Vitamin D3 repletion versus placebo as adjunctive treatment of heart failure patient quality of life and hormonal indices: a randomized, double-blind, placebo-controlled trial

The Efficacy of Vitamins in the Prevention and Treatment of Cardiovascular Disease

Vitamins are known to affect the regulation of several biochemical and metabolic pathways that influence cellular function. Adequate amounts of both hydrophilic and lipophilic vitamins are required for maintaining normal cardiac and vascular function, but their deficiencies can contribute to cardiovascular abnormalities. In this regard, a deficiency in the lipophilic vitamins, such as vitamins A, D, and E, as well as in the hydrophilic vitamins, such as vitamin C and B, has been associated with suboptimal cardiovascular function, whereas additional intakes have been suggested to reduce the risk of atherosclerosis, hypertension, ischemic heart disease, arrhythmias, and heart failure. Here, we have attempted to describe the association between low vitamin status and cardiovascular disease, and to offer a discussion on the efficacy of vitamins. While there are inconsistencies in the impact of a deficiency in vitamins on the development of cardiovascular disease and the benefits associated with supplementation, this review proposes that specific vitamins may contribute to the prevention of cardiovascular disease in individuals at risk rather than serve as an adjunct therapy.

Vitamin D: A Bridge between Kidney and Heart

Chronic kidney disease (CKD) and cardiovascular disease (CVD) are highly prevalent conditions, each significantly contributing to the global burden of morbidity and mortality. CVD and CKD share a great number of common risk factors, such as hypertension, diabetes, obesity, and smoking, among others. Their relationship extends beyond these factors, encompassing intricate interplay between the two systems. Within this complex network of pathophysiological processes, vitamin D has emerged as a potential linchpin, exerting influence over diverse physiological pathways implicated in both CKD and CVD. In recent years, scientific exploration has unveiled a close connection between these two prevalent conditions and vitamin D, a crucial hormone traditionally recognized for its role in bone health. This article aims to provide an extensive review of vitamin D's multifaceted and expanding actions concerning its involvement in CKD and CVD.

Vitamin D on Cardiac Function in Heart Failure: A Systematic Review and Meta-Analysis of 10 RCTs

Background

Systematic evaluation of the effects of vitamin D supplementation in heart failure (HF) patients.

Methods

Searches were conducted on National Library of Medicine, Web of Science, Cochrane Library, Google Scholar, China National Knowledge Infrastructure, and WANFANG databases. We analyzed data by using Review Manager 5.4 software. All are from the earliest records to March 2023. Outcome indicators analyzed the left ventricular ejection fraction (LVEF), the left ventricular end-diastolic internal diameter (LVEDD), the B-type brain natriuretic peptide (BNP) level and the 25-hydroxy vitamin D (25(OH)D) level.

Results

Ten studies with 1099 patients were included. LVEF (mean difference (MD) = 0.74, 95% CI: -0.29 to 1.76, p = 0.41), LVEDD (MD = -0.59, 95% CI: -1.83 to 0.66, p = 0.25), BNP (MD = -0.08, 95% CI: -0.24 to 0.08, p = 0.34), 25(OH)D (MD = 0.41, 95% CI: -0.28 to 1.11, p = 0.25) are not statistically significant. And there is no heterogeneity in the results of LVEF, LVEDD and BNP indicators.

Conclusions

Vitamin D supplementation may not be helpful in the clinical management of patients with HF.

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.

Normal 24-hour Urine Calcium Concentrations after Long-term Daily Oral Intake of Vitamin D in Doses Ranging from 5000 to 50,000 International Units in 14 Adult Hospitalized Psychiatric Patients

