Peripheral arterial disease and osteoporosis in older adults: the Rancho Bernardo Study

Clinical and subclinical arteriosclerotic disease in octagenarians with hip fracture. A case-control study

BACKGROUND AND OBJECTIVES

Evaluate clinical and subclinical arteriosclerotic disease in older patients with hip fracture compared with patients without fracture in order to increase knowledge about the relation between both diseases in older individuals.

PATIENTS AND METHODS

Age- and sex-matched case-control study of octogenarians with and without recent hip fracture. Vascular risk factors, subclinical vascular diseases (assessed by carotid plaques, carotid intima media thickness and arterial stiffness) as well as cardiovascular diseases were analyzed. Univariate and multivariate logistic models were used to estimate odds ratios (OR) with their 95% confidence intervals (CI) to assess the association of the arteriosclerosis and hip fracture.

RESULTS

We analyzed 95 patients per group with a median age of 82 [79-87] years of whom 77.9% were female. Patients in both groups have elevated rates of vascular disease (25%) without differences between them. Patients with hip fracture had higher subclinical arteriosclerotic alterations with higher percentage of carotid plaques (OR 3.25 [1.06-9.97]) compared with the control group.

CONCLUSIONS

Older patients with hip fracture had significantly higher presence of subclinical alterations but not increase on rate of cardiovascular arteriosclerotic disease compared with those without hip fracture.

The Pink Tax: Sex and Gender Disparities in Peripheral Artery Disease

Peripheral artery disease (PAD) is an atherosclerotic disease associated with significant functional impairment, morbidity, and mortality. Among women, PAD remains poorly recognized and undermanaged. Compared with men, women with PAD tend to be underdiagnosed or misdiagnosed, have poorer quality of life, and experience higher rates of PAD-related morbidity and cardiovascular mortality. In this review, we describe the sex- and gender-related differences in the epidemiology, presentation, diagnosis, and management of PAD. We provide specific recommendations to overcome these factors, including greater awareness and an increased emphasis on tailored and more aggressive interventions for women with PAD. Such changes are warranted and necessary to achieve more equitable outcomes in women with PAD, including improved limb outcomes, enhanced lifestyle, and cardiovascular risk reduction.

The association between peripheral arterial disease and risk for hip fractures in elderly men is not explained by low hip bone mineral density. Results from the MrOS Sweden study

In this prospective study in Swedish elderly men, PAD based on an ABI < 0.9 was associated with an increased risk of hip fracture, independent of age and hip BMD. However, after further adjustments for comorbidity, medications, physical function, and socioeconomic factors, the association diminished and was no longer statistically significant.

INTRODUCTION

To examine if peripheral arterial disease (PAD) is associated with an increased risk for hip fracture in men independent of hip BMD.

METHODS

Ankle-brachial index (ABI) was assessed in the Swedish MrOS (Osteoporotic Fractures in Men) study, a prospective observational study including 3014 men aged 69-81 years at baseline. PAD was defined as ABI < 0.90. Incident fractures were assessed in computerized X-ray archives. The risk for hip fractures was calculated using Cox proportional hazard models. At baseline, BMD was assessed using DXA (Lunar Prodigy and Hologic QDR 4500) and functional measurements and blood samples were collected. Standardized questionnaires were used to collect information about medical history, falls, and medication.

RESULTS

During 10 years of follow-up, 186 men had an incident hip fracture. The hazard ratio (HR) for hip fracture in men with PAD was 1.70 (95% CI 1.14-2.54), adjusted for age and study site. Additional adjustment for total hip BMD marginally affected this association (HR 1.64; 95% CI 1.10-2.45). In a final multivariate model, the HR attenuated to a non-significant HR 1.38 (95% CI 0.91-2.11) adjusted for age, site, hip BMD, BMI, falls, smoking, eGFR, handgrip strength, walking speed, former hip fracture, antihypertensive treatment, diabetes, education, and history of cardiovascular disease.

CONCLUSION

This study suggests that PAD is associated with an increased risk for hip fracture independently of hip BMD in elderly Swedish men. However, the high frequency of comorbidity and lower physical performance among men with PAD might partly explain this association.

The Association between Osteoporosis and Peripheral Artery Disease: A Population-Based Longitudinal Follow-Up Study in Taiwan

Background: There are several possible links that have been used to claim that osteoporosis and peripheral artery disease (PAD) are associated; however, the solid evidence is not sufficient. This study aimed to use the Taiwan National Health Insurance Research Database (NHIRD) to determine if osteoporosis is associated with peripheral artery disease (PAD). Method: NHIRD records from 23 million patients were collected to recruit two matched cohort groups: 64,562 patients with and 64,562 patients without osteoporosis. To compare the crude hazard ratio (HR) and the incidence rate ratio between the two cohort groups for PAD, the Cox model was used. Result: With an adjusted HR of 1.18 (95% CI, 1.08-1.29), the osteoporosis cohort group had a significantly greater risk for PAD than the group without osteoporosis. The cumulative incidence of PAD in the cohort group was also statistically higher than it was in the group without osteoporosis (1.71% and 1.39%; p ≤ 0.0001, log-rank) over the 10-year follow-up period. In addition, the osteoporotic patients with ischemic stroke, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) had a significantly increased risk of PAD based on subgroup analysis. Conclusions: There was a positive association between osteoporosis and the development of PAD, as patients with osteoporosis had an increased incidence of PAD over time.

Associations between bone mineral density and subclinical peripheral arterial disease in elderly men with type 2 diabetes mellitus

The association between peripheral arterial disease (PAD) and osteoporosis in elderly men with type 2 diabetes mellitus (T2DM) remains unclear. We demonstrated the association between subclinical PAD and decreased total hip bone mineral density (BMD) in men aged ≥ 55 years with T2DM, providing clinical clues for the early detection of decreased bone density in total hip.

PURPOSE

To investigate the association between subclinical peripheral arterial disease (PAD) and bone mineral density (BMD) at total hip, femoral neck, and lumbar spine (L_1-4) in elderly men with type 2 diabetes mellitus (T2DM).

METHODS

We identified 2,466 patients with confirmed diabetes in this retrospective cross-sectional study. A total of 272 men aged ≥ 55 years with T2DM (50 with subclinical PAD and 222 without PAD) were analyzed. Partial correlation analysis was conducted to explore the associations between ankle-brachial index (ABI) and BMD. Multivariate logistic regression analysis was performed to analyze the contributor for low bone density (T-score <  - 1.0).

RESULTS

Patients with T2DM and subclinical PAD (ABI ≤ 0.9) had significantly lower total hip BMD and T-score (BMD, 0.87 ± 0.14 vs. 0.92 ± 0.15 g/cm², P = 0.014; T-score, -1.30 [-1.70 to -0.45] vs. -0.80 [-1.40 to 0.00], P = 0.009) than those in the control group. The partial correlation analyses indicated that ABI significantly correlated with the total hip T-score (adjusted r = 0.166, P = 0.009). The logistic regression analysis indicated that subclinical PAD was an independent risk factor for the risk of decreased bone density in total hip (adjusted odds ratio [95% CI]: 8.933 [1.075-74.222], P = 0.043).  CONCLUSION: Subclinical PAD (ABI ≤ 0.9) could be used as a risk factor for decreased total hip BMD in men aged ≥ 55 years with T2DM, which provides clinical clues for the early detection of low bone density in total hip in such populations.

