Issue 318 In a nutshell

The association between elevated Hcy, the B vitamins linked to it, and stroke incidence and severity appears strong. So far, a dozen RCTs, (almost all in patients with significant atherosclerosis), have tried to prevent stroke by reducing Hcy through various combinations of folate, B12 and B6. In only one trial did this clearly succeed.

Stroke & prevention - B vitamins
Arbor Clinical Nutrition Updates 2010 (Mar);318:1-5 ISSN 1446-5450

Premium edition
This issue is for the personal use of Premium subscribers only (except where being used within the terms of an institutional subscription). Previous issues Premium subscribers may obtain all past issues of the Updates by logging into our web site at www.nutritionupdates.org.

NUTRITION RESEARCH REVIEW
Study 1: B vitamins and stroke severity A new study from Turkey looked at vitamin B12 and folate levels in relation to outcome of acute stroke. Subjects and method: Longitudinal observational study of 109 patients with acute stroke, (¾ were ischaemic, ¼ haemorrhagic. Baseline vitamin levels were compared with initial clinical stroke severity (Glasgow coma scale) and hospital mortality at 7 days. Results: The mean initial vitamin levels were each significantly lower in those who subsequently died within 7 days than in those who survived, both for vitamin B12 (186 vs 278 pmol/L, p=0.001) and folate (17.6 vs 21.1 pmol/L, p=0.003). A similar relationship was seen between the baseline levels of the two vitamins and worse initial Glasgow coma scale.
Ref. Bayir A. et al. Acute-phase vitamin B12 and folic acid levels in patients with ischemic and hemorrhagic stroke: is there a relationship with prognosis? Neurol Res. 2010 Mar;32(2):115-118.

Graph 1: Hazard ratio for stroke, active vs placebo
(Study 2)

HR
1.4 1.2 1.0 0.8 0.6 0.4 0.2 0
0.75 0.57 0.66 0.72 0.91 0.95

Any with initial Hcy stroke
>13.8 ≤ 13.8
(µmol/L)

Non- Fatal fatal

Functl. depend.

Study 2: Is there any HOPE for stroke? A new analysis of the HOPE-2 trial focused on the stroke outcomes, including severity. Subjects and method: Multi-national RCT on 5,522 patients with known CVD, randomised to receive either placebo or supplements (folic acid 2.5 mg, vitamin B6 50 mg, vitamin B12 1,000 µg) designed to lower homocysteine (Hcy) levels, daily for 5 years. Results: Compared with placebo, the vitaminsupplemented group had 25% fewer strokes, non-fatal ones in particular. Amongst those who had strokes, the severity (as judged by neurological deficit at 24 hrs or functional dependence at 7 days) was not improved by supplementation. See Graph.

Ref. Saposnik G. et al. Homocysteine-lowering therapy and stroke risk, severity, and disability: additional findings from the HOPE 2 trial. Stroke. 2009 Apr;40(4):1365-72.

Study 3: B vitamins and carotid arterial function A recent Australian trial tested the impact of B vitamin supplements on carotid arteries and combined this with a meta-analysis of previous similar RCTs. Subjects and method: 162 patients with previous stroke (from the VITATOPS trial) randomised to receive either placebo or a B vitamin supplement (folic acid 2 mg, vitamin B6 25 mg, vitamin B12 500 µg) for a mean of 3.9 yrs. Carotid intima-medial thickness (CIMT) and brachial flow-mediated dilation (FMD) were measured. In addition a meta-analysis was conducted on this trial combined with a further 6 previous RCTs on CIMT

(n=768, no other trials on stroke patients) and 20 other RCTs on FMD (n=1,282, only one other trial on stroke patients). Results: There was no significant change in CIMT or FMD in their own trial. The meta-analysis showed a

decrease in CIMT (0.10 mm, 95% CI: 0.01-0.20 mm) and increase in FMD (by 1.4%, 0.7-2.1%), mainly seen in trials of less than 9 weeks duration.
Ref. Potter K. et al. The effect of long-term homocysteine-lowering on carotid intima-media thickness and flow-mediated vasodilation in stroke patients: a randomized controlled trial and meta-analysis. BMC Cardiovasc Disord. 2008 Sep 20;8:24.

