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Atherosclerosis 214 (2011) 480485

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Homocysteine is a determinant of ApoA-I and both are associated with ankle

brachial index, in an Ambulatory Elderly Population
Rosa Maria Guant-Rodriguez a,,1 , Rosario Spada b,1 , Maira Moreno-Garcia a,1 , Guido Anello b ,
Paolo Bosco b , Laurent Lagrost c , Antonino Romano b , Maurizio Elia b , Jean-Louis Guant a,b
Inserm U954, Medical Faculty and CHU of Nancy, University Henri Poincar, Nancy, France
IRCCS of Mental Retardation and Brain Aging, Oasi Maria S.S., Troina, Sicily, Italy
INSERM UMR866, Facult de Mdecine, Dijon, France

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The ankle brachial index (ABI) is an indicator of lower extremity peripheral arterial disease
Received 29 September 2010 (PAD) and a predictor of atherothrombosis. ApoA-I and HDL are associated with PAD, in humans. Homo-
Received in revised form 7 November 2010 cysteine inuences the liver expression of ApoA-I and decreases its blood level and HDL in genetic
Accepted 19 November 2010
mice models. We aimed therefore to evaluate whether homocysteine and its nutritional determinants,
Available online 26 November 2010
folate and vitamin B12 are associated with ABI by inuencing HDL metabolism, in an ambulatory elderly
Methods: 667 elderly volunteers from rural Sicily were assessed for ABI, homocysteine and its determi-
Ankle brachial index
nants, lipid markers and other predictors of PAD. HDL size was assessed in 15 sera in upper and lower
HDL quartiles of Hcy distribution.
Folate Results: In multivariate analysis, ApoA-I and homocysteine were two predictors of ABI (-
Vitamin B12 coefcient = 2.86, P < 0.004 and -coefcient = 3.41, P < 0.001, respectively). Homocysteine correlated
negatively with ApoA-I (R = 0.147, P < 0.001) and with HDL-Cholesterol (R = 0.113, P = 0.003). The asso-
ciations of homocysteine, vitamin B12 and methylmalonic acid with ApoA-I and HDL2a particles and that
of homocysteine with increased small size HDL3c suggested mechanisms related with impaired synthesis
of ApoA-I and HDL and abnormal maturation of HDL particles.
Conclusion: The inuence of homocysteine on ApoA-I and HDL metabolism provides new insights on its
role on vascular diseases, at a cross-point between atherosclerosis and atherothrombosis.
2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction thrombosis and vascular disease [9]. Since then, epidemiological

studies have shown an association of elevated plasma Hcy with
Coronary artery and cerebrovascular diseases, together with cerebro-vascular and coronary artery diseases and with left ven-
peripheral arterial disease (PAD), are responsible for the deaths tricular dysfunction [1013]. A recent meta-analysis concluded that
of more adults than any other medical condition in developed patients with PAD have an elevated blood level of Hcy [14]. Hyper-
countries [1] and are strongly related to age, gender and ethnicity, homocysteinemia increases cardiovascular morbidity by various
dyslipidemia and inammation [28]. The ABI is a measure- mechanisms that include oxidant and cellular stress, inammation,
ment that provides objective data for the diagnosis of lower endothelium dysfunction and thrombosis [10,11,15,16]. However,
extremity PAD [3]. Patients with a low ABI have a substantially the association of homocysteine with PAD and ABI needs to deserve
increased risk of death and severe vascular and thrombotic events further attention, in particular concerning its potential inuence
[3]. on lipid metabolism. Two recent studies with mthfr-decient or
Homocysteine (Hcy) was rst implicated as a risk factor when cbs//apoE/ mice showed that the genetically increased Hcy
it was noticed that homocystinuric patients had a propensity to alters the liver expression of ApoA-I and decreases the blood level of
ApoA-I and HDL-cholesterol (HDL-C) [17,18]. We aimed therefore
to evaluate whether homocysteine and its nutritional determi-
nants, folate and vitamin B12 exert deleterious effects on peripheral
Corresponding author at: University Henri Poincare, Inserm U954, Medical Fac-
arteries by inuencing ApoA-I and the HDL-dependent transport
ulty and CHU of Nancy, 54500 Vandoeuvre les Nancy, France.
of cholesterol. We investigated this hypothesis in an ambulatory
Tel.: +33 383154484; fax: +33 383683279.
E-mail address: (R.M. Guant-Rodriguez). elderly population of 667 volunteers, which were systematically
These authors contributed equally to this work. assessed for ABI.

