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Fukae J, Eguchi H, Wada Y, Fuse A, Chishima R, Nakatani M, Nakajima A, Hattori N, Shimo Y. Case report: Young-onset large vessel ischemic stroke due to hyperhomocysteinemia associated with the C677T polymorphism on 5,10-methylenetetrahydrofolate reductase and multi-vitamin deficiency. Front Neurol 2023; 14:1183306. [PMID: 37273715 PMCID: PMC10233819 DOI: 10.3389/fneur.2023.1183306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023] Open
Abstract
Hyperhomocysteinemia is an important risk factor for cerebral infarction. Herein, we report on a 30-year-old man previously diagnosed with epilepsy who presented with right hemiplegia and total aphasia. Magnetic resonance imaging showed a fronto-temporal ischemic lesion due to occlusion of the left middle cerebral artery. Clinical testing and imaging demonstrated that he had hyperhomocysteinemia induced by multiple factors including the C677T polymorphism on 5.10-methylenetetrahydrofolate reductase (MTHFR), and multiple vitamin deficiencies. The C677T polymorphism on MTHFR is closely related to hyperhomocysteinemia and folate deficiency in epileptic patients who are taking multiple anti-convulsants. Given hyperhomocysteinemia can independently cause stroke at a young age, physicians should periodically examine plasma homocysteine and serum folic acid levels in epileptic patients who are on long-term regimens of multiple anti-epileptic drugs.
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Affiliation(s)
- Jiro Fukae
- Department of Neurology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hiroto Eguchi
- Department of Neurology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Yoichi Wada
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Atsuhito Fuse
- Department of Neurology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Rika Chishima
- Department of Clinical Laboratory, Juntendo University Nerima Hospital, Tokyo, Japan
| | | | - Asuka Nakajima
- Department of Neurology, Juntendo University Nerima Hospital, Tokyo, Japan
- Department of Research and Therapeutics for Movement Disorders, Juntendo University School of Medicine, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yasushi Shimo
- Department of Neurology, Juntendo University Nerima Hospital, Tokyo, Japan
- Department of Research and Therapeutics for Movement Disorders, Juntendo University School of Medicine, Tokyo, Japan
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Poglitsch M, Geberth A, Krebs M, Langer FB, Mittlboeck M, Prager G. Plasma homocysteine after laparoscopic Roux-en-Y gastric bypass increases in the early postoperative phase but decreases in the long-term follow-up. A retrospective analysis. Surg Obes Relat Dis 2020; 16:372-380. [PMID: 31959564 DOI: 10.1016/j.soard.2019.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 11/03/2019] [Accepted: 11/24/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Homocysteine is an important independent risk factor for predicting cardiovascular disease (CVD). However, changes in the homocysteine levels after bariatric surgery remain controversial. OBJECTIVES Modeling differences in homocysteine after bariatric surgery. SETTING University Hospital, Austria. METHODS Seven hundred eight consecutive bariatric surgery patients (78% female, 22% male, mean body mass index 41 kg/m2 preoperatively) underwent laparoscopic long-limb Roux-en-Y gastric bypass in a 6-year period and were retrospectively evaluated for changes in their preoperative homocysteine levels, at 3, 6, 9, 12, 18, 24, 36, 48, 60, and 72 months postoperatively. Furthermore, a postal and telephone screening for postoperative CVD with a follow-up of 71% was conducted. RESULTS Hyperhomocysteinemia was present in 11.8% preoperatively (normal range: <15 μmol/L). The median plasma homocysteine level was 10.4 preoperatively, 12.1 at 3, 11.2 at 6, 10.0 at 9, 9.8 at 12, 8.9 at 18, 8.7 at 24, 8.6 at 36, 9.1 at 48, 9.8 at 60, and 10.0 μmol/L at 72 months postoperatively. After subdividing the study population in morbidly obese (n = 509, body mass index 40-50 kg/m2) and super-obese (n = 199, body mass index >50 kg/m2) patients, the short-term increase into homocysteine levels remained. Overall, newly onset CVD risk was 4.2%. After subdividing the CVD risk into risk for myocardial infarction, stroke, and risk for deep vein thrombosis/pulmonary embolism the distribution was as follows: .2% myocardial infarction, .59% stroke, and 2.97% deep vein thrombosis/pulmonary embolism (median 36 [interquartile range 36-48] mo postoperatively). CONCLUSION Laparoscopic Roux-en-Y gastric bypass leads to increased homocysteine levels in the early postoperative period. However, there was no relationship between increased homocysteine levels and CVD event onset.
