Homocysteine lowering with folic acid and B vitamins in vascular disease

Role of hyperhomocysteinemia in atherosclerosis: from bench to bedside

BACKGROUND

Atherosclerosis is a leading cause of global mortality, driven by complex interactions between genetic, metabolic, and environmental factors. Among these, hyperhomocysteinemia (HHcy) has emerged as a significant and modifiable risk factor, contributing to endothelial dysfunction, oxidative stress, and vascular inflammation. Despite increasing recognition of its role in atherogenesis, the precise mechanisms and clinical implications of HHcy remain incompletely understood, necessitating a comprehensive review to connect recent mechanistic insights with practical applications.

METHODS

We analyzed the various mechanisms whereby HHcy accelerates the progression of atherosclerosis, and conducted a comprehensive review of publications in the fields of HHcy and atherosclerosis.

RESULTS

HHcy promotes atherosclerosis through several mechanisms, including inflammation, oxidative stress, epigenetic modification, and lipoprotein metabolism alteration. Moreover, this discussion extends to current strategies for the prevention and clinical management of HHcy-induced atherosclerosis.

CONCLUSION

This review consolidates and elucidates the latest advancements and insights into the role of HHcy in atherosclerosis. The comprehensive narrative connects fundamental research with clinical applications. Contemporary studies highlight the complex interplay between HHcy and atherosclerosis, establishing HHcy as not only a contributing risk factor but also an accelerator of various atherogenic processes.

Reframing Micronutrient Deficiencies for Modern times: A Review

Micronutrient deficiencies are often discounted in as an entity of the past when access to quality nutrition was scarce. However modern-day conditions such as hemodialysis, complex medication interactions, parenteral nutrition, gastrointestinal resections, institutional living, and substance use can place patients at risk. The metabolic demands of critical illness during prolonged hospitalization may provide added stressors. Food insecurity with reliance on inexpensive calorie-rich, nutrient poor diet may lead to deficiency without overt evidence of malnutrition. Moreover, clinical presentation may be subtle and easily attributed to other diagnoses. Increased awareness of current risk factors is essential for detection and treatment.

Dysregulated homocysteine metabolism and cardiovascular disease and clinical treatments

Elevated homocysteine (Hcy) levels, known as hyperhomocysteinemia (HHcy), are recognized as a separate risk factor for cardiovascular disease. Mutations in methylenetetrahydrofolate reductase (MTHFR) and cystathionine beta synthase (CBS)-enzymes pivotal at the juncture of the trans-sulfuration and remethylation pathways-underlie the pathogenesis of HHcy. Although vitamin supplementation has been proven to effectively decrease Hcy levels, there is still uncertainty about whether this reduction translates to a decrease in the incidence rates from cardiovascular diseases (CVDs). This review seeks to explore the linking between Hcy and specific diseases, the role of Hcy in vascular homeostasis, and the research on the possible advantages of therapies designed to lower Hcy levels. Understanding the intricate mechanisms of their metabolism and interactions is essential for pharmacological treatments to mitigate the adverse effects associated with metabolic dysregulation of Hcy. Given the widespread availability and ease of use of Hcy test kits, we strongly advocate for the routine administration of rapid blood tests for individuals at high risk of CVDs, particularly among the elderly population.

Cholesterol Sulfate: Pathophysiological Implications and Potential Therapeutics

Cholesterol sulfate (CS) is a naturally occurring cholesterol derivative that is widely distributed across various tissues and body fluids. In humans, its biosynthesis is primarily mediated by the sulfotransferase (SULT) 2B1b (SULT2B1b). Over the years, CS has been found to play critical roles in various physiological processes, including epidermal cell adhesion, sperm capacitation, platelet adhesion, coagulation, glucolipid metabolism, bone metabolism, gut microbiota metabolism, neurosteroid biosynthesis, T-cell receptor signaling, and immune cell migration. In this review, we first introduce the endogenous regulation of CS biosynthesis and metabolism. We then highlight current advances in the understanding of the physiological roles of CS. Finally, we delve into the implications of CS in various diseases, with a particular focus on its mechanism of action and potential therapeutic applications. A comprehensive understanding of CS's physiological function, biosynthesis regulation, and role as a disease modifier offers novel insights that could pave the way for innovative therapeutic strategies targeting a wide range of conditions.

Homocysteine and Multiple Health Outcomes: An Outcome-Wide Umbrella Review of Meta-analyses and Mendelian Randomization Studies

Elevated levels of homocysteine (Hcy) are associated with various health outcomes. We aimed to systematically assess the credibility and certainty of evidence of associations of Hcy and Hcy-lowering therapies with various health outcomes. We retrieved observational meta-analyses examining the associations between Hcy and health outcomes, interventional meta-analyses investigating health outcomes related to Hcy-lowering treatments, and Mendelian randomization (MR) studies exploring the causal associations of Hcy with health outcomes to perform an umbrella review. A total of 135 observational meta-analyses, 106 MR studies, and 26 interventional meta-analyses were included. Among observational studies, 10 associations of diseases/outcomes were classified as highly suggestive; only 1 outcome (digestive tract cancer) was supported by convincing evidence (class I; odd ratio = 1.27, 95% confidence interval = 1.16, 1.40; P = 6.79 × 10-7; I2 = 0, 95% prediction interval excluding null, >1000 cases; P > 0.1 for tests of both small-study effects and excess significance bias). In MR studies, 5 outcomes associated with Hcy presented robust evidence (P < 0.01, power >80%). Among 25 outcomes explored by both observational meta-analyses and MR studies, 7 had consistent results, indicating that elevated Hcy is causally associated with an increased risk of these outcomes. The 3 types of studies collectively suggested that the association of stroke with Hcy was supported by observational studies, causally by MR studies, and further validated by intervention meta-analyses showing that Hcy-lowering with folic acid significantly reduced risk of stroke. For dementia and colorectal cancer, Hcy was significantly associated in meta-analyses of observational studies and folic acid decreased disease risks in interventional meta-analyses. The current umbrella review indicates that convincing evidence for a definitive role of Hcy exposure solely exists in the context of digestive tract cancer excluding bias; however, Hcy may not be causal for this disease. All the 3 types of studies collectively support that Hcy is a key causal risk factor, and Hcy-lowering (specifically with folic acid) may serve as an effective intervention for stroke. This trial was registered at PROSPERO as CRD42024541335.

How Increased Dietary Folic Acid Intake Impacts Health Outcomes Through Changes in Inflammation, Angiogenesis, and Neurotoxicity

Dietary folic acid supplementation is well known for playing a crucial role in the closure of the neural tube. Individuals have continued to increase dietary intake of folic acid in counties with mandatory fortication laws in place. Some studies have demonstrated adverse health effects in individuals with high dietary intake of folic acid. Nutrition is a modifiable risk factor for ischemic stroke. Specifically, elevated levels of homocysteine, they can be reduced by increasing intake of vitamins, such as folic acid, a B-vitamin. Hypoxia, when levels of oxygen are reduced, is a major component of cardiovascular diseases. The aim of this review paper was to summarize how increased dietary intake of folic acid interaction with hypoxia to impact health outcomes. Our survey of the literature found that increased dietary intake of folic acid promotes inflammation, angiogenesis, and neurotoxicity. We also report negative actions of increased dietary intake of folic acid with vitamin B12 and genetic deficiencies in one-carbon metabolism. Increased dietary intake of folic acid also results in elevated levels of unmetabolized folic acid in the population, of which the impact on health risks has not yet been determined. Our review of the literature emphasizes that a more comprehensive understanding of the action between increased dietary intake of folic acid on disease outcomes could pave the way for improved public health guidelines. Furthermore, adequate knowledge of an individual's one-carbon metabolism status can inform proactive management for patients at higher risk of experiencing negative health outcomes.

Anemia, hematinic deficiencies, hyperhomocysteinemia, and serum gastric parietal cell antibody positivity in oral lichen planus patients with vitamin B12 deficiency

Background/purpose

Our previous study found that 60 of 588 oral lichen planus (OLP) patients have vitamin B12 deficiency. This study assessed whether the vitamin B12-deficient OLP (B12D/OLP) patients had significantly higher frequencies of anemia, hematinic deficiencies, hyperhomocysteinemia, and serum gastric parietal cell antibody (GPCA) positivity than healthy control subjects and evaluated whether all B12D/OLP patients had pernicious anemia (PA).

Materials and methods

The blood hemoglobin (Hb) and serum iron, vitamin B12, folic acid, homocysteine, and GPCA levels in 60 B12D/OLP patients and 588 healthy control subjects were measured and compared.

Results

We found that 60 B12D/OLP patients had significantly lower mean blood Hb and serum iron, vitamin B12, and folic acid levels as well as significantly higher mean corpuscular volume (MCV) and mean serum homocysteine level than 588 healthy control subjects (all P-values <0.01). Moreover, 60 B12D/OLP patients had significantly higher frequencies of macrocytosis (55.0 %), blood Hb (68.3 %) and serum iron (31.7 %) and vitamin B12 (100.0 %) deficiencies, hyperhomocysteinemia (91.7 %), and serum GPCA positivity (66.7 %) than 588 healthy control subjects (all P-values <0.001). The four most common types of anemia in 41 anemic B12D/OLP patients were PA (17 patients, 41.5 %), normocytic anemia (12 patients, 29.3 %), iron deficiency anemia (6 patients, 14.6 %), and macrocytic anemia other than PA (5 patients, 12.2 %).

