Familial Combined Hypolipidemia

Synonyms: Angiopoietin-Like Protein 3 (ANGPTL3) Deficiency, Familial Combined Hypobetalipoproteinemia Type 2 (FHBL2)

Burnett JR, Hooper AJ, Hegele RA.

Publication Details

Estimated reading time: 13 minutes

Summary

Clinical characteristics.

Familial combined hypolipidemia is not associated with any pathologic signs or symptoms; diagnosis is suggested by low plasma concentrations of lipids. The lipid profile is one of hypocholesterolemia with low plasma low-density lipoprotein (LDL) cholesterol, low plasma high-density lipoprotein (HDL) cholesterol, low plasma triglycerides, and low plasma apolipoprotein (apo) B and apo A-I levels.

Diagnosis/testing.

The molecular diagnosis of familial combined hypolipidemia is established in a proband with suggestive laboratory findings and biallelic pathogenic variants in ANGPTL3 identified by molecular genetic testing.

Management.

No specific evaluation, management, or surveillance is required for individuals who have familial combined hypolipidemia; however, consultation with a medical geneticist, certified genetic counselor, or certified advanced genetic nurse to inform affected individuals and their families about the nature, mode of inheritance, and lack of specific clinical implications of familial combined hypolipidemia should be considered.

Genetic counseling.

Familial combined hypolipidemia is inherited in an autosomal recessive manner. At conception, each sib of a person with FCH has a 25% chance of also having FCH, a 50% chance of being a heterozygous carrier, and a 25% chance of being unaffected and not a carrier. Heterozygotes for ANGPTL3 loss-of-function pathogenic variants have mildly reduced LDL cholesterol and triglyceride levels, and protection against atherosclerotic cardiovascular disease. Carrier testing for at-risk relatives is possible if the pathogenic ANGPTL3 pathogenic variants in the family are known. Prenatal and preimplantation genetic testing are also possible, but given the lack of clinical symptoms in most individuals who have FCH, this is not commonly pursued.

Diagnosis

Suggestive Findings

Familial combined hypolipidemia should be suspected in individuals with the following laboratory findings and family history.

Laboratory findings *

  • Hypocholesterolemia with a total cholesterol of 1.9 ± 0.5 mmol/L (1.3-2.8)
  • Low plasma low-density lipoprotein (LDL) cholesterol of 1.3 ± 0.6 mmol/L (0.5-1.4)
  • Low plasma high-density lipoprotein (HDL) cholesterol of 0.6 ± 1.3 mmol/L (0.3-1.2)
  • Low plasma triglycerides of 0.4 ± 0.1 mmol/L (0.2-0.7)
  • Low plasma apolipoprotein (apo) B of 0.5 ± 0.1 g/L (0.3-0.7)
  • Low plasma apo A-I of 0.7 ± 0.2 mmol/L (0.4-1.1)

* Data reported are mean ± standard deviation (range) [Minicocci et al 2013].

Family history is consistent with autosomal recessive inheritance (e.g., affected sibs and/or parental consanguinity). Absence of a known family history does not preclude the diagnosis.

Note: Heterozygous individuals who have one ANGPTL3 pathogenic variant ("carriers") often have lipid profiles that are intermediate between the general population and individuals with biallelic pathogenic variants in ANGPTL3.

Establishing the Diagnosis

The molecular diagnosis of familial combined hypolipidemia is established in a proband with suggestive laboratory findings and biallelic pathogenic (or likely pathogenic) variants in ANGPTL3 identified by molecular genetic testing (see Table 1).

Note: (1) Per ACMG/AMP variant interpretation guidelines, the terms "pathogenic variant" and "likely pathogenic variant" are synonymous in a clinical setting, meaning that both are considered diagnostic and can be used for clinical decision making [Richards et al 2015]. Reference to "pathogenic variants" in this section is understood to include likely pathogenic variants. (2) Identification of biallelic ANGPTL3 variants of uncertain significance (or of one known ANGPTL3 pathogenic variant and one ANGPTL3 variant of uncertain significance) does not establish or rule out the diagnosis.

Molecular genetic testing approaches can include a combination of gene-targeted testing (single-gene testing, multigene panel) and comprehensive genomic testing (exome sequencing, genome sequencing) depending on the phenotype.