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Affiliation(s)
- Marcus Poglitsch
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexander Geberth
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Michael Krebs
- Department of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - Felix B Langer
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Martina Mittlboeck
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Gerhard Prager
- Department of Surgery, Medical University of Vienna, Vienna, Austria.
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Stanescu I, Bulboaca A, Fodor D, Dogaru G. Functional outcome after symtomatic internal carotid artery occlusion. BALNEO RESEARCH JOURNAL 2019. [DOI: 10.12680/balneo.2019.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract Internal carotid artery occlusion accounts for 15-20% of ischemic strokes, caused by atherosclerosis or dissection. Clinical symptoms are variable, from asymptomatic cases to minor or severe strokes. Diagnosis in internal carotid artery (ICA) occlusion is based on imaging techniques. Prognosis after ICA occlusion depends on many factors: severity of neurologic deficit, spontaneous recanalization of the artery, and the occurrence of recurrent strokes. Patients with spontaneous recanalization of the occluded ICA tend to have a retained functional ability and favorable clinical outcomes. Medical treatment, recanalization techniques and intensive rehabilitation program are essential in improving functional outcome of patients with stroke produced by ICA occlusion. We present the case of a young patient diagnosed with ischemic stroke produced by internal carotid artery occlusion, with consecutive severe neurologic deficit, and an unfavorable functional outcome, as evaluated with the Modified Rankin Scale. Spontaneous recanalization of the occluded ICA was observed after 6 weeks, suggesting a carotid dissection. The patient was included in an intensive rehabilitation program, associated with best medical therapy, showing improvement of its functional status at 3 months follow up. Key words: ischemic stroke, carotid artery occlusion, carotid dissection, spontaneous recanalization, functional outcome,
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Affiliation(s)
- Ioana Stanescu
- ¹“Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj- Napoca, Romania ²Rehabilitation Hospital Cluj-Napoca, Romania
| | | | - Dana Fodor
- ¹“Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj- Napoca, Romania
| | - Gabriela Dogaru
- ¹“Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj- Napoca, Romania ²Rehabilitation Hospital Cluj-Napoca, Romania
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Qu Y, Zhang HL, Yu LM, Sun Y, Wu HL, Chen YG. Aldehyde dehydrogenase 2 polymorphism as a protective factor for intracranial vascular stenosis in ischemic stroke in Han Chinese. Int J Neurosci 2015; 126:342-7. [PMID: 26000808 DOI: 10.3109/00207454.2015.1017760] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM Aldehyde dehydrogenase 2 (ALDH2) is a key enzyme that metabolizes acetaldehyde to acetic acid. ALDH2 gene polymorphism modifies its activity and the mutation of ALDH2 gene has been reported to be associated with the protection against ischemic stroke. However, the potential association of allelic variation of ALDH2 with intracranial vascular stenosis and the clinical characteristics of ischemic stroke without coronary artery disease remains unclear. METHODS In this study, ischemic stroke patients were recruited, National Institutes of Health Stroke Scale scores were analyzed, intracranial arterial stenosis were evaluated by magnetic resonance angiography and gene typing of ALDH2 was determined by polymerase chain reaction and sequencing. RESULTS We found that the rate of heavy drinking was significantly lower in the ALDH2 mutation group ((*)1/(*)2 and (*)2/(*)2) than in wild-type group ((*)1/(*)1) (18.6% vs. 38.0%, p = 0.01). Plasma homocysteine (Hcy) levels were significantly different in the two groups (15.45 ± 6.39 vs. 13.14 ± 4.45, p = 0.015). The ALDH2 mutation genotype was negatively correlated with severe intracranial vascular stenosis (OR, 0.34; p = 0.002), even after adjustment for high-density lipoprotein cholesterol, Hcy, and heavy drinking (adjusted OR, 0.44; p = 0.03). CONCLUSION ALDH2(*)2 could be a protective factor and negative predictor for severe intracranial vascular stenosis in ischemic stroke in Han Chinese.
