Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : OC10 - OC13 Full Version

Vitamin-D Levels of Patients with ST-elevation Myocardial Infarction and Association with In-hospital Prognosis: An Exploratory Observational Study in Southern India


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/60340.18118
Shilpa Avarebeel, Roshan Nazirudeen, Vinayarani Gowda, Mohan Goudar, MS Shwetha Shree

1. Associate Professor, Department of Geriatrics, JSS Medical College, Mysore, Karnataka, India. 2. Intern, Department of General Medicine, JSS Medical College, Mysore, Karnataka, India. 3. Clinical Research Officer, Centre for Clinical Research Excellence, JSS Academy of Higher Education and Research, JSS Hospital, Mysore, Karnataka, India. 4. Professor, Department of General Medicine, Mamatha Medical College, Mysore, Karnataka, India. 5. Clinical Research Assistant, Centre for Clinical Research Excellence, JSS Academy of Higher Education and Research, JSS Hospital, Mysore, Karnataka, India.

Correspondence Address :
Dr. Shilpa Avarebeel,
Associate Professor, Department of Geriatrics, JSS Medical College, MG Road, Mysore-570015, Karnataka, India.
E-mail: shilpaavarebeel@gmail.com

Abstract

Introduction: The role of vitamin-D in various diseases, including heart disease, has been a subject of interest in recent years. Many studies revealed low vitamin-D status in patients with Acute Coronary Syndrome (ACS). Studies have shown statistically significant low Vitamin-D levels in patients with Myocardial Infarction (MI) in recent years with some studies showing association of vitamin-D deficiency with worse outcome in patients with severe deficiency.

Aim: To determine serum vitamin-D levels in patients with acute ST-Elevation Myocardial Infarction (STEMI), and its association with in-hospital prognosis.

Materials and Methods: An exploratory observational study was conducted in 100 patients with STEMI consulting a General Medicine Department, JSS Hospital (Tertiary Healthcare Centre), Mysuru, Karnataka, India, from May 2015 to June 2016. The patients were followed-up for in-hospital prognosis. Serum vitamin-D was estimated by Enhanced Chemiluminiscence Immunoassay (ECLIA) method. Electrocardiogram (ECG), Echocardiogram (ECHO) and Coronary Angiogram (CAG) were done in all patients using standard procedures. In-hospital prognosis of the subjects with vitamin-D deficiency and those with normal vitamin-D levels were compared. Data was analysed using Statistical Package for the Social Sciences (SPSS) software version 21.0.

Results: Of total 100 patients, majority (n=59, 15.36%) were in the age group of 50-69 years and there were 81 males and 19 females. The results showed 72% of the subjects were deficient and 19% had insufficient vitamin-D levels, therefore, a total of 91% of the STEMI patients had abnormally low vitamin-D levels. Those with Diabetes Mellitus (DM) (n=52) and past Ischaemic Heart Disease (IHD) (n=9) had significantly low vitamin-D levels, suggesting that the association of vitamin-D deficiency with these risk factors may also contribute to the role of vitamin-D deficiency in STEMI. Among those with cardiac failure (44%), 86.3% had deficient and 11.6% had insufficient vitamin-D levels.

Conclusion: Vitamin-D deficiency was seen in majority of the STEMI patients. Significantly deficient level of vitamin-D was observed in STEMI patients who progressed to cardiac failure (44%) as a complication.

Keywords

Acute coronary syndrome, Cardiac failure, Liver function tests

Vitamin-D is involved in the regulation of Renin Angiotensin Aldosterone System (RAAS) pathway display, immunomodulatory, anti-inflammatory and insulin resistance property. The extent of vitamin-D deficiency has been linked to a range of metabolic disorders, infections, acute and chronic conditions and mortality. There is an increasing trend in the low vitamin-D status worldwide. Data from study based on United States (US) population suggests a 45% of the population have serum 25-hydroxyvitamin D concentrations ≤20 ng/mL (1),(2). Studies from India also show a high prevalence of vitamin-D deficiency in our population (3),(4).

Vitamin-D receptors are present in many organs including major cardiovascular cells and there is a prevailing interest in understanding the cardiovascular benefits of vitamin-D (5),(6). Clinical studies have demonstrated an independent association between vitamin-D deficiency and various manifestations of degenerative cardiovascular disease. Interest in the role of vitamin-D in Cardiovascular Diseases (CVD) arose from evidence of adverse cardiovascular effects of vitamin-D deficiency in animal models and epidemiological studies reporting the increase in cardiovascular events in winter and at increasing distance from the equator (5),(6).