COMMENTARY The connection between homocysteine (Hcy) and stroke is one aspect of the broader and controversial `Hcy hypothesis’ - that elevated Hcy is an independent and treatable cause of atherosclerosis, including heart disease. It also concerns the vitamins closely connected to Hcy through their role in methionine metabolism, regeneration and Hcy breakdown - see Figure opposite. Those `Hcy-vitamins’ are folate, vitamin B12 and, to a lesser extent, vitamin B6 and vitamin B2 1-3. We easily found over two dozen studies on Hcy as a risk factor for stroke, of which the large majority reported a positive association. In some recent examples Hcy levels in stroke cases were a third higher than in controls in one 4, and double in the other (odds ratio for elevated Hcy a remarkable 15.7) 5 !! A recent British study found the association strongest in relation to small vessel strokes 6, whilst one from China reported that elevated Hcy predicted for brain atrophy post-stroke (OR=9.8) 7. Three meta-analyses (curiously, each published in 2002) confirmed this association. One included 30 observational studies involving 1,113 stroke events, and concluded that Hcy is an independent though moderate risk factor for stroke, and that in the prospective studies stroke risk was reduced by 11% for every 25% reduction in Hcy 8. The second metaanalysis collated 20 sets of prospective data to derive OR=1.59 that a future stroke patient would have had a 5% elevation in their baseline Hcy level 9. In the third meta-analysis, the pooled OR for subjects with elevated Hcy having an ischaemic stroke (from 14 studies involving 1,769 stroke cases) was 1.79 10. Other epidemiological research has focused specifically on the Hcy-vitamins and stroke. Although not entirely consistent, there have been many reports of stroke being associated with lower folate levels (e.g. 7, 11-14), somewhat fewer reports of lower vitamin B12 (e.g. 13, 15, 16) and much fewer of lower vitamin B6 (e.g. 17, 18). A single study found lower vitamin B2 level in stroke patients than controls 19, but another did not 20. New Study 1 showed a link between two of these nutrients and stroke severity. There is a genetic factor at play in this association as well, due to the extensively documented impact on Hcy metabolism of polymorphism in the gene for the MTHFR enzyme (whose role is shown in the Figure above). A good many studies have looked at the risk for stroke associated with the particular MTHFR genotype (TT) in which Hcy recycling is impaired.

Methionine

(DNA, RBC etc.)

Nucleotide synthesis

Vit.B12 THF

Methyl donation
(nerves DNA etc.)

SAM (S-Adenosylmethionine)

Methionine cycle

Methionine synthase

Folate cycle
5-methyl THF

MTHFR

NADPH

Vit.B2
NADP+

Homocysteine Vit.B6
Cysteine

Excreted or converted to other a/a

Super simplified Hcy biochemistry lesson
Methyl donation and nucleotide synthesis are both vital functions served by the conversion of methionine to, and regeneration from, Hcy, involving the folate cycle. Vitamin deficiency can lead to Hcy accumulation.

A meta-analysis in 2002 of 19 studies reported the OR for (ischaemic) stroke in the TT genotype to be 1.23 10. Research since then has confirmed the link 21-24. What is not so clear is how much independent risk this genetic variation has beyond the Hcy levels, and whether it affects the impact of Hcy lowering vitamin supplementation, with the general consensus being that such effects are modest at best 10, 25-27. Given that there clearly is an association, three questions spring to mind. Firstly, is it causal or merely an indicator of some other process? Secondly, if causal what is the mechanism, and is it the Hcy or the vitamins that are the most important element? Thirdly, can the damage be corrected by supplementation? In relation to causality, the majority of experts have expressed the view that the weight of evidence suggests this is true (e.g. 1, 28-31). An interesting perspective on this comes from one of the metaanalyses we have already cited, which calculated odds ratios from genetic and prospective studies separately. The authors concluded that, since each analysis had similar highly significant outcomes but were unlikely to share confounders, the evidence for causality was strong 9. Others have not been so sure and have preferred to await the results of quality RCTs 32-35. When it comes to mechanisms, there is no shortage of evidence that elevated Hcy could predispose to stroke, through contribution to inflammation,