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Affiliation(s)
- Yun Qu
- a Yuhuangding Hospital affiliated to Qingdao University , Yantai , China.,b Department of Emergency , Qilu Hospital , Shandong University , Jinan , China
| | - Hui-long Zhang
- a Yuhuangding Hospital affiliated to Qingdao University , Yantai , China
| | - Li-mei Yu
- a Yuhuangding Hospital affiliated to Qingdao University , Yantai , China
| | - Ying Sun
- a Yuhuangding Hospital affiliated to Qingdao University , Yantai , China
| | - Hong-liang Wu
- a Yuhuangding Hospital affiliated to Qingdao University , Yantai , China
| | - Yu-guo Chen
- b Department of Emergency , Qilu Hospital , Shandong University , Jinan , China
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Catena C, Colussi G, Url-Michitsch M, Nait F, Sechi LA. Subclinical carotid artery disease and plasma homocysteine levels in patients with hypertension. ACTA ACUST UNITED AC 2015; 9:167-75. [PMID: 25660367 DOI: 10.1016/j.jash.2014.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/22/2014] [Accepted: 12/23/2014] [Indexed: 11/30/2022]
Abstract
Information on the association between homocysteine (Hcy) levels and subclinical carotid artery disease is limited. We investigated the relationship of plasma Hcy concentration with carotid artery plaques and intima-media thickness (IMT) in patients with hypertension. In 486 essential hypertensive patients who underwent ultrasound examination of the carotid arteries, we measured plasma levels of Hcy, vitamin B12, folate, and C-reactive protein. Plaques were detected in 34% of the study patients. Plasma Hcy levels were significantly greater in hypertensive patients with evidence of carotid plaques than patients without carotid plaques. Carotid IMT progressively increased across quartiles of plasma Hcy levels. Multivariate regression showed that carotid IMT was independently related with age, blood pressure, C-reactive protein, and Hcy levels. In a logistic regression, age, blood pressure, triglyceride, and Hcy independently predicted the presence of carotid plaques. Thus, elevated plasma Hcy levels are associated with asymptomatic carotid disease in hypertensive patients suggesting a role of Hcy in the development and progression of carotid atherosclerosis in these patients.
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Affiliation(s)
- Cristiana Catena
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medicine, University of Udine, Udine, Italy; Division of Cardiology, Medical University of Graz, Graz, Austria.
| | - GianLuca Colussi
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medicine, University of Udine, Udine, Italy
| | | | - Francesca Nait
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medicine, University of Udine, Udine, Italy
| | - Leonardo A Sechi
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medicine, University of Udine, Udine, Italy
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Kim KS. Gender Differences in Risk Factor and Clinical Outcome in Patients with Ischemic Stroke. KOSIN MEDICAL JOURNAL 2014. [DOI: 10.7180/kmj.2014.29.2.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective: Gender is an important determinant for risk factors and outcomes of ischemic stroke. The aim of this study was to compare risk factors, and clinical outcomes after ischemic stroke between male and female patients. Methods: The hospital records of patients with ischemic stroke were reviewed retrospectively. Demographic data, stroke risk factors, clinical severities and outcomes after stroke were collected and compared between male and female patients. Stroke severity and clinical disability after ischemic stroke were evaluated by means of the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) respectively. Results: Among 447 patients with ischemic stroke, 195 (43.6%) patients were women. The mean age at ischemic stroke was higher in women than in men (p<0.01). As compared to men, women had a significantly lower prevalence of hyperhomocysteinemia, smoking and drinking (all p<0.01). NIHSS and mRS scores were not different between the 2 genders. Conclusions: Profiles of risk factors differed between the 2 genders, with men having a higher prevalence of hyperhomocysteinemia, smoking and drinking. There were no gender differences in stroke severity and disability after ischemic stroke.