Many controversies exist regarding vitamin D₃ supplementation. These include not only diseases that are responsive to vitamin D supplementation, but also the long-term safety of prolonged daily oral vitamin D₃ intake above 4000 to 10,000 International Units (IU). In particular, supplementation levels that do not result in adverse events, and the upper limits of safe serum 25-hydroxyvitamin D (25OHD) concentrations. Adverse reactions reported to occur with excessive vitamin D intake include hypercalcemia, renal failure, calcium crystal formation, undetectable parathyroid hormone concentrations, and hypercalciuria, all of which are reported to be reversible. To address the long-term safety of vitamin D supplementation, we previously reported data from patients in our hospital who have been voluntarily supplemented with vitamin D₃ ranging from 5,000 to 10,000 IU/day since July 2011 as a standard of care for the prevention and treatment of vitamin D deficiency. Historically 90% of patients have agreed to daily supplementation, with most taking 10,000 IU/day. These data indicate no evidence for hypercalcemia, renal failure, calcium crystal formation, nephrolithiasis. or undetectable parathyroid hormone concentrations in patients taking 5,000 or 10,000 IU/day for extended periods of time. As another measure for potential vitamin D toxicity, we retrospectively assessed 24-hour urine calcium excretion in 14 individuals on long-term daily oral vitamin D intake ranging from 5,000 to 50,000 IU/day to further assess the safety of supplementation using these doses. This included patients taking either 5,000 (4), 10,000 (9), or 50,000 (1) IU/day. Time on supplementation ranged from 10 to 102 months. A patient taking 400 IU/day and getting frequent sun exposure was also included. All fifteen 24-hour urine calcium measurements were normal. The current findings complement our experience with over 7000 patients in the past 13 years, indicating that prolonged daily oral intake of vitamin D₃ ranging from 5000 to 10,000 IU/day is safe.

Understanding the Role of Vitamin D in Heart Failure

Vitamin D is now believed to have a significant role in cardiac signal transduction and regulation of gene expression, and thus influences normal cardiomyocyte function. It has been reported to provide cardioprotection through its anti-inflammatory, anti-apoptotic and anti-fibrotic actions; and to prevent cardiac remodeling, Ca 2 + -handling defects, and abnormal electrophysiological patterns. A vitamin D deficient state has been associated in the pathogenesis of heart failure; however, while many clinical studies report a benefit of vitamin D to heart function, other clinical studies are inconsistent with these findings. These uncertainties have led to a discord in the recommendation of vitamin D supplementation for the treatment of heart failure or as a preventive agent in patients deemed to be at risk for cardiac dysfunction. Accordingly, this article is intended to describe some of the mechanisms/sites of action of vitamin D in different animal models of heart failure, as well as to review the clinical observations and challenges in the interpretation and understanding of the clinical relevance of vitamin D in relation to heart function.

Vitamin D and heart failure: A two-sample mendelian randomization study

BACKGROUND AND AIMS

The relationship between vitamin D and heart failure (HF) has attracted significant interest, but the association between the two in previous studies remains uncertain. Therefore, we used two-sample Mendelian randomization (MR) to investigate a causal association between 25-hydroxyvitamin D (25OHD) and HF risk.

METHODS AND RESULTS

This study utilized summary statistics from the most extensive genome-wide association studies for 25OHD and HF. To make the results more reliable, we used several methods based on three assumptions for MR analysis. We also used the multivariable MR adjusting for hypertension, BMI, diabetes, chronic kidney disease to further elucidate the association between 25OHD and HF. Considering the potential pleiotropy, we performed an MR analysis with conditionally independent genetic instruments at core genes to further determine the relationship between vitamin D and heart failure. We found that per 1 SD increase in standardized log-transformed 25OHD level, the relative risk of HF decreased by 16.5% (OR: 0.835, 95% Cl: 0.743-0.938, P = 0.002), and other MR methods also showed consistent results. The multivariable MR also reported that per 1 SD increase in standardized log-transformed 25OHD level, the relative risk of HF decreased. And the scatter plots showed a trend towards an inverse MR association between 25OHD levels, instrumented by the core 25OHD genes, and HF.

CONCLUSION

In summary, we found a potential inverse association between elevated 25OHD levels and the risk of HF, which suggested that timely 25OHD supplementation or maintaining adequate 25OHD concentrations may be an essential measure for HF prevention in the general population.

A Study of Vitamin D and Its Correlation With Severity and Complication of Congestive Heart Failure: A Systematic Review

Many studies have shown that vitamin D is a crucial modulator of hypertension and cardiovascular illness, including heart failure. Heart failure (HF) is still the leading cause of mortality worldwide. Patients with heart failure who have low vitamin D levels experience worse outcomes, which associate with known clinical correlations and biomarkers. Additionally, patients with low vitamin D levels are more likely to have diabetes, hypertension, atherosclerosis, and other precursor conditions to heart failure. There are some hints in recent experimental research on how vitamin D can have cardioprotective effects. Vitamin D supplementation might improve ventricular remodeling in heart failure patients, however, this is still unclear. It aims to evaluate the association between vitamin D and congestive heart failure (CHF). This systematic review used research from the previous ten years (January 2012-2022) retrieved from the following databases: PubMed/PMC (PubMed Central)/Medline and Cochrane Library. Using the Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA) 2020 guidelines, removing duplicates, screening of title and abstract, application of eligibility criteria, and quality appraisal, 13 articles were retained for systemic review. There were 10 randomized controlled trials and three observational studies. Vitamin D supplementation lowers serum inflammatory marker levels and improves the quality of life in CHF patients. Vitamin D treatment inhibits ventricular remodeling and improves cardiac function in a patient with CHF.