The association between bone mineral density and postoperative drainage volume following cruciate-substituting primary total knee arthroplasty: a cross-sectional study

Background

The prevalence of osteoporosis in patients who undergo a primary total knee arthroplasty (TKA) is increasing. Low bone mineral density (BMD) is related to unfavorable outcomes following TKA such as migration of uncemented tibial components. Postoperative blood loss in TKA is an important complication. Non-modifying predicting factors for postoperative blood loss in patients undergoing primary TKA need further elucidation. Studies on the association between BMD and blood loss after TKA are limited. We aimed to demonstrate the relationship between BMD and postoperative drainage volume following primary TKA.

Methods

A cross-sectional study was conducted between January 2014 and August 2020. A total of 119 primary varus osteoarthritis knees with BMD results were included in the study. Patients with secondary causes of osteoporosis were excluded.

Results

The median postoperative drainage volume of participants in the normal total hip BMD group and the normal trochanter BMD group was higher than that of patients in the low total hip BMD group and the low trochanter BMD group (285.0 ml vs 230.0 ml, P = 0.003; 282.5 ml vs 240.0 ml, P = 0.013, respectively). Multivariate regression analyses showed that operative time, spinal anesthesia, and normal total hip BMD status were significant predictive factors associated with increased postoperative drainage volume (P = 0.014, 0.022, and 0.013, respectively). No association was identified between the lumbar spine BMD status and postoperative drainage volume.

Conclusions

The relationship between BMD and postoperative blood loss in primary TKA was identified in this study. Normal total hip BMD was found to be associated with an increased postoperative drainage volume after primary TKA compared with low BMD.

Brachial-ankle pulse wave velocity is associated with the risk of osteoporosis: a cross-sectional evidence from a Chinese community-based cohort

Background

Association of arterial stiffness and osteoporosis has been well documented in elderly population. However, it is not clear whether they co-progress from the early stages through common mechanisms. The object of this study was to evaluate possible associations between arterial stiffness and osteoporosis by measuring brachial-ankle pulse wave velocity (baPWV) and the Osteoporosis Self-Assessment Tool for Asia (OSTA) index among a healthy population of Chinese aged 40 years and older. Whether baPWV can be used as a predictor of osteoporosis on OSTA was further assessed.

Methods

This study was cross-sectional in design. Of 3984 adults aged 40 years and older in the Yunyan district of Guiyang (Guizhou, China) who underwent both OSTA and baPWV measurements within 1 month, 1407 were deemed eligible for inclusion (women, 1088; men, 319).

Results

The mean baPWV was 1475 ± 302 cm/s (range,766–3459 cm/s). baPWV in 110 individuals with high risk of osteoporosis (OSTA index < − 4) was higher than that of individuals with non-high risk (1733 ± 461 cm/s vs. 1447 ± 304 cm/s, P < 0.001). OSTA index was negatively correlated with baPWV(ρ = − 0.296, P < 0.001) after adjusting for age, sex, body mass index, waist circumference, diastolic blood pressure, and creatinine clearance rate. baPWV was an independent predictor for the presence of high risk of osteoporosis (β = − 0.001, P < 0.001) and was consistent across age and sex subgroups, and the optimal baPWV cutoff value for predicting the presence of high risk of osteoporosis and fracture was 1693 cm/s. The AUC was 0.722 (95% confidence interval [CI], 0.667–0.777; P < 0.001, sensitivity of 52.8% and specificity of 83.6%).

Conclusions

We conclude that arterial stiffness measured by baPWV is well correlated with the severity of osteoporosis evaluated by OSTA. baPWV index may be a valuable tool for identifying individuals with risk of developing osteoporosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-020-02125-3.

Parental cardiorespiratory conditions and offspring fracture: A population-based familial linkage study

BACKGROUND

The role of parental cardiorespiratory conditions on fracture risk is unclear. We examined the associations between parental cardiorespiratory conditions and offspring fracture risk.

METHODS

In this population-based retrospective cohort study, we identified 279,085 offspring aged≥40 years between April 1, 1997 and December 31, 2015 with successful linkage to 273,852 mothers and 254,622 fathers. Parental cardiorespiratory conditions, including cerebral vascular disease, congestive heart failure, hypertension, ischemic heart disease, myocardial infarction, chronic obstructive pulmonary disease (COPD) and peripheral vascular disease, were ascertained using physician and hospital records dating back to 1979. The outcome was offspring incident major osteoporotic fracture (MOF).

RESULTS

During an average of 11.8 years of offspring follow-up, we identified 8762 (3.1%) incident MOF. Either parent congestive heart failure (adjusted hazard ratio [HR]: 1.13; 95% confidence interval [CI] 1.07-1.19) and COPD (adjusted HR: 1.12; 95% CI 1.07-1.17) were independently associated with increased offspring MOF risk; all their false discovery rates were <0.001. Similar risk estimates were observed when analyses were performed for fathers only, mothers only or both parents, in multivariable models with and without adjustment for offspring cardiorespiratory conditions, and stratified by offspring sex and offspring incident fracture site. Parental cerebrovascular disease, hypertension, ischemic heart disease and myocardial infarction were not associated with offspring MOF.

CONCLUSIONS

Parental congestive heart failure and parental COPD are independent risk factors for offspring MOF.

Brief Report: Aging Attenuates the Association Between Coronary Artery Calcification and Bone Loss Among HIV-Infected Persons

INTRODUCTION

Studies among HIV-uninfected persons (mostly in their sixth decade of life) show that detectable coronary artery calcium (CAC) is independently associated with low bone mineral density (BMD), suggesting a possible common pathogenic mechanism.

AIM

We assessed the relationship between CAC and BMD, which has not been well described among younger to middle-aged HIV-infected persons.

METHODS

We studied participants with baseline CAC and BMD measures from a prospective cohort of HIV-infected persons enrolled in the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) during 2004-2006. We used logistic regression to assess the association between detectable CAC (>0 Agatston score) and BMD (g/cm, T-score), and adjusted for known traditional and HIV-related risk factors.

RESULTS

Among 472 participants (76% male, 30% non-Hispanic black, median age 41 years, and 71% with HIV RNA < 400 copies/mL), the majority had no detectable CAC (82%), but had baseline osteopenia (53%) or osteoporosis (10%). In univariate analysis, participants with detectable CAC had lower femoral neck/total hip T-scores, lower femoral neck/total hip/lumbar spine BMD, and higher rates of osteopenia/osteoporosis. After adjustment for age, all associations were no longer significant; adjustment for traditional risk factors excluding age and HIV-related variables failed to attenuate these associations.