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Kim K, Lee JH. Risk factors and biomarkers of ischemic stroke in cancer patients. J Stroke 2014; 16:91-6. [PMID: 24949315 PMCID: PMC4060273 DOI: 10.5853/jos.2014.16.2.91] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Stroke is common among cancer patients. However, risk factors and biomarkers of stroke in cancer patients are not well established. This study aimed to investigate risk factors and biomarkers as well as etiology of ischemic stroke in cancer patients. METHODS A retrospective review was conducted in cancer patients with ischemic stroke who were admitted to a general hospital in Busan, Korea, between January 2003 and December 2012. The risk factors and biomarkers for stroke and stroke subtypes in cancer patients were compared with age- and sex-matched noncancer patients with ischemic stroke who were admitted to the same hospital during the same period. RESULTS One hundred fifty-six cancer patients with ischemic stroke were identified. Cancer patients with ischemic stroke were found to have a significantly lower proportion of hypertension, atrial fibrillation, hyperlipidemia, and ischemic heart disease than noncancer patients with ischemic stroke. However, stroke biomarkers, such as erythrocyte sedimentation rate and high-sensitivity C-reactive protein, fibrinogen, pro-brain natriuretic peptide, and D-dimer levels, were significantly increased in cancer patients with ischemic stroke than in noncancer patients. Large-artery atherosclerosis and stroke of undetermined cause were more common in cancer patients with ischemic stroke than in noncancer patients with ischemic stroke. CONCLUSIONS Cancer patients with ischemic stroke showed different risk factors, stroke biomarkers, and stroke etiology compared with noncancer patients with ischemic stroke.
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Affiliation(s)
- Kwangsoo Kim
- Department of Neurology, Kosin University College of Medicine, Busan, Korea
| | - Ji-Hun Lee
- Department of Neurology, Kosin University College of Medicine, Busan, Korea
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Yadav BK, Oh SY, Kim NK, Shin BS. Association of rs2075575 and rs9951307 polymorphisms of AQP-4 gene with leukoaraiosis. J Stroke Cerebrovasc Dis 2014; 23:1199-206. [PMID: 24582793 DOI: 10.1016/j.jstrokecerebrovasdis.2013.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 10/14/2013] [Accepted: 10/16/2013] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Leukoaraiosis (LA) is associated with structural and functional vascular changes that correlate with motor and gait disturbances, depressive symptoms, urinary disturbances, and dementia. The blood-brain barrier (BBB) plays a key role in development of lacunar stroke, leukoaraiosis, and other feature of cerebral small-vessel disease, and there are numerous studies examining changes in the BBB with normal aging and in dementia and LA. Aquaporin-4 (AQP-4), the primary water channel protein in the central nervous system, is involved in BBB development, function, and integrity, and its dysfunction induces several neurologic diseases. The aim of our study was to evaluate whether genetic variations in AQP-4 gene are associated with the development of LA. METHODS DNA was amplified and the single-nucleotide polymorphisms in AQP-4 gene were investigated by melting curve analysis using real-time polymerase chain reaction. RESULTS The frequency of both T allele and CT/TT genotypes of rs2075575 was significantly higher in LA group than in control group (C versus T, P = .0145; CC versus CT/TT, P = .038). However, no significant difference was observed between LA group and control group in rs9951307. Interestingly, the rs9951307 AG + GG genotype may confer a synergistic effect in odds ratio (OR) values when combined with the rs2075575 CT + TT genotypes (OR = 1.65 → 2.51). The C-A haplotype was significantly different between LA group and the control group (P = .005). By stratified analysis, rs2075575 and rs9951307 polymorphisms were statistically significant in the subjects with hypertension and hemoglobin A1c (P < .05), whereas the rs2075575 polymorphism was associated with high serum cholesterol (P < .05) and the rs9951307 polymorphism was associated with low serum homocysteine (P < .05). CONCLUSIONS Our results indicate that AQP-4 genetic variations and haplotypes might contribute to the risk factors for LA.
