Environmental Research 158 (2017) 443–449

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Environmental Research
journal homepage: www.elsevier.com/locate/envres

Enhanced vasculotoxic metal excretion in post-myocardial infarction MARK

patients following a single edetate disodium-based infusion
⁎
Ivan A. Arenasa, Ana Navas-Acienb, Ian Erguia, Gervasio A. Lamasa,
a
The Columbia University Division of Cardiology at Mount Sinai Medical Center, Miami Beach, FL, USA
b
Columbia University Mailman School of Public Health, New York, NY, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Toxic metals have been associated with cardiovascular mortality and morbidity. We have hypothesized that
Chelation therapy enhanced excretion of vasculotoxic metals might explain the positive results of the Trial to Assess Chelation
Heavy metals Therapy (TACT). The purpose of this study was to determine whether a single infusion of the edetate disodium-
Lead based infusion used in TACT led to enhanced excretion of toxic metals known to be associated with cardio-
Cadmium
vascular events.
Edetate disodium
Methods: Twenty six patients (post-MI, age > 50 years, serum creatinine ≤ 2.0 mg/dL) were enrolled in this
open-label study. Urinary levels of 20 toxic metals normalized to urinary creatinine concentrations were mea-
sured at baseline in overnight urine collections, for 6 h following a placebo infusion of 500 mL normal saline and
1.2% dextrose, and for 6 h following a 3 g edetate disodium-based infusion. Self-reported metal exposure,
smoking status, food frequency, occupational history, drinking water source, housing and hobbies were collected
at baseline by a metal exposure questionnaire.
Results: The mean age was 65 years (range 51–81 years). All patients were male. 50% had diabetes mellitus and
58% were former smokers. Mean (SD) serum creatinine was 0.95 (0.31) mg/dL. Toxic metals were detected in
the baseline urine of > 80% of patients. After placebo infusion there were no significant changes in total urinary
metal levels. After edetate infusion, total urinary metal level increased by 71% compared to baseline (1500 vs.
2580 µg/g creatinine; P < 0.0001). The effect of edetate was particularly large for lead (3835% increase) and
cadmium (633% increase).
Conclusions: Edetate disodium-based infusions markedly enhanced the urinary excretion of lead and cadmium,
toxic metals with established epidemiologic evidence and mechanisms linking them to coronary and vascular
events.

1. Introduction
This study was designed to explore one hypothesis proposed to ex-
plain the unexpectedly positive results of the Trial to Assess Chelation
Therapy (TACT) (Lamas et al., 2013), that reduction in cardiovascular
events in response to edetate disodium chelation may be related to
enhanced excretion of vasculotoxic metals, particularly lead and cad-
mium. Environmental pollutants have long been thought to contribute
to cardiovascular disease (Cosselman et al., 2015). In particular, there is
a wealth of epidemiologic and mechanistic evidence linking lead and
cadmium to the progression of atherosclerosis (Lustberg and Silbergeld,
2002; Menke et al., 2006; Navas-Acien et al., 2004; Weisskopf et al.,
2009; Menke et al., 2009; Tellez-Plaza et al., 2008, 2012, 2013a; Navas-
Acien et al., 2005; Revis et al., 1981; Agarwal et al., 2011a; Messner
et al., 2009; Bergström et al., 2015; Aalbers and Houtman, 1985; Voors
et al., 1982). For other toxic metals, the link to atherosclerosis is less
robust (Nigra et al., 2016). Lead and cadmium are toxic divalent cations
with no physiological role that are acquired from the environment via
the respiratory or gastrointestinal tracts. After absorption, these metals
are deposited in many tissues including bone and calcified tissues for
lead, and liver, kidney, and the walls of arteries for cadmium. Neither
lead nor cadmium can be readily eliminated, and both metals accu-
mulate in the body with half-lives measured in decades. Ethylene dia-
mine tetraacetic acid and its salts (e.g edetate disodium and edetate
calcium disodium) are chelators able to avidly bind many cations with
valences +2 to +6, forming stable soluble complexes, which can be

Abbreviations: TACT, Trial to Assess Chelation Therapy; edetate disodium, (disodium ethylenediamine tetra acetic acid, Na2EDTA); FDA, Food and Drug Administrations; MI,
Myocardial Infarction;; IND, Investigational New Drug; ICP- MS, Inductively Coupled Plasma Mass Spectrometry; CI, Confidence Interval; IQR, Interquartile Range; SD, Standard
Deviation; MRI, Magnetic Resonance Imaging; NSF, Nephrogenic Systemic Fibrosis
⁎
Correspondence to: Columbia University Division of Cardiology, Mount Sinai Medical Center, 4300 Alton Road Suite 2070A, Miami Beach, FL 33140, USA.
