Download Assessment of the effects of Vitamin D supplementation on patients

Assessment of the impact of Vitamin D
levels on heart failure symptoms.
Jennifer Pineiro RN, BSN &
Carolyn Sutter MSN, CNP
The University of Akron
College of Health Professionals
Heart Failure
 high mortality
 frequent hospitalizations
 reduced quality of life
 Two mechanisms:
-diastolic dysfunction with decreased compliance
-systolic dysfunction with impaired ventricular contractility
 Multi-factoral etiology: ischemic and valvular heart disease, HTN,
dilated cardiomyopathy, DM, metabolic syndrome,
hyperthyroidism and age related changes
(Hunt, Abraham, Chin, Feldman, Francis, Ganiats, …Yancy, 2009; Goroll & Mulley, 2009)
Heart Failure Statistics
 The only cardiovascular condition that is increasing in
incidence in the U.S., prevalence is expected to double in the
twenty-first century.
 According to the AHA, approximately 5.8 million people in the U.S. have
heart failure with 670,000 newly diagnosed each year.
 The incidence approaches 10 per 1000
after age 65.
 One in five who have heart failure
die within one year of diagnosis.
(Lloyd-Jones, Adams, Carnethon, De Simone, Ferguson,
Flegal, K., …Hong,Y., 2009; Argawal, Phan, Willix, Barber, Schwarz, 2011).
Co-Morbid Condition:
Vitamin D Deficiency
25-hydroxyvitamin D 25(OH)D
 Deficiency:
a serum circulating 25hydroxyvitamin D (25(OH)D)
of less than 20 ng/ml.
 Normal:
a 25(OH)D 30 ng/ml and
above
 Insufficiency:
a 25(OH)D of 21–29 ng/ml
The Endocrine Society Practice Guideline:
Evaluation, Treatment and Prevention of Vitamin D
Deficiency
(Holick, M.F., Binkley, N.C., Bischoff-Ferrari,
H.A., Gordon, C.M., Hanley, D.A., Heaney, R.P.,
….Weaver, C.M. , 2011)
Vitamin D and Heart Failure
 The implications of Vitamin D deficiency
extend beyond the skeletal system.
 Vitamin D receptors have been identified within
the cardiovascular system, renal juxtaglomerular
cells and cardiac myocytes.
 Association found between moderate and severe
levels of Vitamin D deficiency and increased
cardiovascular risk.
(Argawal et al.,2011)
Literature Review
 Vitamin D deficiency
-increased risk of heart failure
-increased risk of sudden cardiac death
-multiple medical problems
-coronary vascular disease, HTN, heart failure and DM
(National Health and Nutrition Exam Survey, 2013; Congestive Heart Failure, 2012; Liu, 2011;
(Pilz, Marz, Wellnitz, Seelhorst, Fahrleitner-Pammer, Dimai, ….Dobnig, 2008).
Literature Review
 Vitamin D deficiency and Heart Failure
-increased risk of sudden cardiac death
-higher mortality
-poorer prognosis
-when treated with oral Vitamin D supplementation showed a
higher improvement in NYHA grading compared to
heart failure patients who did not receive the supplement
-Seasonal increase in heart failure hospitalizations and deaths in the
winter, coincides with Vitamin D levels which have been shown to be
seasonal
(Kerdegari, Garacyaraghi, Siavash, & Poormoghaddas, 2012; Congestive Heart Failure, 2012; Liu, 2011; Agarwal et al.,2011; McGreevy &
Williams, 2011)
Research Question
Do adult patients with heart failure and concomitant Vitamin D
deficiency or insufficiency have more significant heart failure
symptoms compared to those adult heart failure patients with
normal Vitamin D levels, as measured by the Minnesota Living
With Heart Failure Questionnaire (MLHFQ)?
Heart Failure Symptom Measurement Tool:
MLHFQ
 measures the patient’s perception of how much their
heart failure and its treatment affect their ability to live
as they want.
 Composed of 21 questions rated on a scale
from 0 (no effect) to 5 (very much).
 Higher scores reflect worse quality of life
 Can be administered by interview,
self-administered or by postal questionnaire
Validity
 One study compared the MLHFQ to the SF-36,
another commonly used heart failure assessment tool.
Cronbach's alpha ranged 0.79 to 0.94
 Patient-reported Outcomes Group (PROM) showed
high internal consistency reliability for the MLHFQ in
a number of studies
Cronbach’s alpha ranged 0.86-0.95
Methods
 Convenience Sampling
 Informed Consent (verbal)
 Sample:
Must have a diagnosis of heart failure
Self report of:
-serum Vitamin D level drawn in the past year
-whether the result was normal or low
-if they are currently on a Vitamin D supplement
Must be able to read and write English
Approved by University of Akron IRB
Methods
-Each patient will complete a Minnesota Living With Heart
Failure Questionnaire (MLHRQ)
The scores will determine the severity
of heart failure symptoms and will be
rated as either:
 Low (0-35)
 Medium (36-70)
 High (70-105)
-These scores will be compared to their self reported Vitamin D
level and evaluated for a relationship between low Vitamin D
levels and heart failure symptoms
Descriptive Statistics were used to
determine a correlation between Vitamin D
levels and heart failure symptoms
Summary of Data
Setting: outpatient cardiac rehabilitation center
N=6
67% male (4/6), 33% female (2/6)
Mean age is 68
All subjects are Caucasian
Results
 33% of the subjects reported a low Vitamin D level
 67% reported a normal Vitamin D level
 The MLHFQ scores ranged between 18 and 79
Vitamin D
MLHFQ Score
Subject 1
low
79
Subject 2
normal
67
Subject 3
normal
49
Subject 4
normal
41
Subject 5
normal
18
Subject 6
low
66
Results
 The subject with the highest MLHFQ score,
representing the most severe heart failure symptoms,
had a low Vitamin D level.