Effect of vitamin D on endothelial and ventricular function in chronic heart failure patients: A prospective, randomized, placebo-controlled trial

BACKGROUND

Low 25-hydroxyvitamin D (25OHD) levels are common in patients with chronic heart failure (HF) and are associated with increased mortality risk. This study aimed to establish the safety and efficacy of oral vitamin D3 (cholecalciferol) supplementation and its effect on endothelial and ventricular function in patients with stable HF.

METHODS

This study was an investigator-initiated, multicenter, prospective, randomized, placebo-controlled trial. Seventy-three HF patients with 25OHD levels < 75 nmol/L (30 ng/mL) were randomized to receive 4000 IU vitamin D daily or a placebo for 6 months. The primary endpoint was a change in endothelial function between the baseline and after 6 months as assessed using EndoPAT. Secondary endpoints included changes in echocardiographic parameters and differences in quality of life (6-min walking test and New York Heart Association functional status) at 6 months.

RESULTS

There were no adverse events in either group during the study period. Vitamin D supplementation did not improve endothelial dysfunction (EndoPAT: baseline, 1.19 ± 0.4 vs 6 months later, 1.22 ± 0.3, P = .65). However, patients' blood pressure, 6-min walking distance, and EQ-5D questionnaire scores improved after vitamin D treatment. In addition, a significant reduction in the left atrial diameter was observed.

CONCLUSION

A daily vitamin D dose of 4000 IU for chronic HF appears to be safe. This dosage did not improve endothelial function but did improve the 6-min walk distance, symptoms, and left atrial diameter at 6 months.

Integrating supplementation in the management of patients with heart failure: an evidence-based review

INTRODUCTION

Complementary, alternative and integrative medicine includes a myriad of therapies including herbal medicines, vitamins, dietary interventions and more, that are taken alone or in adjunct to standard conventional treatment. Often the main goals are to slow progression of disease, increase effectiveness of a drug, reduce side effects and improve quality of life. The study of these therapies and their influence in heart failure is not new. However, even for an experienced clinician, a gap exists between the literature and the application of knowledge to make a confident recommendation.

AREAS COVERED

This review has a focus on specific supplements that are commonly used for individuals with HF. It discusses the mechanism of action, expected benefits, potential adverse effects, suggested doses, forms and drug interactions of these therapies. The literature search methodology included using medical subject headings terms to search in PubMed. Articles used were screened and critically appraised by the authors of this review.

EXPERT OPINION

There are promising outcomes pertaining to the use of CAM in patients with HF. Advances in large scale, randomized, placebo-controlled trials are necessary to support evidence-based decision making regarding the use of supplements in conjunction, and in comparison, to conventional therapies for heart failure.

Sex-Specific Relationship Between Parathyroid Hormone and Platelet Indices in Phenotypes of Heart Failure-Results From the MyoVasc Study

Background: Heart failure (HF) is a multifactorial syndrome with pathophysiological complexities still not fully understood. Higher mean platelet volume (MPV), a potential marker of platelet activation, and high concentrations of parathyroid hormone (PTH) have been implicated in the pathogenesis of HF.

Aim: This study aims to investigate sex-specifically the association between PTH concentrations and platelet indices in phenotypes of HF.

Methods and Results: PTH and platelet indices (MPV and platelet count) were available in 1,896 participants from the MyoVasc study in Mainz, Germany. Multivariable linear regression models, adjusted for age, sex, season, vitamin D status, cardiovascular risk factors, comorbidities, estimated glomerular filtration rate, and medication, were used to assess the associations between platelet indices and PTH. The results showed distinct sex-specific associations between PTH and platelet indices. A positive association between PTH and MPV was found in females with symptomatic HF with reduced ejection fraction (HFrEF) only [β = 0.60 (0.19; 1.00)]. Platelet count was inversely associated with PTH in male HFrEF individuals [β = −7.6 (−15; −0.30)] and in both males and females with HF with preserved ejection fraction (HFpEF).