E-mail address: Gervasio.Lamas@msmc.com (G.A. Lamas).

http://dx.doi.org/10.1016/j.envres.2017.06.039
Received 27 April 2017; Received in revised form 29 June 2017; Accepted 29 June 2017
0013-9351/ © 2017 Elsevier Inc. All rights reserved.
I.A. Arenas et al.
excreted in the urine. The Food and Drug Administration (FDA) has
approved edetate calcium disodium to treat lead toxicity.
Clarke et al., in 1956, first reported a symptomatic benefit of edetate
disodium in patients with atherosclerotic heart disease (Clarke et al.,
1956). At that time, its beneficial effect was thought to be secondary to
removal of calcium from the atherosclerotic plaque. Recently, TACT
reported that in patients with a prior myocardial infarction (MI), an
edetate disodium based infusion, compared with a placebo infusion,
significantly reduced recurrent cardiovascular events (Lamas et al.,
2013, 2014; Escolar et al., 2014). The hypothesis that edetate disodium
enhanced vasculotoxic metal excretion in post-MI patients, however,
has been untested.
In this study, we investigated the pattern of spontaneous (baseline)
urinary excretion of twenty toxic metals in patients with a prior MI, and
the effect on metal excretion of a single edetate disodium-based or
placebo infusion identical to those used in TACT. We also investigated
the association of urinary metal levels with lifestyle and food intake.
2. Methods
This was an unblinded cross sectional study evaluating the urinary
excretion of 20 toxic metals (aluminum, arsenic, barium, beryllium,
bismuth, cadmium, lead, gadolinium, mercury, nickel, platinum, pal-
ladium, antimony, tin, thallium, cesium, tellurium, thorium, tungsten
and uranium) at baseline (spontaneous metal excretion), after a TACT
placebo infusion, and after a TACT active (edetate disodium-based)
infusion (Lamas et al., 2012). The placebo and TACT infusions were
administered on consecutive days. Arsenic levels represent total non-
speciated arsenic. All patients provided written informed consent and
an institutional review board approved the final protocol and provided
ongoing oversight. This study was performed under a US Food and Drug
Administration Investigational New Drug (IND) application.
Patients were recruited from outpatient cardiology clinics. Inclusion
and exclusion criteria precisely mimicked the TACT criteria (Appendix),
as the purpose of this study was to assess the effect of the infusions on
TACT-eligible patients. Participants were at least 50 years of age with a
history of myocardial infarction at least 6 weeks prior to enrollment and
serum creatinine ≤ 2.0 mg/dL. Patients were excluded if they had a
platelet count less than 100,000/mm3, a recent heart failure hospita-
lization, a recent coronary or carotid revascularization or a planned
revascularization procedure. Cigarette smoking in the previous 3
months, prior chelation therapy (within 5 years), abnormal liver func-
tion and diseases of copper, iron or calcium metabolism were also ex-
clusion criteria. A complete list of inclusion and exclusion criteria has
been published (Lamas et al., 2012) and is reproduced in the
Supplementary table.