CONCLUSIONS

We found aging attenuates the association between detectable CAC and BMD in this cohort. Aging remains an important contributor to non-AIDS-defining illnesses. These data reinforce the importance of developing screening and prevention strategies for aging HIV-infected persons given their excess risk across a wide spectrum of end-organ complications.

Vitamin D and cardiovascular disorders

Vitamin D is necessary for bone health but may also have many extra-skeletal effects. The vitamin D endocrine system has major effects on gene and protein expression in many cells and tissues related to the cardiovascular system. In addition, many preclinical studies in animals with vitamin D deficiency or genetically silenced expression of the vitamin D receptor or vitamin D metabolizing enzymes suggest that the absence of vitamin D action may result in cardiovascular events. This includes dysfunctions of endothelial cells, thereby accelerating the process of atherosclerosis, hypertension or abnormal coagulation, ultimately resulting in higher risks for all major cardiovascular or cerebrovascular events. A wealth of observational studies in different parts of the world have fairly consistently found a strong association between a poor vitamin D status and surrogate markers or hard cardiovascular events. A few Mendelian randomization studies did, however, not find a link between genetically lower serum 25OHD concentrations and cardiovascular events. Finally, many RCTs could not demonstrate a consistent effect on surrogate markers, and a limited number of RCTs did so far not find whatever effect on hard cardiovascular endpoints such as myocardial ischemia or infarction, stroke, or cardiovascular death. In conclusion, preclinical data generated a plausible hypothesis of a link between vitamin D status and extra-skeletal events, including cardiovascular endpoints. Whether the vitamin D endocrine system is redundant for the human vascular system or whether the RCTs have not been optimally designed to answer the research question is thus not yet settled.

The associations of subclinical atherosclerotic cardiovascular disease with hip fracture risk and bone mineral density in elderly adults

In the absence of clinically recognized cardiovascular disease, increased carotid artery intimal medial thickness was associated with higher hip fracture risk in older adults, despite its association with higher bone mineral density (BMD). Low ankle brachial index and aortic wall thickness were not associated with fracture risk or BMD.

INTRODUCTION

Clinically recognized cardiovascular disease (CVD) is associated with osteoporosis and hip fracture risk, but the relationship of subclinical atherosclerosis to bone health is not certain.

METHODS

We followed 3385 participants from the Cardiovascular Health Study (mean age 74.7 ± 5.3 years) with a median time to fracture of 12.1 years who underwent baseline carotid artery and aortic wall ultrasound scanning and ankle brachial blood pressure index (ABI) determinations. A subset underwent bone mineral density (BMD) testing.

RESULTS

There were 494 hip fractures during follow-up. Among persons without clinical CVD, an average standard-deviation increase in a composite score of maximal common and internal carotid artery intimal medial thickness (cIMT) was associated with increased risk of hip fracture [(HR 1.18 [1.04, 1.35]), even though cIMT was positively associated with BMD. Neither aortic wall thickness nor ABI were associated with hip fracture risk or BMD. Among participants with clinical CVD, cIMT and aortic wall thickness, but not ABI, were associated with increased hip fracture risk.

CONCLUSION

Subclinical cIMT is associated with an increased risk of hip fractures despite being associated with increased BMD. This finding suggests that vascular health, even in its early stages, is linked to bone health, by pathways other than BMD.

Peripheral artery disease and osteoporosis: Not only age‑related (Review)

Osteoporosis and atherosclerosis are two chronic degenerative diseases that share several biochemical pathways and risk factors. Previous studies have associated osteoporosis with carotid atherosclerosis, cardiovascular mortality and stroke, but data on the relationship with peripheral artery disease are few and conflicting. The OPG/RANK/RANKL system and Wnt/beta catenin signaling seem to be deeply involved in the pathogenesis of bone alterations and atherosclerotic processes also affect arteries of the lower extremities. Hypovitaminosis D could also play a role in the relationship of these two diseases. New and larger studies are necessary to shed light on this association and to design new drugs able to act in both these chronic degenerative diseases.

Bone mineral density and microarchitecture linkages with micro- and macro-vascular impairments at the hand in systemic sclerosis: an HRpQCT study

Objective

To investigate the link between bone alteration and micro- and macro-vascular disease in patients with systemic sclerosis (SSc).

Results

33 SSc patients were included. In univariate analysis, low values of cortical vBMD were significantly associated with a low DBI at the 2nd finger (p = 0.004) and at the 4th (p = 0.002) and with severe capillaroscopic score (p = 0.008). In multivariate analyses, low cortical vBMD was associated with a low DBI at the 4th finger, age and severe capillaroscopic score (adjusted R² = 0.58; p = < 0.001). Low cortical thickness was associated with a low DBI at the 4th finger, severe capillaroscopic score and age (adjusted R² = 0.49, p = < 0.001).

Conclusion

Our study findings showed an association between micro- and macro-vessel damage and altered microarchitectural indices at the radius in SSc.

Methods

We performed a pilot study in female patients with SSc. Microvascular disease was assessed by the capillaroscopic score of Cutolo. Macrovascular involvement was measured by digito-brachial pressure index (DBI) on laser-Doppler at the 2nd and 4th finger. Volumetric bone mineral density (vBMD) and bone microarchitecture involvement were analysed by High-Resolution peripheral Quantitative Computed Tomography (HRpQCT) at the distal radius.

Risk and outcomes of fracture in peripheral arterial disease patients: two nationwide cohort studies

Using national insurance claims data of Taiwan, we found that patients with peripheral arterial disease (PAD) had increased risk of fracture during the follow-up period of 2000-2013. History of PAD was also associated with adverse outcomes in hospitalized fracture patients. Prevention strategies were needed in this susceptible population.

INTRODUCTION

Limited information was available on the association between PAD and fracture. The purpose of this study is to evaluate fracture risk and post-fracture outcomes in patients with PAD.

METHODS

We identified 6647 adults aged ≥ 20 years with newly diagnosed PAD using the Taiwan National Health Insurance Research Database in 2000-2004. Comparison cohort consisted of 26,588 adults without PAD randomly selected with frequency matching in age and sex. Events of fracture were identified during the follow-up period from January 1, 2000 until December 31, 2013, to evaluate adjusted hazard ratios (HR) and 95% confidence interval (CI) of fracture associated with PAD. Another nested cohort study of 799,463 hospitalized fracture patients analyzed adjusted odds ratios (ORs) and 95% CIs of adverse events after fracture among patients with and without PAD in 2004-2013.

RESULTS

Incidences of fracture in people with and without PAD were 22.1 and 15.5 per 1000 person-years, respectively (P < .0001). Compared with control, the adjusted HR of fracture was 1.59 (95% CI, 1.48-1.69) for PAD patients. In the nested cohort study, patients with PAD had higher post-fracture mortality (OR = 1.16; 95% CI, 1.09-1.25) and various complications. PAD patients also had comparatively higher medical expenditure (2691 vs. 2232 USD, P < .0001) and longer hospital stay (10.6 vs. 9.0 days, P < 0.0001) during fracture admission.

