Association between myocardial infarction and fractures: an emerging phenomenon

The heart-bone connection: relationships between myocardial infarction and osteoporotic fracture

Myocardial infarction (MI) and osteoporotic fracture (Fx) are two of the leading causes of mortality and morbidity worldwide. Although these traumatic injuries are treated as if they are independent, there is epidemiological evidence linking the incidence of Fx and MI, thus raising the question of whether each of these events can actively influence the risk of the other. Atherosclerotic cardiovascular disease and osteoporosis, the chronic conditions leading to MI and Fx, are known to have shared pathoetiology. Furthermore, sustained systemic inflammation after traumas such as MI and Fx has been shown to exacerbate both underlying chronic conditions. However, the effects of MI and Fx outside their own system have not been well studied. The sympathetic nervous system (SNS) and the complement system initiate a systemic response after MI that could lead to subsequent changes in bone remodeling through osteoclasts. Similarly, SNS and complement system activation following fracture could lead to heart tissue damage and exacerbate atherosclerosis. To determine whether damaging bone-heart cross talk may be important comorbidity following Fx or MI, this review details the current understanding of bone loss after MI, cardiovascular damage after Fx, and possible shared underlying mechanisms of these processes.

Blood Pressure Variability and the Risk of Fracture: A Nationwide Cohort Study

CONTEXT

Although blood pressure variability (BPV) is associated with various health outcomes, only 1 study suggested that BPV is correlated with hip fractures. As cardiovascular disease and fractures share similar pathophysiology, there might be a link between BPV and fractures.

OBJECTIVE

To investigate the association between BPV and the incident fractures.

DESIGN

Retrospective cohort study.

SETTING

Population-based, using the Korean National Health Insurance System database.

PATIENTS OR OTHER PARTICIPANTS

A total of 3 256 070 participants aged ≥50 who participated in ≥3 health examinations within the previous 5 years, including the index year (2009-2010), were included. Outcome data were obtained through the end of 2016.

EXPOSURE

BPV was calculated using variability independent of the mean. High variability was defined as the highest quartile of variability.

MAIN OUTCOME MEASURES

Newly diagnosed fractures.

RESULTS

During the median follow-up of 7.0 years, there were 337 045 cases of any fracture (10.4%). After adjusting for age, sex, income, lifestyle factors, and comorbidities, a higher risk of fracture was observed with higher quartiles of BPV than the lowest quartile group: the adjusted hazard ratios (95% CIs) for incident any fracture were 1.07 (1.06-1.08) in the higher quartile of systolic BPV, 1.06 (1.05-1.07) in that of diastolic BPV, and 1.07 (1.06-1.08) in that of both systolic and diastolic BPV. Consistent results were noted for vertebral fractures and hip fractures, as well as in various subgroup analyses.

CONCLUSIONS

A positive association was noted between higher BPV and fracture incidence. BPV is an independent predictor for developing fracture.

Systemic bone loss following myocardial infarction in mice

Myocardial infarction (MI) and osteoporotic fracture are leading causes of morbidity and mortality, and epidemiological evidence linking their incidence suggests possible crosstalk. MI can exacerbate atherosclerosis through the sympathetic nervous system (SNS) activation and β₃ adrenoreceptor-mediated release of hematopoietic stem cells, leading to monocytosis. We hypothesized that this same pathway initiates systemic bone loss following MI, since osteoclasts differentiate from monocytes. In this study, MI was created with left anterior descending artery ligation in 12-week-old male mice (n = 24) randomized to β₃ -adrenergic receptor (AR) antagonist (SR 59230A) treatment or no treatment for 10 days postoperatively. Additional mice (n = 21, treated and untreated) served as unoperated controls. Bone mineral density (BMD), bone mineral content (BMC), and body composition were quantified at baseline and 10 days post-MI using dual-energy x-ray absorptiometry; circulating monocyte levels were quantified and the L5 vertebral body and femur were analyzed with microcomputed tomography 10 days post-MI. We found that MI led to circulating monocyte levels increases, BMD and BMC decreases at the femur and lumbar spine in MI mice (-6.9% femur BMD, -3.5% lumbar BMD), and trabecular bone volume decreases in MI mice compared with control mice. β₃ -AR antagonist treatment appeared to diminish the bone loss response (-5.3% femur BMD, -1.2% lumbar BMD), though these results were somewhat inconsistent. Clinical significance: These results suggest that MI leads to systemic bone loss, but that the SNS may not be a primary modulator of this response; bone loss and increased fracture risk may be important clinical comorbidities following MI or other ischemic injuries.

