1
|
Hemilä H, de Man AME. Vitamin C deficiency can lead to pulmonary hypertension: a systematic review of case reports. BMC Pulm Med 2024; 24:140. [PMID: 38504249 PMCID: PMC10949735 DOI: 10.1186/s12890-024-02941-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/01/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND In the early literature, unintentional vitamin C deficiency in humans was associated with heart failure. Experimental vitamin C deficiency in guinea pigs caused enlargement of the heart. The purpose of this study was to collect and analyze case reports on vitamin C and pulmonary hypertension. METHODS We searched Pubmed and Scopus for case studies in which vitamin C deficiency was considered to be the cause of pulmonary hypertension. We selected reports in which pulmonary hypertension was diagnosed by echocardiography or catheterization, for any age, sex, or dosage of vitamin C. We extracted quantitative data for our analysis. We used the mean pulmonary artery pressure (mPAP) as the outcome of primary interest. RESULTS We identified 32 case reports, 21 of which were published in the last 5 years. Dyspnea was reported in 69%, edema in 53% and fatigue in 28% of the patients. Vitamin C plasma levels, measured in 27 cases, were undetectable in 24 and very low in 3 cases. Diet was poor in 30 cases and 17 cases had neuropsychiatric disorders. Right ventricular enlargement was reported in 24 cases. During periods of vitamin C deficiency, the median mPAP was 48 mmHg (range 29-77 mmHg; N = 28). After the start of vitamin C administration, the median mPAP was 20 mmHg (range 12-33 mmHg; N = 18). For the latter 18 cases, mPAP was 2.4-fold (median) higher during vitamin C deficiency. Pulmonary vascular resistance (PVR) during vitamin C deficiency was reported for 9 cases, ranging from 4.1 to 41 Wood units. PVR was 9-fold (median; N = 5) higher during vitamin C deficiency than during vitamin C administration. In 8 cases, there was direct evidence that the cases were pulmonary artery hypertension (PAH). Probably the majority of the remaining cases were also PAH. CONCLUSIONS The cases analyzed in our study indicate that pulmonary hypertension can be one explanation for the reported heart failure of scurvy patients in the early literature. It would seem sensible to measure plasma vitamin C levels of patients with PH and examine the effects of vitamin C administration.
Collapse
Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, POB 41, Helsinki, FI-00014, Finland.
| | - Angelique M E de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands.
| |
Collapse
|
2
|
Hemilä H, Chalker E, de Man AME. Vitamin C May Improve Left Ventricular Ejection Fraction: A Meta-Analysis. Front Cardiovasc Med 2022; 9:789729. [PMID: 35282368 PMCID: PMC8913583 DOI: 10.3389/fcvm.2022.789729] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/21/2022] [Indexed: 01/02/2023] Open
Abstract
Background Vitamin C deprivation can lead to fatigue, dyspnea, oedema and chest pain, which are also symptoms of heart failure (HF). In animal studies vitamin C has improved contractility and mechanical efficiency of the heart. Compared with healthy people, patients with HF have lower vitamin C levels, which are not explained by differences in dietary intake levels, and more severe HF seems to be associated with lower plasma vitamin C levels. This meta-analysis looks at the effect of vitamin C on left ventricular ejection fraction (LVEF). Methods We searched for trials reporting the effects of vitamin C on LVEF. We assessed the quality of the trials, and pooled selected trials using the inverse variance, fixed effect options. We used meta-regression to examine the association between the effect of vitamin C on LVEF level and the baseline LVEF level. Results We identified 15 trials, three of which were excluded from our meta-analysis. In six cardiac trials with 246 patients, vitamin C increased LVEF on average by 12.0% (95% CI 8.1–15.9%; P < 0.001). In six non-cardiac trials including 177 participants, vitamin C increased LVEF on average by 5.3% (95% CI 2.0–8.5%; P = 0.001). In meta-regression analysis we found that the effect of vitamin C was larger in trials with the lowest baseline LVEF levels with P = 0.001 for the test of slope. The meta-regression line crossed the null effect level at a baseline LVEF level close to 70%, with progressively greater benefit from vitamin C with lower LVEF levels. Some of the included trials had methodological limitations. In a sensitivity analysis including only the four most methodologically sound cardiac trials, the effect of vitamin C was not substantially changed. Conclusions In this meta-analysis, vitamin C increased LVEF in both cardiac and non-cardiac patients, with a strong negative association between the size of the vitamin C effect and the baseline LVEF. Further research on vitamin C and HF should be carried out, particularly in patients who have low LVEF together with low vitamin C intake or low plasma levels. Different dosages and different routes of administration should be compared.