CONCLUSIONS

Increased risk of fracture and post-fracture adverse outcomes were associated with PAD. This susceptible population needs care to prevent fracture and to minimize adverse outcomes after it occurs.

The Association between Bone Quality and Atherosclerosis: Results from Two Large Population-Based Studies

OBJECTIVE

It is highly debated whether associations between osteoporosis and atherosclerosis are independent of cardiovascular risk factors. We aimed to explore the associations between quantitative ultrasound (QUS) parameters at the heel with the carotid artery intima-media thickness (IMT), the presence of carotid artery plaques, and the ankle-brachial index (ABI).

METHODS

The study population comprised 5680 men and women aged 20-93 years from two population-based cohort studies: Study of Health in Pomerania (SHIP) and SHIP-Trend. QUS measurements were performed at the heel. The extracranial carotid arteries were examined with B-mode ultrasonography. ABI was measured in a subgroup of 3853 participants. Analyses of variance and linear and logistic regression models were calculated and adjusted for major cardiovascular risk factors.

RESULTS

Men but not women had significantly increased odds for carotid artery plaques with decreasing QUS parameters independent of diabetes mellitus, dyslipidemia, and hypertension. Beyond this, the QUS parameters were not significantly associated with IMT or ABI in fully adjusted models.

CONCLUSIONS

Our data argue against an independent role of bone metabolism in atherosclerotic changes in women. Yet, in men, associations with advanced atherosclerosis, exist. Thus, men presenting with clinical signs of osteoporosis may be at increased risk for atherosclerotic disease.

Novel association between bone mineral density scores and the prevalence of peripheral artery disease in both sexes

The purpose of the current study was to investigate the association between bone mineral density (BMD) scores and the prevalence of peripheral artery disease (PAD) in a large cohort of subjects who underwent arterial Doppler assessments and calcaneal bone densitometry. The study was performed using data obtained from Life Line Screening Inc. Subjects were self-selected and paid for screening tests. The prevalence of PAD was significantly higher in men with osteopenia (4.5%) and osteoporosis (10.9%) compared to men with normal BMD (3.0%) ( p<0.001). Osteopenia (odds ratio (OR) 1.3) and osteoporosis (OR 2.3) were found to be independent risk factors for the presence of PAD in men. The prevalence of PAD was significantly higher in women with osteopenia (4.8%) and osteoporosis (11.8%) compared to women with normal BMD (3.3%) ( p<0.001). Osteopenia (OR 1.15) and osteoporosis (OR 1.8) were found to be independent risk factors for the presence of PAD in women. The current study reports a strong association of abnormal BMD analysis with the prevalence of PAD, which persists even when controlling for age and associated atherosclerotic risk factors. Although the mechanism by which these two disease processes is related is not completely elucidated, the presence of osteoporosis should make clinicians aware of the possibility of occult PAD or associated atherosclerotic disease in appropriate patients.

Systematic review and meta-analysis for the association of bone mineral density and osteoporosis/osteopenia with vascular calcification in women

AIM

The relationships of osteoporosis/osteopenia and bone mineral density (BMD) with vascular calcification (VC) remain controversial. Thus, we performed this systematic review and meta-analysis to evaluate the association between BMD, osteoporosis/osteopenia risk and VC.

METHODS

PubMed, Embase and Springer databases were searched from inception to March, 2015 for studies involving the association of vascular calcification with BMD and osteopenia/osteoporosis in women. A manual search of the references cited in the publications was also employed for more relevant studies. The heterogeneity was assessed using Cochran's Q statistic and I² test. Weighted mean difference (WMD) or odds ratio (OR) and 95% confidence interval (CI) in the VC group and control group were appropriately pooled.

RESULTS

Four studies were enrolled in the meta-analysis. The pooled effects indicated that the spine BMD (WMD = -0.08, 95% CI: -0.11 to -0.06) and hip BMD (WMD = -0.06, 95% CI: -0.10 to -0.07) in VC group were significantly lower than those in control group, respectively. Moreover, patients with VC were prone to develop osteoporosis (OR = 4.39, 95% CI: 2.82-6.83) and osteopenia (OR = 1.72, 95% CI: 1.14-2.60).

CONCLUSION

The results suggest that patients with VC have lower lumbar spine and hip BMD levels and increased risk for developing osteoporosis/osteopenia. Thus, VC patients should be evaluated for the presence of osteoporosis/osteopenia, as well as susceptibility to fractures.

Decreased bone cortical density at the forearm in subjects with subclinical peripheral arterial disease

The association between peripheral arterial disease (PAD) and low bone mass is controversial. In our study, peripheral quantitative computed tomography shows a reduction of cortical but not trabecular, bone mineral density (BMD) at the forearm, in patients with subclinical PAD.

INTRODUCTION

Some controversy exists regarding the association between peripheral arterial disease (PAD) and low bone mass. Previous studies have evaluated bone mineral density (BMD) in patients with subclinical PAD, with mixed results. Inconsistency of data may depend on the fact that most studies measured areal bone mineral density (aBMD) by Dual-energy-x ray absorptiometry (DXA). Because DXA cannot distinguish between cortical and trabecular compartments, we reasoned that a study aimed to establish whether these compartments were differentially affected by PAD status could give more information on the nature of this association.

METHODS

In this cross-sectional study, we used peripheral quantitative computed tomography (pQCT) to examine volumetric cortical and trabecular mineral density at the radius (vBMD) in a cohort of subjects with subclinical PAD as defined by ABI ≤0.90 and compared them with healthy subjects with no evidence of PAD.

RESULTS

Patients with subclinical PAD had significantly reduced cortical density (1101.0 ± 45.4 vs 1156.2 ± 51.3 mg/cm(3), p < 0.001) and cortical area (75.0 ± 20.9 vs 99.9 ± 18.2 mm(2), p < 0.001) than healthy subjects. Trabecular density (178.1 ± 47.9 vs 165.8 ± 29.6 mg/cm(3)) was not significantly different in the two groups.

CONCLUSION

Subclinical PAD induces a selective bone loss at the radius compartment, not identified by standard DXA, which seems to occur primarily at the cortical level.

Ankle-brachial index and bone turnover in patients on dialysis

An association between atherosclerosis and osteoporosis has been reported in several studies. This association could result from local intraosseous atherosclerosis and ischemia, which is shown by limb osteoporosis in patients with peripheral artery disease (PAD), but also could result from bidirectional communication between the skeleton and blood vessels. Systemic bone disorders and PAD are frequent in ESRD. Here, we investigated the possible interaction of these disorders. For 65 prevalent nondiabetic patients on hemodialysis, we measured ankle-brachial pressure index (ABix) and evaluated mineral and bone disorders with bone histomorphometry. In prevalent patients on hemodialysis, PAD (ABix<0.9 or >1.4/incompressible) was associated with low bone turnover and pronounced osteoblast resistance to parathyroid hormone (PTH), which is indicated by decreased double-labeled surface and osteoblast surface (P<0.001). Higher osteoblast resistance to PTH in patients with PAD was characterized by weaker correlation coefficients (slopes) between serum PTH and double-labeled surface (P=0.02) or osteoblast surface (P=0.03). The correlations between osteoclast number or eroded surface and serum mineral parameters, including PTH, did not differ for subjects with normal ABix and PAD. Common vascular risk factors (dyslipidemia, smoking, and sex) were similar for normal, low, and incompressible ABix. Patients with PAD were older and had high C-reactive protein levels and longer hemodialysis vintage. These results indicate that, in prevalent nondiabetic patients with ESRD, PAD associates with low bone turnover and pronounced osteoblast resistance to PTH.