atherosclerosis, thrombogenesis, hypertension and impaired cerebro-arterial function, a good deal of which is contributed to by oxidative stress 29, 30, 36-39. For example, a solid body of work shows the relationship between Hcy and carotid intima-media thickness (CIMT) 40-42, a measure of atherosclerosis generally but also specifically related to stroke risk 43-45. Whilst not all observational data has found a strong connection 46, 47, a number of RCTs have demonstrated improved CIMT after elevated Hcy was lowered through vitamin supplements 48-53, though not all have done so 54. New Study 3 did not demonstrate this, but when its data was added to other trial results in meta-analysis, this conclusion was supported. Another interesting light on mechanism comes from a new Canadian study which showed that excess Hcy can inhibit the expected migration of progenitor cells from bone marrow to repair vascular endothelium damaged in stroke patients 55. Mechanisms involving the Hcy-vitamins which do not involve Hcy are less clear, although some animal evidence suggests folate may have some such role 56, 57, including in endothelial function 58, and perhaps riboflavin in traumatic brain injury 59. This brings us to the third and most important question: can any damage caused by excess Hcy be corrected by supplementation? New Study 2 is a fresh analysis of the HOPE-2 trial, showing that the 25% protection against stroke incidence had a nonsignificant trend to being for non-fatal strokes and particularly in those subjects with higher baseline Hcy. HOPE-2 is best seen in the context of other RCTs that have looked at this question. Eleven have published their results so far 60-71. Various combinations and permutations of these eleven form the basis of no less than three separate meta-analyses 72-74. That these meta-analyses did not reach complete consensus is perhaps not surprising, bearing in mind that they did not include all the same data - see Graph 2. Looking at that Graph, it is hard to find strong support for the idea that giving vitamins to reduce Hcy prevents stroke. Although 7/11 RCTs showed a risk reduction, in only one was this clearly significant. That was the HOPE-2 trial, the largest, on patients with past history of diabetes or vascular disease 63. On the other hand, results from the even more recently completed SEARCH trial of 12,064 heart attack survivors 75 (as yet unpublished) failed to show any stroke prevention 76. Some might take comfort from the sub-grouping data in the Wang meta-analysis 74, which showed a protective effect in patients without a stroke history (i.e. primary prevention, which was true of all trials bar one), in those whose treatment lasted more than 3 years and which successfully reduced their Hcy levels. On the other hand, Wang’s analysis was too early to include the 2 RCT results published in 2008 (n=8,532), both lasting over 3 years but with negative results 60, 61.

Graph 2: RR for stroke: RCTs of Hcy lowering vitamin supplements vs control

RCTs
# meta-analyses trial x1 x2 incl. in: x3 0.85 1.14 0.88 0.76 0.45 0.55 1.04 0.65 3.06 1.17 0.63

N=
WENBIT
60

3,090

WAFACS 61 5,442 NORVIT 62 HOPE-2 63 ASFAST 64 Haemodialysis 65 VISP 66, 67 GOES 68 3,749 5,522 315 88 3,680 593

FOLARDA 69 283 End stage renal 70 LINXIAN 71 510 3,318

Meta-analyses
Cochrane 72 Bazzano 73 Wang 74 Overall Duration > 36/12 Hcy reduc > 20% No stroke history 0.0

N= 18,086 13,806 16,841

0.89 20% 0.86

0.82
0.71 0.77 0.75

9,748 9,018 12,165

0.25

0.50

0.75 1.0

1.25

1.5

Some potential limitations of these trial data have been raised. One is that these supplements in the doses used would be ineffective, or the effect too weak to be detected with the sample sizes tested, in people with the kind of advanced atherosclerotic disease that was true of the subjects in all these trials except one 77. Let alone in patients who recently had a stroke, which was the basis of the VISP trial (included in all three meta-analyses) - that is secondary prevention, hardly comparable with the other RCTs. Moreover, VISP compared high dose Hcy-vitamins not with placebo but with low dose. And control subjects in WAFACS were allowed to take multivitamin supplements up to RDA level 61.