Gene-targeted testing requires that the clinician determine which gene(s) are likely involved, whereas genomic testing does not. Individuals with the distinctive laboratory findings described in Suggestive Findings are likely to be diagnosed using gene-targeted testing (see Option 1), whereas those with a phenotype indistinguishable from many other inherited disorders with abnormal lipid profiles are more likely to be diagnosed using genomic testing (see Option 2).

Option 1

When the lipid laboratory findings suggest the diagnosis of familial combined hypolipidemia, molecular genetic testing approaches can include single-gene testing or use of a multigene panel.

  • Single-gene testing. Sequence analysis of ANGPTL3 is performed first to detect missense, nonsense, and splice site variants and small intragenic deletions/insertions. Note: Depending on the sequencing method used, single-exon, multiexon, or whole-gene deletions/duplications may not be detected. If only one or no variant is detected by the sequencing method used, the next step is to perform gene-targeted deletion/duplication analysis to detect exon and whole-gene deletions or duplications.
  • A hypolipidemia, dyslipidemia, or lipoprotein disorders multigene panel that includes ANGPTL3 and other genes of interest (see Differential Diagnosis) is most likely to identify the genetic cause of the condition while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview. (3) In some laboratories, panel options may include a custom laboratory-designed panel and/or custom phenotype-focused exome analysis that includes genes specified by the clinician. (4) Methods used in a panel may include sequence analysis, deletion/duplication analysis, and/or other non-sequencing-based tests.
    For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.

Option 2

When the diagnosis of familial combined hypolipidemia has not been considered because an individual has atypical laboratory findings, then genomic testing may be considered.

Comprehensive genomic testing does not require the clinician to determine which gene is likely involved. Exome sequencing is most commonly used; genome sequencing is also possible.

For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.

Table Icon

Table 1.

Molecular Genetic Testing Used in Familial Combined Hypolipidemia

Clinical Characteristics

Clinical Description

To date, approximately 30 individuals from a small number of families have been identified with biallelic pathogenic variants in ANGPTL3 [Musunuru et al 2010, Minicocci et al 2012, Noto et al 2012, Pisciotta et al 2012, Minicocci et al 2016, Tikkanen et al 2019]. The following description of the phenotypic features associated with this condition is based on these reports.

Familial combined hypolipidemia is not associated with any pathologic signs or symptoms, and diagnosis is suggested by low plasma concentrations of lipids. Using a mendelian randomization approach, familial combined hypolipidemia has been associated with a reduced risk of atherosclerotic cardiovascular disease [Dewey et al 2017, Stitziel et al 2017]; however, the effect of functionally deficient ANGPTL3 protein on atherosclerosis burden has not been systematically investigated. In contrast to APOB-related familial hypobetalipoproteinemia, the prevalence of hepatic steatosis in familial combined hypolipidemia does not differ from that of the general population [Di Costanzo et al 2017].

Genotype-Phenotype Correlations

No genotype-phenotype correlations for familial combined hypolipidemia have been identified.

Prevalence

The prevalence of familial combined hypolipidemia is not known, but it appears to be very rare; approximately 30 individuals have been reported in the literature. However, the condition is probably underdiagnosed, as in the absence of a clinical phenotype, many clinicians fail to follow up on low plasma lipid levels.

Differential Diagnosis

Table Icon

Table 2.

Genes of Interest in the Differential Diagnosis of Familial Combined Hypolipidemia

Population- and clinic-based studies of individuals with marked hypocholesterolemia have shown that of those without a known monogenic cause, a significant proportion are genetically predisposed to low LDL cholesterol, suggesting a polygenic cause for hypocholesterolemia [Balder et al 2018, Blanco-Vaca et al 2019, Rimbert et al 2021, Cefalù et al 2022]. However, HDL cholesterol levels would generally be normal in this setting.

Acquired conditions that may present with laboratory findings similar to those of familial combined hypolipidemia include intestinal fat malabsorption disorders, severe liver disease, chronic pancreatitis, malnutrition, and hyperthyroidism.

Management

No clinical practice guidelines for familial combined hypolipidemia have been published.