High hip fracture risk in men with severe aortic calcification: MrOS study

A significant link between cardiovascular disease and osteoporosis is established in postmenopausal women, but data for men are scarce. We tested the hypothesis that greater severity of abdominal aortic calcification (AAC) was associated with an increased risk of nonspine fracture in 5994 men aged ≥ 65 years. AAC was assessed on 5400 baseline lateral thoracolumbar radiographs using a validated visual semiquantitative score. Total hip bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry. Incident nonspine fractures were centrally adjudicated. After adjustment for age, body mass index (BMI), total hip BMD, fall history, prior fracture, smoking status, comorbidities, race, and clinical center, the risk of nonspine fracture (n=805) was increased among men with higher AAC (hazard ratio [HR] quartile 4 [Q4] [AAC score ≥ 9] versus quartile 1 [Q1] [0-1], 1.36; 96% confidence interval [CI], 1.10-1.68). This association was due to an increased risk of hip fracture (n=178) among men with higher AAC (HR Q4 versus Q1, 2.33; 95% CI, 1.41-3.87). By contrast, the association between AAC and the risk of nonspine, nonhip fracture was weaker and not significant (HR Q4 versus Q1, 1.22; 95% CI, 0.96-1.55). The findings regarding higher AAC and increased risk of fracture were not altered in additional analyses accounting for degree of trauma, estimated glomerular filtration rate, presence of lumbar vertebral fractures (which may bias AAC assessment), preexisting cardiovascular disease, ankle brachial index, or competing risk of death. Thus, in this large cohort of elderly men, greater AAC was independently associated with an increased risk of hip fracture, but not with other nonspine fractures. These findings suggest that AAC assessment may be a useful method for identification of older men at high risk of hip fracture.

Challenges associated with peripheral arterial disease in women

Peripheral arterial disease (PAD) is an increasingly recognized disorder that is associated with functional impairment, quality-of-life deterioration, increased risk of cardiovascular ischemic events, and increased risk of total and cardiovascular mortality. Although earlier studies suggested that PAD was more common in men, recent reports based on more sensitive tests have shown that the prevalence of PAD in women is at least the same as in men, if not higher. PAD tends to present itself asymptomatically or with atypical symptoms more frequently in women than in men, and is associated with comorbidities or situations particularly or exclusively found in the female sex, such as osteoporosis, hypothyroidism, the use of oral contraceptives, and a history of complications during pregnancy. Fat-distribution patterns and differential vascular characteristics in women may influence the interpretation of diagnostic methods, whereas sex-related vulnerability to drugs typically used in subjects with PAD, differences in risk-factor distribution among sexes, and distinct responses to revascularization procedures in men and women must be taken into account for proper disease management. All these issues pose important challenges associated with PAD in women. Of note, this group has classically been underrepresented in research studies. As a consequence, several sex-related challenges regarding diagnosis and management issues should be acknowledged, and research gaps should be addressed in order to successfully deal with this major health issue.

Association of volumetric bone mineral density with abdominal aortic calcification in African ancestry men

SUMMARY

We tested for association between cortical and trabecular volumetric bone mineral density (vBMD) with abdominal aortic calcification (AAC) prevalence in 278 Afro-Caribbean men. AAC was present in 68.3 % of the men. Greater cortical, but not trabecular, vBMD was associated with significantly decreased odds of AAC independent of traditional risk factors.

INTRODUCTION

The aim of this study is to assess the prevalence and correlates of AAC in a sample of 278 Afro-Caribbean men (mean age 56) and to test for a largely unexplored association between cortical and trabecular vBMD with AAC prevalence.

METHODS

Men were recruited consecutively as part of an ongoing prospective cohort study of body composition in men aged 40+. For this analysis, AAC was assessed by computed tomography of the abdomen from L3 to S1. Aortic calcium was scored using the Agatston method, and prevalence was defined as a score ≥10 to rule out false positives. Men also had BMD assessed using peripheral quantitative computed tomography at 4 % (trabecular vBMD) and 33 % (cortical vBMD) of the radius and tibia.

RESULTS

Abdominal aortic calcification was present in 68.3 % of the men. Significant independent predictors of AAC prevalence were increased age, increased BMI, hypertension, and current smoking. Age was the strongest predictor, with each SD (7.8 year) increase in age conferring 2.7 times increased odds of having AAC (P < 0.0001). A one SD greater cortical, but not trabecular, vBMD was associated with a significant decreased odds of AAC prevalence independent of other traditional risk factors (OR 0.65; 95 % CI 0.45-0.92).

CONCLUSIONS

Cortical vBMD is inversely associated with AAC presence. This finding suggests that there may be shared physiology between cortical bone compartment remodeling and vascular calcification.

Bone mineral density, vertebral fractures and body mass index in postmenopausal women with abdominal aortic calcification

BACKGROUND

Evidence suggest that there are connections between osteoporosis and cardiovascular diseases.

OBJECTIVES

The aim of the study was to analyze the relationship between radiological measurements of abdominal aorta calcifications (AAC) and bone mineral density (BMD) in postmenopausal women.

METHODS

In this cross-sectional study were included 125 postmenopausal women 50-84 years of age. BMD of the spine and hip was measured by dual energy X-ray absorptiometry (DXA). AAC were assessed by lateral radiographs of lumbar spine (L1-L4), using the antero-posterior severity score (0-24). Vertebral fractures were evaluated from T4 to L4 using Genant's semiquantitative method.

RESULTS

Forty-one (32.8%) patients had osteoporosis and 61 (48.8%) had AAC with a mean score of 3.1. Postmenopausal women with AAC were older and had significantly lower femoral neck and trochanteric BMD than subjects without AAC (all p < 0.01). There were no significant differences in the frequency of fractures between subjects with AAC and those without AAC (p > 0.05). In univariate analysis, age, height, weight, femoral and trochanter BMD were significantly associated with the severity of AAC score. In multiple regression analysis, femoral neck BMD, but not lumbar spine, trochanter BMD or age, was an independent predictor of AAC.

CONCLUSIONS

Reduced femoral neck BMD is negatively associated with the presence of AAC in postmenopausal women. The association between BMD and AAC seems to be age-independent, which suggests a common pathogenesis for bone loss and vascular calcifications.