Bone Mineral Density and Content Among Patients With Coronary Artery Disease: A Comparative Study

INTRODUCTION

Some studies indicate an association between coronary artery disease (CAD) and osteoporosis. This case-control study examined the association between body composition and bone mineral content (BMC) and density (BMD) among patients with CAD.

MATERIALS AND METHODS

A group of men (n = 73) with established CAD and age and sex matched controls (n=65) were included in the study. Data collected included socio-demographic information, disease related data (from cases), anthropometric measurements, serum vitamin D, calcium and phosphorous and body composition analysis using DEXA. Two groups were compared using independent sample t-test, Mann Whitney U-test or Chi square test. Pearson correlation and regression models were used to test the associations between body compartments.

RESULTS

Among cases, the mean disease duration was 29 (range 5-192) months and 15% had triple vessel disease. Patients had higher mean total body fat mass (TBFM) (18869.7 vs 16733.0) g, p = 0.018), truncal fat mass (TRFM) (9259.1 vs 7992.5 g, p = 0.009) and fat percentage (28.6 vs 25.9%, p = 0.001) compared to controls. Median serum vitamin D level was significantly lower among patients (20.0 ng/mL) compared to controls (27.1 ng/mL) (p = 0.003). In both groups, TBFM and total body lean mass (TBLM) both showed significant positive correlations with total body BMD/BMC and regional BMDs. Of the two, TBLM emerged the best predictor of TBBMC/TBBMD. These associations were greater among patients than controls.

CONCLUSIONS

TBLM appears to be the strongest predictor of TBBMD and TBBMC in patients and controls. The strength of associations was greater among patients compared to controls even after adjusting for possible confounders .

Atrial Fibrillation and the Risk of Subsequent Fracture

BACKGROUND

There is conflicting evidence regarding the association between atrial fibrillation and the risk of subsequent fractures.

METHODS

We included participants aged 45 years or older from the Framingham Heart Study Offspring, Third-Generation, New Offspring Spouse, Omni 1, and Omni 2 cohorts. We prespecified analyzing index age 65 years as our primary analysis; we repeated analyses for index ages 45, 55, and 75 years. The primary outcome was any incident bone fracture, except finger, toe, foot, skull, and facial fractures. We assessed the association between time-varying atrial fibrillation and subsequent fractures by an illness-death model that accounted for the competing risk of death. We estimated hazard ratios (HR) adjusted for age, sex, body mass index, smoking, diabetes, alcohol intake, and prior fracture.

RESULTS

We included 3403 participants (mean age of 68 years, 53.3% female) in the analysis at index age 65 years and above. In all, 525 (15%) participants suffered incident fractures during follow-up (median 12.5 years). The HR between atrial fibrillation and subsequent fracture was 1.37; 95% confidence interval (CI), 1.06-1.79. There was no evidence of effect modification by sex (HR 1.55; 95% CI, 1.06-2.26 in men; HR 1.22; 95% CI, 0.84-1.77 in women; interaction P value .27). Results were consistent at other index ages.

CONCLUSION

Atrial fibrillation was associated with increased risk of incident fracture in the community-based Framingham Heart Study.

