Submitted by Dr. Andreas Lambrianides
General Surgeon, Brisbane, Australia

Routine folic acid supplements have been recommended for middle-aged men and women to reduce coronary heart disease. By reducing homocysteine levels, supplements of folic acid could potentially prevent almost one in three cases of cardiovascular diseases (JAMA 2001; 286: 936 - 43).

Routine use of the vitamin supplements in men older than forty-five and in women older than fifty-five would be a simple and inexpensive means of reducing deaths from cardiovascular disease.  It has been predicted that the recent introduced policy of fortifying foods with folic acid would reduce coronary heart disease events by 8% in women and 13% in men, with comparable reductions in mortality.

Review studies have shown a strong relationship between homocysteine levels and the risk of coronary heart disease, particularly so in patients with pre-existing heart disease.   A daily supplement of 1mg folic acid would reduce homocysteine levels by 25%.  

Treating all patients with known coronary heart disease would result in more than 300 000 fewer deaths over  a ten-year period.  Another option would be to screen the population and treat those with raised homocysteine levels.  This approach would be cost effective, but a simpler and almost as cost effective alternative would be to offer routine use of supplements for all men over 45, and all women older than 55.

At a cost of approximately US$20 per person per year, the use of routine supplements in men result in a further of 300 000 years of life saved at a net US$2 billion reduction in the cost of treatment of coronary heart disease over ten years. However researches have warned that the evidence linking raised homocysteine levels and coronary heart disease came form observation studies.  There are on going clinical trials that might show whether reduction of homocysteine levels reduces clinically important coronary heart disease events.

Although the precise mechanism by which elevated plasma homocysteine levels increase the risk of coronary heart disease has not been determined, the possibility includes endothelial damage and altered anticoagulant activity.  Deficiency of folic acid can cause elevated plasma homocysteine levels, and supplementation can decrease the levels.