REVIEW

Updating the Relationship between Hyperhomocysteinemia

Lowering Therapy and Cardiovascular Events
Xiaoshu Cheng
Department of Cardiology, Second Affiliated Hospital, Nanchang University, Nanchang, China

Keywords SUMMARY
B vitamin; Cardiovascular disease; Folic acid;
Hyperhomocysteinemia (Hhcy) was defined as an independent risk factor for cardiovascular
Homocysteine.
events. A number of clinical trials had investigated the relationship between Hhcy lowering
Correspondence treatment and cardiovascular diseases, however, the results of these studies remain contro-
Dr. Xiaoshu Cheng, Ph.D., M.D., Department versial. This review article gave an over view of the homocysteine metabolisms and updated
of Cardiology, Second Affiliated Hospital, the recently published results in the role of Hhcy lowering therapy on cardiovascular
Nanchang University, No. 1, Minde Road, events.
Nanchang 330006, China.
Tel.: +86(0)791 86268844;
Fax: +86(0)791 86268844;
E-mail: xiaoshu.cheng@gmail.com

doi: 10.1111/1755-5922.12014

increasing cardiovascular risks as glomerular filtration rate (GFR)

Introduction
Hyperhomocysteinemia (Hhcy) was observed in disorder of hom-
ocysteine (Hcy) metabolism, vitamins deficiency, diabetes mell-
itus, chronic renal failure, systemic arterial hypertension, or
malign neoplasm. Hhcy was correlated with many different kinds
of diseases, in particular cardiovascular diseases (CVD), stroke,
neurodegenerative diseases, neural tube defects, and end-stage
renal disease (ESRD). Other diseases with Hhcy include cute lym-
phoblastic leukemia, psoriasis, use of tobacco or medications such
as sulfzalazine, phenytoin, and methotrexate, etc,. which increase
serum levels of Hcy either by directly depleting folate stores or
impairing synthesis of enzyme cofactors required for normal Hcy
metabolism [1].
Serum Hcy level was determined by several elements, such as
the cofactors vitamin B12, B6, and folic acid and enzymes
involved in methionine metabolism. 8090% of Hcy in circulation
was protein bounded, 1020% of the total Hcy was presented as
homocysteine-cysteine mixed disulfide and dimer of Hcy, and less
than 1% was presented in the free reduced form [2]. According to
American Heart Association, normal serum Hcy concentration
range from 5 to 15 lmol/L, 1531 lmol/L was considered mildly
increased, and 31100 lmol/L was regarded as intermediately ele-
vated, while severely elevated was over 100 lmol/L, although
12 lmol/L was considered elevated by others [3].
Hcy was mainly transsulfurated in kidney, and incomplete renal
transsulfuration lead to the elevation of serum Hcy in various
pathological statuses, such as diabetes mellitus, hypertension or
ESRD [4,5]. In patients with chronic renal failure, Hhcy and
declines, raising the question that Hhcy might be responsible, at
least in part for the high CVD burden in this population. Hhcy was
shown to be associated with a high risk of ischemic myocardial
injury in patients with acute coronary syndrome, and was an
independent predictor of long-term survival in these patients
[6,7].
Normal Hcy metabolism is dependent on folic acid, vitamin B12
(cobalamin), and vitamin B6 (pyridoxal phosphate). Folic acid is a
substrate for cellular production of tetrahydrofolate (THF), a pre-
cursor to 5-methyl-THF that is necessary for normal methionine
synthase enzyme activity. Folate transfers 1-carbon moieties to
various organic compounds by increasing S-adenosylmethionine
(SAM) levels [8]. It is well known that Hcy is metabolized by two
alternative pathways, remethylation and transsulfuration. Reme-
thylation generates methionine by methylenetetrahydrofolate
reductase (MTHFR) by using Hcy as substrate and B vitamins and
folate as cofactors. Transsulfuration is catalyzed by cystathione-
beta-synthase (CBS) and gamma-cystathionase. By this way, Hcy
firstly experiences condensation with serine to form cystathionine
via CBS, and cystathionine is broken down into cysteine by
gamma-cystathionase, then cysteine is finally metabolized into
taurine and sulfate or transferred into glutathione [9].
Cobalamin is a key cofactor required for normal methionine
synthase activity, and can not be synthesized de novo in humans.
In contrast to folic acid, cobalamin is found exclusively in animal
meats [10]. There is a risk for cobalamin deficiency in diseases
with abnormal absorption of cobalamin in the distal jejunum, for
example, achlorhydria, low intrinsic factor levels, pancreatic