The edetate disodium based infusion consisted of up to 3 g of Na2-
EDTA, 2 g of magnesium chloride, 100 mg of procaine HCL, 2500 U of
unfractionated heparin, 7 g of ascorbate, 2 mEq KCl, 840 mg sodium
bicarbonate, 250 mg of pantothenic acid, 100 mg of thiamine, and
100 mg of pyridoxine. The vitamin and other components of the edetate
disodium-based solution developed organically in the complementary
and alternative medicine community, and were used in TACT to reflect
typical practice (Lamas et al., 2012). All components were mixed with
sterile water to a volume of 500 mL. The placebo infusion consisted of
500 mL of normal saline with 1.2% dextrose. All infusions were ad-
ministered over 3 h.
Blood counts, lipid profile, hemoglobin A1c and creatinine con-
centrations were measured in venous blood in all participants before
the first urine collection. Urine samples were collected in trace metal
free containers provided by the metals laboratory and sent to Doctor's
Data Inc, (St. Charles IL), for elemental testing. Urine samples were
tested for creatinine using a kinetic modification of the Jaffe procedure
on a Beckman Coulter AU680. Samples were prepared for elemental
analysis by diluting the sample in dilute nitric acid, based on creatinine
concentration (Shah et al., 2012). The urine sample was analyzed for
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Environmental Research 158 (2017) 443–449
trace elements using an Inductively Coupled Plasma – Mass Spectro-
meter (ICP-MS; Perkin Elmer Elan DRCII). Elemental concentrations are
reported controlled for creatinine concentration. Quality was assured
by measuring three levels of Bio-rad controls and in-house spiked
samples.
A 3-day study protocol was followed. On day 1, patients were asked
to collect all overnight urine. On day 2, patients were given the placebo
infusion and asked to collect post-infusion urine for 6 h. On day 3,
patients were given the TACT active infusion and post-infusion urine
was also collected for 6 h. For baseline urine collections, patients were
instructed to collect all urine from 10:00 p.m. on day 1–6:00 a.m. on
day 2, so that the morning void prior to placebo infusion was the final
pre-infusion collection. For urine collections after placebo or edetate
disodium infusions (days 2 and 3, respectively), patients were in-
structed to collect all urine for 6 h after receiving the infusion.
Self-reported metal exposure, smoking status, food frequency, oc-
cupational history, drinking water source, housing and hobbies were
collected via questionnaire (see Supplementary information). Patients
were enrolled at Mount Sinai Medical Center in Miami Beach, FL and all
lived within easy driving distance of Miami Beach. Telephone follow-up
was conducted one week after active chelation infusion to assess patient
condition and record any adverse events.
2.1. Statistical methods
Urinary metal levels were expressed as μg metal/g of creatinine.
Values under the limit of detection were replaced by the lower limit of
detection provided by the laboratory (Appendix: Supplementary table)
divided by the square root of two. Logarithmic transformation was
applied given the skewed distribution of metals. Geometric means and
their 95% confidence intervals (CI) were calculated. Spearman's rank
test was used to investigate correlations within and between metals in
baseline and/or post EDTA urine. Non-parametric tests (Wilcoxon rank
test, Kruskal-Wallis Test) were used to compare urinary levels of metals
before and after treatment with placebo or edetate disodium infusions,
and to test the association of lifestyle with baseline and post-infusion
urinary metal levels. Given the small sample size, only unadjusted
comparisons were calculated. The Supplementary figure shows the
distribution of metals in baseline and post EDTA urine after log trans-
formation.
3. Results
3.1. Patient characteristics
We enrolled 26 adult male (Table 1), mostly Hispanic (73%) pa-
tients who lived a median 16 miles (IQR 13) away from the main
campus of Mount Sinai Medical center in Miami Beach. Mean (SD)
urinary creatinine was 79 (26) at baseline, 87 (39) post-placebo and 81
(38) mg/dl post-EDTA (P > 0.05, for all comparisons), respectively. No
Table 1
Baseline characteristicsa.
Age (years) 65 (9)
History of diabetes (%) 50
Smoking history (%) 58
Prior CABG (%) 50
Prior PCI (%) 65
LVEF %c 45 (12)
Serum creatinine (mg/dl) 0.95 (0.31)
eCrClb (mL/min) 105 (49)
HbA1c % 6.8 (1.9)
Total cholesterol 170 (53)
a
Results represent mean (SD) unless otherwise indicated.
b
Cockcroft-Gault method.
c
Last left ventricular ejection fraction (LVEF) known.