Multiple Chronic Conditions in Spousal Caregivers of Older Adults With Functional Disability: Associations With Caregiving Difficulties and Gains

OBJECTIVES

Multiple chronic conditions (MCCs) are common and have harmful consequences in later life. Along with managing their own health, many aging adults care for an impaired partner. Spousal caregiving may be more stressful when caregivers have MCCs, particularly those involving complex management. Yet, little is known about combinations of conditions that are most consequential for caregiving outcomes.

METHOD

Using a U.S. sample of 359 spousal caregivers and care recipients from the 2011 National Aging Trends Study and National Study of Caregiving, we examined three categories of MCCs based on similarity of management strategies (concordant only, discordant only, and both concordant and discordant) and their associations with caregiving difficulties and gains. We also considered gender differences.

RESULTS

Relative to caregivers without MCCs, caregivers with discordant MCCs reported fewer gains, whereas caregivers with both concordant and discordant MCCs reported greater emotional and physical difficulties. Wives with discordant MCCs only reported a trend for greater physical difficulties. Caregivers with concordant MCCs did not report more difficulties or gains.

DISCUSSION

Spousal caregivers with MCCs involving discordant management strategies appear to be at risk for adverse care-related outcomes and may benefit from support in maintaining their own health as well as their caregiving responsibilities.

Modeling the Economic Impact of Interventions for Older Populations with Multimorbidity: A Method of Linking Multiple Single-Disease Models

Introduction. Individuals from older populations tend to have more than 1 health condition (multimorbidity). Current approaches to produce economic evidence for clinical guidelines using decision-analytic models typically use a single-disease approach, which may not appropriately reflect the competing risks within a population with multimorbidity. This study aims to demonstrate a proof-of-concept method of modeling multiple conditions in a single decision-analytic model to estimate the impact of multimorbidity on the cost-effectiveness of interventions. Methods. Multiple conditions were modeled within a single decision-analytic model by linking multiple single-disease models. Individual discrete event simulation models were developed to evaluate the cost-effectiveness of preventative interventions for a case study assuming a UK National Health Service perspective. The case study used 3 diseases (heart disease, Alzheimer's disease, and osteoporosis) that were combined within a single linked model. The linked model, with and without correlations between diseases incorporated, simulated the general population aged 45 years and older to compare results in terms of lifetime costs and quality-adjusted life-years (QALYs). Results. The estimated incremental costs and QALYs for health care interventions differed when 3 diseases were modeled simultaneously (£840; 0.234 QALYs) compared with aggregated results from 3 single-disease models (£408; 0.280QALYs). With correlations between diseases additionally incorporated, both absolute and incremental costs and QALY estimates changed in different directions, suggesting that the inclusion of correlations can alter model results. Discussion. Linking multiple single-disease models provides a methodological option for decision analysts who undertake research on populations with multimorbidity. It also has potential for wider applications in informing decisions on commissioning of health care services and long-term priority setting across diseases and health care programs through providing potentially more accurate estimations of the relative cost-effectiveness of interventions.

Treadmill exercise prevents reduction of bone mineral density after myocardial infarction in apolipoprotein E-deficient mice

AIMS

Recent clinical studies demonstrated the association between myocardial infarction (MI) and osteoporotic fractures. We examined whether MI causes bone loss and the effects of exercise training on bone in mice after MI.

METHODS

We created a MI model in 16-week-old male apolipoprotein E-deficient mice (n = 42), which were randomly assigned to exercise group (MI-Ex) and sedentary group (MI-Sed). We also performed sham operations in other mice (n = 10). Treadmill exercise training was performed from one week after operation to eight weeks. At eight weeks, the bone parameters of the femur were measured by quantitative computed tomography, followed by histological analysis (n = 10-17).