0021-9150/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved.
R.M. Guant-Rodriguez et al. / Atherosclerosis 214 (2011) 480485 481

2. Methods 2 with category 1 or distinguishing both categories. Corrections for

multiple comparisons were made using the Bonferroni test. Anal-
2.1. Setting and participants yses were performed using Stata Software version 11.0 SE (Stata
Corporation, TX, USA).
San Teodoro and Cesaro are two rural villages of approximately
1500 inhabitants every one in the territory of Mounts Nebrodi, 3. Results
Sicily (1150 m). In 2005, all the elderly between 60 and 85 years
old were invited to participate in the study. The number of the 3.1. Baseline characteristics
enrollable subjects was 955, including 538 females and the nal
number of volunteers 667 (70.3%), including 400 females. The study The clinical and biochemical characteristics of the population
was conducted door-to-door and undertook clinical examination are presented in Table 1. The average age of the 667 participants was
and personal interview by physicians on clinical conditions, use of 71.5 years, 400 (60.0%) were women and 28.9% had cardiovascular
medications, signs and symptoms of diseases and their risk factors. diseases, including stroke, transitory ischemic attack, angor and/or
Diagnosis of peripheral arterial disease (PAD) was made according myocardial infarction. The average ABI was 1.09 0.01. The preva-
to established criteria [3,19]. All subjects provided written consent lence of low ABI was 5.8% (n = 39). There was 1.5-fold more diabetes
and the local ethic committee (IRCCS Oasi Maria S.S., Troina, Sicily) mellitus and 2-fold more males and smokers in subjects with low
approved the study protocol. ABI, compared with those with a normal ABI (Table 1). In contrast,
the percentage of diabetes mellitus in the high ABI group was
2.2. Measurement of ABI similar to that reported in the whole population (Table 1). Inter-
mittent claudidation was reported in 13 (33%) of the 39 subjects
The ABI was performed as recommended [3], using a hand- with low ABI. Hcy was strongly associated with folate (R = 0.258,
held Doppler probe (V2008, with a 8 MHz probe, GIMA, Gessate, P < 0.001) and vitamin B12 (R = 0.253, P < 0.001), but neither with
Italy). The systolic blood pressure was recorded from both brachial creatinine (P = 0.972) nor with C-reactive protein (P = 0.572).
arteries and from both the dorsalis pedis and posterior tibial arter-
ies after the patient has been at rest in the supine position for 3.2. Predictors of ABI
10 min. Both arm pressures were recorded. If the arm blood pres-
sures were not equal, then the higher blood pressure was used The categories of ABI were positively associated (P for trend)
for subsequent blood pressure ratio calculations. We considered with SBP, DBP, ApoA-I, folate and vitamin B12. Conversely, a nega-
ve ABI categories, ABI <0.90 (denite PAD), 0.900.99 (border- tive trend of ABI groups was noted with age, Hcy, C-reactive protein
line), 1.001.09 (low), 1.101.29 (normal), equal or superior to 1.30 and creatinine. Similar results were obtained when either grouping
(high), as described [19]. category 2 with category 1 (Table 1) or distinguishing both cate-
gories (Table 1bis online). The P for trend of the association of ABI
2.3. Blood collection and biological experiments categories with either SBP or DBP was less signicant when the
high ABI was excluded from the analyses, while the same level
All participants underwent blood sample collection. Venous of signicance was reported for the other associations (Table 1).
