Publications resulting from analysis of the data collected by the FHSC.

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

The Lancet 2023

Published: December 12, 2023

What the authors conclude

Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life.

EAS Commentary

Familial hypercholesterolaemia (FH) is the most common inherited lipid disorder, affecting about one in 300 people worldwide (1). If untreated, elevated low-density lipoprotein cholesterol (LDL‑C) levels from birth confer an increased risk of premature atherosclerotic cardiovascular disease. Early detection and treatment are therefore crucial to reduce the burden of preventable cardiovascular complications.  Unfortunately, as demonstrated by the European Atherosclerosis Society (EAS) Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry in over 42,000 adults, late diagnosis (in the 40s) is usual (2).

Overview of a collaborative global effort to address the burden of
familial hypercholesterolaemia

Indian Heart Journal 2023.

This is an overview of the EAS Familial Hypercholesterolaemia (FH) Studies Collaboration (FHSC) global consortium and registry (established 2015), which broadly addresses the global burden of FH.

Eighty-seven National Lead Investigators from 74 countries form this expanding global consortium, and this global registry currently includes pooled data on 70,000 participants from participating countries to facilitate FH surveillance. Published first results from this global registry concluded that FH is diagnosed late, and management of LDL-cholesterol falls below guideline recommendations, and therefore earlier detection of FH and wider use of combination therapy is required.

Further FHSC studies will follow on updated data including new countries, participants and variables, and non-DNA genetic information, and on the remaining cohorts in the registry. FHSC cross-sectional collaborative global studies are expected to promote FH detection earlier in life to subsequently initiate early lipid lowering therapy to reduce lifelong exposure to cumulative LDL-cholesterol thus reducing cardiovascular disease risk.

2023 Update on European Atherosclerosis Society Consensus Statement on Homozygous Familial Hypercholesterolaemia: new treatments and clinical guidance

Worldwide experience of homozygous familial hypercholesterolaemia: retrospective cohort study

The Lancet 2022

Published: January 28, 2022

What the authors conclude

Worldwide, patients with HoFH are diagnosed too late, undertreated, and at high premature ASCVD risk. Greater use of multi-LLT regimens is associated with lower LDL cholesterol levels and better outcomes. Significant global disparities exist in treatment regimens, control of LDL cholesterol levels, and cardiovascular event-free survival, which demands a critical re-evaluation of global health policy to reduce inequalities and improve outcomes for all patients with HoFH.

EAS Commentary

Worldwide, homozygous familial hypercholesterolaemia (HoFH), the most severe form of this high cholesterol disorder, is poorly managed with adverse health outcomes, especially among less affluent countries. These are the take home messages from the Homozygous Familial Hypercholesterolaemia International Clinical Collaboration (HICC) registry, the only international cohort of HoFH, which is partly funded by the European Atherosclerosis Society (EAS) FH Studies Collaboration. Published January, 2022 in The Lancet, these insights from the HICC registry are crucial to driving change in healthcare policy to improve HoFH care.

In this video, Professor Frederick J. Raal, Steering Committee member HICC Registry and Executive Committee member of the FHSC (University of the Witwatersrand, Johannesburg, South Africa) discusses the findings from the HICC registry.

The HICC is an investigator-initiated project supported by funding from the academic institutions of the collaborators. The EAS provided funding to support a registry coordinator.

Global perspective of familial hypercholesterolaemia: a cross-sectional study from the EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC).

The Lancet 2021

Published: September 07, 2021

What the authors conclude

Familial hypercholesterolaemia is diagnosed late. Guideline-recommended LDL cholesterol concentrations are infrequently achieved with single-drug therapy. Cardiovascular risk factors and presence of coronary disease were lower among non-index cases, who were diagnosed earlier. Earlier detection and greater use of combination therapies are required to reduce the global burden of familial hypercholesterolaemia.

Joint publication — Global Call to Action on FH — FH scientific & patient groups tackle burden of FH

2nd January 2020 – The EAS, together with FH Studies Collaboration and FH Europe, and in collaboration with the World Heart Federation (WHF), IAS and FH Foundation announced today the publication of a Global Call to Action on familial hypercholesterolaemia (FH) — a vastly under-recognized and poorly managed public health concern — in JAMA Cardiology. Authored by a global panel of scientific experts, public health officials, advocacy leaders and individuals with FH from 40 countries, the report notes glaring gaps in screening and guideline-based care for FH, the most common cause of early and aggressive heart disease. 

