Hypovitaminosis D in patients with heart failure: effects on functional capacity and patients' survival

Calcium-Regulating Hormonal System and HMGB1 in Cardiomyopathies

BACKGROUND

Calcium ions play a key role in the heart's functional activity. The steadystate levels of calcium are contingent on the calcium regulating hormonal system, impairment of which might result in the development of cardiac pathology. An important role in these processes is also attributed to the specific inflammatory mediator, HMGB1, one of the damage-associated molecular patterns (DAMPs) released by immune cells or cell damage.

OBJECTIVE

This study investigated the cardioprotective potential of the calcium-regulating hormonal system in cardiomyopathies with an emphasis on the possible role of HMGB1.

METHODS

Ca2+ and inorganic phosphate levels were determined in the serum using an electrolyte analyzer and spectrophotometric analyzer correspondingly. The 1-34 fragment of parathyroid hormone (PTH), calcitonin, vitamin D, and HMGB1 were detected using ELISA kits.

RESULTS

The levels of PTH, calcitonin, phosphate, and HMGB1 were found elevated in females suffering from cardiomyopathy. The same tendency was observed in men; however, statistically significant changes were registered only for PTH and phosphate.

CONCLUSION

It can be suggested that among other reasons, the decrease of the left ventricular function in cardiomyopathy patients can be linked to the high HMGB1, whereas the activation of the calciumregulating system as manifested by the elevated PTH aims at restoration of calcium homeostasis and thus have positive, i.e. cardioprotective consequences.

The effect of vitamin D level on cardiac rehabilitation in patients with Coronary Artery Disease

BACKGROUND

25-hydroxy vitamin D (25OHD) deficiency is associated with cardiovascular disease and poor physical performance.

OBJECTIVE

To assign the effect of 25OHD level on cardiac rehabilitation (CR) in patients with coronary artery disease (CAD).

METHODS

One-hundred-thirty-five patients with CAD who underwent a CR programme were enrolled in this retrospective study. Patients were divided into two-group according to 25OHD level (Group 1: < 20 ng/dl; Group 2: ⩾ 20 ng/dl). All patients received CR for 30 sessions. Each participant performed 40 minutes of aerobic exercise with a cycloergometer followed by muscle strengthening exercises. The patients were evaluated before and after CR by a pulmonary function test (PFT) and a cardiopulmonary exercise test (CPET).

RESULTS

There were 77 (57%) patients in Group 1 and 58 patients (43%) in Group 2. Demographic characteristics between the groups were similar. Pre- and post-rehabilitation CPET parameters were lower in Group 1 (p< 0.05). Both groups had significant improvement in CPET (p< 0.05). Post-rehabilitation PFT parameters (FEV1, FVC) were higher in Group 2 (p< 0.05). There was a positive correlation between the 25OHD-level and the CPET-PFT parameters (p< 0.05).

CONCLUSION

25OHD deficiency in patients with CAD reduces the response to CR. It also affects respiratory function according to the FEV1, FVC parameters. In patients scheduled for CR, 25OHD-levels should be evaluated, and any deficiency corrected.

Is There a Crucial Link Between Vitamin D Status and Inflammatory Response in Patients With COVID-19?

Background

Hypovitaminosis D has been suggested to play a possible role in coronavirus disease 2019 (COVID-19) infection.

Methods

The aim of this study is to analyze the relationship between vitamin D status and a biochemical panel of inflammatory markers in a cohort of patients with COVID-19. A secondary endpoint was to evaluate the correlation between 25OHD levels and the severity of the disease. Ninety-three consecutive patients with COVID-19-related pneumonia were evaluated from March to May 2020 in two hospital units in Pisa, in whom biochemical inflammatory markers, 25OHD levels, P/F ratio at nadir during hospitalization, and complete clinical data were available.

Results

Sixty-five percent of patients presented hypovitaminosis D (25OHD ≤ 20 ng/ml) and showed significantly higher IL-6 [20.8 (10.9-45.6) vs. 12.9 (8.7-21.1) pg/ml, p = 0.02], CRP [10.7 (4.2-19.2) vs. 5.9 (1.6-8.1) mg/dl, p = 0.003], TNF-α [8.9 (6.0-14.8) vs. 4.4 (1.5-10.6) pg/ml, p = 0.01], D-dimer [0.53 (0.25-0.72) vs. 0.22 (0.17-0.35) mg/l, p = 0.002], and IL-10 [3.7 (1.8-6.9) vs. 2.3 (0.5-5.8) pg/ml, p = 0.03]. A significant inverse correlation was found between 25OHD and all these markers, even adjusted for age and sex. Hypovitaminosis D was prevalent in patients with severe ARDS, compared with the other groups (75% vs. 68% vs. 55%, p < 0.001), and 25OHD levels were lower in non-survivor patients.

