Nygård O, Nordrehaug J E, Refsum H, Ueland P M, Farstad M, Vollset S E
Department of Public Health and Primary Health Care, University of Bergen, Haukeland University Hospital, Norway.
N Engl J Med. 1997 Jul 24;337(4):230-6. doi: 10.1056/NEJM199707243370403.
Elevated plasma homocysteine levels are a risk factor for coronary heart disease, but the prognostic value of homocysteine levels in patients with established coronary artery disease has not been defined.
We prospectively investigated the relation between plasma total homocysteine levels and mortality among 587 patients with angiographically confirmed coronary artery disease. At the time of angiography in 1991 or 1992, risk factors for coronary disease, including homocysteine levels, were evaluated. The majority of the patients subsequently underwent coronary-artery bypass grafting (318 patients) or percutaneous transluminal coronary angioplasty (120 patients); the remaining 149 were treated medically.
After a median follow-up of 4.6 years, 64 patients (10.9 percent) had died. We found a strong, graded relation between plasma homocysteine levels and overall mortality. After four years, 3.8 percent of patients with homocysteine levels below 9 micromol per liter had died, as compared with 24.7 percent of those with homocysteine levels of 15 micromol per liter or higher. Homocysteine levels were only weakly related to the extent of coronary artery disease but were strongly related to the history with respect to myocardial infarction, the left ventricular ejection fraction, and the serum creatinine level. The relation of homocysteine levels to mortality remained strong after adjustment for these and other potential confounders. In an analysis in which the patients with homocysteine levels below 9 micromol per liter were used as the reference group, the mortality ratios were 1.9 for patients with homocysteine levels of 9.0 to 14.9 micromol per liter, 2.8 for those with levels of 15.0 to 19.9 micromol per liter, and 4.5 for those with levels of 20.0 micromol per liter or higher (P for trend=0.02). When death due to cardiovascular disease (which occurred in 50 patients) was used as the end point in the analysis, the relation between homocysteine levels and mortality was slightly strengthened.
Plasma total homocysteine levels are a strong predictor of mortality in patients with angiographically confirmed coronary artery disease.
血浆同型半胱氨酸水平升高是冠心病的一个危险因素，但同型半胱氨酸水平在已确诊冠心病患者中的预后价值尚未明确。
我们前瞻性地研究了587例经血管造影证实患有冠心病患者的血浆总同型半胱氨酸水平与死亡率之间的关系。在1991年或1992年进行血管造影时，评估了包括同型半胱氨酸水平在内的冠心病危险因素。大多数患者随后接受了冠状动脉搭桥术（318例）或经皮腔内冠状动脉成形术（120例）；其余149例接受药物治疗。
中位随访4.6年后，64例患者（10.9%）死亡。我们发现血浆同型半胱氨酸水平与总死亡率之间存在强烈的分级关系。四年后，同型半胱氨酸水平低于9微摩尔/升的患者中有3.8%死亡，而同型半胱氨酸水平在15微摩尔/升或更高的患者中有24.7%死亡。同型半胱氨酸水平与冠状动脉疾病的严重程度仅呈弱相关，但与心肌梗死病史、左心室射血分数和血清肌酐水平密切相关。在对这些及其他潜在混杂因素进行校正后，同型半胱氨酸水平与死亡率之间的关系仍然很强。在一项分析中，将同型半胱氨酸水平低于9微摩尔/升的患者作为参照组，同型半胱氨酸水平为9.0至14.9微摩尔/升的患者的死亡率比值为1.9，15.0至19.9微摩尔/升的患者为2.8，20.0微摩尔/升或更高的患者为4.5（趋势P值=0.02）。当将心血管疾病导致的死亡（50例患者发生）作为分析终点时，同型半胱氨酸水平与死亡率之间的关系略有增强。
血浆总同型半胱氨酸水平是经血管造影证实患有冠心病患者死亡率的强有力预测指标。