Other potential limitations of the existing trial data include any masking effect of concurrent treatment (e.g. statins), or the Hcy metabolic situation being different in the RCTs on renal failure patients 77-79. Another possible issue is the baseline status of the Hcy-vitamins and ability to absorb them. For example, people living in areas with folate-fortified flour (higher baseline status) or with B12 malabsorption may show less protective effect from those supplements 74, 79, 80. What all of this might mean is that we have not as yet narrowed down the population group in whom Hcy lowering prevents stroke. For example, we lack trials on patients with high Hcy who have not yet displayed clinical atherosclerosis. Others have argued (both for stroke and heart disease) that the benefits of Hcy lowering may take years to be seen, and that we do not have enough of that kind of long term data. Or that the effect of genetic polymorphism has not been adequately taken into account, or that benefit may be confined to even higher risk patients (such as atherosclerotic smokers) 81, 82. In short, given all these consideration and at least one substantial trial having positive results, there are certainly those who do not believe we should rule these treatments out just yet (e.g. 78-82). At the same time, it would be fair to say that the majority view is that, despite the very strong epidemiological data, such a frankly disappointing set of trial results means that current evidence simply does not justify using these vitamins for stroke prevention, certainly not in a routine way, (e.g.1, 33, 83). Whilst considering these different viewpoints, and maybe even whether it might be worth giving supplements to prevent stroke on a ‘no harm in trying’ basis, we should also think about their safety. On the whole, the supplement regimes used in these trials have been considered safe (and cheap!) interventions 28. There were two exceptions. NORVIT reported a rise, of borderline statistical significance, in nonfatal myocardial infarction (but not in stroke) in the vitamin group (OR=1.30, 95% CI: 1.00–1.68) 62. HOPE-2 found that more of the vitamin subjects were hospitalised for unstable angina (RR=1.24; 95% CI: 1.04-1.49), compared with placebo 63. In the absence of confirmation of such increased risk from other trials it is hard to know what significance to place on this. (There is also the question of whether folate might sometimes promote cancer growth - a complex subject that will be the topic of a later issue). Two further large RCTs involving Hcy-vitamins and stroke prevention are due to report in the next several years: the SU.FOL.OM3 study on some 2,500 patients who had CHD or stroke within the previous year 83, and VITATOPS, with a target of 8,000 patients who had recent transient ischaemic attack 84. The FAVORIT and HOST trials may also offer some less direct information 77. This is definitely a `watch this space’ topic.