Conclusions

The relationship between 25OHD levels and inflammatory markers suggests that vitamin D status needs to be taken into account in the management of these patients. If vitamin D is a marker of poor prognosis or a possible risk factor with beneficial effects from supplementation, this still needs to be elucidated.

Comparative study on beneficial effects of vitamins B and D in attenuating doxorubicin induced cardiotoxicity in rats: Emphasis on calcium homeostasis

The use of doxorubicin (DOX) to treat various tumors is limited by its cardiotoxicity. This study aimed to investigate and compare the cardioprotective effects of nicotinamide (NAM) and alfacalcidol (1α(OH)D₃), against DOX-induced cardiotoxicity. Sprague Dawley male rats received DOX (5 mg/kg, i.p.) once/week for four consecutive weeks. Treated groups received either NAM (600 mg/kg, p.o.) for 28 consecutive days or 1α(OH)D₃ (0.5 ug/kg, i.p.) once/week for four consecutive weeks. DOX elicited marked cardiac tissue injury manifested by elevated serum cardiotoxicity indices, conduction and histopathological abnormalities. Both NAM and 1α(OH)D₃ successfully reversed all these changes. From the mechanistic point of view, DOX provoked intense cytosolic and mitochondrial calcium (Ca²⁺) overload hence switching on calpain1 (CPN1) and mitochondrial-mediated apoptotic cascades as confirmed by upregulating Bax and caspase-3 while downregulating Bcl-2 expression. DOX also disrupted cardiac bioenergetics as evidenced by adenosine triphosphate (ATP) depletion and a declined ATP/ADP ratio. Moreover, DOX upregulated the Ca²⁺ sensor; calmodulin kinase II gamma (CaMKII-δ) which further contributed to cardiac damage. Interestingly, co-treatment with either NAM or 1α(OH)D₃ reversed all DOX associated abnormalities by preserving Ca²⁺ homeostasis, replenishing ATP stores and obstructing apoptotic events. Additionally, DOX prompted nuclear factor kappa B (NF-κB) dependent inflammatory responses and subsequently upregulated interleukin-6 (IL-6) expression. Co-treatment with NAM or 1α(OH)D₃ effectively obstructed these inflammatory signals. Remarkably, NAM showed superior beneficial cardioprotective properties over 1α(OH)D₃. Both NAM and 1α(OH)D₃ efficiently attenuated DOX-cardiomyopathy mainly via preserving Ca²⁺ homeostasis and diminishing apoptotic and inflammatory pathways. NAM definitely exhibited effective cardioprotective capabilities over 1α(OH)D₃.

Vitamin D status and predictors of 25-hydroxyvitamin D levels in patients with heart failure living in a sunny region

Introduction

Aims: hypovitaminosis D has frequently been identified in patients with heart failure (HF). However, few studies have been conducted in regions with high solar incidence. Therefore, this study aimed to evaluate vitamin D status and predictors of 25-hydroxyvitamin D (25(OH)D) levels in patients with HF living in a sunny region (5 °- 6 °S). Methods: this cross-sectional study enrolled 70 patients with HF. Biodemographic, clinical, biochemical, dietary, and sun exposure data were collected, and 25(OH)D levels were measured. Results: the mean 25(OH)D level was 40.1 (12.4) ng/mL, and 24.3 % (95 % CI: 14.2-33.8) of patients with HF had hypovitaminosis D (25(OH)D < 30 ng/mL). Female patients (p = 0.001), those with ischemic etiology (p = 0.03) and those with high parathyroid hormone levels (> 67 pg/mL) (p = 0.034) were more likely to present hypovitaminosis D. Higher 25(OH)D levels were observed in men than in women (β = 7.78, p = 0.005) and in patients with HF in New York Heart Association (NHYA) functional class I when compared to those in class III/IV (β = 8.23, p = 0.032). Conclusions: the majority of patients with HF had sufficient 25(OH)D levels. Sex and functional classification were identified as independent predictors of 25(OH)D levels. These results highlight the need for increased monitoring of vitamin D status among female patients with heart failure and those with more severe symptoms.

