Evaluation of left ventricular mass measured by 3D echocardiography using magnetic resonance imaging as gold standard

OBJECTIVE

Increased left ventricular mass (LVM) and presence of left ventricular hypertrophy (LVH) are predictors of cardiovascular morbidity and mortality, but can be reversed with proper treatment of the underlying cause. Therefore accurate as well as reproducible methods for diagnosis and follow-up are needed. We evaluated different modalities by which to measure LVM in patients with no known LVH using magnetic resonance imaging (MRI) as the gold standard: ECG using the formulae proposed by Sokolow-Lyon and Cornell, 2D echocardiography and 3D echocardiography.

METHODS

34 subjects were included in the study; 17 had a history of myocardial infarction, 7 had pulmonary hypertension and 10 were healthy. All patients and controls had a standard 12-lead ECG, a transthoracic 2D and 3D echocardiographic study and a cardiac MRI.

RESULTS

ECG estimates of LVM correlated poorly with LVM by MRI (r = 0.18, NS and 0.16, NS for Sokolow-Lyon and Cornell, respectively), whereas a moderate correlation between 2D and 3D echocardiography and MRI was observed (r = 0.63, p<0.001 and r = 0.74, p<0.001, respectively). All methods were reproducible with no significant bias.

CONCLUSION

LVM measured by 3D echocardiography is highly accurate compared to LVM measured by MRI. LVM calculated from 2D echocardiography also proved useful, whereas estimates of LVM by ECG are inaccurate in a non-hypertrophic population.

N-terminal proBNP and mortality in hospitalised patients with heart failure and preserved vs. reduced systolic function: data from the prospective Copenhagen Hospital Heart Failure Study (CHHF)

Preserved systolic function among heart failure patients is a common finding, a fact that has only recently been fully appreciated. The aim of the present study was to examine the value of NT-proBNP to predict mortality in relation to established risk factors among consecutively hospitalised heart failure patients and secondly to characterise patients in relation to preserved and reduced systolic function.

MATERIAL

At the time of admission 2230 consecutively hospitalised patients had their cardiac status evaluated through determinations of NT-proBNP, echocardiography, clinical examination and medical history. Follow-up was performed 1 year later in all patients.

RESULTS

161 patients fulfilled strict diagnostic criteria for heart failure (HF). In this subgroup of patients 1-year mortality was approximately 30% and significantly higher as compared to the remaining non-heart failure population (approx. 16%). Using univariate analysis left ventricular ejection fraction (LVEF), New York Heart Association classification (NYHA) and plasma levels of NT-proBNP all predicted mortality independently. However, regardless of systolic function, age and NYHA class, risk-stratification was provided by measurements of NT-proBNP. Having measured plasma levels of NT-proBNP, LVEF did not provide any additional prognostic information on mortality among heart failure patients (multivariate analysis).

CONCLUSION

The results show that independent of LVEF, measurements of NT-proBNP add additional prognostic information. It is concluded that NT-proBNP is a strong predictor of 1-year mortality in consecutively hospitalised patients with heart failure with preserved as well as reduced systolic function.

Septal alcohol ablation and Heyde's syndrome revisited

We describe a 57-year-old male with hypertrophic obstructive cardiomyopathy and occult blood loss. Septal alcohol ablation reduced the left ventricular outflow tract obstruction and eliminated recurrent bleeding. The case resembles Heyde's syndrome, i.e. the association between occult gastrointestinal bleeding and aortic valve stenosis, where resolution of blood loss after corrective aortic valve surgery has also been reported.

NT-proBNP: a new diagnostic screening tool to differentiate between patients with normal and reduced left ventricular systolic function

OBJECTIVE

To evaluate whether measurements of N-terminal pro-brain natriuretic peptide (NT-proBNP) can be used to differentiate patients with normal and reduced left ventricular ejection fraction (LVEF) in an unselected consecutive group of hospital inpatients.

SETTING

City general hospital, Copenhagen, Denmark.

PATIENTS AND DESIGN

During a 10 month period 2230 admissions to a city general hospital (80% of targeted patients) had an echocardiographic evaluation of left ventricular function, a comprehensive clinical evaluation, and blood analysis of N-terminal-pro-brain natriuretic peptide (NT-proBNP) within 24 hours of admission. Exclusions resulted from lack of informed consent or failure to obtain the required evaluations before death or discharge from hospital. Echocardiography was unsatisfactory in 37 patients, so the final number studied was 2193.