Relationship between bone cross-sectional area and indices of peripheral artery disease

Most studies on the relationship between bone mineral density and atherosclerosis have used dual-energy X-ray absorptiometry, but this method is relatively insensitive to bone geometry. The aim of this study was to investigate the relationship between bone area and indices of carotid and peripheral atherosclerosis. We studied 841 persons aged 65 years or older (women = 444, mean age 73.8 years; men = 397, mean age = 75.3 years) enrolled in the InCHIANTI study and free from active malignancies, chronic use of bisphosphonates or steroids, and estrogen replacement therapy. The tibial cortical and total cross-sectional area (CSA) were measured by peripheral quantitative computed tomography and their ratio was calculated (cortical/total cross-sectional area ratio, cCSA/tCSA); carotid plaques were screened by echography, and peripheral artery disease (PAD) was defined as an ankle/brachial index <0.9 or presence of intermittent claudication. No association between cCSA/tCSA and atherosclerosis was observed in men. In women, lower cCSA/tCSA was associated with both carotid plaques [odds ratio (OR) for lowest vs. best quartile = 2.09, 95 % confidence interval (CI) 1.2-3.68] and PAD (OR = 3.43, 95 % CI 1.58-8.12). After correction for potential confounders (age since menopause, body mass index, Parathyroid hormone, vitamin D, leptin, DHEA-S, testosterone, physical activity, chronic obstructive pulmonary disease, and reduced renal function), the association was not confirmed. According to partial logistic regression, the carotid plaque-cCSA/tCSA association, but not the PAD-cCSA/tCSA association, was mostly dependent on years since menopause. In women the association between osteoporosis and carotid plaques likely reflects hormonal deprivation, whereas that between osteoporosis and PAD seems multifactorial in origin.

The impact of sex on angioplasty and primary stenting for femoropopliteal occlusive disease: results of the DURABILITY II trial

BACKGROUND

This study investigates the impact of sex on angioplasty and primary stenting for the treatment of claudicants with femoropopliteal occlusive disease (FPOD).

METHODS

Two hundred eighty-seven patients enrolled in the Safety and Effectiveness Study of EverFlex Stent to Treat Symptomatic Femoral-popliteal Atherosclerosis (DURABILITY II) trial (a prospective, nonrandomized, core laboratory audited, and independently adjudicated investigational device exemption trial) were stratified by sex (190 men and 97 women) and reviewed.

RESULTS

Women presented with FPOD at an older age than men (71.3 ± 11.2 vs. 65.9 ± 9.9 years; P < 0.001). Men were more likely to be hyperlipidemic (89.5% vs. 79.4%; P = 0.030). No other statistically significant differences were observed with regard to periprocedural comorbidities and demographics. Clinically, women presented more often with severe claudication (64.9% vs. 51.1%; P = 0.033) as compared with men that had more moderate claudication (44.2% vs. 29.9%; P = 0.022). The incidence of rest pain and tissue loss was low and did not vary between sexes. Angiographically, women had smaller reference vessels (4.4 ± 0.8 mm vs. 5.0 ± 0.9 mm; P < 0.001). Longer lesions (91.6 ± 46.8 mm vs. 87.8 ± 43.9 mm) and higher primary (79.0% vs. 76.5%), primary-assisted (90.6% vs. 85.1%), and secondary patency (90.6% vs. 85.7%) rates in women did not achieve statistical significance (P = NS). Mean percent stenosis and occlusion rates were similar between groups, but men were more likely to have severe calcification (47.9% vs. 34.0%; P = 0.020). Inter-Society Consensus for the Management of Peripheral Arterial Disease II classifications were similar between groups. The target lesion revascularization, major adverse event, and mortality rates were similar between groups. At baseline, the absolute claudication distance was 0.29 miles for men, while women only reached 0.14 miles (P < 0.0001). Walking improvement questionnaire scores were also compared; women had significantly lower scores at baseline and at 1 year.

CONCLUSIONS

Despite presenting with FPOD at a later age, with more severe claudication, a shorter absolute claudication distance, and smaller vessels than men, women achieved equal patency rates using angioplasty and primary stenting with similar target lesion revascularization, major adverse event, and mortality rates. Despite these findings, women subjectively have worse symptoms at baseline and at 1 year.

Poststroke hip fracture: prevalence, clinical characteristics, mineral-bone metabolism, outcomes, and gaps in prevention

Objective. To assess the prevalence, clinical and laboratory characteristics, and short-term outcomes of poststroke hip fracture (HF). Methods. A cross-sectional study of 761 consecutive patients aged ≥60 years (82.3 ± 8.8 years; 75% females) with osteoporotic HF. Results. The prevalence of poststroke HF was 13.1% occurring on average 2.4 years after the stroke. The poststroke group compared to the rest of the cohort had a higher proportion of women, subjects with dementia, history of TIA, hypertension, coronary artery disease, secondary hyperparathyroidism, higher serum vitamin B12 levels (>350 pmol/L), walking aid users, and living in residential care facilities. The majority of poststroke HF patients had vitamin D insufficiency (68%) and excess bone resorption (90%). This group had a 3-fold higher incidence of postoperative myocardial injury and need for institutionalisation. In multivariate analysis, independent indicators of poststroke HF were female sex (OR 3.6), history of TIA (OR 5.2), dementia (OR 4.1), hypertension (OR 3.2), use of walking aid (OR 2.5), and higher vitamin B12 level (OR 2.3). Only 15% of poststroke patients received antiosteoporotic therapy prior to HF. Conclusions. Approximately one in seven HFs occurs in older stroke survivors and are associated with poorer outcomes. Early implementation of fracture prevention strategies is needed.

Evidence for a genetic link between bone and vascular measures in African ancestry families

Bone mineral density (BMD) has been inversely associated with subclinical and clinical cardiovascular disease (CVD) in population studies, but the potential mechanisms underlying this relationship are unclear. To test if there is a genetic basis underlying this association, we determined the phenotypic and genetic correlations between BMD and carotid artery ultrasound measures in families. Dual-energy X-ray absorptiometry and peripheral quantitative computed tomography were used to measure BMD in 461 individuals with African ancestry belonging to seven large, multigenerational families (mean family size 66; 3414 total relative pairs). Carotid artery ultrasound was used to measure adventitial diameter (AD) and intima-media thickness (IMT). Phenotypic and genetic correlations between BMD and carotid measures were determined using pedigree-based maximum likelihood methods. We adjusted for potential confounding factors, including age, sex, body weight, height, menopausal status, smoking, alcohol intake, walking for exercise, diabetes, hypertension, serum lipid and lipoprotein levels, inflammation markers, and kidney function. We found statistically significant phenotypic (ρ = -0.19) and genetic (ρG  = -0.70) correlations (p < 0.05 for both) between lumbar spine BMD and AD in fully adjusted models. There was also a significant genetic correlation between trabecular BMD at the radius and IMT in fully adjusted models (ρG  = -0.398; p < 0.05). Our findings indicate that the previously observed association between osteoporosis and CVD in population-based studies may be partly mediated by genetic factors and that the pleiotropic effects of these genes may operate independently of traditional risk pathways.

