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Pathophysiology, Screening, and Treatment

James H. Stein, MD; Patrick E. McBride, MD, MPH

Arch Intern Med. 1998;158:1301-1306.

Hyperhomocysteinemia has recently been identified as an important risk factor for atherosclerotic vascular disease. This article reviews homocysteine metabolism, causes of hyperhomocysteinemia, the pathophysiological findings of this disorder, and epidemiological studies of homocysteine and vascular disease. Screening for hyperhomocysteinemia should be considered for patients at high risk for vascular disease or abnormalities of homocysteine metabolism. For primary prevention of vascular disease, treatment of patients with homocysteine levels of 14 µmol/L or higher should be considered. For secondary prevention, treatment of patients with homocysteine levels of 11 µmol/L or higher should be considered. Treatment is most conveniently administered as a folic acid supplement (400-1000 µg) and a high-potency multivitamin that contains at least 400 µg of folate. Higher doses of folic acid and cyanocobalamin supplements may be required in some patients. Until prospective clinical trial data become available, these conservative recommendations provide a safe, effective, and evidence-based approach to the diagnosis, evaluation, and management of patients with hyperhomocysteinemia.

From the Preventive Cardiology Program, Section of Cardiology, Department of Medicine, University of Wisconsin Medical School, Madison.

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