RESULTS

A raised NT-proBNP (>or= 357 pmol/l) identified patients with an LVEF of <or= 40% (n = 157) with a sensitivity of 73% and a specificity of 82%. The negative predictive value of having an NT-proBNP concentration below 357 pmol/l was 98%. Concentrations of NT-proBNP increased with increasing age and with decreasing LVEF (p < 0.05). A predicted concentration of NT-proBNP (corrected for age, sex, and serum creatinine) was determined for each patient. In patients with an NT-proBNP value less than predicted, the probability of having an LVEF of > 40% was more than 97%. This probability rapidly decreased to 70% as the measured NT-proBNP increased to 150% of the predicted value.

CONCLUSIONS

A single measurement of NT-proBNP at the time of hospital admission provides important information about LVEF in unselected patients.

Different effects of calcium antagonist and beta-blocker therapy on left-ventricular diastolic function in ischemic heart disease. A direct comparison of the impact of mibefradil and atenolol

OBJECTIVE

To compare the effect of a calcium antagonist and a beta-blocker on left-ventricular diastolic function in patients with ischemic heart disease.

METHODS

138 patients with chronic stable angina pectoris were randomized in a multicenter, double-blind trial to treatment with either mibefradil or atenolol for 6 weeks (50 mg once daily for 2 weeks followed by 100 mg once daily for 4 weeks). The ratio between early (E) and late (A) diastolic mitral flow velocities (E/A), the E wave deceleration time (DT) and the left ventricular isovolumetric relaxation time (IRT) were measured by Doppler echocardiography as parameters of left-ventricular diastolic function initially, after 4 and after 6 weeks of treatment.

RESULTS

Mibefradil did not change the E/A ratio significantly (+4%, NS), while atenolol treatment resulted in a significant increase in the E/A ratio (+20%, p < 0.001). Mibefradil treatment, on the other hand, resulted in a significant decrease (-8%, p < 0.001) in IRT, while atenolol treatment did not change IRT. Neither mibefradil nor atenolol treatment changed DT significantly.

CONCLUSIONS

Both mibefradil and atenolol treatment significantly improves echocardiographic indices of left-ventricular diastolic function in patients with chronic stable angina. However, they affect different parameters and thus apparently act through different mechanisms.

Changes in bone mineral density with age in men and women: a longitudinal study

We performed a prospective study to evaluate the normal changes in bone mineral density (BMD) in the forearm, hip, spine and total body, and to study the agreement between changes in BMD estimated from cross-sectional data and the actual longitudinal changes. Six hundred and twenty subjects (398 women, 222 men; age 20-89 years) without diseases or medication known to affect bone metabolism undertook baseline evaluations, and 525 (336 women, 189 men) completed the study. BMD was measured twice 2 years apart by dual-energy X-ray absorptiometry. From cross-sectional evaluations the only premenopausal bone loss (<0.003 g/cm2/year) was found in the hip. In women after menopause and in men an age-related bone loss (0.002-0.006 g/cm2/year) was found at all sites. The data from the longitudinal evaluation showed a small bone loss in women before menopause at the hip and lumbar spine (<0.4%/year (<0.004 g/cm2/year)); this bone loss nearly tripled in the early postmenopausal years (<10 years since menopause), and thereafter decreased to the premenopausal rate for the hip, and to zero for the lumbar spine. The most pronounced bone loss after menopause occurred in the forearm (1.2%/year (0.006 g/ cm2/year)), and it remained constant throughout life. In men there was a small longitudinal bone loss in the hip throughout life, and a small bone loss in the distal forearm after the age of 50 years. In all groups, except for the early postmenopausal women, we found a small increase in total body BMD with age. When comparing the changes in BMD estimated from cross-sectional data with the longitudinal changes, only the hip and forearm generally displayed agreement, whereas the changes in the total body and spine generally were incongruous. In conclusion, the hip and forearm appear to be the sites with the best agreement between the cross-sectional estimated and the longitudinal age-related changes in BMD.

Influence of female and male sex steroids on body composition in the rabbit model

OBJECTIVE

To study the influence on body composition of estrogen replacement therapy (ERT) in female rabbits and of replacement therapy with testosterone (TRT) in male rabbits using dual-energy X-ray absorptiometry (DEXA).

METHODS

Cholesterol-fed female and male rabbits receiving a weight-restricted diet (100 g/day) were used. Total lean tissue mass (LTM), total body fat tissue mass (FTM) and total tissue mass (TTM) were determined by DEXA at baseline, after which the animals were gonadectomized and treated with sex steroids. Soft body composition was then determined again after 30-31 weeks of treatment.

