Prognostic impact of Vitamin D deficiency in patients with coronary artery disease undergoing percutaneous coronary intervention

Vitamin D status, physical activity and long-term mortality risk after myocardial infarction: a prospective analysis in the Alpha Omega Cohort

AIM

In post-myocardial infarction (MI) patients, we examined independent and combined associations of vitamin D status and physical activity (PA) with long-term mortality, including effect modification by health determinants.

METHODS

We conducted a prospective analysis of 4,837 MI patients from the Alpha Omega Cohort. Baseline blood samples (2002-2006) were assessed for plasma 25-hydroxyvitamin D (25[OH]D) levels using LC-MS/MS. PA was assessed using a validated questionnaire. Patients were followed for mortality through December 2022. HRs for CVD and all-cause mortality were obtained across sex-specific tertiles of 25(OH)D and four categories of PA using Cox models, adjusted for sociodemographic and lifestyle factors. Potential effect modification by health determinants was examined through stratification.

RESULTS

Patients were 69±5.6 years old, 78% was male, 21% had diabetes, and 10% used vitamin D-containing supplements. Over 14.4 years, 3,206 deaths occurred, including 1,244 from CVD. Median 25(OH)D was 21.1 ng/mL and 44% was vitamin D deficient (<20 ng/mL). Higher 25(OH)D levels were associated with lower CVD (HR:0.63, 95%CI:0.54,0.74) and all-cause mortality (HR:0.68, 95%CI:0.62,0.75). For PA levels (high vs. light), HRs were 0.72 (95%CI:0.61,0.85) for CVD mortality and 0.83 (95%CI:0.75,0.92) for all-cause mortality. Patients with low 25(OH)D and no PA had a threefold higher mortality risk than those with high 25(OH)D levels and high PA. The associations were not significantly modified by sex, comorbidities and other health determinants.

CONCLUSIONS

Vitamin D status and PA were inversely and independently associated with long-term risk of CVD and all-cause mortality after MI, regardless of other health determinants.

How Follow-Up Period in Prospective Cohort Studies Affects Relationship Between Baseline Serum 25(OH)D Concentration and Risk of Stroke and Major Cardiovascular Events

Background/Objectives: Prospective cohort studies are useful for studying how biomolecular status affects risk of adverse health outcomes. Less well known is that the longer the follow-up time, the lower the association (or "apparent effect") due to "regression dilution". Here, we evaluate how follow-up interval from baseline to "event" affects the relationship between baseline serum 25-hydroxyvitamin D [25(OH)D] concentration and the later incidence of stroke and major cardiovascular events (MACEs). Methods: Findings for the relative risk (RR) of stroke and MACEs with respect to serum 25(OH)D concentrations at baseline from prospective cohort studies were plotted against mean follow-up time. Fifteen studies from mainly European countries and the United States were used for stroke and nine studies for MACEs. Linear regression analyses were used to study data for follow-up periods of up to 10 years and for more than 10 years. Results: For stroke, the linear regression fit for 1-10 years is RR = 0.34 + (0.065 × follow-up [years]), r = 0.84, adjusted r2 = 0.67, p < 0.001. No significant variations in association were found for studies with follow-up periods of 10-20 years. For MACEs, the linear fit for 1-8.1 years is RR = 0.61 + (0.055 × follow-up [years]), r = 0.81, adjusted r2 = 0.59, p = 0.03. Discussion: The shorter the follow-up period, the greater the apparent effect of better vitamin D status in reducing risk of stroke and MACEs. In addition, the apparent effect of higher 25(OH)D concentration found for the shortest follow-up time is more than twice as great as the estimate based on average follow-up intervals for all studies. Mechanisms have been found to explain how higher serum 25(OH)D concentrations could reduce risk of stroke and MACEs. Randomized controlled trials have not shown that vitamin D supplementation significantly reduces risk of either stroke or MACEs, probably because risk of both outcomes increases rapidly below 15 ng/mL (38 nmol/L) and it is difficult in Western developed countries to enroll enough participants with concentrations that low. Nonetheless, vitamin D's role in reducing risk of stroke and MACEs could be considered causal on the basis of an evaluation of the evidence using Hill's criteria for causality in a biological system. Conclusions: Serum 25(OH)D concentrations above 20 ng/mL are associated with significantly reduced risk of stroke and MACEs prospectively and in an apparent causal manner. Raising serum 25(OH)D concentrations to >20 ng/mL should, therefore, be recommended for everyone likely to be at risk for stroke or MACEs and indeed in the general population.

