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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.

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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)

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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 ).

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Co-Morbid Condition: Vitamin D Deficiency

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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)

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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)

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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).

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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 )

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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)?

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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

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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

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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

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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

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Descriptive Statistics were used to determine a correlation between Vitamin D levels and heart failure symptoms

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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

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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

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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

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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

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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.

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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.

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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 of patients referred for coronary angiography. The Journal of Clinical Endocrinology and Metabolism,93(10). http://jcem.endojournals.org/content/93/10/3927.abstract