References: 1. Sánchez-Moreno C. et al. Stroke: roles of B vitamins, homocysteine and antioxidants. Nutr Res Rev. 2009 Jun;22(1):49-67. 2. McNulty H. et al. Homocysteine, B-vitamins and CVD. Proc Nutr Soc. 2008 May;67(2):232-7. 3. McNulty H. et al. Riboflavin lowers homocysteine in individuals homozygous for the MTHFR 677C->T polymorphism. Circulation. 2006 Jan 3;113(1):74-80. 4. Narang AP. et al. Homocysteine--risk factor for ischemic stroke? Indian J Physiol Pharmacol. 2009 Jan-Mar;53(1):34-8. 5. Dhamija RK. et al. Homocysteine and lipoprotein (a) correlation in ischemic stroke patients. J Neurol Sci. 2009 Jun 15;281(1-2):64-8. 6. Khan U. et al. Homocysteine and its relationship to stroke subtypes in a UK black population: the south London ethnicity and stroke study. Stroke. 2008 Nov;39(11):2943-9. 7. Yang LK. et al. Correlations between folate, B12, homocysteine levels, and radiological markers of neuropathology in elderly post-stroke patients. J Am Coll Nutr. 2007 Jun;26(3):272-8. 8. Homocysteine Studies Collaboration. Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis. JAMA. 2002 Oct 23-30;288(16):2015-22. 9. Wald DS. et al. Homocysteine and cardiovascular disease: evidence on causality from a meta-analysis. BMJ. 2002 Nov 23;325(7374):1202. 10. Kelly PJ. et al. Homocysteine, MTHFR 677C-->T polymorphism, and risk of ischemic stroke: results of a meta-analysis. Neurology. 2002 Aug 27;59(4):529-36. 11. Weng LC. et al. Is ischemic stroke risk related to folate status or other nutrients correlated with folate intake? Stroke. 2008 Dec;39(12):3152-8. 12. Larsson SC. et al. Folate, vitamin B6, vitamin B12, and methionine intakes and risk of stroke subtypes in male smokers. Am J Epidemiol. 2008 Apr 15;167(8):954-61. 13. Weikert C. et al. B vitamin plasma levels and the risk of ischemic stroke and transient ischemic attack in a German cohort. Stroke. 2007 Nov;38(11):2912-8. 14. Van Guelpen B. et al. Folate, vitamin B12, and risk of ischemic and hemorrhagic stroke: a prospective, nested case-referent study of plasma concentrations and dietary intake. Stroke. 2005 Jul;36(7):1426-31. 15. Pieters B. et al. Periventricular white matter lucencies relate to low vitamin B12 levels in patients with small vessel stroke. Stroke. 2009 May;40(5):1623-6. 16. He K. et al. Folate, vitamin B6, and B12 intakes in relation to risk of stroke among men. Stroke. 2004 Jan;35(1):169-74. 17. Kelly PJ. et al. Inflammation, homocysteine, and vitamin B6 status after ischemic stroke. Stroke. 2004 Jan;35(1):12-5. 18. Robinson K. et al. Low circulating folate and vitamin B6 concentrations: risk factors for stroke, peripheral vascular disease, and coronary artery disease. European COMAC Group. Circulation. 1998 Feb 10;97(5):437-43. 