Fracture and the risk of coronary events in women with heart disease

Common mechanisms and holistic care in atherosclerosis and osteoporosis

Cardiovascular (CV) disease and osteoporosis (OP) have become increasing challenges in the aging population and even more in patients with inflammatory rheumatic diseases, such as rheumatoid arthritis, spondyloarthropathies, and systemic lupus erythematosus. In this review, we discuss how the epidemiology and pathogenesis of CV events and OP are overlapping. Smoking, diabetes mellitus, physical inactivity as conventional risk factors as well as systemic inflammation are among the modifiable risk factors for both CV events and bone loss. In rheumatic patients, systemic “high-grade” inflammation may be the primary driver of accelerated atherogenesis and bone resorption. In the general population, in which some individuals might have low-grade systemic inflammation, a holistic approach to drug treatment and lifestyle modifications may have beneficial effects on the bone as well as the vasculature. In rheumatic patients with accelerated inflammatory atherosclerosis and bone loss, the rapid and effective suppression of inflammation in a treat-to-target regime, aiming at clinical remission, is necessary to effectively control comorbidities.

Relationship Between Low Bone Mineral Density and Fractures With Incident Cardiovascular Disease: A Systematic Review and Meta-Analysis

An increasing evidence base suggests that low bone mineral density (BMD) and fractures are associated with cardiovascular disease (CVD). We conducted a systematic review and meta-analysis summarizing the evidence of low BMD and fractures as risk factors for future CVD. Two independent authors searched major databases from inception to August 1, 2016, for longitudinal studies reporting data on CVD incidence (overall and specific CVD) and BMD status and fractures. The association between low BMD, fractures, and CVD across longitudinal studies was explored by calculating pooled adjusted hazard ratios (HRs) ±95% confidence intervals (CIs) with a random-effects meta-analysis. Twenty-eight studies (18 regarding BMD and 10 fractures) followed a total of 1,107,885 participants for a median of 5 years. Taking those with higher BMD as the reference, people with low BMD were at increased risk of developing CVD during follow-up (11 studies; HR = 1.33; 95%CI, 1.27 to 1.38; I2  = 53%), after adjusting for a median of eight confounders. This finding was confirmed using a decrease in one standard deviation of baseline BMD (9 studies; HR = 1.16; 95% CI, 1.09 to 1.24; I2  = 69%). The presence of fractures at baseline was associated with an increased risk of developing CVD (HR = 1.20; 95% CI, 1.06 to 1.37; I2  = 91%). Regarding specific CVDs, low BMD was associated with an increased risk of developing coronary artery disease, cerebrovascular conditions, and CVD-associated death. Fractures at baseline was associated with an increased risk of cerebrovascular conditions and death due to CVD. In conclusion, low BMD and fractures are associated with a small, but significant increased risk of CVD risk and possibly death. © 2017 American Society for Bone and Mineral Research.

Hip fracture and risk of acute myocardial infarction: a nationwide study

Osteoporotic fractures are associated with increased mortality risk. However, little data are available on the risk of acute myocardial infarction (AMI) after hip fracture. Therefore, we investigated whether hip fracture increased the risk of AMI in a large, nationwide cohort study. We obtained data from 8758 patients diagnosed with hip fracture from 2000 to 2009 and from 4 matched controls for each patient from the Longitudinal Health Insurance Database (LHID 2000), Taiwan. Controls were matched for age, sex, comorbid disorders, and enrollment date. All subjects were followed up from the date of enrollment until AMI, death, or the end of data collection (2009). Cox's regression model adjusted for age, sex, comorbid disorders, and medication was used to assess independent factors determining the risk of development of AMI. As expected, despite the matching, the hip fracture patients had more risk factors for AMI at baseline. A total of 8758 subjects with hip fractures and 35,032 controls were identified. Among these patients, 1183 (257 hip fracture patients and 926 controls) developed AMI during the median 3.2-year (interquartile range 1.4 to 5.8 years) follow-up period. Patients with hip fractures had a higher incidence of AMI occurrence when compared with controls (8.7/1000 person-years versus 6.82/1000 person-years). Multivariate analysis adjusted for baseline covariates indicated that hip fracture was associated with a greater risk for AMI development (hazard ratio [HR] = 1.29; 95% confidence interval [CI] 1.12-1.48; p < 0.001). We conclude that hip fracture is independently associated with a higher risk of subsequent AMI.

