Early determination of homocysteine levels in acute coronary syndromes, is it an independent prognostic factor?

Influence of Narrow-Band Ultra Violet B Phototherapy on Homocysteine Status: A Prospective Study of Patients with Different Cutaneous Disorders

Background: Artificial ultraviolet (UV) radiation is a mainstay in the treatment of a variety of inflammatory skin disorders. Despite existence from a wealth of studies on the impact of narrow-band UVB (NBUVB) on serum levels of nutrients, clinical data on its effect on serum homocysteine (HC) level, which is thought to be a risk factor for cardiovascular disorders, dementia, and depression, are scarce. Objective: To assess serum HC status before and after treatment with at least 30 sessions of NBUVB exposure in patients with various cutaneous disorders. Methods: A prospective cohort study was conducted on 39 patients with psoriasis, vitiligo, atopic dermatitis, and mycosis fungoides who underwent at least 30 sessions of NBUVB phototherapy. Serum HC was measured and compared before and after phototherapy. This study was approved by relevant ethics committee. Results: Levels of HC decreased by 24.8% after 30 sessions of NBUVB phototherapy (10.53 ± 3.64 μmol/L vs. 7.92 ± 3.26 μmol/L, p-value <0.0001) and this decrease was more prominent in male participants and patients older than 40 years. Conclusions: Based to our findings, NBUVB phototherapy might be a modality of choice especially for older male patients not only as an effective treatment for cutaneous conditions, but also as a modality with potential protective effects against cardio-cerebro-vascular accidents.

Homocysteine and long-term recurrent infarction following an acute coronary syndrome

BACKGROUND

There are no well-established predictors of recurrent ischemic coronary events after an acute coronary syndrome (ACS). Higher levels of homocysteine have been reported to be associated with an increased atherosclerotic burden. The primary endpoint was to assess the relationship between homocysteine at discharge and very long-term recurrent myocardial infarction (MI).

METHODS

1306 consecutive patients with ACS were evaluated (862 with non-ST-segment elevation ACS [NSTEACS] and 444 with ST-segment elevation myocardial infarction [STEMI]) discharged from October 2000 to June 2003 in a single teaching-center. The relationship between homocysteine at discharge and recurrent MI was evaluated through bivariate negative binomial regression accounting for mortality as a competitive event.

RESULTS

The mean age was 66.8 ± 12.4 years, 69.1% were men, and 32.2% showed prior diabetes mellitus. Most of the patients were admitted for an NSTEACS (66.0%). The median (interquartile range) GRACE risk score, Charlson comorbidity index, and homocysteine were 144 (122-175) points, 1 (1-2) points, and 11.9 (9.3-15.6) μmol/L, respectively. In-hospital revascularization was performed in 26.3% of patients. At a median follow-up of 9.7 (4.5-15.1) years, 709 (54.3%) deaths were registered and 779 recurrent MI in 478 (36.6%) patients. The rates of recurrent MI were higher in patients in the upper homocysteine quartiles (p < 0.001). After a multivariate adjustment, homocysteine along its continuum remained almost linearly associated with a higher risk of recurrent MI (p = 0.001) and all-cause mortality (p < 0.001).

CONCLUSIONS

In patients with ACS, higher homocysteine levels identified those at a higher risk of recurrent MI at very long-term follow-up.

Relationship between serum homocysteine levels and long-term outcomes in patients with ST-segment elevation myocardial infarction

Background:

The mortality of cardiovascular disease is constantly rising, and novel biomarkers help us predict residual risk. This study aimed to evaluate the predictive value of serum homocysteine (HCY) levels on prognosis in patients with ST-segment elevation myocardial infarction (STEMI).

Methods:

The 419 consecutive patients with STEMI, treated at one medical center, from March 2010 to December 2015 were retrospectively investigated. Peripheral blood samples were obtained within 24 h of admission and HCY concentrations were measured using an enzymatic cycling assay. The patients were divided into high HCY level (H-HCY) and low HCY level (L-HCY) groups. Short- and long-term outcomes were compared, as were age-based subgroups (patients aged 60 years and younger vs. those older than 60 years). Statistical analyses were mainly conducted by Student t-test, Chi-squared test, logistic regression, and Cox proportional-hazards regression.

