Prevalence of Vitamin D Deficiency in Patients With Acute Myocardial Infarction

doi:10.1016/j.amjcard.2011.01.048

The American Journal of Cardiology

Volume 107, Issue 11, 1 June 2011, Pages 1636-1638

https://doi.org/10.1016/j.amjcard.2011.01.048 Get rights and content

Deficiency in 25-hydroxyvitamin D (25[OH]D) is a treatable condition that has been associated with coronary artery disease and many of its risk factors. A practical time to assess for 25(OH)D deficiency, and to initiate treatment, is at the time of an acute myocardial infarction. The prevalence of 25(OH)D deficiency and the characteristics associated with it in patients with acute myocardial infarction are unknown. In this study, 25(OH)D was assessed in 239 subjects enrolled in a 20-hospital prospective myocardial infarction registry. Patients enrolled from June 1 to December 31, 2008, had serum samples sent to a centralized laboratory for analysis using the DiaSorin 25(OH)D assay. Normal 25(OH)D levels are ≥30 ng/ml, and patients with levels <30 and >20 ng/ml were classified as insufficient and those with levels ≤20 ng/ml as deficient. Vitamin D levels and other baseline characteristics were analyzed with the linear or Mantel-Haenszel trend test. Of the 239 enrolled patients, 179 (75%) were 25(OH)D deficient and 50 (21%) were insufficient, for a total of 96% of patients with abnormally low 25(OH)D levels. No significant heterogeneity was observed among age or gender subgroups, but 25(OH)D deficiency was more commonly seen in non-Caucasian patients and those with lower social support, no insurance, diabetes, and lower activity levels. Higher parathyroid hormone levels (45.3 vs 32.7 pg/ml, p = 0.029) and body mass indexes (31.2 vs 29.0 kg/m², p = 0.025) were also observed in 25(OH)D-deficient subjects. In conclusion, vitamin D deficiency is present in almost all patients with acute myocardial infarction in a multicenter United States cohort.

Section snippets

Methods

We studied subjects enrolled in TRIUMPH. This registry collected information on patients admitted for AMI through chart abstraction, detailed patient interviews, as well as serum samples at 24 United States hospitals from April 11, 2005, to December 31, 2008. Inclusion criteria were very similar to TRIUMPH's predecessor, the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER),⁶ and included patients aged ≥18 years with biomarker evidence of myocardial injury

Results

During the enrollment period of June 1 to December 31, 2008, 239 patients from 20 of the 24 TRIUMPH sites consented to baseline blood work and had 25(OH)D levels assessed via the DiaSorin radioimmunoassay method. The total population mean age was 57.6 ± 11.4 years, and 73.2% of the enrolled subjects were men (Table 2).

No significant heterogeneity was observed among age or gender subgroups (Table 2), but vitamin D deficiency was more commonly seen in non-Caucasian patients and those with lower

Discussion

This study describes the vitamin D status in post-AMI patients from a diverse population enrolled from across the United States from 20 separate sites, including academic and private institutions. Our findings of an extraordinarily high prevalence of vitamin D deficiency or insufficiency (96%) in the patients admitted for AMI are consistent with data associating CV disease and many of its risk factors with 25(OH)D deficiency.⁴ In addition to the findings of a high prevalence of 25(OH)D

Acknowledgment

We wish to thank Lori J. Wilson for her help in the preparation of this report.

