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Advances in Medicine
Volume 2019, Article ID 6823417, 4 pages
https://doi.org/10.1155/2019/6823417

Research Article
Serum Vitamin D Level in Patients with Coronary Artery Disease
and Association with Sun Exposure: Experience from a Tertiary
Care, Teaching Hospital in India

Tauseef Akhtar ,1,2 Ramesh Aggarwal ,1 and Sachin Kumar Jain1

1
Department of Medicine, Lady Hardinge Medical College and Dr. Ram Manohar Lohia Hospital, New Delhi, India
2
Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, USA

Correspondence should be addressed to Ramesh Aggarwal; [email protected]

Received 8 June 2018; Revised 5 November 2018; Accepted 10 December 2018; Published 3 February 2019

Academic Editor: Emir Veledar

Copyright © 2019 Tauseef Akhtar et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Vitamin D, a fat-soluble vitamin, has various extraskeletal effects, and several human and animal studies have
suggested that vitamin D deficiency may be a contributory factor in the pathogenesis of coronary artery disease (CAD). However,
such studies in the Indian subcontinent are either lacking or have shown conflicting results. Methods. This was a descriptive cross-
sectional study involving 121 patients with CAD from a tertiary care center and their 80 age-matched healthy controls. Serum
vitamin D levels along with serum and urine chemistries were measured in both the groups. The average duration of sun exposure/
day and use of sunscreen were also considered in the study cohort using a questionnaire. Serum vitamin D levels were categorized
into deficient (<30 nmol/lit), insufficient (30–75 nmol/lit), and sufficient (>75 nmol/lit) groups. Results. Among the cases, 51.2% of
the patients were vitamin D deficient and 44.6% patients had insufficient vitamin D levels, whereas among controls, 40% and 31%
of the population had deficient and insufficient levels of vitamin D, respectively. However, the mean value of the serum vitamin D
level was not statistically different in the cases as compared to that of the controls (34.06 vs 40.19 nmol/lit) (P � 0.08). Corrected
serum calcium (9.26 vs 9.59 mg%) (P ≤ 0.0001) and serum albumin levels (4.21 vs 4.75 gm%) (P ≤ 0.0001) were lower in the cases
than those of the controls. The average sun exposure/day was higher among the cases than that among the controls (2.93 vs
1.85 hours) (P � 0.001). Conclusion. Vitamin D deficiency is widely prevalent in Indian population despite abundant sunshine,
and the duration of sun exposure is not correlated with serum vitamin D levels. Vitamin D deficiency is not associated with CAD.
However, serum calcium is deficient in CAD patients as compared to the controls. Large-scale studies are required to explore the
association further to evaluate the benefits of screening and correction of vitamin D deficiency in patients with CAD.

1. Introduction to result in cardiac hypertrophy and fibrosis by elevation of

matrix metalloproteinase enzyme [1, 2]. It also predisposes
Vitamin D, a fat-soluble vitamin also known as an anti- to hypertension by upregulation of the renin-angiotensin
ricketic factor or sunshine vitamin, is unique in the sense system [3]. Similarly, it is also involved in promoting the
that the body synthesizes it, and it also functions as a formation of atheromatous plaque by increasing the uptake
hormone. Besides its pivotal role in calcium homeostasis and of lipids by macrophages and their conversion into foam
bone mineral metabolism, the vitamin D endocrine system is cells [4]. CAD is an emerging problem in developing
now recognized to be involved in a wide range of funda- countries like India and responsible for significant morbidity
mental biological functions in cell differentiation, inhibition and mortality, and the situation is expected to be worse in
of cell growth, and immunomodulation. Several human and the future [5]. Multiple studies have shown that vitamin D
animal studies have suggested that vitamin D deficiency may deficiency is widely prevalent in the Indian subcontinent
be a contributory factor in the pathogenesis of coronary [6–9], and also, there are studies reporting an early onset and
artery disease (CAD). Vitamin D deficiency has been shown aggressive CAD in South Asian population [10, 11],
2 Advances in Medicine