Results:

The H-HCY group had more males (84.6% vs. 75.4%, P = 0.018), and a lower prevalence of diabetes (20.2% vs. 35.5%, P < 0.001), compared with the L-HCY group. During hospitalization, there were seven mortalities in the L-HCY group and 10 in the H-HCY group (3.3% vs. 4.8%, P = 0.440). During the median follow-up period of 35.8 (26.9–46.1) months, 33 (16.2%) patients in the L-HCY group and 48 (24.2%) in the H-HCY group experienced major adverse cardiovascular and cerebrovascular events (MACCE) (P = 0.120). History of hypertension (hazard ratio [HR]: 1.881, 95% confidence interval [CI]: 1.178–3.005, P = 0.008) and higher Killip class (HR: 1.923, 95% CI: 1.419–2.607, P < 0.001), but not HCY levels (HR: 1.007, 95% CI: 0.987–1.027, P = 0.507), were significantly associated with long-term outcomes. However, the subgroup analysis indicated that in older patients, HCY levels were significantly associated with long-term outcomes (HR: 1.036, 95% CI: 1.011–1.062, P = 0.005).

Conclusion:

Serum HCY levels did not independently predict in-hospital or long-term outcomes in patients with STEMI; however, among elderly patients with STEMI, this study revealed a risk profile for late outcomes that incorporated HCY level.

Serum Homocysteine and Behavioral and Psychological Symptoms of Dementia: Is There Any Correlation in Alzheimer's Disease?

Background

There are studies showing the relation between serum B12, folate and Behavioral and Psychological symptoms of Dementia (BPSD) in Alzheimer's disease (AD). Serum levels of these vitamins do not reflect actual disease status and therefore checking the serum Homocysteine level is considered a better test. Homocysteine has been found to be associated with cognitive impairment and various psychiatric disorders.

Purpose

This study was planned to identify the correlation between serum homocysteine levels and BPSD in AD patients.

Methods

AD patients (n = 18) and healthy controls (n = 18) were included in the study. Diagnosis of AD was confirmed using International Classification Disease-10. AD patients were assessed using Mini Mental Status Examination (MMSE), Clinical Dementia Rating scale (CDR), Global Deterioration scale (GDS), and Neuropsychiatric inventory (NPI). Healthy controls were assessed on MMSE and Mini International Neuropsychiatric Interview. Serum homocysteine, vitamin B12, and folate levels were measured in all study subjects.

Results

Patients with AD had statistically significant higher serum levels of homocysteine as compared to the control group, while the levels of vitamin B12 and folate did not differ significantly. There was statistically significant positive correlation of serum homocysteine levels with total NPI score as well as with NPI sub-domains particularly delusion, agitation/aggression, and depression/dysphoria. Serum homocysteine levels did not correlate significantly with MMSE, CDR, and GDS scores.

Conclusion

Correlation was observed between serum homocysteine levels and behavioral and psychological symptoms of AD. There is a possibility of etiological role, but the underlying pathophysiological mechanisms need to be elucidated. Whether patients will benefit or not with supplements of vitamin B12 and folate requires further research. This was a cross-sectional study and findings should not be generalized. Further prospective longitudinal studies with a large number of patients are needed.

Correlation between behavioural and psychological symptoms of Alzheimer type dementia and plasma homocysteine concentration

The relationship between plasma homocysteine and behavioral and psychological symptoms of dementia (BPSD) has not been specifically investigated in previous research. In this study, we compared plasma homocysteine (Hcy) among 40 Alzheimer's disease (AD) patients with BPSD, 37 AD patients without BPSD, and 39 healthy controls. Our results evidenced that the plasma homocysteine levels in AD patients with BPSD and without BPSD were higher than healthy controls and that the plasma homocysteine concentration in AD patients with BPSD was the highest among the three groups. Significant correlation between plasma homocysteine concentration and cognitive decline and duration of dementia was observed, but there was no correlation between BPSD and cognitive dysfunction or duration of dementia. In conclusion, this study showed for the first time that BPSD were associated with plasma homocysteine concentration in Alzheimer's dementia, and the results supported that hyperhomocysteine may take part in the pathogenesis of BPSD.

Serum homocysteine levels are correlated with behavioral and psychological symptoms of Alzheimer's disease

PURPOSE

Homocysteine has been associated with cognitive impairment and various psychiatric symptoms. This study was designed to clarify whether a relationship exists between the serum levels of homocysteine and the behavioral and psychological symptoms of dementia.

METHODS

Patients with Alzheimer's disease (n=77) and control subjects (n=37) were included in this study. History taking, physical examination, and cognitive assessment were carried out as part of the investigation for the diagnosis of Alzheimer's disease based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The Mini-Mental State Examination, Global Deterioration Scale, Clinical Dementia Rating, and the Korean version of the Neuropsychiatric Inventory were applied to all patients. The patients' serum homocysteine, folate, and vitamin B12 levels were measured.