Effect of preoperative vitamin D on postoperative atrial fibrillation incidence after coronary artery bypass grafting

BACKGROUND

Post-operative atrial fibrillation (POAF) is associated with adverse long-term cardiovascular events.

OBJECTIVES

This study investigated the effects of a high-dose vitamin D administered preoperatively on the postoperative atrial fibrillation (POAF) incidence in patients with vitamin D deficiency following coronary artery bypass grafting (CABG) surgery.

METHODS

This randomized controlled clinical trial was conducted on 246 CABG patients with vitamin D deficiency. All patients were randomly divided into intervention and control groups including 123 cases for each group. In the intervention group, from 3 days before surgery, they received a daily dose of 150,000 units of vitamin D orally (50,000 units of Vit D tablet three times a day) and the patients in the control group received placebo tablets before surgery. All patients in the intervention group were assessed continuously for the occurrence of POAF during the recovery period.

RESULTS

In terms of gender, age, and BMI there were no significant differences between intervention and control groups. Our findings showed that the use of vitamin D supplements did not cause a significant change in the duration of intubation and hospitalization. The ratio of POAF following CABG surgery in the control and treatment groups was 26% and 11.4%, respectively (odds ratio = 0.36; 95% CI = 0.18-0.72; P = 0.003).

CONCLUSIONS

Our findings revealed that high-dose vitamin D supplementation before CABG surgery significantly reduced the incidence of POAF. Further multicenter randomized trials with larger sample sizes are certainly warranted to confirm our results.

Association of different milk fat content with coronary artery disease and myocardial infarction risk: A Mendelian randomization study

BACKGROUND

Numerous observational studies have investigated on the correlation of whole, semi-skimmed, and skimmed milk with coronary artery disease (CAD) and myocardial infarction (MI) risk; However, no consensus has been reached and evidence on any causal links between these exposures and outcomes remains unclear. This study aimed to conduct univariate and multivariate Mendelian randomization (MR) analyses, using publicly released genome-wide association study summary statistics (GWAS) from the IEU GWAS database, to ascertain the causal association of milk with various fat content with CAD and MI risk.

METHODS

For the exposure data, 29, 15, and 30 single-nucleotide polymorphisms for whole milk, semi-skimmed milk, and skimmed milk, respectively, obtained from 360,806 Europeans, were used as instrumental variables. CAD and MI comprised 141,217 and 395,795 samples, respectively. We used inverse variance weighted (IVW), weighted median, MR-Egger regression, and MR Pleiotropy Residual Sum and Outlier analyses to determine whether pleiotropy and heterogeneity could skew the MR results. Sensitivity tests were conducted to verify the robustness of the results.

RESULTS

After adjusting for false discovery rates (FDR), we discovered proof that skimmed milk intake is a genetically predicted risk factor for CAD (odds ratio [OR] = 5.302; 95% confidence interval [CI] 2.261-12.432; P < 0.001; FDR-corrected P < 0.001) and MI (OR = 2.287; 95% CI 1.218-4.300; P = 0.010; FDR-corrected P = 0.009). Most sensitivity assessments yielded valid results. Multivariable MR for CAD and MI produced results consistent with those obtained using the IVW method. There was no causal relationship between whole or semi-skimmed milk, and CAD or MI.

CONCLUSION

Our findings indicate that the consumption of skimmed milk may increase the risk of CAD and MI. This evidence may help inform dietary recommendations for preventing cardiovascular disease. Further studies are required to elucidate the underlying mechanisms.