2012 John Wiley & Sons Ltd Cardiovascular Therapeutics 31 (2013) e19e26 e19
Hhcy Lowering and CVD Events
exocrine deficiency, inflammatory bowel disease, or diseases with
a history of gastric surgery. Pyridoxine phosphate is another cofac-
tor required for normal CBS enzyme activity. Although pyridox-
ine phosphate insufficiency is uncommon in normal population,
however, in patients with a combination of liver diseases, the risk
for pyridoxine deficiency is increased [11].
MTHFR played a pivotal role in the Hcy metabolism and cata-
lyzes the conversion of 5, 10-methylenetetrahydrofolate into
5-methyl-THF, the predominant circulating form of folate. There
were at least two functional polymorphisms of MTHFR gene,
677C/T and 1298A/C, and the 677T allele was involved in
decreased enzymatic activity, reduced concentrations of folate and
mildly enhanced plasma total Hcy levels [12,13]. Individuals with
the 677TT genotype took over approximately 30% of the enzyme
activity in those with the 677CC genotype, and the heterozygotes
677C/T had around 65% of the latter. 1298A/C polymorphism
was also associated with MTHFR activity without biochemical
changes [14]. Combinational heterozygous for 677C/T and
1298A/C polymorphisms led to a lower MTHFR activity than
either of the variants separately.
The Relationship between Hhcy and CVD
Atherosclerosis is a chronic arterial inflammatory disease, demon-
strated as deposits of fatty substances, cholesterol, calcium and
other substances build up in endothelial layer of arteries.
Researchers identified that moderate Hhcy was an independent
risk factor for atherosclerotic diseases [15]. In a study including
176 subjects, those with higher serum concentrations of Hcy had
2.9 times higher rates of atherosclerosis and thrombotic events
[16]. These findings were supported by the Homocysteine Studies
Collaboration meta-analysis, which demonstrated a risk decrease
for ischemic heart disease by 11% per 3 lmol/L reduction in Hcy
concentration [17]. Verkleij-Hagoort et al. [18] displayed that
maternal Hcy concentration was significantly involved with an
increased risk of having a child with congenital heart defects, sug-
gesting that maternal Hcy level is an important risk factor for con-
genital heart defects. In the Physicians Health Study, male
physician with the highest 5% of serum Hcy levels displayed a
5-year relative risk of 3.4 for acute myocardial infarction or death
because of coronary disease compared with the subjects showed
the lowest 90% of serum Hcy levels [7].
Hhcy was seen in 85100% of patients with chronic kidney dis-
ease (CKD), and a 25% decrease of serum concentration of Hcy
can reduce the risk of cardiac ischemic disease by 11% and the risk
of myocardial infarction by 20% [19]. A variety of prospective
clinical studies for subjects with CKD prior to renal failure have
revealed that there was a linear association between total serum
level of Hcy and increased CVD. The participants experienced a
5.05.5 lmol/L reduction during the combinative therapy of folic
acid and B-vitamin agents, and 50% of them maintained their
Hhcy concentrations below 12 lmol/L [20].
A meta-analysis involved with 27 studies displayed the odds
ratio for CVD of a 5 lmol/L increase in Hcy concentration was
0.16 (95% CI, 1.41.7) for men, and 1.8 (95% CI, 1.31.9) for
women, respectively. Based on above findings, the authors
extrapolated that higher folic acid intake by reducing Hhcy levels
promised to prevent arteriosclerotic vascular diseases [21]. Lower-
e20 Cardiovascular Therapeutics 31 (2013) e19e26
X. Cheng
ing Hcy concentration by 3.0 lmol/L would reduce the risk of
ischemic heart disease by 16% (1120%), deep vein thrombosis
by 25% (838%), and stroke by 24% (1533%) [22].
To determine whether Hhcy mutation and the C677T mutation
of MTHFR are associated with CVD prevalence in patients with
ESRD, a cross-sectional sample of 459 patients with chronic ESRD
on dialysis was assessed, researchers found that the C677T geno-
type of MTHFR was associated with CVD in ESRD and might be a
more meaningful marker than Hhcy for abnormal Hcy metabolism
in ESRD [23].
Possible Mechanisms for Hhcy-Induced
CVD
The most commonly observed vascular phenotype in murine mod-
els of hyperhomocysteinemia was endothelial vasomotor dysfunc-
tion due to impaired bioavailability of endothelium-derived nitric
oxide [24]. Hhcy causes vascular damages mainly via impairing
the vasorelaxation activity of endothelial-derived nitric oxide.
