key: cord-0808812-ls5uqe7k authors: Saghir Afifeh, Arraa Maddalena; Verdoia, Monica; Nardin, Matteo; Negro, Federica; Viglione, Filippo; Rolla, Roberta; De Luca, Giuseppe title: Determinants of vitamin D activation in patients with acute coronary syndromes and its correlation with inflammatory markers date: 2020-09-24 journal: Nutr Metab Cardiovasc Dis DOI: 10.1016/j.numecd.2020.09.021 sha: 30bbb9a1e07581b66fc6a7032bceb3af2de12f83 doc_id: 808812 cord_uid: ls5uqe7k Background Vitamin D deficiency is a pandemic disorder affecting over 1 billion of subjects worldwide. Calcitriol (1,25(OH)2D) represents the perpetrator of the several systemic effects of vitamin D, including the anti-inflammatory, antithrombotic and anti-atherosclerotic action potentially preventing acute cardiovascular ischemic events. Variability in the transformation of vitamin D into 1,25(OH)2D has been suggested to modulate its cardioprotective benefits, however, the determinants of the levels of calcitriol and their impact on the cardiovascular risk have been seldom addressed and were therefore the aim of the present study. Methods A consecutive cohort of patients undergoing coronary angiography for acute coronary syndrome(ACS) were included. The levels of 25 and 1,25(OH)2 D were assessed at admission by chemiluminescence immunoassay kit LIAISON® Vitamin D assay (Diasorin Inc) and LIAISON® XL. Hypovitaminosis D was defined as 25(OH)D < 10 ng/ml, whereas Calcitriol deficiency as 1,25(OH)2D < 19.9 pg/ml. Results We included in our study 228 patients, divided according to median values of 1,25(OH)2D ( ULN (respectively 0,04 µg/l for Troponin I and 5,00 µg/l for CK-MB) or electrocardiographic modifications (either ST-segment depression or elevation >2 mm in at least 2 contiguous leads or new LBB onset or T waves change). The protocol was approved by our local Ethical Committee and is in accordance to the Declaration of Helsinki statements. All demographic and clinical data were prospectively collected in a dedicated database. Hypertension was defined as a systolic blood pressure (BP) > 140 mmHg and/or a diastolic BP > 90 mmHg or on-treatment with antihypertensive medications. The diagnosis of diabetes was based on previous history of diabetes treated with or J o u r n a l P r e -p r o o f e without drugs, fasting glycaemia > 126 mg/dl or glycosylated haemoglobin > 6.5%. Hypercholesterolemia was defined as previous history of hypercholesterolemia, chronic treatment with any cholesterol-lowering agent at admission or fasting total cholesterol > 200 mg/dl. Blood samples were drawn at admission from patients undergoing elective (following a fasting period of 12 h) or urgent coronary angiography. Glucose, creatinine, uric acid levels, blood cells count and lipid profile were determined by standard methods, as previously described (12) . Statistical analysis was performed using SPSS 22.0 statistical package. Continuous data were expressed as mean + SD and categorical data as percentage. Analysis of variance and the chisquare test were used for continuous and categorical variables, respectively. Patients were grouped according to median values of 1,25(OH)2D. Forward conditional logistic regression analysis was performed to evaluate the independent predictors of calcitriol deficiency among variables displaying a significant association (p<0.05) at baseline. Linear regression analysis was applied for evaluating the relationship of calcitriol with other continuous laboratory parameters. Results were considered statistically significant for a two-tailed p < 0.05. We included in our study 228 patients, divided according to median values of 1,25(OH)2D (< or ≥ 41.5pg/ml). Major clinical and demographic features of the included population are displayed in Table 1 .Lower calcitriol was associated to age (p=0.005), diabetes (p=0.013), renal failure (p<0.0001), use of diuretics (p=0.007), platelets (p=0.019), WBC (p=0.032), 25(0H)D (p=0.046), higher creatinine (p=0.011), and worse glycaemic and lipid profile. Calcitriol levels, in fact, directly related with the levels of 25(OH)2D (r=0.175, p=0.035, Figure 2 ) whereas an inverse linear relationship was observed with major inflammatory and metabolic markers of cardiovascular risk (C-reactive protein: r=-0.14, p=0.076; uric acid: r=-0.18, p=0.014; homocysteine: r=-0.19, p=0.007; fibrinogen: r=-0.138, p=0.05), as shown in Figure 3 A, B, C and D respectively, and with Lp-PLA2 (r=-0.167, p=0.037, Figure 4 ). No relationship was observed for calcitriol with white blood cells count (r=-0.08; p=0.29), neutrophils (r=0.06, p=0.37) and lymphocytes (r=0.008, p=0.91). This is the first study conducted so far to evaluate the clinical determinants of calcitriol levels and their relationship with inflammatory and cardiovascular risk biomarkers among ACS patients undergoing early invasive management. Even though we observed a significant independent association of 1,2(OH)2D with vitamin D levels, calcitriol deficiency was much less frequent as compared to hypovitaminosis D, suggesting a potential "reserve" of vitamin D activation despite a deficiency of the substrate. Moreover, the prevalence of calcitriol deficiency was non-significantly lower in patients with hypovitaminosis D, therefore suggesting the In fact, in a recent study on dialysis patients no change in the intestinal absorption of Ca was obtained after 3months of 20,000 IU/week of cholecalciferol therapy before the normalisation