Conclusions and Relevance  By adopting the 9 updated public policy recommendations created for this document, covering awareness; advocacy; screening, testing, and diagnosis; treatment; family-based care; registries; research; and cost and value, individual countries have the opportunity to prevent atherosclerotic heart disease in their citizens carrying a gene associated with FH and, likely, all those with severe hypercholesterolemia as well.

Overview of the current status of familial hypercholesterolaemia care in over 60 countries – The EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC)

Atherosclerosis 2018.

Published: October, 2018


  • The EAS FHSC is an international initiative involving a network of investigators interested in FH from around 70 countries.
  • Information on FH prevalence is lacking in most countries; where available, data tend to align with contemporary estimates.
  • FH diagnosis and management varies widely across countries, with overall suboptimal identification and under-treatment.
  • In most countries diagnosis primarily relies on DLCN criteria, and less frequently on Simon Broom or MEDPED.
  • Therapy for FH is not universally reimbursed, and criteria vary across countries. Access to PCSK9i and apheresis is limited.

What the authors conclude

FH is a recognised public health concern. Management varies widely across countries, with overall suboptimal identification and under-treatment. Efforts and initiatives to improve FH knowledge and management are underway, including development of national registries, but support, particularly from health authorities, and better funding are greatly needed.

Pooling and expanding registries of familial hypercholesterolaemia to assess gaps in care and improve disease management and outcomes: Rationale and design of the global EAS Familial Hypercholesterolaemia Studies Collaboration

Atherosclerosis Supplements 22 (2016) 1-32

The potential for global collaborations to better inform public health policy regarding major non-communicable diseases ha-, been successfully demonstrated by several large-scale international consortia. However, the true public health impact of familial hypercholesterolaemia (FH), a common genetic disorder associated with premature cardiovascular disease, is yet to be reliably ascertained using similar approaches. The European Atherosclerosis Society FH Studies Collaboration (EAS FHSC) is a new initiative of international stakeholders which will help establish a global FH registry to generate large-scale, robust data on the burden of FH worldwide. Methods: The EAS FHSC will maximise the potential exploitation of currently available and future FH data (retrospective and prospective) by bringing together regional/national/international data sources with access to individuals with a clinical and/or genetic diagnosis of hetero··.ygous or homozygous FH. A novel bespoke electronic platform and FH Data Warehouse will be developed to allow secure data sharing, validation, cleaning, pooling, harmonisation and analysis irrespective of the source or format. Standard statistical procedures will allow us to investigate cross-sectional associations, patterns of real-world practice, trends over time, and analyse risk and outcomes (e.g. cardiovascular outcomes, all-cause death), accounting for potential confounders and subgroup effects.

What the authors conclude

The EAS FHSC represents an excellent opportunity to integrate individual efforts across the world to tackle the global burden of FH. The information garnered from the registry will help reduce gaps in knowledge, inform best practices, assist in clinical trials design, support clinical guidelines and policies development, and ultimately improve the care of FH patients.

Familial hypercholesterolaemia: A global call to arms

Atherosclerosis 2015.

Published: September 17, 2015

What the authors conclude

Familial Hypercholesterolaemia (FH) is the commonest autosomal co-dominantly inherited condition affecting man. It is caused by mutation in one of three genes, encoding the low-density lipoprotein (LDL) receptor, or the gene for apolipoprotein B (which is the major protein component of the LDL particle), or in the gene coding for PCSK9 (which is involved in the degradation of the LDL-receptor during its cellular recycling). These mutations result in impaired LDL metabolism, leading to life-long elevations in LDL-cholesterol (LDL-C) and development of premature atherosclerotic cardiovascular disease (ASCVD). If left untreated, the relative risk of premature coronary artery disease is significantly higher in heterozygous patients than unaffected individuals, with most untreated homozygotes developing ASCVD before the age of 20 and generally not surviving past 30 years. Although early detection and treatment with statins and other LDL-C lowering therapies can improve survival, FH remains widely underdiagnosed and undertreated, thereby representing a major global public health challenge.