β1 selectivity of β-blockers and reduced risk of fractures in elderly hypertension patients

INTRODUCTION

Hypertension and osteoporosis are prevalent in the elderly population. Treatments beneficial to both conditions would be helpful. We examined the protective effect of β-blockers (BBs) and their receptor selectivity against fractures compared to other antihypertensives.

MATERIALS AND METHODS

A retrospective cohort was assembled using the Korean Health Insurance Review and Assessment Service database from January 2005 to June 2006. The cohort consisted of 501,924 patients (ages 65 and older) on single-drug therapy for hypertension. Participants were followed to either the date of the first fracture, date of death or end of the study period (30 June 2006), whichever came first. Cox's proportional hazard model was used to calculate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) by sex, adjusting for confounders. Risk of fractures by BBs according to β1 selectivity was compared to non BBs measured in aHR.

RESULTS

Among 501,924 (65% female), the incidence density of fractures in non BB users was 29.3 and 48.2 per 1000 person-years for men and women, respectively, which was higher than in BB users (17.2 for men and 30.5 for women). Compared to BB users, non BB users showed an increased risk of all fracture [aHR 1.56 (95% CI, 1.42-1.72) in men and 1.44 (95% CI, 1.36-1.51) in women] and hip fracture [aHR 2.17 (95% CI 1.45-3.24) in men and 1.61 (95% CI 1.31-1.98) in women] after adjusting for confounding variables. Compared to BBs, the risks of all fractures in α-blockers, calcium channel blockers, diuretics, and renin-angiotensin-aldosterone system blockers were significantly higher (1.72, 1.77, 1.58, 1.29 in men; 2.11, 1.50, 1.46, 1.22 in women, respectively). Compared to non BBs, β1 selective BBs showed a lower risk of fracture (39% for men and 33% for women) after adjusting for confounding factors. On the contrary, non-selective BBs were not protective against fracture.

CONCLUSION

Our results suggested that β1 selective BBs reduce the risk of fractures compared to other classes of antihypertensives in an elderly population, which could have practical applications for strategies to control and prevent adverse outcomes from both hypertension and osteoporosis in this population.

Association between beta-blocker use and fracture risk: the Dubbo Osteoporosis Epidemiology Study

INTRODUCTION

In animal model, mice treated with beta-blockers (BB) had increased bone mass. In humans, high bone mass is associated with reduce fracture risk. The present study sought to test the hypothesis that BB use is associated with reduced fracture risk.

MATERIALS AND METHODS

Data from 3488 participants (1285 men) aged 50 years and above in the Dubbo Osteoporosis Epidemiology Study (DOES) were analyzed. Baseline characteristics of participants were obtained at the initial visit which had taken place between 1989 and 1993. Bone mineral density (BMD) at the lumbar spine and femoral neck was measured by dual energy X-ray absorptiometry (GE-LUNAR Corp, Madison, WI). Two hundred and sixty two (20%) men and 411 (19%) women had been on BB, as ascertained by direct interview and verification with medication history. The incidence of fragility fractures was ascertained during the follow-up period (1989-2008).

RESULTS

In men, BB use was associated with higher BMD at the femoral neck (0.96 versus 0.92 g/cm², P < 0.01), higher lumbar spine (1.32 versus 1.25 g/cm², P < 0.01), and lower fracture risk than those not on BB (odds ratio [OR]: 0.49; 95% CI: 0.32-0.75). In women, BB users also had higher femoral neck BMD (0.83 versus 0.81 g/cm², P < 0.01), higher lumbar spine BMD (1.11 versus 1.06 g/cm², P < 0.01), and lower risk of fracture than non-users (OR 0.68, 95% CI: 0.53-0.87). The associations between BB use and fracture risk were independent of age, BMD, and clinical risk factors. Subgroup analysis suggested that the association was mainly found in selective BB, not in non-selective BB.