Hhcy can activate metalloproteinases, induce collagen synthesis,
and lead to imbalance of elastin/collagen ratio resulting in regres-
sion of vascular elastance [24]. Hhcy had been found to inhibit
cystathionine-c lyase (CSE) activity and alter the transulfuration
pathway by inhibiting CSE [24]. Thereby by reducing endogenous
production of H2Sa physiological vasorelaxantit was not sur-
prising that Hhcy can lead to hypertension. Hhcy-induced cell
injury was associated with the inhibition of endothelial cell nitric
oxide production, increased oxidative stress, IL- 8 upregulation
leading to enhanced leukocyte recruitment, and upregulation of
tissue factor within the vasculature [25]. In addition to abnormal
endothelial function, Hhcy mice demonstrated vascular hypertro-
phy, remodeling, altered vascular mechanics, or increased stiffness
of arteries or arterioles [25]. A single subcutaneous dorsal injection
of 0.6 lmol/g Hcy significantly increased platelet count in the
blood and plasma fibrinogen levels of Wistar rats [26].
Hhcy might cause mesenteric artery remodeling and narrowing
by activating matrix metalloproteinase (MMP)-9 and decreasing
dimethylarginine dimethylaminohydrolase-2 and endothelial
nitric oxide synthase expressions, therefore compromising the
blood flow, instigating hypertension [27]. Hcy could also induce
oxidative stress and was able to decrease the bioavailability of
nitric oxide and leading to endothelial dysfunction (as described
in Figure 1). These mechanisms might include asymmetric dime-
thylarginine and oxidative inactivation of nitric oxide mediated
by upregulation of prooxidant enzymes and downregulation of
antioxidant enzymes [27]. Additionally, Hcy could interference
the folding and processing of newly synthesized proteins in the
endoplasmic reticulum [28]. In vitro, Hcy was proven to damage
endothelial cells, promote the proliferation of smooth muscle
cells, and lead to several interactions with platelets, clotting fac-
tors, and lipids [29]. Hhcy might contribute to the scavenger
receptors-mediated uptake of oxidized-LDL (oxLDL) by macro-
phages resulting in foam cell formation in atherosclerosis [30].
Additionally, interaction of monocytes with Hcy-activated endo-
thelial cells resulted in the upregulation of CD36 expression on
monocytes in animal models, suggesting another possible mecha-
nism by which Hcy may upregulate CD36 expression at the lesion
site.
2012 John Wiley & Sons Ltd
X. Cheng
Hyperhomocysteinem Endothelial
dysfunction
Atherothrombosis
Homocysteine thiolactone
Reactive Oxidation of LDL
oxygen
LDL-homocysteine species Lipid peroxidation
thiolactone aggregate
Proliferation of
Vascular smooth
Foam cells
muscle cells
Figure 1 Oxidative injury to vascular endothelial cells and proliferation of
vascular smooth muscle cells after oxidative metabolism of homocystine
and homocysteine thiolactone. LDL, low-density lipoprotein.
Therefore, Hhcy was believed to promote atherogenesis and
atherothrombosis via following mechanisms. Firstly, reactive oxy-
gen species generated by Hcy metabolism directly damaged the
endothelium; Secondly, inhibition of nitric oxide synthase activity
by Hcy lead to endothelial malfunction; and other proatherogenic
mechanisms included dysregulated methylation of proteins and
DNA leading to abnormal vascular smooth muscle cell prolifera-
tion and increased lipid peroxidation [1].
Main Large-Scale Clinical Trials for Hhcy
Lowering Therapy with CVD
As studies showed that Hcy lowing therapy with B vitamins
did not reduce the cardiovascular events, a variety of large-
scale clinical trials have been performed [31,32]. Recently
reported clinical trial of Hcy lowering in approximately 2 000
ESRD or CKD stage four patients, the Hcy in kidney and
ESRD (HOST) study, revealed that even a high-dose vitamin
B regimen (folic acid, B6 and B12) failed to decrease crude
all-cause mortality during a median of 3.2 years of follow-up
[33]. In a trial including 3749 men and women with acute
myocardial infarction, patients received folic acid, vitamin B6
and B12, there was a trend toward an increased risk in recur-
rent myocardial infarction, stroke, and sudden death attributed
to coronary artery disease, but when the actual control event
rate was considered, there was lack of adequate statistical
power to detect a 20% decrease in CVD event rate [34]. In a
trial recruited 5522 patients, the combination of 2.5 mg of
folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12 did
