09 (1.07-1.12)0.42rs141244410q23

Attenuation of neutrophilmigrationCXCL12rs174640810q11

IL-6, E-selectinABO1.10 (1.07-1.13)0.21rs5794599q34

Coronary calcificationPHACTR11.10 (1.06-1.13)0.67rs125264536p24.1

Associated CV risk factorsor phenotypes

Genes of interest

OR per risk allele mean(CI)Risk allele freqLead SNPLocus

GWAS Identified Loci for CAD/MI Not Associated with Risk Factors or Related Phenotypes

(Can J Cardiol. 2013 Jan;29(1):23-9)

ANRIL, CDKN1, CDKN21.29 (1.23-1.36)0.46rs107572749p21.3

SLC5A3, MRPS5, KCNE21.18 (1.12-1.24)0.15rs998260121q22

UBE2Z1.06 (1.04-1.08)0.53rs4652217q21

SMG61.07 (1.05-1.09)0.37rs21617217p13

RASD1, PEMT, RAI11.07 (1.05-1.09)0.56rs1293658717p11

HHIPL11.07 (1.05-1.10)0.43rs289581114q32

PDGFD1.07 (1.04-1.09)0.32rs97481911q22

KIAA14621.07 (1.04-1.09)0.38rs250508310p11

ZC3HC11.09 (1.07-1.12)0.62rs115569247q32

BCAP29, DUS4L1.08 (1.05-1.11)0.8rs109535417q22

TCF211.08 (1.06-1.10)0.62rs121902876q23.2

C60rf1051.65 (1.44-1.90)0.07rs69039566p24.1

ANKS1A1.07 (1.05-1.10)0.75rs176099406p21.31

HLA-C, HLA-B1.140.55rs38691096p21.33

MRAS1.12 (1.07-1.16)0.18rs98188703q22.3

WDR12, NBEAL11.14 (1.09-1.19)0.15rs67258872q33.1

MIA31.14 (1.09-1.20)0.74rs174656371q41

PPAP2B1.17 (1.13-1.22)0.91rs171140361p32.2

Genes of interestOR per risk allele mean (CI)Risk allele freqLead SNPLocus

Consistent Association of 9p21 with CAD/MI(Circ Cardiovasc Genet 2010;3:475-483)

CARDIoGRAM: replication and meta-analysis study for GWAS in Europeanancestries with >22‘000 cases and >60‘000 controls

Risk Haplotypes at 9p21 are Located in ANRIL(Nature. 2011 Feb 10;470(7333):264-8)

Genes in regionANRIL (non-coding)CDKN2B

CAD T2D

Risk Haplotypes at 9p21 May Influence Enhancer Function of this Locus

(Nature. 2011 Feb 10;470(7333):264-8)

The Long Non-Coding mRNA ANRIL Represses CDKN2B Expression

(Cancer Res. 2011 Aug 15;71(16):5365-9)

CDKN2B

PRC: polycomb repressive complex

Risk

for m

yoca

rdial

infar

ction

Strategies for the Prevention of Heart Disease

Intensivelife style change± drugs

10-20%/10 yearsIntermediary(15%)

Intensive, and global reduction ofrisk factors>20%/10 yearsHigh

(7.5%)

Life style change& control

<10%/10 yearsLow(77.5%)

No Major Improvement of Cardiovascular Risk Prediction Through Inclusion of 9p21

(Arterioscler Thromb Vasc Biol. 2012 Feb;32(2):196-206)

CARDIoGRAM: replication and meta-analysis study for GWAS in Europeanancestries with >22‘000 cases and >60‘000 controls

Prospective 2-Stage Risk Screening Strategy for Coronary Heart Disease (n=24‘124)

(Arterioscler Thromb Vasc Biol. 2013 Sep;33(9):2261-6)

28 genetic variants previouslyassociated with CHD in GWAS used to build the genetic riskscore (GRS)

Prospective 2-Stage Risk Screening Strategy for Coronary Heart Disease (n=24‘124)

(Arterioscler Thromb Vasc Biol. 2013 Sep;33(9):2261-6)

Targeted GRS screeningof clinically relevant riskgroup (10%–20%) wouldreclassify 12% in theintermediate- to high-riskcategory

Statin allocation forreclassified individuals(2144) could prevent 135 CHD cases over14 years

Mendelian Randomisation Studies Compared to a Randomised Intervention Trial

(BMJ 2012;345:bmj.e7325)

Mendelian Randomisation Studies to Show Causality of an Intermediate Risk Factor

(TCM Vol. 19, No. 6, 2009)