RESULTS

Relative to controls, ERT with estradiol (E2) doses of 2 and 4 mg/day significantly increased LTM (p < 0.001), whereas E2 0.5 and 1 mg/day had a neutral effect on LTM. The change in fat mass, however, was not statistically significant between groups. In male rabbits, compared with castrated control rabbits, LTM decreased in testosterone-treated animals (by 7-12%; p < 0.001) but FTM decreased relatively more (by 66-79%; p < 0.0001). In both genders, body weight correlated with TTM as determined by DEXA (r = 0.89-0.91, p < 0.0001).

CONCLUSION

In this in vivo model of growing rabbits, estrogen replacement significantly increased LTM in female animals, whereas testosterone replacement significantly decreased FTM in males, suggesting that soft body composition of both genders is significantly affected by replacement with sex steroids. Until comparable human data are available, it is speculated that similar changes in soft body composition may occur in humans treated with sex steroids.

How does quantitative ultrasound compare to dual X-ray absorptiometry at various skeletal sites in relation to the WHO diagnosis categories?

The World Health Organisation (WHO) has proposed a set of guidelines for the diagnosis of osteoporosis in adult women based on a measurement of bone mineral density (BMD) expressed as the number of SD below young adult mean (t-score). In this study, we investigated the number of subjects classified as either osteopenic or osteoporotic according to these guidelines using dual X-ray absorptiometry (DXA), at the hip, at the spine and at the lower forearm and quantitative ultrasound (QUS), at the heel. A total of 247 men, 209 postmenopausal women and 195 premenopausal women were included in the study. Furthermore, the study provides the first normative data showing the influence of sex, age and menopause on broadband ultrasound attenuation (BUA) and speed of sound (SOS), as measured by the DTU-one imaging ultrasound scanner. The difference between the number of patients classified into either diagnosis group by the investigated parameters is large ranging from 25.9% of the women being diagnosed as osteopenic by BUA at the heel to 43.0% by BMD at the femoral neck. For men, the same range is from 20.5% by BUA to 44.1% by BMD at the femoral neck. For the classification into the osteoporotic group, the range is from 2.5% by intertrochanteric BMD to 24.4% by BMD at Ward's triangle for women and from 0% by SOS to 29.0% by BMD at Ward's triangle for men. Using total hip BMD as the reference parameter to categorize the subjects as normal, osteopenic or osteoporotic, the agreement of the other parameters with this classification is assessed in terms of sensitivity and specificity. We conclude that there are significant differences in the classification of osteoporosis/osteopenia depending on the site measured and the technique used for the bone mass assessment. Furthermore, we suggest that development of technique and site specific cut-off values may increase the accuracy of the classification of osteoporosis/osteopenia in both men and women.

Low doses of estradiol in combination with gestodene to prevent early postmenopausal bone loss

OBJECTIVE

Our purpose was to study combinations of estradiol and gestodene for prevention of bone loss in early postmenopausal women.

STUDY DESIGN

We randomly assigned 278 healthy, early postmenopausal women to receive either 2 mg 17beta-estradiol sequentially combined with 25 microg gestodene (group 2/25s), 2 mg estradiol sequentially combined with 50 microg gestodene (group 2/50s), 1 mg estradiol sequentially combined with 25 microg gestodene (group 1/25s), 1 mg estradiol continuously combined with 25 mg gestodene (group 1/25c), or placebo.

RESULTS

After 3 years the changes in bone mineral density of the spine were as follows (mean +/- SEM): group 2/25s, 7. 41% +/- 0.72%; group 2/50s, 8.53% +/- 0.90%; group 1.25s, 6.67% +/- 0.88%; group 1/25c, 4.44% +/- 0.59%; and placebo group, -2.03% +/- 0. 64%. The changes in bone mineral density were mirrored in the biochemical bone markers. The average responses for the urinary C-terminal telopeptide fragments of type I collagen corrected for creatinine excretion were as follows (mean of baseline +/- SEM): group 2/25s, -68.8% +/- 0.03%; group 2/50s, -72.8% +/- 0.02%; group 1/25s, -60.7% +/- 0.03%; group 1/25c, -52.28% +/- 0.04%; and placebo group, 6.5% +/- 0.09%. Beneficial lipid effects were found in all active groups. The decreases in low-density lipoprotein were as follows (mean +/- SEM): group 2/25s, -13.7% +/- 3.0%; group 2/50s, -14.6% +/- 3.2%; group 1/25s, -9.28% +/- 2.2%; group 1/25c, -9.92% +/- 2.4%; and placebo group, 1.53% +/- 1.9%.