blood from fasting subjects was immediately centrifuged and In univariate regression analysis, the predictors of ABI were, by
stored at 20 C until analysis of vitamin B12 and folate. order of signicance, age, SBP, DBP, Log-Hcy, ApoA-I, creatinine,
Other parameters were immediately assayed. Hcy and methyl- C-reactive protein, folate and B12 (Table 2). The predictors were
malonic acid (MMA) were determined by UPLCMS/MS, with age (P < 0.001), SBP (P < 0.001), DBP (P < 0.035), Log-Hcy (P < 0.001),
an Acquity UPLC BEH C18 column (1.7 m, 2.1 mm 50 mm, ApoA-I (P < 0.001) and folate (P = 0.010) when excluding the high
Waters Corporation) [20]. Folate, vitamin B12, HDL-C, creati- ABI group from the analysis. In the multivariate analysis of a sex-
nine and other biological parameters were assayed as described adjusted model that included creatinine and the other signicant
[12,2022]. The Friedewald formula was used to calculate predictors of univariate analysis, the remaining independent pre-
the low-density lipoproteincholesterol (LDLC) concentration dictors of ABI were age, SBP, ApoA-I and Log-Hcy in the whole
except in 2 subjects with serum triglyceride levels greater than population (Table 2). We also performed the multivariate analy-
8.0 mmol/l [23]. Apolipoproteins A-I and B were measured by sis in two models where ApoA-I and Log-Hcy were alternatively
immunonephelemetry (Siemens Co., Ltd., France). HDL size dis- excluded (Table 2). Log-Hcy was associated with ABI with P < 0.001
tribution (HDL2b, 9.7112.90 nm; HDL2a, 8.779.71 nm; HDL3a, in the second model (without ApoA-I), and ApoA-I was associ-
8.178.77 nm; HDL3b, 7.768.17 nm; HDL3c, 7.217.76 nm) was ated with ABI with P < 0.001 in the third model (without Log-Hcy,
assessed by polyacrylamide 1.525% gradient gel electrophoresis Table 2). The same conclusions were reached, when performing the
(PAGE) in 15 serum samples, including 8 in the upper and 7 in the analyses after adjustment for sex, smoking and diabetes mellitus
lower quartile of Hcy, as previously described [24]. (Table 2bis online). When excluding the high ABI group from the
analyses, the predictors were age (P < 0.001), Log-Hcy ( = 3.89,
2.4. Statistics P < 0.001, second model without ApoA-1) and ApoA-I ( = 3.67,
P < 0.001, third model without Log-Hcy). The same conclusion was
Continuous data were summarized as mean SD or median reached when excluding the cases with cardiovascular diseases
with 2575th percentiles. Prevalence was reported as percentage. from the analysis.
MannWhitneys U-test evaluated differences. Multivariate corre-
lation was tested by multiple regression analysis. For variables with 3.3. Association of ApoA-I, HDL-C and HDL particle size with
skewed distribution, log-transformation was done before multi- homocysteine, methylmalonic acid and vitamin B12
ple regression analysis. Such transformation was applied to Hcy.
The associations between blood markers and ABI were evaluated Signicant negative correlations were observed between ApoA-
using analyses of covariance, adjusting either for sex or for sex, I and Hcy (P < 0.001) and between HDL-C and Hcy (P = 0.003) (Fig. 1).
smoking and diabetes mellitus. P-values <0.05 were considered sig- The same signicance was obtained when excluding either the
nicant. Considering the limited size of the borderline ABI category high ABI group or the subjects with cardiovascular diseases from
(n = 5), we evaluated these associations by grouping either category the analyses. In univariate regression analysis, the determinants
482 R.M. Guant-Rodriguez et al. / Atherosclerosis 214 (2011) 480485

