More on aortic valve disease and vitamin D

I hope I'm not getting my hopes up prematurely, but I believe that I've seen it once again: Dramatic reversal of aortic valve disease.

This 64-year old man came to me because of a heart scan score of 212. Jack proved to have small LDL, lipoprotein(a), and pre-diabetes. But there was a wrench in the works: Because of a new murmur, we obtain an echocardiogram that revealed a mildly stiff ("stenotic") aortic valve, one of the heart valves within the heart that can develop abnormal stiffness with time.

You can think of aortic valve disease as something like arthritis--a phenomenon of "wear and tear" that progresses over time, but doesn't just go away. In fact, the usual history is that, once detected, we expect it to get worse over the next few years. The stiff aortic valve eventually causes symptoms like chest pains, breathlessness, lightheadedness, and in very severe cases, passing out. For this reason, when symptoms appear, most cardiologists recommend surgical aortic valve replacement with a mechanical or a bio-prosthetic ("pig") valve.

Now, Jack's first aortic valve area (the parameter we follow by echocardiogram representing the effective area of the valve opening when viewed end on) was 1.6 cm2. A year later: 1.4 cm2. One year later again: 1.1 cm2.

In other words, progressive deterioration and a shrinking valve area. Most people begin to develop symptoms when they drop below 1.0 cm2.

Resigned to a new valve sometime in the next year or two, Jack underwent yet another echocardiogram: Valve area 1.8 cm2.

Is this for real? I had Jack come into the office. Lo and behold, to my shock and amazement, the prominent heart murmur he had all along was now barely audible.

I'm quite excited. However, it remains too early to get carried away. I've now seen this in a handful of people, all with aortic valve disease.

Aortic valve stenosis is generally regarded as a progressive disease that must eventually be corrected with surgery--period. The only other strategy that has proven to be of any benefit is Crestor 40 mg per day, an intolerable dose in my experience.

If the vitamin D effect on aortic valve disease proves consistent in future, even in a percentage of people, then hallelujah! We will be tracking this experience in future.

Comments (22) -

  • Mike

    8/22/2007 1:19:00 PM |

    What does vitamin D have to do with the improved heart valve?

  • Richard A.

    8/22/2007 9:42:00 PM |

    Maybe a little vitamin k with the vitamin d would give even better results for aortic valve disease.

  • Dr. Davis

    8/22/2007 9:46:00 PM |

    If this is true, I can only speculate on the mechanism for vitamin D's effect. It might include anti-inflammatory effects, suppression or modification of calcium deposition, and lipid (cholesterol) effects. However, this is just my speculation.

    I also agree that adding vitamin K2 may exert an effect, particularly in view of the valve disease that develops when people take the vitamin K blocker, Coumadin.

  • Anonymous

    8/31/2007 2:48:00 PM |

    Why do you stress Vitamin D3 supplements be in gel cap form?  Many of these contain Vitamin A in addition to the D.  If capsules of D are taken after a meal containing some fat, woulden't that suffce?

  • Dr. Davis

    8/31/2007 3:25:00 PM |

    If you want consistent absorption of vitamin D, gelcaps are best. Tablets are, in my view, next to worthless because of the erratic absorption, even when taken with a fatty meal.

    You can find D without A. Go to Vitamin Shoppe or buy Carlsons'brand.

  • Jim Chinnis

    9/10/2007 2:31:00 AM |

    Dr. Davis, I think you neglected to mention vitamin D in your blog article. Take a look at what you wrote!

  • Dr. Davis

    9/10/2007 4:17:00 AM |

    Whoops!

    Yes. It was vitamin D supplementation that I presume was the factor behind the effect on valve disease.

  • Adam

    9/13/2007 12:52:00 AM |

    Dr. Davis,

    Thanks for the thoughts. And, I really like your blog.  Thanks for sharing. I'm definitely coming back!

    Cheers,

    Adam
    Adam's Heart Valve Surgery Blog

  • Anonymous

    10/2/2007 4:16:00 PM |

    Any suggestions on dosage requirements of D3 gel caps?