RESULTS

Bone mineral density (BMD) of the femur was significantly decreased in the MI-Sed group as compared with the sham group (P < 0.001), whereas the BMD was significantly increased in the MI-Ex group as compared with the MI-Sed group (P < 0.05). In histological analysis, Rho-associated coiled-coil kinase 2 and tartrate-resistant acid phosphate positive (bone resorptive) area in distal femur were significantly increased in the MI-Sed group as compared with the sham group (P < 0.05), whereas those parameters were significantly decreased in the MI-Ex group as compared with the MI-Sed group (P < 0.05). In contrast, alkaline phosphatase (ALP)-positive (bone-forming) area was significantly decreased in the MI-Sed group as compared with the sham group (P < 0.05), whereas ALP-positive area was significantly increased in the MI-Ex group as compared with the MI-Sed group (P < 0.05).

CONCLUSIONS

The present study demonstrates that MI reduces BMD and treadmill exercise training prevents the reduction of BMD in apolipoprotein E-deficient mice.

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.

Prior fragility fracture and risk of incident ischaemic cardiovascular events: results from UK Biobank

In the large UK Biobank population-based cohort, we found that amongst men, but not women, prior fragility fracture was associated with increased risk of admission with ischaemic heart disease.

INTRODUCTION

We aimed to investigate the relationship between prior fracture and risk of incident ischaemic cardiovascular events in a UK population-based cohort.

METHODS

UK Biobank is a large prospective cohort comprising 502,637 men and women aged 40-69 years, with detailed baseline assessment. History of fracture was self-reported, and details of hospital admissions for ischaemic heart disease (IHD) (ICD-10:I20-I25) were obtained through linkage to UK Hospital Episode Statistics. Cox proportional hazards models were used to investigate the prospective relationships between prior fracture and hospital admission for men and women, controlling for age, BMI, smoking, alcohol, educational level, physical activity, systolic blood pressure, calcium and vitamin D use, ankle spacing-width, heel BUA and HRT use (women).

RESULTS

Amongst men, a fragility fracture (hip, spine, wrist or arm fracture resulting from a simple fall) within the previous 5 years was associated with a 35% increased risk of IHD admission (fully adjusted HR 1.35; 95%CI 1.00, 1.82; p = 0.047), with the relationship predominantly driven by wrist fractures. Associations with hospitalisation for angina in men were similar in age-adjusted models [HR1.54; 95%CI: 1.03, 2.30), p = 0.037], but did not remain statistical significant after full adjustment [HR 1.64; 95%CI: 0.88, 3.07); p = 0.121]. HRs for admission with angina were lower in women, and neither age- nor fully adjusted relationships attained statistical significance.

CONCLUSIONS

Prior fragility fracture is an independent risk factor for incident ischaemic cardiovascular events in men. Further work may clarify whether this association is causal or represents shared risk factors, but these findings are likely to be of value in risk assessment of both osteoporosis and cardiovascular disease.

Contemporary Risk Stratification After Myocardial Infarction in the Community: Performance of Scores and Incremental Value of Soluble Suppression of Tumorigenicity-2

BACKGROUND

Current American Heart Association/American College of Cardiology guidelines recommend the GRACE (Global Registry of Acute Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) scores to assess myocardial infarction (MI) prognosis. Changes in the epidemiological characteristics of MI and the availability of new biomarkers warrant an assessment of the performance of these scores in contemporary practice. We assessed the following: (1) the performance of GRACE and TIMI to predict 1-year mortality in a cohort of patients stratified by ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI) and (2) the incremental discriminatory power of soluble suppression of tumorigenicity-2, a myocardial fibrosis biomarker.

METHODS AND RESULTS

Olmsted County, Minnesota, residents with incident MI (N=1401) were recruited prospectively from November 1, 2002 to December 31, 2012 (mean age, 67 years; 61% men; 79% with NSTEMI). Baseline data were used to calculate risk scores; soluble suppression of tumorigenicity-2 was measured in stored plasma samples obtained at index MI. C-statistics adapted to survival data were used to assess the discriminatory power of the risk scores and the improvement gained by adding other markers. During the first year of follow-up, 190 patients (14%) died. The discriminatory performance to predict death was reasonable for GRACE and poor for TIMI, and was generally worse in those with NSTEMI versus those with STEMI. In people with NSTEMI, sequential addition of comorbidities and soluble suppression of tumorigenicity-2 substantially improved the c-statistic over GRACE (from 0.78 to 0.80 to 0.84) and TIMI (from 0.61 to 0.73 to 0.81), respectively (all P≤0.05).