CONCLUSION

These results demonstrate that estradiol therapy with 1 mg estradiol is fully protective against early postmenopausal bone loss.

Vitamin D receptor and estrogen receptor gene polymorphisms in postmenopausal Danish women: no relation to bone markers or serum lipoproteins

OBJECTIVE

To investigate the polymorphisms of the vitamin D receptor (VDR) and estrogen receptor (ER) genes in relation to biochemical markers of bone turnover (serum osteocalcin and urinary collagen type I degradation products (CrossLaps), and to study ER genotypes in relation to serum lipoproteins, blood pressure, or changes in these parameters after 2 years of hormone replacement therapy (HRT) in 499 Danish postmenopausal women.

METHODS

The VDR gene polymorphisms were determined by means of the three restriction enzymes, i.e. BsmI, ApaI and TaqI, while the ER gene polymorphisms were determined by means of the PvuII and XbaI restriction enzymes. Serum osteocalcin, urinary CrossLaps and the lipoproteins were also assessed. Body mass index was recorded.

RESULTS

The VDR or ER genotypes did not differ significantly with respect to age, age at menopause or body mass index. No significant effect of VDR or ER genotype on bone turnover was found. Furthermore, we were unable to find any relationship between ER genotype and lipoproteins or blood pressure at baseline, or changes in these parameters during HRT.

CONCLUSION

A clinically significant relationship between VDR and ER genotypes and biochemical markers of bone turnover or serum lipoproteins could not be demonstrated in healthy Danish postmenopausal women.

Lack of influence of collagen type Ialpha1 Sp1 binding site polymorphism on the rate of bone loss in a cohort of postmenopausal danish women followed for 18 years

A polymorphism in an Sp1 site in the collagen Ialpha1 (COLIA1) gene has recently been identified and the Ss and ss genotypes were shown to be potentially important determinants of low bone mass in postmenopausal women. Additionally, in a Dutch population, the association of the COLIA1 polymorphism with low bone mineral density (BMD) was more pronounced with increasing age, suggesting a genotype effect on the rate of bone loss. We have investigated the relationship between the COLIA1 Sp1 polymorphism and the rate of bone loss in a longitudinal study with a total of 133 postmenopausal women followed for 18 years. The frequencies of the genotypes were SS 70.7%, Ss 27.8%, ss 1.5% and were in Hardy-Weinberg equilibrium. No association of the COLIA1 genotype with rate of bone loss was detected and there was no difference between the genotype groups with respect to BMD at the femoral neck or lumbar spine. Women with the Ss or ss genotypes, who have been postulated to have low BMD, had even higher BMD at the lower forearm than women with the SS genotype. The levels of serum osteocalcin and urinary collagen type I degradation products were not found to be associated with the COLIA1 Sp1 polymorphism. In conclusion, this study does not support the hypothesis that the Ss COLIA1 genotype predisposes women to increased rate of bone loss or low BMD. However, because of a low absolute number of the ss genotype, it was not possible to reach a conclusion on this particular genotype with regard to an association with low BMD or rate of bone loss.

[Quantitative ultrasound bone measurements]

Quantitative ultrasound (QUS) bone measurement is a relatively new technique for the diagnosis of osteoporosis which is cheaper and easier to use than the more established method of bone densitometry (measurement of bone mineral density, BMD) by x-ray absorptiometry. The two QUS parameters currently measured are BUA (broadband ultrasound attenuation) and SOS (speed of sound). The reported age related changes for healthy women range from -0.27% to -1.62% per year for BUA and from -0.06% to -0.19% per year for SOS. Precision ranges from 1.0-3.8% (CV) for BUA and 0.19-0.30% (CV) for SOS. QUS is believed to reflect mainly BMD. However, studies indicate that QUS also reflects trabecular orientation and other determinants of bone strength independently of BMD. In both cross sectional and prospective studies, QUS seems to be as good a predictor of osteoporotic fractures as BMD.