Conclusion

The B12D/OLP patients have significantly higher frequencies of macrocytosis, blood Hb and serum iron and vitamin B12 deficiencies, hyperhomocysteinemia, and serum GPCA positivity than healthy control subjects. Only 17 (28.3 %) of 60 B12D/OLP patients have PA.

Anemia, hematinic deficiencies, hyperhomocysteinemia, and gastric parietal cell antibody positivity in oral lichen planus patients with iron deficiency

Background/purpose

Our previous study found that 99 of 588 oral lichen planus (OLP) patients have iron deficiency (ID). This study assessed whether all OLP patients with ID (so-called ID/OLP patients) had iron deficiency anemia (IDA) and evaluated whether the ID/OLP patients had significantly higher frequencies of anemia, hematinic deficiencies, hyperhomocysteinemia, and serum gastric parietal cell antibody (GPCA) positivity than healthy control subjects.

Materials and methods

The blood hemoglobin (Hb) and serum iron, vitamin B12, folic acid, homocysteine, and GPCA levels in 99 ID/OLP patients and 588 healthy control subjects were measured and compared.

Results

We found that 99 ID/OLP patients had significantly lower mean blood Hb and serum iron, vitamin B12, folic acid levels as well as significantly higher mean serum homocysteine level than 588 healthy control subjects (all P-values <0.001). Moreover, 99 ID/OLP patients had significantly higher frequencies of blood Hb (64.7 %) and serum vitamin B12 (19.2 %), and folic acid (2.0 %) deficiencies, hyperhomocysteinemia (34.3 %), and serum GPCA positivity (33.3 %) than 588 healthy control subjects (all P-values <0.05). Furthermore, of 64 anemic ID/OLP patients, 2 (3.1 %) had pernicious anemia, 30 (46.9 %) had normocytic anemia, and 32 (50.0 %) had IDA.

Conclusion

ID/OLP patients have significantly higher frequencies of blood Hb and serum vitamin B12 and folic acid deficiencies, hyperhomocysteinemia, and serum GPCA positivity than healthy control subjects. Although the IDA (50.0 %) is the most common type of anemia in our 64 anemic ID/OLP patients, there are still 46.9 % of the 64 anemic ID/OLP patients who had the normocytic anemia.

Anemia, hematinic deficiencies, and hyperhomocysteinemia in male and female oral lichen planus patients

Background/purpose

Our previous study found that 21.9 %, 13.6 %, 7.1 %, 0.3 %, and 14.8 % of 352 oral lichen planus (OLP) patients have anemia, serum iron, vitamin B12, and folic acid deficiencies, and hyperhomocysteinemia, respectively. This study mainly evaluated the anemia, hematinic deficiencies, and hyperhomocysteinemia in 110 male and 478 female OLP patients.

Materials and methods

The blood hemoglobin (Hb) and serum iron, vitamin B12, folic acid, and homocysteine levels in 110 male and 478 female OLP patients were measured and compared with the corresponding levels in 110 male and 478 female healthy control subjects, respectively.

Results

We found that 110 male OLP patients had significantly lower mean blood Hb and serum folic acid levels than 110 male healthy control subjects. Moreover, 478 female OLP patients had significantly lower mean blood Hb and serum iron, vitamin B12, and folic acid levels and significantly higher mean serum homocysteine level than 478 female healthy control subjects. In addition, 110 male OLP patients had significantly higher mean blood Hb and serum iron levels, significantly lower mean serum vitamin B12 and folic acid levels, a significantly higher frequency of folic acid deficiency, and significantly lower frequencies of blood Hb and serum iron deficiencies than 478 female OLP patients.

Conclusion

The male OLP patients do have significantly higher mean blood Hb and serum iron levels, significantly lower mean serum vitamin B12 and folic acid levels, a significantly higher frequency of folic acid deficiency, and significantly lower frequencies of blood Hb and serum iron deficiencies than female OLP patients.

Micro-nutrient sufficiency in mothers and babies: management of deficiencies while avoiding overload during pregnancy

Pregnancy is a period characterized by extensive physiological changes in both the mother and fetus. During this period, the nutritional status of the mother has a profound and irreversible impact on her health and the growth and development of the fetus. The fetus depends exclusively on the mother and drives nutrients through the placenta. Therefore, mothers must be provided with a well-balanced diet that is adequate in both macro- and micronutrients. Most pregnant women generally manage to get adequate macronutrients; however, many women fail to get micronutrients up to the recommended dietary allowance. Micronutrients such as vitamins and minerals are necessary for preventing congenital abnormalities and the optimal development of the brain and body of the fetus. Their inadequacy can lead to complications like anemia, hypertension, pre-eclampsia, maternal and fetal hypothyroidism, premature infants, intrauterine growth restriction, stillbirth, and other negative pregnancy outcomes. New studies recommend the use of prenatal micronutrient supplements to prevent birth defects and health issues caused by deficiencies in folic acid, iron, iodine, and calcium during pregnancy. This is especially important in developing nations where deficiencies are prevalent. Also while using these supplements, their upper limits (UL) must be considered to avoid overload. In this review, we provide an overview of the four most critical micronutrients during pregnancy: iron, folic acid, iodine, and calcium. We provide insight into their sources, RDAs, deficiency consequences, and the need for supplementation while considering the risk of micronutrient overload. To maximize the potential benefits while minimizing the risk of nutrient overload, although knowledge gaps remain.

Association of Homocysteine, S-Adenosylhomocysteine and S-Adenosylmethionine with Cardiovascular Events in Chronic Kidney Disease

Background: Patients suffering from chronic kidney disease (CKD) have a high risk of premature cardiovascular morbidity and mortality. It has been suggested that elevated homocysteine (Hcy) or disturbances in the transmethylation pathway may contribute to this high cardiovascular risk burden due to epigenetic mechanisms. The objective of this study was to explore the prognostic value of Hcy, S-adenosylhomocysteine (SAH) and S-adenosylmethionine (SAM) (one-carbon (C1)-metabolites) among patients with CKD. Methods: Plasma concentrations of Hcy, SAM and SAH were measured among 297 participants with CKD (KDIGO GFR category G2-G5). The predefined endpoint was the occurrence of major cardiovascular events (MACE), defined as carotid, coronary and peripheral arterial revascularization, stroke, acute myocardial infarction, major amputation, cardiovascular death and all-cause mortality during a median (IQR) follow-up period of 4.0 [3.2; 4.3] years. Results: Among all participants, the median (IQR) of plasma Hcy, SAH, and SAM levels were 16.6 [13.5; 21.2] µmol/L, 41.5 [26.6; 63.9] nmol/L, 183.4 [151.1; 223.5] nmol/L, respectively. Estimated glomerular filtration rate (eGFR) correlated more strongly with plasma SAH (r = -0.588) than with SAM (r = -0.497) and Hcy (r = -0.424). During the follow-up period, 55 participants experienced MACE. In a univariate Kaplan Meier analysis, all three C1-metabolites were significantly associated with the occurrence of the primary outcome. In a Cox-regression analysis, the association between Hcy and MACE was not significant after adjustment for age and sex (hazard ratio (HR) and 95% confidence intervals (95% CI) for the 3rd vs. 1st tertile = 1.804 (0.868-3.974)). Both SAH and SAM were not associated with MACE after adjustment for age, sex and additionally for renal function markers (SAH: HR 3rd vs. 1st tertile 1.645 95% (0.654-4.411); SAM: HR 3rd vs. 1st tertile 1.920 95% CI (0.764-5.138)). Conclusions: In people with CKD, plasma Hcy, SAH and SAM were not independent predictors of MACE after adjustment for age, sex and renal function. Disturbed renal function may explain elevated C1-metabolites and disturbed transmethylation, while this pathway is not likely to be an appropriate access point to modify the risk of cardiovascular events in CKD patients.

Mutual mediation effects of homocysteine and PCSK9 on coronary lesion severity in patients with acute coronary syndrome: interplay with inflammatory and lipid markers

BACKGROUND

Homocysteine (Hcy) and the proprotein convertase subtilisin/kexin type 9 (PCSK9) significantly contribute to atherosclerosis (AS) as well as coronary lesion severity. Our previous work demonstrated that Hcy upregulates PCSK9, accelerating lipid accumulation and AS. A PCSK9 antagonist reduces plasma Hcy levels in ApoE-/- mice. These findings suggest complex roles for both Hcy and PCSK9 in AS. This study investigated the mutual mediating influence of Hcy together with PCSK9 on coronary lesion severity among individuals diagnosed with acute coronary syndrome (ACS), focusing on their interplay with inflammatory and lipid-related markers.

METHODS

This cross-sectional study encompassed 617 individuals diagnosed with ACS. Baseline characteristics, including inflammatory and lipid-related markers, were compared between individuals with non-severe (SYNTAX score ≤ 22) and severe (SYNTAX score > 22) coronary lesions. To evaluate both the impacts of Hcy and PCSK9 on coronary lesions severity, multivariate logistic regression along with mediation analyses were utilized. The robustness of the findings was validated by conducting subgroup analyses and sensitivity tests.

RESULTS

Patients with severe conditions showed higher levels of Hcy, PCSK9, and inflammatory markers compared to non-severe cases. Both Hcy and PCSK9 levels were independently linked to a heightened risk of severe coronary lesions(ORs: 1.03-1.04 and 1.01-1.02, respectively, all P < 0.001). PCSK9 mediated 34.04% of Hcy's effect on coronary lesion severity, whereas Hcy mediated 31.39% of PCSK9's effect, indicating significant mutual mediation between these biomarkers. Subgroup analyses revealed consistent associations, with notable interactions based on creatinine levels for Hcy and gender, smoking status, and diagnosis for PCSK9. Sensitivity analyses confirmed the robustness of the mediation effects.

