Supplemental calcium worsens risk for death, AVR in aortic stenosis
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Oral calcium supplementation with or without vitamin D was associated with lower survival and a greater need for aortic valve replacement among older patients with mild to moderate aortic stenosis, researchers reported.
In a large, retrospective analysis with extended follow-up, researchers also found that CV mortality was higher among older patients with mild to moderate aortic stenosis who were supplementing with calcium and did not undergo AVR.
“Strengthened by its large sample size and extended follow-up period, our study suggests that calcium supplementation does not confer any CV benefit, and instead may reflect an elevated overall risk of AVR and mortality especially in those not undergoing AVR,” Samir Kapadia, MD, chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic, and colleagues wrote.
Assessing vitamin D, calcium intake
In a retrospective longitudinal study, Kapadia and colleagues analyzed data from 2,657 patients with mild to moderate native aortic stenosis aged at least 60 years, selected from the Cleveland Clinic Echocardiography Database from 2008 to 2016 and followed until 2018 (mean age, 74 years; 42% women). Researchers stratified patients by supplementation status: no supplementation, supplementation with vitamin D alone and supplementation with calcium with or without vitamin D. The primary outcomes were all-cause, CV and non-CV mortality and AVR. The secondary outcome was aortic stenosis progression by aortic valve area and peak/mean gradients.
During a median follow-up period of 69 months, 49% of patients did not supplement, 12% took vitamin D alone and 39% supplemented with calcium plus vitamin D.
Researchers found that, compared with patients who did not take calcium or vitamin D, those who supplemented with both were 31% more likely to die of any cause (HR = 1.31; 95% CI, 1.07-1.62; P = .009), twice as likely to experience CV mortality (HR = 2; 95% CI, 1.31-3.07; P = .001) and 48% more likely to need AVR (HR = 1.48; 95% CI, 1.24-1.78; P < .001).
Among 115 patients who supplemented with calcium alone, researchers observed similar risk for all-cause mortality (HR = 1.24; 95% CI, 0.77-1.99; P = .38) but a higher risk for AVR (HR = 2.7; 95% CI, 1.76-4.08; P < .001).
Any supplementation was not associated with longitudinal change in aortic stenosis parameters.
“Our findings suggest that supplemental calcium in this population does not confer any CV benefit and instead these relationships should be thoughtfully considered in light of growing evidence and concern for CV harm particularly with unnecessary supplementation,” the researchers wrote.
Avoid calcium ‘if not mandatory’
In a related editorial, Jutta Bergler-Klein, MD, FESC, FHFA, FEACVI, professor of medicine in the department of cardiology at the Medical University of Vienna, wrote that clinicians must consider artificial supplementary calcium intake carefully and on a patient-by-patient basis.
“Future studies in osteoporosis should focus even more on CV events determining the overall mortality,” Bergler-Klein wrote. “Visualization of CV calcifications in osteoporosis imaging modalities should be particularly included in the stratification of when to give only vitamin D or also additional calcium. In patients with calcific aortic stenosis and high-risk CV, the present study strongly adds to the evidence that long-term continuous calcium supplementation should be avoided if not mandatory.”
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