Biojournal of Science and Technology

A Scholarly Journal for Biological Publications

Biojournal of Science and Technology
Volume 4, P-ISSN:2412-5377, E-ISSN:2410-9754, Article ID:m170011

Research Article

Effects of vitamin D and Ca on the occurrence of myocardial infarction in Bangladesh

Jyosna Khanam1, Roksana Yeasmin2, Md. Siddik Alom3 and Md. Bayejid Hosen3,4*

1Institute of Nutrition and Food Science, University of Dhaka, Bangladesh

2Department of Biochemistry, Ibrahim Medical College, Dhaka, Bangladesh.

3Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka, Bangladesh

4National Forensic DNA Profiling Laboratory, Dhaka Medical College, Dhaka, Bangladesh

Date of Acceptance: Monday, November 27, 2017
Date of Published: Saturday, December 23, 2017

Address corresponds to

Md. Bayejid Hosen
Scientific Officer
Divisional Forensic DNA Screening Laboratory
Khulna Medical College Hospital
Khulna, Bangladesh
Mobile: 8801723654492

Acedemic Editor: Editor-in-Chief

Article Tags
Calcium, HPLC, Myocardial infarction, Vitamin D

To cite this article
Jyosna Khanam, Roksana Yeasmin, Md. Siddik Alom and Md. Bayejid Hosen .Effects of vitamin D and Ca on the occurrence of myocardial infarction in Bangladesh.Biojournal of Science and Technology.Volume 4,2017

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Myocardial infarction (MI), which is the most important manifestation of coronary artery disease, is the leading cause of morbidity and mortality in the world. The aim of the present study was to find out the association of vitamin D and calcium (Ca) with the risk of myocardial infarction in Bangladeshi population. A case-control study on 100 cardiac patients who has experienced MI one or more times and 150 control subjects was conducted. The serum troponin I and Ca levels were measured using Demension Xpand Plus Biochemistry Analyser. Vitamin D was estimated by HPLC method. Over all, we found significantly (p< 0.001) higher level of troponin I in cardiac patients when compared to the control subjects. The serum AST and ALP levels were significantly (p< 0.001, respectively) higher in patients when compared to controls. The level of vitamin D and Ca were also significantly lower (p< 0.001, respectively) in patients. There were significantly negative correlations between Troponin I and Vitamin D as well as Ca (r=-0.68, p< 0.001 and r=-0.27, p< 0.05, respectively) levels were found while between Vitamin D and Ca correlated (r=0.43, p< 0.01) positively. Thus our recent study suggested that may have Vitamin D & C and Ca a significant association with the occurrence of myocardial infarction.


Myocardial infarction (MI) is one of the major manifestations of coronary artery disease (CAD). CAD is considered to be one of the main causes of morbidity around the world (Gouvinhas et al., 2013). According to the World Health Organization (WHO, 2017), every year approximately 17.9 million people die of cardiovascular diseases worldwide that is 31% of all deaths and most of these occur in developing countries. CAD is a multifactorial disorder that is a consequence of an interaction between genetic background and environmental factors such as diet, smoking and physical activity (Smith et al., 1997; Prins et al., 2012). Atherosclerotic plaque formation, hypercholesterolemia, hypertension, and diabetes are considered as major risk factors for CAD (Smith et al., 1997). Vitamins and minerals act as prosthetic groups and cofactors of almost all enzymes and deficiency of vitamin and mineral has been proved to be a major risk factor for coronary artery diseases (Aggarwal et al., 2016; Chowdhury et al. 2015; Reid et al. 2017).

Vitamin D, a fat-soluble vitamin also known as an antiricketic factor or sunshine vitamin, is unique in the sense that the body synthesizes it, and it also functions as a hormone. Besides its pivotal role in calcium homeostasis and bone mineral metabolism, the vitamin D endocrine system is now recognized to be involved in a wide range of fundamental biological functions in cell differentiation, inhibition of cell growth, and immunomodulation. Several human and animal studies have suggested that vitamin D deficiency may be a contributory factor in the pathogenesis of CAD. Vitamin D deficiency has been shown to result in cardiac hypertrophy and fibrosis by elevation of matrix metalloproteinase enzyme (Weishaar et al., 1990; Loftus and Thompson, 2016). It also predisposes to hypertension by upregulation of the renin-angiotensin system (Kong et al., 2010). Similarly, it is also involved in promoting the formation of atheromatous plaque by increasing the uptake of lipids by macrophages and their conversion into foam cells (Wang et al., 2008). CAD is an emerging problem in developing countries like India and responsible for significant morbidity and mortality, and the situation is expected to be worse in the future (Aggarwal et al., 2016). Multiple studies have shown that vitamin D deficiency is widely prevalent in the Indian subcontinent (Ritu and Gupta, 2014; Kumar et al., 2008), and also, there are studies reporting an early onset and aggressive CAD in South Asian population (Sharma and Ganguly, 2005; Joshi et al., 2007). However, only a few studies explore the role of vitamin D deficiency in CAD patients from the Indian subcontinent and have shown conflicting results (Dhibar et al., 2016; Karur et al., 2014; Syal et al., 2012).