CONCLUSIONS

These findings emphasize the mutual mediating effects of Hcy and PCSK9 on coronary lesion severity in patients suffering from ACS. These results highlight the complex interactions between lipid metabolism and inflammation in the pathophysiology of ACS, suggesting that targeting both Hcy and PCSK9 may offer novel therapeutic strategies to mitigate severe coronary lesions among high-risk patients.

Homocysteine Metabolites, Endothelial Dysfunction, and Cardiovascular Disease

Atherosclerosis is accompanied by inflammation that underlies cardiovascular disease (CVD) and its vascular manifestations, including acute stroke, myocardial infarction, and peripheral artery disease, the leading causes of morbidity/mortality worldwide. The monolayer of endothelial cells formed on the luminal surface of arteries and veins regulates vascular tone and permeability, which supports vascular homeostasis. Endothelial dysfunction, the first step in the development of atherosclerosis, is caused by mechanical and biochemical factors that disrupt vascular homeostasis and induce inflammation. Together with increased plasma levels of low-density lipoprotein (LDL), diabetes, hypertension, cigarette smoking, infectious microorganisms, and genetic factors, epidemiological studies established that dysregulated metabolism of homocysteine (Hcy) causing hyperhomocysteinemia (HHcy) is associated with CVD. Patients with severe HHcy exhibit severe CVD and die prematurely due to vascular complications. Biochemically, HHcy is characterized by elevated levels of Hcy and related metabolites such as Hcy-thiolactone and N-Hcy-protein, seen in genetic and nutritional deficiencies in Hcy metabolism in humans and animals. The only known source of Hcy in humans is methionine released in the gut from dietary protein. Hcy is generated from S-adenosylhomocysteine (AdoHcy) and metabolized to cystathionine by cystathionine β-synthase (CBS) and to Hcy-thiolactone by methionyl-tRNA synthetase. Hcy-thiolactone, a chemically reactive thioester, modifies protein lysine residues, generating N-homocysteinylated (N-Hcy)-protein. N-Hcy-proteins lose their normal native function and become cytotoxic, autoimmunogenic, proinflammatory, prothrombotic, and proatherogenic. Accumulating evidence, discussed in this review, shows that these Hcy metabolites can promote endothelial dysfunction, CVD, and stroke in humans by inducing pro-atherogenic changes in gene expression, upregulating mTOR signaling, and inhibiting autophagy through epigenetic mechanisms involving specific microRNAs, histone demethylase PHF8, and methylated histone H4K20me1. Clinical studies, also discussed in this review, show that cystathionine and Hcy-thiolactone are associated with myocardial infarction and ischemic stroke by influencing blood clotting. These findings contribute to our understanding of the complex mechanisms underlying endothelial dysfunction, atherosclerosis, CVD, and stroke and identify potential targets for therapeutic intervention.

Anemia, hematinic deficiencies, hyperhomocysteinemia, and serum gastric parietal cell antibody positivity in 588 patients with oral lichen planus

Background/purpose

Our previous study found that 21.9 %, 13.6 %, 7.1 %, 0.3 %, and 14.8 % of 352 oral lichen planus (OLP) patients have anemia, serum iron, vitamin B12, and folic acid deficiencies, and hyperhomocysteinemia, respectively. This study mainly evaluated the anemia, hematinic deficiencies, hyperhomocysteinemia, and serum gastric parietal cell antibody (GPCA) positivity in a large group of 588 OLP patients.

Materials and methods

The blood hemoglobin (Hb) and serum iron, vitamin B12, folic acid, homocysteine, and GPCA levels in 588 OLP patients were measured and compared with the corresponding levels in 588 age- and sex-matched healthy control subjects.

Results

We found that 148 (25.2 %), 99 (16.8 %), 60 (10.2 %), 7 (1.2 %), 124 (21.1 %), and 139 (23.6 %) OLP patients had blood Hb, serum iron, vitamin B12, and folic acid deficiencies, hyperhomocysteinemia, and serum GPCA positivity, respectively. Moreover, 588 OLP patients had significantly higher frequencies of blood Hb and serum iron, vitamin B12, and folic acid deficiencies, hyperhomocysteinemia, and serum GPCA positivity than 588 healthy control subjects (all P-values <0.001 except P = 0.023 for folic acid deficiency). Of 148 anemic OLP patients, 68 had normocytic anemia, 32 had iron deficiency anemia, 19 had thalassemia trait-induced anemia, 17 had pernicious anemia, 7 had macrocytic anemia other than pernicious anemia, and 5 had microcytic anemia other than iron deficiency anemia and thalassemia trait-induced anemia.

Conclusion

OLP patients have significantly higher frequencies of blood Hb and serum iron, vitamin B12, and folic acid deficiencies, hyperhomocysteinemia, and serum GPCA positivity than healthy control subjects.

Homocysteine Blood Levels and Mandatory Folic Acid Fortification in Serbia

INTRODUCTION

The current study aims to investigate the blood Hcy levels in patients with CAD and hypertension in Serbia, a country with a high incidence and mortality of both diseases.

METHODS

The level of Hcy in the Serbian population was assessed in 123 patients with chronic coronary artery disease (CAD) and hypertension. There were 53 patients with chronic CAD and 70 patients with hypertension (HTA), but without CAD.

RESULTS

The Hcy levels were high in both groups of patients (the mean Hcy level of 16.0 ± 7.0 μmol/L) without a statistical difference between the patients in the CAD (14.9 ± 7.3 μmol/L) and hypertension (16.7 ± 6.7 μmol/L) groups. Hypercholesterolemia was found in 81% of the patients with CAD and 92.0% of the patients with HTA, as a common concern across both clinical conditions. It was also found that not a single conventional risk factor (diabetes, hypertension, the smoking status, the family history of CAD, and hyperlipidemia) may individually influence Hcy levels. By contrast, the low levels of vitamin B12 may be related to the high levels of Hcy.

CONCLUSION

Given the fact that it is known that various factors interact and influence Hcy levels and associated cardiovascular risks, specific dietary habits, lifestyle and the other Serbia-specific possible factors were done.

Metabolites and metabolism in vascular calcification: links between adenosine signaling and the methionine cycle

The global population of individuals with cardiovascular disease is expanding, and a key risk factor for major adverse cardiovascular events is vascular calcification. The pathogenesis of cardiovascular calcification is complex and multifaceted, with external cues driving epigenetic, transcriptional, and metabolic changes that promote vascular calcification. This review provides an overview of some of the lesser understood molecular processes involved in vascular calcification and discusses the links between calcification pathogenesis and aspects of adenosine signaling and the methionine pathway; the latter of which salvages the essential amino acid methionine, but also provides the substrate critical for methylation, a modification that regulates the function and activity of DNA and proteins. We explore the complex and dynamic nature of osteogenic reprogramming underlying intimal atherosclerotic calcification and medial arterial calcification (MAC). Atherosclerotic calcification is more widely studied; however, emerging studies now show that MAC is a significant pathology independent from atherosclerosis. Furthermore, we emphasize metabolite and metabolic-modulating factors that influence vascular calcification pathogenesis. Although the contributions of these mechanisms are more well-define in relation to atherosclerotic intimal calcification, understanding these pathways may provide crucial mechanistic insights into MAC and inform future therapeutic approaches. Herein, we highlight the significance of adenosine and methyltransferase pathways as key regulators of vascular calcification pathogenesis.

Is autoimmunity associated with the development of premalignant oral conditions and the progression to oral squamous cell carcinoma?: A literature review

OBJECTIVE

Oral potentially malignant disorders (OPMDs) are oral mucosal conditions that may progress to oral squamous cell carcinoma (OSCC). Although autoimmunity has linked to the malignant transformation potential of various precancerous conditions, its role in OPMD remains unclear. This review aimed to identify the role of systemic autoimmunity on OPMD development and their progression to OSCC.

METHODS

A comprehensive literature search was conducted using PubMed, Cochrane CENTRAL, and SCOPUS database for articles published up to January 2024. The key questions addressed by this review were "Is autoimmunity associated with the development of OPMD" and "How does systemic autoimmunity influence the potential for malignant transformation of OPMD?". This review followed the PRISMA guidelines for scoping reviews (PRISMA-ScR).

RESULTS

Of the 1265 articles initially identified, 21 fulfilled the search criteria. Three themes were emerged; 1) the prevalence and prognosis of oral cancers in patients with systemic autoimmune diseases, 2) circulating autoantibodies in OPMD patients, and 3) autoimmune-related markers linked to malignant transformation in OPMD patients. This review indicated that systemic autoimmunity may contribute to chronic inflammatory conditions, disruption of oral mucosal integrity, and interference with the DNA damage repair process, thus influencing malignant transformation in the oral epithelium of patients with OPMD.

CONCLUSION

The co-occurrence of OPMD with circulating autoantibodies or systemic autoimmune diseases underscores the importance of understanding these interactions for improved management of OPMD and early detection of OSCC.

Homocysteine in androgenetic alopecia: A case control study and observational experiments on mice

OBJECTIVE

To investigate the relationship between homocysteine (HCY) and androgenetic alopecia (AGA).

METHODS

A case control study and two observational experiments on mice were conducted. In the first part, a total of 528 Chinese AGA patients and 500 age-matched healthy controls were included. Serum HCY levels of AGA and controls were compared. In the second part, eight mice were divided into two groups. Both groups of mice had their hair removed. AGA group received a DHT injection, and the other as control group. HCY levels in hair follicles (HFs) were detected by ELISA and compared. In the third part, twelve mice were divided into three groups and fed with different concentrations of methionine. After 4 weeks, serum HCY levels, parameters related to hair growth through observation and HE staining, and expression of immunohistochemistry (IHC) hair-growth-related markers Ki67, VEGF, IGF-1, Krt27, FGF9, and TGF-β1 were compared among the three groups.