  • Dr. Davis

    10/2/2007 6:22:00 PM |

    We've used anywhere from 4000-8000 units per day of an oil-based gelcap to achieve this effect.
    Please see my numerous prior posts on vit D dosing, along with commentary on our website, www.trackyourplaque.com.

  • William Ball, Pharm.D.

    9/30/2008 5:38:00 AM |

    I'm 60 and just this week was diagnosed by echo as having a bicuspid aortic valve that is clacified, sclerosed and fused with a valve area of 1.1cm.  I'm asymptomatic, but my reading shows I'm headed for valve replacement within a few years at most.  I read you anecdotal reports of vitmain D apparent reversal of aortic stenosis.  However, I am aware that vitamin D can increase calcium deposition in tissues.  Are you sure this is safe for patients like me?  You are aware that nothing to date has been proven to change the natural history of this disease, so I find your blog posts to be provocative at best and perhaps rather reckless despite your medical credentials.  Do you have any recent follow-up on your initial anecdotal report?

  • Anonymous

    12/18/2008 5:11:00 PM |

    Hell of a way to ask for help, Bill!

  • William Ball

    5/5/2009 3:40:00 AM |

    Being as I see no further follow-up on this one patient back in 2007, I'll just add that I had my vitamin D levels checked in September and they were low, so I decided to try Dr. Davis's idea.  On 10K IU of D3 I achieved normal vitmain D levels.  Unfortunately, in the last 6 months my AS has progressed with my valve opening going down from 1.1 to 0.9cm.  I still am asymptomatic but will have another echo in 4 months.  My cardiologist is concerned as my left ventricle also increased in size from 5.6 to 6.8cm in 6 months. I'll give the D3 another 4 months, but so far, it appears not to be helping at best and perhaps is accelerating the progression of my AS.

  • William Ball

    7/8/2009 2:28:57 AM |

    Further follow-up on my case.  Today I just got back from Stanford where I had another echo and met with Dr. Craig Miller, Chief of Cardiothoracic Surgery, to discuss my options.  My valve has further stenosed down to 0.7cm from 0.9 only 3 months earlier.  So, despite healthy doses of vitamin D, it looks like, if anything, the calcification of my valve has accelerated. This really points out how a single anecdotal report can be rather misleading.  Although I can believe that the patient's AS in the original report may have receded, there is no way you can attribute this to vitamin D.  It could be a completely unrepeatable coincidence.  Dr, Davis, with all due respect for your good intentions and the benefit you may otherwise provide to your patients, you really ought to remove your case report until you have some more concrete, repeateable evidence.  It not only may not have helped me, but it may have harmed me.

  • Dr. William Davis

    7/8/2009 12:29:17 PM |

    William--

    Sorry to hear about your valve "progression."

    My experience is not one patient, but around 20. Most have shown either modest reversal of aortic valve stenosis or stabilization (i.e., no change); two have progressed.

    So your experience is the exception, not the rule, compared to what I am seeing. I cannot claim that vitamin D is the "cure all," but I believe this phenomenon can teach us some interesting lessons.

    By the way, your disease, I believe is just showing the natural progression. Small leaps in severity like this are not uncommon in the absence of vitamin D.

  • Anonymous

    7/28/2009 8:39:00 PM |

    There are some people who's bodies are predisposed to use vitamin d the wrong way. Here's a link to one page that can take you to the research on this subject.
    http://www.examiner.com/x-7160-Sacramento-Nutrition-Examiner~y2009m4d15-Will-taking-vitaminD3-calcify-your-aorta-if-you-have-a-certain-genetic-variation

  • Anonymous

    10/19/2009 11:41:50 AM |

    Dr. Davis,
    Following the previous post from 'anonymous' I would add this comment in support of Bills thoughts that your posts may be 'reckless'.