However, only a few studies explore the role of vitamin D levels, respectively (Table 2). Similarly, among 80 controls,
deficiency in CAD patients from the Indian subcontinent 50% and 38.8% of the subjects had deficient and insufficient
and have shown conflicting results [12–16]. This study was serum vitamin D levels, respectively. The clinical and bio-
undertaken to examine the association of vitamin D de- chemical characteristics of the cases and controls are shown
ficiency in patients with CAD and to assess the serum vi- in Table 1. The average duration of sun exposure (hours/day)
tamin D level in relation to the duration of sun exposure. among the CAD patients was higher than that among the
controls (P � 0.001). The mean waist-to-hip ratio, implying
2. Materials and Methods central obesity, was higher in CAD patients than that in the
controls (P � 0.04). Serum albumin (P < 0.0001) and cor-
This was a descriptive cross-sectional study conducted at a rected serum calcium levels (P < 0.0001) were lower in CAD
tertiary care center and teaching hospital in New Delhi. The patients than those in the controls. We did not find a sig-
protocol for the study was duly approved by the ethical nificant difference in the levels of serum vitamin D
committee of our institute. Participation in the study was (P � 0.25), serum alkaline phosphatase (P � 0.10), serum
voluntary, and informed consent was obtained from all the phosphate (0.06), 24-hour urine calcium (P � 0.41), and
participants of the study before enrollment. About 121 cases phosphorus (P � 0.30) between the CAD patients and
who were admitted to our hospital or who attended a controls.
cardiology clinic and their 80 age-matched healthy controls
from the year 2010 to 2012 were enrolled. Subjects were 4. Discussion
included if they had CAD proved by either angiography or
ECG changes and suggestive symptoms with elevated bio- Vitamin D deficiency is prevalent in both CAD patients and
markers (CK-MB and troponin) belonging to the age group healthy controls. Although CAD patients were slightly more
of 40 to 70 years. Subjects were excluded from the study if deficient in vitamin D than the controls, the difference was
they had diabetes mellitus, liver insufficiency, acute and not statistically significant. Our study reinforces the findings
chronic kidney diseases, history of intake of vitamin D of previous studies [6–9] and suggests that vitamin D de-
supplements, and consumption of drugs like rifampicin, ficiency is widely prevalent in Indian population despite the
phenytoin, barbiturate, and thiazide diuretics which in- presence of abundant sunshine. Interestingly, on analysis of
terfere with vitamin D metabolism. Subjects with tubercu- the serum vitamin D level with respect to the length of time
losis and a history suggestive of chronic malabsorption were of sun exposure, the average time of sun exposure/day was
also excluded from the study. higher in the CAD patients than that of the controls.
Study participants were administered a questionnaire to However, increased sun exposure did not translate into
determine the symptoms of vitamin D deficiency, average increased serum vitamin D levels in CAD patients. Binkley
duration of sun exposure/day, and use of sunscreen. An- et al. in their study supported our finding and proposed that
thropometric measurements were taken, and blood samples this might be due to variations in individual response to
were drawn in vacutainer tubes under sterile conditions. ultraviolet B rays, which are mainly responsible for vitamin
Samples were allowed to clot at room temperature and then D synthesis [17]. It is also important to note the time of the
centrifuged for 5 minutes. Serum was then collected and day during which sun exposure occurs as maximum ul-
stored at −40°C for further batch analysis to measure the traviolet B rays exposure occurs during 11 am to 1 pm [18].
25(OH) vitamin D level in the preserved samples using a In addition to sun exposure, increased pigmentation of the
DRG 25OH vitamin D ELISA kit. Serum calcium, phos- Indian population may also affect cutaneous vitamin D
phate, alkaline phosphatase, and albumin were measured synthesis [19].
using the chemical autoanalyzer. Urine calcium and phos- We did not find any significant difference between the
phorus were measured in a 24-hour urine sample. Patients serum vitamin D levels in the CAD patients and controls. In
were labeled as vitamin D deficient, insufficient, and suffi- a cross-sectional observational study, Dhibar et al. [12]
cient if their levels were between <30 nmol/lit, 30–75 nmol/ concluded that vitamin D deficiency is also prevalent in
lit, and >75 nmol/lit, respectively. Statistical analysis was subjects with angiography-proven normal coronary artery,
done using Microsoft Excel 2007 and SPSS version 16. and vitamin D deficiency and severity of deficiency does not
Student’s t-test and chi-square test were used with the level correlate with angiographic severity of the disease. Karur
of significance set at ≤0.05. et al. [13] in their study noted that vitamin D deficiency is
widely prevalent in newly diagnosed CAD patients pre-
3. Results senting with myocardial infarction. However, they did not
include the control group for comparison; also, their study
The average age of CAD patients was 54 years and that of the population included subjects with diabetes mellitus which
control group was 48 years (Table 1). 76% of the CAD pa- itself has been shown to be associated with vitamin D de-
tients were men, whereas in the control group, men com- ficiency and therefore can confound the association of vi-
prised 42.5% of the subjects. Out of 121 CAD patients, 44% tamin D deficiency with CAD [20]. Similarly, Syal et al. [15]
presented with the acute coronary syndrome and the reported a higher prevalence of vitamin D deficiency in
remaining subjects had stable angina and ischemic car- angiographically proven CAD patients and noted a positive
diomyopathy. In the CAD group, 51.2% and 44.6% of the association with severity of CAD and endothelial dysfunc-
subjects had deficient and insufficient serum vitamin D tion with vitamin D deficiency, but their study lacks a control
Advances in Medicine 3

