Table of Contents

Cardiovascular diseases

Related articles: Managing cardiac symptoms, Health maintenance with Olmesartan

Heart disease or cardiovascular diseases is the class of diseases that involve the heart or blood vessels (arteries and veins). While the term technically refers to any disease that affects the cardiovascular system, it is usually used to refer to those related to arteriosclerosis (hardening of the arteries).

Macrophages are central to atherogenesis because they regulate cholesterol traffic and inflammation in the arterial wall.

Excess 25-hydroxyvitamin D3 exacerbates tubulointerstitial injury in mice by modulating macrophage phenotype. 1)

According to the Marshall PathogenesisA description for how chronic inflammatory diseases originate and develop., cardiovascular diseases result from the combined effects of communities of microbes that people gradually accumulate over time via the process of successive infection. In fact, there is some evidence that arterial plaque may at least be partly composed of biofilm, a community of diverse microbes that work together.

While many more pathogens will likely be identified in patients with cardiovascular diseases, certain easily cultured and readily identifiable microbes have been repeatedly identified in people with such conditions including H. pylori, cytomegalovirus, and Chlamydia pneumoniae.2) 3)

One of the best known links between two different inflammatory diseases – and a prototypical illustration of successive infection – is the relationship between cardiovascular diseases such as heart attack and stroke, and periodontal disease.

OlmesartanMedication taken regularly by patients on the Marshall Protocol for its ability to activate the Vitamin D Receptor. Also known by the trade name Benicar. , the most essential component of the Marshall Protocol, has several benefits for patients with cardiovascular disease, beyond its role in activating the innate immune system.

Types of cardiovascular disease

In samples collected from patients with coronary artery disease, more than 50+ species were found in coronary artery plaque. The arrows point to groups of bacteria emitting a fluorescent signal. Source: Ott et al.

Evidence of infectious cause

Immunoinflammatory processes due to chronic infection are thought to be one of the definitive atherogenetic processes.

K. Ayada et al.5)

According to the Marshall Pathogenesis, cardiovascular diseases result from the combined effects of communities of microbes that people gradually accumulate over time via the process of successive infection.

Role of infectious burden in cardiovascular disease

Related articles: Successive infection and variability in disease, Koch's postulates

Chronic and acute infections have been implicated as risk factors that increase the risk of stroke, myocardial infarction and other vascular events. The lack of consistency among studies attempting to link exposure to infectious pathogens and cardiovascular disease risk is evidence that a single pathogen is likely not responsible for these diseases. However:

Reconsidering exposure as an “infectious burden” (IB) aligns with our understanding that the totality of pro-inflammatory agents can contribute to atherosclerosis and vascular risk. We define IB as the cumulative life-course exposure to infectious agents that elicit strong inflammatory responses….

Elkind et al.6)

Arterial plaque may contain biofilm

Arterial plaque may contain and/or be caused by biofilm, that is, a community of diverse microbes that work together. Ott et al.'s work which showed a diverse groups of bacterial “signatures” in atherosclerotic lesions of patients with coronary heart disease. Using 16S rDNA sequencing, the team was able to identify over 50 different species including Staphylococcus species, Proteus vulgaris, Klebsiella pneumoniae, and Streptococcus species in plaque. The team concluded, “Detection of a broad variety of molecular signatures in all [coronary heart disease] specimens suggests that diverse bacterial colonization may be more important than a single pathogen.”7)

In a commentary following Ott's paper, Katz and Shannon concluded that his work suggested that atherosclerotic plaques are composed of “functional biofilm.” The team noted that the characteristics of a “mature” arterial wall make it well-suited for biofilm formation. These findings further suggest:

A “conspiracy” of bacterial pathogens as opposed to a single infection is involved in atherogenesis, which may help to explain the inefficacy of antibiotics, such as macrolides or fluoroquinolones, in clinical trials.

Joel T. Katz, MD and Richard P. Shannon, MD 8)

Immune cells are abundant in the walls of the arteries even during the initial stages of plaque formation.9) Macrophages have been shown to infiltrate arterial plaque and express a variety of matrix-degrading enzymes that weaken and sometimes break apart the fibrous caps which holds the plaque intact.10) 11) A portion of arterial plaque consists of apoptized (dead) macrophages.

Individual pathogens already implicated in cardiovascular disease

While many more pathogens will likely be identified in patients with cardiovascular diseases, certain easily cultured and readily identifiable microbes have been repeatedly identified in people with such conditions. These include:

Taken together [the large variety of demonstrated proatherogenic changes set into motion by Chlamydia pneumoniae] suggested that Cpn infections could contribute to the initiation and progression of atherosclerosis leading to atherosclerotic plaque growth and increased arterial stenosis. Moreover, Cpn infection may also play a role in the development of an unstable atherosclerotic plaque leading to acute cardio- and/or cerebrovascular events.

Frank R. Stassen 21)

Other evidence

Infections May be Causal in the Pathogenesis of Atherosclerosis

A causal relationship between periodontal disease and cardiovascular disease?

One of the best known links between two different inflammatory diseases – and a prototypical illustration of successive infection – is the relationship between cardiovascular diseases such as heart attack and stroke, and periodontal disease. A BMJ paper showed a correlation between dental disease and systemic disease (stroke, heart disease, diabetes). After correcting for age, exercise, diet, smoking, weight, blood cholesterol level, alcohol use and health care, people who had periodontal disease had a significantly higher incidence of heart disease, stroke and premature death. More recently, these results were confirmed in studies in the United States, Canada, Great Britain, Sweden, and Germany. The magnitude of the association is striking: one study found that people with periodontal disease had a two times higher risk of dying from cardiovascular disease.45)

A 2010 study using pyrosequencing compared the bacterial diversity of atherosclerotic plaque, oral, and gut samples of 15 patients with atherosclerosis, and oral and gut samples of healthy controls.46) The team concluded that there was a high degree of correlation between the presence of certain bacteria in the oral cavity (and to a somewhat lesser extent the gut) with bacteria in the gastrointestinal tract. Interestingly, several bacterial taxa in the oral cavity and the gut correlated with plasma cholesterol levels. A 2011 study that compared heart attack victims to healthy volunteers found the heart patients had higher numbers of bacteria in their mouths.47) Their tests on 386 men and women who had suffered heart attacks and 840 people free of heart trouble showed two types – Tannerella forsynthesis and Prevotella intermedia – were more common among the heart attack patients. Interestingly, the total number of species that could be identified in the saliva was the best indicator that somebody was likely to have had a heart attack.

Successive infection dictates that as a person accumulates pathogens in one area of the body, those pathogens likely have mechanisms that allow them to slow the immune response. So, if people harbor greater number of pathogens in their mouths, the immune response may slow in the heart and arteries, making it easier for microbes to spread their as well. The same can be said for the opposite scenario. Also, it may be possible that microbes in the mouth spread toward the heart and arteries, although this has yet to be completely confirmed. However, some of the same bacteria identified in the salivary microbiome, such as Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis - both of which cause tooth decay48) - have also been identified in atherosclerotic plaque.49) 50)

Work by Kozarov et al. strongly suggests that “the key step [towards systemic infection] is the persistence of intracellular bacteria in phagocytes.” Bacterial strains, they conclude, “once in the circulation, are internalized by phagocytic cells, at which stage selected species avoid immediate killing and spread and colonize distant sites.”51) The group also showed that older patients, when compared to younger controls, have atheromas (plaques) which contain greater proportions of pathogens traditionally associated with periodontitis.52)

Our data demonstrate that the elderly individuals (mean age 67 years) have higher incidence of periodontopathogens in their plaques than the younger individuals…. Species from the Bacteroides family were found in about 17% of the young but in about 80% of the elderly patients, as expected given the association of this family with adult and refractory periodontitis.