CONCLUSION

Beta-blockers use, particularly selective BB, was associated with reduced fracture risk in both men and women, and the association was independent of BMD.

(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.

Lipid profiles and bone mineral density in pre- and postmenopausal women in Korea

Although it has been hypothesized that an atherogenic lipid profile might be associated with lower bone mineral density (BMD), the previous results are controversial. We investigated the association between lipid profile and BMD in premenopausal and postmenopausal women in a large Korean population. This study considered 10,402 women who underwent measurements of lipid profile and BMD from October 2003 to October 2005 at Healthcare System Gangnam Center, Seoul National University Hospital. Participants with potential confounding factors affecting BMD (n = 3,128) were excluded. The associations between lipid profiles (total cholesterol [TC], low-density lipoprotein [LDL-C] and high-density lipoprotein [HDL-C] cholesterol, and triglyceride [TG]) and BMD at various skeletal sites (lumbar spine [L1-L4], proximal total hip, femoral neck, and trochanter) were explored by Pearson's correlation and partial correlation, adjusting for age, body mass index, and menarche age. Multiple linear regression analyses adjusting for all other covariates were also performed. Data on 4,613 premenopausal and 2,661 postmenopausal women aged 20-91 years were finally included in the analysis. In multivariate analyses, there was no significant relationship between lipid profiles and BMD, except that HDL-C was positively associated with BMD at only the lumbar spine in postmenopausal women and that the quartiles of TG were negatively associated with BMD at the total hip and trochanter in only premenopausal women. We conclude that although there were some weak associations between lipid profiles and BMD, the results of this study hardly support the hypothesis that an atherogenic lipid profile is associated with osteoporosis.

Abdominal aortic calcification, BMD, and bone microstructure: a population-based study

To better define the relationship between vascular calcification and bone mass/structure, we assessed abdominal aortic calcification (AAC), BMD, and bone microstructure in an age-stratified, random sample of 693 Rochester, MN, residents. Participants underwent QCT of the spine and hip and high-resolution pQCT (HRpQCT) of the radius to define volumetric BMD (vBMD) and microstructural parameters. AAC was quantified with the Agatston scoring method. In men, AAC correlated with lower vertebral trabecular and femoral neck vBMD (p < 0.001), but not after age or multivariable (age, body mass index, smoking status) adjustment. Separation into <50 and >or=50 yr showed this pattern only in the older men. BV/TV and Tb.Th inversely correlated with AAC in all men (p < 0.001), and Tb.Th remained significantly correlated after age adjustment (p < 0.05). Tb.N positively correlated with AAC in younger men (p < 0.001) but negatively correlated in older men (p < 0.001). The opposite was true with Tb.Sp (p = 0.01 and p < 0.001, respectively). Lower Tb.N and higher Tb.Sp correlated with AAC in older men even after multivariable adjustment. Among all women and postmenopausal women, AAC correlated with lower vertebral and femoral neck vBMD (p < 0.001) but not after adjustment. Lower BV/TV and Tb.Th correlated with AAC (p = 0.03 and p = 0.04, respectively) in women, but not after adjustment. Our findings support an age-dependent association between AAC and vBMD. We also found that AAC correlates with specific bone microstructural parameters in older men, suggesting a possible common pathogenesis for vascular calcification and deterioration in bone structure. However, sex-specific differences exist.

Effects of raloxifene on fracture risk in postmenopausal women: the Raloxifene Use for the Heart Trial

Using data from a randomized placebo-controlled trial of 10,101 postmenopausal women not selected on the basis of osteoporosis, we examined whether the effect of raloxifene treatment on fractures was consistent across categories of fracture risk. Treatment with raloxifene for 5 yr reduced the risk of clinical vertebral fractures, but not nonvertebral fractures, irrespective of the presence or absence of risk factors for fracture.