Conclusion: This study reports differential, sex-specific relationships between PTH and platelet indices in HF individuals independent of vitamin D status and clinical profile. Particularly in phenotypes of symptomatic HF, distinct associations were observed, suggesting a sex-specific mechanism involved in the interaction between PTH and platelets.

Adipokines, Myokines, and Cardiokines: The Role of Nutritional Interventions

It is now established that adipose tissue, skeletal muscle, and heart are endocrine organs and secrete in normal and in pathological conditions several molecules, called, respectively, adipokines, myokines, and cardiokines. These secretory proteins constitute a closed network that plays a crucial role in obesity and above all in cardiac diseases associated with obesity. In particular, the interaction between adipokines, myokines, and cardiokines is mainly involved in inflammatory and oxidative damage characterized obesity condition. Identifying new therapeutic agents or treatment having a positive action on the expression of these molecules could have a key positive effect on the management of obesity and its cardiac complications. Results from recent studies indicate that several nutritional interventions, including nutraceutical supplements, could represent new therapeutic agents on the adipo-myo-cardiokines network. This review focuses the biological action on the main adipokines, myokines and cardiokines involved in obesity and cardiovascular diseases and describe the principal nutraceutical approaches able to regulate leptin, adiponectin, apelin, irisin, natriuretic peptides, and follistatin-like 1 expression.

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.

Disassociation of Vitamin D's Calcemic Activity and Non-calcemic Genomic Activity and Individual Responsiveness: A Randomized Controlled Double-Blind Clinical Trial

The aims of this randomized controlled double-blind clinical trial were to assess the impact of vitamin D supplementation on calcium metabolism and non-calcemic broad gene expression by relating them to the individual's responsiveness to varying doses of vitamin D3. Thirty healthy adults were randomized to receive 600, 4,000 or 10,000 IU/d of vitamin D3 for 6 months. Circulating parathyroid hormone (PTH), 25(OH)D, calcium and peripheral white blood cells broad gene expression were evaluated. We observed a dose-dependent increase in 25(OH)D concentrations, decreased PTH and no change in serum calcium. A plateau in PTH levels was achieved at 16 weeks in the 4000 and 10,000 IU/d groups. There was a dose-dependent 25(OH)D alteration in broad gene expression with 162, 320 and 1289 genes up- or down-regulated in their white blood cells, respectively. Our results clearly indicated that there is an individual's responsiveness on broad gene expression to varying doses of vitamin D3. Vitamin D3 supplementation at 10,000 IU/d produced genomic alterations several fold higher than 4,000 IU/d even without further changes in PTH levels. Our findings may help explain why there are some inconsistency in the results of different vitamin D's clinical trials.

Impact of serum 25-hydroxyvitamin D on cardiac prognosis in Chinese patients with heart failure

There is growing evidence that suggests the association of vitamin D status with the development and progression of heart failure (HF). The objective of the present study is to assess the impact of concentration of serum 25-hydroxyvitamin D (25(OH)D) on cardiac prognosis in patients with HF. Between 1 January 2015 and 31 December 2016, we consecutively recruited patients with HF. Patients were followed prospectively for a median duration of 1 year. Serum concentration of 25(OH)D was measured with competitive chemiluminescent immunoassay. The endpoints were cardiac events, including CVD death and rehospitalisation for worsening HF. Univariate and multivariable adjustments were performed with Cox proportional-hazard regression analyses. The 25(OH)D concentration was obtained in 343 patients with a median value of 17·4 (interquartile range 12·6-23·4) ng/ml. There were 102 cardiac events, including forty-three deaths and fifty-nine rehospitalisations. Multivariate Cox hazard analysis found that the serum concentration 25(OH)D was independently associated with cardiac events (hazard ratio 0·93, 95 % CI 0·88, 0·97) and CVD mortality (hazard ratio 0·83; 95 % CI 0·77, 0·89) after adjustment for confounding factors. We divided the HF patients into four groups according to the 25(OH)D quartiles. Kaplan-Meier analysis found that the patients with lower serum 25(OH)D concentration had a higher risk of cardiac events or CVD mortality than those with high serum 25(OH)D concentration (log-rank test P < 0·001 and P = 0·032). Decreased serum concentrations of 25(OH)D were associated with cardiac prognosis and CVD mortality in a Chinese population with HF independent of other baseline HF markers.