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Affiliation(s)
- Binod K Yadav
- Department of Medical Science, Chonbuk National University Graduate School, Jeonju, Republic of Korea; Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea; Department of Biochemistry, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Sun-Young Oh
- Department of Neurology, Chonbuk National University Medical School, Jeonju, Republic of Korea; Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Nam-Keun Kim
- Institute for Clinical Research, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Byoung-Soo Shin
- Department of Neurology, Chonbuk National University Medical School, Jeonju, Republic of Korea; Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea.
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Ko MKC, Ikeda S, Mieno-Naka M, Arai T, Zaidi SAH, Sato N, Muramatsu M, Sawabe M. Association of COMT gene polymorphisms with systemic atherosclerosis in elderly Japanese. J Atheroscler Thromb 2012; 19:552-8. [PMID: 22790479 DOI: 10.5551/jat.11254] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM Atherosclerotic disease is a major health problem among the elderly, which arises from a complex interaction between genetic and environmental factors. The catechol-O-methyltransferase (COMT) gene encodes an enzyme that degrades catecholamines and estrogens to less active metabolites. The objective of this study was to examine whether polymorphisms of the COMT gene affected the severity of atherosclerotic disease in a Japanese elderly population. METHOD A total of 1536 autopsy cases of hospital deaths were assessed for the degree of pathological atherosclerotic index (PAI), coronary stenotic index (CSI) and intracranial stenotic index (ICAI), which were obtained by macroscopic examination of the luminal surface of formalin-fixed arteries. Two single nucleotide polymorphisms (SNPs) in the COMT gene, rs4633 (C/T) and rs4680 (G/A) were genotyped. The rs4680 (G/A) corresponds to a functional SNP with the substitution of valine to methionine. RESULT The CC genotype of rs4633 (C/T) and the GG genotype of rs4680 (G/A) showed a significantly higher degree of PAI and the association remained positive after adjustment for age, hypertension, diabetes, smoking and drinking (p=0.035 and p=0.031, respectively). There were no significant associations between COMT genotypes and CSI or ICAI. When male and female subjects were analyzed separately, the association was observed only in female subjects (p=0.012 and p=0.027) after adjustment for age, hypertension, diabetes, smoking and drinking. CONCLUSION The functional SNP in the COMT gene associated with the severity of atherosclerosis in a Japanese elderly population, whereby the influence of the genotype appears to be stronger in females than in males.
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Affiliation(s)
- Maung Kyi Chan Ko
- Department of Molecular Epidemiology, Medical Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
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Cacciapuoti F. Hyper-homocysteinemia: a novel risk factor or a powerful marker for cardiovascular diseases? Pathogenetic and therapeutical uncertainties. J Thromb Thrombolysis 2011; 32:82-8. [PMID: 21234645 DOI: 10.1007/s11239-011-0550-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Increased homocysteine levels can be responsible for arterial ischemic events, such as MI, stroke or peripheral vascular disease. Homocysteine is metabolized by two pathways: re-methylation and trans-sulfuration. Both involve folic acid, and vitamins B(6-12.) Several studies assumed that the folates and vitamins B supplementation or dietary source to normalize plasma homocysteine. But, even if tends to normalize homocysteine levels, lowering homocysteine by B-group vitamins and/or folates does not reduce cardiovascular risk. In fact, recent reports confirmed that hyper-homocysteinemia is not directly responsible for cardiovascular disease, but is merely present in individuals suffering for acute and/or chronic cardiovascular events, as a collateral finding. Reduced methylation potential (MP) [due to decreased S-adenosyl-methionine (AdoMet)/S-adenosyl-homocysteine (AdoHcy) ratio] induced by the elevated plasma homocysteine levels seems to be the true responsible for cardiovascular diseases (CVD). The pathogenic mechanisms responsible for CVD appear to be dependent of DNA hypomethylation inducing an inhibition of cyclin A transcription and a reduction of endothelial cells growth. But, other human studies performed in a wide range are requested.
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Affiliation(s)
- Federico Cacciapuoti
- Department of Internal Medicine, Second University of Naples, Piazza L. Miraglia, Naples, Italy.
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Kim DS, Kim YK, Park HK, Cho YI, Jeong SK. Serum Folate and Low-Density Lipoprotein Particle Size. J Atheroscler Thromb 2010; 17:1218-25. [DOI: 10.5551/jat.5629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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