I.A. Arenas et al. Environmental Research 158 (2017) 443–449

side effects were reported after placebo or edetate disodium infusion. 3.4. Correlations of pre and post-chelation metal levels

There was a strong correlation between baseline and post-chelation

3.2. Metal levels in baseline urine samples lead (r=0.88; P < 0.0001); in this sample, post-chelation lead (µg/g
creatinine) could be estimated based on baseline urinary lead levels
)Toxic metals were detected in the baseline urine samples of all using the following equation: Exp (3.43 + Ln spontaneous Pb (µg/g
patients. The most commonly detected metals were barium, cesium and creatinine) x 0.771). There were also significant (P < 0.05) correlations
tin, which were detected in all patients. Other metals detected in the between baseline and post-chelation cadmium (r=0.49), thallium
majority of participants included thallium (detected in 96%), cadmium (r=0.68), and nickel (r=0.57).
(96%), lead (92%), nickel (92%), arsenic (92%), aluminum (81%),
mercury (65%) and tungsten (54%). Metals that were detected less 3.5. Urinary level of metals in patients with and without diabetes mellitus
frequently included bismuth (31%), antimony (15%), gadolinium
(15%), and platinum (4%). Beryllium, palladium, tellurium, thorium, Urine metal levels were similar between diabetic and non-diabetic
and uranium were below limits of detection in all patients. patients. Cadmium levels for diabetic and non-diabetic patients were
(geometrical mean (SD): 0.35 (2.0) vs. 0.39 (1.3); P=0.6 and 1.8 (3.1)
vs. 2.3 (1.9) µg/g creatinine; P=0.9, for baseline and chelated cad-
3.3. Effect of placebo or edetate infusion on urinary metal levels mium, respectively, whereas lead levels for diabetic and non-diabetic
patients were (geometrical mean (SD): 0.36 (2.5) vs. 0.39 (1.3); P=0.2
After placebo infusion, uranium became detectable at a low level in and 10.2 (5.3) vs. 16.6 (1.7) µg/g creatinine; P=0.6, for baseline and
one patient. Levels of other metals remained similar before and after chelated lead, respectively.
placebo infusion (Table 1). The total urinary metal level did not change
(Post-placebo vs Baseline urine: 1510 vs. 1500 µg/g creatinine; < 1% 3.6. Lifestyle and urinary levels of toxic metals
increase; P=0.3).
After edetate infusion, there was a 72% increase in total urinary Frequent intake of leafy greens (more than once per week) was
metal levels compared to baseline (post EDTA vs. baseline urine: 2580 associated with higher lead in both baseline (0.6 (1.8) vs. 0.24 (2.0) µg/
vs.1,500 µg/g creatinine; P < 0.001). Levels of aluminum, cadmium, g creatinine; P=0.002) and chelated urine (22.1 (1.8) vs. 6.8 (4.9) µg/g
gadolinium, lead, nickel and thallium increased (Table 2). Thorium creatinine; P=0.005), as well as higher baseline levels of Ba (1.3 (2.2)
became detectable in the urine of two patients. The increase in urinary vs. 0.4 (3.1) µg/g creatinine; P=0.007) and Ni (4.4 (1.5) vs. 1.75 (3.5);
excretion in response to edetate was particularly large for lead (3835% P=0.03).