No major effect of estrogen receptor gene polymorphisms on bone mineral density or bone loss in postmenopausal Danish women

The polymorphisms of the estrogen receptor (ER) gene defined by the restriction enodonucleases PvuII and XbaI have recently been reported to be associated with bone mineral density (BMD) in postmenopausal women. To investigate the possible relation of the PvuII and XbaI restriction fragment-length polymorphisms of the ER gene with BMD in Danish postmenopausal women, two studies were undertaken: 1) a cross-sectional study of 499 postmenopausal women, where the ER genotypes and alleles were related to BMD of the hip, spine, and lower forearm; and 2) a longitudinal study of 101 postmenopausal women followed up for 18 years. In the latter study, late postmenopausal bone loss in the hip and spine was determined over a period of 6 years in women (mean age of 63 to 69 years), and long-term postmenopausal bone loss in the lower forearm was determined over a period of 18 years in women (mean age of 51 to 69 years). Genotyping was performed through the restriction cleavage of polymerase chain reaction-amplified genomic DNA with the two restriction enzymes, PvuII and XbaI. Restriction fragment-length polymorphisms were represented as P or p (PvuII) and X or x (XbaI), with the lower case letters signifying the presence of the restriction site. The frequencies of the ER genotypes were similar to previously published genotype frequencies in Caucasian and Asian populations. No significant effect of the ER genotypes or alleles on BMD was found at any site, nor was there a relation between ER genotypes and the rate of bone loss either in the hip and spine over 6 years, or in the lower forearm over 18 years. In conclusion, we could not demonstrate any major effect of the ER gene polymorphisms on BMD or rate of bone loss in healthy postmenopausal Danish women.

Hip fracture discrimination by imaging ultrasound measurements of the calcaneus

Quantitative ultrasound measurements of the os calcis have recently been upgraded with imaging facilities. This has made measurements of a specific region of interest possible and improved the reproducibility of the method, but the diagnostic ability of imaging ultrasound has not yet been investigated thoroughly. We measured broadband ultrasound attenuation (BUA) and speed of sound (SOS) using imaging ultrasound as well as forearm bone mineral density (BMDarm) using dual-energy X-ray absorptiometry in three age-matched groups of women: (1) 25 women who were admitted to hospital due to a hip fracture; (2) 23 women who were admitted to hospital due to a fall without any fracture; and (3) 26 normal women. Furthermore, BMD of the hip (BMDhip) was measured in a subgroup of the hip fracture patients and those who had fallen. All measurements were performed during the index hospitalization in order to avoid any influence from bone loss due to immobilization after the fracture. We found a -0.48 SD deviation from expected age-matched values in BUA among the hip fracture patients, whereas the patients who had fallen showed a +0.16 SD deviance. For SOS, the figures were -0.70 SD for the hip fracture group and -0.06 SD for the patients who had fallen. For BMD of the arm we found values of -0.65 SD and +0.08 SD, respectively, whereas the figures for BMD of the hip were -0.66 SD and +0.13 SD, respectively. All parameters were significantly lower in the hip fracture group compared with the patients who had fallen. None of the parameters in the patients who had fallen deviated significantly from expected normal age-matched values. Neither BMD of the arm or BMD of the hip separated hip fracture patients and patients who had fallen significantly better than ultrasound (BUA or SOS) did. We conclude that imaging ultrasound (BUA or SOS) separates age-matched groups of hip fracture and non-fracture patients as well as BMD measurements do.

Assessment of bone mineral density in adults with a history of juvenile chronic arthritis: a cross-sectional long-term followup study

OBJECTIVE

To assess bone mineral density (BMD) and bone turnover in adults with a history of juvenile chronic arthritis (JCA) or persistent JCA, and to identify predictors of reduced BMD.

METHODS

Sixty-five white patients (mean age 32.2 years) with a history of JCA and 65 age-, sex-, height-, and weight-matched healthy control subjects participated in the study. Densitometry of the left hip and the lumbar spine was performed, and osteocalcin (bone formation marker) and crosslinks (bone resorption marker) were measured. In addition, bone-related clinical parameters were assessed in the JCA group.

RESULTS

BMD in the hip and lumbar spine was significantly lower in the JCA group than in the controls. Levels of osteocalcin and crosslinks were significantly increased in the JCA group. According to WHO definitions, significantly more subjects in the JCA group had "osteopenia" and "osteoporosis" than would be expected in a normal population sample. Active disease at the time of the study (1996-1997), baseline erosions evaluated in 1979, Steinbrocker functional class in 1996-1997, polyarticular course of JCA, and history of systemic steroid treatment for more than 1 year were significantly associated with reduced BMD. In linear regression analysis including both the JCA and control groups, presence of JCA proved to be the factor most strongly associated with reduced BMD, explaining approximately 20% of its variation.