Vitamin-D deficiency increases the chance of coronary artery disease and the association between IHD and vitamin-D deficiency remains significant even after adjustment for cardiovascular risk factors such as diabetes, smoking, obesity, physical activity and high blood cholesterol (6). The role of vitamin-D in various diseases including heart disease has been a subject of interest in recent years. Clinical studies have evidenced significant association of low vitamin-D levels in patients with ACS undergoing coronary angiography and severe deficiency correlating with adverse outcomes (7). However, the precise understanding of the cause-and-effect relationship and the CV risk benefits of vitamin-D supplementation in prone individuals is lacking. With this background the study aimed to determine serum vitamin-D levels in patients with acute STEMI, and its correlation with in-hospital prognosis.

Material and Methods

An exploratory observational study was conducted in the Department of General Medicine, JSS Hospital (Tertiary Healthcare Centre), Mysuru, Karnataka, India, from May 2015 to June 2016 in patients with STEMI. The Institutional Ethics Committee had approved the study (IEC letter No: JSS/MC/PG/6109, meeting date 30.10.2014). Serum levels of 25-hydroxy vitamin-D (25-OHD) <20 ng/mL indicate vitamin-D deficiency and levels above 30 ng/ mL are considered optimal while vitamin-D levels of 21-29 ng/mL are considered insufficient (8),(9). Serum vitamin-D levels 10 ng/mL is considered severe deficiency according to Mayo Medical Laboratories reference ranges for total serum 25-hydroxy vitamin-D (9).

Sample size calculation: Assuming the overall prevalence of vitamin-D deficiency in patients with acute Myocardial Infarction (MI) to be 75% (10) with an alpha error 5% and confidence level of 95% at least 75 or more subjects needs to be studied. The final sample size was taken as 100.

Inclusion criteria: Patients above 18 years of age, with clinical features of MI, confirmed to have STEMI based on Electrocardiogram (ECG) findings and elevated troponin levels with symptoms of ischaemia or echocardiographic Regional Wall Motion Abnormalities (RWMA) abnormality on Echocardiogram (ECHO) were included in the study.

Exclusion criteria: Pregnant women, patients with renal disease or hepatic dysfunction {history of chronic liver disease or deranged Liver Function Tests (LFT)}, patients on vitamin-D supplementation, bisphosphonates or hormone replacement therapy within past six months from the conduct of the study were excluded from the study.

Study Procedure

Data was collected in a pretested proforma. Detailed history, general physical examination, systemic examination, and investigations like Troponin-T, blood urea and serum creatinine, serum electrolytes and LFT were carried out from non heparinised venous blood sample. Serum vitamin-D was estimated by Electrochemiluminescence Immunoassay (ECLIA) method. ECG, ECHO and Coronary Artery Angiography (CAG) were done in all patients using standard procedures. In-hospital prognosis of the subjects with vitamin-D deficiency and those with normal vitamin-D levels were compared.

Assessment of in-hospital prognosis: The patients included in the study were followed-up till the time of discharge for complications namely cardiac failure, arrhythmias including conduction abnormalities, cardiogenic shock, mechanical complications, ischaemic complications such as stent thrombosis and postinfarction angina, Left Ventricular (LV) apical clot formation, embolic complications, pericarditis and major bleeding as well as mortality. A note was also made of other complications that the patients developed such as contrast induced nephropathy.

Statistical Analysis

Data was analysed using statistical SPSS software version 21.0 and were expressed as descriptive statistics such as mean, median and standard deviation for parametric variables and actual frequencies and percentages for non parametric data. Comparisons between groups were done using Chi-square test, one-way Analysis of Variance (ANOVA) test, Mann-Whitney U test and Kruskal-Wallis test (KW test). A p-value <0.05 was considered as statistically significant.

Results

The study was conducted in 100 STEMI patients. (Table/Fig 1) presents the demographic characteristics of the included participants. The mean vitamin-D levels were 15.6 ng/mL with almost three-fourth of population having vitamin-D deficiency (normal-9%, insufficient-19%, deficient-72%). Vitamin-D levels of females were 8.4 ng/mL which was lower than males (17.2 ng/mL). Vitamin-D deficiency was maximum in housewives.

Significantly low vitamin-D levels were seen in those with DM and history of IHD (Table/Fig 2). Duration of hospitalisation was significantly longer among the vitamin-D deficient group. Complications like cardiac failure, arrythmias, cardiogenic shock, heart block, contrast induced nephropathy, LV apical clot, stent thrombosis were noted, among those who developed complications (56% of the total population), 75% were vitamin-D deficient and 23.2% had insufficient levels. Vitamin-D deficiency therefore, had a statistically significant association with the risk of development of complications in patients with acute MI.