Kozarov et al.53)

Given these similarities between the two disease states, along with the evidence presented above, it would be surprising if cardiovascular disease were not also definitively shown to be caused by the communities of microbes.

Tests

C-reactive protein

Main article: C-reactive protein

C-reactive protein (CRP) is an important and evolutionarily ancient component of the innate immune responseThe body's first line of defense against intracellular and other pathogens. According to the Marshall Pathogenesis the innate immune system becomes disabled as patients develop chronic disease..54) CRP has been described as “the prototypical acute-phase reactant to infections and inflammationThe complex biological response of vascular tissues to harmful stimuli such as pathogens or damaged cells. It is a protective attempt by the organism to remove the injurious stimuli as well as initiate the healing process for the tissue. in human beings.” In the clinical setting, CRP is used “as a clinical indicator of acute infections and response to treatment, and to assess inflammatory status in chronic diseases.”55) Initially it was thought that CRP might be a pathogenic secretion as it was elevated in people with a variety of illnesses including cancer.56) However, discovery of synthesis in the liver demonstrated that it is manufactured by the human body.

The fact that CRP is an independent predictor of stroke and coronary artery disease but also a key contributor to effective bacterial clearance,57) underscores the importance of microbes in the pathogenesis of these diseases. Some patients on the Marshall ProtocolA curative medical treatment for chronic inflammatory disease. Based on the Marshall Pathogenesis. (MP) have reported temporary increases in CRP, an observation which is consistent with a heightened immune response.

CRP's name comes from its capacity to bind the C-polysaccharide of Streptococcus pneumoniae, which provides innate defense against pneumococcal infection.58)

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Cholesterol

Main article: Tests: cholesterol and triglycerides (lipids)

The lipid profile is a group of tests that are often ordered together to determine risk of coronary heart disease such as heart attack or atherosclerosis. The lipid profile typically includes:

  • high density lipoprotein cholesterol (HDL-C) — often called “good” cholesterol
  • low density lipoprotein cholesterol (LDL-C) — often called “bad” cholesterol
  • total cholesterol
  • triglycerides

In many of the diseases the Marshall ProtocolA curative medical treatment for chronic inflammatory disease. Based on the Marshall Pathogenesis. (MP) treats, patients may present with elevated cholesterol. Traditionally, it has been assumed that the elevated cholesterol is causing or contributing to the disease process. However, the alternate hypothesis is no less plausible; in certain inflammatory diseases, the body may be deliberately upregulating levels of cholesterol in order to better manage the disease process. Increasing evidence suggests that this alternative explanation may be true.59) 60) For example, a 2010 study found that several bacterial taxa in the oral cavity and the gut correlated with plasma cholesterol levels61), and another study found that high cholesterol protects against endotoxemia.62)

Both “good” and “bad” forms of cholesterol play pivotal roles in fighting infection, for example, scavenging endotoxins that are released during destruction of pathogenic bacterial forms. While higher levels of total cholesterol are associated with some forms of cardiovascular disease in some patient populations, a number of statistically significant inverse correlations have been found between total cholesterol and various diseases including chronic heart failure, respiratory and gastrointestinal diseases, and various acute infections.

Correlations between the abundances of different genera and disease markers in oral and fecal samples. Pearson correlation coefficients are represented by color ranging from blue, negative correlation (−1), to red, positive correlation (1). (A) Oral samples; (B) Fecal samples. Significant correlations are noted by *P < 0.05; <html></html>P < 0.01, and <html>*</html>P < 0.001. Source: Koren et al.

Thus, high cholesterol levels among patients on the MP are not seen as a problem but as a sign of the inflammatory response to infection. This means that MP patients do not need to take any measures to lower cholesterol. Over time, as the MP medications work to gradually lower infectious agents causing inflammationThe complex biological response of vascular tissues to harmful stimuli such as pathogens or damaged cells. It is a protective attempt by the organism to remove the injurious stimuli as well as initiate the healing process for the tissue., it is expected that cholesterol will return to a normal range. In this same vein, statins, in particular, should not be used to lower cholesterol, because they have effects on the same receptors as olmesartanMedication taken regularly by patients on the Marshall Protocol for its ability to activate the Vitamin D Receptor. Also known by the trade name Benicar. , which may prevent the drug from working effectively.

<html><!– Most researchers today consider that a high intake of saturated fat and elevated LDL cholesterol are the most important causes of atherosclerosis and coronary heart disease. This lipid hypothesis has dominated cardiovascular research and prevention for almost half a century although the number of contradictory studies may exceed those that are supportive.63)

Both “good” and “bad” form of cholesterol play pivotal roles in fighting infection, for example, scavenging endotoxins that are released during destruction of pathogenic bacterial forms. While higher levels of total cholesterol are associated with some forms of cardiovascular disease in some patient populations, a number of statistically significant inverse correlations have been found between total cholesterol and various diseases including chronic heart failure, respiratory and gastrointestinal diseases, and various chronic infections as well.

There is also broad evidence that cholesterol does not promote plaque as evidenced by studies that show therapies which directly lower cholesterol may make patients sicker. The article devoted to statins reviews the evidence that statins offer mild protection against disease not through its effect on cholesterol but through their underreported immunomodulatory properties.

Some patients on the Marshall Protocol (MP) have reported temporary increases in cholesterol and triglycerides, an observation which is consistent with a heightened immune response.

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The cumulative evidence suggests that infections may induce or promote atherosclerosis.64) 65) 66) 67) 68) 69) 70) From our point of view, scientists might readily explain the correlation between infections and atherosclerosis on the basis of the double-edged sword property of the anti-infective immune effects of lipoproteins, and might be able to design more rational and systemic experiments to test this correlation.

R. Han 71)

much confusion has arisen from unclear nomenclature with regard to polyunsaturated fatty acids and the lack of reporting of food sources in prospective cohorts. Data from prospective cohort studies and randomized controlled trials generally support the replacement of saturated fats with mixed polyunsaturated fatty acids to reduce the risk of death from coronary artery disease. However, it is unclear whether oils rich in omega-6 linoleic acid but low in omega-3 α-linolenic acid also reduce this risk.

Richard P. Bazinet, PhD and Michael W.A. Chu, MD MEd 72)

Key points

  • The replacement of dietary saturated fats with some, but not all polyunsaturated fatty acids reduces serum cholesterol levels and the risk of heart disease.
  • New analyses suggest that replacing saturated animal fats with linoleic acid, an omega-6 polyunsaturated fatty acid, lowers serum cholesterol levels but increases the risk of death from coronary artery disease.
  • Health Canada’s Food Directorate should reconsider the health claim that omega-6 polyunsaturated fatty acids reduce the risk of heart disease by lowering blood cholesterol levels.

Richard P. Bazinet, PhD and Michael W.A. Chu, MD MEd

Homocysteine

Related article: Folic acid and folate

A high level of blood serum homocysteine (known as “homocysteinemia”) is a strong risk factor for cardiovascular disease,73) This has led some to conclude homocysteine “has many deleterious cardiovascular effects.”74) However the amino acid does not appear to cause disease.

Because supplementation of the B vitamins lower levels of homocysteine, one common intervention for altering this risk factor is to supplement patients at risk for cardiovascular disease with folic acid (B9), pyridoxine (B6), and cyanocobalamin (B12). In fact, interventions designed to lower levels of homocysteine with high-dose supplementation of the B vitamins been equivocal, in some cases, seeming to exacerbate disease.