Calcium plays a number of critically important roles in physiology and pathology, in addition to its most widely recognised function as a critical structural component of bone (Reid et al. 2017). Many cells have calcium-sensing receptors, with evidence that the concentrations of calcium ions in the extracellular fluid directly regulate cell function (e.g., parathyroid, renal tubule, and many more) (Chowdhury et al. 2015). Extracellular calcium concentration directly impacts on cell membrane potentials, and so impacts on function of all excitable tissues, particularly the nervous system and the heart (Campbell, 1983). Calcium is a key messenger in the contraction of muscle, including the myocardium. A recent study documented that individuals who consume hard water rich in calcium and magnesium have a lower mortality rate from circulatory disease than those who consume soft water (Jin et al. 2013). Several other studies have shown that serum calcium may influence the level of high-density lipoprotein (HDL) cholesterol and decrease the level of low-density lipoprotein (LDL) cholesterol (De Bacquer et al., 1994; Reid et al., 2002). However, some researchers have drawn the opposite conclusion reporting no association between changes in the hardness or calcium content of drinking water and cardiovascular mortality (Lake t al., 2010). The aim of the present study was to investigate the association of vitamin D and calcium (Ca) with the occurrence of myocardial infarction in Bangladeshi population.


The study was a case-control study conducted in 250 subjects (Table 1). The case group comprises 100 cardiac patients who have experienced MI one or more times. The cardiac patients were recruited for this study immediately after being hospitalized with MI symptoms at Coronary Care Unit (CCU) of Sir Salimullah Medical College Hospital without any medical history of other chronic diseases. A total of 150 healthy controls with no history of cardiac or chronic diseases were recruited from different hospitals of Dhaka city where they came for regular health check-up (Table 1). All participants were given an explanation of the nature of the study, and informed consent was obtained. They completed a structured questionnaire covering information on age, gender, medical, family history of chronic diseases and smoking status. Smoking status was summarized as smoker or nonsmoker (Table 1). The study was conducted in accordance with the declaration of Helsinki and its subsequent revisions (World Medical Association, 2013).

Sample Collection

Approximately 3.0 mL of venous blood was drawn from each individual following all aseptic precautions with the help of a trained person, using a disposable syringe. The drawn blood was transferred into a plain tube for the separation of serum and transported to the laboratory using ice-box. The serum was isolated by centrifugation and the biochemical parameters including serum troponin I and Ca levels were measured by Dimension Xpand auto biochemistry analyzer.

Assay of Vitamin D

HPLC method was used to measure serum vitamin D. Sample for vitamin D was prepared according to Turpeinen et al. (2003). Isocratic elution was used to detect vitamin D. In our study, we used a C18 HPLC column (4.6 ×100 mm, 3 μm particle size) and run time was 10 min for each sample. Injection volume was 20 μl. Vitamin D was detected using a UV detector at 265 nm.

Statistical Analysis

All the results were expressed as mean±SEM. GraphPad Prism software were used to perform statistical analyses. The comparisons between two groups were tested by independent samples t-test. A 95% confidence interval was used. P values less than 0.05 were considered as statistically significant. The correlation between two continuous outcomes among MI patients was evaluated using Pearson correlation coefficient.


In this study we have studied the association of vitamin D and Calcium with myocardial infarction in Bangladeshi population. We have also measured the serum levels total protein and hepatic enzymes in study subjects. Statistically significant differences among patients and controls are indicated in Table 1 & 2 and in Fig. 1 along with their significant values.

As shown in Table 1 the Alkaline phosphatase (p<0.001) and Aspartate aminotransferase (p<0.001) levels were significantly higher in MI patients than the control subjects (Table 1). On the other hand, the levels of total protein and Alanine aminotransferase (ALT) were almost similar among the both study groups (Table 1).

