Persistence of vitamin D deficiency among Italian patients with acute myocardial infarction

BACKGROUND AND AIMS

Vitamin D deficiency is a common cardiovascular risk factor associated with the development of atherosclerosis. We evaluated changes in 25(OH)D concentrations in 1510 patients with acute myocardial infarction (AMI) over a long observation period, including the COVID-19 pandemic.

METHODS AND RESULTS

Patients were separated into four groups according to the year of enrolment, group 1 (2009-2010), group 2 (2014-2016), group 3 (2017-2019), and group 4 (2020-2022). The median 25(OH)D concentration in the overall cohort was 17.15 (10.3-24.7) ng/mL. The median plasma concentrations of 25(OH)D for groups 1, 2, 3, and 4 were 14.45 (7.73-22.58) ng/mL, 17.3 ng/mL (10.33-24.2), 18.95 (11.6-26.73) ng/mL and 19.05 (12.5-27.3) ng/mL, respectively. Although 25(OH)D levels increased over the years, the prevalence of vitamin D deficiency remained high in each group (68.4%, 61.4%, 53.8%, and 52% respectively). Hypovitaminosis D was predicted by the season influence (OR:2.03, p < 0.0001), higher body mass index (OR:1.25; p = 0.001), diabetes mellitus (OR:1.54; p = 0.001), smoking (OR:1.47; p = 0.001), older age (OR:1.07; p = 0.008), higher triglycerides levels (OR:1.02; p = 0.01), and female gender (OR:1.3; p = 0.038). After multivariable adjustment, vitamin D ≤ 20 ng/mL was an independent predictor of mortality.

CONCLUSION

Vitamin D deficiency is highly prevalent and persistent in patients with AMI despite a trend towards increasing 25(OH)D concentrations over the years. The frequent lockdowns did not reduce the levels of 25(OH)D in the fourth group. Low levels of 25(OH)D are an independent predictor of mortality.

Subcellular Effectors of Cocaine Cardiotoxicity: All Roads Lead to Mitochondria-A Systematic Review of the Literature

Cocaine abuse is a serious public health problem as this drug exerts a plethora of functional and histopathological changes that potentially lead to death. Cocaine causes complex multiorgan toxicity, including in the heart where the blockade of the sodium channels causes increased catecholamine levels and alteration in calcium homeostasis, thus inducing an increased oxygen demand. Moreover, there is evidence to suggest that mitochondria alterations play a crucial role in the development of cocaine cardiotoxicity. We performed a systematic review according to the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) scheme to evaluate the mitochondrial mechanisms determining cocaine cardiotoxicity. Among the initial 106 articles from the Pubmed database and the 17 articles identified through citation searching, 14 final relevant studies were extensively reviewed. Thirteen articles included animal models and reported the alteration of specific mitochondria-dependent mechanisms such as reduced energy production, imbalance of membrane potential, increased oxidative stress, and promotion of apoptosis. However, only one study evaluated human cocaine overdose samples and observed the role of cocaine in oxidative stress and the induction of apoptosis though mitochondria. Understanding the complex processes mediated by mitochondria through forensic analysis and experimental models is crucial for identifying potential therapeutic targets to mitigate or reverse cocaine cardiotoxicity in humans.

342 TMAO PLASMA LEVELS PREDICT RECURRENT ISCHEMIC EVENTS IN SURVIVORS OF MYOCARDIAL INFARCTION

Background

Recent studies have highlighted a direct link between dietary nutrients, microbiota and cardiovascular disease (CVD). In this context, trimethylamine-N-oxide (TMAO), a metabolite derived from the intestinal microbiota, stands out, paving its way as one of the important biomarkers associated with atherosclerosis, increased risk of CVD, recurrent events and adverse outcomes.

Methods

81 patients who survived acute myocardial infarction (AMI), (both STEMI 50 / NSTEMI 31) were enrolled in this study together with 10 healthy individuals. Further, we evaluated the relationship between plasma TMAO levels and cardiovascular events during the follow-up. The measurement of plasma levels of TMAO was performed using liquid chromatography-tandem mass spectrometry (LC-MS).