Table 1: Clinical and biochemical characteristics of the cases and controls.

Cases N � 121 Controls N � 80
Variable P values
Mean SD Mean SD
Age (years) 54.22 9 48.9 6 0.001
Average sun exposure (hours/day) 3 2.1 1.88 1.27 0.001
BMI (kg/m2) 24.31 0.12 24.86 0.07 0.31
W/H ratio 0.98 0.12 0.94 0.07 0.04
Serum alkaline phosphatase (IU/L) 126.06 0.3 138.24 0.29 0.10
Serum albumin (g/dl) 4.21 5.3 4.75 4.31 <0.0001
Corrected serum calcium (mg/dl) 9.26 7 9.59 4.59 <0.0001
Serum phosphate (mg/dl) 3.80 38 4.02 35.9 0.06
Serum 25(OH)D (nmol/l) 34.06 18.79 40.19 27.8 0.25
24-hour urine calcium (mg/d) 1075.71 89.56 747.08 100.01 0.41
24-hour urine phosphorus (mg/d) 471.77 381.29 468.85 401.86 0.30
BMI: body mass index, W/H: waist-to-hip ratio, S 25(OH)D: serum vitamin D.

Table 2: Serum 25(OH)D in cases and controls. and the level of serum vitamin D is not associated with the
25(OH)D level Case Control
duration of sun exposure. Vitamin D deficiency is not as-
sociated with CAD. However, serum calcium is deficient in
<30 nmol/L (deficiency) 62 (51.2%) 40 (50%)
30 to 75 nmol/L (insufficiency) 54 (44.6%) 31 (38.8%)
the CAD patients as compared to the controls. In the Indian
>75 nmol/L (sufficiency) 5 (4.1%) 9 (11.2%) population where vitamin D deficiency is widely prevalent
Total 121 80 and data on the normal serum vitamin D level are not
available, the importance of a control group in future studies
for comparison should be overemphasized. Given the lack of
group. Shanker et al. [16] also reported an increased preva- the studies exploring the association of vitamin D deficiency
lence of vitamin D deficiency in CAD patients but did not in CAD patients and conflicting results, large-scale multi-
exclude subjects with diabetes mellitus which is a con- centric prospective studies with controls are required to
founding factor, therefore weakening the association. In- examine the association further and to evaluate the benefits
terestingly, Rajasree et al. [14] in their study reported a higher of screening and correction of vitamin D deficiency in
prevalence of elevated vitamin D and calcium levels in CAD patients with CAD.
patients than controls and proposed the hypothesis of vitamin
D-mediated arteriolar calcification leading to atherosclerosis. Data Availability
In our study, the serum calcium level was lower in the
CAD patients than that of the controls. Lu et al. [21] reported The data used to support the findings of this study are
higher in-hospital mortality in patients admitted with ST- available from the corresponding author upon request.
elevation myocardial infarction and a lower serum calcium
level on admission in Chinese population. Rajasree et al. [14] Conflicts of Interest
reported a higher prevalence of above-normal calcium levels
in patients with acute myocardial infarction than controls. The authors declare that they have no conflicts of interest.
Shiyovich et al. [22] proposed that serum calcium is an in-
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