Elevated plasma total homocysteine (tHcy) is a risk factor for occlusive cardiovascular disease (CVD). This concept is based on the observations of premature vascular disease in patients with homocystinuria, the relation between tHcy and both clinical CVD as well as preclinical atherosclerotic disease, the relation between tHcy in children and CVD in their parents or relatives, and reduction in CVD or surrogate endpoints after tHcy-lowering intervention with B vitamins. Plausible mechanisms include the in vivo interference with nitric oxide-dependent reactive vasodilatation. Some observations have raised questions about tHcy as a risk factor. 1) Some prospective studies showed a weak relation or no relation between tHcy and CVD. 2) Several traditional risk factors are associated with tHcy and may confound the relation between tHcy and CVD. 3) tHcy is related to renal function, and hyperhomocysteinemia may reflect early nephrosclerosis. 4) The C677T transition of the methylenetetrahydrofolate reductase gene causes a moderate increase in tHcy but no or only minor increased CVD risk. However, the strength of some of these arguments can be questioned because there is increasing evidence that tHcy is a proximate risk factor provoking the acute event, it strongly interacts with traditional risk factors, and it may predict CVD or death in patients with chronic renal failure. Furthermore, the studies of the C677T polymorphism lack statistical power, and the TT genotype may even modulate CVD risk independently of homocysteine. Thus, only placebocontrolled intervention studies with tHcy-lowering B vitamins and clinical endpoints can provide additional valid arguments for the debate over whether tHcy is a causal CVD risk factor. Am J Clin Nutr 2000;72:324-32.KEY WORDS Homocysteine, cardiovascular disease, methylenetetrahydrofolate reductase polymorphism, renal, nephrosclerosis
INTRODUCTIONPatients with the inborn metabolic error homocystinuria have markedly elevated homocysteine concentrations in plasma and urine and occlusive vascular disease in early adulthood or even in childhood (1). On the basis of these observations, McCully (2) formulated the homocysteine theory of atherosclerosis in 1969 (2). In 1976, Wilcken and Wilcken (3) published their pioneering work on abnormal homocysteine metabolism in patients with coronary artery disease. Since then, convincing evidence has been gathered on the relation between moderate elevation of plasma total homocysteine (tHcy) and the risk of occlusive vascular disease in the coronary, cerebral (4), and peripheral arteries and, more recently, of venous thrombosis (5-7). The literature on this subject now includes > 120 articles reporting on > 12 000 patient-control subject sets. Almost all of the retrospective case-control studies and most of the prospective studies support the concept of hyperhomocysteinemia as a risk factor for cardiovascular disease (CVD; 6, 8), and several meta-analyses showed similar, consistent results, as summarized in Figure 1.Some observations may s...