Table 1
Clinical and biological characteristics of the study population, according to the 5 groupsa of ankle brachial index (ABI).

Characteristic (%, All groups (n = 667) 12 (denitive and 3 (low/normal) 4 (normal) 5 (High) (n = 155) P-for trend all
median and borderline) (n = 44) (n = 164) (24.6%) (n = 304) (45.6%) (23.2%) groups/groups 14
interquartiles or (6.6%)
mean SD)

Men, n (%) 267 (40.0) 32 (72.7) 69 (42.1) 107 (35.2) 59 (38.1) <0.001/<0.001
Age (years) 71.5 0.3 76.1 1.0a 72.0 0.5 71.1 6.9 70.6 6.8 <0.001/<0.001
Systolic blood pressure 141 1 147 23a 147 21 142 20 130 17 <0.001/0.021
Diastolic blood 78 1 78 14a 82 11 80 12 74 12 <0.001/0.947
pressure (mmHg)
Current smoker, n (%) 78 (11.7) 9 (23.1) 23 (14.0) 36 (11.8) 10 (6.5) 0.035/0.235
Diabetes mellitus, n (%) 153 (22.9) 17 (38.6) 35 (21.3) 64 (21.1) 37 (23.9) 0.025/0.011
Total cholesterol 202 (176226) 198 (164227) 204 (177226) 199 (172224) 206 (182235) 0.220/0.654
Triglycerides (mmol/L) 108 (79146) 115 (84182) 98 (74133) 110 (79150) 110 (831141) 0.953/0.800
HDL cholesterol 58 (4868) 59 (496) 58 (4670) 57 (4869) 58 (4969) 0.325/0.771
LDL cholesterol 118 (95141) 116 (83-138) 120 (97141) 114 (94137) 122 (85147) 0.373/0.954
ApoA-I (g/L) 1.7 (1.51.9) 1.5 (1.3-1.7) 1.6 (1.41.9) 1.7 (1.51.9) 1.7 (1.51.9) <0.001/<0.001
ApoB (g/L) 1.0 (0.91.2) 1.0 (0.91.1) 1.0 (0.91.2) 1.0 (0.91.2) 1.0 (0.91.2) 0.449/0.414
Homocysteine 14.5 (11.918.1) 19.8 (14.622.5) 15.3 (12.619.7) 14.0 (11.716.9) 13.5 (10.916.9) <0.001/<0.001
Folate (nmol/L) 11.8 (8.715.8) 9.9 (7.213.5) 10.9 (8.316.1) 12.1 (9.216.0) 12.4 (9.316.3) 0.002/0.009
Vitamin B12 (pmol/L) 297 (209401) 237 (178391) 299 (213404) 283 (204404) 323 (240401) 0.018/0.222
Methylmalonic acid 0.15 (0.110.24) 0.23 (0.130.36) 0.16 (0.110.24) 0.15 (0.110.23) 0.14 (0.090.21) 0.014/0.018
Creatinine (mmol/L) 9 (8-11) 9 (811) 9 (811) 9 (811) 9 (811) 0.192/0.846
Albumin (g/L) 43 (4145) 42 (4144) 43 (4145) 43 (4145) 42 (4144) 0.425/0.632
C-reactive protein 2.8 (1.65.4) 2.3 (1.05.1) 3.3 (1.96.6) 2.6 (1.55.1) 2.9 (1.75.4) 0.615/0.727
Groups of ABI: (1) <0.90 (denite PAD); (2) 0.900.99 (borderline); (3) 1.001.09 (low); (4) 1.101.29 (normal); (5) equal or superior.

of ApoA-I were albumin, Log -C-reactive protein, total cholesterol, tion of Hcy. We observed an increased concentration of the small
triglycerides, HDL-cholesterol, Log-MMA and Log-Hcy and in mul- size HDL3c in subjects with a concentration of Hcy exceeding the
tivariate analysis, cholesterol, triglycerides, HDL-cholesterol and upper-quartile, compared to those in the lowest quartile (Fig. 2). In
Log-Hcy (Table 3). The determinants of HDL-C were serum cre- addition, a signicant correlation was evidenced between HDL2a
atinine, albumin, total cholesterol, triglycerides, ALAT, Log-Hcy, and vitamin B12.
vitamin B12, ApoA-I, Log C-reactive protein and folate (P < 0.001,
P < 0.001, P < 0.001, P < 0.001, P = 0.003, P = 0.004, P = 0.009, P = 0.010, 4. Discussion
P = 0.020 and P = 0.040, respectively). In multivariate analysis, the
independent predictors of HDL-C were cholesterol, triglycerides, In this study of an ambulatory elderly population, the prevalence
Log-Hcy and albumin (-coefcient = 11.8 and P < 0.001, = 13.9 of low ABI was similar to that observed in other community-based
and P < 0.001, = 2.3 and P < 0.001 and = 2.1 and P = 0.022, studies [2,4,19]. We reported also a high incidence of cases with
respectively). We investigated further the inuence of Hcy on HDL high ABI, indicative of non-compressible arteries in elderly patients
size distribution by PAGE in 15 subjects with contrasted concentra- [3]. These individuals may have arterial disease, despite high ABI.

Table 2
Sex adjusted univariate and multivariate analyses of the determinants of the ankle brachial index (ABI) in 667 elderly volunteers.