INTRODUCTION

In The Raloxifene Use for The Heart (RUTH) trial, women assigned to raloxifene had a lower risk of clinical vertebral fractures but not nonvertebral fractures. However, it is uncertain whether the effect of raloxifene on fractures in this population not selected for low BMD differs according to risk factors for fractures.

MATERIALS AND METHODS

We randomly assigned 10,101 postmenopausal women >or=55 yr of age with documented coronary heart disease or at high risk for coronary events to 60 mg raloxifene daily or placebo and followed them for a median of 5.6 yr. Fractures (nonvertebral and clinical vertebral) were prespecified secondary endpoints that were reported at semiannual visits. Fractures were adjudicated and confirmed using X-ray reports or medical records.

RESULTS

There was no difference between raloxifene and placebo groups in risk of nonvertebral fractures (428 versus 438 events; hazard ratio [HR], 0.96; 95% CI, 0.84-1.10), including hip/femur (89 versus 103 events; HR, 0.85; 95% CI, 0.64-1.13) and wrist (107 versus 111 events; HR, 0.95; 95% CI, 0.73-1.24) fractures. Women treated with raloxifene had a lower risk of clinical vertebral fractures (64 versus 97 events; HR, 0.65; 95% CI, 0.47-0.89). The effect of treatment with raloxifene on risk of nonvertebral and clinical vertebral fractures was consistent across fracture risk categories defined at baseline by age, smoking status, physical activity level, prior history of fracture, family history of hip fracture, diabetes mellitus, previous use of hormone therapy, thyroid hormone use, statin use, weight loss, body mass index, or fracture specific summary risk score.

CONCLUSIONS

In older women with or at high risk of coronary heart disease not selected on the basis of osteoporosis or increased fracture risk, treatment with raloxifene for 5 yr reduced the risk of clinical vertebral fractures, but not nonvertebral fractures, irrespective of presence or absence of risk factors for fracture.

The effects of organic nitrates on osteoporosis: a randomized controlled trial [ISRCTN94484747]

Background

Osteoporotic fractures are common and are associated with increased morbidity, mortality and health care costs. The most effective way to moderate increases in health care costs and the sickness and premature death associated with osteoporotic fractures, is to prevent osteoporosis. Several lines of evidence suggest that nitrates, drugs typically prescribed for the treatment of angina, may be effective in preventing postmenopausal osteoporosis.

Methods

We have designed a multicentre randomized controlled trial to determine the effects of nitrates on bone. The trial consists of two studies. The objective of the first study is to determine whether isosorbide mononitrate at 20 mg/day or nitroglycerin ointment at 15 mg/day leads to fewer headaches. The nitrate that is best tolerated will be used in a second study with one main objective: To determine if postmenopausal women with a T-score at the lumbar spine (L1 to L4) between 0 and -2.0 randomized to two years of treatment with intermittent nitrates have a greater increase in spine bone mineral density as compared to women randomized to placebo.

We hypothesize that: 1. Women will report fewer headaches when they are randomized to intermittent nitroglycerin ointment at 15 mg/day compared to intermittent oral isosorbide mononitrate at 20 mg/day, and, 2. After two years, women randomized to intermittent nitrates will have a greater percent increase in lumbar spine bone mineral density compared with women randomized to placebo.

Discussion

We have completed our pilot study and found that transdermal nitroglycerin was associated with fewer headaches than oral isosorbide mononitrate. We are currently recruiting patients for our second main study.