CONCLUSION

Reduced BMD and evidence of increased bone turnover suggest that JCA patients may be at risk of developing premature osteoporosis and associated fractures later in life. The data are consistent with the concept that BMD in JCA is determined by many factors.

Acute fasting diminishes the circadian rhythm of biochemical markers of bone resorption

OBJECTIVE

Biochemical markers of bone turnover exhibit circadian rhythms with the peak during the night/early morning and the nadir in the late afternoon. The nocturnal increase in bone resorption could theoretically be caused by the absence of food consumption which brings about a decrease in net calcium absorption and an increase in parathyroid hormone (PTH), followed by increased bone resorption in response to the body's demand for calcium. The aim of the present study was to assess the influence of a 33-h fast on the circadian variation in biochemical markers of bone turnover.

DESIGN

Eleven healthy premenopausal women (age: 24+/-5 years) participated in a randomised, cross-over study consisting of two periods: either 33h of fasting (fasting) followed 1 week later by a 33-h period with regular meals eaten at 0800-0830h, 1130-1230h and 1800-1900h (control) or vice versa.

METHODS

Urinary CrossLaps (U-CL/Cr) corrected with creatinine, as a marker of bone resorption; serum osteocalcin (sOC) as a marker of bone formation; serum intact PTH (iPTH); serum phosphate; and serum calcium corrected with albumin.

RESULTS

Both the fasting and the control periods showed a significant circadian rhythm in U-CL/Cr (P<0.001), but the decrease was significantly less pronounced in the morning hours during the fasting period. Fasting resulted in a significant decrease in serum iPTH (throughout the study period) as compared with the control period (P<0.05-0.001). No change was observed in sOC by fasting.

CONCLUSION

Food consumption has a small influence on the circadian variation in bone resorption, independent of PTH. The fall in iPTH during fasting may be secondary to an increased bone resorption produced by fasting.

The association between low bone mass at the menopause and cardiovascular mortality

BACKGROUND

Low bone mineral density in late postmenopausal women has been associated with increased nontrauma mortality. We investigated whether bone mass in women soon after menopause was also associated with the risk of mortality in later life.

METHODS

Between 1977 and 1988, two samples of healthy women were enrolled; one group soon after the menopause (age 50 +/- 2 years [mean +/- SD], n = 309) and another later after menopause (age 70 +/- 2 years, n = 754). The baseline visit included a medical examination and a measurement of bone mineral content in the distal forearm. In 1994, vital status was checked. All causes of death were registered, excluding those that were due to trauma or suicide. Multivariate relative risks (RR) and 95% confidence intervals (CI) were determined.

RESULTS

In the early postmenopausal group, each decrease of one SD (0.4 g/cm) in bone mineral content was associated with a 43% increase in mortality (RR = 1.4; 95% CI 1.0 to 2.0; P < 0.05). When only cardiovascular death was considered, the relative risk of dying within 17 years of the menopause was increased 2.3-fold (95% CI 1.0 to 5.3; P < 0.05). Correspondingly, a 70-year-old woman with a bone mineral content 1 SD below the mean for her age had a 1.8-fold increased risk of dying from cardiovascular disease (95% CI 1.0 to 3.2; P = 0.06). Expressed as quartiles, women with bone mass in the lowest quartile had twice the risk of cardiovascular death compared with those in the highest quartile. A prevalent vertebral compression fracture in the late postmenopausal group was independently associated with cardiovascular death (RR = 2.0; 95% CI 1.4 to 3.3; P = 0.004).

CONCLUSION

Low bone mineral content at the menopause is a risk factor for increased mortality in later life, especially from cardiovascular disease.

Hemodynamic and renal effects of indomethacin in losartan-treated hypertensive individuals

