Background: /Objectives: Despite the success of statin and PCSK9 inhibitor therapies, significant residual cardiovascular risk persists, driven by atherogenic triglyceride-rich lipoproteins (TRLs) and the independent, causal risk factor, lipoprotein(a) [Lp(a)]. This review aims to elucidate the pathophysiology of three key genetic drivers of this risk—Apolipoprotein C-III (APOC3), Angiopoietin-like protein 3 (ANGPTL3), and Lp(a)—and to comprehensively analyze the groundbreaking efficacy and safety data from 2025 clinical trials for novel RNA-silencing and gene-editing therapies targeting them. Methods: This narrative review synthesizes foundational genetic validation studies with a focused analysis of late-breaking Phase 1, 2, and 3 clinical trial data presented at major 2025 cardiometabolic conferences (AHA 2025, ACC 2025) and simultaneously published in high-impact journals. Results: Landmark 2025 trials demonstrated profound efficacy. (1) For APOC3, the Phase 3 CORE-TIMI 72a/b trials showed the antisense oligonucleotide (ASO) olezarsen not only reduced severe hypertriglyceridemia (sHTG) (up to -72.2%) but also achieved a pivotal 85% reduction in acute pancreatitis events. (2) For ANGPTL3, the first-in-human Phase 1 trial of CTX310 (CRISPR-Cas9) validated in vivo gene editing as a clinical tool, achieving deep, dose-dependent reductions from a single infusion in ANGPTL3 (-73%), triglycerides (-55%), and LDL-C (-49%). (3) For Lp(a), the Phase 2 ALPACA trial of the siRNA lepodisiran demonstrated >94% Lp(a) reduction with unprecedented durability, sustained at >90% at day 540.15 (4) Concurrently, the 2024-2025 pause of the VERVE-101 base-editing trial due to LNP-related toxicity (thrombocytopenia, ALT elevation) and successful 2025 pivot to the reformulated VERVE-102 20 highlighted delivery, not just payload, as a critical safety hurdle. Conclusions: The year 2025 marks a paradigm shift from chronic oral therapy toward long-acting injectable (ASO/siRNA) or permanent "one-and-done" (CRISPR/base editing) treatments for cardiovascular disease. These genetic therapies show immense promise for targeting previously "undruggable" risk factors. Future success now hinges on demonstrating MACE reduction in large cardiovascular outcome trials (CVOTs) and navigating the critical translational hurdles of delivery vehicle (LNP) safety and the long-term, off-target monitoring of in vivo gene editing.
| Date: | 2025-11-13 |
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| Authors: | Mansoor M, Ibrahim A, Rizwan A. |
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| Ref: | Preprints.org |
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