The Art of Primary Prevention and Risk Assessment

See related article, pages 730–736. The paradigm that homocysteine is associated with atherosclerotic disease has been discussed since the 1960s. Since then, large observational studies and meta-analyses showed a strong relationship between homocysteine and cardiovascular risk. However, several recent trials using homocysteine-lowering therapies for secondary prevention failed to show beneficial effects in patients with prior stroke or known coronary artery disease.1–3 These trials showed no advantage of either folic acid and/or vitamin B complex therapy on “hard” end points such as mortality or cardiovascular events. Thus, the “homocysteine hypothesis” for atherothrombotic disease became controversial. Kaul et al4 stated in a recent review that it remains unclear whether a causal relationship exists between homocysteine and cardiovascular risk, or if homocysteine is related to other confounding risk factors or is a marker of existing disease burden.This discussion is now continued and refuelled with a new study published in this issue of Stroke . Hodis and coworkers present a work that assesses homocysteine-lowering therapy as primary prevention in patients without preexisting cardiovascular disease. The goal was to show a reducing effect of a high-dose combination of B-vitamins on progression of carotid intima media thickness …