Table 1 Baseline characteristics and clinical parameters

Study parameters

Healthy Control (n=150)

CAD Patients (n=100)

P value


53 ± 17

55 ± 12


Gender (n, %)





113 (75)

76 (76)



37 (25)

24 (24)

Smoking Status





60 (40)

41 (41)



90 (60)

59 (59)

Family history




Chemical parameters



     TP (g/dL)

6.95 ± 0.2

6.89 ± 0.15


     ALT (IU/L)

34.4 ± 3.2

27.6 ± 2.2


     AST (IU/L)

29.1 ± 2.2

55.2 ± 4.8


     ALP (IU/L)

74.5 ± 3.8

92.3 ± 3.1


Results are expressed as Mean ± SEM and as number (percentage). Student t-tests were performed to estimate the level of significances. p<0.05 was taken as level of significance. ns; Non-significant. TP; Total Protein, ALT; Alanine aminotransferase, AST; Aspartate aminotransferase, ALP; Alkaline phosphatase.

According to Table 2 the Troponin I level was significantly (p<0.001) higher among MI patients while the Troponin I level was nil in healthy volunteers. On the other hand, The Vitamin D and Calcium levels were significantly lower (p<0.001, respectively) in MI patients than in control subjects.

Table 2 Level of Troponin I, Vitamin D and Calcium in study subjects.


Healthy Controls


MI Patients


p value

Troponin I (ng/mL)

0.028 ± 0.002

22.3± 4.3


Vitamin D (ng/mL)

43.41 ± 2.52

20.17 ± 3.18


Calcium (mg/dL)

8.9 ± 0.25

7.6 ± 0.16


Results are expressed as Mean±SEM. T-test was performed to analyse significance between two groups. p<0.05 was taken as level of significance.

Correlations of Troponin I with Vitamin D as well as Ca, and between Vitamin D & Ca among the patients were estimated and showed in Fig. 1 along with their significant values. There were significantly negative correlations between Troponin I and Vitamin D as well as Ca (r=-0.68, p<0.001 and r=-0.27, p<0.05, respectively) levels were found (Fig. 1a and 1b, respectively) while between Vitamin D and Ca correlated (r=0.43, p<0.01) positively (Fig. 1c).


Figure 1: Correlation of Troponin I with (a) Vitamin D as well as (b) Ca, and (c) between Vitamin D & Ca among the patients.


Vitamin D deficiency appears to be common in acute myocardial infarction (AMI), and preliminary studies indicate a possible association of vitamin deficiency with AMI prognosis in the short and long term (Milazzo et al., 2017). Moreover, vitamin D deficiency seems to predispose to recurrent adverse cardiac events, due to its association with the number of affected coronary arteries, AMI complications, and cardiac remodelling (De Metrio et al., 2015).

Our case control study on AMI suggests that deficiency of vitamin D is highly prevalent in Bangladesh. It revealed that vitamin D level is significantly lower in cases as compared to controls. The Health Professionals Follow-up Study followed up 18,225 men during 10 years and observed an association between low vitamin D levels and increased AMI risk, even after adjustment for other risk factors (Giovannucci et al., 2008).45 Prospective studies have also found a high prevalence of vitamin D deficiency in patients hospitalized with AMI (Roy et al., 2015; Lee et al., 2011). A previous case-control study in patients of acute MI performed in the USA reported similar inverse association between 25(OH) vitamin D levels and risk of acute MI (Scragg et al., 1990). A more recent study from Pakistan revealed that individuals with normal levels of had lower risk of MI as compared to those with vitamin D deficiency (Iqbal et al., 2013). Similarly a study by Syal et al. (2012) from North India in 100 patients undergoing coronary angiography revealed more severe coronary artery disease and greater endothelial dysfunction among individuals with low vitamin D.

Our results show that serum calcium was lower in cases than in controls. A recent study demonstrated a weak causal relationship between the hardness of drinking water and mortality from cardiovascular disease in males (Schroeder, 1960). Another study documented that individuals who consume hard water rich in calcium and magnesium have a lower mortality rate from circulatory disease than those who consume soft water (Jin et al. 2013). However, some researchers have drawn the opposite conclusion. Sabanayagam and Shankar (2011) reported that higher serum calcium levels were positively correlated with hypertension in a representative sample of US adults, which is consistent with our findings. Similarly, in a previous study Lind et al. (1997) found that subjects with a history of MI have significantly higher serum calcium than those without infarction.

