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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Panel A - baseline right carotid bulb &#40;long axis view&#41;&#59; Panel B - baseline focal intimal hyperplasia &#40;1&#46;0 mm - arrowhead&#41; of the left carotid bulb &#40;long axis view&#41;&#59; Panel C - 2 years&#8217; follow-up of the right carotid bulb with presence of eccentric calcified plaque &#40;1&#46;4 mm - long axis - yellow arrowheads&#59; short axis view - red arrowheads&#41;&#59; Panel D - 2 years follow-up of focal intimal hyperplasia &#40;1&#46;1 mm - arrowhead&#41; of the lest carotid bulb &#40;long axis view&#41;&#46; To note the we recorded a significant reduction in Doppler-derived coronary flow reserve &#40;from &#62;2&#46;00 to 1&#46;74&#41;&#46; Panel E - right coronary artery at CT coronary angiography with focal&#44; eccentric calcified plaques &#40;arrowheads&#41;&#59; Panel F - calcified eccentric plaque of the anterior descending artery of the left coronary artery &#40;arrowheads&#41;&#46; Agatson score 69&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LCCA&#58; left common carotid artery&#59; LICA&#58; left internal carotid artery&#59; RCCA&#58; right common carotid artery&#59; RICA&#58; right internal carotid artery&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Homozygous familial hypercholesterolemia &#40;HoFH&#41; is a rare disease &#40;OMM &#35;143890&#41; characterized by low-density lipoprotein cholesterol receptor gene mutations and progressive atherosclerosis&#44; leading to death before the age of 30 if not treated&#46; The high cardiovascular risk is hard to manage&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Fondazione Toscana Gabriele Monasterio is a cardiopulmonary tertiary-level Institute with 123 beds&#59; &#62;5000 hospital admissions per year&#44; a cath-lab hub for acute coronary syndrome&#44; adult and pediatric cardiac surgery center&#44; referral facility for heart failure&#44; primitive pulmonary hypertension patients and reference center for inherited dyslipidemias&#44; rare lipid disorders with lipoprotein apheresis unit&#41;&#44; HoFH clinical follow-up includes annually carotid artery ultrasound with intima-media thickness evaluation and stress echocardiography wall motion criteria with Doppler-derived coronary flow reserve of the mid-distal left anterior descending artery &#40;LAD&#41;&#46; This test is a valid tool for assessing inducible myocardial ischemia&#44; LAD stenosis&#44; and coronary microvascular dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In view of the availability of new lipid lowering therapy &#40;LLT&#41;&#44; their role in coronary plaque and heart valves calcification is a particularly intriguing issue&#46; HoFH represents per se a clinical model to assess these LLT interactions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Since 2013&#44; we have followed four siblings with compound heterozygotes for LDL-receptor gene mutations&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> All patients were asymptomatic for angina and&#47;or dyspnea&#44; a satisfactory lipid profile was obtained adding evolocumab to high-intensity statin therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> During follow-up&#44; two subjects developed significant coronary artery disease treated with percutaneous coronary revascularization while the 37-year old female twins presented&#44; on a dipyridamole stress echocardiography&#44; progressive CRF reduction and increased carotid calcification&#46; Both subjects underwent computed tomography coronary angiography with evidence of diffuse non-critical calcific atherosclerotic disease &#40;see <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Familial hypercholesterolemia shows altered endothelial function and reduced coronary vasodilatation capacity with subsequent coronary atherosclerosis due to vascular calcification&#46; While the role of lipoproteins is well characterized in the pathogenesis of atherosclerotic plaques&#44; their roles in plaque calcification are not well understood&#46; In the arterial intima calcification process it is assumed that a role of spotty early-stage calcification perpetuates the inflammatory cycle leading to plaque instability followed by plaque macrocalcification&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Statin therapy&#44; which reduces cardiovascular mortality&#44; has been shown to exert its dual actions on plaque