RESULTS

In the first part, HCY levels were higher in AGA than the controls of both genders. However, there was no difference in HCY levels between groups with varying severity. Rates of hyperhomocysteinemia was higher in AGA patients than the controls. Logistic regression analysis showed serum HCY levels was positively correlated with the incidence of AGA. In the second part, HCY of the HFs in the AGA group was significantly higher than that in the control group. The third part showed that the increase in serum HCY levels inhibited the growth of mice hair, with the less expressed stimulative markers Ki67, VEGF, IGF-1, Krt27, and FGF9, while there was no difference in the expression of inhibitory markers TGF-β1.

CONCLUSION

There is a potential relationship between HCY and AGA. HCY had an inhibitory effect on hair growth. Further studies are necessary to explore the specific mechanism.

Epigenetic DNA Methylation and Protein Homocysteinylation: Key Players in Hypertensive Renovascular Damage

Hypertension has been a threat to the health of people, the mechanism of which, however, remains poorly understood. It is clinically related to loss of nephron function, glomerular sclerosis, or necrosis, resulting in renal functional declines. The mechanisms underlying hypertension's development and progression to organ damage, including hypertensive renal damage, remain to be fully elucidated. As a developing approach, epigenetics has been postulated to elucidate the phenomena that otherwise cannot be explained by genetic studies. The main epigenetic hallmarks, such as DNA methylation, histone acetylation, deacetylation, noncoding RNAs, and protein N-homocysteinylation have been linked with hypertension. In addition to contributing to endothelial dysfunction and oxidative stress, biologically active gases, including NO, CO, and H2S, are crucial regulators contributing to vascular remodeling since their complex interplay conducts homeostatic functions in the renovascular system. Importantly, epigenetic modifications also directly contribute to the pathogenesis of kidney damage via protein N-homocysteinylation. Hence, epigenetic modulation to intervene in renovascular damage is a potential therapeutic approach to treat renal disease and dysfunction. This review illustrates some of the epigenetic hallmarks and their mediators, which have the ability to diminish the injury triggered by hypertension and renal disease. In the end, we provide potential therapeutic possibilities to treat renovascular diseases in hypertension.

Low concentration of serum vitamin B12 may be a strong predictor of large-artery atherosclerosis stroke: A case-control study

INTRODUCTION

Identifying controllable risk factors for large-artery atherosclerosis (LAA) stroke is crucial due to its significant role as a leading cause of ischemic stroke. We aimed to validate the correlation of serum vitamin B12 with LAA stroke.

METHODS

Inpatients with LAA stroke and healthy controls were retrospectively collected for a case-control study from January 2020 to May 2022. Serum vitamin B12 concentration and other blood indicators, demographic, lifestyle factors and comorbidities were investigated. Logistic regression analysis was used to identify the correlation of serum vitamin B12 concentrations with LAA stroke, meanwhile adjusted for confounding factors.

RESULTS

Patients with LAA stroke had significantly lower serum vitamin B12 concentrations in comparison to those of controls. In the fully adjusted model, vitamin B12 (per 1 interquartile range increase, odds ratio [OR] = 0.84, 95 % confidence interval [CI]: 0.77-0.91), vitamin B12 < 200 pg/mL (OR=7.70, 95 %CI: 2.19-27.03) and vitamin B12 < 300 pg/mL (OR=4.19, 95 %CI: 1.82-9.66) were independently factors for LAA stroke. Furthermore, the optimal cut-off values for vitamin B12 to predict LAA stroke were 305.25 pg/mL (area under the curve [AUC] = 0.71) when unadjusted and 308.25 pg/mL when adjusted for age and sex (AUC=0.68). Lower vitamin B12 concentrations were significantly associated with male sex, smoking, older age, higher neutrophil count, higher creatinine, lower folate and higher total homocysteine.

CONCLUSION

Results indicate that low concentration of serum vitamin B12 may be a strong predictor for the risk of LAA stroke.

Comprehensive assessment on the association of dietary vitamins with all-cause and cardiovascular mortality among individuals with prediabetes: evidence from NHANES 1999-2018

Background: Prediabetes has become a global health issue, and currently, the relationship between vitamin levels and mortality in prediabetes remains unclear. This study aims to investigate the association between the levels of eleven vitamins and all-cause and cardiovascular disease (CVD) mortality in prediabetes patients. Methods: This cross-sectional study included 14 634 prediabetes patients from 10 cycles of the National Health and Nutrition Examination Survey between 1999 and 2018. Mortality and underlying causes of death were determined by linking records from the National Death Index until December 31, 2019. Multivariable Cox proportional hazards regression models were established to assess hazard ratios and 95% confidence intervals for all-cause, CVD, cancer, and other mortalities. Restricted cubic splines were used to visualize non-linear associations between various vitamins and mortality risk. Results: During the follow-up period, 2316/14 634 prediabetes patients died (12.55%), with 722 deaths (3.68%) attributed to CVD. After multivariable adjustment, vitamin B1, niacin, folate, vitamin C, vitamin E, and vitamin K levels exhibited non-linear associations with all-cause mortality (all p < 0.05). Vitamin B1, niacin, and vitamin E levels showed non-linear associations with CVD mortality (p < 0.05). Vitamin B6 exhibited a linear negative association with all-cause, CVD, and other mortalities (p > 0.05). However, vitamins A and B2 levels were not significantly associated with mortality rates (all p > 0.05). Consistent results were observed in the subgroup analyses after complete adjustment for variables. Conclusions: Higher levels of dietary vitamins B1, B6, niacin, folate, vitamin C, vitamin E, and vitamin K were significantly associated with lower risk of all-cause mortality and CVD mortality in patients with prediabetes. There was no association between vitamin A and B2 levels and all-cause and CVD mortality among individuals with prediabetes. These findings suggest the importance of correcting vitamin deficiencies to prevent mortality in prediabetes patients.

Serum Vitamin B12 Levels as a Risk Factor and Prognostic Marker in Patients With Acute Ischemic Stroke at a Tertiary Care Center in Northern India: A Case-Control Study

Objective Stroke is a leading cause of death and disability globally, with its incidence, prevalence, and mortality rising significantly over the past decades. Beyond traditional risk factors, vitamin B12 has garnered attention for its role in stroke prevention due to its influence on homocysteine metabolism. Deficiencies in vitamin B12 are linked to hyperhomocysteinemia, which increases the risk of ischemic stroke. This study aims to compare vitamin B12 and homocysteine levels in stroke patients versus control subjects. Methodology This observational case-control study was conducted at King George's Medical University (KGMU), Lucknow, involving 75 acute ischemic stroke patients and 75 age- and sex-matched controls. Serum vitamin B12 and homocysteine levels were measured, and stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score. The modified Rankin scale (MRS) evaluated functional outcomes at discharge. Statistical analysis was performed to identify associations between vitamin B12 levels, stroke severity, and patient outcomes. Results Stroke patients had significantly lower vitamin B12 levels (194.24 ± 91.11 pmol/L) and higher homocysteine levels (16.33 ± 3.29 µmol/L) compared to controls (271.13 ± 91.19 pmol/L and 9.76 ± 4.55 µmol/L, respectively). Vitamin B12 levels were lower, and homocysteine levels were higher in patients who died during the study. Additionally, vitamin B12 levels were negatively correlated with MRS scores at discharge and 28 days post-discharge, and positively correlated with NIHSS scores, indicating worse outcomes in patients with lower vitamin B12 levels. Conclusions  This study demonstrates a significant association between vitamin B12 deficiency and the occurrence and severity of ischemic stroke. Lower vitamin B12 levels correlated with higher stroke severity and poorer functional outcomes, highlighting the potential role of vitamin B12 in stroke management. Further research is needed to explore the therapeutic implications of vitamin B12 supplementation in reducing stroke risk and improving patient outcomes.

Homocysteine contributes to atherogenic transformation of the aorta in rabbits in the absence of hypercholesterolemia

Atherosclerosis, the leading cause of cardiovascular disease, cannot be sufficiently explained by established risk factors, including cholesterol. Elevated plasma homocysteine (Hcy) is an independent risk factor for atherosclerosis and is closely linked to cardiovascular mortality. However, its role in atherosclerosis has not been fully clarified yet. We have previously shown that rabbits fed a diet deficient in B vitamins and choline (VCDD), which are required for Hcy degradation, exhibit an accumulation of macrophages and lipids in the aorta, aortic stiffening and disorganization of aortic collagen in the absence of hypercholesterolemia, and an aggravation of atherosclerosis in its presence. In the current study, plasma Hcy levels were increased by intravenous injections of Hcy into balloon-injured rabbits fed VCDD (VCDD+Hcy) in the absence of hypercholesterolemia. While this treatment did not lead to thickening of aortic wall, intravenous injections of Hcy into rabbits fed VCDD led to massive accumulation of VLDL-triglycerides as well as significant impairment of vascular reactivity of the aorta compared to VCDD alone. In the aorta intravenous Hcy injections into VCDD-fed rabbits led to fragmentation of aortic elastin, accumulation of elastin-specific electron-dense inclusions, collagen disorganization, lipid degradation, and autophagolysosome formation. Furthermore, rabbits from the VCDD+Hcy group exhibited a massive decrease of total protein methylated arginine in blood cells and decreased creatine in blood cells, serum and liver compared to rabbits from the VCDD group. Altogether, we conclude that Hcy contributes to atherogenic transformation of the aorta not only in the presence but also in the absence of hypercholesterolemia.

