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.
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)