In this study, we have found increased levels of Troponin I, AST and ALP as well as decreased level of Albumin among the patients while we could not found any association between ALT and MI. A population based cohort study in the United State also reported no association between MI and ALT, while several investigations showed that ALT and AST are associated with myocardial infarction (Ruhl et al., 2009; Moon et al., 2014; Gao et al., 2017). A recent meta-analysis study conducted on over 9.24 million participants and reported contradictory results (Kunutsor et al., 2014).

In conclusion, our recent study suggested that Vitamin D and Ca deficiency may have a significant association with the occurrence of myocardial infarction and patients should receive hepatic care in Bangladeshi population. Therefore, measurement of Vitamin D, Ca, AST, ALT and ALP would be a biomarker of early diagnosis of CAD and also be helpful to intervene a novel treatment of CAD. However, our study has a small sample size resulting in low power to detect minor to modest associations, therefore further study with large sample size is required.


We would like to acknowledge the support and cooperation of the participants of this study. This research did not receive any specific grant from funding agencies in the public, commercial or not-for profit sectors.


The authors reported that there is no conflict of interest.


Aggarwal R, Akhthar T, Jain S. Coronary artery disease and its association with vitamin D deficiency. Journal of Mid- Life Health. 2016, 7(2):56–60.

Campbell AK. Intracellular Calcium, its universal role as regulator. John Wiley and sons, Chichester, England. 1983.

Chowdhury SN, Sultana N, Chowdhury AH, Mazumder P, Sharmin N, Rahman T. Association of serum Calcium with acute myocardial infarction. Bangladesh J Med Biochem. 2015, 8(1): 16-20. 

De Bacquer D, De Henauw S, De Backer G, Kornitzer M. Epidemiological evidence for an association between serum calcium and serum lipids. Atherosclerosis. 1994, 108(2):193–200.

De Metrio M, Milazzo V, Rubino M, Cabiesti A Moltrasio M, Marana I, et al. Vitamin D plasma levels and in-hospital and 1-year outcomes in acute coronary syndromes: a prospective study. Medicine (Baltimore). 2015, 94(19):e857.

Dhibar DP, Sharma YP, Bhadada SK, Sachdeva N, Sahu KK. Association of vitamin D deficiency with coronary artery disease. Journal of Clinical and Diagnostic Research. 2016, 10(9):OC24–OC28.

Gao M, Cheng Y, Zheng Y, Zhang W, Wang L, Qin L. Association of serum transaminases with short- and long-term outcomes in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. BMC Cardiovasc. Disor. 2017, 17:43.

Giovannucci E, Liu Y, Hollis BW, Rimm EB. 25-hydroxyvitamin D and risk of myocardial infarction in men: a prospective study. Arch Intern Med. 2008, 168(11):1174-80.

Gouvinhas C, Severo M, Azevedo A, Lunet N. Worldwide patterns of ischemic heart disease mortality from 1980 to 2010. Int. J. Cardiol. 2013, 170:309-314.

Iqbal MP, Mehboobali N, Azam I, et al. Association of alkaline phosphatase with acute myocardial infarction in a population with high prevalence of hypovitaminosis D. Clin Chim Acta. 2013, 425:192e195.

Jin Y, He L, Wang Q, Chen Y, Ren X, Tang H, Song X, Ding L, Qi Q, Huang Z, Yu J, Yao Y. Serum calcium levels are not associated with coronary heart disease. Vascular Health and Risk Management. 2013, 9:517–520.

Joshi P, Islam S, Pais P et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA. 2007, 297(3):286–294.

Karur S, Veerappa V, Nanjappa MC. Study of vitamin D deficiency prevalence in acute myocardial infarction. IJC Heart & Vessels. 2014, 3:57–59.

Kong J, Kim GH, Wei M et al. Therapeutic effects of vitamin D analogs on cardiac hypertrophy in spontaneously hypertensive rats. American Journal of Pathology. 2010, 177(2):622–631.

Kumar R, Mishra RK, Kochupillai N. Prevalence & potential significance of vitamin D deficiency in Asian Indians. Indian Journal of Medical Research. 2008, 127(3):229–238.

Kunutsor SK, Apekey TA, Seddoh D, Walley J. Liver enzymes and risk of all-cause mortality in general populations: A systematic review and meta-analysis. Int. J. Epidemiol. 2014. 43;187-201.