Marino et al. showed that eradication of Helicobacter pylori associated with gastritis reduced abnormally high levels of homocysteine.77)

The role of hyperhomocysteinemia in coronary artery disease (CAD) patients remains unclear. 78)

Effect of olmesartan on cardiovascular diseases

Main article: Science behind olmesartan

As is the case with the antivirals,79) antibiotics such as clarithomycin have consistently failed to reduce the rate of cardiovascular disease.80) However, these failures are not conclusive evidence that cardiovascular diseases are not caused by infections nor do they show that these diseases cannot be treated as a chronic infection. These trials did not induce immunopathology and they did not use high dose olmesartan, which has several benefits beyond its role in activating the innate immune system.

Several prospective, randomized studies show vascular benefits with olmesartan medoxomil: reduced progression of coronary atherosclerosis in patients with stable angina pectoris (OLIVUS); decreased vascular inflammatory markers in patients with hypertension and micro- (pre-clinical) inflammation (EUTOPIA); improved common carotid intima-media thickness and plaque volume in patients with diagnosed atherosclerosis (MORE); and resistance vessel remodeling in patients with stage 1 hypertension (VIOS).

R. Preston Mason81)

Olmesartan and other ARBs have been used to block various bad effects of Angiotensin II, including heart failure. In this regard, olmesartan has been shown to:-

  • protect the heart from damage from inflammation in myocarditis82)
  • ameliorate acute experimental autoimmuneA condition or disease thought to arise from an overactive immune response of the body against substances and tissues normally present in the body myocarditis, in rats, suppressing cytotoxic myocardial injury 83)
  • prevent acute left ventricular dysfunction84)
  • lower C-reactive protein, one of the acute phase proteins that increase during systemic inflammation85)
  • act as an antiarrhythmic86)
  • block the production of Angiotensin II, thus improving mortality rates in heart failure patients87)
  • This study demonstrated that olmesartan reduced angiotensin II and aldosterone levels more effectively than azilsartan, resulting in a stable antihypertensive effect. Olmesartan also had an inhibitory effect on cardiac hypertrophy. Accordingly, it may be effective for patients with increased RAAS activity after cardiac surgery or patients with severe cardiac hypertrophy. 88)

Pharmacotherapy targeting the renin-angiotensin system [the mechanism of the ARBs] is one of the most effective means of reducing hypertension and cardiovascular morbidity.89) 90)

Nien-Chen Li et al.91)

Olmesartan has also been shown to

  • prevent or delay left ventricular remodeling and hypertrophy in patients with type 2 diabetes 92)
  • reduce the volume of atherosclerotic plaques93) 94)
  • mildly reduce the risk of stroke in people at high risk for strokes (cerebrovascular events).95)
  • significantly remodel and destiffen the arterial wall material during long-term treatment 96).

Jigsaw wrote Since Elizabeth Blackburn won a Nobel prize for telomerase in 2009, I have wondered what effect olmesartan might have on it. Are our telomeres getting shorter and shorter, so we just go POP? while getting healthier and healthier in other respects. This report 97) is re-assuring. Olmesartan raises ACE2 which converts angII to Ang 1-7

Other treatments

The level of vitamin D in our blood should neither be too high nor to low. Scientists have now shown that there is a connection between high levels of vitamin D and cardiovascular deaths. vitamin D is suspected of increasing mortality rate

According to a 2006 estimate, 18% of the global cancer burden is attributable to infectious agents, but almost every indication is that this figure is far too conservative.106) Researchers confined by the logic of Koch's postulatesCentury-old criteria designed to establish a causal relationship between a causative microbe and a disease. Koch's belief that only one pathogen causes one disease has now been called into question as multiple postulates are increasingly considered out of date. have looked for a single microbe causing a single disease. Evidence suggests, however, that it is communities of microbes that are responsible for cancer. According to the Marshall PathogenesisA description for how chronic inflammatory diseases originate and develop., chronic microbes persist, in large part, by dysregulating the Vitamin D ReceptorA nuclear receptor located throughout the body that plays a key role in the innate immune response. (VDRThe Vitamin D Receptor. A nuclear receptor located throughout the body that plays a key role in the innate immune response.), a key nuclear receptorIntracellular receptor proteins that bind to hydrophobic signal molecules (such as steroid and thyroid hormones) or intracellular metabolites and are thus activated to bind to specific DNA sequences which affects transcription. with a well-characterized role in both the innate immune responseThe body's first line of defense against intracellular and other pathogens. According to the Marshall Pathogenesis the innate immune system becomes disabled as patients develop chronic disease. and metastasis suppression. Indeed one of the hallmarks of cancer is a disruption in the vitamin D endocrine system including high 1,25-DPrimary biologically active vitamin D hormone. Activates the vitamin D nuclear receptor. Produced by hydroxylation of 25-D. Also known as 1,25-dihydroxycholecalciferol, 1,25-hydroxyvitamin D and calcitirol. and slowed activity of the receptor. As they progressively multiply through a process known as successive infectionAn infectious cascade of pathogens in which initial infectious agents slow the immune response and make it easier for subsequent infections to proliferate., microbes elicit an inflammatory response, a response which has been shown to increase over time the risk of metastasis.

Several patients have worked with their doctors to treat their cancer with the Marshall Protocol. However, the MP appears to be most effective as a preventative measure.

It may be particularly important for MP patients with cancer in the family to avoid caffeine as far as possible.

“It is difficult to assess the practical significance of phagocytic suppression, but our previous work (unpublished) has shown that cancer cells can suppress phagocytosis in a similar manner. If this is the case, caffeine may be aiding in the suppression of immune response in the tumor microenvironment.” 107)

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Vitamin D supplementation is ineffective in improving cardiovascular health among various patient populations, including in the presence or absence of vitamin D deficiency. 108)

Patient interviews

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neurosarcoidosis, systemic sarcoidosis; spasticity, myasthenia, CNS dysfunction, joint pain, pulmonary, splenic and cardiac involvement

Read the interview

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sarcoidosis of the heart, coronary artery disease, atrial fibrillation

Read the interview

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Interviews of patients with other diseases are also available.

Patients experiences

I am happy to report that on the MP, my cardiac symptoms [including angina, cardiac arrhythmias] have been reduced at this point to almost nil.

Even with a good size dose of Verapamil daily and nitroglycerine, pre-MP, I was experiencing cardiac symptoms and events. Once I started the Benicar, they stopped. :) I haven't had to pop sub-lingual nitroglycerine tabs since starting! (Prior to starting the Benicar, I was taking 3 nitro tabs during an event, and then sometimes that wasn't enough.)

Hrts, MarshallProtocol.com

My heart inflammation over the past year has diminished considerably and so I no longer have the pain levels that I once suffered. That to me verifies that I am improving and I am on the right track. I still get heart herxes but they are controllable, and the pressure and arrhythmia, although are very irritating, no longer cause me such concern. I have been through the cycles enough times to have a good feel for what is going on and I can regulate them without too much distress.

CelticLadee, MarshallProtocol.com

When I was diagnosed with MVP [mitral valve prolapse], I was told I might also have dysautonomia, an imbalance of the central nervous system. This is part of something called MVP Syndrome, and the imbalance can cause jittery anxiety, irritable bowel syndrome, headaches, physical sensations that mimic low blood sugar, etc. So I decided that I must have this syndrome, because I had all these symptoms. Now I realize it probably all goes back to the sarcoidosis.

If you look at the symptoms list, you'll be amazed at how many of them are Th1 inflammationThe complex biological response of vascular tissues to harmful stimuli such as pathogens or damaged cells. It is a protective attempt by the organism to remove the injurious stimuli as well as initiate the healing process for the tissue. disease symptoms. There's also a link to anxiety/depression. When I found this site 10 years ago I was relieved to find that I wasn't the only MVP person suffering with odd things. At different times, I've suffered from about 90% of the MVP Syndrome symptoms listed, but then I found the MP site and it all began to click.

