Association of low-density lipoprotein cholesterol - Related genetic variants with aortic valve calcium and incident aortic stenosis

J. Gustav Smith, Kevin Luk, Christina Alexandra Schulz, James C. Engert, Ron Do, George Hindy, Gull Rukh, Line Dufresne, Peter Almgren, David S. Owens, Tamara B. Harris, Gina M. Peloso, Kathleen F. Kerr, Quenna Wong, Albert V. Smith, Matthew J. Budoff, Jerome I. Rotter, L. Adrienne Cupples, Stephen Rich, Sekar KathiresanMarju Orho-Melander, Vilmundur Gudnason, Christopher J. O'Donnell, Wendy S Post, George Thanassoulis

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Abstract

IMPORTANCE Plasma low-density lipoprotein cholesterol (LDL-C) has been associated with aortic stenosis in observational studies; however, randomized trials with cholesterol-lowering therapies in individuals with established valve disease have failed to demonstrate reduced disease progression.

OBJECTIVE To evaluate whether genetic data are consistent with an association between LDL-C, high-density lipoprotein cholesterol (HDL-C), or triglycerides (TG) and aortic valve disease.

DESIGN, SETTING, AND PARTICIPANTS Using a Mendelian randomization study design, we evaluated whether weighted genetic risk scores (GRSs), a measure of the genetic predisposition to elevations in plasma lipids, constructed using single-nucleotide polymorphisms identified in genome-wide association studies for plasma lipids, were associated with aortic valve disease. We included community-based cohorts participating in the CHARGE consortium (n = 6942), including the Framingham Heart Study (cohort inception to last follow-up: 1971-2013; n = 1295), Multi-Ethnic Study of Atherosclerosis (2000-2012; n = 2527), Age Gene/Environment Study-Reykjavik (2000-2012; n = 3120), and the Malmö Diet and Cancer Study (MDCS, 1991-2010; n = 28 461).

MAIN OUTCOMES AND MEASURES Aortic valve calcium quantified by computed tomography in CHARGE and incident aortic stenosis in the MDCS.

RESULTS The prevalence of aortic valve calcium across the 3 CHARGE cohorts was 32% (n = 2245). In the MDCS, over a median follow-up time of 16.1 years, aortic stenosis developed in 17 per 1000 participants (n = 473) and aortic valve replacement for aortic stenosis occurred in 7 per 1000 (n = 205). Plasma LDL-C, but not HDL-C or TG, was significantly associated with incident aortic stenosis (hazard ratio [HR] per mmol/L, 1.28; 95% CI, 1.04-1.57; P =.02; aortic stenosis incidence: 1.3% and 2.4% in lowest and highest LDL-C quartiles, respectively). The LDL-C GRS, but not HDL-C or TG GRS, was significantly associated with presence of aortic valve calcium in CHARGE (odds ratio [OR] per GRS increment, 1.38; 95% CI, 1.09-1.74; P =.007) and with incident aortic stenosis in MDCS (HR per GRS increment, 2.78; 95% CI, 1.22-6.37; P=.02; aortic stenosis incidence: 1.9% and 2.6% in lowest and highest GRS quartiles, respectively). In sensitivity analyses excluding variants weakly associated with HDL-C or TG, the LDL-C GRS remained associated with aortic valve calcium (P =.03) and aortic stenosis (P =.009). In instrumental variable analysis, LDL-C was associated with an increase in the risk of incident aortic stenosis (HR per mmol/L, 1.51; 95% CI, 1.07-2.14; P =.02).

CONCLUSIONS AND RELEVANCE Genetic predisposition to elevated LDL-C was associated with presence of aortic valve calcium and incidence of aortic stenosis, providing evidence supportive of a causal association between LDL-C and aortic valve disease. Whether earlier intervention to reduce LDL-C could prevent aortic valve disease merits further investigation.

Original languageEnglish (US)
Pages (from-to)1764-1771
Number of pages8
JournalJournal of the American Medical Association
Volume312
Issue number17
DOIs
StatePublished - Nov 5 2014

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ASJC Scopus subject areas

  • Medicine(all)

Cite this

Smith, J. G., Luk, K., Schulz, C. A., Engert, J. C., Do, R., Hindy, G., Rukh, G., Dufresne, L., Almgren, P., Owens, D. S., Harris, T. B., Peloso, G. M., Kerr, K. F., Wong, Q., Smith, A. V., Budoff, M. J., Rotter, J. I., Cupples, L. A., Rich, S., ... Thanassoulis, G. (2014). Association of low-density lipoprotein cholesterol - Related genetic variants with aortic valve calcium and incident aortic stenosis. Journal of the American Medical Association, 312(17), 1764-1771. https://doi.org/10.1001/jama.2014.13959