Genetic variationat the LDLR locus

IncreasedLDL levels

Coronaryheart disease

YES

Intermediate phenotype Disease

Circulating CRP is not a Causal Factor in CHD: Mendelian Randomisation Meta-Analysis

(n=194 ‘418)(BMJ 2012;345:bmj.e7325)

NO

Genetic variationat the CRP locus

IncreasedCRP levels

Coronaryheart disease

Intermediate phenotype Disease

Other risk factorsEnvironment

Mendelian Randomisation Studies forCHD Risk Factors

(Hypertension. 2013 May;61(5):987-94 / PLoS One. 2008 Aug 20;3(8):e2986 / Lancet. 2012 Mar 31;379(9822):1214-24 / Lancet. 2012 Aug 11;380(9841):572-80 / Lancet. 2010 May 8;375(9726):1634-9 / N

Engl J Med 2009; 361: 2518–28 / J Clin Endocrinol Metab. 2012 Feb;97(2):E248-56 / BMJ. 2011 Feb 15;342:d548 / JACC Vol. 62, No. 21, 2013 / Circulation. 2013 Sep 17;128(12):1310-24 )

NoFibrinogenFibrinogenNoCRPCRPYesIL-6R signalingIL-6R

YesHypertensionHypertension GRS

NosPLA2sPLA2

NoHDLEndothelial LipaseNoHDLApoA1

NoHDLLCAT

YesLp(a)Lp(a)YesTriglyceridesApoA5

YesLDLLDLR

Intermediate phenotypecausal for CHD

Intermediatephenotype

Polymorphism in gene

12/15-LOX: Janus Enzymes(Prostaglandins Leukot Essent Fatty Acids. 2007 Aug;77(2):67-77)

Lipoxins,12-HETE, 15-HETE,

13-HODE

12-HETE, 15-HETE, 13-HODE

Ox-LDL formation

Increased angiotensin II

signalling

Anti-inflammatory

mediators

ANTIANTI--

Increased monocyteadhesion

Activity of recombinant proteins from E. coli

ALOX15 c.1693C>T (Met560Thr) Abolishes ALOX15 Activity

(Atherosclerosis. 2008 May;198(1):136-44)

Association of ALOX15 c.1693C>T(Met560Thr) with CAD

(Atherosclerosis. 2009 Jul;205(1):192-6 / Atherosclerosis. 2008 May;198(1):136-44)

ADVANCE (n = 3169) OR p-valueALOX15 Met560Thr 1.62 0.02

MAF: 8 % in Hispanics, 1.2 % in Caucasians and absent in East Asians

ARIC (n = 11567) OR p-valueALOX15 Met560Thr 1.31 0.06

Case-control: symptomatic early onset CAD, older subjects presentingwith stable angina or AMI

Prospective: AMI, coronary artery bypass surgery, unstable angina, orcoronary-related death

KORA (n = 2629) OR p-valueALOX15 Met560Thr 1.73 0.06Case-control for MI

ConclusionsRisk prediction using the GWAS SNPs or meta-analysis genetic risk estimates for functional SNPs may improve risk prediction for CHD or MI above the traditional risk factors in the future

The GWAS SNPs explain 10%-25% of the genetic risk for cardiovasculardisease and intermediate phenotypes

GWAS identified several loci associated with CAD or MI which encodegenes or enhancers not previously implicated with atherosclerosis

Novel targets for drug intervention will eventually emerge from the GWAS studies

Mendelian randomisation studies seem powerful in dissecting causality of an intermediate phenotype with CAD

Association of functional polymorphisms with CAD can dissect the role of genes with no intermediate phenotype

Prof. Dr. Armin MosandlDr. Mathias Bayer

Johann Wolfgang GoetheUniversity Frankfurt am MainInstitute of Food Chemistry

Prof. Dr. Thomas F. LüscherPD Dr. Jörg Muntwyler

University of ZurichCardiovascular Center Division of Cardiology

In Collaboration with …

Prof. Dr. I. HeidProf. Dr. Th. Illig

GSF - National Research Center for Environment and Health MunichInstitute of Epidemiology

Prof. Dr. F. Kronenberg

University of InnsbruckDivision of Genetic Epidemiology

C. GemperleDr. M. HerovaJ. Marti-JaunM. SchmidM. RösingerDr. V. WaechterA. WeberDr. A. WeissDr. J. WittwerDr. S. Wüst

University Children’s Hospital ZurichClinical Chemistry and Biochemistry

Besten Dank für Ihre Aufmerksamkeit!