Document Type : Original Article
Authors
- Amir Askarinejad 1
- hooman bakhshande 2
- Mona Heidarali 2
- Sara Adimi 1
- Zahra Ghaemmaghami 1
- Majid Haghjoo 3
1 Rajaie Cardiovascular Medical and Research Center, Iran university of medical sciences, Tehran, Iran
2 Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
3 Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
Abstract
BACKGROUND: Atrial fibrillation (AF) augments the risk of stroke by 4-5 times. Vitamin D is pivotal in numerous metabolic pathways. A handful of studies have explored the correlation between vitamin D deficiency (VDD) and AF outcomes. Hence, the authors sought to assess the relationship between VDD and AF outcomes.
METHODS: From December 2021 to February 2023, 190 patients with AF were incorporated into the authors’ study. Given the seasonal fluctuation of vitamin D levels, these levels were examined from the start of December until the end of March.
RESULTS: The final analysis comprised 190 patients (55.8% male) with an average age of 46.22±15.03. Vitamin D deficiency, insufficiency, and sufficiency were noted in 77 (40.5%), 46 (24.2%), and 67 (35.3%) patients, respectively. Fatigue and syncope were significantly more prevalent in the VDD group than in other groups. Three-vessel disease was more frequent in the VDD group (p-value=0.04). Mortality was more prevalent in patients with VDD (6.31%) compared to the VDI (2.10%) and VDS (0.05%) groups (p = 0.03). Successful cardioversion was significantly more prevalent in the VDS group (p = 0.03).
CONCLUSION: A sufficient level of vitamin D was linked with a better response to cardioversion. However, low vitamin D levels are correlated with higher mortality in AF patients.
Keywords
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3. Björck S, Palaszewski B, Friberg L, Bergfeldt L. Atrial fibrillation, stroke risk, and warfarin therapy revisited: a population-based study. Stroke. 2013 Nov;44(11):3103-8. https://doi.org/10.1161/STROKEAHA.113.002329
4. Krijthe BP, Kunst A, Benjamin EJ, Lip GYH, Franco OH, Hofman A, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J. 2013 Sep;34(35):2746-51. https://doi.org/10.1093/eurheartj/eht280
5. Lau DH, Nattel S, Kalman JM, Sanders P. Modifiable Risk Factors and Atrial Fibrillation. Circulation 2017;136(6):583-96. https://doi.org/10.1161/CIRCULATIONAHA.116.023163
6. Guta AC, Badano LP, Tomaselli M, Mihalcea D, Bartos D, Parati G, et al. The Pathophysiological Link between Right Atrial Remodeling and Functional Tricuspid Regurgitation in Patients with Atrial Fibrillation: A Three-Dimensional Echocardiography Study. J Am Soc Echocardiogr. 2021 Jun;34(6):585-594.e1. https://doi.org/10.1016/j.echo.2021.01.004
7. Kassi E, Adamopoulos C, Basdra EK, Papavassiliou AG. Role of vitamin D in atherosclerosis. Circulation. 2013 Dec 3;128(23):2517-31. https://doi.org/10.1161/CIRCULATIONAHA.113.002654
8. Beveridge L, Witham M. Vitamin D and the cardiovascular system. Osteoporos Int 2013;24:2167-80. https://doi.org/10.1007/s00198-013-2281-1
9. Turin A, Bax JJ, Doukas D, Joyce C, Lopez JJ, Mathew V, et al. Interactions Among Vitamin D, Atrial Fibrillation, and the Renin-Angiotensin-Aldosterone System. Am J Cardiol 2018;122(5):780-4. https://doi.org/10.1016/j.amjcard.2018.05.013
10. Hu Y-F, Chen Y-J, Lin Y-J, Chen S-A. Inflammation and the pathogenesis of atrial fibrillation. Nat Rev Cardiol 2015;12(4):230-43. https://doi.org/10.1038/nrcardio.2015.2
11. Heidarali M, Bakhshandeh H, Golpira R, Fazelifar A, Alizadeh‐Diz A, Emkanjoo Z, et al. A prospective survey of atrial fibrillation management in Iran: Baseline results of the Iranian Registry of Atrial Fibrillation (IRAF). Int J Clin Pract. 2021;75(8):e14313. https://doi.org/10.1111/ijcp.14313
12. Flack JM, Adekola B. Blood pressure and the new ACC/AHA hypertension guidelines. Trends Cardiovasc Med. 2020;30(3):160-4. https://doi.org/10.1016/j.tcm.2019.05.003
13. Halawani AFM, Alahmari ZS, Asiri DA, Albraheem AA, Alsubaie AMA, Alqurashi AG, et al. Diagnosis and Management of Dyslipidemia. Arch Pharm Pract 2019;10(4):67-70.
14. Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A. Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med 2016;164(8):542-52. https://doi.org/10.7326/M15-3016
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18. Dilaveris PE, Kennedy HL. Silent atrial fibrillation: epidemiology, diagnosis, and clinical impact. Clin Cardiol 2017;40(6):413-8. https://doi.org/10.1002/clc.22667
19. Group CW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int 2013;3(1):1-150.
20. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015; 16(3):233-70. https://doi.org/10.1093/ehjci/jev014
21. Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2019;32(1):1-64. https://doi.org/10.1016/j.echo.2018.06.004
22. Qayyum F, Landex NL, Agner BR, Rasmussen M, Jøns C, Dixen U. Vitamin D deficiency is unrelated to type of atrial fibrillation and its complications. Dan Med J 2012;59(9):A4505.
23. Ozcan OU, Gurlek A, Gursoy E, Gerede DM, Erol C. Relation of vitamin D deficiency and new-onset atrial fibrillation among hypertensive patients. J Am Soc Hypertens 2015;9(4):307-12. https://doi.org/10.1016/j.jash.2015.01.009
24. Beckmann Y, Türe S, Duman SU. Vitamin D deficiency and its association with fatigue and quality of life in multiple sclerosis patients. EPMA J 2020;11:65-72. https://doi.org/10.1007/s13167-019-00191-0
25. Roy S, Sherman A, Monari-Sparks MJ, Schweiker O, Hunter K. Correction of Low Vitamin D Improves Fatigue: Effect of Correction of Low Vitamin D in Fatigue Study (EViDiF Study). N Am J Med Sci 2014;6(8):396-402. https://doi.org/10.4103/1947-2714.139291
26. Wadhwania R. Is Vitamin D Deficiency Implicated in Autonomic Dysfunction? J Pediatr Neurosci 2017;12(2):119-23. https://doi.org/10.4103/jpn.JPN_1_17
27. Gilani A, Ramsay SE, Welsh P, Papacosta O, Lennon LT, Whincup PH, et al. Vitamin D deficiency is associated with orthostatic hypotension in older men: a cross-sectional analysis from the British Regional Heart Study. Age Ageing 2020;50(1):198-204. https://doi.org/10.1093/ageing/afaa146
28. Usalp S, Kemal H, Yüksek Ü, Yaman B, Günsel A, Edebal O, et al. Is there any link between vitamin D deficiency and vasovagal syncope? J Arrhythm 2020;36(2):371-6. https://doi.org/10.1002/joa3.123 09
29. Han L, Xu X-J, Zhang J-S, Liu H-M. Association between Vitamin D Deficiency and Levels of Renin and Angiotensin in Essential Hypertension. Int J Clin Pract 2022: 8975396. https://doi.org/10.1155/2022/8975396
30. Ni W, Watts SW, Ng M, Chen S, Glenn DJ, Gardner DG. Elimination of vitamin D receptor in vascular endothelial cells alters vascular function. Hypertension 2014;64(6):1290-8. https://doi.org/10.1161/HYPERTENSIONAHA.114.03971
31. Tomaschitz A, Pilz S, Ritz E, Grammer T, Drechsler C, Boehm BO, et al. Independent association between 1, 25-dihydroxyvitamin D, 25-hydroxyvitamin D and the renin-angiotensin system: the Ludwigshafen Risk and Cardiovascular Health (LURIC) study. Clin Chim Acta 2010;411(17-18):1354-60. https://doi.org/10.1016/j.cca.2010.05.037
