presented in kolkata

1. VITAMIN D
DEFICIENCY
&
CARDIOVASCULAR
RISKS
HYPE OR REALITY
Dr. Dibbendhu Khanra
Dr. A. Talukdar
Medical College, Kolkata

2. OBJECTIVE
 Introduction
 Vit D: Metabolism & MOA
 Cardiovascular risks & mortality
 Deficiency status/ Treatment recommendation
 Our experience and Conclusion

3. A PubMed search with “vitamin D”
and selecting articles published in
the past two years resulted in
more than 2,864 hits
Vitamin D
The Nobel prize for chemistry for 1928
was awarded to Adolf Windaus, the
first person to receive an award
mentioning ‘vitamins’. What was the
contribution Windaus made to our
knowledge of vitamins that deserved
the highest scientific accolade?
(New York Times 1978)
Superstar
Heart,, DMCancer, Obesity,
RA, TB, Depression..etc

4. “SUNSHINE
VITAMIN”
SECOND
MASSENGER
BIOCHEMISTRY
MOLECULAR
BIOLOGY
VIT D RECEPTOR
Also
- Brain
- Beta cells
- Adipose tissue
Status of Vit D hyped over time

5. Li et al, Tomaschitz et al, Forman et al
Apoptosis
Fibrosis
Vascular SMC
hypertrophy
calcium effect on insulin secretion
expression of the insulin receptor
enhancing insulin responsiveness for glucose transport
hsCRP,
IL10
MMP9

8.  UVB radiation from tanning 3 times a week for 3 months led to a nearly 200% increase in
25(OH)D levels and a 6 mmHg decrease in both systolic and diastolic blood pressure
Krause R. Lancet 1998
Vit D deficiency & hypertension
 In the NHANES III study, the average SBP was nearly 3 mm Hg lower in subjects with
the highest quartile of 25(OH)D compared to subjects in the lowest quartile
Scragg R. Third National Health and Nutrition Examination Survey. Am J Hypertens 2007

9. Vit D deficiency & DM
 A study of >10,000 Finnish children who were given 2,000 IU vitamin D3 per day during
the first year of life demonstrated a 78% reduced risk of type 1 diabetes over a 30-year
follow-up. Subsequently, this finding was confirmed by a meta-analysis of 5 observational
studies in England.
Hyppönen E, Lancet 2001, Zipitis CS Arch Dis Child 2008
 Daily intake of >800 IU of vitamin D compared with <400 IU vitamin D reduced the risk
of T2DM by nearly one-third. It is hoped that starting vitamin D supplementation soon after
birth may be a protective strategy against the development of type 1 diabetes.
Pittas AG. Diabetes Care 2006, Rifkin J. Pract Diabetol 2009
 Low vitamin D levels have also been shown to be predictive of the future development
of type 2 diabetes. Increasing vitamin D serum levels to normal led to a 55% relative
reduction in the risk of developing type 2 diabetes.
Forouohi NG. Diabetes 2008, Parker J. Maturitas 2010
 In high-risk type 2 diabetic patients with elevated UAER, low levels of vitamin D are
associated with asymptomatic CAD.
Joergensen . Diabetes Care 2011

10.  Administration of 1,25(OH)2Din the setting of vitamin D deficiency has been shown to
down-regulate inflammatory biomarkers such as CRP.
Schleithoff SS. Am J Clin Nutr 2006
 In a 10-year follow-up of 18,225 men in the Health Professionals Follow-up Study, low
levels of 25(OH)D were associated with higher risk of myocardial infarction, even after
controlling for other CHD risk factors.
Giovannucci E. Arch Intern Med 2008
 In an analysis of 27,000 patients from the Inter-mountain Healthcare System, the
prevalence of vitamin D deficiency (<30 ng/ml) was 60%; and vitamin D deficiency was
associated with highly significant (p <0.0001) increases in the prevalence of dyslipidemia.
Anderson JL. Am J Cardiol 2010
A recently published multicenter study evaluating patients admitted with acute coronary
syndromes found that 96% of these patients had abnormal 25(OH)D levels<30 ng/ml.
Lee JH. Am J Cardiol 2011
Vit D deficiency & ACS/IHD