19. Gariballa S. et al. Riboflavin status in acute ischaemic stroke. Eur J Clin Nutr. 2007 Oct;61(10):1237-40. 20. Ross RK. et al. Prospective evaluation of dietary and other predictors of fatal stroke in Shanghai, China. Circulation. 1997 Jul 1;96(1):50-5. 21. Biswas A. et al. Homocystine levels, polymorphisms and the risk of ischemic stroke in young Asian Indians. J Stroke Cerebrovasc Dis. 2009 MarApr;18(2):103-10. 22. Sánchez-Marín B. et al. [Prevalence of methylenetetrahydrofolate reductase C677T mutation among patients with acute ischemic cerebrovascular disease in Aragon] An Med Interna. 2006 Apr;23(4):153-5. 23. Panigrahi I. et al. Role of MTHFR C677T polymorphism in ischemic stroke. Neurol India. 2006 Mar;54(1):48-50. 24. Cantu C. et al. Hyperhomocysteinemia, low folate and vitamin B12 concentrations, and methylene tetrahydrofolate reductase mutation in cerebral venous thrombosis. Stroke. 2004 Aug;35(8):1790-4. 25. Lim PS. et al. Polymorphism in methylenetetrahydrofolate reductase gene: its impact on plasma homocysteine levels and carotid atherosclerosis in ESRD patients receiving hemodialysis. Nephron. 2001 Mar;87(3):249-56. 26. Demuth K. et al. Opposite effects of plasma homocysteine and the methylenetetrahydrofolate reductase C677T mutation on carotid artery geometry in asymptomatic adults. Arterioscler Thromb Vasc Biol. 1998 Dec;18(12):1838-43. 27. Ho GY. et al. Methylenetetrahydrofolate reductase polymorphisms and homocysteine-lowering effect of vitamin therapy in Singaporean stroke patients. Stroke. 2006 Feb;37(2):456-60. 28. Terwecoren A. et al. Ischemic stroke and hyperhomocysteinemia: truth or myth? Acta Neurol Belg. 2009 Sep;109(3):181-8. 29. Pezzini A. et al. Homocysteine and cerebral ischemia: pathogenic and therapeutical implications. Curr Med Chem. 2007;14(3):249-63. 30. Hankey GJ. et al. Clinical usefulness of plasma homocysteine in vascular disease. Med J Aust. 2004 Sep 20;181(6):314-8. 31. Stanger O. et al. DACH-LIGA homocystein (german, austrian and swiss homocysteine society): consensus paper on the rational clinical use of homocysteine, folic acid and B-vitamins in cardiovascular and thrombotic diseases: guidelines and recommendations. Clin Chem Lab Med. 2003 Nov;41(11):1392-403. 32. Herrmann W. et al. Hyperhomocysteinaemia: a critical review of old and new aspects. Curr Drug Metab. 2007 Jan;8(1):17-31. 33. Ntaios GC. et al. Vitamins and stroke: the homocysteine hypothesis still in doubt. Neurologist. 2008 Jan;14(1):2-4. 34. Lonn E. Homocysteine in the prevention of ischemic heart disease, stroke and venous thromboembolism: therapeutic target or just another distraction? Curr Opin Hematol. 2007 Sep;14(5):481-7. 35. Wierzbicki AS. Homocysteine and cardiovascular disease: a review of the evidence. Diab Vasc Dis Res. 2007 Jun;4(2):143-50.