morphology&#44; i&#46;e&#46;&#44; regression of atheroma and increment of macroscopic calcium deposits&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> while the PCSK9i effect is not univocal&#58; for evolocumab there is evidence of inverse correlation between changes in LDL cholesterol and coronary plaque calcification&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Meanwhile alirocumab has been able to progressively reduce carotid plaque lipid core increasing the plaque fibrous tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We decided to intensify the high-intensity statin therapy opting for rosuvastatin because&#44; compared to atorvastatin&#44; it might be more effective at reducing coronary atherosclerotic plaque volume&#44; even if there is a lack of long-term evidence on cardiovascular outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The cases reported herein underline the difficulty of managing patients at high risk to develop coronary heart disease as HoFH&#44; with respect to <span class="elsevierStyleItalic">&#8220;null receptor</span>&#8221; HoFH in which&#44; instead&#44; the lipoprotein apheresis treatment&#44; keep the patient free of cardiovascular events and allows the complete regression of lipid deposition&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding sources</span><p id="par0040" class="elsevierStylePara elsevierViewall">No financial support was received&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Panel A - baseline focal intimal hyperplasia &#40;1 mm - arrowhead&#41; of the right carotid bulb &#40;long axis view&#41;&#59; Panel B - baseline focal intimal hyperplasia &#40;1&#46;1 mm - arrowheads&#41; of the left carotid bulb &#40;long axis view&#41;&#59; Panel C - 2 years&#8217; follow-up of focal intimal hyperplasia &#40;1 mm - arrowhead&#41; of the right carotid bulb &#40;long axis view&#41;&#59; Panel D - 2 years follow-up with hyper-echogenicity and dimensional reduction &#40;0&#46;8 mm - arrowheads&#41; at left carotid bulb &#40;long axis view&#41;&#46; We recorded a significant reduction in Doppler-derived coronary flow reserve &#40;from 2&#46;57 to 1&#46;90&#41;&#46; Panel E - right coronary artery at CT coronary angiography with focal&#44; eccentric calcified plaques &#40;arrowheads&#41;&#59; Panel F - calcified eccentric plaque of the common trunk of the left coronary artery &#40;arrowhead&#41;&#59; Panel G - calcified eccentric plaque of the diagonal branch of the left coronary artery &#40;arrowheads&#41;&#46; Agatson score 93&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">LCCA&#58; left common carotid artery&#59; LECA&#58; left external carotid artery&#59; LICA&#58; left internal carotid artery&#59; RICA&#58; right internal carotid artery&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Panel A - baseline right carotid bulb &#40;long axis view&#41;&#59; Panel B - baseline focal intimal hyperplasia &#40;1&#46;0 mm - arrowhead&#41; of the left carotid bulb &#40;long axis view&#41;&#59; Panel C - 2 years&#8217; follow-up of the right carotid bulb with presence of eccentric calcified plaque &#40;1&#46;4 mm - long axis - yellow arrowheads&#59; short axis view - red arrowheads&#41;&#59; Panel D - 2 years follow-up of focal intimal hyperplasia &#40;1&#46;1 mm - arrowhead&#41; of the lest carotid bulb &#40;long axis view&#41;&#46; To note the we recorded a significant reduction in Doppler-derived coronary flow reserve &#40;from &#62;2&#46;00 to 1&#46;74&#41;&#46; Panel E - right coronary artery at CT coronary angiography with focal&#44; eccentric calcified plaques &#40;arrowheads&#41;&#59; Panel F - calcified eccentric plaque of the anterior descending artery of the left coronary artery &#40;arrowheads&#41;&#46; Agatson score 69&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LCCA&#58; left common carotid artery&#59; LICA&#58; left internal carotid artery&#59; RCCA&#58; right common carotid artery&#59; RICA&#58; right internal carotid artery&#46;</p>"
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RESEARCH LETTER
Paradoxical effect of lipid lowering therapy in homozygous familial hypercholesterolemia: Atherosclerotic plaque calcifications and increased cardiovascular events
Efeito paradoxal da terapêutica hipolipemiante em doentes com hipercolestrolemia familiar homozigótica: calcificações da placa aterosclerótica e eventos cardiovasculares acrescidos
Tiziana Sampietro, Francesco Sbrana
Autor para correspondência
francesco.sbrana@ftgm.it

Corresponding author.