increase; Fig. 1A) and cadmium (633% increase; Fig. 1B). There was Levels of baseline or chelated cadmium tended to be higher in
also a moderate increase in nickel (373% increase; Fig. 1C) and alu- former smokers compared to never smokers (geometrical mean (SD):
minum (275% increase; Fig. 1D). Gadolinium appeared in the urine of 0.43 (1.6) vs. 0.31 (1.7); P=0.3 and 2.5 (3.0) vs. 1.8 (1.9) µg/g crea-
14 patients after edetate treatment (10 with undetectable gadolinium in tinine; P=0.07), for baseline and chelated cadmium, respectively, al-
the baseline urine). The four patients with detectable gadolinium levels though the differences were of borderline significance. Patients who
at baseline demonstrated a marked increase (8662%) in gadolinium reported the intake of fruit juice more than once per week had higher
urinary levels following EDTA infusion. urinary levels of aluminum compared to those with less frequent intake
(geometrical mean (SD): 5.0 (2.6) vs. 1.6 (2.5) µg/g creatinine;
P=0.03). Consumption of brown rice more than once per week had a
borderline association with a higher level of total arsenic (49.4 (3.4) vs.
Table 2 13.8 (3.0) µg/g creatinine; P=0.05). Moreover, patients who ate rice
Geometric means (95% CI) of urinary metal excretion (µg/g creatinine) in spontaneous
urine collections (Baseline) or after placebo or Edetate (EDTA) infusions in patients with
cereal more than once a week had higher baseline urinary arsenic
history of myocardial infarction. (111.9 (1.6) vs. 13.9 (2.9) µg/g creatinine; P=0.007), aluminum (19.1
(1.7) vs. 2.4 (2.1) µg/g creatinine; P=0.01), and tended to have more
Metal Baseline urine Placebo EDTA lead (0.96 (2.1) vs. 0.39 (2.1) µg/g creatinine; P=0.09). Frequent
Aluminum (Al) 3.59(2.35–5.87) 4.23(2.95–6.06) 7.97(6.19–10.27)b
consumption of fish (at least once per week) was not associated with
Antimony (Sb) 0.06(0.05–0.07) 0.07(0.06–0.09) 0.07(0.05–0.09) higher levels of mercury (0.59 (0.8) vs. 0.35 (1.2) µg/g creatinine;
Arsenic (As) 17.1(10.3–28.5) 21.5(12.9–35.9) 13.05(6.48–26.30) P=0.1) and a borderline association with total arsenic (30.8 (3.3) vs.
Barium (Ba) 0.87(0.54–1.42) 0.74(0.46–1.16) 0.65(0.38–1.11) 11.5 (2.6) µg/g creatinine; P=0.08).
Beryllium (Be) < DL < DL < DL
Patients who self-reported living near a side street with considerable
Bismuth (Bi) 0.13(0.06–0.28) 0.17(0.07–0.39) 0.20(0.08–0.47)
Cadmium (Cd) 0.39(0.30–0.50) 0.37(0.30–0.47) 2.18(1.49–3.20)c traffic (including a busy road or highway) had borderline higher
Cesium (Cs) 5.56(4.68–6.59) 5.84(4.65–7.34) 5.81(4.78–7.08) baseline (geometrical mean (SD):0.54 (2.2) vs. 0.3 (2.1).; P=0.08) or
Gadolinium (Gd) 0.05(0.04–0.07) 0.06(0.04–0.08) 0.52(0.18–1.54)b chelated lead (20.6 (1.9) vs. 11.8 (1.7); P=0.05), and significantly
Lead (Pb) 0.42(0.30–0.60) 0.43(0.31–0.59) 13.47(8.10–22.41)c higher arsenic levels (30.9 (2.9) vs. 7.8 (2.3); P=0.01) than those that
Mercury (Hg) 0.39(0.21–0.72) 0.54(0.38–0.76) 0.58(0.41–0.80)
Nickel (Ni) 3.40(2.36–4.90) 2.86(2.04–4.03) 7.52(5.81–9.73)c
reported living by a street with little or no traffic.
Palladium (Pd) < DL < DL < DL We found no statistically significant associations among metal levels
Platinum (Pt) < DL 0.08(0.04–0.15) 0.06(0.05–0.07) and work history or recreational activities (See Supplementary data:
Tellurium (Te) < DL < DL < DL Lifestyle Questionnaire).