Catalpol inhibits HHcy-induced EndMT in endothelial cells by modulating ROS/NF-κB signaling

BACKGROUND

Hyperhomocysteinemia (HHcy) is an independent risk factor for atherosclerosis (AS). Endothelial mesenchymal transition (EndMT) refers to the process in which endothelial cells lose endothelial cell morphology and characteristic gene expression, and acquire phenotypic characteristics and gene expression related to mesenchymal cells. Numerous studies have confirmed that EndMT is involved in the formation of atherosclerosis. Catalpol is one of the active components of Rehmannia, which has antioxidant, anti-inflammatory, anti-tumor, neuroprotective and other biological activities. Studies have shown that catalpol can reduce atherosclerotic plaque induced by high sugar or fat. However, the effect of catalpol on HHCY-induced EndMT is unclear.

METHODS AND RESULTS

In vitro HHcy-treated primary human umbilical vein endothelial cells (HUVECs) were used to construct a cell model, and the antioxidants N-acetylcysteine (NAC) and catalase alcohol were administered. In vivo C57BL/6N mice were given a diet fed with 4.4% high methionine chow to construct a HHcy mice model and were treated with catalpol. The results showed that hhcy could induce morphological transformation of endothelial cells into mesenchymal cells, increase intracellular ROS content, up-regulate α-SMA, N-cadherin, p-p65 protein expression, down-regulate VE-cadherin, CD31 protein expression, induce pathological changes of aortic root endothelium, and increase aortic endothelial ROS content. Catalpol reversed these hhcy induced outcomes.

CONCLUSIONS

Catalpol inhibits HHcy-induced EndMT, and the underlying mechanism may be related to the ROS/NF-κB signaling pathway. Catalpol may be a potential drug for the treatment of HHcy-related AS.

Optimal folic acid dosage in lowering homocysteine: Precision Folic Acid Trial to lower homocysteine (PFAT-Hcy)

BACKGROUND

While folic acid (FA) is widely used to treat elevated total homocysteine (tHcy), promoting vascular health by reducing vascular oxidative stress and modulating endothelial nitric oxide synthase, the optimal daily dose and individual variation by MTHFR C677T genotypes have not been well studied. Therefore, this study aimed to explore the efficacy of eight different FA dosages on tHcy lowering in the overall sample and by MTHFR C677T genotypes.

METHODS

This multicentered, randomized, double-blind, controlled clinical trial included 2697 eligible hypertensive adults with elevated tHcy (≥ 10 mmol/L) and without history of stroke and cardiovascular disease. Participants were randomized into eight dose groups of FA combined with 10 mg enalapril maleate, taken daily for 8 weeks of treatment.

RESULTS

The intent to treat analysis included 2163 participants. In the overall sample, increasing FA dosage led to steady tHcy reduction within the FA dosing range of 0-1.2 mg. However, a plateau in tHcy lowering was observed in FA dose range of 1.2-1.6 mg, indicating a ceiling effect. In contrast, FA doses were positively and linearly associated with serum folate levels without signs of plateau. Among MTHFR genotype subgroups, participants with the TT genotype showed greater efficacy of FA in tHcy lowering.

CONCLUSIONS

This randomized trial lent further support to the efficacy of FA in lowering tHcy; more importantly, it provided critically needed evidence to inform optimal FA dosage. We found that the efficacy of FA in lowering tHcy reaches a plateau if the daily dosage exceeds 1.2 mg, and only has a small gain by increasing the dosage from 0.8 to 1.2 mg.

CLINICALTRIALS

GOV IDENTIFIER

NCT03472508 (Registration Date: March 21, 2018).

Serum levels of vitamin B12 combined with folate and plasma total homocysteine predict ischemic stroke disease: a retrospective case-control study

PURPOSE

This study aimed to identify and quantify the association and investigate whether serum vitamin B12 alone or vitamin B12 combined with folate and plasma total homocysteine (tHcy) levels could be used to predict the risk of acute ischemic stroke.

MATERIALS AND METHODS

This retrospective case-control study was conducted in the Department of Neurology, First Affiliated Hospital of Chongqing Medical University. It included 259 inpatients experiencing their first-ever acute ischemic stroke and 259 age-matched, sex-matched healthy controls. Patients were categorized into groups based on the etiology of their stroke: large-artery atherosclerosis (LAAS, n = 126), cardio embolism (CEI, n = 35), small vessel disease (SVD, n = 89), stroke of other determined etiology (ODE, n = 5), and stroke of undetermined etiology (UDE, n = 4). The associations of serum vitamin B12, folate, and plasma tHcy levels with the risk of ischemic stroke were evaluated using multivariable logistic regression analysis. Receiver operator characteristic (ROC) curves were used to assess the diagnostic power of vitamin B12, folate, and tHcy levels for ischemic stroke.

RESULTS

Serum vitamin B12 and folate levels were significantly lower in ischemic stroke patients compared to controls, while plasma tHcy levels were significantly higher. The first quartile of serum vitamin B12 levels was significantly associated with an increased risk of LAAS (aOR = 2.289, 95% CI = 1.098-4.770), SVD (aOR = 4.471, 95% CI = 1.110-4.945) and overall ischemic stroke (aOR = 3.216, 95% CI = 1.733-5.966). Similarly, the first quartile of serum folate levels was associated with an increased risk of LAAS (aOR = 3.480, 95% CI = 1.954-6.449), CEI (aOR = 2.809, 95% CI = 1.073-4.991), SVD (aOR = 5.376, 95% CI = 1.708-6.924), and overall ischemic stroke (aOR = 3.381, 95% CI = 1.535-7.449). The fourth quartile of tHcy levels was also significantly associated with an increased risk of LAAS (aOR = 2.946, 95% CI = 1.008-5.148), CEI (aOR = 2.212, 95% CI = 1.247-5.946), SVD (aOR = 2.957, 95% CI = 1.324-6.054), and overall ischemic stroke (aOR = 2.233, 95% CI = 1.586-4.592). For predicting different types of ischemic stroke, vitamin B12 alone demonstrated the best diagnostic value for SVD, evidenced by a sensitivity of 71.0% and negative predictive value of 90.3%, along with the highest positive likelihood ratio (+ LR) for SVD. Vitamin B12 + tHcy + folate are valuable in predicting different types of ischemic stroke, with the most significant effect observed in SVD, followed by LAAS, and the weakest predictive effect in CEI. Additionally, vitamin B12 alone in combination with other indicators, such as folate alone, tHcy alone, and folate + tHcy could reduce negative likelihood ratio (-LR) and improve + LR.

CONCLUSIONS

Vitamin B12 was an independent risk factor for acute ischemic stroke. The risk calculation model constructed with vitamin B12 + tHcy + folate had the greatest diagnostic value for SVD.

Folic acid supplementation for stroke prevention: A systematic review and meta-analysis of 21 randomized clinical trials worldwide

BACKGROUND & AIMS

The AHA/ASA guidelines for primary stroke prevention are almost a decade old. The current recommendation regarding folic acid supplementation is based on only 8 clinical trials, and an additional 13 folate trials have been published since then. This meta-analysis aims to fill in critical evidence gaps by comprehensively evaluating 21 published trials with particular attention given to identifying the true influences through stratification.

METHODS

PubMed, the Cochrane Central Register of Controlled Trials, and Embase were searched from inception to April 4, 2023. This study included all randomized controlled trials (RCTs) of folic acid with stroke as one of the reporting endpoints. Relative risks and 95% confidence intervals were used to assess the association between folic acid supplementation and the risk of stroke in a random-effects model.

RESULTS

Results from the 21 pooled RCTs totaling 115,559 participants showed that folic acid supplementation significantly reduced the risk of stroke by 10% (RR 0.90, 95%CI 0.83 to 0.98). Subgroup analyses showed that folic acid efficacy was greater in areas without fortified grain or with partially-fortified grain (RR = 0.83, 95% CI 0.75 to 0.93; RR = 1.04 in areas with grain fortification, P-interaction = 0.003). In this group, folic acid supplementation was most efficacious in those without a history of stroke or myocardial infarction (RR = 0.77, 95% CI 0.68 to 0.86; RR = 0.94 for participants with a history of stroke or myocardial infarction, P-interaction = 0.008). The efficacy of folic acid remained consistent regardless of baseline folate levels, folic acid dosage, baseline vitamin B12 levels, vitamin B12 dosage, homocysteine reduction, intervention duration, and whether folic acid was taken alone or in combination (all P-interaction>0.05). All 21 trials were free of attrition bias and reporting bias, and there was no significant publication bias.

CONCLUSIONS

This is by far the largest meta-analysis of RCTs regarding folic acid supplementation and stroke, demonstrating the overall benefit of folic acid for stroke prevention. Grain fortification and history of stroke or myocardial infarction may be the most important influences on the efficacy of folic acid for stroke prevention.

A Mendelian randomisation, propensity score matching study to investigate causal association between serum homocysteine and intracranial aneurysm

BACKGROUND AND PURPOSE

Recent observational studies have reported that serum total homocysteine (tHcy) is associated with intracranial aneurysms (IAs). However, the causal effect of tHcy on IAs is unknown. We leveraged large-scale genetic association and real-world data to investigate the causal effect of tHcy on IA formation.