Jen Hicks, MarshallProtocol.com

More information

Hyperuricaemia was associated with an unfavourable cardiovascular risk profile in HF patients. Treatment with low doses of allopurinol did not improve the prognosis of HF patients. 109)

Increased risks per 10 000 person-years found in estrogen plus progestin therapy for 16608 healthy postmenopausal women (studied over 5 years) were 7 more CHD events, 8 more strokes, 8 more PEs, and 8 more invasive breast cancers. 110)

===== Notes and comments =====

— Sallie Q 08.25.2017 removed broken links

— Sallie Q 06.04.2017 adding uTube on smart meter effect

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  • legacy content

Benicar and cardiovascular events: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789932/?tool=pubmed https://clinicaltrials.gov/ct2/show/NCT00185159?term=ROADMAP&rank=2 https://clinicaltrials.gov/ct2/show/NCT00141453?term=ORIENT+olmesartan&rank=1 https://www.biosciencetechnology.com/News/Feeds/2010/06/sections-regulatory-news-fda-drug-safety-communication-ongoing-safety-revi/

FDA Drug Safety Communication: Ongoing safety review of Benicar and cardiovascular events

[Cardiovascular effects of VDRThe Vitamin D Receptor. A nuclear receptor located throughout the body that plays a key role in the innate immune response. and CaSR activation.] Brancaccio D, Cozzolino M G Ital Nefrol ; 26(S-49) :18-22 Download citation Affiliation Cattedra di Nefrologia, Universita' degli Studi, Milano and Unita' di Nefrologia e Centro Dialisi Simone Martini, Milano - Italy. Abstract Cardiovascular complications are the most common cause of death in uremic patients, especially those on chronic dialysis. One of the major findings is massive calcium deposition in the vessel walls. There is general consensus about the correlation between the distribution of vascular calcification and increased risk of death due to cardiovascular disease. An emerging issue is the possible beneficial role of vitamin D receptorA nuclear receptor located throughout the body that plays a key role in the innate immune response. (VDR) activation in reducing the morbidity and mortality rates in patients on chronic dialysis, as shown in large, although retrospective, studies. Still open is the possible role of CaSR activators in ameliorating the clinical course of patients on dialysis, although calcimimetics are able to improve the Ca-P-PTH serum profile and increase the number of patients within the international guidelines parameters. This review has been structured to give the readers an updated opinion on the possible positive impact of VDR and CaSR activators in terms of all-cause and cardiovascular morbidity and mortality in dialysis patients.

See this too: https://www.theheart.org/article/1024539.do

Lancet. 2009 Nov 28;374(9704):1840-8. Epub 2009 Nov 16. Effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure (HEAAL study): a randomised, double-blind trial.111)

Konstam MA, Neaton JD, Dickstein K, Drexler H, Komajda M, Martinez FA, Riegger GA, Malbecq W, Smith RD, Guptha S, Poole-Wilson PA; HEAAL Investigators. Collaborators (293) Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA. mkonstam@tuftsmedicalcenter.org Erratum in: Lancet. 2009 Dec 5;374(9705):1888. Comment in: Lancet. 2009 Nov 28;374(9704):1808-9. Lancet. 2010 Mar 27;375(9720):1079; author reply 1079-80. Expert Opin Pharmacother. 2010 Aug;11(12):2117-9. Lancet. 2010 Mar 27;375(9720):1079; author reply 1079-80. Evid Based Med. 2010 Apr;15(2):51-2. Abstract BACKGROUND: Angiotensin-receptor blockers (ARBs) are effective treatments for patients with heart failure, but the relation between dose and clinical outcomes has not been explored. We compared the effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure. METHODS: This double-blind trial was undertaken in 255 sites in 30 countries. 3846 patients with heart failure of New York Heart Association class II-IV, left-ventricular ejection fraction 40% or less, and intolerance to angiotensin-converting-enzyme (ACE) inhibitors were randomly assigned to losartan 150 mg (n=1927) or 50 mg daily (n=1919). Allocation was by block randomisation stratified by centre and presence or absence of beta-blocker therapy, and all patients and investigators were masked to assignment. The primary endpoint was death or admission for heart failure. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00090259. FINDINGS: Six patients in each group were excluded because of poor data quality. With 4.7-year median follow-up in each group (IQR 3.7-5.5 for losartan 150 mg; 3.4-5.5 for losartan 50 mg), 828 (43%) patients in the 150 mg group versus 889 (46%) in the 50 mg group died or were admitted for heart failure (hazard ratio [HR] 0.90, 95% CI 0.82-0.99; p=0.027). For the two primary endpoint components, 635 patients in the 150 mg group versus 665 in the 50 mg group died (HR 0.94, 95% CI 0.84-1.04; p=0.24), and 450 versus 503 patients were admitted for heart failure (0.87, 0.76-0.98; p=0.025). Renal impairment (n=454 vs 317), hypotension (203 vs 145), and hyperkalaemia (195 vs 131) were more common in the 150 mg group than in the 50 mg group, but these adverse events did not lead to significantly more treatment discontinuations in the 150 mg group. INTERPRETATION: Losartan 150 mg daily reduced the rate of death or admission for heart failure in patients with heart failure, reduced left-ventricular ejection fraction, and intolerance to ACE inhibitors compared with losartan 50 mg daily. These findings show the value of up-titrating ARBA drug which is an angiotensin receptor blocker. One of the ARBs is olmesartan (Benicar). Not all ARBs activate the Vitamin D Receptor. doses to confer clinical benefit. FUNDING: Merck (USA). PMID: 19922995

Need to put this in Science Behind Olmesartan, etc. also

Heart Vessels. 2010 Nov 10. [Epub ahead of print]

Olmesartan reduces arterial stiffness and serum adipocyte fatty acid-binding protein in hypertensive patients.

Miyoshi T, Doi M, Hirohata S, Kamikawa S, Usui S, Ogawa H, Sakane K, Izumi R, Ninomiya Y, Kusachi S. Department of Molecular Biology and Biochemistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan, miyoshit@cc.okayama-u.ac.jp. Abstract

Adipocyte fatty acid binding protein (A-FABP) has been reported to be involved in insulin resistance, lipid metabolism, and atherosclerosis; however, little is known about the effect of medication on the change in circulating A-FABP in human subjects. We evaluated the effects of angiotensin II type 1 receptor blocker (ARB) on arterial stiffness and its association with serum A-FABP in patients with hypertension. Thirty patients newly diagnosed with essential hypertension were treated with olmesartan (20 mg/day), an ARB, for 6 months. Serum levels of A-FABP and high-sensitivity C-reactive protein (hsCRP) were examined and the cardio-ankle vascular index (CAVI), which is a marker of arterial stiffness, was also determined. Serum A-FABP at baseline was significantly correlated with the body mass index (r = 0.45, P = 0.01), homeostasis model assessment as a marker of insulin resistance (r = 0.53, P < 0.01), and systolic blood pressure (r = 0.37, P = 0.047), and tended to be correlated with low-density lipoprotein cholesterol, triglyceride, and CAVI. Olmesartan treatment resulted in a significant decrease in CAVI, serum A-FABP levels, and hsCRP, besides a significant reduction of blood pressure. Multiple regression analysis revealed that the change in CAVI was independently correlated with the change in serum A-FABP. Olmesartan ameliorated arterial stiffness in patients with hypertension, which may be involved in the reduction of serum A-FABP.

