This document discusses the uses of chelation therapy in cardiology, specifically focusing on EDTA. It summarizes that EDTA chelation therapy can be used to treat refractory angina, environmental cardio toxicity from metal poisoning, and iron overload cardiomyopathy. The document outlines evidence from the Trial to Assess Chelation Therapy (TACT) showing benefits of EDTA chelation for patients with a history of myocardial infarction, particularly those with diabetes. The proposed mechanisms of action include removing toxic metals like lead and cadmium to reduce oxidative stress and inflammation.

1. CHELATION THERAPY
IN CARDIOLOGY
DR.V.VIVEK
1ST YEAR CARDIOLOGY RESIDENT

2. USES
• REFRACTORY ANGINA
• ENVIRONMENTAL CARDIOLOGY (METAL POISONING)
• IRON OVERLOAD CARDIOMYOPATHY

3. EDTA AND MECHANISM
• EDTA is a synthetic amino acid and polydentate chelator with high affinity for divalent
cations, such as lead, cadmium, and calcium, that may be beneficial in the treatment
of cardiovascular disease (CVD).
• Chelation removes select cations from tissues by forming a chelator‐chelate complex
subsequently excreted by the kidneys or liver.
• EDTA binds metal ions with differing affinity because of differences in the binding
constants of EDTA for different metals, with lead and zinc excreted in a greater
amount than cadmium and calcium.

4. REFRACTORY ANGINA

5. FOR REFRACTORY ANGINA
• Since 1956, some medical professionals have administered EDTA to treat
cardiovascular disease (CVD).
• EDTA chelation therapy for stable ischemic heart disease was classified as a IIB
treatment with level B evidence in the 2014 American College of
Cardiology/American Heart Association.
• The ‘Trial to Assess Chelation Therapy (TACT)’ serves as the first sufficiently
powered trial studying EDTA therapy in CAD.

6. TACT
• In 2013, the TACT (Trial to Assess Chelation Therapy) generated renewed interest
on the potential cardiovascular benefits of EDTA‐based chelation.
• TACT is a National Institutes of Health–funded randomized clinical trial (RCT).
• It examined the effects of 40 infusions of an EDTA‐based mixture in patients with
a history of myocardial infarction. The study found a reduction in the primary
composite cardiovascular end point, with the greatest benefit among patients
with diabetes.

7. • In the TACT, no difference in allergic reactions, renal function, or heart failure
exacerbations observed between the treatment and placebo groups.
• EDTA may cause symptomatic hypocalcemia because of its high affinity for
calcium, and therefore lengthy infusion periods (3–4 hours) are used.
• Only 1 of >27,000 EDTA infusions resulted in symptomatic hypocalcemia
requiring an emergency department visit,

8. • The effect of chelation was most pronounced in patients with diabetes or prior
anterior MI, setting the framework for the forthcoming TACT-2 trial that aims to
assess the benefit of combination chelation plus oral vitamin and mineral therapy
in diabetic CAD patients specifically.
• A pathophysiologic mechanism accounting for the benefits of chelation therapy
in the original TACT study remains unclear, however, and additional data are
necessary to clarify indications, timing, and duration of the chelation therapy.

9. ADVANTAGE IN DIABETES
• The added benefit for patients with diabetes identified in this systematic review may
stem from advanced glycation end products causing oxidative stress in diabetes.
• Advanced glycation end products are oxidized, cross‐linked glucose molecules that
interact with endothelial cells, contributing to increased inflammatory cytokine
expression. These effects can subsequently contribute to subclinical changes, such as
atherogenesis and hypertension, leading to clinical CVD effects.
• It is possible that EDTA reduces toxic metal burden and formation of oxidation
products, thus improving patient outcomes more significantly among patients with
diabetes.

10. MECHANISM OF EDTA IN CAD
• Early practitioners proposed decalcification of atherosclerotic plaque as a
possible mechanism for EDTA benefit as EDTA has been suggested to lower vessel
calcification through calcium removal, although these hypotheses have not been
confirmed.
• More recent investigations suggest that benefits of chelation may stem from
removal of established cardiotoxic metals, such as lead or cadmium.

11. ENVIRONMENTAL CARDIOLOGY
METAL POISONING

12. EDTA IN ENVIRONMENTAL CARDIOLOGY
• On entering the body, heavy metals, including lead and cadmium, affect multiple
cellular and molecular mechanisms and result in downstream vascular changes.
• Elevated lead levels may cause a reduction in antioxidant effects, such as reduced
glutathione activity, paraoxonase inactivation, and impaired calcium signaling,
resulting in decreased ability of the cell to clear reactive oxygen species and free
radicals as well as elevated expression of inflammatory markers.

13. • Similarly, cadmium has also been associated with reduced glutathione activity,
cadmium‐induced cell death through apoptotic pathway activation, and DNA
methylation, resulting in increased oxidative stress, inflammation, and endothelial
cell death leading to CVD.
• EDTA chelation of heavy metals may therefore benefit patients with CVD through
antioxidant effects by reducing toxic metal burden.

14. IRON OVERLOAD CARDIOMYOPATHY

15. HEREDITARY HEMOCHROMATOSIS
• Phlebotomy and iron chelators (parenteral deferoxamine or the oral iron chelators
deferiprone and deferasirox) remain the standard therapy.
• Adequately treated patients (ie, target ferritin of 50-100 μg/L achieved)
demonstrate better prognosis.
• Chelation improves ventricular function, prevents ventricular arrhythmias, and
reduces mortality in patients with secondary iron overload.

16. THANK YOU