not reduce the risk of major cardiovascular events in patients
with vascular disease for an average of 5 years follow-up
[35].
The results of Atherosclerosis and Folic Acid Supplementation
Trial (ASFAST) displayed that high-dose folic acid did not slow the
progression of atherosclerosis and reduce cardiovascular events in
315 chronic renal failure (CRF) patients, although plasma total
Hcy was reduced by 19% in the folic acid group [36]. A subgroup
analysis of CKD subjects with GFR <60 mL/min in the Heart Out-
comes Prevention Evaluation 2 (HOPE-2) Study failed to display
the beneficial results of Hcy lowering on cardiovascular risk [37].
After 7.3 years of treatment and follow-up, a combination pill of
folic acid (2.5 mg), vitamin B6 (50 mg), and vitamin B12(1 mg)
did not decrease the total cardiovascular events among the
women with age over 42 years, with either a history of CVD or
2012 John Wiley & Sons Ltd
Hhcy Lowering and CVD Events
three or more coronary risk factors, despite significant Hcy
lowering [38]. To determine whether high doses of folic acid and
B vitamins administered daily reduce mortality, a double-blind
randomized controlled trial for 2056 participants with high serum
Hcy (  15 lmol/L) found that the treatments did not improve
survival or reduce the incidence of vascular disease in patients
with advanced CKD or ESRD [39].
In a survey of 659 subjects with advanced CKD or ESRD,
treatment with high daily doses of vitamin B agents reduced
serum level of total Hcy, but did not improve cognitive out-
comes, therefore, should not be recommended for prevention
of cognitive dysfunction [40]. Double-blind randomized con-
trolled trial of 12,064 survivors of myocardial infarction in the
Study of the Effectiveness of Additional Reductions in Choles-
terol and Homocysteine (SEARCH) displayed that substantial
long-term reductions in blood Hcy levels with folic acid and
vitamin B(12) did not have beneficial effects on vascular out-
comes [41]. In a double-blind controlled study including 4110
kidney transplant recipients, treatment with a high-dose folic
acid, B6, and B12 multivitamin did not reduce a composite car-
diovascular disease outcome and all-cause mortality [42].
Although Hcy concentration was a strong predictor of major
adverse cardiovascular events (MACE), folic acid plus vitamin
B12 treatment did not influence MACE incidence during
39 months of following up, or cardiovascular mortality during
78 months of follow-up. Therefore, the authors concluded that
short-term or long-term combinative use of these two agents
has no benefit on cardiovascular outcomes in patients with
ischemic heart disease [43].
The folate after coronary intervention trial (FACIT) displayed
that application of folic acid, vitamin B12 and B6 after coronary
stenting might increase the risk of in-stent restenosis and the need
for target-vessel revascularization [31]. To assess the effect of
homocysteine-lowering B-vitamin treatment on angiographic
progression of coronary artery disease, the Western Norway B
Vitamin Intervention Trial (WENBIT) study investigated 348
patients and followed up for a median period of 10.5 months,
researchers found that vitamin B treatment showed no beneficial
effect on angiographic progression of coronary artery diseases.
Moreover, the post hoc analyses suggested that folic acid/vitamin
B(12) treatment might promote more rapid progression [44].
A randomized, double-blind and controlled study, which
involved with 818 individuals aged 5070 years who daily intakes
800 lg folic acid for 3 years, found that serum concentrations
increased and Hcy levels decreased in participants compared with
that in controls [45]. In a casecontrol study carried out in 326
patients with thrombosis, the researchers found that vitamin B12
deficiency was common among subjects with Hhcy and thrombo-
sis. Furthermore, Hhcy was caused by vitamin B12 deficiency
and/or chronic renal failure in most subjects with thrombosis,
indicating that vitamin B12 with or without folic acid should be
administered for the treatment of these patients [46].
Main large completed randomized controlled studies testing the
effects of Hcy lowering vitamins on CVD have been summarized
in Table 1 [31,32,3436,38,39,4144,4751].
There were several possible potential reasons for lack of
demonstrating cardiovascular benefits in interventional homo-
cysteine-lowering treatment studies. Firstly, established CVD
Cardiovascular Therapeutics 31 (2013) e19e26 e21
Hhcy Lowering and CVD Events X. Cheng