PMID: 21063874

Expression of the vitamin d receptor is increased in the hypertrophic heart. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690395/?tool=pubmed

The liganded vitamin D receptor is thought to play an important role in controlling cardiac function. Specifically this system has been implicated as playing an anti-hypertrophic role in the heart. Despite this, studies of the VDR in the heart have been limited in number and scope. In the present study we use a combination of real time PCR, Western blot analysis, immunofluorescence and transient transfection analysis to document the presence of functional VDR in both the myocytes and fibroblasts of the heart, as well as in the intact ventricular myocardium. We also demonstrate the presence of 1-α-hydroxylase and 24-hydroxylase in the heart, two enzymes involved in the synthesis and metabolism of 1,25 dihydroxyvitamin D (VD3). VDR is shown to interact directly with the human B-type natriuretic peptide (hBNP) gene promoter, a surrogate marker of the transcriptional response to hypertrophy. Of note, induction of myocyte hypertrophy either in vitroA technique of performing a given procedure in a controlled environment outside of a living organism - usually a laboratory. or in vivoA type of scientific study that analyzes an organism in its natural living environment. leads to an increase in VDR mRNA and protein levels. Collectively, these findings suggest that the key components required for a functional VD3-dependent signaling system are present in the heart and that this putatively anti-hypertrophic system is amplified in the setting of cardiac hypertrophy.

Olmesartan reduces arterial stiffness and serum adipocyte fatty acid-binding protein in hypertensive patients.

https://www.ncbi.nlm.nih.gov/pubmed/21063874

Adipocyte fatty acid binding protein (A-FABP) has been reported to be involved in insulin resistance, lipid metabolism, and atherosclerosis; however, little is known about the effect of medication on the change in circulating A-FABP in human subjects. We evaluated the effects of angiotensin II type 1 receptor blocker (ARB) on arterial stiffness and its association with serum A-FABP in patients with hypertension. Thirty patients newly diagnosed with essential hypertension were treated with olmesartan (20 mg/day), an ARB, for 6 months. Serum levels of A-FABP and high-sensitivity C-reactive protein (hsCRP) were examined and the cardio-ankle vascular index (CAVI), which is a marker of arterial stiffness, was also determined. Serum A-FABP at baseline was significantly correlated with the body mass index (r = 0.45, P = 0.01), homeostasis model assessment as a marker of insulin resistance (r = 0.53, P < 0.01), and systolic blood pressure (r = 0.37, P = 0.047), and tended to be correlated with low-density lipoprotein cholesterol, triglyceride, and CAVI. Olmesartan treatment resulted in a significant decrease in CAVI, serum A-FABP levels, and hsCRP, besides a significant reduction of blood pressure. Multiple regression analysis revealed that the change in CAVI was independently correlated with the change in serum A-FABP. Olmesartan ameliorated arterial stiffness in patients with hypertension, which may be involved in the reduction of serum A-FABP.

Body's Bacteria Affect Atherosclerosis https://www.sciencedaily.com/releases/2010/10/101018074538.htm

“The causes of atherosclerosis have recently become clearer, but we know less about why the plaque in the arteries ruptures and contributes to clot formation,” says Fredrik Bäckhed, researcher at the Sahlgrenska Academy's Department of Molecular and Clinical Medicine.

Inflammation increases the risk of the plaque rupture in the arteries, but the underlying mechanisms for inflammation are not clear. Our bodies are home to ten times more bacteria than cells, and research in recent years has shown that our gut flora is altered in obesity , which over time may lead to cardiovascular disease. Poor dental health and periodontitis have also been linked to atherosclerosis, which would indicate that the bacteria in the mouth or gut could affect the condition.

“We tested the hypothesis that bacteria from the mouth and/or the gut could end up in the atherosclerotic plaque and thus contribute to the development of cardiovascular disease.”

The researchers initially found that the number of bacteria in the plaque correlated with the number of white blood cells, a measure of inflammation. Next they used modern sequencing methods to determine the composition of the bacteria in the mouth, gut and arterial plaque of 15 patients, and in the mouth and gut of 15 healthy control subjects. They found that several bacteria were found in the atherosclerotic plaques and, primarily, the mouth, but also the gut, of the same patient and that the bacteria Pseudomonas luteola and Chlamydia pneumoniae were present in all atherosclerotic plaques. These results would suggest that the bacteria can enter the body from the mouth and gut and end up min the plaque where they ultimately may contribute toinflammation and rupture of the plaque. The researchers also found that some of the bacteria in the mouth and gut correlated with biomarkers associated with cardiovascular disease.

“Finding the same bacteria in atherosclerotic plaque as in the mouth and gut of the same individual paves the way for new diagnosis and treatment strategies that work on the body's bacteria,” says Bäckhed. “However, our findings must be backed up by larger studies, and a direct causal relationship established between the bacteria identified and atherosclerosis.”

Med Hypotheses. 2011 Jan 7. [Epub ahead of print] Infectious atherosclerosis: Is the hypothesis still alive? A clinically based approach to the dilemma.

Alviar CL, Echeverri JG, Jaramillo NI, Figueroa CJ, Cordova JP, Korniyenko A, Suh J, Paniz-Mondolfi A.

St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.

Abstract

Among the multiple factors involved in the pathophysiology of heart disease, infections have been proposed to play a role in atherosclerosis with most of the available evidence implicating Chlamydia pneumonia, influenza virus and Mycoplasma pneumoniae. Based on a model case presentation, we speculate that in the absence of traditional risk factors and in the context of an ongoing respiratory infection caused by a pro-inflammatory pathogen (M. pneumoniae) along with a past positive serologic history for potentially proven atherogenic microorganism (C. pneumoniae) and infection may elicit potentially pathogenic events on vascular wall cells and leukocytes of atheromatous lesions, supporting the hypothesis that such infections may potentiate atherosclerotic cardiovascular disease (CVD).

Copyright © 2010 Elsevier Ltd. All rights reserved. PMID: 21216537

Old but interesting:

Br Med J. 1974 Sep 14;3(5932):647-50. Vitamin D and myocardial infarction. Lindén V. Abstract A detailed investigation was carried out into the consumption of vitamin D from different sources in patients who had suffered from myocardial infarction, angina pectoris, and degenerative joint diseases. Randomly selected controls of the same ages and sex were drawn from the Central Bureau of Statistics. The consumption was significantly higher in infarction patients. A daily intake of 30 mug may be the critical level. Student's t test for trend showed increasing probability of myocardial infarction with increasing intake of vitamin D, and more infarction patients than controls had a history of kidney stone. Long-term high consumption of vitamin D may be a precipitating cause of myocardial infarction. PMID: 4425790