32. Pittas AG, Lau J, Hu FB, Dawson-Hughes B. The Role of Vitamin D and Calcium in Type 2 Diabetes. A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2007;92(6):2017-29. https://doi.org/10.1210/jc.2007-0298
33. Targher G, Bertolini L, Padovani R, Zenari L, Scala L, Cigolini M, et al. Serum 25‐hydroxyvitamin D3 concentrations and carotid artery intima‐media thickness among type 2 diabetic patients. Clin Endocrinol 2006;65(5):593-7. https://doi.org/10.1111/j.1365-2265.2006.02633.x
34. Isaia G, Giorgino R, Adami S. High prevalence of hypovitaminosis D in female type 2 diabetic population. Diabetes Care 2001;24(8):1496. https://doi.org/10.2337/diacare.24.8.1496
35. Herrington W, Lacey B, Sherliker P, Armitage J, Lewington S. Epidemiology of atherosclerosis and the potential to reduce the global burden of atherothrombotic disease. Circ Res 2016;118(4):535-46. https://doi.org/10.1161/CIRCRESAHA.115.307611
36. Menezes AR, Lamb MC, Lavie CJ, DiNicolantonio JJ. Vitamin D and atherosclerosis. Curr Opin Cardiol 2014;29(6):571-7. https://doi.org/10.1097/HCO.0000000000000108
37. Syal SK. Vitamin D deficiency, coronary artery disease, and endothelial dysfunction: observations from a coronary angiographic study in Indian patients. J Invasive Cardiol 2012;24(8): (8):385-9.
38. Akin F, Ayça B, Köse N, Duran M, Sarı M, Uysal OK, et al. Serum vitamin D levels are independently associated with severity of coronary artery disease. J Investig Med 2012;60(6):869-73. https://doi.org/10.2310/JIM.0b013e31825457cb
39. Schnatz PF, Nudy M, O’Sullivan DM, Jiang X, Cline JM, Kaplan JR, et al. The quantification of vitamin D receptors in coronary arteries and their association with atherosclerosis. Maturitas 2012;73(2):143-7. https://doi.org/10.1016/j.maturitas.2012.03.014
40. Yaman B, Cerit L, Günsel HK, Cerit Z, Usalp S, Yüksek Ü, et al. Is there any link between vitamin d and recurrence of atrial fibrillation after cardioversion? Braz J Cardiovasc Surg 2020;35:191-7. https://doi.org/10.21470/1678-9741-2019-0166
41. Effat Fakhry E, Tawfik Ibrahim M. Relationship between vitamin D deficiency and success of cardioversion in patients with atrial fibrillation. Herzschrittmacherther Elektrophysiol 2022;33(2): 209-16. https://doi.org/10.1007/s00399-022-00846-y
42. Yaman B, Cerit L, Günsel HK, Cerit Z, Usalp S, Yüksek Ü, et al. Is there any Link Between Vitamin D and Recurrence of Atrial Fibrillation after Cardioversion? Braz J Cardiovasc Surg 2020;35(2):191-7. https://doi.org/10.21470/1678-9741-2019-0166
43. Canpolat U, Aytemir K, Hazirolan T, Özer N, Oto A. Relationship between vitamin D level and left atrial fibrosis in patients with lone paroxysmal atrial fibrillation undergoing cryoballoon-based catheter ablation. J Cardiol 2017;69(1):16-23. https://doi.org/10.1016/j.jjcc.2016.06.012