CONCLUSIONS

Guideline-recommended scores for risk assessment after MI underperform in contemporary community patients, particularly those with NSTEMI, which now represents most infarcts. Incorporating comorbidities and soluble suppression of tumorigenicity-2 substantially improves risk prediction, thereby delineating opportunities to improve clinical care.

Epidemiology of fractures in type 2 diabetes

Type 2 diabetes affects an increasing proportion of older adults, the population that is also at elevated risk of fracture. Type 2 diabetes itself increases the risk of fracture, particularly in African-American and Latino populations. In Western countries, overweight and obesity, associated with reduced fracture risk, are highly prevalent in diabetic patients. Studies in East Asian countries that have a lower prevalence of obesity with diabetes may help to disentangle the effects of diabetes and obesity on the skeleton. Type 2 diabetes is also associated with higher bone density, and as a result standard tools for fracture prediction tend to underestimate fracture risk in this population, an important challenge for risk assessment in the clinical setting. Contributing factors to the increased fracture risk in type 2 diabetes include more frequent falls and deficits in diabetic bone, not captured by dual X-ray absorptiometry (DXA), that are as yet not clearly understood. Recent epidemiological studies indicate that poor glycemic control contributes to increased fracture risk although intensive lowering of A1C is not effective in preventing fracture. This article is part of a Special Issue entitled "Bone and diabetes".

Mortality Associated With Heart Failure After Myocardial Infarction: A Contemporary Community Perspective

BACKGROUND

Contemporary data are lacking on the prognostic importance of heart failure (HF) after myocardial infarction (MI). We evaluated the prognostic impact of HF post MI according to preserved/reduced ejection fraction and the timing of its occurrence.

METHODS AND RESULTS

All Olmsted County, Minnesota, residents (n=2596) with incident MI diagnosed in 1990 to 2010 and no prior HF were followed through March 2013. Cox models were used to examine (1) the hazard ratios for death associated with HF type and timing and (2) secular trends in survival by HF status. During a mean follow-up of 7.6 years, there were 1116 deaths, 634 in the 902 patients who developed HF (70%) and 482 in the 1694 patients who did not develop HF (28%). After adjustment for age and sex, HF as a time-dependent variable was strongly associated with mortality (hazard ratio =3.31, 95% confidence interval: 2.93-3.75), particularly from cardiovascular causes (hazard ratio =4.20, 95% confidence interval: 3.50-5.03). Further adjustment for MI severity and comorbidity, acute treatment, and recurrent MI moderately attenuated these associations (hazard ratio =2.49 and 2.94 for all-cause and cardiovascular mortality, respectively). Mortality did not differ by ejection fraction, but was higher for delayed- versus early-onset HF (P for heterogeneity =0.002). The age- and sex-adjusted 5-year survival estimates in 2001 to 2010 versus 1990 to 2000 were 82% and 81% among HF-free and 61% and 54% among HF patients, respectively (P for heterogeneity of trends =0.05).

CONCLUSIONS

HF markedly increases the risk of death after MI. This excess risk is similar regardless of ejection fraction but greater for delayed- versus early-onset HF. Mortality after MI declined over time, primarily as a result of improved HF survival.

Ischemic heart disease is associated with lower cortical volumetric bone mineral density of distal radius

In this study, high-resolution peripheral quantitative computed tomography (HR-pQCT) was used to investigate geometric, volumetric and microstructural parameters at the distal radius and at the distal tibia in participants with ischaemic heart disease. We found that, compared with participants without ischaemic heart disease, they had substantially lower cortical volumetric bone mineral density (BMD) at the distal radius.