Results

The median plasma concentration of TMAO were significantly higher in patients with AMI compared with healthy control (1.62 (1.37–2.25) µM. vs 0.55 (0.35–0.74) µM, p &lt; 0.0001). During a median follow-up of 61.74 (59.34–64.24) months, 10 out of 81 patients (12.3%) had a re-infarction. Patients who had another ischemic event had higher TMAO values compared with individuals who did not (2.29 (1.60–6.49) µM vs 1.60 (1.34–2.09) µM, p = 0.026). Further, TMAO values positively correlate with CRP, a pro-inflammatory marker. However, at multivariate Cox regression analysis, plasma TMAO values were not predictive of re-infarction.

Conclusions

The data of our pilot study show that higher TMAO values are associated with the risk of recurrent ischemic event. A future prospective study, including larger cohort is necessary to analyze this issue.

338 PREVALENCE AND PERSISTENCE OF HYPOVITAMINOSIS D AMONG ITALIAN PATIENTS WITH MYOCARDIAL INFARCTION

Background

Hypovitaminosis D is common in the Italian population and has a comparable effect to diabetes mellitus on survival after an acute myocardial infarction (AMI). We aimed to evaluate if the prevalence of hypovitaminosis D changed over time, considering also frequent lockdowns in the last years due to COVID-19 pandemic.

Methods

According to the year of enrollment, we divided our cohort of 1042 patients hospitalized for AMI, into three groups (group 1 with 368 patients enrolled from 2014 till 2016, group 2 with 470 patients enrolled in the period from 2017 till 2019, and group 3 including 204 patients enrolled in the last three years, from 2020 till 2022) and evaluate whether the concentration of vitamin D changed in the last decade.

Results

The median concentration of vitamin D in our cohort of patients with AMI was 18.2 (11.48-25.73) ng/ml). Throughout the three groups (2014-2016, 2017-2019, 2020-2022), the median plasma vitamin D showed a trend toward an increase (17.3 (10.33–24.2) ng/ml, 18.95 (11.6–26.73) ng/ml, and 19.05 (12.5–27.3) ng/ml respectively), which was significant between the group 1 vs 2 and 3 (p = 0.033 and p = 0.004, respectively), while between the group 2 and 3 did not. Despite the trend of increase, the percentage of patients with hypovitaminosis D in each group remained high (61.4%, 53.8% and 52.0% respectively). As expected, samples taken between May and September have significantly higher vitamin D values compared to ones taken from October to April for each group (the group 1: 21.80 (15.55–31.23) ng/ml vs 15.8 (9.22–23.98) ng/ml, p &lt; 0.0001; the group 2: 22.05 (14.10–30.98) ng/ml vs 16.50 (11.03–23.90) ng/ml, p &lt; 0.0001); the group 3: 20.00 (11.90–26.90) ng/ml vs 16.30 (9.75–22.30) ng/ml, p = 0.001).

Conclusions

There has been a trend of increasing vitamin D values over the years, but hypovitaminosis D remains frequent. During the pandemic, vitamin D levels did not decrease due to frequent lockdowns, possibly due to media awareness that emphasized the significance of vitamin D administration against viral infection.

Long-term effect of SARS-CoV-2 infection on cardiovascular outcomes and all-cause mortality

Since the very beginning of the coronavirus disease 2019 (COVID-19) pandemic in early 2020, it was evident that patients with cardiovascular disease (CVD) were at an increased risk of developing severe illness, and complications spanning cerebrovascular disorders, dysrhythmias, acute coronary syndrome, ischemic and non-ischemic heart disease, pericarditis, myocarditis, heart failure, thromboembolic disease, stroke, and death. Underlying these was excessive systemic inflammation and coagulopathy due to SARS-COV-2 infection, the effects of which also continued long-term as evidenced by post-COVID-19 cardiovascular complications.

The acute and chronic cardiovascular effects of COVID-19 occurred even among those who were not hospitalized and had no previous CVD or those with mild symptoms.

This comprehensive review summarizes the current understanding of molecular mechanisms triggered by the SARS-CoV-2 virus on various cells that express the angiotensin-converting enzyme 2, leading to endothelial dysfunction, inflammation, myocarditis, impaired coagulation, myocardial infarction, arrhythmia and a multisystem inflammatory syndrome in children or Kawasaki-like disease.