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Vitamin D has an established role in calcium homeostasis but its deficiency is emerging also as a new risk factor for cardiovascular disease (CVD). In particular, several epidemiological and clinical studies have reported a close association between low vitamin D levels and several cardiovascular risk factors and major CVDs, such as coronary artery disease, heart failure, and cardiac arrhythmias.
In all these clinical settings, vitamin D deficiency seems to predispose to increased morbidity, mortality, and recurrent cardiovascular events. Despite this growing evidence, interventional trials with supplementation of vitamin D in patients at risk of or with established CVD are still controversial.
In this chapter, we summarize the currently available evidence on the links between vitamin D deficiency and major cardiovascular risk factors and CVD, in terms of both clinical relevance and potential therapeutic implications.
Vitamin D deficiency during the perioperative period increases the rate of hardware failure and the need for revision fusion in adult patients undergoing single-level lumbar spine instrumentation surgery
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Vitamin D has been shown to play important roles in both calcium homeostasis and bone healing. Only three studies have directly examined the relationship between vitamin D deficiency and hardware failure, nonunion, and/or revision surgery. Results are contradictory and none were large enough to provide the statistical power necessary to make definitive conclusions.
A retrospective analysis was performed utilizing the PearlDiver national insurance claims database consisting of 91 million individual patient records. Patients aged 30 and over who underwent a non-segmental posterior lumbar fusion procedure (CPT-22840) in 2012-2019 were included. Data collected included, hardware failure, revision surgery occurrence, and vitamin D deficiency. Hardware failure and revision rates were compared between vitamin D deficient and non-deficient groups. We ran a logistic regression analysis using the following variables: age, Charlson Comorbidity Index (CCI), gender, vitamin D deficiency, obesity, tobacco use, diabetes, osteoporosis, rheumatoid arthritis, and Crohn's disease.
108,137 patients matching inclusion criteria were identified, with an overall hardware failure rate of 2.7% and revision rate of 4.1%. Failure rates were significantly higher for patients diagnosed with vitamin D deficiency during the full queried period (3.3% vs. 2.6%, OR = 1.26; p < 0.0001), as were revision rates (4.3% vs 3.5%, OR = 1.25; p < 0.0001). Patients diagnosed with deficiency pre-surgery, higher failure (3.1% vs 2.6%, OR = 1.19; p < 0.01) and rates of revision (4.4% vs 3.5%, OR = 1.27; p < 0.0001) were increased compared to the non-deficient group. In the logistic regression analysis, vitamin D deficiency remains a significant contributor to hardware failure and revision surgery.
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Citation Excerpt :
Vitamin D deficiency has been previously associated with the prevalence and extent of coronary artery disease, increased platelet reactivity and an enhanced inflammatory response favouring a pro-thrombotic milieu, that could account for the higher occurrence of myocardial infarction in case of inadequate levels. In effect, lower levels of 25(OH)D have been reported in patients with STEMI: a multicenter study performed in 239 ACS patients showed that 96% of them had vitamin D levels <30 ng/mL at hospital presentation [31] and in Ng et al. [32] 74% of AMI patients had low vitamin D levels, of whom 36% had a severe deficiency. Moreover, Safaie et al. reported that STEMI presentation was more common among patients with acute coronary syndrome in case of lower vitamin D levels [33].
Vitamin D displays a broad spectrum of cardioprotective effects, preventing oxidative stress, inflammation and thrombosis and improving endothelial function.
Previous studies have associated vitamin D deficiency with more extended and severe coronary artery disease (CAD) and worse outcome, and especially among patients with ST-segment elevation myocardial infarction (STEMI). However, few data have been reported on the association of vitamin D levels with the angiographic findings and epicardial reperfusion in STEMI patients undergoing primary percutaneous coronary intervention (pPCI), that was therefore the aim of the present study.
A consecutive cohort of patients admitted for STEMI and treated with pPCI were included. The levels of 25(OH)D were assessed at admission by chemiluminescence immunoassay kit LIAISON® Vitamin D assay (Diasorin Inc). Hypovitaminosis D was defined for 25(OH)D < 10 ng/ml.
We included in our study 450 patients, divided according to tertiles values of 25(OH)D. Lower vitamin D was associated to a higher use of diuretics (p = 0.02), higher levels of white blood cells and glycemia (p < 0.001), lower prevalence of lesions on bifurcations (p = 0.03) and smaller diameter of the target coronary vessel (p = 0.03). Procedural characteristics and pre-procedural TIMI flow were not different according to vitamin D levels, but for a higher rate of impaired epicardial reperfusion (12.8% vs 8.1% vs 5.3%, p = 0.03, adjusted OR[95%CI] = 2.6[1.05–6.6], p = 0.04 for I vs III tertile), requiring higher use of adenosine (p = 0.006) and glycoprotein IIbIIIa inhibitors (p = 0.01).