Bacteria Eyed for Possible Role in Atherosclerosis ScienceDaily (Jan. 6, 2011) — Dr. Emil Kozarov and a team of researchers at the Columbia University College of Dental Medicine have identified specific bacteria that may have a key role in vascular pathogenesis, specifically atherosclerosis, or what is commonly referred to as “hardening of the arteries” – the number one cause of death in the United States. See Also: Health & Medicine Heart Disease Stroke Prevention Dentistry Infectious Diseases Diseases and Conditions Wounds and Healing Reference Inflammation Ulcer Coronary heart disease Biological tissue Fully understanding the role of infections in cardiovascular diseases has been challenging because researchers have previously been unable to isolate live bacteria from atherosclerotic tissue. Using tissue specimens from the Department of Surgery and the Herbert Irving Comprehensive Cancer Center at Columbia University, Dr. Kozarov and his team, however, were able to isolate plaques from a 78-year-old male who had previously suffered a heart attack. Their findings are explained in the latest Journal of Atherosclerosis and Thrombosis. In the paper, researchers describe processing the tissue using cell cultures and genomic analysis to look for the presence of culturable bacteria. In addition, they looked at five pairs of diseased and healthy arterial tissue. The use of cell cultures aided in the isolation of the bacillus Enterobacter hormaechei from the patient's tissue. Implicated in bloodstream infections and other life-threatening conditions, the isolated bacteria were resistant to multiple antibiotics. Surprisingly, using quantitative methods, this microbe was further identified in very high numbers in diseased but not in healthy arterial tissues. The data suggest that a chronic infection may underlie the process of atherosclerosis, an infection that can be initiated by the systemic dissemination of bacteria though different “gates” in the vascular wall – as in the case of a septic patient, through intestinal infection. The data support Dr. Kozarov's previous studies, where his team identified periodontal bacteria in carotid artery, thus pointing to tissue-destructing periodontal infections as one possible gate to the circulation. Bacteria can gain access to the circulation through different avenues, and then penetrate the vascular walls where they can create secondary infections that have been shown to lead to atherosclerotic plaque formation, the researchers continued. “In order to test the idea that bacteria are involved in vascular pathogenesis, we must be able not only to detect bacterial DNA, but first of all to isolate the bacterial strains from the vascular wall from the patient,” Dr. Kozarov said. One specific avenue of infection the researchers studied involved bacteria getting access to the circulatory system via internalization in white blood cells (phagocytes) designed to ingest harmful foreign particles. The model that Dr. Kozarov's team was able to demonstrate showed an intermediate step where Enterobacter hormaechei is internalized by the phagocytic cells, but a step wherein bacteria are able to avoid immediate death in phagocytes. Once in circulation, Dr. Kozarov said, bacteria using this “Trojan horse” approach can persist in the organism for extended periods of time while traveling to and colonizing distant sites. This can lead to multitude of problems for the patients and for the clinicians: failure of antibiotic treatment, vascular tissue colonization and initiation of an inflammatory process, or atherosclerosis, which ultimately can lead to heart attack or stroke. “Our findings warrant further studies of bacterial infections as a contributing factor to cardiovascular disease, and of the concept that 'bacterial persistence' in phagocytic cells likely contributes to systemic dissemination,” said Dr. Kozarov, an associate professor of oral biology at the College of Dental Medicine. Dr. Jingyue Ju, co-author and director of the Columbia Center for Genome Technology & Bio-molecular Engineering, also contributed to this research, which was supported in part by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health and by the Columbia University Section of Oral and Diagnostic Sciences.

The JUPITER lipid lowering trial and vitamin D: Is there a connection? Ware WR Dermatoendocrinol Apr 2010; 2(2) :50-4 Free full text via publisher | Download citation Affiliation Faculty of Science (Emeritus); University of Western Ontario; London, ON CA. Abstract There is growing evidence that vitamin D deficiency significantly increases the risk of adverse cardiovascular events and that a vitamin D status representing sufficiency or optimum is protective. Unfortunately, in clinical trials that address interventions for reducing risk of adverse cardiovascular events, vitamin D status is not generally measured. Failure to do this has now assumed greater importance with the report of a study that found rosuvastatin at doses at the level used in a recent large randomized lipid lowering trial (JUPITER) had a large and significant impact on vitamin D levels as measured by the metabolite 25-hydroxyvitamin D. The statin alone appears to have increased this marker such that the participants on average went from deficient to sufficient in two months. The difference in cardiovascular risk between those deficient and sufficient in vitamin D in observational studies was similar to the risk reduction found in JUPITER. Thus it appears that this pleiotropic effect of rosuvastatin may be responsible for part of its unusual effectiveness in reducing the risk of various cardiovascular endpoints found in JUPITER and calls into question the interpretation based only on LDL cholesterol and CRP changes. In addition, vitamin D status is a cardiovascular risk factor which up until now has not been considered in adjusting study results or in multivariate analysis, and even statistical analysis using only baseline values may be inadequate.

J Hypertens. 2006 Nov;24(11):2255-61. Synergistic protective effects of erythropoietin and olmesartan on ischemic stroke survival and post-stroke memory dysfunctions in the gerbil. Faure S, Oudart N, Javellaud J, Fournier A, Warnock DG, Achard JM. Source Division of Nephrology & Department of Pharmacology and Physiology, University of Limoges, France. Abstract OBJECTIVES: Treatment with erythropoietin and AT1 blockers is protective in experimental acute cerebral ischemia, with promising results in pilot clinical studies in human stroke. This paper examines the effects of using both agents as combination therapy in acute ischemic stroke. METHODS: We used the single carotid ligation stroke model in the gerbil. Six groups of 50 gerbils were treated either with placebo, erythropoietin (intraperitoneally, 5000 IU/kg, 2 and 48 h after stroke), olmesartan (10 mg/kg per day in drinking water started 36 h after stroke), ramipril (2.5 mg/kg per day in drinking water started 36 h after stroke), erythropoietin + olmesartan, or erythropoietin + ramipril. Long-term (1 month) Kaplan-Meyer survival curves were obtained, and survivors were submitted at day 30 to immediate (object recognition test) and spatial (Morris water maze) memory function tests. RESULTS: Erythropoietin alone and olmesartan alone, but not ramipril, significantly increased survival at day 30 compared with untreated controls (38, 30 and 6% versus 12%, respectively). Combined treatment with erythropoietin and olmesartan further increased the survival rate to 56%, whereas combined therapy with erythropoietin and ramipril decreased 30-day survival to 24% (P < 0.0001, erythropoietin + olmesartan versus erythropoietin + ramipril). Untreated stroke survivors had markedly altered performances in both the object recognition test (P = 0.0007) and the Morris water maze (P < 0.0001) tests at day 30 compared with normal gerbils. In erythropoietin-treated animals, ramipril therapy had no beneficial effect whereas olmesartan fully restored normal response to the memory tests. CONCLUSION: Post-infarct treatment with olmesartan combined with early erythropoietin therapy has a protective effect on survival, and markedly improves long-term memory dysfunction in this experimental model. PMID: 17053548

Arterioscler Thromb Vasc Biol. 2011 May 19. [Epub ahead of print] Endothelial Microparticle Formation by Angiotensin II Is Mediated via AT1R/NADPH Oxidase/Rho Kinase Pathways Targeted to Lipid Rafts.

Burger D, Montezano AC, Nishigaki N, He Y, Carter A, Touyz RM. Source

Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.

Abstract

OBJECTIVE:

Circulating microparticles are increased in cardiovascular disease and may themselves promote oxidative stress and inflammation. Molecular mechanisms underlying their formation and signaling are unclear. We investigated the role of reactive oxygen species (ROS), Rho kinase, and lipid rafts in microparticle formation and examined their functional significance in endothelial cells (ECs).

METHODS AND RESULTS:

Microparticle formation from angiotensin II (Ang II)-stimulated ECs and apolipoprotein E(-/-) mice was assessed by annexin V or by CD144 staining and electron microscopy. Ang II promoted microparticle formation and increased EC O(2)(-) generation and Rho kinase activity. Ang II-stimulated effects were inhibited by irbesartan (AT(1)R blocker) and fasudil (Rho kinase inhibitor). Methyl-β-cyclodextrin and nystatin, which disrupt lipid rafts/caveolae, blocked microparticle release. Functional responses, assessed in microparticle-stimulated ECs, revealed increased O(2)(-) production, enhanced vascular cell adhesion molecule/platelet-EC adhesion molecule expression, and augmented macrophage adhesion. Inhibition of epidermal growth factor receptor blocked the prooxidative and proinflammatory effects of microparticles. In vitro observations were confirmed in apolipoprotein E(-/-) mice, which displayed vascular inflammation and high levels of circulating endothelial microparticles, effects that were reduced by apocynin.

