Bridging the gap in familial hypercholesterolaemia detection: the EPIRUS familial hypercholesterolaemia reverse cascade project as a model for paediatric and family-based screening

Familial hypercholesterolaemia remains substantially underdiagnosed worldwide despite effective preventive therapies. Evidence increasingly supports paediatric-centred detection combined with cascade and reverse cascade strategies to improve population-level identification and reduce premature atherosclerotic cardiovascular disease. We summarise contemporary familial hypercholesterolaemia screening models with emphasis on paediatric approaches, implementation barriers, and health system requirements, and we present the EPIRUS Familial Hypercholesterolaemia Reverse Cascade Project as a pragmatic regional model in Greece. A literature search (December 2025 to January 2026) was performed in PubMed, Scopus, and Google Scholar using terms related to "familial hypercholesterolemia," "familial hypercholesterolaemia," "screening," "cascade," "reverse cascade," and "population programme." Eligible publications included human studies and evidence syntheses evaluating universal, opportunistic, cascade, or paediatric screening strategies, and implementation or economic analyses. Evidence consistently indicates that opportunistic detection and conventional cascade screening alone cannot close the diagnostic gap because of low index-case ascertainment and fragmented pathways. Universal or structured paediatric programmes demonstrate feasibility, high diagnostic yield after infancy, and capacity to trigger family-based case-finding. Recent data show low-density lipoprotein cholesterol discrimination is limited in newborns but becomes reliable from age ≥1 year, supporting childhood screening. We describe EPIRUS Familial Hypercholesterolaemia, a targeted paediatric programme (primarily ages 4-16 years) using lipid thresholds and family history triggers, systematic phenotyping, and next-generation sequencing to confirm diagnosis and enable cascade and reverse cascade screening. EPIRUS Familial Hypercholesterolaemia illustrates how paediatric entry points can operationalise family-based detection within routine clinical care in a decentralised setting and can generate real-world implementation evidence to inform scalable national strategies.