Thallium (Tl) 0.14(0.10–0.20) 0.16(0.12–0.20) 0.20(0.16–0.26)a
Thorium (Th) < DL < DL 0.02(0.02–0.02)
Tin (Sn) 0.61(0.40–0.91) 0.59(0.39–0.89) 0.78(0.51–1.19) 4. Discussion
Tungsten (W) 0.07(0.05–0.11) 0.07(0.05–0.10) 0.06(0.05–0.09)
Uranium (U) < DL 0.04(0.04–0.04) < DL Urine toxic metals were highly prevalent in this non-randomly se-
lected sample of Greater Miami patients with coronary artery disease.
< DL: Below detection limit. Significant changes from baseline are underlined.
These patients had no history of occupational exposure to metals and
Superscript letters indicate P-values for comparisons vs. Baseline:
a
P < 0.05.
were recruited from the outpatient cardiology clinics based on having a
b
P < 0.001. prior MI and adequate renal function. Nine metals including arsenic,
c
P < 0.0001 (Wilcoxon matched pairs test). cadmium and lead, which have been associated with cardiovascular

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I.A. Arenas et al.
Fig. 1. Effect of placebo or edetate disodium on urinary lead (1A), cadmium (1B), nickel (1C) and aluminum (1D) excretion. Lines represent individual patient values of each metal in
baseline urine, after placebo or edetate infusion. Bar graphs are mean ± SE of the percentage of change from baseline; lead (Placebo: 28 ± 26% increase; Edetate: 3835 ± 296% increase;
A), cadmium (Placebo: 13 ± 9% increase; Edetate: 633 ± 70% increase; B), nickel (Placebo: 41 ± 26% increase; Edetate: 373 ± 154% increase; C) and aluminum (Placebo: 80 ± 32%
increase; Edetate 275 ± 95% increase; D).
disease and are in the top ten of the priority list of hazardous substances
(www.atsdr.cdc.gov/spl/), were detected in the spontaneous urine of
more than 80% of patients. Compared with the Fourth National Report
on Human Exposure to Environmental Chemicals (www.cdc.gov/
exposurereport), urinary excretion of total arsenic, barium, beryllium,
cadmium, cesium, lead, mercury, platinum, thorium, tin, tungsten and
uranium were within the 75th percentile of reported values for the
adult (20 years and older) US population.
We have hypothesized that the beneficial effect of edetate disodium
therapy found in TACT may be related to enhanced excretion of toxic
metals (Lamas et al., 2013). Waters et al., (2001) nearly 20 years ago,
reported that after an edetate disodium-based infusion similar to that
used in TACT, the excretion of lead over 2 days increased by 3830% and
of cadmium by 514%. The present study showed that the active TACT
infusion containing edetate disodium, but not the placebo infusion,
increased the urinary excretion of toxic metals with a marked increase
in lead and cadmium excretion. Both metals have robust epidemiologic
evidence supporting a vasculotoxic effect. They are associated with
coronary disease (Lustberg and Silbergeld, 2002; Menke et al., 2006;
Tellez-Plaza et al., 2013a; Agarwal et al., 2011b; Everett and Frithsen,
2008), peripheral artery disease (Weisskopf et al., 2009; Navas-Acien
et al., 2005; Tellez-Plaza et al., 2013b), hypertension (Navas-Acien
et al., 2007, 2008; Vaziri and Khan, 2007) and stroke (Tellez-Plaza
et al., 2013a), as well as with cardiac and all-cause mortality (Lustberg
and Silbergeld, 2002; Menke et al., 2006, 2009; Weisskopf et al., 2009;
Tellez-Plaza et al., 2012). Thus, these findings are consistent with the
hypothesis that the reduction in vascular events reported in TACT may
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Environmental Research 158 (2017) 443–449
be related to the enhanced excretion of lead and cadmium. Other stu-
dies have shown that EDTA infusions can also enhance excretion of
essential elements such as calcium and zinc, and small amounts of
chromium and copper (Waters et al., 2001). It is unclear, however,
whether the increased excretion of those elements contributes to car-
diovascular risk.