11. Vit D deficiency & depression
 vitamin D concentrations have been found to be low in patients with mood disorders,
including depression.
Kalueff A. CNS Neurol Disord Drug Targets 2006
 In data from the NHANES III study, in nearly 8,000 noninstitutionalized U.S. residents,
the likelihood of having depression was significantly higher among those with vitamin D
deficiency.
Ganji V. Int Arch Med 2010

12. Vit D deficiency & Hemodialysis

13. Vit D deficiency & mortality

14. After stardom comes controversy!

15. Vit D deficiency & controversies
 Prospective trials of vitamin D and diabetes to date were either too small or used
inadequate amounts of vitamin D.
Schwallenberg G Can Fam Phys 2008
Another meta-analysis of 8 randomized trials showed statistically nonsignificant reduction
in CV disease risk with vitamin D supplementation at moderate to high doses
(approximately 1,000 IU daily)
Wang L. Ann Intern Med 2010
 A very recent meta-analysis of 51 studies found that the effects of vitamin D were
nonsignificant on the endpoints of death, myocardial infarction, and stroke.
Elamin MB. Am J Cardiol 2011
 In a meta-analysis of 10 trials, supplementation with vitamin D only nonsignificantly
reduced systolic blood pressure by 2 mm Hg and did not reduce diastolic blood pressure
DerSimonian R. Control Clin Trials 2012

16. Will the hype regarding this
vitamin/hormone will stand the test of time?
Will this ‘jack of all trade’ vitamin D pass the rigors of
randomized controlled trials?
Will vitamin D be another vitamin E, C, or folic acid, or
will the results be more similar to those with omega-3
fatty acids (or better)?
VITAMIN D: HYPE OR REALITY

17. New challenge is on the way for vitamin D

19. SELECTED FOOD SOURCES OF VIT D
Food IU/serving
Cod Liver Oil, (1 tablespoon) 1,360
Wild Salmon, (3 oz) 600-1,000
Farmed Salmon, (3 oz) 100-250
Mackerel, (3 oz) 345
Tuna fish in oil, (3 oz) 200
Sardines in oil, (1 oz) 250
Milk, (1 cup) 98
NIH

20. TREATMENT RECOMMENDATIONS FOR
VITAMIN D DEFICIENCY
Vitamin D Deficiency
25(OH)D < 20 ng/dL
60,000 IU of D2 or D3
Per Week X 8 weeks
Maintenance Therapy
60,000 IU of D2
Every month
Recheck 25(OH)D in 3 to 6 months
Statin myopathy Metformin induced
peripheral neuropathy

21. SPECIFIC OBJECTIVES OF THE STUDY
1. To assess serum 25-Hydroxy vitamin D levels in Ischemic heart disease
patients and their age, sex matched controls
2. To compare the vitamin D status between Ischemic heart disease cases and the
control group and see if there is any relationship between vitamin D deficiency and
Ischemic heart disease
3. To explore for any correlation between vitamin D levels and other
conventional cardiovascular risk factors in Ischemic heart disease
A STUDY OF VITAMIN D LEVELS IN PATIENTS OF ISCHEMIC
HEART DISEASE WITH SPECIAL REFERENCE TO ITS ROLE AS A
CARDIOVASCULAR RISK FACTOR

22. EXCLUSION CRITERIA
a) All known/diagnosed patients of DM/on OHA/
insulin therapy
b) All known/ suspected patients of osteomalacia
c) Patients suffering from neoplastic disease
d) Patients older than 70 years and younger than
30 years.
e) Patients of chronic renal failure
INCLUSION CRITERIA
nondiabetic patients between age group of
30-70 years seeking medical attention with the
complaint of acute chest pain/ chest
discomfort/ dyspnea/ orthopnea etc, together
with either elevated serum cardiac biomarkers/
Echocardiographic evidence of new onset
regional wall motion abnormality of left
ventricle/ specific ECG changes consistent with
myocardial ischemia/infarction. Along with
this symptomatic patients of chronic ischemic
heart disease with either documented TMT test
positive ECG or prior history of acute
coronary syndrome (STEMI/ NSTEMI) as
evident by ECG changes of old infarction will
be taken.
PARAMETERS
a) Serum 25(OH) vitamin D levels.
b) Serum lipid profile.
c) Fasting and postprandial blood sugar

23. CONCLUSION
 Vit D levels correlate with CV Disease
 Supplementation possibly may improve CV Outcomes but trials are
needed
 Vit D levels should be obtained in CV patients and supplementation
considered, especially if treated with Statins
Thank you