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(Circulation. 2007;116:e86.)
© 2007 American Heart Association, Inc.

Correspondence

Letter by Wallis and Penckofer Regarding Article, "Calcium/Vitamin D Supplementation and Cardiovascular Events"

Diane E. Wallis, MD

Midwest Heart Specialists, Downers Grove, Ill

Sue Penckofer, PhD, RN

Professor and Loyola Faculty Scholar, Loyola University Chicago, School of Nursing, Maywood, Ill

To the Editor:

We read with interest the article by Dr Hsia and colleagues.¹ We concur that the null finding was primarily caused by inadequate replacement. Dietary vitamin D supplements were never meant to replace the daily requirements needed to achieve the physiological levels of 25-hydroxyvitamin D levels (>40 ng/mL).² There is little assurance that over-the-counter vitamin D supplements are biologically active or even contain what the package labeling asserts. Age- or drug-induced hypochlorhydria may interfere with the absorption of calcium-complexed supplements.³ There is evidence that approximately half of patients who take supplements remain severely deficient in vitamin D.⁴

States of calcium and vitamin D deficiency are also associated with changes in parathyroid hormone, the counterregulatory hormone. Hyperparathyroidism, regardless of whether it is primary or secondary, has been causally linked to increased cardiovascular morbidity and mortality, hypertension, hypertensive heart disease diastolic dysfunction, myocardial fibrosis, and calcification of the aortic valve and annulus.⁵ In our opinion, no conclusions can be drawn on lack of efficacy of vitamin D replacement without evidence that maximal parathyroid hormone suppression has occurred and that adequate calcium absorption is present (24-hour urinary calcium levels of 100 to 300 mg/d).⁶ We have found no studies where "treat to target" has been performed. Thus, we believe that it is important to complete studies that use adequate vitamin D and calcium replacement and demonstrate normalization of parathyroid hormone before it can be concluded that such therapy is ineffective.

	Acknowledgments

 
Disclosures

None.

	References

Top References

 

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2. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr. 1999; 69: 842–856.[Abstract/Free Full Text]
   
3. Yang YU, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006; 296: 2947–2953.[Abstract/Free Full Text]
   
4. Thomas MK, Lloyd-Jones DM, Thadhani RI, Shaw AC, Deraska DJ, Kitch BT, Vamvakas EC, Dick IM, Prince RL, Finkelstein JS. Hypovitaminosis D in medical inpatients. NEJM. 1998; 338: 777–783.[Abstract/Free Full Text]
   
5. Symons C, Fortune F, Greenbaum RA, Dandona P. Cardiac hypertrophy, hypertrophic cardiomyopathy, and hyperparathyroidism: an association. Br Heart J. 1985; 54: 539–542.[Abstract/Free Full Text]
   
6. Steingrimsdottir L, Gunnarsson O, Indridason OS, Franzson L, Sigurdsson G. Relationship between serum parathyroid hormone levels, vitamin D sufficiency and calcium intake. JAMA. 2005; 294: 2336–2341.[Abstract/Free Full Text]
   

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