Bone mineral density is associated with site-specific atherosclerosis in patients with severe peripheral artery disease

Recent studies have highlighted a significant association between the severity of atherosclerosis and bone mineral density (BMD) among healthy subjects, although its connection to angiographically determined peripheral artery disease (PAD) has never been investigated. We evaluated the connection between the angiographic severity and site specificity of peripheral atherosclerosis and osteoporosis among patients with chronic lower limb ischemia. In our cross-sectional study we investigated 172 patients with PAD. The anatomic sites of the lesions were analyzed. The severity of atherosclerosis was diagnosed using the Bollinger angiographic score (BS). BMD was measured at the lumbar spine (l-BMD) and at femoral (f-BMD) and radial (r-BMD) sites by dual-energy X-ray absorptiometry. Dyslipidemia, the level of vitamin D(3), and different bone turnover markers were also noted. Among PAD patients, regardless of the lesion site, we did not find any association between BMD and BS. Among patients with iliac disease, BS was associated with l-BMD (p = 0.038, r = -0.467) and with f-BMD (p = 0.002, r = -0.642). The level of r-BMD among patients with iliac disease was not associated with BS (p = 0.233, r = -0.306). We did not find any difference between the group of patients with and that without dyslipidemia and low or normal levels of vitamin D(3). Our results show a connection between the severity of atherosclerosis and osteoporosis among patients with PAD, specific to the site of the lesion. The findings regarding dyslipidemia, bone markers, and site specificity support the hypothesis that reduced blood flow is the key factor responsible for the inverse association of BMD with atherosclerosis.

Peripheral arterial disease increases the risk of subsequent hip fracture in older men: the Health in Men Study

The aim of the present study was to assess whether peripheral arterial disease is associated with an increased risk of hip fracture in a cohort of 12,094 older men. There was no association between claudication and hip fracture, but there was a significant association with an ankle brachial index (ABI) <0.9.

INTRODUCTION

It is uncertain whether peripheral arterial disease (PAD) is associated with an increased risk of subsequent hip fracture. The aim of the present study was to assess this in a large cohort of men aged 65 years and over.

METHODS

Claudication was assessed by means of the Edinburgh Claudication Questionnaire in 12,094 men, and the ABI was measured in 4,321 of these men. Hospitalisations with hip fracture were identified by record linkage. The association between both claudication and an ABI <0.9 and subsequent hip fractures was assessed using survival curves and Cox regression models.

RESULTS

Amongst the 12,094 men, the baseline prevalence of claudication according to the ECQ was 5.3 %. Amongst the 4,321 men with ABI results, the prevalence of an ABI <0.9 was 11.7 %. Of the 506 men with an ABI <0.9, 129 (25.5 %) also had claudication. Over a median (range) follow-up of 10.8 (0.3-12.7) years, 343 (2.8 %) of the 12,094 men were admitted to hospital with a hip fracture. There was no association between claudication and subsequent hip fractures (hazard ratio (HR) = 0.95; 95 % confidence interval (CI), 0.60, 1.52). Over a median (range) follow-up of 11.1 (0.06-12.3) years 135 (3.1 %) of the 4,321 men with ABI data were admitted to hospital with hip fractures. There was a significant association between an ABI <0.9 and subsequent hip fracture (HR = 1.69; 95 % CI, 1.08, 2.63).

CONCLUSION

Older men with PAD defined as ABI < 0.9 are at increased risk of hip fracture, whereas the symptom of claudication is not an independent predictor of hip fracture.

Prevalence of thoracic vertebral fractures in hospitalized elderly patients with heart failure

OBJECTIVE

Heart failure (HF) has been associated with increased risk of fragility fractures. Indeed, most literature data on fractures were based on an historical and clinical approach focused on the identification of peripheral fractures, whereas the risk of vertebral fractures in this clinical setting is still unclear.

DESIGN

Cross-sectional study.

AIM

To evaluate the prevalence and determinants of radiological thoracic vertebral fractures in patients with HF.

METHODS

The study includes 1031 elderly hospitalized patients (491 females and 540 males; median age, 75 years; range, 65-90; 430 patients with HF) who were evaluated for the presence of thoracic vertebral fractures by quantitative morphometric analysis, using chest X-ray routinely performed in the diagnostic work-up of HF.

RESULTS

Vertebral fractures were found in 166 patients (16.1%), the prevalence being significantly higher in patients with HF as compared with those without HF, both in females (30.9 vs 15.8%; P<0.001) and in males (16.4 vs 7.4%; P=0.001). The association between HF and vertebral fractures remained statistically significant (odds ratio, 2.14; 95% CI, 1.25-3.66; P=0.01) even after adjustment for age, sex, loop diuretic therapy, anticoagulant therapy, proton pump therapy, coexistent chronic obstructive pulmonary disease, diabetes mellitus, renal insufficiency, and chronic liver diseases. In patients with HF, vertebral fractures were positively correlated with female sex, duration of HF, ischemic heart disease, cigarette smoking, and treatment with anti-osteoporotic drugs, and inversely correlated with left ventricular ejection fraction.

CONCLUSIONS

Hospitalized patients suffering from HF are at higher risk of vertebral fractures than patients without HF in the same clinical context.

Arterial calcification and bone physiology: role of the bone-vascular axis

Bone never forms without vascular interactions. This simple statement of fact does not adequately reflect the physiological and pharmacological implications of the relationship. The vasculature is the conduit for nutrient exchange between bone and the rest of the body. The vasculature provides the sustentacular niche for development of osteoblast progenitors and is the conduit for egress of bone marrow cell products arising, in turn, from the osteoblast-dependent haematopoietic niche. Importantly, the second most calcified structure in humans after the skeleton is the vasculature. Once considered a passive process of dead and dying cells, vascular calcification has emerged as an actively regulated form of tissue biomineralization. Skeletal morphogens and osteochondrogenic transcription factors are expressed by cells within the vessel wall, which regulates the deposition of vascular calcium. Osteotropic hormones, including parathyroid hormone, regulate both vascular and skeletal mineralization. Cellular, endocrine and metabolic signals that flow bidirectionally between the vasculature and bone are necessary for both bone health and vascular health. Dysmetabolic states including diabetes mellitus, uraemia and hyperlipidaemia perturb the bone-vascular axis, giving rise to devastating vascular and skeletal disease. A detailed understanding of bone-vascular interactions is necessary to address the unmet clinical needs of an increasingly aged and dysmetabolic population.