Old and Novel Therapeutic Approaches in the Management of Hyperglycemia, an Important Risk Factor for Atherosclerosis

Hyperglycemia is considered one of the main risk factors for atherosclerosis, since high glucose levels trigger multiple pathological processes, such as oxidative stress and hyperproduction of pro-inflammatory mediators, leading to endothelial dysfunction. In this context, recently approved drugs, such as glucagon-like-peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2i), could be considered a powerful tool for to reduce glucose concentration and cardiovascular risk. Interestingly, many patients with type 2 diabetes mellitus (T2DM) and insulin resistance have been found to be deficient in vitamin D. Recent studies pointed out the unfavorable prognostic values of T2DM and vitamin D deficiency in patients with cardiac dysfunction, either when considered individually or together, which shed light on the role of vitamin D in general health status. New evidence suggests that SGLT2i could adversely affect the production of vitamin D, thereby increasing the risk of fractures, which are common in patients with T2DM. Therefore, given the biological effects of vitamin D as an anti-inflammatory mediator and a regulator of endothelial function and calcium equilibrium, these new findings should be taken into consideration as well. The aim of this review is to gather the latest advancements regarding the use of antidiabetic and antiplatelet drugs coupled with vitamin D supplementation to control glucose levels, therefore reducing the risk of coronary artery disease (CAD).

The Role of Exercise-Induced Molecular Processes and Vitamin D in Improving Cardiorespiratory Fitness and Cardiac Rehabilitation in Patients With Heart Failure

Heart failure (HF) still affects millions of people worldwide despite great advances in therapeutic approaches in the cardiovascular field. Remarkably, unlike pathological hypertrophy, exercise leads to beneficial cardiac hypertrophy characterized by normal or enhanced contractile function. Exercise-based cardiac rehabilitation improves cardiorespiratory fitness and, as a consequence, ameliorates the quality of life of patients with HF. Particularly, multiple studies demonstrated the improvement in left ventricular ejection fraction (LVEF) among patients with HF due to the various processes in the myocardium triggered by exercise. Exercise stimulates IGF-1/PI3K/Akt pathway activation involved in muscle growth in both the myocardium and skeletal muscle by regulating protein synthesis and catabolism. Also, physical activity stimulates the activation of the mitogen-activated protein kinase (MAPK) pathway which regulates cellular proliferation, differentiation and apoptosis. In addition, emerging data pointed out the anti-inflammatory effects of exercises as well. Therefore, it is of utmost importance for clinicians to accurately evaluate the patient’s condition by performing a cardiopulmonary exercise test and/or a 6-min walking test. Portable devices with the possibility to measure exercise capacity proved to be very useful in this setting as well. The aim of this review is to gather together the molecular processes triggered by the exercise and available therapies in HF settings that could ameliorate heart performance, with a special focus on strategies such as exercise-based cardiac rehabilitation.

The peculiar role of vitamin D in the pathophysiology of cardiovascular and neurodegenerative diseases

Vitamin D is a hormone with both genomic and non-genomic actions. It exerts its activity by binding vitamin D receptor (VDR), which belongs to the superfamily of nuclear receptors and ligand-activated transcription factors. Since VDR has been found in various tissues, it has been estimated that it regulates approximately 3% of the human genome. Several recent studies have shown pleiotropic effects of vitamin D in various processes such as cellular proliferation, differentiation, DNA repair and apoptosis and its involvement in different pathophysiological conditions as inflammation, diabetes mellitus, and anemia. It has been suggested that vitamin D could play an important role in neurodegenerative and cardiovascular disorders. Moderate to strong associations between lower serum vitamin D concentrations and stroke and cardiovascular events have been identified in different analytic approaches, even after controlling for traditional demographic and lifestyle covariates. The mechanisms behind the associations between vitamin D and cerebrovascular and cardiologic profiles have been widely examined both in animal and human studies. Optimization of vitamin D levels in human subjects may improve insulin sensitivity and beta-cell function and lower levels of inflammatory markers. Moreover, it has been demonstrated that altered gene expression of VDR and 1,25D3-membrane-associated rapid response steroid-binding (1,25D3-MARRS) receptor influences the role of vitamin D within neurons and allows them to be more prone to degeneration. This review summarizes the current understanding of the molecular mechanisms underlying vitamin D signaling and the consequences of vitamin D deficiency in neurodegenerative and cardiovascular disorders.

191 Prognostic value of amyloid beta (1–40) in patients with acute myocardial infarction

Aims

Patients who have survived acute myocardial infarction (AMI) are at higher risk of developing several cardiovascular complications during follow-up and, unfortunately, appropriate risk stratification remains a major challenge. Amyloid-β 1–40 [Aβ (1–40)] has already emerged as a prognostic biomarker of cardiovascular mortality among patients with stable coronary heart disease due to its pathophysiological vascular inflammation properties.