INTRODUCTION

HR-pQCT captures novel aspects of bone geometry and volumetric bone mineral density (vBMD) and offers the ability to measure bone microarchitecture, but data relating measures obtained from this technique in patients with ischemic heart disease (IHD) are lacking.

METHODS

Here, we report an analysis from the Hertfordshire Cohort Study, where we were able to study associations between measures obtained from HR-pQCT of distal radius and distal tibia in 350 participants (184 men and 166 women) aged 71.5-80.5 years with or without IHD (e.g. heart attack, angina or heart failure; n = 75 and n = 275, respectively).

RESULTS

Analyses for all participants (men and women together) revealed that cortical vBMD (Ct.vBMD) was lower (p < 0.001) and cortical thickness (Ct.th) was not different (p = 0.519), whereas cortical porosity (Ct.Po) was higher (p = 0.016) in participants with IHD at the distal radius. Moreover, trabecular microarchitectural parameters were not significantly different in patients with IHD (p > 0.05 for all). Adjustment for a priori confounders (age, gender, body mass index, smoking status, alcohol consumption, high blood pressure and diabetes mellitus) did not materially affect the relationship described for Ct.vBMD (p = 0.002), but differences in Ct.Po were attenuated. Analyses in men alone revealed that only Ct.vBMD was lower at the distal radius in participants with IHD with and without adjustment for a priori confounders (p = 0.0002 and p = 0.004, respectively), whereas no statistical differences were found in women, although patterns of differences were similar in both sexes. Moreover, no association was found between IHD and bone parameters at the distal tibia either in men or women.

CONCLUSIONS

We have demonstrated that IHD is associated with lower Ct.vBMD of the distal radius.

Cumulative incidence of death and rehospitalization among the elderly in the first year after NSTEMI

BACKGROUND

Age is associated with outcomes in non-ST-segment elevation myocardial infarction; however, less is known about rehospitalization or death among elderly survivors. We aimed to evaluate mortality and cause-specific rehospitalization rates in this growing population of older adults with ischemic heart disease.

METHODS

We linked 36,711 patients aged ≥65 years who survived an index non-ST-segment elevation myocardial infarction from the CRUSADE registry to Medicare claims data for follow-up. One-year survival estimates were compared by age group-65-79, 80-84, 85-89, and ≥90 years-and Cox models were used to analyze the association between age and 1-year mortality.

RESULTS

Death at 1 year increased markedly with age (from 13.3% for 65-79 years to 45.5% for ≥90 years). In contrast, rehospitalization rates at 1 year were similar and high across ages (65-79 years, 52.7%; ≥90 years, 56.5%), with nearly as many noncardiovascular-related as cardiovascular-related rehospitalizations. At 1 year, nonagenarians had substantially higher rates of death with or without preceding rehospitalization and twice the adjusted mortality than the group aged 65-79 years.

CONCLUSIONS

Evolving care delivery models should consider the high mortality in older adults after a non-ST-segment elevation myocardial infarction. Contrary to expectations, rehospitalization rates do not rise substantially with advancing age, and rehospitalization is often for noncardiac diagnoses.

Are myocardial infarction and venous thromboembolism associated? Population-based case-control and cohort studies

INTRODUCTION

Because the association of myocardial infarction (MI) and venous thromboembolism (VTE) is uncertain, we tested MI as a VTE risk factor and VTE as a predictor of MI.

MATERIALS AND METHODS

Using Rochester Epidemiology Project resources, we identified all Olmsted County, MN residents with objectively-diagnosed incident VTE over the 13-year period, 1988-2000 (n=1311), one to two resident controls per VTE case (n=1511), and all residents with incident MI over the 31-year period, 1979-2010. For VTE cases and controls, we reviewed their complete medical records in the community for VTE and MI risk factors. Using conditional logistic regression we tested MI as a potential VTE risk factor, both unadjusted and after adjusting for VTE risk factors. We also followed VTE cases and controls without prior MI forward in time for incident MI through 12/31/2010, and using Cox proportional hazards modeling, tested VTE as a predictor of MI, both unadjusted and after adjusting for MI risk factors.

