Jennifer Pineiro RN, BSN & Carolyn Sutter MSN, CNP The
University of Akron College of Health Professionals Assessment of
the impact of Vitamin D levels on heart failure symptoms.
Slide 2
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)
Slide 3
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 ).
Slide 4
Co-Morbid Condition: Vitamin D Deficiency
Slide 5
25-hydroxyvitamin D 25(OH)D Deficiency: a serum circulating 25-
hydroxyvitamin D (25(OH)D) of less than 20 ng/ml. Insufficiency: a
25(OH)D of 2129 ng/ml The Endocrine Society Practice Guideline:
Evaluation, Treatment and Prevention of Vitamin D Deficiency
Normal: a 25(OH)D 30 ng/ml and above (Holick, M.F., Binkley, N.C.,
Bischoff-Ferrari, H.A., Gordon, C.M., Hanley, D.A., Heaney, R.P.,
.Weaver, C.M., 2011)
Slide 6
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)
Slide 7
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).
Slide 8
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 )
Slide 9
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)?
Slide 10
Heart Failure Symptom Measurement Tool: MLHFQ measures the
patients 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
Slide 11
Slide 12
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 Cronbachs alpha ranged 0.86-0.95
Slide 13
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
Slide 14
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
Slide 15
Descriptive Statistics were used to determine a correlation
between Vitamin D levels and heart failure symptoms
Slide 16
Setting: outpatient cardiac rehabilitation center N=6 67% male
(4/6), 33% female (2/6) Mean age is 68 All subjects are Caucasian
Summary of Data
Slide 17
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 DMLHFQ Score Subject 1low79 Subject 2normal67
Subject 3normal49 Subject 4normal41 Subject 5normal18 Subject
6low66
Slide 18
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
Slide 19
Slide 20
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
Slide 21
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.
Slide 22
References Agarwal, M., Phan, A., Willix, R., Barber, M., &
Schwarz, E. (2011). Is vitamin D deficiency 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/congestive-
Holick, 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
DVitamin D Supplementation Effects in Patients with Heart Failure.
Supplementation Effects in Patients with Heart Failure. Journal of
Isfahan Medical School, 28(109), p1-8. EBSCO Host.
Slide 23
References Liu, L.C., Voors, A.A., Van Veldhuisen, D.J., Van
der Veer, E., Belonje, A.M., Szymanski, M.K.,De Boer, R.A. (2011).
Vitamin D status and outcomes in heart failure patients.
EuropeanVitamin D status and outcomes in heart failure patients.
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-Jurez, D.M., Romero, B.A., Rebollo-Gutirrez,F.,
Rodrguez- Martnez, A. Naveiro-Rilo, J.CDiez-Jurez, D.MRomero,
B.ARebollo-Gutirrez,FRodrguez- Martnez, A & Rodrguez-Garca,
M.A. (2010). Validation of the Minnesota living withRodrguez-Garca,
M.A 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
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http://jcem.endojournals.org/content/93/10/3927.abstract