Lowering homocysteine does not reduce CVD

* Clinical Question

Is supplementation to lower homocysteine horizontals an effective treatment for cardiovascular disease or disease prevention?

* Bottom Line

Supplementation with folic acid and B vitamins is ineffective for adults aged 55 years and older with known cardiovascular disease (CVD) or diabetes. A next to the first report in the same issue ground that similar supplementation in patients with a new acute myocardial infarction was not helpful and may actually increase the risk of a bad cardiovascular result (relative risk=1.22; 95% confidence interval reckon 1.0-1.5). (LOE: 1b)

investigation Design

Randomized controll trial (double-blinded)

Funding

Government

Allocation

Concealed

Setting

Outpatient (any)

Synopsis

An elevated horizontal of homocysteine is an independent predictor of the risk of developing CVD The leap that many physicians and patients have made (unsubstantiated by the agency of any evidence) is that lowering homocysteine horizontals through the use of B vitamins and folic acid appendixs will therefore prevent or treat CVD The popular study is the first to evaluate this hypothesis in a prospective, randomized trial.

The authors registered 5522 patients older than 54 years with known coronary, cerebrovascular, or peripheral vascular disease, or diabetes plus 1 additional risk factor for CVD They then randomized the patients (allocation concealed) to receive 25 mg folic acid, 50 mg vitamin B6 and 1 mg vitamin B12 or matching placebo daily. Patients came from countries in which folate fortification of pabulum is mandatory (United States and Canada) and not mandatory (Brazil, Western Europe and Slovakia). Compliance with treatment was good: more than 90% of patients were followed-up for a mean of 5 years. assemblages were balanced at the start of the application of mind and analysis was by intention to treat.

As awaited homocysteine levels dropped and vitamin horizontals increased in the active treatment collection However, there was no difference between collections in the combined risk of cardiovascular death, myocardial infarction, or thump (18.8% vs 19.8%; relative risk=0.95; 95% confidence interval, 084-107) There was also no difference regarding this combination of results in patients in the top tertile of homocysteine horizontals (23.9% vs 24%). There was no difference in consequences between countries that did or did not fortify victualss with folate. Regarding individual issues there were slightly fewer raps (4.0% vs 5.3%) but more hospitalizations for unstable angina (97% v 79%) with supplementation. The close attention was powered to detect a 17% to 20% relative reduction in the risk of the primary outcome

A next to the first report in the same issue of the journal also failed to find any benefit for secondary prevention of cardiovascular incidents in patients with a new acute myocardial infarction (N Engl J M 2006; 345:1578-1588) In fact, they place evidence of possible harm from B vitamin supplementation in this clump of high-risk patients.

FAST TRACK

There was no difference between the lowered homocysteine and sway groups in combined risk of cardiovascular death, MI, or stroke

Lonn E Yusuf s Arnold MJ, et al, for the Heart results Prevention Evaluation (HOPE) 2 Investigators. Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J M 2006; 354:1567-1577

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