Data from representative samples of the US population found no
safe threshold in the association of lead with cardiac mortality, with an
increased risk observed at levels that are currently common in the US
population (Menke et al., 2006). There is biological and experimental
evidence supporting a role of lead and cadmium in the development of
atherosclerosis. When added to drinking water, both lead and cadmium
have additive effects in promoting atherosclerotic plaque formation in
the experimental animal (Revis et al., 1981). Elevated cadmium levels
are associated with carotid (Messner et al., 2009; Bergström et al.,
2015), coronary (Messner et al., 2009) and aortic atherosclerosis
(Aalbers and Houtman, 1985; Voors et al., 1982). Lead and cadmium
content in arteries may be associated with acute vascular events since
lead in the aortic wall is a predictor of cardiac death (Voors et al., 1982)
and atherosclerotic plaques prone to rupture are rich in cadmium
(Bergström et al., 2015). Although the exact mechanism leading to
atherosclerosis is unclear, chronic exposure to these metals may favor
oxidative stress and nitric oxide inactivation leading to endothelial and
vascular dysfunction (Messner et al., 2009; Vaziri et al., 1999; Ding
et al., 1998). Elevated lead and cadmium levels can also result in hy-
pertension (Navas-Acien et al., 2007; Donpunha et al., 2011) and dia-
betes (Schwartz et al., 2003), which are themselves important risk
I.A. Arenas et al.
factors for atherosclerosis.
Edetate disodium therapy also resulted in a modest increase in the
excretion of aluminum, nickel, thallium and gadolinium. However, the
association of these metals with cardiovascular disease is less clear.
With regards to nickel, some studies have shown that exposure to fine
ambient particulate matter containing nickel can cause endothelial
dysfunction and enhance atherosclerosis in mice fed with a high-fat diet
(Sun et al., 2005). Many nickel containing compounds are soluble in
water, and drinking water and food are the main sources of exposure to
nickel for the general population (Barceloux and Nickel, 1999). There is
no known association of thallium with cardiac disease.
In the present study, all but one patient with gadolinium in urine
recalled having contrast enhanced magnetic resonance (MRI) studies in
the past. Gadolinium-enhanced MRIs have been associated with risk of
nephrogenic systemic fibrosis (NSF) in patients with impaired renal
function, and some studies suggest that free gadolinium can accumulate
in the brain (Kanda et al., 2014). The physiological consequences of
gadolinium retention and its chelation by edetate disodium may de-
serve further investigation in light of the poor prognosis of NSF.
We found associations of food intake patterns with urinary metal
levels; frequent consumption of brown rice was associated with a nearly
3-fold increase in non-speciated urinary arsenic, a finding that is con-
sistent with other studies in the US (Karagas et al., 2016). The water-
flooded conditions used for rice cultivation facilitate the absorption of
arsenic, which tends accumulate in the outer hulls of grain rice that are
stripped off in the refining process (thus, brown rice may contain more
arsenic than white, refined rice). Rice products such as infant cereal
also contain arsenic, and the FDA has released a draft guidance to limit
the amount of inorganic arsenic in infant rice cereal (U.S. Food and
Drug Administration, 2017). In the present study, frequent consump-
tion of rice cereal was associated with higher arsenic as well as higher
aluminum and lead. Urinary aluminum was also higher in patients who
reported frequent consumption of fruit juices. Foods and beverages
including fruit juices and soft drinks are the single largest contributor of
aluminum intake for humans (Yokel, 2012; López et al., 2002). Food
additives account for a significant percentage of daily aluminum intake.
Among food additives, sodium aluminum phosphates are the primary
contributors of endogenous aluminum (Yokel and McNamara, 2001).
These additives are used in milk, processed cheese, yogurt, baking soda,
sugars, and cereals (Pennington, 1988). In addition, additives used in
food-contact articles such as adhesives and components of coatings may
contribute to small quantities of aluminum in food products during
processing or packaging.