METHODS

We performed a two-sample Mendelian randomisation (MR) using publicly available genome-wide association studies summary statistics to investigate the causal relationship between tHcy and IAs, following the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology-MR statement. Furthermore, a propensity score matching (PSM) analysis was conducted to evaluate the detailed effects of tHcy on risk of IA formation by utilizing real-world multicentre data, including 9902 patients with and without IAs (1:1 matched). Further interaction and subgroup analyses were performed to elucidate how tHcy affects risk of IA formation.

RESULTS

MR analyses indicated that genetically determined tHcy was causally associated with IA risk (OR, 1.38, 95% CI 1.07 to 1.79; p=0.018). This is consistent with the more conservative weighted median analysis (OR, 1.41, 95% CI 1.03 to 1.93; p=0.039). Further sensitivity analyses showed no evidence of horizontal pleiotropy or heterogeneity of single nucleotide polymorphisms in causal inference. According to the PSM study, we found that, compared with low tHcy (≤15 µmol/L), moderate tHcy (>15-30 µmol/L) (OR 2.13, 95% CI 1.93 to 2.36) and high tHcy (>30 µmol/L) (OR 3.66, 95% CI 2.71 to 4.95) were associated with a higher IA risk (p trend <0.001). Subgroup analyses demonstrated significant ORs of tHcy in each subgroup when stratified by traditional cardiovascular risk factors. Furthermore, there was also a synergistic effect of tHcy and hypertension on IA risk (p interaction <0.001; the relative excess risk due to interaction=1.65, 95% CI 1.29 to 2.01).

CONCLUSION

Both large-scale genetic evidence and multicentre real-world data support a causal association between tHcy and risk of IA formation. Serum tHcy may serve as a biomarker to identify high-risk individuals who would particularly benefit from folate supplementation.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

What Causes Premature Coronary Artery Disease?

PURPOSE OF REVIEW

This review provides an overview of genetic and non-genetic causes of premature coronary artery disease (pCAD).

RECENT FINDINGS

pCAD refers to coronary artery disease (CAD) occurring before the age of 65 years in women and 55 years in men. Both genetic and non-genetic risk factors may contribute to the onset of pCAD. Recent advances in the genetic epidemiology of pCAD have revealed the importance of both monogenic and polygenic contributions to pCAD. Familial hypercholesterolemia (FH) is the most common monogenic disorder associated with atherosclerotic pCAD. However, clinical overreliance on monogenic genes can result in overlooked genetic causes of pCAD, especially polygenic contributions. Non-genetic factors, notably smoking and drug use, are also important contributors to pCAD. Cigarette smoking has been observed in 25.5% of pCAD patients relative to 12.2% of non-pCAD patients. Finally, myocardial infarction (MI) associated with spontaneous coronary artery dissection (SCAD) may result in similar clinical presentations as atherosclerotic pCAD. Recognizing the genetic and non-genetic causes underlying pCAD is important for appropriate prevention and treatment. Despite recent progress, pCAD remains incompletely understood, highlighting the need for both awareness and research.

Homocysteine concentration in coronary artery disease and severity of coronary lesions

Our previous study reckons that the impact of the rs1801133 variant of 5,10-methylenetetrahydrofolate reductase (MTHFR) on coronary artery disease (CAD) is possibly mediated by cardiometabolic disorder. This study is performed to verify this hypothesis. Four hundred and thirty CAD patients and 216 CAD-free individuals were enrolled in this case-control study. The rs1801133 variant was genotyped by PCR-RFLP. Severity of coronary lesions was evaluated by number of stenotic coronary vessels and extent of coronary stenosis. The rs1801133 T allele significantly increased homocysteine levels in patients with CAD and CAD-free individuals. Individuals with the T allele of rs1801133 had an increased risk of developing CAD. In contrast, individuals with the TT genotype of rs1801133 were at high risk of multiple vessel lesions. The carriers of CT genotype had higher levels of systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and high-sensitivity C-reactive protein (hs-CRP), and lower levels of apolipoprotein A1 (APOA1) than those with CC genotype in male patients with CAD. The receiver operating characteristic (ROC) curve and precision-recall (PR) curve indicated that hyperhomocysteinemia was sensitive to predict the severity of CAD. Multivariate logistic regression revealed that homocysteine, rs1801133, age, smoking, weight, body mass index (BMI), lipoprotein(a) [Lp(a)], and hs-CRP were independent risk factors for CAD. The increased risk of CAD and severity of coronary lesions associated with rs1801133 in the Chinese Han population were attributed, at least partly, to high homocysteine levels. Hyperhomocysteinemia had a high predictive value for severe CAD or multiple vessel lesions.

Effect of Methylfolate, Pyridoxal-5'-Phosphate, and Methylcobalamin (SolowaysTM) Supplementation on Homocysteine and Low-Density Lipoprotein Cholesterol Levels in Patients with Methylenetetrahydrofolate Reductase, Methionine Synthase, and Methionine Synthase Reductase Polymorphisms: A Randomized Controlled Trial

Exploring the link between genetic polymorphisms in folate metabolism genes (MTHFR, MTR, and MTRR) and cardiovascular disease (CVD), this study evaluates the effect of B vitamin supplements (methylfolate, pyridoxal-5'-phosphate, and methylcobalamin) on homocysteine and lipid levels, potentially guiding personalized CVD risk management. In a randomized, double-blind, placebo-controlled trial, 54 patients aged 40-75 with elevated homocysteine and moderate LDL-C levels were divided based on MTHFR, MTR, and MTRR genetic polymorphisms. Over six months, they received either a combination of methylfolate, P5P, and methylcobalamin, or a placebo. At the 6 months follow-up, the treatment group demonstrated a significant reduction in homocysteine levels by 30.0% (95% CI: -39.7% to -20.3%) and LDL-C by 7.5% (95% CI: -10.3% to -4.7%), compared to the placebo (p < 0.01 for all). In the subgroup analysis, Homozygous Minor Allele Carriers showed a more significant reduction in homocysteine levels (48.3%, 95% CI: -62.3% to -34.3%, p < 0.01) compared to mixed allele carriers (18.6%, 95% CI: -25.6% to -11.6%, p < 0.01), with a notable intergroup difference (29.7%, 95% CI: -50.7% to -8.7%, p < 0.01). LDL-C levels decreased by 11.8% in homozygous carriers (95% CI: -15.8% to -7.8%, p < 0.01) and 4.8% in mixed allele carriers (95% CI: -6.8% to -2.8%, p < 0.01), with a significant between-group difference (7.0%, 95% CI: -13.0% to -1.0%, p < 0.01). Methylfolate, P5P, and methylcobalamin supplementation tailored to genetic profiles effectively reduced homocysteine and LDL-C levels in patients with specific MTHFR, MTR, and MTRR polymorphisms, particularly with homozygous minor allele polymorphisms.

Is There a Connection between Hyperhomocysteinemia and the Cardiometabolic Syndrome?

This study investigates the distribution of hyperhomocysteinemia and cardiovascular metabolic syndrome (SM) among participants, shedding light on their prevalence and co-occurrence within the study cohort. Through an analysis of demographic characteristics and health parameters, including age, gender, and body mass index (BMI), alongside nutritional data, correlations between these factors and health risks are explored. Results reveal a notable prevalence of hyperhomocysteinemia, with 45.3% of participants exhibiting this condition. Furthermore, 31.4% of the cohort does not present hyperhomocysteinemia or SM, while 23.3% shows SM without hyperhomocysteinemia. The study underscores gender-specific dietary recommendations due to significant variations in nutrient intake patterns. Additionally, inverse correlations between health risks like obesity, hypertension, and hypercholesterolemia and nutrient requirements highlight the need for tailored dietary interventions. Age-related changes in nutrient needs and the positive correlation between physical activity levels and certain nutrient demands further emphasize the importance of personalized dietary strategies. Variations in nutrient intake by gender, inverse correlations with health risks, and age-related changes underscore the need for tailored dietary strategies. These findings provide valuable insights for healthcare professionals in developing targeted nutritional interventions to mitigate disease risk and promote overall health and well-being.

The Etiology of the Thrombotic Phenomena Involved in the Process of Coronary Artery Disease-What Is the Role of Thrombophilic Genes in the Development of This Pathology?

Cardiovascular diseases, among which includes coronary artery disease, represent one of the most important causes of mortality and morbidity worldwide. Research aimed at determining the risk factors involved recognizes a group of "traditional" risk factors, but also more recent studies identified over 100 "novel" ones which may have a role in the disease. Among the latter is the thrombophilia profile of a patient, a pathology well-established for its involvement in venous thromboembolism, but with less studied implications in arterial thrombosis. This paper reviews the literature, explaining the pathophysiology of the thrombophilia causes associated most with coronary thrombosis events. Results of several studies on the subject, including a meta-analysis with over 60,000 subjects, determined the significant involvement of factor V Leiden, prothrombin G20210A mutation, plasminogen activator inhibitor-1 and antiphospholipid syndrome in the development of coronary artery disease. The mechanisms involved are currently at different stages of research, with some already established and used as therapeutic targets.

Vascular dementia: From pathobiology to emerging perspectives

Vascular dementia (VaD) is the second most common type of dementia. VaD is synonymous with ageing, and its symptoms place a significant burden on the health and wellbeing of older people. Despite the identification of a substantial number of risk factors for VaD, the pathological mechanisms underpinning this disease remain to be fully elucidated. Consequently, a biogerontological imperative exists to highlight the modifiable lifestyle factors which can mitigate against the risk of developing VaD. This review will critically examine some of the factors which have been revealed to modulate VaD risk. The survey commences by providing an overview of the putative mechanisms which are associated with the pathobiology of VaD. Next, the factors which influence the risk of developing VaD are examined. Finally, emerging treatment avenues including epigenetics, the gut microbiome, and pro-longevity pharmaceuticals are discussed. By drawing this key evidence together, it is our hope that it can be used to inform future experimental investigations in this field.

