Anthony Rosenzweig, M.D.Coronary artery disease remains an enormous clinical problem,
affecting more than 15 million people in the United States alone,
where it is the most common cause of death (accounting for one
in three deaths).
1 The prevalence of coronary heart disease
is increasing at a particularly alarming rate in developing
nations, which are ill equipped to shoulder the associated economic
burden.
2,3 The clinical need this represents underscores the
importance of understanding the causes of coronary disease and
identifying persons at risk.
Much progress has been made toward these goals. We now recognize
many clinical risk factors — such as hyperlipidemia and
diabetes — and realize that they can induce an inflammatory
cascade marked by endothelial dysfunction, leukocyte recruitment,
and proliferation of smooth-muscle cells, ultimately culminating
in plaque formation.
4 The addition of thrombosis, plaque rupture,
or hemorrhage can lead to plaque instability and acute coronary
syndromes. This suggests that risk factors could, in theory,
affect primarily plaque formation or stability and in turn,
measures of plaque burden (such as coronary calcification) or
clinical events (such as myocardial infarction), respectively.
However, most factors identified to date have qualitatively
similar effects on both aspects of atherosclerosis.
he identification of genetic contributors to coronary disease
could provide more precise estimates of risk while defining
the pathways important in individual patients, revealing new
targets for intervention, and ultimately enabling a personalized
approach to care. These laudable goals have been elusive, since
numerous previous studies have reported associations of candidate
genes with diseases (including coronary disease) that were not
replicated.
6,7 In this issue of the
Journal, Samani et al.
8 have used a different approach — a genomewide association
study — to identify chromosomal loci associated with coronary
disease in two relatively large cohorts, from the Wellcome Trust
Case Control Consortium (WTCCC) study and the German MI [Myocardial
Infarction] Family Study. Although this work is still years
from enabling personalized coronary care or elucidating new
mechanisms, it provides important proof of concept for the power
of the genomewide approach and insight into the nature of genetic
coronary risk, while implicating several genetic loci not previously
linked to coronary disease.
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