Familial Hypercholesterolemia: Prevalence and Discrepancy between Genotype and Phenotype

Findings of the Population-based Hamburg City Health Study

Background: Familial hypercholesterolemia (FH) is among the more common monogenic diseases, yet population-based data on genetically confirmed FH (genFH) and its association with LDL cholesterol (LDL-C) in Germany are lacking.

Methods: In the Hamburg City Health Study (registration: ClinicalTrials.gov, NCT03934957), five FH-associated genes were examined for pathogenic mutations with whole genome sequencing and compared with LDL-C levels that had been corrected for lipid-lowering medication. Severe hypercholesterolemia was defined as an LDL-C level of 190 mg/dL or above.

Results: There were 7373 adult participants (49.1% women; median age 62 years), of whom 23 had FH, corresponding to a prevalence of 0.31% (95% confidence interval [CI]: [0.21; 0.47]), or a prevalence ratio of 1:321 [1:213; 1:476]. All genFH cases were due to mutations in the LDLR gene. The median treatment-adjusted LDL-C level was higher in genFH cases (191 mg/dL) than in persons without genFH (128 mg/dL; p <0.001). Eleven of the participants with genFH had severe hypercholesterolemia. Among the 7253 participants without genFH, 465 had severe hypercholesterolemia. Only 2.3% (n = 11) of the severely hypercholesterolemic participants had genFH. Forty-three people would need to be genetically tested to identify one genFH case if an LDL-C threshold of ≥190 mg/dL is selected, 98 people at ≥160 mg/dL, and 175 people at ≥130 mg/dL.

Conclusion: The prevalence of genFH in this German study was 0.31%, which corresponds to the global average. As only half of the persons from our adult cohort identified as having genFH had severe hypercholesterolemia, population-based genetic screening would seem to be of questionable benefit.

Cite this as: Riccio C, Arnold N, Koliopanos G, Link V, Guo L, Betschart RO, Zeller T, Blankenberg S, Ziegler A, Twerenbold R: Familial hypercholesterolemia: Prevalence and discrepancy between genotype and phenotype. Findings of the population-based Hamburg City Health Study. Dtsch Arztebl Int 2025; 122: 511–6. DOI: 10.3238/arztebl.m2025.0110

Genetically determined lipid metabolism disorders, or dyslipidemias, are recognized causes of early-onset atherosclerotic cardiovascular disease (1). Familial hypercholesterolemia (FH) is classified as a congenital dyslipidemia (2). It is usually caused by autosomal dominant mutations in genes which are involved in the metabolism of low-density lipoprotein cholesterol (LDL-C). Most commonly, a mutation in the LDL receptor (LDLR) gene results in reduced LDL-C uptake in hepatocytes, leading to elevated blood LDL-C levels (3, 4). Other genes associated with causal FH mutations include apolipoprotein B (APOB) (5), proprotein convertase subtilisin/kexin type 9 (PCSK9) (6), and apolipoprotein E (APOE) (7). With a worldwide estimated prevalence of one in 313 individuals, the autosomal dominant form of FH is regarded as one of the more common monogenic inherited diseases in the general population (8). The autosomal recessive form of FH is rare and is caused by mutations in the LDLR adapter protein gene (LDLRAP1) (3, 4).

The diagnosis of monogenic FH can be made on the basis of clinical features. Key criteria include LDL-C levels of 190 mg/dL or above, characteristic findings such as tendon xanthomas or arcus lipoides corneae (9), and a positive personal or family history of early-onset cardiovascular events (10). According to European guidelines, genetic testing is desirable for the diagnosis, but not essential (11). Only around ten percent of FH cases are in fact diagnosed (12). The diagnosis is often made following initial manifestation of an atherosclerotic disorder (12).

A key criterion for identifying FH, especially the heterozygous form, is an LDL-C level of 190 mg/dL or above. According to the guidelines of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS), target levels for patients with FH are determined by their individual cardiovascular risk: less than 70 mg/dL and at least 50% reduction from baseline for patients at high risk, less than 55 mg/dL for those at very high risk, and less than 40 mg/dL may be considered for patients at extremely high risk (11).