Another suggestive finding of this study was the association of fre-
quent ingestion of leafy green vegetables with barium, nickel and,
importantly, a greater than two-fold increase in urinary lead. Lead can
accumulate in green leafy vegetables like lettuce and in some root crops
(Clemens and Ma, 2016). Several studies have investigated the con-
centrations of heavy metals in frequently consumed vegetables (Sinha
et al., 2006; Singh and Kumar, 2006; Sharma et al., 2006; Mapanda
et al., 2005). The variations in metal concentration in leafy vegetables
depends on their absorption from the soil and their translocation within
plants (Voutsa et al., 1996). Lead concentration in plants is related to
lead content in the soil and the use of fertilizers and pesticides that
contain this metal. In some areas of the world, the reported mean
concentration of lead in leafy vegetables is above the safe limits given
by the World Health Organization/ Food and Agriculture Organization
(Gupta et al., 2013). There is concern that soils in urban areas (e.g
community gardens) or close to highways have higher lead content and
could increase lead concentration in vegetables grown in those fields
(Alaimo et al., 2016). In this study, we found higher levels of arsenic
and lead in patients that self-reported living near a street with con-
siderable traffic. Residential roadway proximity has been associated
with an elevated risk of developing coronary events (Kan et al., 2008)
and sudden cardiac death (Hart et al., 2014).
In this sample of patients with coronary artery disease, there were
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Environmental Research 158 (2017) 443–449
no significant differences in baseline or chelated metal levels between
diabetic and non-diabetic patients. However, given the greater benefit
of edetate chelation in the diabetic subgroup seen in TACT (Escolar
et al., 2014), it is possible that although diabetic patients may have a
similar internal metal load than non-diabetics, they may be more sus-
ceptible to the vasculotoxic effect of metals. In fact, micro and macro-
vascular complications of diabetes mellitus are in part mediated
through accumulation of advanced glycation end-products, which re-
quires transition metal-catalyzed oxidations of organic compounds
(Goh and Cooper, 2008; Qian et al., 1998). The role of metal-metalloid
interactions in cardiovascular disease and diabetes deserves further
investigation. For instance, the pro-atherosclerotic effects of lead and
cadmium in animal models are additive and are influenced by level of
calcium or magnesium in drinking water (Revis et al., 1981).
Strengths of the present study include the rigorous method used for
urine metal collection and quantification, and the use of a 3-day sample
collection protocol (baseline, placebo and post-chelation), which
minimizes potential variations in metal exposure that could affect metal
levels. Moreover, baseline and placebo urine metal quantifications in
each patient allowed direct comparisons with metal levels before and
after the edetate infusion. Among the study limitations, the most im-
portant are derived from the small sample size and the geographically
restricted population of mostly Hispanic men with coronary disease in
Greater Miami.
In conclusion, we have shown that edetate disodium significantly
enhances the urinary excretion of lead and cadmium in patients with a
history of MI. The mechanisms whereby chelation therapy improves
cardiovascular outcomes are still unclear. Mechanisms of action pro-
posed include removal of toxic metals (e.g. total body burden, the
vascular wall, adipose tissue, etc.), stabilization of atherosclerotic
plaque (by changing vascular matrix remodeling and/or plaque cal-
cium), reduction in platelet aggregation, and reduction in free-radical-
related oxidative damage. Repeat edetate infusions are associated with
a reduction in blood lead (> 70%) (Guldager et al., 1996) and urinary
cadmium (unpublished results). Whether the effects of repeated che-
lation infusions in blood lead or pre-infusion urine cadmium are related
to outcomes is unknown and will be investigated in TACT2.
The findings of this study, in conjunction with the epidemiologic
and experimental evidence supporting the vasculotoxicity of lead and
cadmium, and the clinical results of TACT justify prospectively testing
this hypothesis in the ongoing TACT2. If positive, TACT2 may lead to
the conclusion that lead and cadmium may be modifiable risk factors
for cardiovascular disease. Those interested in learning more about
TACT2 are invited to visit www.tact2.org for information and updates
on the trial.
Conflicts of interest
The authors have no conflicts of interest or disclosures.
Source of funding
This study was funded by Mount Sinai Medical Center and the
James P. Carter Memorial Grant for EDTA Chelation Research.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at http://dx.doi.org/10.1016/j.envres.2017.06.039.
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