44. Hussain A, Al Anazi F, Alanazi A, Alshahrani A, Alharbi N, Aleshaiwy T, et al. The relation between atrial fibrillation cardioversion success rate with Vitamin D Level in patients underwent elective cardioversion in King Abdulaziz Cardiac Center, King Abdulaziz Medical City for National Guards, Riyadh Saudi Arabia. Heart Views 2023;24(1):17-23. https://doi.org/10.4103/heartviews.heartviews_80_22
45. Melamed ML, Michos ED, Post W, Astor B. 25-Hydroxyvitamin D Levels and the Risk of Mortality in the General Population. Arch Intern Med 2008;168(15):1629-37. https://doi.org/10.1001/archinte.168.15.1629
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3. Björck S, Palaszewski B, Friberg L, Bergfeldt L. Atrial fibrillation, stroke risk, and warfarin therapy revisited: a population-based study. Stroke. 2013 Nov;44(11):3103-8. https://doi.org/10.1161/STROKEAHA.113.002329
4. Krijthe BP, Kunst A, Benjamin EJ, Lip GYH, Franco OH, Hofman A, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J. 2013 Sep;34(35):2746-51. https://doi.org/10.1093/eurheartj/eht280
5. Lau DH, Nattel S, Kalman JM, Sanders P. Modifiable Risk Factors and Atrial Fibrillation. Circulation 2017;136(6):583-96. https://doi.org/10.1161/CIRCULATIONAHA.116.023163
6. Guta AC, Badano LP, Tomaselli M, Mihalcea D, Bartos D, Parati G, et al. The Pathophysiological Link between Right Atrial Remodeling and Functional Tricuspid Regurgitation in Patients with Atrial Fibrillation: A Three-Dimensional Echocardiography Study. J Am Soc Echocardiogr. 2021 Jun;34(6):585-594.e1. https://doi.org/10.1016/j.echo.2021.01.004
7. Kassi E, Adamopoulos C, Basdra EK, Papavassiliou AG. Role of vitamin D in atherosclerosis. Circulation. 2013 Dec 3;128(23):2517-31. https://doi.org/10.1161/CIRCULATIONAHA.113.002654
8. Beveridge L, Witham M. Vitamin D and the cardiovascular system. Osteoporos Int 2013;24:2167-80. https://doi.org/10.1007/s00198-013-2281-1
9. Turin A, Bax JJ, Doukas D, Joyce C, Lopez JJ, Mathew V, et al. Interactions Among Vitamin D, Atrial Fibrillation, and the Renin-Angiotensin-Aldosterone System. Am J Cardiol 2018;122(5):780-4. https://doi.org/10.1016/j.amjcard.2018.05.013
10. Hu Y-F, Chen Y-J, Lin Y-J, Chen S-A. Inflammation and the pathogenesis of atrial fibrillation. Nat Rev Cardiol 2015;12(4):230-43. https://doi.org/10.1038/nrcardio.2015.2
11. Heidarali M, Bakhshandeh H, Golpira R, Fazelifar A, Alizadeh‐Diz A, Emkanjoo Z, et al. A prospective survey of atrial fibrillation management in Iran: Baseline results of the Iranian Registry of Atrial Fibrillation (IRAF). Int J Clin Pract. 2021;75(8):e14313. https://doi.org/10.1111/ijcp.14313
12. Flack JM, Adekola B. Blood pressure and the new ACC/AHA hypertension guidelines. Trends Cardiovasc Med. 2020;30(3):160-4. https://doi.org/10.1016/j.tcm.2019.05.003
13. Halawani AFM, Alahmari ZS, Asiri DA, Albraheem AA, Alsubaie AMA, Alqurashi AG, et al. Diagnosis and Management of Dyslipidemia. Arch Pharm Pract 2019;10(4):67-70.
14. Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A. Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med 2016;164(8):542-52. https://doi.org/10.7326/M15-3016
15. Cesar L, Ferreira J, Armaganijan D, Gowdak L, Mansur A, Bodanese LC, et al. Guideline for stable coronary artery disease. Arq Bras Cardiol 2014;103:01-59. https://doi.org/10.5935/abc.2014S004
16. Weintraub WS, King III SB, Douglas Jr JS, Kosinski AS. Percutaneous transluminal coronary angioplasty as a first revascularization procedure in single-, double-and triple-vessel coronary artery disease. J Am Coll Cardiol 1995;26(1):142-51. https://doi.org/10.1016/0735-1097(95)00136-N
17. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010;137(2):263-72. https://doi.org/10.1378/chest.09-1584
18. Dilaveris PE, Kennedy HL. Silent atrial fibrillation: epidemiology, diagnosis, and clinical impact. Clin Cardiol 2017;40(6):413-8. https://doi.org/10.1002/clc.22667
19. Group CW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int 2013;3(1):1-150.
20. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015; 16(3):233-70. https://doi.org/10.1093/ehjci/jev014
21. Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2019;32(1):1-64. https://doi.org/10.1016/j.echo.2018.06.004
22. Qayyum F, Landex NL, Agner BR, Rasmussen M, Jøns C, Dixen U. Vitamin D deficiency is unrelated to type of atrial fibrillation and its complications. Dan Med J 2012;59(9):A4505.
23. Ozcan OU, Gurlek A, Gursoy E, Gerede DM, Erol C. Relation of vitamin D deficiency and new-onset atrial fibrillation among hypertensive patients. J Am Soc Hypertens 2015;9(4):307-12. https://doi.org/10.1016/j.jash.2015.01.009
24. Beckmann Y, Türe S, Duman SU. Vitamin D deficiency and its association with fatigue and quality of life in multiple sclerosis patients. EPMA J 2020;11:65-72. https://doi.org/10.1007/s13167-019-00191-0
25. Roy S, Sherman A, Monari-Sparks MJ, Schweiker O, Hunter K. Correction of Low Vitamin D Improves Fatigue: Effect of Correction of Low Vitamin D in Fatigue Study (EViDiF Study). N Am J Med Sci 2014;6(8):396-402. https://doi.org/10.4103/1947-2714.139291
26. Wadhwania R. Is Vitamin D Deficiency Implicated in Autonomic Dysfunction? J Pediatr Neurosci 2017;12(2):119-23. https://doi.org/10.4103/jpn.JPN_1_17
27. Gilani A, Ramsay SE, Welsh P, Papacosta O, Lennon LT, Whincup PH, et al. Vitamin D deficiency is associated with orthostatic hypotension in older men: a cross-sectional analysis from the British Regional Heart Study. Age Ageing 2020;50(1):198-204. https://doi.org/10.1093/ageing/afaa146
28. Usalp S, Kemal H, Yüksek Ü, Yaman B, Günsel A, Edebal O, et al. Is there any link between vitamin D deficiency and vasovagal syncope? J Arrhythm 2020;36(2):371-6. https://doi.org/10.1002/joa3.123 09
29. Han L, Xu X-J, Zhang J-S, Liu H-M. Association between Vitamin D Deficiency and Levels of Renin and Angiotensin in Essential Hypertension. Int J Clin Pract 2022: 8975396. https://doi.org/10.1155/2022/8975396
30. Ni W, Watts SW, Ng M, Chen S, Glenn DJ, Gardner DG. Elimination of vitamin D receptor in vascular endothelial cells alters vascular function. Hypertension 2014;64(6):1290-8. https://doi.org/10.1161/HYPERTENSIONAHA.114.03971
31. Tomaschitz A, Pilz S, Ritz E, Grammer T, Drechsler C, Boehm BO, et al. Independent association between 1, 25-dihydroxyvitamin D, 25-hydroxyvitamin D and the renin-angiotensin system: the Ludwigshafen Risk and Cardiovascular Health (LURIC) study. Clin Chim Acta 2010;411(17-18):1354-60. https://doi.org/10.1016/j.cca.2010.05.037