Self-reported diseases and the risk of non-vertebral fractures: the Tromsø study

We wanted to estimate the independent fracture risk associated with chronic diseases for men and women separately, adjusting for other known risk factors. This is a population-based study of all those who attended the fourth survey (1994-1995) in the Tromsø Study (n=27,159) who were followed until 31 December 2000 with respect to non-vertebral fractures. At baseline the age range was 25-98 years. Chronic disease cases were defined by self-report in questionnaires. All non-vertebral fractures were registered by computerized search in radiographic archives in the sole provider of radiographic service in the area. A total of 446 and 803 non-vertebral fractures were registered among men and women, respectively. Self-reported diabetes mellitus, stroke, asthma, hypo- and hyperthyroidism and psychiatric disorders were associated with increased fracture risk. Multivariate analyses showed an independent risk of fractures associated with self-reported diabetes mellitus, hypothyroidism and psychiatric disorders among men. Among women the independent risk was associated with self-reported asthma, hypo- and hyperthyroidism and psychiatric disorders. Self-reported heart disease had a protective effect on wrist fracture, especially in women. Increased burden of chronic diseases increase the risk of all non-vertebral (P<0.0001), wrist (P=0.005), proximal humerus (P=0.0004) and hip fracture (P=0.0002) in men, and for the proximal humerus (P=0.003) and hip fracture (P=0.04) in women. There was an independent fracture risk associated with self-reported diabetes mellitus, asthma, hypo- and hyperthyroidism and psychiatric disorders in men and women. Increasing burden of disease increased fracture risk in both men and women.

Features of the metabolic syndrome and the risk of non-vertebral fractures: the Tromsø study

INTRODUCTION

We wanted to examine whether the features of the metabolic syndrome carried an increased risk of non-vertebral fracture.

METHODS

This is a population-based, 6-year follow-up of 27,159 subjects from the municipality of Tromsø, followed from 1994 until 2001. Age range was 25-98 years. Non-fasting serum levels of high-density lipoprotein (HDL), triglycerides and glucose, blood pressure (BP), weight and height were measured at baseline. All non-vertebral fractures were registered by computerised search in radiographic archives.

RESULTS

A total of 1,249 non-vertebral fractures were registered. Increasing number of metabolic syndrome features was associated with significantly reduced fracture risk in both men and women, p= 0.004 and p<0.0001, respectively. High BP was protective against fracture in men [relative risk (RR) 0.89; 95% confidence interval (CI) 0.8-0.99)] while increased body mass index (BMI) was protective in women (RR 0.91; 95% CI 0.84-0.98). Increasing non-fasting serum levels of HDL increased fracture risk in women (RR 1.12; 95% CI 1.05-1.21). BMI modified the effect of HDL in men. Accordingly, high HDL increased fracture risk in men with high BMI (RR 1.51; 95% CI 1.2-1.9).

CONCLUSIONS

Increasing burden of metabolic syndrome features protects against non-vertebral fractures. Reduced non-vertebral fracture risk was associated with high BP in men and increased body mass in women. Lower non-fasting serum levels of HDL protect against fractures in women and obese men.

Lipid levels and bone mineral density

PURPOSE

There has been considerable debate about the potential relationship between the use of statin lipid-lowering drugs and fracture risk; several observational studies suggest a protective effect but no randomized controlled trials have confirmed such a benefit. Because statins are given preferentially to persons with hyperlipidemia, if lipid levels were associated with bone mineral density, this could explain the discrepancy between epidemiological observations and randomized controlled trials. The aim of this study was to examine the relationship between lipid levels and bone mineral density.

SUBJECTS AND METHODS

We included the 13592 participants in the National Health and Nutritional Examination Survey (NHANES) III who had bone mineral density and lipid levels measured; participants who reported the use of a lipid-lowering therapy were excluded. We examined the unadjusted bone mineral density across quintiles of total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL). We then constructed multivariable models, including age, sex, body mass index, and other potential confounders.

RESULTS

In crude analyses, higher total cholesterol and LDL levels were associated with lower bone mineral densities (both P values for trend <.001), whereas higher HDL levels were associated with higher bone mineral densities (P value for trend <.001). However, in fully adjusted models, there was no significant relationship between total cholesterol, LDL, or HDL levels and bone mineral density (all P values for trend >.1).

CONCLUSIONS

These results do not support a relationship between lipid levels and bone mineral density.