, Federico Bigazzi, Beatrice Dal Pino
Lipoapheresis Unit - Reference Center for Diagnosis and Treatment of Inherited Dyslipidemias, Fondazione Toscana “Gabriele Monasterio”, Pisa, Italy
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HoFH clinical follow-up includes annually carotid artery ultrasound with intima-media thickness evaluation and stress echocardiography wall motion criteria with Doppler-derived coronary flow reserve of the mid-distal left anterior descending artery &#40;LAD&#41;&#46; This test is a valid tool for assessing inducible myocardial ischemia&#44; LAD stenosis&#44; and coronary microvascular dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In view of the availability of new lipid lowering therapy &#40;LLT&#41;&#44; their role in coronary plaque and heart valves calcification is a particularly intriguing issue&#46; HoFH represents per se a clinical model to assess these LLT interactions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Since 2013&#44; we have followed four siblings with compound heterozygotes for LDL-receptor gene mutations&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> All patients were asymptomatic for angina and&#47;or dyspnea&#44; a satisfactory lipid profile was obtained adding evolocumab to high-intensity statin therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> During follow-up&#44; two subjects developed significant coronary artery disease treated with percutaneous coronary revascularization while the 37-year old female twins presented&#44; on a dipyridamole stress echocardiography&#44; progressive CRF reduction and increased carotid calcification&#46; Both subjects underwent computed tomography coronary angiography with evidence of diffuse non-critical calcific atherosclerotic disease &#40;see <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Familial hypercholesterolemia shows altered endothelial function and reduced coronary vasodilatation capacity with subsequent coronary atherosclerosis due to vascular calcification&#46; While the role of lipoproteins is well characterized in the pathogenesis of atherosclerotic plaques&#44; their roles in plaque calcification are not well understood&#46; In the arterial intima calcification process it is assumed that a role of spotty early-stage calcification perpetuates the inflammatory cycle leading to plaque instability followed by plaque macrocalcification&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Statin therapy&#44; which reduces cardiovascular mortality&#44; has been shown to exert its dual actions on plaque morphology&#44; i&#46;e&#46;&#44; regression of atheroma and increment of macroscopic calcium deposits&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> while the PCSK9i effect is not univocal&#58; for evolocumab there is evidence of inverse correlation between changes in LDL cholesterol and coronary plaque calcification&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Meanwhile alirocumab has been able to progressively reduce carotid plaque lipid core increasing the plaque fibrous tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We decided to intensify the high-intensity statin therapy opting for rosuvastatin because&#44; compared to atorvastatin&#44; it might be more effective at reducing coronary atherosclerotic plaque volume&#44; even if there is a lack of long-term evidence on cardiovascular outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The cases reported herein underline the difficulty of managing patients at high risk to develop coronary heart disease as HoFH&#44; with respect to <span class="elsevierStyleItalic">&#8220;null receptor</span>&#8221; HoFH in which&#44; instead&#44; the lipoprotein apheresis treatment&#44; keep the patient free of cardiovascular events and allows the complete regression of lipid deposition&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding sources</span><p id="par0040" class="elsevierStylePara elsevierViewall">No financial support was received&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Panel A - baseline focal intimal hyperplasia &#40;1 mm - arrowhead&#41; of the right carotid bulb &#40;long axis view&#41;&#59; Panel B - baseline focal intimal hyperplasia &#40;1&#46;1 mm - arrowheads&#41; of the left carotid bulb &#40;long axis view&#41;&#59; Panel C - 2 years&#8217; follow-up of focal intimal hyperplasia &#40;1 mm - arrowhead&#41; of the right carotid bulb &#40;long axis view&#41;&#59; Panel D - 2 years follow-up with hyper-echogenicity and dimensional reduction &#40;0&#46;8 mm - arrowheads&#41; at left carotid bulb &#40;long axis view&#41;&#46; We recorded a significant reduction in Doppler-derived coronary flow reserve &#40;from 2&#46;57 