RESULTS

The number (%) of MI prior to VTE among cases and controls were 75 (5.7) and 51 (3.4), respectively, and the number (%) of MI after VTE among cases and controls were 58 (4.4) and 77 (5.1), respectively. In univariate analyses, MI was significantly associated with VTE but not after adjusting for VTE risk factors. In both univariate and multivariate analyses, VTE (overall or idiopathic) was not a predictor of MI.

CONCLUSIONS

MI is not an independent risk factor for VTE, and VTE is not a predictor of MI.

Contemporary trends in heart failure with reduced and preserved ejection fraction after myocardial infarction: a community study

Major changes have recently occurred in the epidemiology of myocardial infarction (MI) that could possibly affect outcomes such as heart failure (HF). Data describing trends in HF after MI are scarce and conflicting and do not distinguish between preserved and reduced ejection fraction (EF). We evaluated temporal trends in HF after MI. All residents of Olmsted County, Minnesota (n = 2,596) who had a first-ever MI diagnosed in 1990-2010 and no prior HF were followed-up through 2012. Framingham Heart Study criteria were used to define HF, which was further classified according to EF. Both early-onset (0-7 days after MI) and late-onset (8 days to 5 years after MI) HF were examined. Changes in patient presentation were noted, including fewer ST-segment-elevation MIs, lower Killip class, and more comorbid conditions. Over the 5-year follow-up period, 715 patients developed HF, 475 of whom developed it during the first week. The age- and sex-adjusted risk declined from 1990-1996 to 2004-2010, with hazard ratios of 0.67 (95% confidence interval (CI): 0.54, 0.85) for early-onset HF and 0.63 (95% CI: 0.45, 0.86) for late-onset HF. Further adjustment for patient and MI characteristics yielded hazard ratios of 0.86 (95% CI: 0.66, 1.11) and 0.63 (95% CI: 0.45, 0.88) for early- and late-onset HF, respectively. Declines in early-onset and late-onset HF were observed for HF with reduced EF (<50%) but not for HF with preserved EF, indicating a change in the case mix of HF after MI that requires new prevention strategies.

The association between osteoporosis and hypertension: the role of a low dairy intake

Hypertension and related cardiovascular diseases are reported to be associated with osteoporosis. A nutritional pathway related to dairy intake has been postulated for both diseases. The aim of this study was to assess calcium intake from dairy sources as a possible pathogenic link between osteoporosis and hypertension. This was a cross-sectional observational study performed on 3,301 postmenopausal women referred for a densitometry screening. Osteoporosis was diagnosed by lumbar dual-energy X-ray absorptiometry and hypertension was defined by blood pressure data and/or the use of antihypertensive medication. Dairy food consumption was evaluated using a weekly food-frequency questionnaire. The odds of being affected by osteoporosis, hypertension, or both diseases were calculated for quartiles of dairy intake by logistic regression analyses. Women with hypertension were affected more frequently by osteoporosis (33.2 vs. 23.3 %; p = 0.000), and there was a higher prevalence of hypertension among women with osteoporosis (32.2 vs. 22.5 %; p = 0.000). The proportion of women with hypertension, osteoporosis, and both diseases significantly increased across decreasing quartiles of dairy intake. A dairy intake in the lowest quartile was a significant predictor of osteoporosis [OR (95 % CI): 1.43 (1.12, 1.82)] and hypertension [OR (95 % CI): 1.46 (1.15, 1.85)] when compared to the highest quartile. Similarly, a low dairy intake was associated with increased odds to have both the diseases [OR (95 % CI): 1.60 (1.10, 2.34)]. From these results we conclude that osteoporosis and hypertension are associated in postmenopausal women, and a low dairy intake may increase the risk of both diseases, acting as a possible pathogenic link.