No specific evaluation, management, or surveillance is required for individuals who have familial combined hypolipidemia [Bredefeld et al 2022].

Consultation with a medical geneticist, certified genetic counselor, or certified advanced genetic nurse to inform affected individuals and their families about the nature, mode of inheritance, and lack of specific clinical implications of familial combined hypolipidemia should be considered

Evaluation of Relatives at Risk

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Genetic Counseling

Genetic counseling is the process of providing individuals and families with information on the nature, mode(s) of inheritance, and implications of genetic disorders to help them make informed medical and personal decisions. The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members; it is not meant to address all personal, cultural, or ethical issues that may arise or to substitute for consultation with a genetics professional. —ED.

Mode of Inheritance

Familial combined hypolipidemia is inherited in an autosomal recessive manner.

Risk to Family Members

Parents of a proband

  • The parents of an affected individual are presumed to be heterozygous for an ANGPTL3 pathogenic variant.
  • Molecular genetic testing should be considered for the parents of the proband to confirm that both parents are heterozygous for an ANGPTL3 pathogenic variant and to allow reliable recurrence risk assessment.
  • If a pathogenic variant is detected in only one parent and parental identity testing has confirmed biological maternity and paternity, it is possible that one of the pathogenic variants identified in the proband occurred as a de novo event in the proband or as a postzygotic de novo event in a mosaic parent [Jónsson et al 2017]. If the proband appears to have homozygous pathogenic variants (i.e., the same two pathogenic variants), additional possibilities to consider include:
    • A single- or multiexon deletion in the proband that was not detected by sequence analysis and that resulted in the artifactual appearance of homozygosity;
    • Uniparental isodisomy for the parental chromosome with the pathogenic variant that resulted in homozygosity for the pathogenic variant in the proband.
  • Heterozygotes for ANGPTL3 loss-of-function pathogenic variants have mildly reduced LDL cholesterol and triglyceride levels, and protection against atherosclerotic cardiovascular disease [Stitziel et al 2017].

Sibs of a proband

  • If both parents are known to be heterozygous for an ANGPTL3 pathogenic variant, each sib of an affected individual has at conception a 25% chance of being affected, a 50% chance of being heterozygous, and a 25% chance of inheriting neither of the familial pathogenic variants.
  • Heterozygotes for ANGPTL3 loss-of-function pathogenic variants have mildly reduced LDL cholesterol and triglyceride levels, and protection against atherosclerotic cardiovascular disease [Stitziel et al 2017].

Offspring of a proband. Unless an affected individual's reproductive partner also has familial combined hypolipidemia or is heterozygous for an ANGPTL3 loss-of-function variant, offspring will be obligate heterozygotes for an ANGPTL3 pathogenic variant.

Other family members. Each sib of the proband's parents is at a 50% risk of being heterozygous for an ANGPTL3 pathogenic variant.

Heterozygote Detection

Heterozygote testing for at-risk relatives requires prior identification of the ANGPTL3 pathogenic variants in the family.

Related Genetic Counseling Issues

Family planning

  • The optimal time for determination of genetic risk and discussion of the availability of prenatal/preimplantation genetic testing is before pregnancy.
  • It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected, are heterozygotes, or are at risk of being carriers.

Prenatal Testing and Preimplantation Genetic Testing

Once the ANGPTL3 pathogenic variants have been identified in an affected family member, prenatal and preimplantation genetic testing are possible.

Differences in perspective may exist among medical professionals and within families regarding the use of prenatal testing. While most centers would consider use of prenatal testing to be a personal decision, discussion of these issues may be helpful.

Resources

GeneReviews staff has selected the following disease-specific and/or umbrella support organizations and/or registries for the benefit of individuals with this disorder and their families. GeneReviews is not responsible for the information provided by other organizations. For information on selection criteria, click here.

Molecular Genetics

Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.

Table Icon

Table A.

Familial Combined Hypolipidemia: Genes and Databases

Table Icon

Table B.