 The subject with the lowest MLHFQ score, representing the least
heart failure symptoms, had a normal Vitamin D level.
 Both subjects with low Vitamin D levels scored medium to high on
the MLHFQ, representing medium to high levels of HF symptoms
 The subjects with normal Vitamin D levels scored low to medium on
the MLHFQ, representing low to medium levels of HF symptoms
90
80
70
60
50
vitamin D
MLHFQ score
40
30
20
10
0
subject 1 subject 2 subject 3 subject 4 subject 5 subject 6
LIMITATIONS
 Small sample size
 Time
 HIPPA/hospital policy-Denies access to computer records for
actual serum Vitamin D levels at the site of the data collection,
prior to this at a different site, was denied the right to speak to
patients regarding my study
 Relied on actual word/memory of the subjects regarding
recollection of previous vitamin D level results
 Limited ethnic representation
FURTHER STUDY
RECOMMENDATIONS
 As predicted, this study shows a correlation between Vitamin D
deficiency and heart failure symptoms.
 Further larger observational studies and randomized controlled trials
are needed to determine if this relationship exists and whether vitamin
D supplementation could potentially reduce heart failure symptoms.
 According to clinicaltrials.gov, a service of the U.S. National Institutes
of Health, there are currently 16 trials underway which are specific to
vitamin D and heart failure.
References
 Agarwal, M., Phan, A., Willix, R., Barber, M., & Schwarz, E. (2011). Is vitamin D deficiency

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associated with heart failure? A review of current evidence. Journal of Cardiovascular Pharmacology and
Therapeutics, 16(4): 354-363. DOI: 10.1177/1074248410390214
Congestive Heart Failure. (2012). Vitamin D Council. Retrieved from
http://www.vitamindcouncil.org/health-conditions/cardiovascular-diseases/congestiveHolick, M.F., Binkley, N.C., Bischoff-Ferrari, H.A., Gordon, C.M., Hanley, D.A., Heaney, R.P.,
…Weaver, C.M. (2011). Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine
Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 96(7): 1911–
1930.
Hunt, S.A., Abraham, W.T., Chin, M.H., Feldman, A.M., Francis, G.S., Ganiats, T.G., …Yancy, C.W.
(2009). Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and
Management of Heart Failure in Adults. A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines: Developed in
Collaboration With the International Society for Heart and Lung Transplantation. Circulation, 119:
391-479. doi: 10.1161/CIRCULATIONAHA.109.192065
Kerdegari, M., Garacyaraghi, M., Siavash, M., Poormoghaddas, A. (2012). Vitamin D
Supplementation Effects in Patients with Heart Failure. Journal of Isfahan Medical School, 28(109),
p1-8. EBSCO Host.
References
 Liu, L.C., Voors, A.A., Van Veldhuisen, D.J., Van der Veer, E., Belonje, A.M., Szymanski,
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M.K.,…De Boer, R.A. (2011). Vitamin D status and outcomes in heart failure patients. European
Journal of Heart Failure,13(6), 619-625. EBSCO Host.
Mackintosh, A., Gibbons, E. & Fitzpatrick, R. (2009). Patient Reported Outcome Measurement
Group. A Structured Review of Patient-Reported Outcome Measures (PROMs) for Heart
Failure. Report to the Department of Health. University of Oxford. http://phi.uhce.ox.ac.uk/
McGreevy, C. & Williams, D. (2011). New insights about Vitamin D and cardiovascular disease.
Annals of Internal Medicine, 155(12), 820-826. EBSCO Host.
Naveiro-Rilo, J.C., Diez-Juárez, D.M., Romero, B.A., Rebollo-Gutiérrez,F., Rodríguez- Martínez, A.
& Rodríguez-García, M.A. (2010). Validation of the Minnesota living with
heart failure questionnaire in primary Care. Revista Espanola de Cardiologia,63(12), 1419-1427.
National Health and Nutrition Exam Survey. (2013). Centers for Disease Control and Prevention.
Retrieved from http://www.cdc.gov/nchs/nhanes.htm
Pilz, F., Marz, W., Wellnitz, B., Seelhorst, U., Fahrleitner-Pammer, A., Dimai, H….Dobnig, H.
(2008). Association of vitamin D deficiency with heart failure and sudden cardiac
death in a large cross-sectional study of patients referred for coronary angiography.
The Journal of Clinical Endocrinology and Metabolism,93(10).
http://jcem.endojournals.org/content/93/10/3927.abstract