Thiamine Level in Hospitalized Elderly Egyptian Patients with Congestive Heart Failure and Left Ventricular Systolic Dysfunction

To the Editor: Heart failure is a major cause of morbidity and mortality in the world and is the leading cause of hospitalization in older patients.1 There is a growing interest in the role of metabolic abnormalities in myocardial damage and dysfunction.2 Thiamine pyrophosphate (TPP) serves as coenzyme for the oxidative decarboxylation in the mitochondria. It accounts for more than 80% of total erythrocyte thiamine and alone is taken as the best expression of thiamine nutritional status.3 The incidence of thiamine deficiency in patients with heart failure ranges from 13% to 93%.2 Most studies concerning that issue have been conducted in developed countries, with sparse data from developing countries. The current study aimed to determine thiamine status in elderly Egyptian patients with congestive heart failure (CHF) with left ventricular systolic dysfunction (LVSD). A case control study was conducted of 126 individuals aged 60 and older recruited from geriatric, cardiology, and internal medicine departments and a geriatrics outpatient clinic at Ain Shams University hospital, subdivided into two groups matched for age, sex and nutritional risk: cases group (63 individuals with CHF diagnosed according to the Framingham criteria with left ventricular ejection fraction (LVEF) less than 50%) and control group (63 individuals). Subjects taking vitamins or other drugs, having diseases affecting thiamine level, or unable to give informed consent were excluded. Demographic data, medical history, mini-nutritional assessment, and assessment of liver and kidney functions and fasting blood sugar were evaluated for all participants. TPP (normal range 32–95 ng/mL) was determined using high-performance liquid chromatography (Vitamin B1 HPLC Kit, Immunodiagnostic, Bensheim, Germany). Sixty-three patients with CHF with LVEF less than 50% were recruited between June 2006 and June 2007. Mean age was 67.0±4.6; 40 (63.5%) were male and 23 (36.5%) female. None had diabetes mellitus. All were receiving furosemide diuretic therapy. Twenty-eight were New York Heart Association (NYHA) Class II, 26 were Class III, and nine were Class IV; 22 had a LVEF of 35% to 49%, 28 of 25% to 34%, and 13 of less than 25%. There was no difference in nutritional status between cases and controls, with 32 of cases having good nutrition, 22 probably being malnourished, and nine having bad nutrition, versus 34 of controls with good nutrition, 25 probably malnourished, and four with bad nutrition (P=.69). Seventeen cases with CHF were found to be thiamine deficient, compared with nine in the control group, but this was not statistically significant (P=.08). TPP level was significantly lower in cases (45.1 ng/mL (range 16.0–79.5 ng/mL) than controls (52.6 ng/mL (range 20.1–90.1 ng/mL) (P=.01). There was a highly significant positive correlation between TPP level and LVEF (correlation coefficient=0.63, P<.001) (Figure 1). The relationship between thiamine pyrophosphate level and left ventricular ejection fraction. Two-thirds of cases of Egyptians with CHF had systolic heart failure, and these patients require more hospitalization, as found in a retrospective study assessing the frequency of systolic versus diastolic heart failure in an Egyptian cohort.4 In agreement with many studies,5,6 the current study showed that TPP was significantly lower in elderly Egyptian subjects with heart failure. Most studies assumed that using loop diuretics increased urinary excretion of thiamine7 and that malnutrition were the causes of thiamine deficiency in patients with CHF. The current study population was characterized by being probably malnourished, and all were receiving diuretic therapy, but assessing the relationship between these variables and thiamine level was outside of the scope of the study. The current study showed a highly significant positive correlation between TPP level and LVEF, which may be explained in two ways: lower thiamine level worsens myocardial performance or patients with greater impairment in EF are more vulnerable to thiamine deficiency. Thiamine repletion can improve left ventricular function and biochemical evidence of thiamine deficiency in some patients with moderate to severe CHF who are receiving long-term furosemide therapy.8 In a study of 30 patients with CHF (aged 75.4±0.7, LVEF ≤35%), LVEF increased by 5.3±1.4% after they took capsules containing a combination of high-dose micronutrients including thiamine for 9 months and was unchanged in the placebo group (P<.05),9 and in a recent case series, normalization of cardiac function was observed in 11 patients with dilated cardiomyopathy who received standard therapy in addition to micronutrient supplementation with coenzyme Q10, vitamin B1, and amino acids.10 Elderly Egyptian patients with left ventricular systolic dysfunction had lower thiamine levels than their matched controls, with a positive correlation between thiamine level and ejection fraction. We are indebted to Mr. Abd-Elziz Elgarf, statistician, for his kind effort in statistical analysis. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. This study was supported and funded by the Faculty of Medicine, Ain Shams University. Author Contributions: Prof. Ahmed K. Mortagy: design, provision the scientific material, and revising the letter. Prof. Hosam M. Fahmy: supervising the laboratory work and revising the manuscript. Dr. Sarah A. Hamza: writing the letter. Dr. Manar M.A. Maamoun: writing the manuscript, analysis of data. Rania M. Abo-Hashem: clinical work and acquisition of subjects and data. Sponsor's Role: None.