    There is some evidence that vitamin D can actually CAUSE aortic valve calcification, both in animal models (see The Journal of the American College of Cardiology 2003, Volume 41, Issue 7, Pages 1211-1217: Experimental aortic valve stenosis in rabbits) and in human patients (see Heart 2001, Volume 85, pages 635-638: The vitamin D receptor genotype predisposes to the development of calcific aortic valve stenosis). In this case, you should be very careful in extrapolating your observations of one patient (perhaps with unusually low LDL) to a blanket 'vitamin D restoration' model. It could cause deterioration in the health status of those who seek your expertise without a proper diagnosis.
    A good PubMed search will provide the necessary literature for you to research (rather than speculate) on the mechanism for vitamin D's effect, and may help you to follow the ongoing debate about the validity of the animal model.

  • Dr. William Davis

    10/19/2009 8:51:52 PM |

    Anon--

    I believe you are confusing two things: vitamin D at physiologic replacement levels (as we do in humans) and vitamin D at toxic, supraphysiologic levels (as in rats and mice).

    Like any hormone, too little is not good, too much is not good. We want just right to obtain the benefits.

  • Anonymous

    10/20/2009 10:12:52 AM |

    Hi again Dr. Williams,

    forgive me for pushing you on this, but I am not confusing two things at all.

    One should, of course, always be cautious when extrapolating animal studies to humans and, while the supraphysiological (toxic) levels shown in some animal models is a potential issue (though also debatable, as physiological - or nutritionally relevant - levels CAN induce valve stenosis in mice with sub-optimal lipid metabolism), the main issue is that we are beginning to understand the complexity and potential danger of untested 'nutritional supplements' because of the wide genetic variation that exists in any population (see the second reference I provided for you comparing 630 HUMAN patients). Further, there is very little data on what actually represents 'toxic' levels in humans who take complex multivitamin mixtures, regardless of geographic considerations, environmental load and preexisting baseline blood concentrations (e.g., would you advise selenium supplementation for someone living in Nebraska?).

    This is perhaps demonstrated by your own reports of "around 20" patients (the complete statistics for which I would be interested to see). What is meant by "modest reversal or stabilization in most"? Is not the "around" 10% who have regressed worthy of your interest? I would have thought that without a recovery in all of your patients, you may consider that you are indeed "getting your hopes up prematurely" and that you may be more keen to understand the biochemistry behind the failures. Perhaps you could secure funding to follow these patients in a well designed scientific study? There must be other doctors with similar experiences who would be keen to push the science forward and take it out of the realm of anecdote?

    While I absolutely agree with you that prevention is better than intervention (I saw an excellent seminar just yesterday from professor Richard Cooper [from Loyola Chicago] demonstrating how just reducing salt intake can have dramatic effects on heart health in most people, and Professor Valentin Fuster [Mount Sinai] knows how a good exercise regime can reverse coronary desease). And while I also don't like the 'statin-and-stent' mentality (do statins work at all in women??), I also believe that drug disposition and pharmacokinetics are incredibly important.

    I simply think that you should place an enormous caveat on any of your posts that suggest that supplements such as vitamin D (and perhaps K, A, E, C, selenium etc. etc.) might be a 'magic bullet'. None of them is when applied across the board. In fact, there is strong, reputable and repeatable science that demonstrates potential damage caused by some of these unregulated concoctions that are marketed as 'healthy' (the topic of another of your 'scam' posts when applied to health foods).

    You are absolutely correct that the vitamin D phenomenon "can teach us some interesting lessons", but you are not the first person to have noted this idea and it is being investigated in fairly comprehensive studies. When the results are in, perhaps we will have a better understanding of the types of patient for whom it would work (and those for whom it may be dangerous).

    As with other eminent 'web-doctors' (e.g., Dr. Mercola, who advises vitamin D instead of the flu vaccine, or those who push "vitamin B17" instead of cancer chemotherapy), I would suggest that a blog is not a good place to practice science or medicine and I would hope you would regularly advise your readers to go to a good doctor in their area who perhaps agrees with your alternative methodologies for a full and well considered diagnosis.