36. Osanai T. et al. Novel pro-atherogenic molecule coupling factor 6 is elevated in patients with stroke: a possible linkage to homocysteine. Ann Med. 2010;42(1):79-86. 37. Kumar M. et al. Homocysteine decreases blood flow to the brain due to vascular resistance in carotid artery. Neurochem Int. 2008 Dec;53(6-8):214-9. 38. Stanger O. et al. Clinical use and rational management of homocysteine, folic acid, and B vitamins in cardiovascular and thrombotic diseases. Z Kardiol. 2004 Jun;93(6):439-53. 39. Guilland JC. et al. [Hyperhomocysteinemia: an independent risk factor or a simple marker of vascular disease?. 1. Basic data] Pathol Biol (Paris). 2003 Mar;51(2):101-10. 40. Baptista AP. et al. Inflammation, homocysteine and carotid intima-media thickness. Rev Port Cardiol. 2008 Jan;27(1):39-48. 41. Sabaliauskene Z. et al. [Hyperhomocysteinemia in patients with atherosclerotic extracranial disease of the carotid artery] Klin Lab Diagn. 2006 Jun;(6):20-2, 35. 42. Wang H. et al. Serum level of homocysteine is correlated to carotid artery atherosclerosis in Chinese with ischemic stroke. Neurol Res. 2006 Jan;28(1):25-30. 43. Silvestrini M. et al. Carotid wall thickness and stroke risk in patients with asymptomatic internal carotid stenosis. Atherosclerosis. 2010 Jan 4. Epub. 44. Cobble M. et al. Carotid intima-media thickness: knowledge and application to everyday practice. Postgrad Med. 2010 Jan;122(1):10-8. 45. Sahoo R. et al. Common carotid intima-media thickness in acute ischemic stroke: A case control study. Neurol India. 2009 Sep-Oct;57(5):627-30. 46. Ntaios G. et al. Homocysteine and carotid intima-media thickness in ischemic stroke patients are not correlated. Neuropsychiatr Dis Treat. 2008 Apr;4(2):477-9. 47. Held C. et al. Correlations between plasma homocysteine and folate concentrations and carotid atherosclerosis in high-risk individuals: baseline data from the Homocysteine and Atherosclerosis Reduction Trial (HART). Vasc Med. 2008 Nov;13(4):245-53. 48. Nanayakkara PW. et al. Effect of a treatment strategy consisting of pravastatin, vitamin E, and homocysteine lowering on carotid intima-media thickness, endothelial function, and renal function in patients with mild to moderate chronic kidney disease: results from the Anti-Oxidant Therapy in Chronic Renal Insufficiency (ATIC) Study. Arch Intern Med. 2007 Jun 25;167(12):1262-70. 49. Fernández-Miranda C. et al. Effect of folic acid treatment on carotid intimamedia thickness of patients with coronary disease. Int J Cardiol. 2007 Jun 12;118(3):345-9. 50. Hodis HN. et al. High-dose B vitamin supplementation and progression of subclinical atherosclerosis: a randomized controlled trial. Stroke. 2009 Mar;40(3):730-6. 51. Vianna AC. et al. Uremic hyperhomocysteinemia: a randomized trial of folate treatment for the prevention of cardiovascular events. Hemodial Int. 2007 Apr;11(2):210-6. 52. Tungkasereerak P. et al. Effect of short-term folate and vitamin B supplementation on blood homocysteine level and carotid artery wall thickness in chronic hemodialysis patients. J Med Assoc Thai. 2006 Aug;89(8):1187-93. 53. Till U. et al. Decrease of carotid intima-media thickness in patients at risk to cerebral ischemia after supplementation with folic acid, Vitamins B6 and B12. Atherosclerosis. 2005 Jul;181(1):131-5. 54. van Dijk RA. et al. Long-term homocysteine-lowering treatment with folic acid plus pyridoxine is associated with decreased blood pressure but not with improved brachial artery endothelium-dependent vasodilation or carotid artery stiffness: a 2-year, randomized, placebo-controlled trial. Arterioscler Thromb Vasc Biol. 2001 Dec;21(12):2072-9. 55. Alam MM. et al. Homocysteine reduces endothelial progenitor cells in stroke patients through apoptosis. J Cereb Blood Flow Metab. 2009 Jan;29(1):157-65. 56. Hwang IK. et al. Folic acid deficiency increases delayed neuronal death, DNA damage, platelet endothelial cell adhesion molecule-1 immunoreactivity, and gliosis in the hippocampus after transient cerebral ischemia. J Neurosci Res. 2008 Jul;86(9):2003-15. 57. Huang GW. et al. [Effects of folic acid, vitamin B(6) and vitamin B(12) on learning and memory function in cerebral ischemia rats] Zhonghua Yu Fang Yi Xue Za Zhi. 2007 May;41(3):212-4. 58. Doshi SN. et al. Folic acid improves endothelial function in coronary artery disease via mechanisms largely independent of homocysteine lowering. Circulation. 2002 Jan 1;105(1):22-6. 59. Hoane MR. et al. Administration of riboflavin improves behavioral outcome and reduces edema formation and glial fibrillary acidic protein expression after traumatic brain injury. J Neurotrauma. 2005 Oct;22(10):1112-22. 60. Ebbing M. et al. Mortality and cardiovascular events in patients treated with homocysteine-lowering B vitamins after coronary angiography: a randomized controlled trial. JAMA. 2008 Aug 20;300(7):795-804.

