Key result
Folic acid supplementation did not reduce ischaemic heart disease risk (RR 1.00), likely because concomitant aspirin use in trials negated the anti-platelet effect of lowering homocysteine.
Why the study?
Does homocysteine lowering with folic acid reduce ischaemic heart disease events, and is this effect modified by concurrent antiplatelet therapy?
Meta-Analysis (n=85,283)
Does homocysteine lowering with folic acid reduce ischaemic heart disease events, and is this effect modified by concurrent antiplatelet therapy?
The discrepancy between genetic studies and randomized trials regarding homocysteine and ischaemic heart disease may be explained by concurrent aspirin use negating the anti-platelet effect of homocysteine lowering.
Supports withholding folic acid for IHD prevention; extends evidence by reconciling null trials with genetic data via aspirin interaction.
BACKGROUND: Results from genetic epidemiological studies suggest that raised serum homocysteine is a cause of ischaemic heart disease, but the results of randomised trials suggest otherwise. We aimed to update meta-analyses on each type of study using the latest published data and test a hypothesis based on antiplatelet therapy use in the trials to explain the discrepancy. METHODS AND FINDINGS: Meta-analyses of ischaemic heart disease using (i) 75 studies in which the prevalence of a mutation (CT) in the MTHFR gene (which increases homocysteine) was determined in cases (22,068) and controls (23,618), and (ii) 14 randomised trials (39,597 participants) of homocysteine lowering and ischaemic heart disease events. The summary estimates from the two analyses were compared. Meta-analysis of the MTHFR studies showed a statistically significantly increased risk of ischaemic heart disease in TT compared with CC homozygotes; odds ratio 1.16 (1.04 to 1.29) for a 1.9 µmol/L homocysteine difference (TT minus CC). Meta-analysis of randomised trials showed no significant reduction in IHD risk from folic acid; relative risk 1.00 (0.93 to 1.08), despite a reduction in homocysteine of 3.3 µmol/L. There was a statistically significant difference in risk reduction between the 5 trials with the lowest prevalence of antiplatelet therapy (60% on average, usually aspirin), RR 0.93 (0.84 to 1.05) and the 5 trials with the highest prevalence (91% on average), RR 1.09 (1.00 to 1.19), p = 0.037 for the difference. CONCLUSION: Discordant results from MTHFR studies and randomised trials could be explained by aspirin reducing or negating the anti-platelet effect of lowering homocysteine. On this basis, folic acid would have a role in the primary prevention of ischaemic heart disease, when aspirin is not taken routinely, but not in secondary prevention, when it is routine.
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Wald et al. (2011) conducted a meta-analysis in Ischaemic heart disease (n=85,283). Folic acid (homocysteine lowering) vs. Placebo was evaluated on Ischaemic heart disease events (cardiac death or non-fatal myocardial infarction) (RR 1.00, 95% CI 0.93 to 1.08). Folic acid supplementation did not reduce ischaemic heart disease risk (RR 1.00), likely because concomitant aspirin use in trials negated the anti-platelet effect of lowering homocysteine.
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