  • Dr. William Davis

    10/21/2009 2:15:12 AM |

    Thank you, Anonymous.

    First of all, it's Dr. Davis, not Williams.

    Second of all, I agree with one of your points: This is the Heart Scan BLOG, not the Heart Scan Journal, not the Heart Scan List of Facts. It is a BLOG--pure and simple.  

    I hope anyone coming here for my musings and thoughts realize that's all they are. If anyone is stupid enough to make more of it than that, well that's not my problem.

  • Anonymous

    10/21/2009 9:09:51 AM |

    Hi Dr. Davis (apologies for the previous mistake),

    I wanted to point out that I enjoy your Blog and I share your interest in a nutritional basis for the prevention of cardiovascular disease. However, you allude in your various blogs to several of the unanswered issues behind our understanding of a highly complex topic. Salt reduction, resveratrol, caloric restriction and the enormous array of vitamins provide clear benefits for some people and yet seem to have almost no effect (or, when combined carelessly, even a detrimental effect) on others.

    Based on your last response, I have a final comment on this "more on aortic valve disease and vitamin D" post on your 'blog - not advice'. Then you can choose to be incensed by it, or take it as it is meant - a comment from a concerned cardiovascular research scientist who would dearly like to see these alternative approaches brought into the mainstream.

    Whether you accept responsibility for it or not, it is clear that some people read your postings and act on your "musings". You are, after all, a cardiologist and seen as an expert in medical matters. Further, you and I both know that the vast majority of people neither have access to nor the potential to understand the scientific literature, so the internet has become a frequently dangerous tool by which millions get their information and advice.

    In this thread alone, there are people asking for (and receiving) specific advice on the type of vitamin D to acquire (gel caps) and the purported optimum dosage (anywhere from 4000-8000 units per day). Further, while you don't actually tell him to, William Ball was clearly following what he perceives as 'Doctor's advice' when he "decided to try Dr. Davis's idea".

    His subsequent decline was then 'diagnosed' by you as likely being a "natural progression", even though he states that his vitamin D levels were "normal". This was apparently after taking 10,000 IU per day? Perhaps Mr. Ball would have been interested to know that 10,000 IU is the figure proposed by Hathcock et al., in 2007 as being the upper tolerance limit for humans [Am. J. Clin. Nutr. 85 (1): 6–18] - and should perhaps raise alarm bells.

    There were several opportunities for you to make more clear that this is just "a blog" and should not be used as an alternative for sound medical advice. There is a lot still unknown about this topic and while "not your problem" (and to use your words) there are plenty of people "stupid enough to make more of" your post that you might wish.

    I have several friends for whom I have great concerns because they follow potentially dangerous alternative health approaches based on the "knowledge" they glean from the internet. One friend takes potentially toxic doses of the cyanide compound 'vitamin' B17 to prevent cancer. I have family members who have not vaccinated their children because they KNOW vaccines cause autism. Another refuses to use toothpaste and spends a fortune on bottled water because fluoride will reduce his IQ and give him cancer.

    Big Pharma is now seen almost universally as demonic and conspiracy theories abound. According to such theories, without the influence of doctors, scientists and pharmaceutical companies, we would already be living in a world without cancer and cardiovascular disease - but we are hiding the answers for the sake of profit. While you clearly hold some cynical views about the profitability of the 'conventional treatment' of heart disease, most doctors are doing the best they can under hugely difficult circumstances (and in the face of patients refusing to change bad behavior). We can only hope that the future is brighter as a result of the research being conducted on the alternative preventive measures to which you subscribe.

    In the meantime, as a doctor, you should perhaps be more aware of your influence and how blindly some people will follow your advice, whether you think you have given it or otherwise.

  • buy jeans

    11/3/2010 8:43:50 PM |

    Aortic valve stenosis is generally regarded as a progressive disease that must eventually be corrected with surgery--period. The only other strategy that has proven to be of any benefit is Crestor 40 mg per day, an intolerable dose in my experience.

