Fasting plasma total Hcy (tHcy) levels: |
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The prevalence of HHcy in the general population is between five and ten percent (using a threshold set at the 90th to 95th percentile of 15 micromol / liter). Keep in mind that this figure may escalate to, as high as, 30% to 40 % in the elderly. |
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Normal: 5–15 micromol/L (Based on table below 5 – 9 micromol/L) |
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Moderate: 15–30 micromol/L |
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Intermediate: 31–100 micromol/L |
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Severe: >100 micromol/L |
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Goal of Treatment: 9 micromol / Liter or less. (Based on table below) |
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HYPERHOMOCYSTEINEMIA |
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Check for secondary causes: |
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Renal dysfunction |
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Folate B12 B6 deficiency * Significant to exclude Pernicious Anemia |
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Hypothyroidism and others (table 2) |
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GLOBAL RISK REDUCTION (table 9) |
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1. Diet rich in B vitamins and folate [IF NOT TO GOAL] |
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2. Advance to multivitamin therapy 400 microgram folic acid, 2 mg B6, and 6 mg B12. [IF NOT TO GOAL] |
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3. Advance to prescription strength 1 mg folic acid, 25 mg B6, and 500 microgram B12. [IF NOT TO GOAL] |
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4. Advance to 2–5 mg folic acid, B12 to 1,000 microgram, and B6 25 – 100 mg. |
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5. Sublingual and injectable B12 may be used if necessary, as well as, a trial of Betaine hydrocloride in intractable cases. Higher doses of up to 15 mg of folic acid may be required in hemodialysis patients. |
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6. Global Risk Reduction (table 9) |
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Consider: Total Hcy is associated with a graded mortality risk. Patients with known CAD have the following graded risk [95,97]: |
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tHCY in micromol/liter |
Relative risk of all cause death. |
Relative risk of CAD death |
< 9 |
1.0 |
1.0 |
9 – 14.9 |
1.9 (0.7 – 5.1) |
2.3 (0.7 – 7.7) |
15 – 19.9 |
2.8 (0.9 – 9.0) |
2.5 (0.6 – 10.5) |
> 20 |
4.5 (1.2 – 16.6) |
7.8 (1.7 – 35.1) |