61. Albert CM. et al. Effect of folic acid and B vitamins on risk of cardiovascular events and total mortality among women at high risk for cardiovascular disease: a randomized trial. JAMA. 2008 May 7;299(17):2027-36. 62. Bønaa KH. et al. Homocysteine lowering and cardiovascular events after acute myocardial infarction. N Engl J Med. 2006 Apr 13;354(15):1578-88. 63. Lonn E. et al. Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J Med. 2006 Apr 13;354(15):1567-77. 64. Zoungas S. et al. Cardiovascular morbidity and mortality in the Atherosclerosis and Folic Acid Supplementation Trial (ASFAST) in chronic renal failure: a multicenter, randomized, controlled trial. J Am Coll Cardiol. 2006 Mar 21;47(6):1108-16. 65. Righetti M. et al. Homocysteine-lowering vitamin B treatment decreases cardiovascular events in hemodialysis patients. Blood Purif. 2006;24(4):379-86. 66. Spence JD. et al. Vitamin Intervention For Stroke Prevention trial: an efficacy analysis. Stroke. 2005 Nov;36(11):2404-9. 67. Toole JF. 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 Feb 4;291(5):565-75. 68. Liem A. et al. Secondary prevention with folic acid: results of the Goes extension study. Heart. 2005 Sep;91(9):1213-4. 69. Liem AH. et al. Efficacy of folic acid when added to statin therapy in patients with hypercholesterolemia following acute myocardial infarction: a randomised pilot trial. Int J Cardiol. 2004 Feb;93(2-3):175-9. 70. Wrone EM. et al. Randomized trial of folic acid for prevention of cardiovascular events in end-stage renal disease. J Am Soc Nephrol. 2004 Feb;15(2):420-6. 71. Mark SD. et al. Lowered risks of hypertension and cerebrovascular disease after vitamin/mineral supplementation: the Linxian Nutrition Intervention Trial. Am J Epidemiol. 1996 Apr 1;143(7):658-64. 72. Martí-Carvajal AJ. et al. Homocysteine lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD006612. 73. Bazzano LA. et al. Effect of folic acid supplementation on risk of cardiovascular diseases: a meta-analysis of randomized controlled trials. JAMA. 2006 Dec 13;296(22):2720-6. 74. Wang X. et al. Efficacy of folic acid supplementation in stroke prevention: a meta-analysis. Lancet. 2007 Jun 2;369(9576):1876-82. 75. SEARCH Study Collaborative Group. et al. Study of the effectiveness of additional reductions in cholesterol and homocysteine (SEARCH): characteristics of a randomized trial among 12064 myocardial infarction survivors. Am Heart J. 2007 Nov;154(5):815-23, 823. 76. Amritage J. et al. SEARCH Study Collaborative Group. SEARCH (Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine): randomized comparison of folic acid 2 mg plus vitamin b12 1 mg daily versus placebo for 7 years in 12,064 myocardial infarction survivors. Circulation 2008 Nov;118(22);2309-2317. 77. Marcus J. et al. Homocysteine lowering and cardiovascular disease risk: lost in translation. Can J Cardiol. 2007 Jul;23(9):707-10. 78. Pietrzik K. Opinion on the COCHRANE Review ‘’Homocysteine-lowering interventions for preventing cardiovascular events. European Nutraceutical Association website at: http://www.enaonline.org 79. Spence JD. Perspective on the efficacy analysis of the Vitamin Intervention for Stroke Prevention trial. Clin Chem Lab Med. 2007;45(12):1582-5. 80. Ueland PM. et al. Homocysteine and folate status in an era of folic acid fortification: balancing benefits, risks, and B-vitamins. Clin Chem. 2008 May;54(5):779-81. 81. Wald DS. et al. Folic acid, homocysteine, and cardiovascular disease: judging causality in the face of inconclusive trial evidence. BMJ. 2006 Nov 25;333(7578):1114-7. 82. Nainggolan L. Folic acid modestly protects against cardiovascular events Heartwire 2006 reproduced in Medscape web site www.medscape.com. 83. Bazzano LA. Folic acid supplementation and cardiovascular disease: the state of the art. Am J Med Sci. 2009 Jul;338(1):48-9. 84. Galan P. et al. The SU.FOL.OM3 Study: a secondary prevention trial testing the impact of supplementation with folate and B-vitamins and/or Omega-3 PUFA on fatal and non fatal cardiovascular events, design, methods and participants characteristics. Trials. 2008 Jun 10;9:35. 85. VITATOPS Trial Study Group. et al. VITATOPS, the VITAmins TO prevent stroke trial: rationale and design of a randomised trial of B-vitamin therapy in patients with recent transient ischaemic attack or stroke (NCT00097669) (ISRCTN74743444). Int J Stroke. 2007 May;2(2):144-50.

Disclaimer, copyright, terms of use and subscribing
Your use of these Updates in any form or format constitutes your agreement to our disclaimer and terms of use which can be found on our web site at: www.nutritionupdates.org/sub/terms_prem.php . You can also obtain the disclaimer and terms of use by emailing us at: upT@arborcom.com . © Copyright Arbor Communications PTL 2010. All rights reserved. This document may NOT be forwarded onto others without our written permission. If you want to receive the Clinical Nutrition Updates on an ongoing basis, please register at www.nutritionupdates.org/sub/ Or send a request email to upD@arborcom.com. This is a FREE service to health professionals and students. Include details of your name, email address, country, institution (if relevant) and professional background. The Updates are available in English, Spanish, Portuguese, Italian, French, Turkish, Korean and Russian.