Secondary hyperparathyroidism and thoracic vertebral fractures in heart failure middle-aged patients: a 3-year prospective study

PURPOSE

Vertebral fractures (VFs) were described in elderly patients with heart failure (HF) whereas their prevalence and determinants in younger HF patients are still unknown. This study aimed at assessing whether secondary hyperparathyroidism (SHPT) may influence the risk of VFs in middle-aged patients with HF.

METHODS

84 patients (44 males, median age 48.5 years, range 43-65) with HF were prospectively evaluated at the baseline and after 36-month follow-up for bone mineral density (BMD) and VFs by quantitative morphometry on chest X-rays. Serum PTH, calcium, 25-hydroxyvitamin D and 24-h-urinary calcium were evaluated at the baseline and every 6-12 months during the study period.

RESULTS

At baseline, SHPT, hypovitaminosis D and VFs were found in 43 patients (51.2%), 73 patients (86.9%) and 29 patients (34.5%), respectively. SHPT was associated with VFs at baseline [inverse probability-weighted (ipw) odds ratio (OR) 12.2, p < 0.001]. Patients were treated with vitamin D3 alone (56%), vitamin D3 plus calcium carbonate (21.4%), calcitriol alone (4.8%), bisphosphonates plus vitamin D3 (8.3%) or a combination of bisphosphonates, vitamin D3 and calcium carbonate (9.5%). At the end of follow-up, hypovitaminosis D was corrected in all patients, whereas 19/84 patients (22.6%) had persistent SHPT. During the follow-up, 16 patients developed incident VFs which resulted to be associated with baseline SHPT (ipw OR 55.7, p < 0.001), even after adjusting from BMD change from baseline to follow-up (ipw OR 46.4, p < 0.001).

CONCLUSIONS

This study provides a first evidence that SHPT may be a risk factor for VFs in middle-aged patients with HF.

An Update on Vitamin D Metabolism

Vitamin D is a steroid hormone classically involved in the calcium metabolism and bone homeostasis. Recently, new and interesting aspects of vitamin D metabolism has been elucidated, namely the special role of the skin, the metabolic control of liver hydroxylase CYP2R1, the specificity of 1α-hydroxylase in different tissues and cell types and the genomic, non-genomic and epigenomic effects of vitamin D receptor, which will be addressed in the present review. Moreover, in the last decades, several extraskeletal effects which can be attributed to vitamin D have been shown. These beneficial effects will be here summarized, focusing on the immune system and cardiovascular system.

The Association between Serum Levels of 25[OH]D, Body Weight Changes and Body Composition Indices in Patients with Heart Failure

We try to determine the association between weight changes (WC), both loss or gain, body composition indices (BCI) and serum levels of 25[OH]D during heart failure (HF). WC was determined in 412 patients (14.3% female, aged: 53.6 ± 10.0 years, NYHA class: 2.5 ± 0.8). Body fat, fat percentage and fat-free mass determined by dual energy X-rays absorptiometry (DEXA) and serum levels of 25[OH]D were analyzed. Logistic regression was used to calculate odds ratios for 25[OH]D insufficiency (<30 ng/mL) or deficiency (<20 ng/mL) by quintiles of WC, in comparison to weight-stable subgroup. The serum 25[OH]D was lower in weight loosing than weight stable subgroup. In fully adjusted models the risk of either insufficient or deficient 25[OH]D levels was independent of BCI and HF severity markers. The risk was elevated in higher weight loss subgroups but also in weight gain subgroup. In full adjustment, the odds for 25[OH]D deficiency in the top weight loss and weight gain subgroups were 3.30; 95%CI: 1.37–7.93, p = 0.008 and 2.41; 95%CI: 0.91–6.38, p = 0.08, respectively. The risk of 25[OH]D deficiency/insufficiency was also independently associated with potential UVB exposure, but not with nutritional status and BCI. Metabolic instability in HF was reflected by edema-free WC, but not nutritional status. BCI is independently associated with deficiency/insufficiency of serum 25[OH]D.

Is vitamin D deficiency related to a higher risk of hospitalization and mortality in veterans with heart failure?

OBJECTIVES

25-hydroxyvitamin D [25(OH)D] deficiency is related to an increase in cardiovascular risk but the association between low 25(OH)D and hospitalization and mortality in heart failure (HF) patients remains unclear. The objective of this study was therefore to determine whether 25(OH)D deficiency is associated with a higher risk of all-cause hospitalizations and mortality in veterans with HF, as well as the differential effect of frailty.