Lake IR, Swift L, Catling LA, Abubakar I, Sabel CE, Hunter PR. Effect of water hardness on cardiovascular mortality: an ecological time series approach. J Public Health (Oxf). 2010, 32(4):479–487.

Lee JH, Gadi R, Spertus JA, Tang F, O’Keefe JH. Prevalence of vitamin D deficiency in patients with acute myocardial infarction. Am J Cardiol. 2011, 107(11):1636-1638.

Lind L, Skarfors E, Berglund L, Lithell H, Ljunghall S. Serum calcium: a new, independent, prospective risk factor for myocardial infarction in middle aged men followed for 18 years. J clin epidemiol. 1997, 50(8):967-973.

Loftus I, Thompson M. The role of matrix metalloproteinases in vascular disease. Vascular Medicine. 2016, 7(2):117–133.

Milazzo V, De Metrio M, Cosentino N, Marenzi G, Tremoli E. Vitamin D and acute myocardial infarction. Word J Cardiol. 2017, 9(1):14-20.

Moon J, Kang W, Oh PC, Lee K, Han SH, Ahn T, Shin E. Serum transaminase determined in the emergency room predicts outcomes in patients with acute ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention. Int. J. Cardiol. 2014, 177:442-447.

Prins BP, Lagou V, Asselbergs FW, Snieder H, Fu J. Genetics of coronary artery disease: Genome-wide association studies and beyond. Atherosclerosis. 2012, 225:1-10.

Reid IR, Bristow SM, Bolland MJ. Calcium and cardiovascular disease. Endocrinol Metab. 2017, 32:339-349.

Reid IR, Mason B, Horne A, et al. Effects of calcium supplementation on serum lipid concentrations in normal older women: a randomized controlled trial. Am J Med. 2002, 112(5):343–347.

Ritu G, Gupta A. Vitamin D deficiency in India: prevalence, causalities and interventions. Nutrients. 2014, 6(2):729–775.

Roy A, Lakshmy A, Tarik M, Tandon N, Reddy KS, Prabhakaran D. Independent association of severe vitamin D deficiency as a risk of acute myocardial infarction in Indians. Indian Heart Journal. 2015, 167:27e32.

Ruhl CE, Everhart JE. Elevated serum alanine aminotransferase and gamma-glutamyltransferase and mortality in the United States population. Gastroenterology. 2009, 136:477-485.

Sabanayagam C, Shankar A. Serum calcium levels and hypertension among US adults. J Clin Hypertens (Greenwich). 2011, 13(10):716–721.

Schroeder HA. Relations between hardness of water and death rates from certain chronic and degenerative diseases in the United States. J Chronic Dis. 1960, 12:586–591.

Scragg R, Jackson R, Holdaway IM, et al. Myocardial infarction is inversely associated with plasma 25-hydroxyvitamin D 3 levels: a community based study. Int J Epidemiol. 1990, 19:559e563.

Sharma M, Ganguly NK. Premature coronary artery disease in Indians and its associated risk factors. Vascular Health and Risk Management. 2005, 1(3):217–225.

Smith F, Lee A, Fowkes F, Price J, Rumley A, Lowe G. Hemostatic factors as predictors of ischemic heart disease and stroke in the Edinburgh Artery Study. Arterioscler. Thromb. Vasc. Biol. 1997, 17:3321-3325.

Syal SK, A. Kapoor, E. Bhatia et al. Vitamin D deficiency, coronary artery disease, and endothelial dysfunction: observations from a coronary angiographic study in Indian patients. Journal of Invasive Cardiology. 2012, 24(8):385–389.

Syal SK, Kapoor A, Bhatia E, et al. Vitamin D deficiency, coronary artery disease, and endothelial dysfunction:observations from a coronary angiographic study in Indian patients. J Invasive Cardiol. 2012, 24(8):385-389.

Turpeinen U, Hohenthal U, Stenman UH. Determination of 25-hydroxyvitamin D in serum by HPLC and immunoassay. Clin. Chem. 2003, 49:1521–1524.

Wang TJ, Pencina MJ, Booth SL et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation. 2008, 117(4):503–511.

Weishaar RE, Kim SN, Saunders DE, Simpson RU. Involvement of vitamin D3 with cardiovascular function. III. Effects on physical and morphological properties. American Journal of Physiology Endocrinology and Metabolism. 1990, 258(1):134–142.

World Health Organization (WHO)., Accessed on July 21, 2017.

World Medical Association. 2013. World medical association declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA. 310, 2191-2194.