Collapse
Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, Helsinki, Finland
- *Correspondence: Harri Hemilä
| | - Elizabeth Chalker
- Biological Data Science Institute, Australian National University, Canberra, ACT, Australia
| | - Angelique M. E. de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| |
Collapse
|
3
|
Babcock MC, DuBose LE, Witten TL, Stauffer BL, Hildreth KL, Schwartz RS, Kohrt WM, Moreau KL. Oxidative Stress and Inflammation Are Associated With Age-Related Endothelial Dysfunction in Men With Low Testosterone. J Clin Endocrinol Metab 2022; 107:e500-e514. [PMID: 34597384 PMCID: PMC8764347 DOI: 10.1210/clinem/dgab715] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Vascular aging, including endothelial dysfunction secondary to oxidative stress and inflammation, increases the risk for age-associated cardiovascular disease (CVD). Low testosterone in middle-aged/older men is associated with increased CVD risk. OBJECTIVE We hypothesized that low testosterone contributes to age-associated endothelial dysfunction, related in part to greater oxidative stress and inflammation. METHODS This cross-sectional study included 58 healthy, nonsmoking men categorized as young (N = 20; age 29 ± 4 years; testosterone 500 ± 58 ng/dL), middle-aged/older with higher testosterone (N = 20; age 60 ± 6 years; testosterone 512 ± 115 ng/dL), and middle-aged/older lower testosterone (N = 18; age 59 ± 8 years; testosterone 269 ± 48 ng/dL). Brachial artery flow-mediated dilation (FMDBA) was measured during acute infusion of saline (control) and vitamin C (antioxidant). Markers of oxidative stress (total antioxidant status and oxidized low-density lipoprotein cholesterol), inflammation (interleukin [IL]-6 and C-reactive protein [CRP]), and androgen deficiency symptoms were also examined. RESULTS During saline, FMDBA was reduced in middle-aged/older compared with young, regardless of testosterone status (P < 0.001). FMDBA was reduced in middle-aged/older lower testosterone (3.7% ± 2.0%) compared with middle-aged/older higher testosterone (5.7% ± 2.2%; P = 0.021), independent of symptoms. Vitamin C increased FMDBA (to 5.3% ± 1.6%; P = 0.022) in middle-aged/older lower testosterone but had no effect in young (P = 0.992) or middle-aged/older higher testosterone (P = 0.250). FMDBA correlated with serum testosterone (r = 0.45; P < 0.001), IL-6 (r = -0.41; P = 0.002), and CRP (r = -0.28; P = 0.041). CONCLUSION Healthy middle-aged/older men with low testosterone appear to have greater age-associated endothelial dysfunction, related in part to greater oxidative stress and inflammation. These data suggest that low testosterone concentrations may contribute to accelerated vascular aging in men.
Collapse
Affiliation(s)
- Matthew C Babcock
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Lyndsey E DuBose
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Teresa L Witten
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Brian L Stauffer
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Division of Cardiology, Denver Health Medical Center, Denver, CO 80045, USA
| | - Kerry L Hildreth
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Robert S Schwartz
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Veterans Affairs Eastern Colorado Geriatric Research, Educational and Clinical Center, Denver, CO 80045, USA
| | - Wendy M Kohrt
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Veterans Affairs Eastern Colorado Geriatric Research, Educational and Clinical Center, Denver, CO 80045, USA
| | - Kerrie L Moreau
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Veterans Affairs Eastern Colorado Geriatric Research, Educational and Clinical Center, Denver, CO 80045, USA
- Correspondence: Kerrie L. Moreau, Ph.D., University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Geriatric Medicine, 12631 East 17th Ave., Mail Stop B179, Aurora, CO 80045, USA.
| |
Collapse
|
4
|
Ranadive SM, Dillon GA, Mascone SE, Alexander LM. Vascular Health Triad in Humans With Hypertension-Not the Usual Suspects. Front Physiol 2021; 12:746278. [PMID: 34658930 PMCID: PMC8517241 DOI: 10.3389/fphys.2021.746278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/25/2021] [Indexed: 11/13/2022] Open
Abstract
Hypertension (HTN) affects more than one-third of the US population and remains the top risk factor for the development of cardiovascular disease (CVD). Identifying the underlying mechanisms for developing HTN are of critical importance because the risk of developing CVD doubles with ∼20 mmHg increase in systolic blood pressure (BP). Endothelial dysfunction, especially in the resistance arteries, is the primary site for initiation of sub-clinical HTN. Furthermore, inflammation and reactive oxygen and nitrogen species (ROS/RNS) not only influence the endothelium independently, but also have a synergistic influence on each other. Together, the interplay between inflammation, ROS and vascular dysfunction is referred to as the vascular health triad, and affects BP regulation in humans. While the interplay of the vascular health triad is well established, new underlying mechanistic targets are under investigation, including: Inducible nitric oxide synthase, hydrogen peroxide, hydrogen sulfide, nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and nuclear factor activated T cells. This review outlines the role of these unusual suspects in vascular health and function in humans. This review connects the dots using these unusual suspects underlying inflammation, ROS and vascular dysfunction especially in individuals at risk of or with diagnosed HTN based on novel studies performed in humans.