In order to detect FH early, populationwide, multi-tiered screening programs are used to identify people with elevated LDL-C levels who may then undergo genetic testing (13, 14). Cascade screening targets family members of an index case. Slovenia has implemented an established populationwide screening program (15). Cascade programs are also conducted in the Netherlands (16) and the Czech Republic (17). A pilot study is currently underway in Germany involving a population-based screening program in children and adolescents (13). In Austria, the FHkids Study identifies familial predisposition in preschool children (18).

Recent studies show that LDL-C levels in people with genetically confirmed FH (genFH) can vary considerably (19, 20). Only one quarter of those with genFH actually fulfill the clinical criteria for definite or probable FH. While at the same time, the vast majority of individuals with severe hypercholesterolemia (LDL-C ≥ 190 mg/dL) have no pathogenic FH mutations at all (20, 21, 22, 23, 24). This emphasizes that pathogenic FH mutations are not necessarily associated with high LDL-C values and vice versa.

The primary aim of the present study was to determine the prevalence of genFH in Hamburg, Germany. Another aim was to assess the associations between genFH and LDL-C levels.

Methods

Study population

The Hamburg City Health Study (HCHS) (registration: ClinicalTrials.gov, NCT03934957) is a population-based, prospective, single-center cohort study that has been in progress since 2016. A detailed description may be found in Jagodzinski et al. (25). A random selection of individuals aged between 45 and 74 years taken from the general population of the Hanseatic City of Hamburg were invited to participate voluntarily in the study. All study participants gave their written informed consent on enrollment. The study was conducted in accordance with the principles of Good Epidemiological Practice and the ethical guidelines of the Declaration of Helsinki (26). The Ethics Committee of the Hamburg Medical Association (PV5131) had no objections against the conduct of the study, and the study is conducted in accordance with current data protection regulations. The data of the baseline examination of the first 16 411 participants of the HCHS were used for this analysis. This figure corresponds to around 24% (response rate) of the originally invited and eligible participants. Recruitment was conducted between 8 February 2016 and 31 December 2021. After quality control, whole-genome sequences were available for 7373 of these participants. Selection was based on availability and quality biomaterial sampling as well as on consent for genotyping and data transfer having been submitted to cooperating partners. Basic characteristics of the participants with and without whole-genome sequencing are presented in Table 1.

Table 1

Characteristics of the participants with genetically confirmed familial hypercholesterolemia

Data acquisition and definition of risk factors and comorbidities

Information regarding data acquisition and definition of risk factors and comorbidities are available online in the Supplementary material.

Laboratory methods

Venous blood samples were taken under standardized conditions from all participants on enrollment in the study. All analyses were conducted blind. Total cholesterol, HDL-C, and triglyceride analysis was performed as part of routine clinical care, and LDL-C levels were calculated using the Friedewald equation. Untreated LDL-C levels were estimated using correction factors in individuals taking lipid-lowering medication. These correction factors are based on the results of several clinical trials and meta-analyses which investigated the average LDL-C reduction achieved by the respective active substances (19, 27, 28, 29) (eTable 2).

eTable 2

Correction factors for calculating untreated LDL-C levels in patients on lipid-lowering medication

Genetic analyses

All participants underwent whole-genome sequencing using Illumina short-read technology (30). The five genes LDLR, APOB, PCSK9, LDLRAP1, and APOE were specifically examined for mutations considered pathogenic for FH (eTable 3). Variants causing FH were defined according to two criteria: on the one hand, variants classified in ClinVar (31) as pathogenic or likely pathogenic for FH were included (eTable 4). On the other hand, loss-of-function variants in LDLR and LDLRAP1 were also considered causative of FH. Participants were classified as genFH-positive if they carried at least one of the FH variants in LDLR, APOB, PCSK9, or APOE, as defined above, or were homozygous or complex heterozygous for an FH variant in LDLRAP1.

eTable 3

Genomic coordinates of genes associated with FH mutations identified in ClinVar

eTable 4

Overview of the ClinVar entries for FH genes categorized by clinical significance

Statistical methods

A description of the statistical methods is available in the eMethods section.

Results

Prevalence and characterization of mutations of familial hypercholesterolemia

The data of 7373 participants of the population-based HCHS were analyzed for this study (49.1% women, median age 62 years [IQR 54–69 years]). A genetic mutation responsible for the heterozygous form of autosomal-dominant FH was identified in 23 participants. This corresponds to a genFH prevalence of 0.31% [0.21%; 0.47%] or 1 in 321 [1 in 213; 1 in 47]) individuals.