of 25D and improvement of 1,25D levels (25) . In further studies, no effect on bone metabolism parameters was evident following cholecalciferol supplementation of dialysis patients (26) . In addition, calcitriol has been shown to raise the levels of IL-12, that is relevant to macrophage activity and atherogenesis (30) and to modulate the coagulation cascade, increasing thrombomodulin and down-regulating tissue factor (31) . However, its role in coronary thrombosis has never been assessed. Indeed, it could be hypothesized that the direct assessment of the levels of calcitriol could provide a more strict correlation with the pathogenesis of atherosclerotic lesions and their transient variations could favour plaques rupture, which represents the well-established causal mechanisms for acute coronary syndromes. Nevertheless, such hypothesis has never been considered so far in a dedicated clinical study. We firstly report the prevalence and predictors of calcitriol deficiency in a consecutive cohort of ACS patients undergoing early invasive management. We documented that lower calcitriol levels were associated with main established cardiovascular risk factors, and in particular with hypertension, diabetes and worse lipid profile, but also with renal function, and with a nonsignificant trend for presentation with ST-segment elevation MI. However, at multivariate analysis, only renal failure and baseline levels of 25(OH)D emerged as independent predictors of calcitriol inadequate levels, whereas no impact was played by age or J o u r n a l P r e -p r o o f j gender, in accordance to the previous reports by Levin et al. (32) in an unselected cohort of 1814 subjects. However, in this study, 1,25(OH)2D levels were related to diabetic status and parameters of renal function, as glomerular filtration and albumin-to-creatinine levels, although they recruited a large proportion of patients with kidney disease. In addition, oppositely to our results, in the study by Levin et al. the prevalence of calcitriol deficiency was much higher than cholecalciferol deficiency. However, in the above study (32) , about 35-40% of the study cohort was receiving a multivitamin supplementation, thus potentially accounting for the lower prevalence of hypovitaminosis D, as compared to our data. In fact, similarly to our conclusion, in a previous study over 500 patients with different degrees of renal dysfunction (from no chronic kidney disease-CKD to haemodialysis), Pasquali et al. (33) documented that both vitamin D levels, renal function and parathyroid hormone could modulate the efficiency of the hydroxylation of 25(OH)D to calcitriol. In fact, the lowest absolute values were observed in haemodyalisis patients without cholecalciferol deficiency, as these patients cannot be expected to substantially increase circulating levels of calcitriol from damaged kidneys simply because of substrate availability. In comparison, Vitamin D-replete CKD patients exhibited a hydroxylation efficiency that, on average, did not significantly differ from haemodyalisis patients, suggesting that the system is blunted in spite of some residual renal function. In our study,the rate of patients with inadequate calcitriol levels was less than 50% of the patients displaying severe cholecalciferol deficiency, suggesting the possibility to recruit a synthetic "reserve" for preserving the levels and function of the active hormone. In fact, the efficiency of 1,25(OH)2 D hydroxylation, however, can be rapidly increased by paracrine and auto-regulatory mechanisms, stimulating a local activity of the 1-α-hydroxylase in presence of J o u r n a l P r e -p r o o f k high PTH, low calcium or inflammatory factors and cytokines. In fact, Pasquali et al. (33) showed in subjects with no CKD, that the efficiency of calcitriol production was linearly related to the levels of substrate, but became an exponential increment when 25(OH)D levels declined below 20 ng/ml. On the contrary, such reserve was not observed in presence of renal dysfunction, confirming that kidney activity and vitamin D levels represent the principal determinants of calcitriol production. (35, 36) , rather than an isolated pulmonary disease, that may strongly condition the survival of these patients. The first limitation to our study is the relatively small sample size, with subsequent low statistical power. In fact, our study represents the first exploratory investigation in ACS. Therefore, in the absence of specific references, we could not appropriately calculate a priori the sample size. The present study shows that among ACS patients, calcitriol deficiency is frequent and can occur even among patients with adequate vitamin D levels. We identified renal failure and vitamin D levels as independent predictors of 1,25(OH)2D deficiency. We observed a significant inverse relationship of calcitriol with inflammatory and metabolic biomarkers, therefore pointing at a potential more relevant and accurate role of calcitriol, as compared to vitamin D in the prediction of cardiovascular risk. Future trials should certainly investigate the potential role of acute calcitriol administration in the setting of acute coronary syndromes as much as in other inflammatory disorders. DisclosureNo conflict of interest to disclose. Data Availability StatementNo shared data to report. The data belong to the Authors of the manuscript. 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