the catalytic domain and keeps it in an inhibited state. PCSK9 is highly expressed in liver and small intestine and is readily measured by ELISA in plasma. PCSK9 binds the EGF-A domain of the LDLR via its catalytic domain and promotes its internalization and degradation in the endosome/lysosome pathway, independently of its enzymatic activity. The roles of its Nterminal prosegment and C-terminal Cys/His-rich domain in the subcellular trafficking of the PCSK9;LDLR complex remain unclear. The rare gain-of-function mutations of PCSK9 identified in ADH-affected patients resulted in a higher ability of PCSK9 to promote LDLR degradation. The strongest one, D374Y increases.10-fold the affinity of PCSK9 for the LDLR and results in very high circulating LDLc and early death due to CAD. Loss-of-function mutations were also identified, and the 2 nonsense ones Y142X and C679X are particularly frequent in African-Americans. These heterozygote mutations were associated with a,40 reduction of LDLc and an 88 reduction in the risk of coronary heart disease. Pcsk92/2 mouse livers exhibit,3-fold more LDLR protein RWJ 64809 levels and a substantial accumulation of the receptor at the hepatocyte cell surface. This leads to hypocholesterolemia, with a,5-fold drop in LDLc levels. In humans, where 70 of cholesterol is associated with LDL, the 1268454-23-4 hypocholesterolemia due to complete PCSK9-deficiency is even more dramatic. This also provided a proof of principle that PCSK9 is a promising and safe target to treat hypercholesterolemia and prevent CAD. Current Canadian guidelines for the prevention and treatment of cardiovascular diseases recommend achieving an LDLc reduction in subjects considered at moderate or high risk. Statins, which inhibit the rate-limiting step of cholesterol synthesis catalyzed by hydroxymethylglutaryl coenzyme A reductase, considerably reduced the incidence of atherosclerosis. This cholesterol reduction up-regulates the transcription factor SREBP2, which in turn stimulates the expression of the LDLR resulting in increased LDLc uptake by hepatocytes, and lowering its circulating levels. Statins were shown to reduce cardiovascular events. Statins have an unparalleled safety and efficacy profile, but often lead to suboptimal levels of LDLc in patients with ADH, show variable
