High Dose Vitamin D, Digoxin, and BiDil Reverse Congestive Heart Failure in a Critically ILL Trauma Patient and a Severely Obese Male Patient

Presently, the prevalence of congestive heart failure in the United States is 6.5 million people. We report two cases of severe congestive heart failure patients with a very poor prognosis, treated successfully with a combination of high dose vitamin D, digoxin, and BiDil (Matthews’ Two Inotrope Protocol). Further studies are needed to fully appreciate the overall healthcare changes associated with this simple drug therapy. Case Report


Introduction
According to the Centers for Medicaid/Medicare, the prevalence of congestive heart failure (CHF) in the United States today is 6.5 million people, and is projected to be greater than 8 million people by 2030 [1]. Re-hospitalization for CHF within 30 days of discharge is 27% [2]. Total cost for treating congestive heart failure in the United States is $115.4 billion annually [3].
Congestive heart failure is a complex, debilitating disease, that require at least two inotropes (vitamin D, digoxin) to treat the severe pump failure and a very powerful anti-infl ammatory agent (vitamin D) to treat the chronic infl ammation associated with CHF. Vitamin D is a steroid hormone that increases calcium absorption by the heart. Thus, this makes vitamin D a cheap, inexpensive inotrope, plus one of the strongest antiinfl ammatory and anti-oxidant agents in the human body.
Vitamin D and digoxin work synergistically on the human heart to increase calcium absorption (cardiac contractility) with the end result being an increased ejection fracture (EF). Positive clinical results are usually seen in 4-6 weeks (increased ejection fracture and increased exercise tolerance).
BiDil (isosorbide dinitrate 20 mg/hydralazine 37.5 mg) is a combination medication that has reduced the risk of death by 43% and the risk of re-hospitalization by 39% in African Americans [4].
Vitamin D, digoxin, and Lasix combination works equally as well in the Caucasian population as the vitamin D, digoxin, BiDil, Lasix combination in African Americans in treating CHF.
The only difference in the two groups is the addition of BiDil in the African American population. We lowered our overall mortality rate at a Level I trauma center to 3% in 2015 and reduced our myocardial infarction/stroke rate by 50% using high dose vitamin D. Vitamin D levels less than 18 ng/ml increases all-cause mortality rate by 30% [5].
We report two cases of patient with CHF with different pathophysiology's who were successfully treated with vitamin D, digoxin, and BiDil with a 40-50% increase in ejection fracture (EF) and no re-hospitalizations for 2 years and 12 years, respectively.

Case 1
Patient is a 54-year-old African American male brought to the Emergency Room by ambulance after a ground level fall.
His past medical history was signifi cant for hypertension, alcohol abuse, and an unknown psychiatric disorder.
On physical exam, his vital signs were as follows: temperature 36.8; blood pressure 135/83; heart rate 93; respiratory rate 20; and oxygen saturation 100% on room air. On hospital day #26, patient was re-dosed with high dose vitamin D (50,000 IU) down his nasogastric tube, loaded with IV digoxin, and started on BiDil down his nasogastric tube which he tolerated well. Patient had no adverse reactions to any of the three medications.
A repeat echocardiogram on hospital day #56 (30 days later showed an improved EF of 45-50%, moderately dilated right ventricle, and mildly reduced left ventricle systolic function.
Patient's condition improved rapidly after the threemedication combination was started. He was transferred to the surgical fl oor for in-patient rehab which he tolerated well. His GSC was 15. He was discharged to a nursing home without any restrictions. He has not been re-admitted for CHF in 2 years since his discharge.
He was placed on disability at his job as an assembly line worker. Patient was unable to bend/lift, which his job required, without getting short of breath and feeling like he was about to pass out. He was initially diagnosed as having asthma/ bronchial problems. His symptoms got progressively worse until he noticed bilateral ankle swelling and weight gain. Almost all patients with congestive heart failure are vitamin D defi cient [7]. Severe vitamin D defi ciency is associated with worsening prognosis in CHF patients. Vitamin D levels less than 18 ng/ml increases the all-cause mortality rate by 30%.
One million new patients are diagnosed with congestive heart failure annually. This ever-growing problem can only be managed when vitamin D defi ciency is fully understood in the pathogenesis of congestive heart failure: 1. Vitamin D-defi ciency promotes activation of the reninangiotensin -aldosterone system which contributes to salt and water retention that is seen in congestive heart failure which may make CHF patients more diffi cult to diuresis [8,9].  11. Vitamin D-defi ciency promotes free oxygen radical production which damages the cardiac cell membranes, cardiac DNA, and cardiac mitochondria which is the powerhouse of each cardiac cell.
Vitamin D and digoxin are both powerful inotropes that work synergistically in severe pump failure/CHF patients to increase cardiac contractility (i.e., EF). No adverse medication reactions were noted using vitamin D, digoxin, BiDil, and Lasix combination. Readmission rate for our trauma patients with congestive heart failure remains low. Most report a better quality of life. Some have returned to physical activities abandoned years ago due to reduced exercise capacity. Others report less depression and more independence with renewed energy. The largest reward other than a better quality of life has been that many are able to return to some form of employment without government assistance.

Conclusion
We conclude that a combination of vitamin D, digoxin, BiDil, and Lasix improves congestive heart failure patient's quality of life, results in fewer hospital readmissions, and reduce overall hospital costs for the care of patients with CHF. Severe congestive heart failure (CHF) require at least two inotropes to reverse the downward spiral of CHF patients. Further studies are needed to fully appreciate the overall healthcare changes associated with this simple drug therapy.