Methods and results

The relationship between plasma Aβ (1–40) concentrations and follow-up outcome was examined in a large prospective cohort of patients hospitalized for AMI (NSTEMI or STEMI). Total RNA was extracted from peripheral blood mononuclear cells (PBMC) to assess the expression levels of BACE1 and BACE1-AS. A total of 894 subjects (607 patients with STEMI and 287 patients with NSTEMI) were included in this study. The median plasma Aβ (1–40) concentration at admission was 96.59 (60.94–134.5) pg/ml. During the 83 month follow-up, 123 patients died and 78 patients developed HF. Higher Aβ (1–40) concentrations were able to predict an increased mortality risk during follow-up. In addition, in the cohort of patients older than 67 years, the plasma concentration of Aβ (1–40) strongly correlated with an unfavourable outcome, whereas in the cohort younger than 67 years did not.

Conclusions

This is the largest single centre study investigating the role of plasma Aβ (1–40) concentration in predicting patient outcomes after AMI both STEMI and NSTEMI. Our data show a strong correlation between plasma Aβ (1–40) levels and mortality risk during follow-up. In addition, we confirmed a correlation between age and plasma Aβ (1–40) concentration, noting that Aβ (1–40) values are an incremental risk factor in relation to age for adverse outcomes.

Traditional and Emerging Biomarkers in Asymptomatic Left Ventricular Dysfunction-Promising Non-Coding RNAs and Exosomes as Biomarkers in Early Phases of Cardiac Damage

Heart failure (HF) is one of the major causes of morbidity and mortality worldwide and represents an escalating problem for healthcare systems. The identification of asymptomatic patients with underlying cardiac subclinical disease would create an opportunity for early intervention and prevention of symptomatic HF. Traditional biomarkers are very useful as diagnostic and prognostic tools in the cardiovascular field; however, their application is usually limited to overt cardiac disease. On the other hand, a growing number of studies is investigating the diagnostic and prognostic potential of new biomarkers, such as micro-RNAs (miRNA), long non-coding RNAs, and exosome cargo, because of their involvement in the early phases of cardiac dysfunction. Unfortunately, their use in asymptomatic phases remains a distant goal. The aim of this review is to gather the current knowledge of old and novel biomarkers in the early diagnosis of cardiac dysfunction in asymptomatic individuals.

Effects of SARS-CoV-2 on Cardiovascular System: The Dual Role of Angiotensin-Converting Enzyme 2 (ACE2) as the Virus Receptor and Homeostasis Regulator-Review

Angiotensin-converting enzyme 2 (ACE2) is the entry receptor for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the cause of Coronavirus Disease-2019 (COVID-19) in humans. ACE-2 is a type I transmembrane metallocarboxypeptidase expressed in vascular endothelial cells, alveolar type 2 lung epithelial cells, renal tubular epithelium, Leydig cells in testes and gastrointestinal tract. ACE2 mediates the interaction between host cells and SARS-CoV-2 spike (S) protein. However, ACE2 is not only a SARS-CoV-2 receptor, but it has also an important homeostatic function regulating renin-angiotensin system (RAS), which is pivotal for both the cardiovascular and immune systems. Therefore, ACE2 is the key link between SARS-CoV-2 infection, cardiovascular diseases (CVDs) and immune response. Susceptibility to SARS-CoV-2 seems to be tightly associated with ACE2 availability, which in turn is determined by genetics, age, gender and comorbidities. Severe COVID-19 is due to an uncontrolled and excessive immune response, which leads to acute respiratory distress syndrome (ARDS) and multi-organ failure. In spite of a lower ACE2 expression on cells surface, patients with CVDs have a higher COVID-19 mortality rate, which is likely driven by the imbalance between ADAM metallopeptidase domain 17 (ADAM17) protein (which is required for cleavage of ACE-2 ectodomain resulting in increased ACE2 shedding), and TMPRSS2 (which is required for spike glycoprotein priming). To date, ACE inhibitors and Angiotensin II Receptor Blockers (ARBs) treatment interruption in patients with chronic comorbidities appears unjustified. The rollout of COVID-19 vaccines provides opportunities to study the effects of different COVID-19 vaccines on ACE2 in patients on treatment with ACEi/ARB.