Vitamin D and Cardiovascular Diseases: From Physiology to Pathophysiology and Outcomes

Vitamin D is rightly recognized as an essential key factor in the regulation of calcium and phosphate homeostasis, affecting primary adequate bone mineralization. In the last decades, a more complex and wider role of vitamin D has been postulated and demonstrated. Cardiovascular diseases have been found to be strongly related to vitamin D levels, especially to its deficiency. Pre-clinical studies have suggested a direct role of vitamin D in the regulation of several pathophysiological pathways, such as endothelial dysfunction and platelet aggregation; moreover, observational data have confirmed the relationship with different conditions, including coronary artery disease, heart failure, and hypertension. Despite the significant evidence available so far, most clinical trials have failed to prove any positive impact of vitamin D supplements on cardiovascular outcomes. This discrepancy indicates the need for further information and knowledge about vitamin D metabolism and its effect on the cardiovascular system, in order to identify those patients who would benefit from vitamin D supplementation.

Vitamin D and cardiovascular diseases

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.

Effects of Vitamin D Levels on Long-Term Coronary Events in Patients with Proven Coronary Artery Disease: Six-Year Follow-Up

Although some clinical studies have claimed that low-dose vitamin D (Vit-D) increases the risk of long-term cardiac events, in others, no association was found. To better understand the impact of Vit-D levels on long-term cardiac events in coronary artery disease patients, this study was designed. There were 408 patients with coronary artery disease (CAD). The patients were separated into three groups based on their Vit-D levels: group 1 had levels below 10 ng/mL, group 2 had levels between 10 and 20, and group 3 had levels above 20 ng/mL. Six years were spent monitoring the patients for non-fatal MI, death, vascular revascularization, and stable course data. Mortality was found to be similar between groups (group 1: 24.5%; group 2: 13.8%; group 3: 17.4%; p > 0.05). In group 3, 47.8% of the patients did not experience any cardiac event, while 28.7% in group 2 and 27.6% in group 1 did not experience any cardiac event, and these values were found to be significant in favor of group 3 (p = 0.006). Group 3 was found to have considerably lower rates of non-ST-elevated myocardial infarction (non-STEMI) and unstable angina (UA) than the other groups did (group 1: 49%; group 2: 38%; group 3: 27%; p = 0.001). In conclusion, although vitamin D deficiency does not accompany an increase in mortality, it is associated with an increase in non-STEMI and UA in patients who have previously been diagnosed with CAD.

Serum 25(OH)D Concentration, Vitamin D Supplementation, and Risk of Cardiovascular Disease and Mortality in Patients with Type 2 Diabetes or Prediabetes: a Systematic Review and Dose-Response Meta-Analysis

BACKGROUND

Evidence is uncertain about the association between serum 25-hydroxyvitamin D (25(OH)D) concentration and health outcomes in people with type 2 diabetes.

OBJECTIVES

We aimed to assess the association between vitamin D status and all-cause mortality and cardiovascular disease in people with type 2 diabetes.

METHODS

We did a systematic search in PubMed, Scopus, CENTRAL, and Web of Science until May 2022. We selected 1) cohort studies investigating the association between serum 25(OH)D concentration and mortality or cardiovascular disease in people with type 2 diabetes or prediabetes and 2) randomized trials of vitamin D supplementation in these patients. We used random-effects pairwise meta-analyses to calculate summary relative risks (RRs) and 95% confidence intervals (CI).

RESULTS

21 cohort studies and 6 randomized trials were included. Compared with sufficient vitamin D status (≥50 nmol/L), the RR of all-cause mortality was 1.36 (95% CI: 1.23, 1.49; n = 11 studies, GRADE = moderate) for vitamin D insufficiency (25 to <50 nmol/L), and 1.58 (1.33, 1.83; n = 16, GRADE = moderate) for deficiency (<25 nmol/L). Similar findings were observed for cardiovascular mortality and morbidity but not for cancer mortality. The certainty of evidence ranged from very low to moderate. Dose-response meta-analyses indicated nonlinear associations, with the lowest risk at 25(OH)D ∼60 nmol/L for all-cause and cardiovascular mortality. Supplementation with vitamin D did not reduce the risk of all-cause mortality (RR: 0.96, 95% CI: 0.79, 1.16; risk difference per 1000 patients: 3 fewer, 95% CI: 16 fewer, 12 more; n = 6 trials with 7316 participants; GRADE = low) or the risk of cardiovascular mortality and morbidity (very low- to low-certainty evidence).