The 23 participants with genFH carried 16 different mutations in the LDLR gene. Two further individuals each had one mutation in the LDLRAP1 gene. These mutations were not interpreted as causative of FH due to their autosomal recessive pattern of inheritance. An overview of the molecular features of all FH mutations identified in the present analysis is available eTable 5.

eTable 5

List of FH mutations identified in the participants

Participant characteristics according to their genFH status

Basic information on participants is broken down in eTable 6 according to genFH status. Age and sex were comparable between genFH-positive and genFH-negative participants. The prevalence of classic risk factors was also similar in both groups—with the exception of hypercholesterolemia which was diagnosed in 68.2% of the genFH-positive individuals as compared with 22.5% of the genFH-negatives. Fourteen of the 23 genFH-positive participants (60.9 %) stated that they were taking lipid-lowering medication in comparison with 14.8% of genFH-negative individuals. Furthermore, there was evidence of carotid atherosclerosis in 47.8% of genFH-positive participants, as compared with only 22.9% of genFH-negative individuals. A case description of the genFH-positive participants is presented in Table 1.

eTable 6

Baseline: demographic, clinical, and laboratory characteristics of the study participants, stratified by the presence of genetically confirmed familial hypercholesterolemia

Association between genFH status and low-density lipoprotein C levels

There was a difference between the LDL-C levels of genFH-positive and genFH-negative participants (Figure). The LDL-C levels were adjusted to account for lipid-lowering medication and are henceforth referred to as “untreated”. The median untreated LDL-C levels were 191 mg/dL (IQR 149–210) in genFH-positive participants, as compared with 128 mg/dL (IQR 105–153) in genFH-negative participants (Figure).

Figure

Distribution of LDL cholesterol levels (LDL-C; mg/dL) by genetic FH status

Exactly one half of the genFH-positive participants had an untreated LDL-C level of 190 mg/dL or above. The untreated LDL-C levels were below 160 mg/dL in 31.8% of the genFH-positive participants and even below 130 mg/dL in 9.1%. Of the 7275 individuals for whom LDL-C levels were available, 6.5% (n = 476) had severe hypercholesterolemia. Only eleven of them also had genFH, corresponding to a prevalence of 2.3%.

Clinical relevance of familial hypercholesterolemia mutations in the Hamburg population

In order to assess the clinical relevance of genFH, the prevalences of manifest ASCVD was estimated among genFH-negative and genFH-positive participants (eTables 1 and 2). Manifest ASCVD was diagnosed twice as often in genFH-positive individuals as compared with genFH-negatives (25% versus 12%, eTable 1; [–3%; 34%]). ASCVD prevalences of participants with severe hypercholesterolemia were similar among genFH-positive and genFH-negative participants (18.2% versus 16.8%, Table 2). Moreover, none of the genFH-positive individuals with an LDL-C level below 130 mg/dL presented manifest ASCVD, whereas its prevalence in genFH-negative individuals with the same LDL-C levels was 10.7%. The presence of carotid atherosclerosis as confirmed by duplex ultrasound was evident in 47.8% of genFH-positive participants as compared with 22.9% of the genFH-negative participants. After stratification for untreated LDL-C categories, genFH-positive participants demonstrated approximately twice the prevalence of carotid atherosclerosis as compared with genFH-negative participants in each category from at least 130 mg/dL and above (Table 2).

Table 2

Prevalence of ASCVD and carotid atherosclerosis, stratified by genFHstatus and LDL-C status

eTable 1

Baseline: demographic, clinical, and laboratory characteristics of the study participants

The application of LDL-C threshold values of 190 mg/dL and above, 160 mg/dL and above, and 130 mg/dL and above to screen for genFH identified 50.0%, 68.2%, and 90.9% of individuals with genFH, respectively. Depending on the chosen LDL-C threshold value, 43 people would need to be genetically tested to identify one genFH case if an LDL-C threshold of 190 mg/dL and above were selected, 98 people at 160 mg/dL and above, and 175 people at ≥130 mg/dL and above.