were more difficult to reverse with folic acid and B-vitamin

agents, regardless of the serum Hcy levels. Secondly, folic acid
fortification of grain might diminish the benefits of homocyste-
ine-lowering vitamins. Thirdly, folic acid and B-vitamin agents
might promote atherosclerosis via increasing cell proliferation
in atherosclerosis plaques, increasing methylation of DNA, and
enhancing asymmetric dimethylarginine levels [52]. Fourthly,
total serum Hcy might be less important in toxicity than its
aminothiol constituents, especially in patients with chronic
renal failure. Its aminothiol constituent of Hcy typically only
comprised <3% of total serum level, but was the most injuri-
ous component to endothelium [53].
The Hhcy Lowering Treatment
Controversy
A meta-analysis with 18 retrospective and 12 prospective studies
indicated that a 25% decrease in Hcy was associated with an 11%
lower ischemic heart disease risk [17]. However, in the Athero-
sclerosis Risk In Communities (ARIC) study and the Multiple Risk
Factor Intervention Trial (MRFIT), the association between Hcy
and cardiovascular disease was unable to erect [54,55]. The Car-
diovascular Risk Extended Evaluation in Dialysis patients
(CREED) study found that a 10 lmol/L increase in homocysteine
was associated with 20% increased risk of cardiovascular events in

Table 1 Completed randomized controlled studies testing the effects of Hcy lowering vitamins on cardiovascular diseases

Trials (number of
included subjects) Subjects Clinical outcomes Results (risk ratio, RR)

Albert [38] n = 5442
ASFAST [36] n = 315
Ebbing [47] n = 3096
Ebbing [43] n = 6837
FACIT [31] n = 636
FAVORIT [42] n = 4110
Hankey [48] n = 6609
for taking antiplatelet,
1463 for not taking
antiplatelet
Heinz [49] n = 650
HOPE 2 [35] n = 5522
HOST [39] n = 2056
Liem [50] n = 593
NORVIT [34] n = 3749
SEARCH [41] n = 12,064
VISP [51] n = 3680
WENBIT [44] n = 3088
Wrone [32] n = 510
Women with one or more
coronary risk factors
Chronic renal failure
Patients undergoing
coronary angiography
Patients with ischemic
heart diseases
Successful coronary
stenting
Stable kidney
transplant recipients
Recent stroke or transient
ischemic attack
End-stage renal diseases
Vascular diseases or diabetes
Advanced chronic kidney
diseases or renal failure
Coronary artery diseases
Acute myocardial infarction
Survivors of myocardial
infarction
Nondisabling stroke
Patients with percutaneous
coronary intervention
End-stage renal diseases
Myocardial infarction, 1.03 (95% CI, 0.901.19)
coronary revascularization
Myocardial infarction, 0.98 (95% CI, 0.661.47)
stroke, cardiovascular death
All-cause death, nonfatal 1.09 (95% CI, 0.901.32)
acute myocardial infarction,
unstable angina pectoris, etc.
Cardiovascular death, 1.07 (95% CI, 0.951.21)
acute myocardial
infarction, or stroke
Minimal luminal diameter, Increased the risk of
late loss, restenosis rate restenosis
Myocardial infarction, stroke, 0.99 (95% CI, 0.841.17)
cardiovascular disease death,
resuscitated sudden death,
coronary artery, or renal
artery revascularization, etc.
Stroke, myocardial infarction, 0.94 (95% CI, 0.831.07)
or death from vascular causes and 0.76 (95% CI, 0.600.96)
Total mortality, fatal and 1.13 (95% CI, 0.851.50)
nonfatal cardiovascular event
Mortality from cardiovascular 0.95 (95% CI, 0.841.07)
causes, myocardial infarction
and stroke
All-cause mortality 1.04 (95% CI, 0.911.18)
Vascular death 0.85 (95% CI, 0.561.31)
Recurrent myocardial 1.08 (95% CI, 0.931.25)
infarction, stroke, and
sudden death attributed to
coronary artery disease
Coronary death, myocardial 1.04 (95% CI, 0.971.12)
infarction, coronary or
noncoronary revascularization,
fatal or nonfatal stroke
Coronary heart disease 1.00 (95% CI, 0.801.10)
Coronary artery disease OR 1.84 (95% CI, 1.073.18)
Cardiovascular events No difference between groups

