Abstract P340: Assessment of Vitamin Levels on Atherosclerotic Cardiovascular Disease Risk: A Resident Driven Quality Improvement Initiative
Authors: Chang Eric Y , Umar Anam , Stevens Elyse S , Bilal Muhammad , Sukkari Mohamad , Padigala Pooja , Gopalakrishnan Anita , Elhammali Balsam , Bakinde Nicolas 
Published: March 2019

Background:
Hypertension is a significant risk factor for cardiovascular disease. According to the Centers for Disease Control and Prevention (CDC) half of all United States citizens with hypertension (HTN) do not have their blood pressure under control. As such, HTN remains a large public health challenge, especially in patients with other comorbidities such as diabetes or poor nutritional status. Our goal was to assess the correlation between various vitamin levels with both HTN and atherosclerotic cardiovascular disease (ASCVD) risk in diabetic patients in order to identify potential targets for intervention to further decrease ASCVD and HTN risk.

Methods:
We obtained data from the medical record data warehouse of a primary care outpatient clinic predominantly run by internal medicine residents within a large safety-net hospital from January to December 2015. Patients with a diagnosis of diabetes mellitus (both type 1 and 2) were identified and electronic medical records were reviewed. ASCVD risk scores were calculated using the American College of Cardiology ASCVD risk estimator. Linear and logistical regression analyses were performed using SPSS software to assess the correlation between Vitamin B12, Vitamin D, and folic acid levels with both HTN and ASCVD risk.

Results:
Our patient population was predominantly African American (93%, 1633 of 1750). ASCVD scores could be calculated for 883 patients (60% female) and 94% (829 of 883) of these patients had elevated ASCVD risk scores ≥7.5. 86% (760 of 883) of patients had a diagnosis of hypertension or were on anti-hypertensive treatment. However, analyses of Vitamin D (14%, 126 of 883), Vitamin B12 (31%, 273 of 883), and folic acid (18%, 159 of 883) levels did not reveal any statistically significant correlation with HTN or ASCVD risk, even when stratified for different levels of a1c, ASCVD, or categories of HTN. There was however, a non-statistically significant correlation between vitamin D deficiency and HTN across all a1c levels (a1c <7, r=0.767, p=0.08; a1c ≥7 & <10, r=0.703, p=0.11; a1c ≥7, r=0.543, p=0.09)

Conclusion:
Our mathematical model cannot be used to explain any statistically significant correlation between Vitamin D, Vitamin B12, or folic acid levels with HTN or ASCVD risk in diabetic patients despite the fact that some studies have noted a potential association. This may reflect an inherent difference in our population (predominantly African American) or may be due to the low baseline monitoring rates of these vitamins. Future aims include initiating a targeted educational intervention for residents in the continuity clinic to not only actively monitor these vitamin levels in high risk populations, but to also demonstrate that resident driven intervention is an effective way to modify both HTN and ASCVD risk factors. Further studies are necessary to elucidate the long term relationship between vitamin levels and CVD risk.