Discussion

The present analysis determined for the first time the prevalence of genFH in individuals living in Hamburg who are genetically similar to a European reference population. The genetic data used are described in the eMethods section and have been previously discussed in more detail (30). Only 2.3% of people with severe hypercholesterolemia presented genFH, and 50% of genFH-positive participants had untreated LDL-C levels of 190 mg/dL or above.

No data has been available to date on the prevalence of genFH in the general population of Germany. Based on clinical criteria, the estimated prevalence of FH of 1 in 300 (32) is similar to the worldwide estimation of 1 in 313 (8). The genFH prevalence of 1 in 321 (1 in 213; 1 in 476) as estimated in the present study is of a similar magnitude, despite differences between the clinical and genetic definition of FH. In the present study, all genFH cases were due to mutations in the LDLR gene. This resembles the results from other countries which attributed 80% (24) to 93% (33) of genFH cases to LDLR mutations, depending on the particular study.

Simply determining LDL-C plays a central part in the FH diagnostic workup of FH. An LDL-C level above the threshold of 190 mg/dL provides an initial clinical indication of potential FH. Our analyses, however, revealed that only one half of participants with genFH had LDL-C levels above the threshold value. Around 30% of individuals with genFH had untreated LDL-C levels below 160 mg/dL, so FH was possibly overlooked in one third of cases. To make matters worse, there is at the moment no simple method in clinical routine practice to calculate untreated LDL-C levels which reflect values prior to starting lipid-lowering medication. After correcting for lipid-lowering medication, the median LDL-C level in genFH-positive participants increased from 127.5 to 190.7 mg/dL. Without correction, the proportion of genFH-positive individuals deemed hypercholesterolemic based on their LDL-C levels would have been even smaller. The uncorrected LDL-C levels did not differ statistically in those with genFH from those without. However, the use of lipid-lowering medication and the presence of carotid atherosclerosis were more common in FH individuals. Also worthy of note is the low prescription rate for statin-free lipid-lowering agents. This may be explained by the lower prevalence of hypercholesterolemia (23 %) in our cohort and the high proportion of individuals without prevalent ASCVD (88 %). Furthermore, PCSK9 inhibitors are only approved for use in Germany for clearly defined indications. One study showed that only 0.3% of high-risk patients received PCSK9 therapy (34).

Our analyses show that only 2.3% of participants with severe hypercholesterolemia have genFH. Genetic analysis would therefore return no results in 97.3% of cases. This is in line with the findings of studies reporting 0.57% to 2.5% genFH prevalence when LDL-C was 190 mg/dL or above (20, 21, 23). Thus, other criteria are required to reliably diagnose FH, such as a positive family history or clinical signs of FH.

The clinical repercussions of FH mutations in the presence of normal to moderate increases in LDL-C are of particular interest. Earlier studies have shown that the presence of FH mutations is associated with a higher risk of coronary heart disease despite similar LDL-C levels (21, 35). It was noticed in the present study that genFH-positive participants presented advanced atherosclerosis, both subclinically and clinically, more often than genFH-negative individuals. In the present study, neither subclinical atherosclerosis nor manifest ASCVD were diagnosed in the two genFH-positive individuals with LDL-C levels below 130 mg/dL. This substantiates the incomplete penetrance of FH mutations.

Current ESC/EAS dyslipidemia guidelines recommend founding the diagnosis of FH primarily on clinical criteria to be confirmed, when possible, using DNA analysis (1C recommendation) (11). The variability in LDL-C levels as observed among our genFH-positive participants, as well as the uncertain clinical significance of FH mutations in individuals with LDL-C levels below 190 mg/dL demonstrate the complexity of diagnosing FH. This should be taken into consideration when developing FH screening programs.

FH in children, especially in its homozygous pattern, is regarded as a prime example of the causality between elevated LDL-C levels and the development of coronary heart disease. Children do not usually present additional risk factors, so sensitivity and specificity of LDL-C-based FH screening could be higher in children than in adults whose LDL-C levels are affected by a large number of factors and may not be entirely determined by genetics. Scientific evidence is still lacking.