32. Pittas AG, Lau J, Hu FB, Dawson-Hughes B. The Role of Vitamin D and Calcium in Type 2 Diabetes. A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2007;92(6):2017-29. https://doi.org/10.1210/jc.2007-0298
33. Targher G, Bertolini L, Padovani R, Zenari L, Scala L, Cigolini M, et al. Serum 25‐hydroxyvitamin D3 concentrations and carotid artery intima‐media thickness among type 2 diabetic patients. Clin Endocrinol 2006;65(5):593-7. https://doi.org/10.1111/j.1365-2265.2006.02633.x
34. Isaia G, Giorgino R, Adami S. High prevalence of hypovitaminosis D in female type 2 diabetic population. Diabetes Care 2001;24(8):1496. https://doi.org/10.2337/diacare.24.8.1496
35. Herrington W, Lacey B, Sherliker P, Armitage J, Lewington S. Epidemiology of atherosclerosis and the potential to reduce the global burden of atherothrombotic disease. Circ Res 2016;118(4):535-46. https://doi.org/10.1161/CIRCRESAHA.115.307611
36. Menezes AR, Lamb MC, Lavie CJ, DiNicolantonio JJ. Vitamin D and atherosclerosis. Curr Opin Cardiol 2014;29(6):571-7. https://doi.org/10.1097/HCO.0000000000000108
37. Syal SK. Vitamin D deficiency, coronary artery disease, and endothelial dysfunction: observations from a coronary angiographic study in Indian patients. J Invasive Cardiol 2012;24(8): (8):385-9.
38. Akin F, Ayça B, Köse N, Duran M, Sarı M, Uysal OK, et al. Serum vitamin D levels are independently associated with severity of coronary artery disease. J Investig Med 2012;60(6):869-73. https://doi.org/10.2310/JIM.0b013e31825457cb
39. Schnatz PF, Nudy M, O’Sullivan DM, Jiang X, Cline JM, Kaplan JR, et al. The quantification of vitamin D receptors in coronary arteries and their association with atherosclerosis. Maturitas 2012;73(2):143-7. https://doi.org/10.1016/j.maturitas.2012.03.014
40. Yaman B, Cerit L, Günsel HK, Cerit Z, Usalp S, Yüksek Ü, et al. Is there any link between vitamin d and recurrence of atrial fibrillation after cardioversion? Braz J Cardiovasc Surg 2020;35:191-7. https://doi.org/10.21470/1678-9741-2019-0166
41. Effat Fakhry E, Tawfik Ibrahim M. Relationship between vitamin D deficiency and success of cardioversion in patients with atrial fibrillation. Herzschrittmacherther Elektrophysiol 2022;33(2): 209-16. https://doi.org/10.1007/s00399-022-00846-y
42. Yaman B, Cerit L, Günsel HK, Cerit Z, Usalp S, Yüksek Ü, et al. Is there any Link Between Vitamin D and Recurrence of Atrial Fibrillation after Cardioversion? Braz J Cardiovasc Surg 2020;35(2):191-7. https://doi.org/10.21470/1678-9741-2019-0166
43. Canpolat U, Aytemir K, Hazirolan T, Özer N, Oto A. Relationship between vitamin D level and left atrial fibrosis in patients with lone paroxysmal atrial fibrillation undergoing cryoballoon-based catheter ablation. J Cardiol 2017;69(1):16-23. https://doi.org/10.1016/j.jjcc.2016.06.012
44. Hussain A, Al Anazi F, Alanazi A, Alshahrani A, Alharbi N, Aleshaiwy T, et al. The relation between atrial fibrillation cardioversion success rate with Vitamin D Level in patients underwent elective cardioversion in King Abdulaziz Cardiac Center, King Abdulaziz Medical City for National Guards, Riyadh Saudi Arabia. Heart Views 2023;24(1):17-23. https://doi.org/10.4103/heartviews.heartviews_80_22
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