CONCLUSIONS

Vitamin D deficiency and insufficiency are associated with a higher risk of all-cause and cardiovascular mortality in patients with type 2 diabetes or prediabetes. Vitamin D deficiency should be corrected in patients with type 2 diabetes to reach normal serum 25(OH)D concentrations, preferably 60 nmol/L.

SYSTEMATIC REVIEW REGISTRATION

This systemic review was registered at PROSPERO as CRD42022326429 (=https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=326429).

Recent Advances in Association Between Vitamin D Levels and Cardiovascular Disorders

PURPOSE OF REVIEW

In this review, we discuss the evidence that vitamin D affects cardiovascular disease through interventional and observational studies and their corresponding association mechanisms. We also highlight the need for further research to definitively conclude clinical recommendations based on preliminary data and determine the extent to which vitamin D levels may impact the incidence and prognosis of major cardiovascular diseases in the future.

RECENT FINDINGS

Cardiovascular disease has long been recognized as the leading cause of morbidity and mortality worldwide, with many risk factors implicated in its pathogenesis. Vitamin D is a risk factor that, despite being known to be crucial for its role in maintaining bone health, also has several extra-skeletal effects due to vitamin D receptors in vascular smooth muscle and cardiomyocytes. Recent studies have documented a significant association between higher vitamin D levels and lower risk of each cardiovascular disease entity; 11 studies between serum vitamin D and heart failure, 7 studies between serum vitamin D and hypertension, 8 studies between serum vitamin D and coronary artery disease, and 5 studies between serum vitamin D and atrial fibrillation. More studies documenting a significant association between increased serum vitamin D and cardiovascular disease are in the context of heart failure compared to hypertension, coronary artery disease, and atrial fibrillation. Conversely, a significant association between increased serum vitamin D and a lower risk of atrial fibrillation is reported in fewer studies compared to the association of vitamin D with other cardiovascular disease entities. Although there is evidence documenting a clear significant association of vitamin D under each category, further research is still needed to definitively conclude the role of vitamin D in cardiovascular disease management.

Predictive value of 25-hydroxyvitamin D level in patients with coronary artery disease: A meta-analysis

Background

A consensus has not been made about the predictive value of blood vitamin D level in patients with coronary artery disease (CAD). This meta-analysis aimed to assess the association between blood 25-hydroxyvitamin D level and adverse outcomes in patients with CAD.

Methods

Two independent authors searched the articles indexed in PubMed and Embase databases until June 28, 2022. Cohort studies or post-hoc analysis randomized trials evaluating the value of 25-hydroxyvitamin D level in predicting cardiovascular or all-cause mortality, and major adverse cardiovascular events ([MACEs] including death, non-fatal myocardial infarction, heart failure, revascularization, stroke, etc.) were included.

Results

The literature search identified 13 eligible studies for our analysis, including 17,892 patients with CAD. Meta-analysis showed that the pooled adjusted risk ratio (RR) was 1.60 (95% confidence intervals [CI] 1.35–1.89) for all-cause mortality, 1.48 (95% CI 1.28–1.71) for cardiovascular mortality, and 1.33 (95% CI 1.18–1.49) for MACEs. Leave-out one study sensitivity analysis suggested that the predictive values of blood 25-hydroxyvitamin D level were reliable.

Conclusions

Low blood 25-hydroxyvitamin D level is possibly an independent predictor of cardiovascular or all-cause mortality and MACEs in patients with CAD. Baseline 25-hydroxyvitamin D level may provide useful information in CAD patients.

Hypovitaminosis D and cardiovascular outcomes: A systematic review and meta-analysis

Background

The relation between blood vitamin D levels and the risk of cardiovascular outcomes is debatable. To our knowledge this is the first comparative meta-analysis of more than 100,000 patients' data with the aim to inspect the relevance of low vitamin D levels with adverse cardiovascular events.