OMIM Entries for Familial Combined Hypolipidemia (View All in OMIM)

Molecular Pathogenesis

Angiopoietin-related protein 3 (ANGPTL3) is a regulatory protein secreted by the liver that modulates plasma triglycerides [Kersten 2017]. It inhibits lipoprotein lipase, the enzyme responsible for the hydrolysis of triglycerides within circulating triglyceride-rich lipoproteins, namely, chylomicrons and very low-density lipoproteins. Homozygous or compound heterozygous loss-of-function ANGPTL3 pathogenic variants are associated with higher lipoprotein lipase activity and mass, with the enhanced lipolysis associated with markedly reduced plasma LDL cholesterol, HDL cholesterol, and triglyceride concentrations [Tarugi et al 2019, Arca et al 2020, Bredefeld et al 2022]. Cell models have shown ANGPTL3 silencing or deletion is associated with elevated LDL receptor expression and LDL uptake and reduced nascent apo B-100 secretion [Xu et al 2018].

A gene-dosage effect can be observed such that heterozygotes for ANGPTL3 loss-of-function pathogenic variants have mildly reduced LDL cholesterol and triglyceride levels, and protection against atherosclerotic cardiovascular disease [Stitziel et al 2017].

Mechanism of disease causation. Loss of function

Chapter Notes

Acknowledgments

RAH is supported by the Jacob J Wolfe Distinguished Medical Research Chair, the Edith Schulich Vinet Research Chair, and the Martha G Blackburn Chair in Cardiovascular Research. RAH holds operating grants from the Canadian Institutes of Health Research (Foundation award), the Heart and Stroke Foundation of Ontario.

Revision History

  • 20 July 2023 (ma) Review posted live
  • 28 November 2022 (jb) Original submission

References

Literature Cited

  • Arca M, D'Erasmo L, Minicocci I. Familial combined hypolipidemia: angiopoietin-like protein 3 deficiency. Curr Opin Lipidol. 2020;31:41–8. [PubMed: 32022755]

  • Balder JW, Rimbert A, Zhang X, Viel M, Kanninga R, van Dijk F, Lansberg P, Sinke R, Kuivenhoven JA. Genetics, lifestyle, and low-density lipoprotein cholesterol in young and apparently healthy women. Circulation. 2018;137:820–31. [PubMed: 29459468]

  • Blanco-Vaca F, Martin-Campos JM, Beteta-Vicente Á, Canyelles M, Martínez S, Roig R, Farré N, Julve J, Tondo M. Molecular analysis of APOB, SAR1B, ANGPTL3, and MTTP in patients with primary hypocholesterolemia in a clinical laboratory setting: evidence supporting polygenicity in mutation-negative patients. Atherosclerosis. 2019;283:52–60. [PubMed: 30782561]

  • Bredefeld C, Hussain MM, Averna M, Black DD, Brin MF, Burnett JR, Charrière S, Cuerq C, Davidson NO, Deckelbaum RJ, Goldberg IJ, Granot E, Hegele RA, Ishibashi S, Karmally W, Levy E, Moulin P, Okazaki H, Poinsot P, Rader DJ, Takahashi M, Tarugi P, Traber MG, Di Fillippo M, Peretti N. Guidance for the diagnosis and treatment of hypolipidemia disorders. J Clin Lipidol. 2022;16:797–812. [PubMed: 36243606]

  • Cefalù AB, Spina R, Noto D, Rabacchi C, Giammanco A, Simone ML, Brucato F, Scrimali C, Gueli-Alletti MG, Barbagallo CM, Tarugi P, Averna MR. Comparison of two polygenic risk scores to identify non-monogenic primary hypocholesterolemias in a large cohort of Italian hypocholesterolemic subjects. J Clin Lipidol. 2022;16:530–7. [PubMed: 35589500]

  • Cohen J, Pertsemlidis A, Kotowski IK, Graham R, Garcia CK, Hobbs HH. Low LDL cholesterol in individuals of African descent resulting from frequent nonsense mutations in PCSK9. Nat Genet. 2005;37:161–5. [PubMed: 15654334]