e22 Cardiovascular Therapeutics 31 (2013) e19e26 2012 John Wiley & Sons Ltd
X. Cheng
subjects with chronic renal failure; however, rather than high
serum levels, low levels of Hcy were associated with more than
twofold increase in the risk of hospitalizations and death during a
1-year follow-up [56,57].
Bazzano et al. [58] performed a meta-analysis included 12 ran-
domized controlled trials (RCTs, not including NORVIT and
HOPE-2) to examine the effect of folic acid therapy for the preven-
tion of cardiovascular events and found that the relative risk was
0.95 (95% CI, 0.881.03) for cardiovascular disease and 1.04
(95% CI, 0.921.17) for coronary heart disease. Although the
presence of cardiovascular disease was associated with higher Hcy
levels only in the subjects with Hcy over 15 lmol/L [59], unex-
pectedly, in a randomized trial, which evaluated the efficacy of
high-dose folic acid in preventing cardiovascular events in 510
patients with ESRD, researchers found that high baseline Hhcy
was associated with lower event rates, that was to say, they dem-
onstrated a reverse relationship between Hhcy and cardiovascular
events in patients with ESRD [32].
One potential explanation for this phenomenon was that Hcy
was directly correlated with indicators of nutritional status, for
example creatinine and albumin; therefore, in renal failure
patients, low Hcy level might denote malnutrition or poor progno-
sis. However, clinically stable renal transplant recipients had an
excess prevalence of Hcy, indicating that improvement in GFR in
this subject did not completely reflect serum Hcy to average [60].
More directly, recently published studies showed that serum Hcy
was inversely related to the GFR for the so-called malnutrition
inflammationcachexia syndrome [61].
Several possible reasons were considered to explain the incon-
sistencies between findings from clinical interventional trials and
epidemiological studies. First, generally, RCTs included only sub-
jects with mild elevation of serum Hcy (not more than 15 lmol/
L); however, successful vitamin supplemental therapy might be
determined by a salient Hcy concentration threshold, above
which the risk of Hcy to the progression of cardiovascular disease
was unconvertible. Second, folic acid treatment might adversely
influence vascular reactivity via promoting proatherogenic
changes in vascular endothelial cells. Additionally, folate and B
vitamins could promote DNA synthesis, stimulate cell prolifera-
tion, and lead to neointimal proliferation in patients with estab-
lished atherosclerosis [62]. And last, other than serum total Hcy,
highly reactive thiolactone formation and protein homocysteiny-
lation were processed directly associated with endothelial toxicity
in clinical assessment of cardiovascular risk [63].
New Insights for Hhcy to CVD
Although recently published meta-analyses indicated that homo-
cysteine-lowing therapy did not decrease the risk of nonfatal or
fatal CVD [6468], the main findings of the Vitamin Intervention
for Stroke Prevention (VISP) trial indicated no benefit of B vita-
mins on the risk of myocardial infarction, whereas a subgroup
analysis of the VISP trial showed effect in a defined subset of the
population [51,69]. The effects of Hcy lowering by B vitamins
might be dependent on the disease stage. In the absence of athero-
sclerotic lesions in any more or less advanced stage, the lower Hcy
might have beneficial effects, whereas in subjects with significant
2012 John Wiley & Sons Ltd
Hhcy Lowering and CVD Events
atherosclerotic lesions, the B vitamins might have detrimental
effects, neutralizing the benefit of Hcy lowering [25].
The progress of an atherosclerosis plaque was slow, generally
taking 3040 years from initial development to a clinical event,
whereas most intervention trials relating plasma Hcy concentra-
tions to CVD incidence were based on exposure to Hhcy for dura-
tion of <5 years. A meta-analysis on vitamin B supplement for
prevention of stroke showed a full absence of any effect in the
short-term studies, but a significant 29% decrease in the subjects