RESULTS

Patients with Alzheimer's disease had statistically significantly lower Mini-Mental State Examination scores and higher serum homocysteine levels compared to the control subjects. Mean serum folate and vitamin B12 concentration were significantly lower in patients with Alzheimer's disease compared to control subjects. A statistically significant positive correlation was found between the serum homocysteine levels and the Neuropsychiatric Inventory subdomains, including delusion, agitation/aggression, depression/dysphoria, elation/euphoria, apathy/indifference, and disinhibition. No statistically significant correlation was found between the serum homocysteine concentration and the Mini-Mental State Examination, Global Deterioration Scale, or Clinical Dementia Rating.

CONCLUSION

Associations between the serum homocysteine levels and behavioral and psychological symptoms of dementia were observed, raising the possibility of an etiological role. However, the correlations between the folate or vitamin B12 levels and the Neuropsychiatric Inventory scores were not significant. The pathophysiological mechanisms underlying these findings remain to be elucidated. This was a cross-sectional study and the findings should be confirmed by repetitive, prospective longitudinal studies in a larger group of patients with neurodegenerative disorders.

Are plasma homocysteine levels related to neurological severity and functional outcome after ischemic stroke in the Korean population?

Hyperhomocysteinemia is known to be an independent risk factor for arteriosclerosis. However, the prognosis of functional disability in cerebrovascular disease has not been well established. Therefore, we conducted this study to determine the prognostic significance of plasma homocysteine (Hcy) levels in Asian patients with functional disabilities after acute ischemic stroke. A total of 267 patients were examined within 24 h after symptom onset. Hcy was measured at admission. The correlations between plasma Hcy concentration and functional disability at 1-month, 3-months, 6-months, and 12-months after stroke onset were analyzed. In addition, the associations between each risk factor for stroke or neurological severity and plasma Hcy level were evaluated. The results of the present study showed that there was no significant correlation between Hcy level on admission and modified Rankin Scale score obtained at 1-month, 3-months, 6-months, and 12-months after stroke onset. There was also no association between plasma Hcy level and neurological severity after stroke or stroke subtype. This study showed that there is no association between Hcy levels and functional outcome after stroke. Therefore, we cautiously assert that plasma Hcy levels have no value as predictors of functional disability in Asian patients with stroke.

The impact of circulating total homocysteine levels on long-term cardiovascular mortality in patients with acute coronary syndromes

BACKGROUND

To evaluate the possible independent impact of circulating total homocysteine (tHcy) levels on long-term cardiovascular mortality, in patients with either ST-segment elevation myocardial infarction (STEMI), or non-ST-segment elevation acute coronary syndromes (NSTE-ACS).

METHODS

A total of 458 STEMI and 476 NSTE-ACS patients who presented consecutively, within the first 12 and 24 h of index pain respectively were studied. Each cohort was divided according to tertiles of circulating tHcy levels upon presentation. Early (30 days) and late (31 days through 5 years) cardiovascular mortality was the predefined study endpoint.

RESULTS

There was no difference in the risk of 30-day cardiovascular death among the tertiles of tHcy in patients with STEMI (7.2%, 8.5% and 12.4% for the first, second and third tertiles respectively; p(trend)=0.3) or NSTE-ACS (3.1%, 3.8% and 5.7% for the first, second and third tertiles respectively; p(trend)=0.5). Patients in the upper tHcy tertile were at significantly higher unadjusted risk of late (from 31 days trough 5 years) cardiovascular death than those in the other two tertiles in STEMI (23.4%, 27.9% and 41.8% for the first, second and third tertiles respectively; p(trend) <0.001), and NSTE-ACS (24.7%, 28.1% and 45.6% for the first, second and third tertiles respectively; p(trend) <0.001) cohorts. However, after adjustment for baseline differences, there was no significant difference in the risk of late cardiovascular death among tHcy tertiles in either cohort. When circulating tHcy levels were treated as a continuous variable, they were significantly associated with late cardiovascular death (p<0.001 for both cohorts) by univariate Cox regression analysis, but not by multivariate Cox regression analysis (p=0.8, and p=1 for STEMI and NSTE-ACS cohorts, respectively).

CONCLUSIONS

Based on the present data circulating tHcy levels determined upon admission do not serve as an independent predictor of long-term cardiovascular mortality in patients with either STEMI or NSTE-ACS.

Role of asymmetric dimethylarginine in homocysteine-induced apoptosis of vascular smooth muscle cells

Homocysteine (Hcy) could induce apoptosis of vascular smooth muscle cells (VSMC). Asymmetric dimethylarginine (ADMA) has been thought as a novel risk factor for cardiovascular diseases. We hypothesized that ADMA mediates homocysteine-induced apoptosis of VSMC. In this experiment the level of ADMA in the medium measured by high-performance liquid chromatography (HPLC) was elevated when the apoptosis of T/G HA-VSMC was induced by Hcy which was detected by Hoechst33342 staining or flow cytometry (FCM) with Annecin V+Propidium Iodide (PI). Exogenous ADMA induced the apoptosis of VSMC. At the same time, ADMA elevated the level of intracellular reactive oxidative species (ROS) determined by fluorescent ROS detection kit. The activation of JNK and p38MAPK contributed to ADMA-induced apoptosis of VSMC. The present results suggest that endogenous ADMA is involved in apoptosis of VSMC induced by Hcy, and the effects of ADMA is related to elevation of intracellular ROS and activation of JNK/p38MAPK signaling pathways.