CONCLUSIONS:

We demonstrated direct actions of Ang II on endothelial microparticle release, mediated through NADPH oxidase, ROS, and Rho kinase targeted to lipid rafts. Microparticles themselves stimulated endothelial ROS formation and inflammatory responses. Our findings suggest a feedforward system whereby Ang II promotes EC injury through its own endothelial-derived microparticles.

PMID: 21597004

cardiac cardiac_disease cardiovascular_disease

Infect Immun. 2011 Jun;79(6):2277-84. Epub 2011 Mar 21.The Collagen-Binding Protein Cnm Is Required for Streptococcus mutans Adherence to and Intracellular Invasion of Human Coronary Artery Endothelial Cells. Abranches J, Miller JH, Martinez AR, Simpson-Haidaris PJ, Burne RA, Lemos JA. Source Center for Oral Biology, University of Rochester Medical Center, Box 611, 601 Elmwood Ave., Rochester, NY 14642. jacqueline_abranches@urmc.rochester.edu. Abstract Streptococcus mutans is considered the primary etiologic agent of dental caries, a global health problem that affects 60 to 90% of the population, and a leading causative agent of infective endocarditis. It can be divided into four different serotypes (c, e, f, and k), with serotype c strains being the most common in the oral cavity. In this study, we demonstrate that in addition to OMZ175 and B14, three other strains (NCTC11060, LM7, and OM50E) of the less prevalent serotypes e and f are able to invade primary human coronary artery endothelial cells (HCAEC). Invasive strains were also significantly more virulent than noninvasive strains in the Galleria mellonella (greater wax worm) model of systemic disease. Interestingly, the invasive strains carried an additional gene, cnm, which was previously shown to bind to collagen and laminin in vitro. Inactivation of cnm rendered the organisms unable to invade HCAEC and attenuated their virulence in G. mellonella. Notably, the cnm knockout strains did not adhere to HCAEC as efficiently as the parental strains did, indicating that the loss of the invasion phenotype observed for the mutants was linked to an adhesion defect. Comparisons of the invasive strains and their respective cnm mutants did not support a correlation between biofilm formation and invasion. Thus, Cnm is required for S. mutans invasion of endothelial cells and possibly represents an important virulence factor of S. mutans that may contribute to cardiovascular infections and pathologies.

PMID: 21422186

J Inflamm (Lond). 2011 Apr 28;8:9.Innate immunityThe body's first line of defense against intracellular and other pathogens. According to the Marshall Pathogenesis the innate immune system becomes disabled as patients develop chronic disease. and monocyte-macrophage activation in atherosclerosis. Shalhoub J, Falck-Hansen MA, Davies AH, Monaco C. Source CytokineAny of various protein molecules secreted by cells of the immune system that serve to regulate the immune system. Biology of Atherosclerosis, Kennedy Institute of Rheumatology, Faculty of Medicine, Imperial College London, UK. c.monaco@imperial.ac.uk. Abstract ABSTRACT: Innate inflammation is a hallmark of both experimental and human atherosclerosis. The predominant innate immune cell in the atherosclerotic plaque is the monocyte-macrophage. The behaviour of this cell type within the plaque is heterogeneous and depends on the recruitment of diverse monocyte subsets. Furthermore, the plaque microenvironment offers polarisation and activation signals which impact on phenotype. Microenvironmental signals are sensed through pattern recognition receptors, including toll-like and NOD-like receptors - the latter of which are components of the inflammasome - thus dictating macrophage behaviour and outcome in atherosclerosis. Recently cholesterol crystals and modified lipoproteins have been recognised as able to directly engage these pattern recognition receptors. The convergent role of such pathways in terms of macrophage activation is discussed in this review.

PMID: 21526997

Vitamin D in synthetic form was introduced into the human food chain in the 1920’s, coincidentally with the beginning of what was called the ‘epidemic’ of coronary heart disease. It had, at that time, been shown to prevent rickets in laboratory animals.

For decades, vitamin D has been used experimentally to create coronary heart disease in animals like the dog and the rat where it is not otherwise possible to simulate the forms of disease seen in man.

In 1936, obstetrician Dr. Wayne Brehm of Columbus, OH, showed the maternal and neonatal toxic effects of Viosterol, a synthetic form of Vitamin D, in his patients. This noteworthy study, unknown and unheralded to this day, deserves a place in the annals of medicine as one of the first randomized prospective clinical trials.

In 1972, Swedish and German researchers published striking pictures of heavy calcification in the arteries of ‘normal’ newborns killed in automobile accidents. Vitamin D supplementation of the mothers’ diet was considered as a cause, and no better reason has since been suggested. From South America in the 1970’s came news of a rapidly fatal calcific disease of naturally grazing animals caused by consuming large quantities of Vitamin D in the leaves of Solanum malacoxylon, a shrub of the potato family. In Europe the same occurred in animals eating vitamin D-rich golden oat grass, Trisetum flavescens.

As a practising cardiologist concerned with the calcification of arteries, especially the coronaries, I have long been deeply skeptical of widespread supplementation of the human diet with Vitamin D. The idea that there is wide deficiency is based on a threshold of 30 ng/ml. This is in fact the average value found in the US (admittedly by dubious measurement techniques), but has served to define half the population as being in need of medical attention and supplementation.

The threshold is largely arbitrary, and ‘deficiency’ has been said to cause cancer, multiple sclerosis, hypertension and atherosclerosis. A key assertion in these arguments is that prevalence is related to latitude –for example, the notion that the further north in the US that you go, the more colorectal cancer you see. Examination of the official cancer statistics shows that this again is untrue, and that much of the other supportive evidence is unacceptable.

Sporadic deficiency does exist and must be treated, but this applies to identifiable groups such as older people in institutions. The relationship of Vitamin D metabolism jointly to atherosclerosis and osteoporosis requires further examination. I have expressed these views and the reasoning behind them in some detail in a small book available from a publisher called Lulu.com. It is entitled “Vitamin D in Disarray.” They will also appear in more extended form in the wider context of coronary heart disease and its causes in a book which is about to be published in England entitled “Medicine sans Statistics.”

Hywel Davies MD

Vitamin D and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis.Elamin MB, Abu Elnour NO, Elamin KB, Fatourechi MM, Alkatib AA, Almandoz JP, Liu H, Lane MA, Mullan RJ, Hazem A, Erwin PJ, Hensrud DD, Murad MH,Montori VM J Clin Endocrinol Metab Jun 2011; Download citation Affiliation Knowledge and Evaluation Research Unit (M.B.E., N.O.A.E., M.M.F., A.A.A., M.A.L., R.J.M., A.H., P.J.E., M.H.M., V.M.M.), Mayo Clinic, Rochester, Minnesota 55905; Department of Medicine (K.B.E.), Case Western Reserve University, Metrohealth Medical Center, Cleveland, Ohio 44109; Division of Endocrinology, Diabetes, Metabolism, Nutrition (J.P.A., V.M.M.), Mayo Clinic, Rochester, Minnesota 55905; Division of Endocrinology and Metabolism (H.L.), Santa Clara Valley Medical Center, San Jose, California 95128; and Division of Preventive, Occupational, and Aerospace Medicine (A.H., D.D.H., M.H.M.), Mayo Clinic, Rochester, Minnesota 55905. Abstract Context: Several studies found association between vitamin D levels and hypertension, coronary artery calcification, and heart disease. Objective: The aim of this study was to summarize the evidence on the effect of vitamin D on cardiovascular outcomes. Design and Methods: We searched electronic databases from inception through August 2010 for randomized trials. Reviewers working in duplicate and independently extracted study characteristics, quality, and the outcomes of interest. Random-effects meta-analysis was used to pool the relative risks (RR) and the weighted mean differences across trials. Results: We found 51 eligible trials with moderate quality. Vitamin D was associated with nonsignificant effects on the patient-important outcomes of death [RR, 0.96; 95% confidence interval (CI), 0.93, 1.00; P = 0.08], myocardial infarction (RR, 1.02; 95% CI, 0.93, 1.13; P = 0.64), and stroke (RR, 1.05; 95% CI, 0.88, 1.25; P = 0.59). These analyses were associated with minimal heterogeneity. There were no significant changes in the surrogate outcomes of lipid fractions, glucose, or diastolic or systolic blood pressure. The latter analyses were associated with significant heterogeneity, and the pooled estimates were trivial in absolute terms. Conclusions: Trial data available to date are unable to demonstrate a statistically significant reduction in mortality and cardiovascular risk associated with vitamin D. The quality of the available evidence is low to moderate at best.