Dosage exploration of combined B-vitamin supplementation in stroke prevention: a meta-analysis and systematic review

BACKGROUND

The optimal dosage range for B-vitamin supplementation for stroke prevention has not received sufficient attention.

OBJECTIVE

Our aim was to determine the optimal dosage range of a combination of folic acid, vitamin B12, and vitamin B6 supplementation in stroke prevention.

METHODS

We searched PubMed, the Cochrane Central Register of Controlled Trials, and Embase database for randomized controlled trials published between January 1966 and April 2023, whose participants received B-vitamin supplementation and that reported the number of stroke cases. Relative risk (RR) was used to measure the effect of combined supplementation on risk of stroke using a fixed-effects model. Risk of bias was assessed with the Cochrane risk-of-bias algorithm.

RESULTS

The search identified 14 randomized controlled trials of folic acid combined with vitamin B12 and vitamin B6 supplementation for stroke prevention that included 76,664 participants with 2720 stroke cases. In areas without and with partial folic acid fortification, combined B-vitamin supplementation significantly reduced the risk of stroke by 34% [RR: 0.66; 95% confidence interval (CI): 0.50, 0.86] and 11% (RR: 0.89; 95% CI: 0.79, 1.00), respectively. Further analysis showed that a dosage of folic acid ≤0.8 mg/d and vitamin B12 ≤0.4 mg/d was best for stroke prevention (RR: 0.65; 95% CI: 0.48, 0.86) in these areas. In contrast, no benefit of combined supplementation was found in fortified areas (RR: 1.04; 95% CI: 0.94, 1.16).

CONCLUSIONS

Our meta-analysis found that the folic acid combined with vitamin B12 and vitamin B6 supplementation strategy significantly reduced the risk of stroke in areas without and with partial folic acid fortification. Combined dosages not exceeding 0.8 mg/d for folic acid and 0.4 mg/d for vitamin B12 supplementation may be more effective for populations within these areas. This trial was registered at PROSPERO asCRD42022355077.

Micronutrients status as a contributing factor in secondary burning mouth syndrome: A review of the literature

Background and Aims

Patients with burning mouth syndrome (BMS) experience an annoying feeling without clinical evidence of any mucosal lesion. Deficiency or excess of micronutrients is a common feature in secondary BMS. There is limited knowledge among oral healthcare providers regarding the significance of micronutrients in oral health, so the current review focuses on the critical role of these elements in oral health implications as secondary BMS.

Methods

For the data collection, the authors searched for key terms without time limitation (1900-2021) in databases comprised of PubMed, Google Scholar, Scopus, Web of Science (SCI), and Embase.

Results

The total number of matched articles with inclusion criteria involved in this review article was 59 original articles. Among these, 20 randomized clinical trials (RCT), 31 case-control or Crossectional, and 8 case reports/series are reviewed in this review article.

Conclusion

One of the important etiological factors in patients with secondary BMS is micronutrient imbalance. The iron, zinc, vitamin B family, vitamin D deficiency and increased levels of homocysteine and oxidant agents were examined in secondary BMS patients. In addition, oral medicine specialists must consider the possible toxic effects of some elements in restorations and dental prostheses. Further studies, such as RCTs in the future, are recommended.

Homocysteine serum levels in patients with ruptured and unruptured intracranial aneurysms: a case-control study

BACKGROUND

There is very few data regarding homocysteine's influence on the formation and rupture of intracranial aneurysms.

OBJECTIVE

To compare homocysteine levels between patients with ruptured and unruptured intracranial aneurysms, and to evaluate possible influences of this molecule on vasospasm and functional outcomes.

METHODS

This is a retrospective, case-control study. We evaluated homocysteinemia differences between patients with ruptured and unruptured aneurysms; and the association of homocysteine levels with vasospasm and functional outcomes. Logistic regressions were performed.

RESULTS

A total of 348 participants were included: 114 (32.8%) with previous aneurysm rupture and 234 (67.2%) with unruptured aneurysms. Median homocysteine was 10.75µmol/L (IQR = 4.59) in patients with ruptured aneurysms and 11.5µmol/L (IQR = 5.84) in patients with unruptured aneurysms. No significant association was detected between homocysteine levels and rupture status (OR = 0.99, 95% CI = 0.96-1.04). Neither mild (>15µmol/L; OR = 1.25, 95% CI 0.32-4.12) nor moderate (>30µmol/L; OR = 1.0, 95% CI = 0.54-1.81) hyperhomocysteinemia demonstrated significant correlations with ruptured aneurysms. Neither univariate (OR = 0.86; 95% CI 0.71-1.0) nor multivariable age-adjusted (OR = 0.91; 95% CI = 0.75-1.05) models evidenced an association between homocysteine levels and vasospasm. Homocysteinemia did not influence excellent functional outcomes at 6 months (mRS≤1) (OR = 1.04; 95% CI = 0.94-1.16).

CONCLUSION

There were no differences regarding homocysteinemia between patients with ruptured and unruptured intracranial aneurysms. In patients with ruptured aneurysms, homocysteinemia was not associated with vasospasm or functional outcomes.

Association between dietary vitamin intake and mortality in US adults with diabetes: A prospective cohort study

AIMS

To explore the association of dietary vitamin intake from food and/or supplement with mortality in US adults with diabetes.

MATERIALS AND METHODS

This prospective cohort study was conducted on 5418 US adults with diabetes from the National Health and Nutrition Examination Survey 1999-2018. Vitamin intake from food and supplements was estimated via dietary recall. Sufficient intake from food or food + supplement was defined as ≥ estimated average requirement (EAR) and ≤ tolerable upper intake level (UL), insufficient intake, < EAR; and excess intake, > UL. Medium supplementary intake was classified as > median level and ≤75th percentile; low intake, ≤ median level; and high intake, >75th percentile, as reported by supplement users.

RESULTS

A total of 1601 deaths occurred among the participants over a median follow-up of 11.0 years. Cox regression analysis of the single-vitamin model demonstrated that sufficient vitamin A and folate intake from food and food + supplement and medium vitamin A and folate intake from supplement; sufficient riboflavin, niacin, and vitamin B6 intake from food and food + supplement; and sufficient thiamin and vitamin E intake from food + supplement were significantly associated with reduced all-cause mortality (all p < 0.05). In the multivitamin model, sufficient vitamin A and folate intake from food and food + supplement, medium vitamin A and folate intake from the supplement, and sufficient niacin intake from food and food + supplement were inversely associated with mortality (all p < 0.05).

CONCLUSIONS

Vitamin A and folate intake from food or supplement and niacin intake from food were significantly associated with reduced mortality in US adults with diabetes.

Eradicating Atherosclerotic Events by Targeting Early Subclinical Disease: It Is Time to Retire the Therapeutic Paradigm of Too Much, Too Late

Recent decades have seen spectacular advances in understanding and managing atherosclerotic cardiovascular disease, but paradoxically, clinical progress has stalled. Residual risk of atherosclerotic cardiovascular disease events is particularly vexing, given recognized lifestyle interventions and powerful modern medications. Why? Atherosclerosis begins early in life, yet clinical trials and mechanistic studies often emphasize terminal, end-stage plaques, meaning on the verge of causing heart attacks and strokes. Thus, current clinical evidence drives us to emphasize aggressive treatments that are delayed until patients already have advanced arterial disease. I call this paradigm "too much, too late." This brief review covers exciting efforts that focus on preventing, or finding and treating, arterial disease before its end-stage. Also included are specific proposals to establish a new evidence base that could justify intensive short-term interventions (induction-phase therapy) to treat subclinical plaques that are early enough perhaps to heal. If we can establish that such plaques are actionable, then broad screening to find them in early midlife individuals would become imperative-and achievable. You have a lump in your coronaries! can motivate patients and clinicians. We must stop thinking of a heart attack as a disease. The real disease is atherosclerosis. In my opinion, an atherosclerotic heart attack is a medical failure. It is a manifestation of longstanding arterial disease that we had allowed to progress to its end-stage, despite knowing that atherosclerosis begins early in life and despite the availability of remarkably safe and highly effective therapies. The field needs a transformational advance to shift the paradigm out of end-stage management and into early interventions that hold the possibility of eradicating the clinical burden of atherosclerotic cardiovascular disease, currently the biggest killer in the world. We urgently need a new evidence base to redirect our main focus from terminal, end-stage atherosclerosis to earlier, and likely reversible, human arterial disease.

The Multitarget Action of Vitamins in the Ischemic Stroke

A stroke, also known as a cerebral hemorrhage, occurs when there is an interruption in the blood supply to a part of the brain, resulting in damage to brain cells. This issue is one of the leading causes of death in developed countries, currently killing about 5 million people annually. Individuals who survive ischemic stroke often face serious vision problems, paralysis, dementia, and other sequelae. The numerous efforts to prevent and/or treat stroke sequelae seem insufficient, which is concerning given the increasing global elderly population and the well-known association between aging and stroke risk. In this review, we aim to present and discuss the importance of vitamins in stroke prevention and/or incidence. Vitamins from diet or dietary supplements influence the body at various levels; they are a relevant factor but are reported only in isolated articles. This review reports and updates the multitarget role of vitamins involved in reducing stroke risk.