Meta-analysis of vitamin D supplementation in the treatment of chronic heart failure

Objectives. We performed a meta-analysis to determine whether vitamin D supplementation is beneficial in patients with chronic heart failure (CHF). Design. Meta-analysis of randomised controlled trials. Results. Vitamin D supplementation in patients with CHF improved health-related quality of life and C-reactive protein levels [weighted mean difference (WMD): 6.75, 95% confidence interval (CI): 2.87 to 10.64, p < .001; standardised mean difference (SMD): -0.41, 95% CI: -0.71 to -0.11, p = .007]. However, this supplementation was not superior to conventional treatment in terms of mortality, changes in left ventricular ejection fraction (ΔLVEF), N-terminal pro-B-type natriuretic peptide or B-type natriuretic peptide levels, and 6-minute walk distance (risk ratio: 1.11, 95% CI: 0.79 to 1.57, p = .53; WMD: 2.56, 95% CI: -2.18 to 7.31, p = .29; SMD: -0.18, 95% CI: -0.42 to 0.06, p = .15; WMD: -23.30, 95% CI: -58.31 to 11.72, p = .19). In contrast, ΔLVEF significantly improved (WMD: 6.75, 95% CI: 4.16 to 9.34, p < .001) in the subgroup without calcium supplementation. Additionally, some randomised controlled trials showed that adverse events were more frequent in people with high vitamin D levels. Conclusions. Vitamin D supplementation decreases serum levels of inflammatory markers and improves quality of life in CHF patients. Pooled analysis of vitamin D supplementation did not show reduced mortality or improved left ventricular function perhaps because of excessive increase in plasma 25-hydroxyvitamin D and calcium levels. Future studies should pay attention to vitamin D and calcium levels achieved.

Vitamin D levels and vitamin D receptor variants are associated with chronic heart failure in Chinese patients

Background

Vitamin D is an indispensable molecule for human health. Wide ranges of diseases are linked with vitamin D deficiencies. Role of vitamin D in chronic heart failure has been demonstrated in different populations; however, reports are limited in Chinese population. Vitamin D exerts its effect through vitamin D receptor and variants in vitamin D receptor (VDR) gene are shown to affect vitamin D signaling. In the present study, we hypothesized that both vitamin D levels and VDR variants could be associated with the development of chronic heart failure.

Materials and Methods

We enrolled 145, chronic heart failure patients those admitted to Department of Cardiothoracic Surgery, Beijing Luhe Hospital of Capital Medical University and fulfilled NYHA inclusions criteria. In addition, ninety healthy subjects from similar geographical location were enrolled as healthy controls. Plasma levels of vitamin D were quantified by ELISA. VDR variants (BsmI, ApaI, TaqI, and FokI) were genotyped by PCR‐RFLP.

Results

Plasma levels of vitamin D were significantly lower in chronic heart patients compared to healthy controls. Heterozygous and minor allele for FokI and TaqI polymorphisms were significantly higher in heart failure patients when compared to healthy controls. In addition, combined analysis of vitamin D levels and VDR mutants revealed association of vitamin D deficiencies and VDR mutants with chronic heart failure.

Conclusions

The results of the present investigation showed an important role of vitamin D and VDR variants with chronic heart failure.

Vitamin D deficiency is an independent predictor of mortality in patients with chronic heart failure

Purpose

Low 25-hydroxyvitamin D (25[OH]D) concentrations have been associated with adverse outcomes in selected populations with established chronic heart failure (CHF). However, it remains unclear whether 25[OH]D deficiency is associated with mortality and hospitalisation in unselected patients receiving contemporary medical and device therapy for CHF.

Methods

We prospectively examined the prevalence and correlates of 25[OH]D deficiency in 1802 ambulatory patients with CHF due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤ 45%) attending heart failure clinics in the north of England.

Results

73% of patients were deficient in 25[OH]D (< 50 nmol/L). 25[OH]D deficiency was associated with male sex, diabetes, lower serum sodium, higher heart rate, and greater diuretic requirement. During a mean follow-up period of 4 years, each 2.72-fold increment in 25[OH]D concentration (for example from 32 to 87 nmol/L) is associated with 14% lower all-cause mortality (95% confidence interval (CI) 1, 26%; p = 0.04), after accounting for potential confounding factors.

Conclusions

Low 25-hydroxyvitamin D deficiency is associated with increased mortality in patients with chronic heart failure due to left ventricular systolic dysfunction. Whether vitamin D supplementation will improve outcomes is, as yet, unproven.

Electronic supplementary material

The online version of this article (10.1007/s00394-018-1806-y) contains supplementary material, which is available to authorized users.