The present study shows that among patients with STEMI undergoing pPCI, lower levels of vitamin D are independently associated with impaired reperfusion, Future dedicated studies will shed light on the prognostic implications of hypovitaminosis D in these patients and the potential therapeutic perspectives.
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The principal source of vitamin D in humans is its biosynthesis in the skin through a chemical reaction dependent on sun exposure. In lesser amounts, the vitamin can be obtained from the diet, mostly from fatty fish, fish liver oil and mushrooms. Individuals with vitamin D deficiency, defined as a serum level of 25 hydroxyvitamin D < 20 ng/dl, should be supplemented. Vitamin D deficiency is a prevalent global problem caused mainly by low exposure to sunlight. The main role of 1,25 dihydroxyvitamin D is the maintenance of calcium and phosphorus homeostasis. However, vitamin D receptors are found in most human cells and tissues, indicating many extra-skeletal effects of the vitamin, particularly in the immune and cardiovascular (CV) systems. Vitamin D regulates blood pressure by acting on endothelial cells and smooth muscle cells. Its deficiency has been associated with various CV risk factors and appears to be linked to a higher mortality and incidence of CV disease (CVD). Several mechanisms have been proposed relating vitamin D deficiency to CV risk factors such as renin-angiotensin-aldosterone system activation, abnormal nitric oxide regulation, oxidative stress or altered inflammatory pathways. However, in the latest randomized controlled trials no benefits of vitamin D supplementation for CVD have been confirmed. Although more work is needed to establish the protective role of vitamin D in this setting, according to current evidences vitamin D supplements should not be recommended for CVD prevention.
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Phosphorus equilibrium in the body is regulated through uptake and release of phosphate via the intestine, kidney, and bone. These processes are coordinated primarily through the activity and regulation of fibroblast growth factor 23 (FGF23). FGF23 is largely produced in osseous structures by osteocytes and osteoblasts. Under normal physiological conditions, elevations in serum phosphorus or active 1,25-dihydroxyvitamin D₃ stimulate transcriptional upregulation of FGF23 and promote the release of the full-length intact FGF23 protein into the blood where it is then delivered to downstream target tissues. Studies in rare heritable forms of phosphate dysregulation revealed novel additional pathways of FG23 regulation including iron deficiency and inflammation. Notably, FGF23 expression under these conditions is not confined to the skeleton but is produced in many additional tissues as well. Thus, this chapter will examine the regulation of FGF23 in normal and altered metabolic states as well as how these multiple agents affect expression within bone and extra-skeletal tissues.
Vitamin D gene polymorphisms and risk of acute cardiovascular events
2020, Clinical Epidemiology and Global Health
Citation Excerpt :
In addition, epidemiological studies have linked low serum levels of 25-(OH)D, with a range of medical conditions, including cardiovascular diseases.7–12 In particular, low levels of vitamin D have been associated with acute myocardial infarction (MI).13,14 There even is evidence that lower vitamin D levels are linked to increased mortality.15
Low vitamin D levels have been associated with various diseases, including cardiovascular disease, although data are not consistent. Serum vitamin D levels depend on different synthesis steps which are controlled by gene cascade. This study investigated whether low serum levels of vitamin D and single nucleotide polymorphisms (SNPs) in genes involved in the vitamin D cascade (VDR, CYP2R1, CYP27B1, CYP24 and DBP) could be risk factors for acute coronary syndrome (ACS).
71 Patients with ACS and 443 healthy controls were genotyped for polymorphisms in genes of the vitamin D cascade. Clinical findings were correlated with serum levels of the vitamin D metabolites 1,25(OH)₂D₃ and 25(OH)D₃.
25(OH)D₃ and 1,25(OH)₂D₃ insufficiency was more common in ACS patients than in controls (p < 0.05). After adjustments for variables and propensity score the SNPs rs4646536 and rs2296241 within CYP24 and CYP27B1 are significantly associated with ACS (p < 0.05). CYP27B1 rs4646536 genotype TT is more frequently found in ACS patients compared to healthy controls, whereas genotype TC is found at higher frequency in controls (79% vs 44% and 42% vs 5%, respectively, p < 0.01). CYP24 rs2296241 SNP genotype GG occurred less frequently in ACS vs controls (7% vs 18%), while genotype AG was found more frequently in ACS (79% vs 57%, p < 0.01).
Lower vitamin D levels as well as polymorphisms within the CYP27B1 and CYP24 genes seem to promote ACS. These findings may offer potential for identification of patients at increased risk for cardiovascular incidents.

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: NIH funding support of the TRIUMPH registry was through the National Heart, Lung and Blood Institute (P50 HL077113).

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ReviewPrevalence of Vitamin D Deficiency in Patients With Acute Myocardial Infarction

Section snippets

Methods

Results

Discussion

Acknowledgment

Prog Biophys Mol Biol

J Am Coll Cardiol

Am Heart J

Am J Clin Nutr

Am J Clin Nutr

Vitamin D deficiency

N Engl J Med

Vitamin D deficiency and risk of cardiovascular disease

Circulation

Review
Prevalence of Vitamin D Deficiency in Patients With Acute Myocardial Infarction