Summary and Future Directions for Epidemiological, Preventive and Basic Research

Abstract

Future research on the epidemiology of homocysteine as a risk factor for cardiovascular disease must be understood in the general context of research on epidemiology and prevention. The major causes of cardiovascular disease are well understood, particularly as they contribute to epidemic cardiovascular disease, and include mass exposure to high levels of dietary saturated fat, physical inactivity, obesity, hypertension and cigarette smoking. While it is frequently stated that these “classical” risk factors account for only 50% of the cardiovascular disease incidence, this statement is based on the imprecision of multivariate risk models and ignores the significant limitations to the predictive power of these models from measurement error (1). From a population perspective, the classical risk factors are likely to account for 70 to 85 percent of cardiovascular disease incidence (2). Thus, one of the principal challenges to cardiovascular disease prevention is to apply current knowledge to a much higher proportion of the population at risk by improving clinical prevention efforts and by finding effective ways of changing health-related behavior at the community level (3). This will be a particularly great challenge in the developing world, where the majority of cardiovascular disease events already occurs (4–6).