The most commonly encountered complication was cardiac failure (44%). Among those with cardiac failure, 86.3% had deficient and 11.6% had insufficient vitamin D levels which was statistically significant. The vitamin-D levels were significantly lower in patients who developed cardiac failure (mean vitamin-D level=12.55). All patients with cardiogenic shock, stent thrombosis, heart blocks and acute MR had abnormally low vitamin-D levels, though not statistically significant. Only one patient who expired had highest vitamin-D deficiency. There was no statistically significant correlation between the types of MI according to site of MI based on ECG findings and the vitamin-D levels in STEMI patients (Table/Fig 3). There was no statistically significant correlation between the vitamin-D levels of patients and their CAG findings.

Among the patients whose duration of stay was longer than seven days, 87.5% (7 out of 8) were vitamin-D deficient and 12.5% had insufficient vitamin-D levels. Among those with duration of stay between 5-7 days, 95.2% were vitamin-D deficient and remaining 4.8% had insufficient vitamin-D levels. Thus, vitamin-D deficiency was associated with significantly longer duration of stay (p-value=0.048). Moreover, mean duration of hospitalisation was also significantly longer among the patients with vitamin-D deficiency with p-value=0.008. Vitamin-D deficiency in STEMI patients was associated with a statistically significant increased risk of complications in general with p-value=0.01 (Table/Fig 4).

There was statistically significant difference in vitamin-D status of patients who developed cardiac failure as compared to those without cardiac failure with p-value of 0.01. The patients who developed stent thrombosis (100%) were also vitamin-D deficient. All patients with cardiac arrhythmias, heart block and mitral regurgitation had abnormally low vitamin-D levels. All the patients (100%) who developed cardiogenic shock and contrast induced nephropathy following CAG were vitamin-D deficient. Although clinically significant, none of these findings were statistically significant which could be due to a small sample size. There was one mortality among the study population. The patient was an elderly male aged 72 years with anterolateral MI, had severe vitamin-D deficiency (vitamin-D level was 3.02 ng/mL). He also had hypertension, lifestyle habits of smoking and alcohol consumption, and had developed complications of cardiac failure and cardiac arrhythmia (ventricular fibrillation).

Discussion

Multiple lines of evidence suggest a link between vitamin-D and cardiovascular disease. The risk of complications of coronary artery disease and MI is observed to be higher in patients with vitamin-D deficiency (2),(11),(12). The present study observed a high prevalence of vitamin-D deficiency (72%) among STEMI patients. Vitamin-D deficiency and insufficiency reported by various studies fall in the range of 67-75% and 16-22%, respectively (13),(14),(15),(16). Similar to other observations, the mean vitamin-D levels in our study population of STEMI patients was 15.6 ng/mL. Vitamin-D deficiency is significantly associated with female sex and indoor occupations with less sun exposure.

In the present study, majority belonged to the age group 50 to 69 years, concordant with the general observation of incidence of coronary artery disease (14),(15),(17). Although not statistically significant, vitamin-D levels seem to progressively decrease with age (10),(13),(15). About 85% of individuals above 70 years and 73% of individuals in the age group of 50-69 years were deficient for vitamin-D with median levels of 8.9 and 12.5 IU, respectively.

Among STEMI patients with DM and history of IHD, it was observed that a significantly lower vitamin-D levels. Many of the earlier studies have evidenced vitamin-D deficiency in greater proportion of individuals with diabetes (10),(11),(15). Although the underlying biological mechanisms are poorly understood, the association of low serum 25-hydroxy vitamin-D concentrations with type 2 diabetes may be mediated through effects on glucose homeostasis and a direct effect of vitamin-D on the β-cell function and thus insulin secretion. Several studies have suggested that low vitamin-D status also contributes to insulin resistance (18). Contrary to the present study findings, Metrio MD et al., showed no significant association between vitamin-D levels and past IHD (14). A positive correlation between lower vitamin-D levels and past IHD is suggestive of higher risk for recurrent MI in patients with vitamin-D deficiency and IHD long-term prospective studies are warranted to investigate this possibility. In the pool of conflicting evidence regarding the association of vitamin-D levels and hypertension in this study observations do not find a significant correlation (2),(13),(15),(19),(20). Outcomes such as duration of hospital stay were significantly longer in patients and relatively in-hospital complications were higher among individuals with vitamin-D deficiency (13),(14),(20). Cardiac failure is the most common complication and there was statistically significant association between cardiac failure and low vitamin-D levels in STEMI patients.