Limitations

Illumina sequencing using short reads allows recognition of single nucleotide variants (SNVs) and small insertions and deletions (36), which constitute over 99% mutations reported as FH variants in the ClinVar database operated by the US National Institutes of Health. Larger structural variants which account for around ten percent of the known FH variants in the LDLR gene are identified less reliably (37). Furthermore, the age distribution of the study participants may result in a selection bias, given that individuals with FH could be underrepresented due to their potentially reduced life expectancy. However, FH-positive and FH-negative individuals in the present study have a comparable age range which would indicate limited bias. Thirdly, ClinVar is a database which does not contain all FH mutations, and its entries are not systematically kept up to date (31). The present study does not provide any information on the role of LDL-C measurement in the prevention of cardiovascular disease. These limitations affect the relevance of LDL-C levels in the presence of genFH.

Summary

The prevalence of heterozygous genFH in the resident population of Hamburg was, for the first time, estimated at 1 in 321, which is similar to the global prevalence. Two findings are particularly noteworthy: only one half of the participants with genFH suffered from severe hypercholesterolemia, and only 2.3 % of those with severe hypercholesterolemia had genFH. These results reinforce the need to better understand the associations between genetic variants and LDL-C levels before introducing genetic screening programs to identify cases of genFH.

Funding

The participating institutes and departments of the University Medical Center Hamburg-Eppendorf contribute to the overall funding of the HCHS with individual and staggered budgets. The HCHS is also financed by the euCanSHare funding agreement (grant number 825903-euCanSHare H2020), the Kühne Foundation, the Joachim Herz Foundation, the Leducq Foundation (grant number 16 CVD 03), and the Innovative Medicines Initiative (grant number 116074). Furthermore, the HCHS is supported by the German Statutory Accident Insurance (DGUV), the German Cancer Research Center (DKFZ), the German Center for Cardiovascular Research (DZHK), the German Heart Research Foundation, the Seefried Foundation, and by the companies Bayer, Amgen, Novartis, Schiller, Siemens, Topcon, Unilever. Further support is provided through donations by the “Supporting Association for the Promotion of the HCHS” as well as by TePe (2014). The sponsors had no influence on study design, data analysis, or interpretation of the results. Certain support services, such as technical equipment, were used during the implementation of the study. Whole-genome sequencing and bioinformatic processing and analysis were financed by the Kühne Foundation.

Acknowledgments

We would like to thank all those who participated in the Hamburg City Health Study. We would also like to express our thanks to Alena Haack, Marie Neumann, and Dr. Ines Schäfer from the University Medical Center Hamburg-Eppendorf for their administrative support and data management. Our thanks also go to Sabrina Vollenweider from the Hochgebirgsklinik in Davos, Switzerland, for her feedback on the linguistic presentation of the manuscript.

Registration

The study was approved by the Ethics Committee of the Hamburg Medical Association (PV5131) and complies with current data protection regulations.

Conflict of interest statement

NA received lecture fees from Amgen, Novartis, and Sanofi, research funding from Novartis, and reimbursement of travel expenses from Daiichi Sankyo. NA also received consulting fees (advisory boards) from Arrowhead and Apontis Pharma.

SB received lecture fees from Bristol Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo, and GSK plc. SB is member of advisory boards and consultant for Thermo Fisher Scientific. He is honorary president of the German Cardiac Society and honorary spokesperson of the German Center for Cardiovascular Research, partner site North. He is also honorary board member of the Global Cardiovascular Research Funder Forum. He is scientific consultant of Cardio-CARE, a 100% nonprofit subsidiary of the Kühne Foundation.

AZ is honorary board member of the Basel Biometric Society. He is scientific director and managing director of Cardio-CARE, a 100% nonprofit subsidiary of the Kühne Foundation.

AZ, RT, TZ, and SB are listed as co-developers of an international patent for the use of a computer-implemented system for assessing the likelihood of myocardial infarction (international publication number WO2022043229A1, TW202219980A). AZ, TZ, RT, and SB are co-founders of ART-EMIS. AZ and SB sold their shares in 2023.

CR, GK, VL, and RB are bioinformaticians at Cardio-CARE. Cardio-CARE is shareholder of ART-EMIS Hamburg.

RT received study support from Kühne Foundation and lecture fees from Amgen.

The other authors declare that there are no conflicts of interest.

Manuscript received on 10 February 2025, revised version accepted on 17 June 2025

Translated from the original German by Dr. Grahame Larkin

Corresponding authors:
Prof. Dr. rer. nat. Andreas Ziegler

Prof. Dr. med. Raphael Twerenbold

[e-mail]

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