  • Dewey FE, Gusarova V, Dunbar RL, O'Dushlaine C, Schurmann C, Gottesman O, McCarthy S, Van Hout CV, Bruse S, Dansky HM, Leader JB, Murray MF, Ritchie MD, Kirchner HL, Habegger L, Lopez A, Penn J, Zhao A, Shao W, Stahl N, Murphy AJ, Hamon S, Bouzelmat A, Zhang R, Shumel B, Pordy R, Gipe D, Herman GA, Sheu WHH, Lee IT, Liang KW, Guo X, Rotter JI, Chen YI, Kraus WE, Shah SH, Damrauer S, Small A, Rader DJ, Wulff AB, Nordestgaard BG, Tybjærg-Hansen A, van den Hoek AM, Princen HMG, Ledbetter DH, Carey DJ, Overton JD, Reid JG, Sasiela WJ, Banerjee P, Shuldiner AR, Borecki IB, Teslovich TM, Yancopoulos GD, Mellis SJ, Gromada J, Baras A. Genetic and pharmacologic inactivation of ANGPTL3 and cardiovascular disease. N Engl J Med. 2017;377:211–21. [PMC free article: PMC5800308] [PubMed: 28538136]

  • Di Costanzo A, Di Leo E, Noto D, Cefalù AB, Minicocci I, Polito L, D'Erasmo L, Cantisani V, Spina R, Tarugi P, Averna M, Arca M. Clinical and biochemical characteristics of individuals with low cholesterol syndromes: a comparison between familial hypobetalipoproteinemia and familial combined hypolipidemia. J Clin Lipidol. 2017;11:1234–42. [PubMed: 28733173]

  • Jónsson H, Sulem P, Kehr B, Kristmundsdottir S, Zink F, Hjartarson E, Hardarson MT, Hjorleifsson KE, Eggertsson HP, Gudjonsson SA, Ward LD, Arnadottir GA, Helgason EA, Helgason H, Gylfason A, Jonasdottir A, Jonasdottir A, Rafnar T, Frigge M, Stacey SN, Th Magnusson O, Thorsteinsdottir U, Masson G, Kong A, Halldorsson BV, Helgason A, Gudbjartsson DF, Stefansson K. Parental influence on human germline de novo mutations in 1,548 trios from Iceland. Nature. 2017;549:519–22. [PubMed: 28959963]

  • Kersten S. Angiopoietin-like 3 in lipoprotein metabolism. Nat Rev Endocrinol. 2017;13:731–9. [PubMed: 28984319]

  • Minicocci I, Montali A, Robciuc MR, Quagliarini F, Censi V, Labbadia G, Gabiati C, Pigna G, Sepe ML, Pannozzo F, Lütjohann D, Fazio S, Jauhiainen M, Ehnholm C, Arca M. Mutations in the ANGPTL3 gene and familial combined hypolipidemia: a clinical and biochemical characterization. J Clin Endocrinol Metab. 2012;97:E1266–75. [PMC free article: PMC5393441] [PubMed: 22659251]

  • Minicocci I, Santini S, Cantisani V, Stitziel N, Kathiresan S, Arroyo JA, Marti G, Pisciotta L, Noto D, Cefalù AB, Maranghi M, Labbadia G, Pigna G, Pannozzo F, Ceci F, Ciociola E, Bertolini S, Calandra S, Tarugi P, Averna M, Arca M. Clinical characteristics and plasma lipids in subjects with familial combined hypolipidemia: a pooled analysis. J Lipid Res. 2013;54:3481–90. [PMC free article: PMC3826694] [PubMed: 24058201]

  • Minicocci I, Tikka A, Poggiogalle E, Metso J, Montali A, Ceci F, Labbadia G, Fontana M, Di Costanzo A, Maranghi M, Rosano A, Ehnholm C, Donini LM, Jauhianen M, Arca M. Effects of angiopoietin-like protein 3 deficiency postprandial lipid and lipoprotein metabolism. J Lipid Res. 2016;57:1097–107. [PMC free article: PMC4878193] [PubMed: 27040449]

  • Musunuru K, Pirruccello JP, Do R, Peloso GM, Guiducci C, Sougnez C, Garimella KV, Fisher S, Abreu J, Barry AJ, Fennell T, Banks E, Ambrogio L, Cibulskis K, Kernytsky A, Gonzalez E, Rudzicz N, Engert JC, DePristo MA, Daly MJ, Cohen JC, Hobbs HH, Altshuler D, Schonfeld G, Gabriel SB, Yue P, Kathiresan S. Exome sequencing, ANGPTL3 mutations, and familial combined hypolipidemia. N Engl J Med. 2010;363:2220–7. [PMC free article: PMC3008575] [PubMed: 20942659]