This study was undertaken to examine whether prostaglandin (PG) inhibition with indomethacin interferes with angiotensin II receptor blockade (losartan) during treatment for arterial hypertension. In a double-blind crossover design 10 patients with essential arterial hypertension and treated with losartan were randomized to supplementary treatment with indomethacin or placebo for 1 week, with a 2-week washout period interposed. At the end of each treatment period the following examinations were performed, preceded by 4 days on sodium-fixed diet: 24-h blood pressure (BP), 24-h sodium excretion (UNaV), supine BP, glomerular filtration rate (GFR), renal resistive index (RRI), extracellular fluid volume (ECV), sodium clearance (Cl(Na)), body weight, peripheral blood flow (PBF), and plasma concentrations of aldosterone, renin (PRC), and atrial natriuretic peptide (ANP). Indomethacin did not change BP. Indomethacin increased weight (P < .05) and ECV (P < .05). A nonsignificant decrease in UNaV was seen after indomethacin, as in 24-h Cl(Na). Conversely, in the laboratory in the supine position Cl(Na) increased after indomethacin (P = .05). Indomethacin increased plasma ANP (P < .01). No changes were observed in GFR, RRI, PBF, PRC, or plasma aldosterone. Thus indomethacin did not attenuate the antihypertensive effect of losartan, neither was peripheral blood flow affected. Indomethacin caused sodium retention in the nonresting situation, which was not counterbalanced by the increased Cl(Na) in the resting supine position. The observed changes during prostaglandin (PG) inhibition seem most likely due to lack of PG "protection" of renal function, when the sympathetic nervous system is activated throughout the day.

Quantitative ultrasound (QUS) on a specific region of interest (ROI) of the Os calcis: a new imaging technique

Broadband ultrasound attenuation was measured in 28 premenopausal women, 30 postmenopausal women, and 25 men using a new imaging device, the DTU-one. Short term in vivo precision was 1.2 CV%. The r-values for the correlation of BUA vs BMD at the hip, spine and lower forearm were 0.66, 0.64 and 0.62, respectively.

Postmenopausal bone remodelling and hormone replacement

Osteoporosis is a serious, frequently occurring disease. Sensitive, specific and precise biochemical measures of bone remodelling, thus, are important tools in the evaluation of bone loss, fracture risk and treatment response. Bone turnover is predictive of the subsequent rate of loss. A high bone turnover documented by increased levels of biochemical markers predicts an increased rate of loss in bone mass. Additionally, as a high bone turnover leads to an increase in the extent of bone resorption as well as an increase of the erosion depth, this may also cause deterioration of the bone structure, thereby leading to an increased risk of fracture. That the predictive values of bone mass and markers of bone turnover are additive suggests that these measures describe different properties of bone. Hormone replacement induces a reduction in postmenopausal bone turnover, arrests loss of bone mass and decreases fracture risk. The skeletal response to therapy is reflected by bone markers and these may be used for monitoring purposes. Those who are in most need of treatment can be identified by a combination of bone mass and bone marker measurement. Furthermore, those who need the treatment most will demonstrate the best response in terms of bone mass. Concern has arisen because of a relatively large day-to-day variation, especially in urinary markers; however, this seems to be resolved through use of the new serum markers.

Leptin in overweight postmenopausal women: no relationship with metabolic syndrome X or effect of exercise in addition to diet

OBJECTIVE

To examine the effect of diet with exercise on serum leptin and whether leptin is associated with the metabolic syndrome X in a high risk population such as overweight postmenopausal women.

STUDY DESIGN AND SUBJECTS

121 healthy overweight, postmenopausal women (aged 49-58y, body mass index (BMI) 25-42 kg/m2) were randomized to: A low-energy-diet, 4.2 MJ/d (n = 51), low-energy-diet + standardized physical exercise (n=49) or no intervention (control: n=21) for 12 weeks, followed by 6 months follow-up without intervention.

MEASUREMENTS

S-leptin was measured by Radio Immuno Assay (RIA), body composition and fat distribution by dual energy X-ray absorptiometry (DEXA) and anthropometry. Factors associated with the metabolic syndrome X and sex hormones were measured.

RESULTS

S-leptin was two-fold higher than in normal-weight postmenopausal women and S-leptin was normalized after weight loss induced by the 12-week low-energy-diet, without any additive effect of the exercise. Of the factors associated with the metabolic syndrome X, serum-leptin correlated significantly only with sex-hormone-binding-globulin and plasminogen-activator-inhibitor-1, whereas factors associated with obesity per se correlated significantly with leptin. Changes in S-leptin correlated with changes in fat tissue mass during the follow-up, but not during the intervention. S-leptin at baseline did not correlate with either short term or long term weight loss.

CONCLUSION

There is no effect of exercise added to diet on S-leptin in overweight postmenopausal women. Leptin does not seem to be associated with the metabolic syndrome X, but rather with fatness. S-leptin is probably associated with both dynamic and static effects of adipose tissue. S-leptin did not predict weight loss.