Determinant Univariate Multivariate

Correlation P-Value First model (with ApoA1 Second model (without Third model (without
and Log-homocysteine) ApoA1) Log-homocysteine)

Beta coefcient P-Value Beta coefcient P-Value Beta coefcient P-Value

Age 0.163 <0.001 2.74 0.006 2.63 0.009 3.22 0.001

Serum creatinine 0.102 0.008
Albumin 0.028 0.461
ApoA-I +0.136 <0.001 2.79 0.005 2.86 0.004
C-reactive protein 0.007 0.851
Total cholesterol +0.061 0.116
Triglycerides +0.005 0.895
HDL-cholesterol +0.066 0.089
LDL-cholesterol +0.034 0.378
ALAT 0.059 0.130
ASAT 0.051 0.191
Log-homocysteine 0.218 <0.001 2.41 0.016 3.41 <0.001
Folate +0.116 0.003
Vitamin B12 +0.114 0.003
Methylmalonic acid 0.109 0.060
Systolic blood pressure 0.324 <0.001 7.91 <0.001 7.67 <0.001 8.06 <0.001
Diastolic blood pressure 0.229 <0.001
R.M. Guant-Rodriguez et al. / Atherosclerosis 214 (2011) 480485 483

Table 3
Sex adjusted univariate and multivariate analyses of the determinants of the plasma
level of ApoA-I in 667 elderly volunteers.

Determinant Univariate Multivariate

Correlation P-Value Beta coefcient P-Value

Age 0.031 0.455

Serum creatinine 0.085 0.038
Albumin +0.134 0.001
Log-C-reactive protein 0.143 0.001
Total cholesterol +0.377 0.001 3.43 0.006
Triglycerides 0.139 0.001 4.65 <0.001
HDL-cholesterol +0.762 <0.001 25.41 <0.001
LDL-cholesterol 0.012 0.772
ALAT 0.034 0.407
ASAT +0.059 0.152
Log-homocysteine 0.147 <0.001 3.08 0.002
Folates +0.034 0.411
Vitamin B12 +0.088 0.031
Methylmalonic acid 0.162 0.009

To undertake this diagnosis limitation, we evaluated also the asso-

ciation of ABI with determinants of Hcy and lipid metabolism after
exclusion of the subjects with high ABI and found results similar
to those obtained in the whole population.
A recent consensus review considered that Hcy could be a
stronger risk factor for PAD than for coronary artery disease [25].
Fig. 1. Correlation (Pearson analysis) between logarithmically transformed total
homocysteine (Log-Hcy) and either Apoprotein A1 (ApoA-I) (top) or HDL- Most of the risk factors of low ABI may inuence the Hcy blood level
Cholesterol (HDL-C) (bottom). Dotted lines: 95% condence intervals of the slope. [28,10], making difcult to establish whether it is a cause or a con-
sequence of low ABI or both. From this point of view, it should be

Fig. 2. (A) Box plots (median and quartiles) of the distribution (in percentage) of HDL particles in 15 serum samples, including 8 in the upper and 7 in the lower quartile of Hcy.
The size of HDL particles (HDL2a, 8.779.71 nm; HDL2b, 9.7112.90 nm; HDL3a, 8.178.77 nm; HDL3b, 7.768.17 nm; HDL3c, 7.217.76 nm) was assessed by polyacrylamide
1.525% gradient gel electrophoresis. (B) Correlation (Pearson analysis) between HDL2a and serum vitamin B12. Dotted lines: 95% condence intervals of the slop.
484 R.M. Guant-Rodriguez et al. / Atherosclerosis 214 (2011) 480485