Collapse
Affiliation(s)
- Sushant M Ranadive
- Department of Kinesiology, University of Maryland, College Park, College Park, MD, United States
| | - Gabrielle A Dillon
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States.,Center for Healthy Aging, The Pennsylvania State University, University Park, PA, United States
| | - Sara E Mascone
- Department of Kinesiology, University of Maryland, College Park, College Park, MD, United States
| | - Lacy M Alexander
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States.,Center for Healthy Aging, The Pennsylvania State University, University Park, PA, United States
| |
Collapse
|
5
|
Scalzo RL, Bauer TA, Harrall K, Moreau K, Ozemek C, Herlache L, McMillin S, Huebschmann AG, Dorosz J, Reusch JEB, Regensteiner JG. Acute vitamin C improves cardiac function, not exercise capacity, in adults with type 2 diabetes. Diabetol Metab Syndr 2018; 10:7. [PMID: 29456629 PMCID: PMC5813393 DOI: 10.1186/s13098-018-0306-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 01/04/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND People with type 2 diabetes (T2D) have impaired exercise capacity, even in the absence of complications, which is predictive of their increased cardiovascular mortality. Cardiovascular dysfunction is one potential cause of this exercise defect. Acute infusion of vitamin C has been separately shown to improve diastolic and endothelial function in prior studies. We hypothesized that acute vitamin C infusion would improve exercise capacity and that these improvements would be associated with improved cardiovascular function. METHODS Adults with T2D (n = 31, 7 female, 24 male, body mass index (BMI): 31.5 ± 0.8 kg/m2) and BMI-similar healthy adults (n = 21, 11 female, 10 male, BMI: 30.4 ± 0.7 kg/m2) completed two randomly ordered visits: IV infusion of vitamin C (7.5 g) and a volume-matched saline infusion. During each visit peak oxygen uptake (VO2peak), brachial artery flow mediated dilation (FMD), reactive hyperemia (RH; plethysmography), and cardiac echocardiography were measured. General linear mixed models were utilized to assess the differences in all study variables. RESULTS Acute vitamin C infusion improved diastolic function, assessed by lateral and septal E:E' (P < 0.01), but did not change RH (P = 0.92), or VO2peak (P = 0.33) in any participants. CONCLUSION Acute vitamin C infusion improved diastolic function but did not change FMD, forearm reactive hyperemia, or peak exercise capacity. Future studies should further clarify the role of endothelial function as well as other possible physiological causes of exercise impairment in order to provide potential therapeutic targets.Trial registration NCT00786019. Prospectively registered May 2008.
Collapse
Affiliation(s)
- Rebecca L. Scalzo
- Division of Endocrinology, Department of Medicine, University of Colorado School of Medicine (UCSOM), 12801 E17th Ave, Aurora, CO 80045 USA
- Department of Medicine, Center for Women’s Health Research, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| | - Timothy A. Bauer
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| | - Kylie Harrall
- Department of Medicine, Center for Women’s Health Research, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| | - Kerrie Moreau
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
- Department of Medicine, Center for Women’s Health Research, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
- VAMC-Geriatric Research Education and Clinical Center (GRECC), Denver, CO 80215 USA
| | - Cemal Ozemek
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| | - Leah Herlache
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| | - Shawna McMillin
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| | - Amy G. Huebschmann
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
- Department of Medicine, Center for Women’s Health Research, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| | - Jennifer Dorosz
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| | - Jane E. B. Reusch
- Division of Endocrinology, Department of Medicine, University of Colorado School of Medicine (UCSOM), 12801 E17th Ave, Aurora, CO 80045 USA
- Department of Medicine, Center for Women’s Health Research, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
- Veterans Administration Medical Center (VAMC), Denver, CO 80215 USA
| | - Judith G. Regensteiner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
- Department of Medicine, Center for Women’s Health Research, University of Colorado School of Medicine (UCSOM), Aurora, CO USA
| |
Collapse
|