Influence of high homocysteine and low folate plasmatic levels in medium-term prognosis after acute coronary syndromes

BACKGROUND

To test prospectively whether moderate hyperhomocysteinemia and low folate levels could have an influence in the prognosis of 155 patients who presented with an acute coronary syndrome.

METHODS AND RESULTS

After a mean follow-up of 13.4+/-7.4 months, patients with low folate levels had higher percentages of cardiovascular death and major cardiovascular events (33% vs. 5%, p<0.001; 44% vs. 22%, p<0.05) and patients with high homocysteine levels had a higher percentage of major cardiovascular events (31% vs. 14.5%, p<0.03). Kaplan-Meier survival estimates analysis showed that patients with low folate levels had a significantly higher probability of cardiovascular death and lower free-of-events survival (log rank statistic: 21.17, p<0.001 and 6.59, p=0.01). Patients with high homocysteine levels had a lower free-of-events survival (log rank statistic: 4.95, p=0.02). Different survival multivariate analysis model showed that the presence of low folate levels was an independent predictor of cardiovascular death (hazard ratio 8.85, 95% confidence interval 2.6-29.3, p<0.000) and high homocysteine levels was identified as independent predictor of major cardiovascular events (hazard ratio 2.34, 95% confidence interval 1.07-5.12, p<0.03).

CONCLUSIONS

Low folate levels and moderate hyperhomocysteinemia were identified as independent predictors of cardiovascular events in the follow-up.

Hyperhomocysteinemia is a risk factor of recurrent coronary event in young patients irrespective to the MTHFR C677T polymorphism

Despite the well-known pro-coagulant effect of hyperhomocysteinemia, data is limited regarding the result on recurrent coronary event (RCE) in young people. One hundred and forty patients <55 years old with a first acute coronary syndrome (ACS) were prospectively followed for a mean (+/-S.D.) follow-up of 49+/-14 months in order to investigate the relationship between homocysteine levels (tHcy) at admission and the incidence of RCE. The tHcy values were divided into quartiles to examine their relationship with end points. Furthermore, we determined the effect of C677T methylene tetrahydrofolate reductase (MTHFR) polymorphism, as well as other risk factors for developing a RCE. The median plasma homocysteine concentration was 9.6 mumol/L (interquartile range, 3.7). In the screening of MTHFR C677T polymorphism in patients with ACS, the T allele frequency was 0.4 and the genotype frequency distributions were in Hardy-Weinberg equilibrium. At time of final evaluation, 49 (35%) of the 140 valuable patients had developed a RCE. Increasing numbers of RCE were observed for increasing quartiles of tHcy according to Kaplan-Meier survival (Log-rank test=0.0092). The MTHFR C677T polymorphism was not associated with an increased incidence of RCE. In multivariate analysis, the variables independently associated with a higher risk of RCE were age older than 45 years [HR=2.7; (95% CI, 1.3-6.1); p=0.030], body mass index more than 25 [HR=2.6; (95% CI, 1.1-5.9); p=0.034] and tHcy levels into quartile 4 (tHcy>12.37 mumol/L) [HR=2.5; (95% CI, 1.1-4.7); p=0.04]. Elevated plasma homocysteine level at admission is an independent risk factor for RCE after the first episode of ACS in young patients irrespective of the status of MTHFR C677T.

Is Taurine A Biomarker?

Taurine, a sulfur-containing amino acid present in high concentrations in mammals, plays an important role in several essential biological processes. Taurine is not incorporated into protein and is the most abundant free amino acid in the heart, retina, skeletal muscle, brain, and leukocytes. The ideal biomarker or biological measure should be reliable, reproducible, noninvasive, simple to perform, and inexpensive. Samples for biological measures should be easily obtained from physiological fluids such as blood or urine. Taurine levels in physiologic fluids have been useful for both diagnosing pathology and establishing a disease modifying therapy. In the specific case of taurine, it is important that patient information include nutritional supplementation as well as information on disease status and medications. Taurine has been measured in biological fluids due to the importance of this simple amino acid and its relative ease of determination. Taurine has been measured in animal models of disease as well as a variety of human conditions. However, it remains unclear how taurine should be used as a biomarker and in which situations this measurement would be a good prognostic or diagnostic indicator.