noticed that Hcy was neither associated with creatinine nor with Appendix A. Supplementary data
C-reactive protein in our population. In agreement with a previous
study, we found an association of ABI with age, SBP, C-reactive pro- Supplementary data associated with this article can be found, in
tein, HDL and ApoA-I in univariate analysis [26]. The ABI was also the online version, at doi:10.1016/j.atherosclerosis.2010.11.031.
associated with the nutritional determinants of Hcy, folate and vita-
min B12 and with MMA, a metabolic marker of vitamin B12 cellular References
status. Hcy and ApoA-I were the two independent predictors of ABI, [1] Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics2008
in the rst model of our multivariate analysis, showing that other update: a report from the American Heart Association Statistics Committee and
effects of Hcy than those inuencing apoA-I plasma levels may also Stroke Statistics Subcommittee. Circulation 2008;117:e25146.
[2] Fowkes FG, Housley E, Cawood EH, et al. Edinburgh Artery Study: prevalence
play a role in peripheral artery disease. The association of Hcy with
of asymptomatic and symptomatic peripheral arterial disease in the general
PAD has been clearly evidenced in a recent meta-analysis based on population. Int J Epidemiol 1991;20:38492.
14 studies [13]. [3] Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for
the management of patients with peripheral arterial disease (lower extremity,
In agreement with the association between ApoA-I and Hcy in
renal, mesenteric, and abdominal aortic). Circulation 2006;113:e463654.
our elderly ambulatory population, a reduced expression of ApoA-I [4] Khawaja FJ, Bailey KR, Turner ST, et al. Association of novel risk factors with the
was reported in mice with genetically induced hyperhomocys- ankle brachial index in African American and non-Hispanic white populations.
teinemia and in patients with coronary artery disease [17,18]. In Mayo Clin Proc 2007;82:70916.
[5] McDermott MM, Ferrucci L, Guralnik JM, et al. Elevated levels of inammation,
the mthfr+/ decient mice model, the reduced liver expression of d-dimer, and homocysteine are associated with adverse calf muscle character-
apoA-I resulted from the inuence of Hcy on the expression of per- istics and reduced calf strength in peripheral arterial disease. J Am Coll Cardiol
oxisome proliferator-activated receptor alpha (PPAR) and on the 2007;50:897905.
[6] Vidula H, Tian L, Liu K, et al. Biomarkers of inammation and thrombosis as
related activity of ApoA-I promoter [18]. The association of vita- predictors of near-term mortality in patients with peripheral arterial disease:
min B12 and MMA with ApoA-I and HDL2a particles observed in a cohort study. Ann Intern Med 2008;148:8593.
our study may reect an inuence of cellular B12 (needed for both [7] Senti M, Nogues X, Pedro-Botet J, et al. Lipoprotein prole in men with periph-
eral vascular disease. Role of intermediate density lipoproteins and apoprotein
metabolisms of Hcy and MMA) on the synthesis and metabolism of E phenotypes. Circulation 1992;85:306.
HDL particles. These associations should deserve further attention [8] Ridker PM, Stampfer MJ, Rifai N. Novel risk factors for systemic atherosclerosis:
in the light of recent data on the effects of the decreased cellular a comparison of C-reactive protein, brinogen, homocysteine, lipoprotein(a),
and standard cholesterol screening as predictors of peripheral arterial disease.
availability of B12 on TNF and MAPK pathways and the inuence of
JAMA 2001;285:24815.
these pathways on ApoA-1 [20,27]. In addition to its inuence on [9] McCully KS. Vascular pathology of homocysteinemia: implications for the
ApoA-I, we also observed that hyperhomocysteinemia was asso- pathogenesis of arteriosclerosis. Am J Pathol 1969;56:11128.
[10] Wald D, Law M, Morris J. Serum homocysteine and severity of coronary artery
ciated with an increased concentration of the small size HDL3c.
disease. Thromb Res 2003;111:557.
This suggested an impaired HDL maturation via an ApoA-I related [11] Herrmann W, Herrmann M, Obeid R. Hyperhomocysteinaemia: a critical review
mechanism, which was in agreement with the absence of large HDL of old and new aspects. Curr Drug Metab 2007;8:173112.
particles observed in hyperhomocysteinemic cbs/apoe/ mice [12] Gueant-Rodriguez RM, Juilliere Y, Nippert M, et al. Left ventricular systolic
dysfunction is an independent predictor of homocysteine in angiographi-
[17]. cally documented patients with or without coronary artery lesions. J Thromb
Most of the interventional studies that aimed to decrease the Haemost 2007;5:120916.
risk of coronary artery diseases by lowering Hcy with vitamin B sup- [13] Lentz SR. Mechanisms of homocysteine-induced atherothrombosis. J Thromb