Lifestyle habits including smoking, alcohol consumption and regular exercise patterns are considered to be common factors (13),(15). A finding in the present study that contradicts previous studies is that vitamin-D deficiency was more in non smokers and non alcoholic patients as compared to smokers and alcoholics, with significantly higher vitamin-D levels in smokers and alcoholics. This needs to be further evaluated for possible effect of confounding factors such as occupation and sun exposure. In the present study, most (81%) of the patients did not exercise, though there was no statistically significant association between vitamin-D deficiency and lack of exercise.

The most commonly encountered complication was cardiac failure in individuals with vitamin-D deficiency, as reported by UK in-hospital prognosis study in 1259 MI which observed 80% of the patients who developed cardiac failure were vitamin-D deficient (2). Although the mean vitamin-D levels were lower (12 ng/mL) in patients with cardiac arrhythmia during hospital stay there was no statistically significant correlation between development arrhythmias and vitamin-D deficiency (13). This is contrary to the findings of some earlier studies which had reported statistically significant association of cardiac arrhythmias and vitamin-D deficiency in ACS patients (2),(14),(18). All of the present study patients who developed cardiogenic shock and contrast induced nephropathy were vitamin-D deficient.

Out of the 100 patients in the present study only one patient died. In the study by Metrio MD et al., the in-hospital mortality was 2.6% but this study included both STEMI and Non ST-Elevation Myocardial Infarction (NSTEMI) patients and mortality was noted to be more in STEMI patients, and this is comparable to the present study. No significant association between vitamin-D levels and in-hospital mortality has been observed in most previous studies (13),(15),(19),(20).

To the best of the present search, this study is the first one from South India that delved into the prevalence of vitamin-D deficiency and associated risk factors in STEMI patients and specifically on the in-hospital outcomes. Clinical interest derives from the fact that vitamin-D deficiency can be readily determined by blood testing and treated by supplementation. A single oral ultra-high dose of vitamin-D has been shown to restore normal 25 (OH)D levels within two days in critically ill patients, without causing adverse effects, thus providing the basis of an easy-to-administer dosing regimen for prospective intervention trials in acute cardiovascular settings (21). The present study demonstrates high prevalence vitamin D deficiency in patients presenting with STEMI as well as strengthens the evidence of a close association between low vitamin-D levels and increased risk of complications in patients with STEMI. Hence, it paves the way for studies based on pharmacologic supplementation of vitamin-D in selected high-risk ACS patients with severe vitamin-D deficiency, in order to improve their prognosis.

Limitation(s)

The major limitation in the present study was that there is no clearly defined control group in the study as majority of the patients in the study (91%) had abnormally low vitamin-D levels and only 9% of the patients had normal vitamin D levels. Even though the sample size was adequate to study the vitamin-D levels in patients with acute STEMI and outcome in general, a larger sample would have helped in a better understanding of the association of vitamin-D levels with the complications and in-hospital prognosis. Although clinically significant association could be noted, the association between vitamin-D levels and some of the complications individually such as cardiogenic shock, Artrioventricular (AV) conduction blocks, stent thrombosis could not be statistically demonstrated due to the low incidence of these complications in the present limited sample. The present study findings were based on single-centre population and would need to be verified in large cohorts. Moreover, this study is limited to complications and mortality during the hospital stay which varied from a period of 3-12 days. This is a relatively short period and further long-term follow-up after discharge as done in similar previous studies is lacking. The present study was only an observational study, further appropriately designed Randomised Controlled Trials (RCTs) are required to confirm if vitamin-D supplementation can help in improving outcome in STEMI patients and if it can be of help in prevention of MI in patients with risk factors for MI.

Conclusion

Vitamin-D deficiency is associated with higher risk of STEMI and with worse outcome following STEMI. The correction of vitamin-D deficiency and maintenance of optimal vitamin-D levels may be a promising approach for prevention of MI in patients with risk factors and for improving the outcome in patients with acute MI. Further larger scale prospective studies and interventional trials studies are warranted to assess the potential role of vitamin-D supplementations in patients with STEMI and its risk factors.

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DOI and Others

DOI: 10.7860/JCDR/2023/60340.18118

Date of Submission: Sep 20, 2022
Date of Peer Review: Nov 15, 2022
Date of Acceptance: Jan 21, 2023
Date of Publishing: Jun 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 27, 2022
• Manual Googling: Dec 14, 2022
• iThenticate Software: Jan 05, 2023 (11%)

Etymology: Author Origin

Emendations: 7

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