STUDY DESIGN

A retrospective cohort study of veterans with HF.

MAIN OUTCOME

Association between 25(OH)D deficiency and risk of hospitalization and mortality.

MEASURES

25(OH)D status was dichotomized as deficiency (<30 ng/mL) and non-deficiency (≥30 ng/mL). A 44-item Frailty Index (FI) was constructed and used to categorize patients as non-frail (FI < .21) or frail (FI ≥ .21). The association of 25(OH)D deficiency with recurrent hospitalization was analyzed through an Andersen-Gill model and the association with mortality using Cox regression.

RESULTS

We identified 284 patients, of whom 141 (50 %) exhibited 25(OH)D deficiency (67.3 ± 10.5 years of age). The mean 25(OH)D levels in the deficiency and non-deficiency groups were 21.3±5.9 ng/mL and 40.9 ± 10.9 ng/mL, respectively. Over a median follow-up of 1136 days (IQR = 691), there were 617 hospitalizations (68 % in those with 25(OH)D deficiency) and 131 deaths (40 % in those with 25(OH)D deficiency). A significantly higher risk of hospitalization was found in patients with 25(OH)D deficiency: hazard ratio (HR) = 1.8 (95 % CI:1.3-2.5),p < 0.001. Frail veterans had a greater risk of hospitalization than non-frail veterans: HR = 1.7 (95 % CI:1.2-2.7),p < 0.05. Mortality did not show any significant association with 25(OH)D deficiency.

CONCLUSIONS

25(OH)D deficiency was an independent risk factor for hospitalization in patients with HF and the effect persisted in those with frailty.

Role of Vitamin D in Patients with Heart Failure with Reduced Ejection Fraction

Heart failure (HF) with reduced ejection fraction (HFrEF) presents as the severest phenotype on the spectrum of HF. Although great progress has been made with respect to its treatment over the past 3 decades, morbidity and mortality remain high, posing a big burden on human health. Recent evidence suggests vitamin D has a critical role in maintaining heart health through activation of the vitamin D receptor expressed in cardiomyocytes, and vitamin D deficiency may be implicated in the pathophysiology of HFrEF through activation of the renin-angiotensin system, impaired calcium handling, exaggerated inflammation, secondary hyperparathyroidism, pro-fibrotic properties, and proatherogenic potential. Additionally, epidemiological data disclosed that vitamin D deficiency is highly prevalent in patients with HFrEF and is associated with poor clinical outcomes. However, randomized control trials of vitamin D supplementation in HF, especially in HFrEF, have shown inconsistent results. Thus, this article aims to review the epidemiology, pathophysiology, and prognostic value of vitamin D deficiency in HF, with a special focus on randomized control trials associated with vitamin D supplementation in patients with HFrEF.

Vitamin D status and cardiovascular outcome

INTRODUCTION

Vitamin D is classically involved in maintaining bone and mineral health, but it has been shown to exert many extraskeletal functions, including pleiotropic effects on cardiovascular system.

MATERIALS AND METHOD

This review aims to summarize evidences in literature about vitamin D and cardiovascular outcome.

RESULTS AND CONCLUSIONS

Calcitriol or 1,25(OH)₂D, the active hormone, binds to the specific nuclear receptor VDR, which is expressed in rat and human heart and vasculature and has effects on myocardiocytes, smooth cells, and endothelial cells. 25-Hydroxy-vitamin D (25OHD) represents the biomarker of vitamin D levels and reflects vitamin D status. There is consistent evidence that low serum 25OHD levels are associated with increased risk of cardiovascular diseases, including hypertension, coronary artery disease, ischemic heart disease, heart failure, stroke, and type 2 diabetes. Randomized-controlled trials and Mendelian randomization studies so far have not succeeded in proving a benefit of vitamin D supplementation. However, the latter investigations are affected by some methodological limitations, and therefore, it is still unclear if vitamin D deficiency has a causative role in cardiovascular diseases or is rather a marker of poor health in chronic disease.

Vitamin D Status and Exercise Capacity in Older Patients with Heart Failure with Preserved Ejection Fraction

BACKGROUND

Older patients with heart failure with preserved ejection fraction have severe exercise intolerance. Vitamin D may play a role in cardiovascular and skeletal muscle function, and may therefore be implicated in exercise intolerance in heart failure with preserved ejection fraction. However, there are few data on vitamin D status and its relationship to exercise capacity in heart failure with preserved ejection fraction patients.

