On the mechanism of homocysteine pathophysiology and pathogenesis: a unifying hypothesis.

Studies have shown that hyperhomocysteinemia is an important and independent risk factor for a variety of human cardiovascular diseases. In this paper, a unifying hypothesis is proposed which suggests that hyperhomocysteinemia may exert its pathogenic effects largely through metabolic accumulation of S-adenosyl-L-homocysteine, a strong noncompetitive inhibitor of the catechol-O-methyltransferase (COMT)-mediated methylation metabolism of various catechol substrates (such as catecholamines and catechol estrogens). In the case of endogenous catecholamines in peripheral tissues, inhibition of their methylation by S-adenosyl-L-homocysteine will result in elevation of blood or tissue levels of catecholamines, and consequently, over-stimulation of the cardiovascular system's functions. Moreover, because the vasculature is constantly exposed to high levels of endogenous catecholamines (due to high levels of circulating neurohormone epinephrine plus rich innervation with sympathetic nerve terminals), vascular endothelial cells would incur chronic cumulative damage caused by the large amounts of the oxidative products (catechol quinones/semiquinones and oxyradicals) generated from endogenous catecholamines. This mechanistic explanation for the vascular toxicity of hyperhomocysteinemia is supported by many experimental findings, and it also fully agrees with the known protective effects of folate, vitamins B6 and B12 in hyperhomocysteinemic patients. In addition, based on the predictable effects of hyperhomocysteinemia on the methylation of catecholamines in the central nervous system as well as on the methylation of catechol estrogens in estrogen target organs, it is also suggested that hyperhomocysteinemia is an important risk factor for the development of neurodegerative disorders (Parkinson's and Alzheimer's diseases) and estrogen-induced hormonal cancers. More studies are warranted to test these intriguing ideas.