Vitamin D Deficiency in Acute Coronary Syndrome – Clinically Relevant or Incidental Finding?

By Praveček, Marijana Knežević; Vuković-Arar, Željka et al. | Central European Journal of Public Health, September 2017 | Go to article overview

Vitamin D Deficiency in Acute Coronary Syndrome – Clinically Relevant or Incidental Finding?


Praveček, Marijana Knežević, Vuković-Arar, Željka, Miškić, Blaženka, Hadžibegović, Irzal, Central European Journal of Public Health


INTRODUCTION

Vitamin D is a precursor of the steroid hormone calcitriol which is necessary for mineral homeostasis and bone metabolism (1). Upon vitamin D discovery in almost all body cells, such as immune system, vascular and myocardial cells, a more diversified role of vitamin D than previously believed has been recognized. This has resulted in extensive research into the role of vitamin D in the pathogenesis of chronic non-skeletal diseases such as infectious, autoimmune, malignant, and cardiovascular diseases (CVD) (2).

Cardiovascular risk factors such as arterial hypertension, obesity, dyslipidemia, and diabetes mellitus (DM), and the resulting CVD including acute coronary syndrome (ACS), coronary artery disease (CAD) and stroke are the most prevalent illnesses and the leading causes of death worldwide. Therefore, it is of utmost importance to determine the role of vitamin D in CVD.

Vitamin D deficiency has been recorded all over the world. Estimates of vitamin D status in various European countries show great differences. According to literature data, the prevalence of vitamin D deficiency is between 2% and 30% in adult European population; however, some studies report a figure as high as 75% in elderly institutionalized individuals. Accordingly, vitamin D deficiency has grown into a major public health problem (3).

The 1,25(OH)2D is a bioactive form of vitamin D, while 25 hydroxyvitamin D (25(OH)D) is the best indicator of vitamin D status. Serum concentration of 25(OH)D reflects the level of vitamin D synthesized in the dermis as a function UV radiation and dietary vitamin D intake. Cold season, old age, female sex, obesity, dark skin, inadequate sun exposure, fat malabsorption, and poor dietary habits along with the absence of dietary vitamin D enrichment are the major risk factors for vitamin D deficiency.

In scientific community, there is no consensus on the adequate vitamin D level. The opinions concerning optimal and borderline 25(OH)D levels vary considerably. According to the Institute of Medicine Committee to Review Dietary Reference Intakes for Vitamin D and Calcium, serum 25(OH)D level > 50 nmol/L is considered normal, 30-50 nmol/L inadequate and < 30 nmol/L deficient. The recommended level of 50 nmol/L is based on evidence on the vitamin D level necessary for bone health. On the other hand, according to the recommendations issued by the American Geriatrics Society, International Osteoporosis Foundation and American Association of Clinical Endocrinologists, serum 25(OH)D level < 50 nmol/L is considered inadequate and > 75 nmol/L appropriate to reduce the risk of fractures and falls in the elderly (4, 5). There is ever more evidence pointing to a U-shaped curve for several vitamin D level associated health outcomes, including CVD and all-cause mortality, the risk being lowest at moderate but increased at low and high 25(OH) D levels (6).

Vitamin D deficiency was found in patients with ACS and preliminary studies suggest it to be potentially associated with prognosis as well. However, convincing evidence confirming the impact of vitamin D insufficiency or deficiency on ACS patient morbidity and mortality is still lacking (7). The biological mechanism of vitamin D deficiency in ACS is not simple; we can only speculate on a dual effect of vitamin D in ACS, i.e. its direct immunomodulatory action and indirect action on the known cardiovascular risk factors.

There is evidence for vitamin D to suppress the renin-angiotensin system and to influence endothelial function, inflammatory processes, platelet function, insulin resistance, and blood pressure (8). All these effects are highly relevant in ACS influencing the patient clinical course. In addition, low vitamin D level has been associated with ventricular dysfunction and cardiac remodeling following ACS, as well as with heart failure and sudden cardiac death (9-12). Therefore, it appears that vitamin D level can influence both short-term and long-term outcomes in ACS patients. …

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