Methods

Online databases including PubMed, Embase and Cochrane Central were queried to compare the cardiovascular outcomes among hypovitaminosis D (HVD) and control group. The outcomes assessed included differences in major adverse cardiovascular events (MACE), mortality, myocardial infarction, and heart failure. Unadjusted odds ratios (OR) were calculated using a random-effect model with a 95% confidence interval (CI) and P less than 0.05 as a statistical significance.

Results

A total of 8 studies including 426,039 patients were included in this analysis. HVD group was associated with a higher incidence of MACE (OR 1.92, 95% CI 1.24 to 2.98, p = 0.003), while there was no significant association of HVD and all-cause mortality (OR 1.77, 95% CI 0.75 to 4.17, p = 0.19), risk of myocardial infarction (OR 0.69, 95% CI 0.39 to 1.24, p = 0.22), and heart failure (OR 1.20, 95% CI 0.34 to 4.25, p = 0.78).

Conclusions

This meta-analysis suggested that low blood levels of vitamin D are associated with MACE, but no such difference in all-cause mortality, myocardial infarction or heart failure was observed. Appropriate supplementation of vitamin D in selected populations might be cardioprotective in nature and warrants extensive trials.

A Narrative Review of Recent Studies on the Role of Vitamin D in the Prevention of Cardiac and Renal Risk and Additional Considerations for COVID-19 Vulnerability

The role of vitamin D in maintaining a healthy cardiovascular (CV) and the renal system has received increasing attention. Low vitamin D levels are associated with the incidence of hypertension, cardiac remodeling, and chronic congestive heart failure. Low vitamin D levels also influence renal disease progression and albuminuria deterioration. Moreover, recent research indicates that vitamin D deficiency can be a potential risk factor for coronavirus disease-19 (COVID-19) infection and poorer outcomes. Data are inconclusive as to whether supplementation with vitamin D agents reduces CV disease risk or COVID-19 severity. Conversely, in patients with kidney disease, vitamin D supplementation is associated with an improvement in kidney function and albuminuria. This narrative review considers recent data on the effects of vitamin D on the CV and renal system, as well as its possible role regarding COVID-19 complications.

Circulating 25-hydroxy-vitamin D and the risk of cardiovascular diseases. Systematic review and meta-analysis of prospective cohort studies

AIMS

Circulating vitamin D is linked with the risk of cardiovascular disease (CVD). A meta-analysis has yet to explicitly explore correlation between vitamin D and the risk of CVD incidence and recurrent CVD. This meta-analysis examines the association between 25-hydroxy-vitamin D (25(OH)D) and the risk of CVD incidence (fatal, non-fatal, fatal and non-fatal combined events) and the risk of recurrent CVD (fatal, recurrent, and fatal and recurrent combined events). PROSPERO registration-CRD42021251483.

DATA SYNTHESIS

A total of 79 studies (46 713 CVD cases in 1 397 831 participants) were included in the meta-analysis, of which 61 studies examined the risk of CVD incidence events, and 18 studies examined risk of recurrent CVD events. The risk of CVD incidence events (RR = 1.34, 95% CI: 1.26-1.43, p < 0.001) and recurrent CVD events (RR = 1.86, 95% CI: 1.46-2.36, p < 0.001) was higher in the lowest than the highest category of circulating 25(OH)D. Dose-response analysis reported a linear association for every 10 ng/ml increment of 25(OH)D and non-fatal CVD incidence events (RR = 0.94; 95% CI = 0.89-0.98, p = 0.005), lower fatal recurrent CVD events (RR = 0.45; 95% CI = 0.32-0.62, p < 0.001) and lower combined recurrent CVD events (RR = 0.80; 95% CI = 0.65-0.97, p = 0.023). A non-linear association was observed between higher 25(OH)D and lower fatal CVD incidence events (P-nonlinear<0.001), lower combined CVD incidence events (P-nonlinear = 0.001), and lower non-fatal recurrent CVD events (P-nonlinear = 0.044).

CONCLUSIONS

The lowest category of circulating 25(OH)D was associated with a higher risk of CVD incidence events and recurrent CVD events.

Vitamin D deficiency is associated with impaired reperfusion in STEMI patients undergoing primary percutaneous coronary intervention

BACKGROUND AND AIMS

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.

METHODS AND RESULTS

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).

CONCLUSION

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.