METHODS

Plasma 25-hydroxyvitamin D (25[OH]D) and exercise capacity (peak oxygen consumption, [VO₂], 6-minute walk distance) were measured in 112 older heart failure with preserved ejection fraction patients (mean ± SD age = 70 ± 8 years) and 37 healthy age-matched controls. General linear models were used to compare 25(OH)D between heart failure with preserved ejection fraction patients and healthy controls, and to determine the cross-sectional association between 25(OH)D and exercise capacity. The association between 25(OH)D and left ventricular function was evaluated secondarily in heart failure with preserved ejection fraction patients.

RESULTS

25(OH)D concentrations were significantly lower in heart failure with preserved ejection fraction vs healthy controls (11.4 ± 0.6 ng/mL vs 19.1 ± 2.1 ng/mL; P = .001, adjusted for age, race, sex, body mass index, season). More than 90% of heart failure with preserved ejection fraction patients had 25(OH)D insufficiency (<20 ng/mL) and 30% had frank 25(OH)D deficiency (<10 ng/mL). In heart failure with preserved ejection fraction patients, but not healthy controls, 25(OH)D was significantly correlated with peak VO₂ (r = 0.26; P = 0.007) and 6-minute walk distance (r = 0.34; P < .001).

CONCLUSIONS

More than 90% of heart failure with preserved ejection fraction patients had 25(OH)D insufficiency, and 30% were frankly deficient. Lower 25(OH)D was associated with lower peak VO₂ and 6-minute walk distance in heart failure with preserved ejection fraction, suggesting that 25(OH)D insufficiency could contribute to exercise intolerance in this patient population. These findings provide the data and rationale for a future randomized trial designed to test the potential for vitamin D supplementation to improve exercise intolerance in heart failure with preserved ejection fraction.

Vitamin D measurement and effect on outcome in a cohort of patients with heart failure

OBJECTIVES

The aims of this paper were to evaluate the levels of Vitamin D (VitD) in patients with heart failure (HF), compared to a control group, to assess the effects of VitD on HF outcome and to compare VitD measurement between LIAISON immunoassay and HPLC-MS-MS methods in this population.

DESIGN AND METHODS

We collected clinical, biochemical and outcome data from 247 patients with HF and in a subgroup of 151 patients, we measured VitD both with LIAISON and HPLC-MS-MS.

RESULTS

HF patients had statistically lower 25OHD levels (45.2 ± 23.7 nmol/L vs 58.2 ± 24.0 nmol/L, P < 0.001) and a statistically higher prevalence of VitD insufficiency (61.1% vs 39.5%, P < 0.001) and deficiency (24.7% vs 6.6%, P < 0.001), compared to healthy controls. There was a significant inverse relationship between baseline 25OHD and risk of HF-related death, with a HR of 0.59 (95% CI 0.37–0.92, P = 0.02), confirmed in a multivariate adjusted analysis. Kaplan–Meier survival analyses showed that VitD insufficiency was associated with reduced survival in HF patients (log rank P = 0.017). There was a good agreement between LIAISON and HPLC-MS-MS (Cohen’s kappa coefficient 0.70), but the prevalence of VitD insufficiency was significantly higher with the former compared to the latter method (58.3%, n = 88 vs 55.6%, n = 84, P < 0.001). LIAISON underestimated the 25OHD levels and showed a mean relative bias of −0.739% with 95% of limits of agreement (−9.00 to +7.52%), when compared to HPLC-MS-MS.

CONCLUSIONS

25OHD levels adequately measured by HPLC-MS-MS showed to be low in HF population and to be correlated with HF-related risk of death.

Vitamin D and Heart Failure

PURPOSE

Vitamin D is principally known for its role in calcium homeostasis, but preclinical studies implicate multiple pathways through which vitamin D may affect cardiovascular function and influence risk for heart failure. Many adults with cardiovascular disease have low vitamin D status, making it a potential therapeutic target. We review the rationale and potential role of vitamin D supplementation in the prevention and treatment of chronic heart failure.

RECENT FINDINGS

Substantial observational evidence has associated low vitamin D status with the risk of heart failure, ventricular remodeling, and clinical outcomes in heart failure, including mortality. However, trials assessing the influence of vitamin D supplementation on surrogate markers and clinical outcomes in heart failure have generally been small and inconclusive. There are insufficient data to recommend routine assessment or supplementation of vitamin D for the prevention or treatment of chronic heart failure. Prospective trials powered for clinical outcomes are warranted.