  • Noto D, Cefalù AB, Valenti V, Fayer F, Pinotti E, Ditta M, Spina R, Vigna G, Yue P, Kathiresan S, Tarugi P, Averna MR. Prevalence of ANGPTL3 and APOB gene mutations in subjects with combined hypolipidemia. Arterioscler Thromb Vasc Biol. 2012;32:805–9. [PubMed: 22247256]

  • Pisciotta L, Favari E, Magnolo L, Simonelli S, Adorni MP, Sallo R, Fancello T, Zavaroni I, Ardigò D, Bernini F, Calabresi L, Franceschini G, Tarugi P, Calandra S, Bertolini S. Characterization of three kindreds with familial combined hypolipidemia caused by loss-of-function mutations of ANGPTL3. Circ Cardiovasc Genet. 2012;5:42–50. [PubMed: 22062970]

  • Richards S, Aziz N, Bale S, Bick D, Das S, Gastier-Foster J, Grody WW, Hegde M, Lyon E, Spector E, Voelkerding K, Rehm HL, et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med. 2015;17:405–24. [PMC free article: PMC4544753] [PubMed: 25741868]

  • Rimbert A, Vanhoye X, Coulibaly D, Marrec M, Pichelin M, Charrière S, Peretti N, Valéro R, Wargny M, Carrié A, Lindenbaum P, Deleuze JF, Genin E, Redon R, Rollat-Farnier PA, Goxe D, Degraef G, Marmontel O, Divry E, Bigot-Corbel E, Moulin P, Cariou B, Di Filippo M. Phenotypic differences between polygenic and monogenic hypobetalipoproteinemia. Arterioscler Thromb Vasc Biol. 2021;41:e63–e71. [PubMed: 33207932]

  • Stenson PD, Mort M, Ball EV, Chapman M, Evans K, Azevedo L, Hayden M, Heywood S, Millar DS, Phillips AD, Cooper DN. The Human Gene Mutation Database (HGMD®): optimizing its use in a clinical diagnostic or research setting. Hum Genet. 2020;139:1197–207. [PMC free article: PMC7497289] [PubMed: 32596782]

  • Stitziel NO, Khera AV, Wang X, Bierhals AJ, Vourakis AC, Sperry AE, Natarajan P, Klarin D, Emdin CA, Zekavat SM, Nomura A, Erdmann J, Schunkert H, Samani NJ, Kraus WE, Shah SH, Yu B, Boerwinkle E, Rader DJ, Gupta N, Frossard PM, Rasheed A, Danesh J, Lander ES, Gabriel S, Saleheen D, Musunuru K, Kathiresan S., PROMIS and Myocardial Infarction Genetics Consortium Investigators. ANGPTL3 deficiency and protection against coronary artery disease. J Am Coll Cardiol. 2017;69:2054–63. [PMC free article: PMC5404817] [PubMed: 28385496]

  • Tarugi P, Bertolini S, Calandra S. Angiopoietin-like protein 3 (ANGPTL3) deficiency and familial combined hypolipidemia. J Biomed Res. 2019;33:73–81. [PMC free article: PMC6477171] [PubMed: 29752428]

  • Tikkanen E, Minicocci I, Hällfors J, Di Costanzo A, D'Erasmo L, Poggiogalle E, Donini LM, Würtz P, Jauhiainen M, Olkkonen VM, Arca M. Metabolomic signature of angiopoietin-like protein 3 deficiency in fasting and postprandial state. Arterioscler Thromb Vasc Biol. 2019;39:665–74. [PubMed: 30816800]

  • Xu YX, Redon V, Yu H, Querbes W, Pirrucello J, Liebow A, Deik A, Trindade K, Wang X, Musunuru K, Clish CB, Cowan C, Fizgerald K, Rader D. Kathiresan. Role of angiopoietin-like 3 (ANGPTL3) in regulating plasma level of low-density lipoproteins. Atherosclerosis. 2018;268:196–206. [PMC free article: PMC5750127] [PubMed: 29183623]