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Stenosis detection vs. plaque detection

Stenosis detection vs. plaque detection

One of the most common misunderstandings encountered by both physicians and the public is that, to create an effective heart disease prevention program, we need tools for atherosclerotic plaque detection. What we do not need is a tool for stenosis detection. (Stenosis means percent blockage. A 50% stenosis means 50% of the diameter of an artery is reduced by atherosclerosis.)

This issue came to mind recently with the ongoing conversation at Heart.org forum, in which the conversation predictably degenerated into a "what good are heart scans when there are better tests to detect blockage" sort of mentality.
They are right: There are better tests to detect stenoses or blockages, such as stress tests, heart catheterization, and CT coronary angiography. If someone is having chest pain or breathlessness, these tests are useful to help understand why. These tests are preludes to stents, bypass surgery, and the like. They are the popular tools in hospitals, the ones that provide entry into the revenue-yielding world of heart disease procedures.

Plaque detection, on the other hand, is principally a tool for the person without symptoms. In this regard, it is more like cholesterol testing. I doubt my colleagues would bash cholesterol because it doesn't reveal blockages. Plaque detection identifies the person who has already started developing atherosclerosis.

Dr. William Blanchett of Colorado articulates this idea well:

EBT calcium imaging not only identifies the vast majority of individuals at risk, it also identifies individuals with minimal risk. In other words, it distinguishes those who are likely to benefit from treatment . . .and it identifies those unlikely to benefit from treatment. Furthermore, the greatest value of EBT calcium imaging is that with serial imaging you can determine who is and who is not responding to treatment.

Those patients not responding to the initial treatment are identified by progression of their calcified plaque on a subsequent scan are then placed on additional therapies. The net result is a remarkable reduction in heart attack rates.

Ahh, the voice of reason. Plaque detection empowers you in your prevention program. If you know how much plaque your begin with, you can track that value to know whether you have having a full effect or not. Stenosis detection, on the other hand, empowers your doctor and provides the irresistible impulse to stent.

Another common objection raised to plaque detection is "why bother if you're going to give everybody a statin anyway?" We know the origins of that argument, don't we? If the only strategy known to your doctor is cholesterol reduction with statin drugs, then perhaps that's right. But, with awareness of all the things that go beyond statin drugs, often make them unnecessary, then knowledge of who should engage in an intensive program of prevention or not is enabled by plaque detection.

Comments (5) -

  • BarbaraW

    11/23/2007 3:30:00 AM |

    Happy Thanksgiving to you and your family.  One of the things I am thankful for is that you and others are blogging about these important health and nutrition issues.

  • jpatti

    11/23/2007 11:35:00 PM |

    Since I've already had a bypass, a heart scan is unlikely to give me useful info.  So I'm kind of in the place where understanding tests other than heart scans is more important.  

    Is heart.org a good place to learn things like how to interpret an echocardiogram?  I've got a report in the mail to me right now so I can try to figure it out.

    If not, where would you recommend for the "advanced" post-prevention type of information?

  • Dr. Davis

    11/24/2007 1:18:00 AM |

    jpatti--

    Sorry, I don't know of any such sites that focus on these sorts of tests.

    Have you considered reading a general cardiology text? Most provide more than you will need to know, but a visit to your medical bookstore or library will yield a number of "entry-level" texts that might help you navigate through the maze.

  • Anonymous

    8/20/2010 10:54:26 AM |

    Dear Dr. Davis,

    I'm new to your blog, which I find very interesting and full of what appears to be insightful comments and recommendations. I also find your "unorthodox" stance on many issues very refreshing. I would like to know:
    1.have you published research backing the advice you give on your blog?
    2. has your work been peer reviewed?
    3. could you, please, let me know where I can find them?

    Thanks in advance for your help.

  • buy jeans

    11/3/2010 3:49:24 PM |

    Ahh, the voice of reason. Plaque detection empowers you in your prevention program. If you know how much plaque your begin with, you can track that value to know whether you have having a full effect or not. Stenosis detection, on the other hand, empowers your doctor and provides the irresistible impulse to stent.

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