Vitamin D Deficiency and Replacement: Relationships to Cardiovascular Health

Abstract Background: Cardiovascular disease is the most common cause of mortality and morbidity in the United States as well as many other nations. Recent evidence supports an association of vitamin D deficiency with hypertension, peripheral vascular disease, diabetes mellitus, metabolic syndrome, coronary artery disease, and heart failure. We wished to study the association of vitamin D deficiency in a cohort of patients followed by a large cardiovascular practice at an academic medical institution, as well as the association of vitamin D replacement with improvement in cardiovascular outcomes. Methods: Serum vitamin D measurements for 5 years and 8 months (1/1/2004 to 10/8/2009) from The University of Kansas Hospital were obtained. These values were matched to patient demographic, physiologic and disease state variables from the cardiovascular database. Serum vitamin D levels were analyzed as a continuous variable and as normal (>30ng/ml) or deficient. Descriptive statistics, univariate analysis, multivariate analysis, survival analysis, and Cox proportional hazard modeling were performed. Results: 10,899 patients were available for analysis. Mean age was 58.3 +/- 14.9 years. There were 7758 (71%) women and 3141 (29%) men. Mean weight was 185.7 +/-52.0 lbs and BMI was 29.9 +/- 7.7 Ejection fraction was 57.2 +/- 10.4%. Mean vitamin D was 24.1 +/- 13.6 ng/ml.. 3294 (29.7%) subjects were in normal range (&#8805;30ng/ml) and 7665 (70.3%) were deficient (30ng/ml) or deficient. Descriptive statistics, univariate analysis, multivariate analysis, survival analysis, and Cox proportional hazard modeling were performed. Results: 10,899 patients were available for analysis. Mean age was 58.3 +/- 14.9 years. There were 7758 (71%) women and 3141 (29%) men. Mean weight was 185.7 +/-52.0 lbs and BMI was 29.9 +/- 7.7 Ejection fraction was 57.2 +/- 10.4%. Mean vitamin D was 24.1 +/- 13.6 ng/ml.. 3294 (29.7%) subjects were in normal range (&#8805;30ng/ml) and 7665 (70.3%) were deficient (<30ng/ml). Vitamin D deficiency was found to be associated with several cardiovascular disease states including hypertension, coronary artery disease and cardiomyopathy; as well as diabetes and death (all P's < .05). Logistic regression analysis found vitamin D deficiency to be a strong predictor of death (OR 2.64, CI 1.901-3.662, P < .0001). This association persisted with other clinical variables such as, BMI, gender, and ejection fraction added to the model and was confirmed by survival as well as hazard function analysis. Vitamin D replacement conferred substantial survival benefit (OR for death 0.39, CI 0.277-0.534, P < .0001) and was particularly beneficial in vitamin D deficient patients. The interaction of vitamin D deficiency and supplementation was analyzed as well as the association of vitamin D deficiency and certain coronary artery disease risk factors. Conclusions: Vitamin D deficiency is a significant risk factor for several cardiovascular disease states and is a significant independent predictor of reduced survival. Vitamin D supplementation improves survival with greater benefit in deficient patients. Prospective randomized trials of vitamin D supplementation in patients with cardiovascular diseases are warranted, as well as consideration for increased supplementation in the general public

Imaging Techniques in Acute Coronary Syndromes: A Review

Coronary heart disease (CHD) remains the leading cause of death in the United States. National review of Emergency Department (ED) visits from 2007 to 2008 reveals that 9% are for chest pain. Of these patients, 13% had acute coronary syndromes (ACSs) (Antman et al., 2004). Plaque rupture with thrombus formation is the most frequent cause of ACS, and identifying patients prior to this event remains important for any clinician caring for these patients. There has been an increasing amount of research and technological advancement in improving the diagnosis of patients presenting with ACS. Low-to-intermediate risk patients are the subgroup that has a delay in definitive treatment for ACS, and a push for methods to more easily and accurately identify the patients within this group that would benefit from an early invasive strategy has arisen. Multiple imaging modalities have been studied regarding the ability to detect ischemia or wall motion abnormalities (WMAs), and an understanding of some of the currently available noninvasive and invasive imaging techniques is important for any clinician caring for ACS patients

Ezetimibe in combination with a statin does not reduce all-cause mortality

BACKGROUND: Although the ezetimibe-statin combination has been shown to reduce LDL cholesterol by 12% compared to a statin alone, its effect on hard clinical endpoints such as mortality is less certain. Prior trials evaluated this combination in highly select population groups, but impact on all- cause mortality in the general population has not been reported. METHODS: A total of 3,827 subjects who were prescribed either a statin (group 1) or the combination of statin with ezetimibe (group 2) between January 1st, 2005 and January 1st, 2008 were studied. Socio-demographic and clinical variables and mortality records were analyzed. Univariate and stepwise multivariate logistic regression analysis was performed to identify the impact of ezetimibe on all-cause mortality, controlling for patient characteristics, selected cardiovascular diseases and risk factors, and medications. RESULTS: Group 1 (n = 2,909), and group 2 (n = 918) were similar in regards to most demographic variables, 152 patients died from any cause during the study period. There was no difference in all cause mortality between the groups. Hypertension, higher HDL-C and omega-3 fatty acid use were associated with ezetimibe use in this cohort of patients and were considered as covariates in the analysis. Patients on the drug combination did not experience lower mortality after controlling for covariates and other significant risk factors. CONCLUSIONS: No significant mortality benefit was found with the use of ezetimibe in combination with a statin over use of a statin alone. Omega-3 fatty acid use and higher HDL-C demonstrated a substantial survival benefit

Calcium effects on vascular endpoints

Abstract Calcium is one of the most abundant minerals in the body and its metabolism is one of the basic biologic processes in humans. Although historically linked primarily to bone structural development and maintenance, calcium is now recognized as a key component of many physiologic pathways necessary for optimum health including cardiovascular, neurological, endocrine, renal, and gastrointestinal systems. A recent meta-analysis published in August 2011 showed a potential increase in cardiovascular events related to calcium supplementation. The possible mechanism of action of this correlation has not been well elucidated. This topic has generated intense interest due to the widespread use of calcium supplements, particularly among the middle aged and elderly who are at the most risk from cardiac events. Prior studies did not control for potential confounding factors such as the use of statins, aspirin or other medications. These controversial results warrant additional well-designed studies to investigate the relationship between calcium supplementation and cardiovascular outcomes. The purpose of this review is to highlight the current literature in regards to calcium supplementation and cardiovascular health; and to identify areas of future research.Peer Reviewe

The impact of omega-3 fatty acid use on the risk of atrial fibrillation in patients with cardiovascular disease

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