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Enalapril plus folic acid reduces risk for first stroke in certain patients with hypertension
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Among patients with hypertension, those with high total homocysteine and low platelet count showed an elevated risk for first stroke, which was reduced when folic acid was added to enalapril treatment, according to a study published in the Journal of the American College of Cardiology.
“If confirmed, these results have enormous public health implications given the high incident rate of stroke in many developing countries, in addition to China,” Yong Huo, MD, director of the Heart Center of Peking University First Hospital in Beijing, said in a press release. “Based on our findings, we can detect hypertensive adults at particular high risk of stroke and incorporate a folic acid supplement tailored to individual genetic, nutritional and clinical characteristics. We are on the right path to figuring out cost-effective primary prevention strategies for stroke in China and beyond.”
H ypertension in China
Xiangyi Kong, MD, of the department of cardiology at Peking University First Hospital, and colleagues analyzed data from 10,789 patients (mean age, 60 years; 38% men) with hypertension from the China Stroke Primary Prevention Trial. Those with a history of physician-diagnosed MI, stroke, post-coronary revascularization, HF or congenital heart disease were excluded.
Patients were assigned 10 mg enalapril and 0.8 mg folic acid once per day (n = 5,408) or 10 mg enalapril only once per day (n = 5,381). During the trial, patients were allowed to use other antihypertensive drugs except B vitamins. Follow-up was conducted every 3 months.
Blood samples were collected at baseline to measure fasting lipids, fasting glucose, creatinine, serum total homocysteine, serum folate and vitamin B12.
The primary outcome was first fatal or nonfatal stroke. Patients were followed up for a median of 4.2 years.
During follow-up, 161 first strokes occurred in the enalapril-folic acid group vs. 210 in the enalapril-only group.
Patients with high platelet counts and low total homocysteine had the lowest incidence rate of first stroke (3.3%), and the highest incidence rate (5.6%) was seen in patients with low platelet counts and high total homocysteine.
Stroke risk reduction
Folic acid treatment reduced the risk for first stroke by 73% (HR = 0.27; 95% CI, 0.11-0.64) in patients with high total homocysteine and low platelet counts. Risk reduction in other subgroups was modest or nonsignificant.
“Our data suggest that identifying those patients with a combination of low [platelet count] and high [total homocysteine] (both biomarkers are easy to obtain) could help detect those individuals who are at high risk of stroke and who would particularly benefit from folic acid supplementation, a treatment that is simple, safe and inexpensive,” Kong and colleagues wrote.
“This study not only invites confirmation, but opens the door to wider applications,” J. David Spence, MD, director of the Stroke Prevention and Atherosclerosis Research Centre at Robarts Research Institute at Western University in London, Ontario, and Vladimir Hachinski, MD, professor of neurology and epidemiology at Western University, wrote in a related editorial. “For each clinical stroke, there are about five so-called ‘silent strokes.’ This is a misnomer because these patients have cognitive and subtle neurological signs. Because silent cerebrovascular disease may be much more common than clinical stroke, a study of folic acid treatment in patients with silent infarcts, low platelet count and high homocysteine levels seems fully justified.” – by Darlene Dobkowski
Disclosures: Hachinski, Huo, Kong and Spence report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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