Haemost 2005;3:164654.
plements failed to nd a benet of the supplementation [28,29]. In [14] Khandanpour N, Loke YK, Meyer FJ, et al. Homocysteine and peripheral arte-
contrast, a recent randomized clinical trial that included folate sup- rial disease: systematic review and meta-analysis. Eur J Vasc Endovasc Surg
plementation increased ABI and decreased the pulse wave velocity, 2009;38:31622.
[15] Ventura E, Durant R, Jaussent A, et al. Homocysteine and inammation as
suggesting an inuence on lower extremity PAD [30]. These con- main determinants of oxidative stress in the elderly. Free Radic Biol Med
trasting results suggest that Hcy exerts more critical effects in 2009;46:73744.
arterial diseases of extremities than in those of large vessels, despite [16] Woo KS, Sanderson JE, Sun YY, et al. Hyperhomocyst(e)inemia is a risk factor
for arterial endothelial dysfunction in humans. Circulation 2000;101:E116.
the lack of knowledge about the mechanisms that underlie the
[17] Liao D, Tan H, Hui R, et al. Hyperhomocysteinemia decreases circulating high-
association between Hcy and PAD. Our data suggest that the inu- density lipoprotein by inhibiting apolipoprotein A-I Protein synthesis and
ence of Hcy on ApoA-I and HDL metabolism could be one of enhancing HDL cholesterol clearance. Circ Res 2006;99:598606.
[18] Mikael LG, Genest Jr J, Rozen R. Elevated homocysteine reduces apolipopro-
tein A-I expression in hyperhomocysteinemic mice and in males with coronary
artery disease. Circ Res 2006;98:56471.
[19] McDermott MM, Liu K, Criqui MH, et al. Ankle-brachial index and subclinical
5. Conclusions cardiac and carotid disease: the multi-ethnic study of atherosclerosis. Am J
Epidemiol 2005;162:3341.
[20] Battaglia-Hsu SF, Akchiche N, Noel N, et al. Vitamin B12 deciency reduces pro-
Little is known about the mechanisms that underlie the associa- liferation and promotes differentiation of neuroblastoma cells and up-regulates
tion of homocysteine with peripheral arterial disease. We showed PP2A, proNGF, and TACE. Proc Natl Acad Sci USA 2009;106:219305.
[21] Gueant-Rodriguez RM, Juilliere Y, Candito M, et al. Association of MTRRA66G
that Log-homocysteine and ApoA-I are two interacting biological polymorphism (but not of MTHFR C677T and A1298C, MTRA2756G, TCN
predictors of ankle brachial index in an ambulatory elderly popu- C776G) with homocysteine and coronary artery disease in the French popu-
lation. Taken together, the associations of homocysteine, vitamin lation. Thromb Haemost 2005;94:5105.
[22] Sugiuchi H, Uji Y, Okabe H, et al. Direct measurement of high-density lipopro-
B12 and methylmalonic acid with ApoA-I and HDL2a particles and
tein cholesterol in serum with polyethylene glycol-modied enzymes and
that of homocysteine with small size HDL3c suggest mechanisms sulfated alpha-cyclodextrin. Clin Chem 1995;41:71723.
related with the impaired synthesis of ApoA-1 and HDL and abnor- [23] Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of
mal maturation of HDL particles. low-density lipoprotein cholesterol in plasma, without use of the preparative
ultracentrifuge. Clin Chem 1972;18:499502.
[24] Lagrost L, Athias A, Herbeth B, et al. Opposite effects of cholesteryl ester transfer
protein and phospholipid transfer protein on the size distribution of plasma
Acknowledgement high density lipoproteins. Physiological relevance in alcoholic patients. J Biol
Chem 1996;271:1905865.
[25] Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Man-
This study was nanced by the Region Lorraine and by a grant agement of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg
from the national agency for research (ANR Nutrivigne). The 2007;33(Suppl. 1):S175.
[26] Pradhan AD, Shrivastava S, Cook NR, et al. Symptomatic peripheral arterial
authors have no conicts of interests and disclosures of nancial
disease in women: nontraditional biomarkers of elevated risk. Circulation
support to declare. 2008;117:82331.
R.M. Guant-Rodriguez et al. / Atherosclerosis 214 (2011) 480485 485

[27] Beers A, Haas MJ, Wong NC, Mooradian AD. Inhibition of apolipoprotein AI [29] Lonn E, Yusuf S, Amold MJ, et al. Homocysteine lowering with folic acid and B
gene expression by tumor necrosis factor alpha: roles for MEK/ERK and JNK vitamins in vascular disease. N Engl J Med 2006;354:156777.
signaling. Biochemistry 2006;45:240813. [30] Carrero JJ, Lopez-Huertas E, Salmeron LM, et al. Daily supplementation with
[28] Bonaa KH, Njolstad I, Ueland PM, et al. Homocysteine lowering and cardiovas- (n-3) PUFAs, oleic acid, folic acid, and vitamins B-6 and E increases pain-free
cular events after acute myocardial infarction. N Engl J Med 2006;354:1578 walking distance and improves risk factors in men with peripheral vascular
88. disease. J Nutr 2005;135:13939.