to 1&#46;90&#41;&#46; Panel E - right coronary artery at CT coronary angiography with focal&#44; eccentric calcified plaques &#40;arrowheads&#41;&#59; Panel F - calcified eccentric plaque of the common trunk of the left coronary artery &#40;arrowhead&#41;&#59; Panel G - calcified eccentric plaque of the diagonal branch of the left coronary artery &#40;arrowheads&#41;&#46; Agatson score 93&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">LCCA&#58; left common carotid artery&#59; LECA&#58; left external carotid artery&#59; LICA&#58; left internal carotid artery&#59; RICA&#58; right internal carotid artery&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Panel A - baseline right carotid bulb &#40;long axis view&#41;&#59; Panel B - baseline focal intimal hyperplasia &#40;1&#46;0 mm - arrowhead&#41; of the left carotid bulb &#40;long axis view&#41;&#59; Panel C - 2 years&#8217; follow-up of the right carotid bulb with presence of eccentric calcified plaque &#40;1&#46;4 mm - long axis - yellow arrowheads&#59; short axis view - red arrowheads&#41;&#59; Panel D - 2 years follow-up of focal intimal hyperplasia &#40;1&#46;1 mm - arrowhead&#41; of the lest carotid bulb &#40;long axis view&#41;&#46; To note the we recorded a significant reduction in Doppler-derived coronary flow reserve &#40;from &#62;2&#46;00 to 1&#46;74&#41;&#46; Panel E - right coronary artery at CT coronary angiography with focal&#44; eccentric calcified plaques &#40;arrowheads&#41;&#59; Panel F - calcified eccentric plaque of the anterior descending artery of the left coronary artery &#40;arrowheads&#41;&#46; Agatson score 69&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LCCA&#58; left common carotid artery&#59; LICA&#58; left internal carotid artery&#59; RCCA&#58; right common carotid artery&#59; RICA&#58; right internal carotid artery&#46;</p>"
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                      "titulo" => "Plaque calcification&#58; do lipoproteins have a role&#63;"
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                          "etal" => false
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                            2 => "B&#46;A&#46; Di Bartolo"
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                        "fecha" => "2019"
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                      "titulo" => "Plaque calcification during atherosclerosis progression and regression"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
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                      "titulo" => "Effect of evolocumab on coronary plaque composition"
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                        0 => array:2 [
                          "etal" => true
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Regression in carotid plaque lipid content and neovasculature with PCSK9 inhibition&#58; a time course study"
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                        0 => array:2 [
                          "etal" => true
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                            0 => "N&#46;E&#46; Lepor"
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                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.atherosclerosis.2021.05.008"
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                        "fecha" => "2021"
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                      "titulo" => "Impact of rosuvastatin versus atorvastatin on coronary atherosclerotic plaque volume &#8211; a systematic review and meta-analysis with trial sequential analysis of randomized control trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Kumar"
                            1 => "M&#46; Shariff"
                            2 => "R&#46; Doshi"
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                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1177/2047487319868035"
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                        "tituloSerie" => "Eur J Prev Cardiol"
                        "fecha" => "2020"
                        "volumen" => "27"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Null receptor homozygous familial hypercholesterolaemia&#58; Quoad valetudinem long life treatment"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "T&#46; Sampietro"
                            1 => "F&#46; Sbrana"
                            2 => "F&#46; Bigazzi"
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                      ]
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                  ]
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