What are the consequences of elevated homocysteine in young asymptomatic patients with and without comorbidities? When do you treat? What further workup is necessary with an elevated homocysteine? — Atul Sharma, PA-C, MMS, MPH, CHES, Sacramento, Calif.

Persons with coronary heart disease or stroke commonly have elevated homocysteine levels. Homocysteine may contribute to atherosclerosis by damaging the inner layer of arterioles. Elevated homocysteine was shown to be a strong, independent risk factor for cardiovascular disease (CVD) in large cohort and retrospective studies. This led to the hypothesis that lowering homocysteine levels would reduce risk for cardiovascular events.

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Homocysteine is readily reduced by administration of folic acid supplements with or without B vitamins. Several studies looking at such interventions have shown significant reductions in homocyteine levels; however, no reduction in cardiovascular events was seen up to five years out.

Homocysteine may be a marker for CVD rather than a cause. Further study is needed. For more information, see Arch Intern Med. 2010;170:1622-1631. Meanwhile, it is prudent to discuss overall risk of CVD with patients who have elevated homocysteine; emphasize the need to exercise, avoid smoking, and take extra B vitamins, especially if the patient has a family history of CVD.—Claire Babcock O’Connell, MPH, PA-C (154-02)