with at least 36 months of follow-up [70].
Chronic Hhcy induced vascular remodeling that transduced
changes in vascular wall in a way that artery demonstrated vein
phenotype [71]. In a high-methionine dietinduced rats model,
Hhcy might contribute to restrain cardiac stem cells (CSC)-mediated
cardiac repair by reducing stem cell factor (SCF)-induced homing
of CSCs [72]. A global loss of cytosine methylation in DNA has
been implicated, and growing evidence indicated that modifica-
tion in DNA methylation can be brought about by altering the
intake of methyl donors such as folate. However, in a randomized
double-blind placebo-controlled study with 818 participants,
there was no difference in global DNA methylation between those
randomized to folic acid and those to placebo (difference = 0.008,
95% CI, 0.005 to 0.07, P = 0.79) and was also no difference
between treatment groups when stratified for MTHFR 677C/T
genotype (CC, n = 76; CT, n = 70; TT, n = 70) [73].
Recently, a 12th 5-year-plan program for the Discovery in New
Drugs, named the Study on Comparative Effectiveness in Type H Hyper-
tension, had been started in China. This program was aimed to find
the discrepancies of folic acid fortification in Chinese patients with
hypertension and hyperhomocysteinemia.
New Therapeutic Replacements for Hhcy
Hhcy was associated with dietary intake, metabolic clearance,
vitamin deficiencies, enzyme blocks, age, gender, serum creati-
nine, and multivitamin application [74]. The anatomic and meta-
bolic reason for folate deficiency is described in Table 2 [75].
Fortification of folic acid was used to reduce the incidence of neu-
ral tube defects in USA and Canada since 1998, and this public
health strategy lowered the Hhcy levels not only reduced the
prevalence of congenital anomalies, but also decreased the inci-
dence of stroke mortality [76].
N-Acetylcysteine therapy could decrease serum Hcy level and
potentially representing an alternative approach to lower cardio-
vascular risk in hemodialysis patients [77]. Hhcy was also associ-
ated with hypothyroidism and estrogen deficiency. Therefore, it
was not surprising that estrogen replacement treatment reduced
the Hhcy in postmenopausal women [10, 78]. Although N-acetyl-
cysteine and estrogen supplementations decreased serum Hcy lev-
els in some certain population, the preventing effects of these
treatments on CVD events were largely unknown.
Conclusions
Although the efficacy of combined vitamins fortification in
reducing the risks of CVD in patients with Hhcy is in
Cardiovascular Therapeutics 31 (2013) e19e26 e23
Hhcy Lowering and CVD Events X. Cheng

Table 2 The anatomic and metabolic reasons for folate deficiency, adapted from Maron et al. [75]

Malabsorption Increased utilization Increased loss

Tropical sprue Pregnancy Chronic inflammatory conditions that

Gluten-induced enteropathy Lactation increase folate demands, but decrease
Intestinal megaloblastosis Prematurity appetite: TB, Crohns disease, psoriasis, etc.
Extensive jejunal resection Alcoholism Congestive heart failure
Inflammatory bowel disease Chronic hematologic diseases of Peritoneal dialysis, hemodialysis
Diabetic enteropathy increased cell turnover: hemolytic Alcoholism
anemia, sickle cell anemia, myelofibrosis Active liver disease
Chronic oncologic diseases of
increased cell turn over: carcinoma,
lymphoma, leukemia, myeloma

debate, identification of subjects who are most likely to ben-

efit from this supplementation needs further investigation.
Although many large sample clinical trials do not support
the administration of high-dose vitamin supplements in
decreasing the risks of CVD in CKD or ESRD patients, a
smaller protective effect of the vitamins on CVD events is
possible.
Conflict of Interest
The article is not under consideration elsewhere. None of the arti-
cles contents has been previously published. All the authors have
read and approved the manuscript. There was not any potential
conflict of interest in this article.

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