Body composition and fat distribution measured by dual-energy x-ray absorptiometry in premenopausal and postmenopausal insulin-dependent and non-insulin-dependent diabetes mellitus patients

The study aim was to measure body composition and fat distribution in premenopausal and postmenopausal women with insulin-dependent ([IDDM] n = 53) and non-insulin-dependent ([NIDDM] n = 32) diabetes mellitus by dual-energy x-ray absorptiometry. IDDM and NIDDM patients had similar, normal lean tissue mass (LTM) and 24-hour urinary excretion of creatinine. Total body and abdominal fat percentages were higher in the NIDDM group (approximately 40%) than in the IDDM group (-27%, P < .001) and were constant with age and menopausal status in both groups. In postmenopausal patients with IDDM, total body and abdominal fat values were less than in postmenopausal healthy women (approximately 27% v approximately 37%, P < .001). In premenopausal patients with NIDDM, total body and abdominal fat were higher than in premenopausal healthy women (approximately 42% v approximately 25%, P < .001). In conclusion, women with IDDM or NIDDM have a normal LTM and probably a normal muscle mass. Total body and abdominal fat were higher for women with NIDDM than for those with IDDM.

[Relation between common allelic variation in a cross-sectional longitudinal population study. Vitamin D receptor locus, bone mineral density and postmenopausal bone loss]

The aim of this study was to determine whether common allelic variation at the vitamin D receptor locus is related to bone mineral density and postmenopausal bone loss. Five hundred and ninety-nine healthy women aged 27 to 72 and 125 women with low bone mass aged 55-77 were measured once in a cross-sectional design. Furthermore, 136 women aged 45-54 were followed longitudinally for 18 years. The vitamin D receptor genotypes were determined using Polymerase Chain Reaction-Restriction Fragment Length Polymorphism analysis for three different polymorphic restriction sites (BsmI, ApaI and TaqI). Bone mineral density was measured by photon and X-ray absorptiometry. The cross-sectional study showed no significant relationship between vitamin D receptor genotype and bone mineral density. The maximum difference between homozygotes was 1.3%, P = 0.33, N = 723. The low bone mineral density group had virtually the same genotype frequencies as the normal bone mineral density group. The results of the longitudinal study showed that vitamin D receptor genotype was neither related to early postmenopausal bone loss: age 51-53 (total bone loss at the lower forearm: -3.6% [3.6%], mean [standard deviation]), late postmenopausal bone loss: age 63-69 (total bone loss at the hip: -6.2% [8.7%]) nor to long term postmenopausal bone loss: age 51-69 (total bone loss at the lower forearm: -24.5% [11.4%]). Using analysis of variance to test for differences in the rates of bone loss between the vitamin D receptor genotypes, P values ranged from 0.07 to 0.79. We conclude that common allelic variation at the vitamin D receptor locus as defined by the endonucleases ApaI, BsmI and TaqI is neither related to bone mineral density nor to the rate of bone loss in healthy postmenopausal Danish women.

The role of quantitative ultrasound in the assessment of bone: a review

Quantitative ultrasound (QUS) bone measurement is a promising, relatively new technique for the diagnosis of osteoporosis. Unlike to the more established method of bone densitometry [measurement of bone mineral density (BMD) e.g. using dual X-ray absorptiometry (DEXA)], QUS does not use ionizing radiation. It is cheaper, takes up less space and is easier to use than densitometry techniques. The two QUS parameters currently measured are broadband ultrasound attenuation (BUA) and speed of sound (SOS). The reported age-related changes for healthy women range from -0.27% to -1.62% per year for BUA and from -0.06% to -0.19% per year for SOS. Precision ranges from 1.0 to 3.8% (CV) for BUA and from 0.19 to 0.30% (CV) for SOS. The new method of imaging ultrasound has improved the precision of QUS measurements. QUS is significantly correlated with BMD. Studies with the latest equipment have shown r-values between 0.6 and 0.9 in site-specific measurements, and QUS is thus believed to reflect mainly BMD. However, other studies indicate that QUS measures something other than the actual mineral content of bone, namely bone quality, e.g. in vitro studies have shown that QUS reflects trabecular orientation independently of BMD. In both cross-sectional and prospective studies, QUS seems to be as good a predictor of osteoporotic fractures as BMD. In two large prospective studies, QUS also predicted fracture risk independently of BMD. QUS has just begun to be used systematically for monitoring the response to anti-osteoporotic treatments in prospective trials. In the studies performed, QUS has been found to be useful in the follow-up of patients. QUS is thus a promising new technique for bone assessment.