PMID: 21677037

Controversies in Vitamin D Supplementation https://escholarship.org/uc/item/4m84d4fn

Concurrent with this rise in vitamin D ingestion in Canada, United States, Sweden, Israel, and England were the epidemic onsets of atherosclerosis and osteoporosis, which led Moon et al. to hypothesize that chronic vitamin D excess contributes to the development of these two illnesses (1). Moon and colleagues supported their postulate by citing 37 studies, some dated as early as 1945, which documented cardiovascular and skeletal effects similar to atherosclerosis and osteoporosis in humans and laboratory animals after high vitamin D intake. Subsequently, Haddad et al. showed in seven healthy human volunteers that while endogenously synthesized dermal vitamin D is transported on vitamin D binding protein and causes a more sustained increase in serum 25-hydroxy vitamin D, the orally administered vitamin D is absorbed from the intestinal tract via chylomicrons and carried in the circulation by lipoproteins such as VLDL and LDL, which may end up in the artery wall (3, 4). This finding supports Fraser’s earlier speculation that the toxicity of orally acquired vitamin D might be due to its unnatural route through the body and, consequently, it is less finely regulated than endogenously synthesized dermal vitamin D (5).

A recent study by Rebsamen and colleagues found that vitamin D induced a dose-dependent increase in vascular smooth muscle cell migration in rat aorta, suggesting a possible mechanism of vitamin D in atherosclerosis and vascular remodeling (6). They showed that vitamin D- induced migration is a rapid, non-transcriptional response that requires the activation of phosphatidylinositol 3-kinase pathway, which concurs with the role of phosphatidylinositol 3- kinase in cell migration processes previously shown in numerous cell types including vascular smooth muscle cells. The validity of these results is enhanced by the fact that Rebsamen et al. performed all the experiments in triplicates and obtained comparable results each time. Moreover, the investigators reported statistically significant differences (P<0.05) between the vitamin D and control groups, using the unpaired, 2-tailed Student’s t test. The major limitation of this study, however, is that it was performed in vitro on rat aortic smooth muscle cell cultures, which may not be translatable to human subjects in vivo.

In another study, nine breeding pairs of Sprague–Dawley rats and their offsprings were fed either normal chow (control), modified chow supplemented with low-dose vitamin D, or modified chow supplemented with high-dose vitamin D (7). Norman et al. found that increased exposure to vitamin D during gestation and early life significantly reduced the aortic elastin content and force generation in these rats. This result is alarming since prior studies have indicated that reduction in the elastin content and increased aortic wall stiffness might be predispositions to aneurysm and hypertension (8, 9). Based on the fact that reduced elastin expression was associated with an increase in elastic lamellae in the aorta (10), Norman et al. proposed that the reduction in elastic lamellae associated with vitamin D was mostly likely due to vitamin D’s effect on proteins involved in the synthesis and/or catabolism of elastic fibrils, rather than fetal or neonatal elastin gene expression. The graded reduction in aortic force generation with increasing exposure to vitamin D found in this study was consistent with the findings of Weishaar et al. who previously demonstrated that chronically vitamin-D deficient rats had increased aortic force generation (11). Since there is evidence that vitamin D crosses the placenta (12, 13), excessive maternal vitamin D intake also means excessive fetal exposure. Norman et al. found this to be disturbing because they believe that Western countries have been consuming excessive vitamin D since the discovery of preventive effect of cod liver oil in rickets in 1919 (14). The validity of these results have been most strongly questioned by Reinhold Veith, who believes that Norman et al. have supplemented the rats’ diet with the more potent, vitamin D-derived hormone, 1,25(OH)2D, instead of vitamin D (15). Furthermore, he contends that “modern adults are not consuming physiologically meaningful amounts of vitamin D through foods or vitamin pills.”

1. Moon J, Bandy B, Davison AJ. Hypothesis: etiology of atherosclerosis and osteoporosis: are imbalances in the calciferol endocrine system implicated? J Am Coll Nutr. 1992;11:567-83. 2. Norman AW. Vitamin D and milk, Department of Biochemistry & Biomedical Sciences at the University of California, Riverside website https://vitamind.ucr.edu/milk.html December 12, 2000. Comment: Highly respected institution. Anthony Norman is a professor in the Department of Biochemistry & Biomedical Sciences at the University of California, Riverside. 3. Haddad JG, Matsuoka LY, Hollis BW, Hu YZ, Wortsman J. Human plasma transport of vitamin D after its endogenous synthesis. J Clin Invest. 1993;91:2552–5. 4. Demer LL. Vitamin D supplementation and atherosclerosis, Personal communication. 2003. Comment: Dr. Demer is a professor in the Departments of Medicine and Physiology at the David Geffen School of Medicine at UCLA, a highly respected institution. 5. Fraser DR. The physiological economy of vitamin D. Lancet. 1983;1:969–72. 6. Rebsamen MC, Sun J, Norman AW, Liao JK. 1 ,25-dihydroxyvitamin D3 induces vascular smooth muscle cell migration via activation of phosphatidylinositol 3-kinase. Circ Res. 2002;91:17-24. 7. Norman P, Moss I, Sian M, Gosling M, Powell J. Maternal and postnatal vitamin D ingestion influences rat aortic structure, function and elastin content. Cardiovasc Res. 2002;55:369-74. 8. Martyn C, Greenwald S. Impaired synthesis of elastin in walls of aorta and large conduit arteries during development as an initiating event in pathogenesis of hypertension. Lancet. 1997;350:953–955. 9. He CM, Roach MR. The composition and mechanical properties of abdominal aortic aneurysms. J Vasc Surg. 1994;20:6–13. 10. Li D, Faury G, Taylor D, et al.Novel arterial pathology in mice and humans hemizygous for elastin. J Clin Invest. 1998;102:1783–7. 11. Weishaar R, Kim SN, Saunders D, Simpson R. Involvement of vitamin D3Form of vitamin D made in the skin when exposed to light. Also available in fish and meat. This secosteroid is sometimes converted into 25-D. Also known as cholecalciferol and activated 7-dehydrocholesterol. with cardiovascular function. Effects on physical and morphological properties. Am J Physiol. 1990;258:E134-42. 12. Toda T, Toda Y, Kummerow F. Coronary arterial lesions in piglets from sows fed moderate excesses of vitamin D. Tohoku J Exp Med. 1985;145:303-10. 13. Clements MR, Fraser DR. Vitamin D supply to the rat fetus and neonate. J Clin Invest. 1988;81:1768–73. 14. Holmes R, Kummerow F. The relationship of adequate and excessive intake of vitamin D to health and disease. J Am Coll Nutr. 1983;2:173–99.

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