Association between cardiovascular diseases and osteoporosis-reappraisal

Positive association between cardiovascular diseases and osteoporosis is important because it concerns two major public health problems. Men and women with cardiovascular diseases (including severe abdominal aortic calcification (AAC) and peripheral arterial disease) tend to have lower areal and volumetric bone mineral density (BMD) as well as faster bone loss, although findings vary according to skeletal site. On one hand, severe forms of cardiovascular diseases (heart failure, myocardial infarction, hypertension, severe AAC) are associated with higher risk of osteoporotic fracture, especially hip fracture. This link was found in the studies based on healthcare databases and the cohort studies. On the other hand, low BMD, history of fragility fracture, vitamin D deficit and increased bone resorption are associated with higher risk of major cardiovascular events (myocardial infraction, stroke, cardiovascular mortality). Moreover, osteocalcin secreted by osteoblasts may be involved in the regulation of energetic and cardiovascular metabolism. The association between both pathologies depends partially on the shared risk factors, and also on the mechanisms that are involved in the regulation of bone and cardiovascular metabolism. Interpretation of the data should take into account methodological limitations: representativeness of the cohorts, quality of the registers and the information obtained from questionnaires, severity of diseases, number of events (statistical power) and their temporal closeness, availability of the information on potential confounders. It seems that patients with severe form of osteoporosis would benefit from assessment of the cardiovascular status and vice versa. However, official guidelines for the clinical practice are still lacking.

Clinical review. Risk factors for low bone mass-related fractures in men: a systematic review and meta-analysis

CONTEXT

Testing men at increased risk for osteoporotic fractures has been recommended.

OBJECTIVE

The aim of this study was to estimate the magnitude of association and quality of supporting evidence linking multiple risk factors with low bone mass-related fractures in men.

DATA SOURCES

We searched MEDLINE, EMBASE, Web of Science, SCOPUS and Cochrane CENTRAL through February 2010. We identified further studies by reviewing reference lists from selected studies and reviews.

STUDY SELECTION

Eligible studies had to enroll men and quantitatively evaluate the association of risk factors with low bone density-related fractures.

DATA EXTRACTION

Reviewers working independently and in duplicate determined study eligibility and extracted study description, quality, and outcome data.

DATA SYNTHESIS

Fifty-five studies provided data sufficient for meta-analysis. The quality of these observational studies was moderate with fair levels of multivariable adjustment and adequate exposure and outcome ascertainment. Statistically significant associations were established for age, low body mass index, current smoking, excessive alcohol use, chronic corticosteroid use, history of prior fractures, history of falls, history of hypogonadism, history of stroke, and history of diabetes. Statistical heterogeneity of the meta-analytic estimates of all associations was significant except for chronic corticosteroid use. None of these associations were of large magnitude (i.e. adjusted odds ratios were generally <2). No evidence supporting a particular effective testing or screening strategy was identified.

CONCLUSIONS

Multiple risk factors for fractures in men were identified, but their usefulness for stratifying and selecting men for bone density testing remains uncertain.

(Sub)clinical cardiovascular disease is associated with increased bone loss and fracture risk; a systematic review of the association between cardiovascular disease and osteoporosis

Introduction

Both cardiovascular disease and osteoporosis are important causes of morbidity and mortality in the elderly. The co-occurrence of cardiovascular disease and osteoporosis prompted us to review the evidence of an association between cardiovascular (CV) disease and osteoporosis and potential shared common pathophysiological mechanisms.

Methods

A systematic literature search (Medline, Pubmed and Embase) was conducted to identify all clinical studies that investigated the association between cardiovascular disease and osteoporosis. Relevant studies were screened for quality according to guidelines as proposed by the Dutch Cochrane Centre and evidence was summarized.

Results

Seventy studies were included in this review. Due to a large heterogeneity in study population, design and outcome measures a formal meta-analysis was not possible. Six of the highest ranked studies (mean n = 2,000) showed that individuals with prevalent subclinical CV disease had higher risk for increased bone loss and fractures during follow-up compared to persons without CV disease (range of reported risk: hazard ratio (HR) 1.5; odds ratio (OR) 2.3 to 3.0). The largest study (n = 31,936) reported a more than four times higher risk in women and more than six times higher risk in men. There is moderate evidence that individuals with low bone mass had higher CV mortality rates and incident CV events than subjects with normal bone mass (risk rates 1.2 to 1.4). Although the shared common pathophysiological mechanisms are not fully elucidated, the most important factors that might explain this association appear to be, besides age, estrogen deficiency and inflammation.

Conclusions

The current evidence indicates that individuals with prevalent subclinical CV disease are at increased risk for bone loss and subsequent fractures. Presently no firm conclusions can be drawn as to what extent low bone mineral density might be associated with increased cardiovascular risk.

Is there a role for bone morphogenetic proteins in osteoporotic fractures?

The central role of bone morphogenetic proteins (BMPs) in the remodelling process of the human skeleton has been identified in numerous experimental and clinical studies. BMPs appear to be key agents in the osteoblastic differentiation of mesenchymal stem cells, and more recent evidence implicates them with the cells of the osteoclastic lineage. BMP-2, BMP-4, BMP-6 and BMP-7 have been studied in the context of osteoporosis and have been associated with its pathophysiological pathways. The theoretical advantages of local or systemic treatment of osteoporotic fractures with BMPs include the potential of inducing a rapid increase in bone strength locally at the fractured area and systemically in the entire skeleton, as well as accelerating the bone-healing period. Animal models of osteoporotic fractures suggested that the induction of new bone by local or systemic use of BMP-7 should be investigated as potential bone augmentation therapy to improve bone quality in symptomatic spinal osteoporosis. As our knowledge expands, new innovations may provide clinicians with advanced biologically-based therapies for the successful treatment of osteoporotic fractures.

Effects of peripheral arterial disease on outcomes in advanced chronic systolic heart failure: a propensity-matched study

BACKGROUND

The effect of peripheral arterial disease (PAD) on outcomes in patients with chronic heart failure (HF) has not been examined in propensity-matched studies.

METHODS AND RESULTS

Of the 2689 patients with advanced chronic systolic HF in the Beta-Blocker Evaluation of Survival Trial, 441 had a history of PAD. Propensity scores for a history of PAD, calculated for each patient using a multivariable logistic regression model, were used to assemble a matched cohort of 299 and 1015 patients, respectively, with and without PAD who were well balanced on 65 measured baseline characteristics. Cox regression models were used to estimate hazard ratios and 95% CIs for associations between PAD and outcomes during 4.1 years of follow-up. Patients had a mean age of 63+/-11 years, 19% were women, and 19% were black. All-cause mortality occurred in 43% and 33% of patients with and without a history of PAD, respectively (hazard ratio when PAD was compared with no history of PAD, 1.40; 95% CI, 1.14 to 1.72; P=0.001). All-cause hospitalization occurred in 75% and 63% of patients with and without PAD, respectively (hazard ratio when PAD was compared with no history of PAD, 1.36; 95% CI, 1.16 to 1.58; P<0.0001). PAD-associated hazard ratios for cardiovascular mortality, HF mortality, and HF hospitalization were 1.31 (95% CI, 1.04 to 1.63; P=0.019), 1.40 (95% CI, 0.97 to 2.02; P=0.076), and 1.05 (95% CI, 0.86 to 1.29; P=0.635), respectively.

CONCLUSIONS

In a well-balanced propensity-matched population of chronic systolic HF patients, a history of PAD was independently associated with increased mortality and hospitalization.