The dos, don'ts, and nuances of thrombophilia testing

Considerable progress has been made in elucidating genetic and biologic risk factors for venous thromboembolism (VTE). Despite being able to identify heritable defects in a substantial proportion of patients with VTE, testing has not, in general, proven useful in management. Despite efforts to reduce inappropriate testing, it often falls to the hematologist to consult on patients having undergone thrombophilia testing. Through a series of cases, we discuss how D-dimer testing can be helpful in VTE recurrence risk stratification in younger women as well as how to approach patients with persistently elevated D-dimer levels in the absence of thrombosis. While elevated factor VIII coagulant activity levels are a significant risk factor for a first episode of VTE, its biologic basis is not fully understood, and studies have not shown it to be a useful predictor of recurrence. Abnormal results of genetic tests for methylene tetrahydrofolate reductase or plasminogen activator 1 promoter polymorphisms may be encountered, which carry little if any thrombotic risk and should never be ordered. We also discuss protein S deficiency, the most difficult of the hereditary thrombophilias to diagnose due to a wider "normal" range in the general population as compared with protein C, the presence of both free and bound forms in plasma, and the characteristics of the various assays in use. We also present a rare type of protein C deficiency that can be missed by functional assays using an amidolytic rather than a clotting end point.

Predicting long-term prognosis after percutaneous coronary intervention in patients with acute coronary syndromes: a prospective nested case-control analysis for county-level health services

Purpose

We aimed to establish and authenticate a clinical prognostic nomogram for predicting long-term Major Adverse Cardiovascular Events (MACEs) among high-risk patients who have undergone Percutaneous Coronary Intervention (PCI) in county-level health service.

Patients and methods

This prospective study included Acute Coronary Syndrome (ACS) patients treated with PCI at six county-level hospitals between September 2018 and August 2019, selected from both the original training set and external validation set. Least Absolute Shrinkage and Selection Operator (LASSO) regression techniques and logistic regression were used to assess potential risk factors and construct a risk predictive nomogram. Additionally, the potential non-linear relationships between continuous variables were tested using Restricted Cubic Splines (RCS). The performance of the nomogram was evaluated based on the Receiver Operating Characteristic (ROC) curve analysis, Calibration Curve, Decision Curve Analysis (DCA), and Clinical Impact Curve (CIC).

Results

The original training set and external validation set comprised 520 and 1,061 patients, respectively. The final nomogram was developed using nine clinical variables: Age, Killip functional classification III-IV, Hypertension, Hyperhomocysteinemia, Heart failure, Number of stents, Multivessel disease, Low-density Lipoprotein Cholesterol, and Left Ventricular Ejection Fraction. The AUC of the nomogram was 0.79 and 0.75 in the training set and external validation set, respectively. The DCA and CIC validated the clinical value of the constructed prognostic nomogram.

Conclusion

We developed and validated a prognostic nomogram for predicting the probability of 3-year MACEs in ACS patients who underwent PCI at county-level hospitals. The nomogram could provide a precise risk assessment for secondary prevention in ACS patients receiving PCI.

Methylmalonic acid, vitamin B12, and mortality risk in patients with preexisting coronary heart disease: a prospective cohort study

BACKGROUND

The inconsistent relationship between Vitamin B12 (B12), methylmalonic acid (MMA, marker of B12 deficiency) and mortality was poorly understood, especially in patients with coronary heart disease (CHD). This study aims to investigate the association of serum MMA, and B12-related biomarkers (serum level, dietary intake, supplement use, and sensibility to B12) with all-cause and cardiovascular mortality in adults with CHD.

METHODS

The data of this study were from a subcohort within the US National Health and Nutrition Examination Survey (NHANES). We included adults with preexisting CHD with serum MMA and B12, and dietary B12 intake measurements at recruitment. All participants were followed up until 31 December 2019. Weighted Cox proportional hazard regression was used to estimate hazard ratios (HR) and 95% CI of mortality risk.

RESULTS

Overall, 1755 individuals (weighted mean [SE] age, 65.2 [0.5] years; 1047 men [weighted 58.5%]) with CHD were included, with geometric mean levels of serum MMA 182.4 nmol/L, serum B12 494.5 pg/ml, and dietary B12 intake 4.42 mg/day, and percentage of B12 supplements use 39.1%. During a median follow-up of 7.92 years, 980 patients died. Serum B12 concentration, dietary B12 intake and supplements use were not significantly associated with mortality risk (each p ≥ 0.388). In contrast, individuals in the top tertile of MMA had multivariable-adjusted HRs (95% CIs) of 1.70 (1.31-2.20) for all-cause mortality, and 2.00 (1.39-2.89) for cardiovascular mortality (both p trend < 0.001) compared to those in the bottom tertile of MMA. MMA-related mortality risk was particularly higher among participants with sufficient serum B12 (p < 0.001). CHD patients with increased levels of both MMA and B12 had a doubled mortality risk compared to those with lower MMA and B12 (p < 0.001).

CONCLUSION

MMA accumulation but not serum or dietary vitamin B12 was associated with increased cardiovascular mortality risk among patients with CHD. This paradox may be related to decreased response to vitamin B12.

Genome-wide interaction analysis of folate for colorectal cancer risk

BACKGROUND

Epidemiological and experimental evidence suggests that higher folate intake is associated with decreased colorectal cancer (CRC) risk; however, the mechanisms underlying this relationship are not fully understood. Genetic variation that may have a direct or indirect impact on folate metabolism can provide insights into folate's role in CRC.

OBJECTIVES

Our aim was to perform a genome-wide interaction analysis to identify genetic variants that may modify the association of folate on CRC risk.

METHODS

We applied traditional case-control logistic regression, joint 3-degree of freedom, and a 2-step weighted hypothesis approach to test the interactions of common variants (allele frequency >1%) across the genome and dietary folate, folic acid supplement use, and total folate in relation to risk of CRC in 30,550 cases and 42,336 controls from 51 studies from 3 genetic consortia (CCFR, CORECT, GECCO).

RESULTS

Inverse associations of dietary, total folate, and folic acid supplement with CRC were found (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.90, 0.96; and 0.91; 95% CI: 0.89, 0.94 per quartile higher intake, and 0.82 (95% CI: 0.78, 0.88) for users compared with nonusers, respectively). Interactions (P-interaction < 5×10-8) of folic acid supplement and variants in the 3p25.2 locus (in the region of Synapsin II [SYN2]/tissue inhibitor of metalloproteinase 4 [TIMP4]) were found using traditional interaction analysis, with variant rs150924902 (located upstream to SYN2) showing the strongest interaction. In stratified analyses by rs150924902 genotypes, folate supplementation was associated with decreased CRC risk among those carrying the TT genotype (OR: 0.82; 95% CI: 0.79, 0.86) but increased CRC risk among those carrying the TA genotype (OR: 1.63; 95% CI: 1.29, 2.05), suggesting a qualitative interaction (P-interaction = 1.4×10-8). No interactions were observed for dietary and total folate.

CONCLUSIONS

Variation in 3p25.2 locus may modify the association of folate supplement with CRC risk. Experimental studies and studies incorporating other relevant omics data are warranted to validate this finding.

The magic of a methyl group: Biochemistry at the service of medicine

A carbon-carbon linkage is created when a methyl group is implanted on dUMP, thus resulting in the formation of dTMP by thymidylate synthase. The methyl group is deleted by aromatase when androgens are converted to estrogens. The methyl group is rearranged with the help of vitamin B12 in the isomerization of methylmalonyl-CoA to succinyl-CoA. S-adenosylmethionine (SAM) serves as the universal methyl donor involved in the biosynthesis of adrenaline and creatine(phosphate). It also interferes with the 5'-mRNA capping and the degradation of catecholamines (i.e. adrenaline, noradrenaline). Cholesterol could be viewed as a conglomeration of methyl groups. Finally, as part of valine, two methyl functions participate in the origin of one of the most frequent hereditary diseases on earth, sickle cell anemia.

Unprovoked Venous Thromboembolism: The Search for the Cause

Venous thromboembolism (VTE) is a common vascular disorder encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). There is no data on global estimates of VTE prevalence and incidence. Most patients with unprovoked VTE require secondary thromboprophylaxis upon the completion of the primary treatment phase if they have no high bleeding risk. Risk prediction models can help identify patients at low VTE recurrence risk who may discontinue anticoagulation upon the completion of the primary treatment phase.

Modulation of DNA methylation by one-carbon metabolism: a milestone for healthy aging

Healthy aging can be defined as an extended lifespan and health span. Nutrition has been regarded as an important factor in healthy aging, because nutrients, bioactive food components, and diets have demonstrated beneficial effects on aging hallmarks such as oxidative stress, mitochondrial function, apoptosis and autophagy, genomic stability, and immune function. Nutrition also plays a role in epigenetic regulation of gene expression, and DNA methylation is the most extensively investigated epigenetic phenomenon in aging. Interestingly, age-associated DNA methylation can be modulated by one-carbon metabolism or inhibition of DNA methyltransferases. One-carbon metabolism ultimately controls the balance between the universal methyl donor S-adenosylmethionine and the methyltransferase inhibitor S-adenosylhomocysteine. Water-soluble B-vitamins such as folate, vitamin B6, and vitamin B12 serve as coenzymes for multiple steps in one-carbon metabolism, whereas methionine, choline, betaine, and serine act as methyl donors. Thus, these one-carbon nutrients can modify age-associated DNA methylation and subsequently alter the age-associated physiologic and pathologic processes. We cannot elude aging per se but we may at least change age-associated DNA methylation, which could mitigate age-associated diseases and disorders.