Abstract
Whether elevated serum homocysteine concentrations (ie, hyperhomocysteinaemia) are a risk factor for ischaemic stroke and if normalising hyperhomocysteinaemia might reduce stroke risk are controversial issues. Hyperhomocysteinaemia can be primary (ie, hereditary) or secondary (ie, due to vitamin B12 deficiency, diabetes, etc). The effect of both primary and secondary hyperhomocysteinaemia on putative stroke risk is debated. One study 1 Wang W Gao C Yu C et al. No association between elevated total homocysteine levels and functional outcome in elderly patients with acute cerebral infarction. Front Aging Neurosci. 2017; 9: 70 Crossref PubMed Scopus (13) Google Scholar has shown that hyperhomocysteinaemia is an independent risk factor for ischaemic stroke, whereas other studies have reached different conclusions. 2 Pang H Han B Fu Q Zong Z Association of high homocysteine levels with the risk stratification in hypertensive patients at risk of stroke. Clin Ther. 2016; 38: 1184-1192 Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar , 3 Toole JF Malinow MR Chambless LE et al. Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial. JAMA. 2004; 291: 565-575 Crossref PubMed Scopus (1212) Google Scholar , 4 Bønaa KH Njølstad I Ueland PM et al. Homocysteine lowering and cardiovascular events after acute myocardial infarction. N Engl J Med. 2006; 354: 1578-1588 Crossref PubMed Scopus (1264) Google Scholar , 5 Lonn E Yusuf S Arnold MJ et al. Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J Med. 2006; 354: 1567-1577 Crossref PubMed Scopus (1527) Google Scholar In The Lancet Neurology, J David Spence and colleagues 6 Spence D Yi Q Hankey GJ B Vitamins in stroke prevention: time to reconsider. Lancet Neurology. 2017; 16: 750-760 Summary Full Text Full Text PDF PubMed Scopus (81) Google Scholar advocate the use of B vitamins (folic acid, vitamin B12, and vitamin B6) to normalise hyperhomocysteinaemia for the prevention of ischaemic stroke. Their Personal View raises concerns about arguments in favour of normalising hyperhomocysteinaemia. B vitamins in stroke prevention: time to reconsiderB vitamin therapy lowers plasma total homocysteine concentrations, and might be a beneficial intervention for stroke prevention; however, cyanocobalamin (a form of vitamin B12) can accelerate decline in renal function and increase the risk of cardiovascular events in patients with impaired renal function. Although early trials did not show benefit in reduction of stroke, these results might have been due to harm in participants with impaired renal function. In patients with diabetic nephropathy, cyanocobalamin is harmful, whereas B vitamins appear to reduce cardiovascular events in study participants with normal renal function. Full-Text PDF
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