Sternal insufficiency fracture related to steroid-induced osteoporosis: A case report

Osteoporosis often results in fractures, deformity and disability. A rare but potentially challenging complication of osteoporosis is a sternal insufficiency fracture. This case report details a steroid-induced osteoporotic male who suffered a sternal insufficiency fracture after minimal trauma. Prompt diagnosis and appropriate management resulted in favourable outcome for the fracture, though a sequalae involving a myocardial infarction ensued with his osteoporosis and complex health history. The purpose of this case report is to heighten awareness around distinct characteristics of sternal fractures in osteoporotic patients. Discussion focuses on the incidence, mechanism, associated factors and diagnostic challenge of sternal insufficiency fractures. This case report highlights the role primary contact practitioners can play in recognition and management of sternal insufficiency fractures related to osteoporosis.

Cardiovascular and noncardiovascular disease associations with hip fractures

BACKGROUND

There is growing awareness of an association between cardiovascular disease and fractures, and a temporal increase in fracture risk after myocardial infarction has been identified. To further explore the nature of this relationship, we systematically examined the association of hip fracture with all disease categories and assessed related secular trends.

METHODS

By using resources of the Rochester Epidemiology Project, a population-based incident case-control study was conducted. Disease history was compared among all Olmsted County, Minnesota, residents aged 50 years or more with a first radiographically confirmed hip fracture in 1985-2006 and community control subjects individually matched (1:1) to cases on age, sex, and index year (n = 3808; mean age, 82 years; standard deviation, 9 years; 76% were women).

RESULTS

All cardiovascular and numerous non-cardiovascular disease categories (eg, infectious diseases, nutritional and metabolic diseases, mental disorders, diseases of the nervous system and sense organs, and diseases of the respiratory system) were associated with fracture risk. However, increasing temporal trends were detected almost exclusively in cardiovascular disease categories. The largest increases in association were observed for ischemic heart disease, other forms of heart disease (including heart failure), hypertension, and diabetes, and were more pronounced among elderly women than other demographic subgroups.

CONCLUSIONS

Although the association with hip fracture was not specific to cardiovascular disease, temporal increases were mainly detected in cardiometabolic diseases, all of which have been linked previously to frailty. This mechanism and others warrant further investigation.

Higher prevalence of morphometric vertebral fractures in patients with recent coronary events independently of BMD measurements

Cardiovascular disease and osteoporosis are important causes of morbi-mortality in the elderly and may be mutually related. Low bone mineral density (BMD) may be associated with increased risk of cardiovascular events. We investigated the prevalence of low bone mass and fractures in metabolic syndrome patients with acute coronary events. A case-control study was conducted with 150 individuals (30-80years-old) with metabolic syndrome. Seventy-one patients had had an acute coronary syndrome episode in the last 6months (cases) and the remaining 79 had no coronary event (controls). Cases and controls were matched for gender, BMI and age. DXA measurements and body composition were performed while spine radiographs surveyed for vertebral fractures and vascular calcification. Biochemical bone and metabolic parameters were measured in all patients. No statistically significant difference in BMD and the prevalence of osteopenia, osteoporosis and non-vertebral fractures was observed between cases and controls. The prevalence of vertebral fractures and all fractures was higher in the cases (14.1 versus 1.3%, p=0.003 and 22.5versus7.6%, p=0.010, respectively). Male gender (OR=0.22 95% CI 0.58 to 0.83, p=0.026) and daily intake of more than 3 portions of dairy products (OR=0.19 95% CI 0.49 to 0.75, p=0.017) were associated with lower prevalence of fractures. Cases had higher risk for fractures (OR=4.97, 95% CI 1.17 to 30.30, p=0.031). Bone mass and body composition parameters were not associated with cardiovascular risk factors or bone mineral metabolism. Patients with fragility fractures had higher OPG serum levels than those without fractures (p<0.001). Our findings demonstrated that patients with recent coronary events have a higher prevalence of vertebral fractures independently of BMD.

Investigation of the prevalent fall-related risk factors of fractures in elderly referred to Tehran hospitals

BACKGROUND

Prevalence of fall-related mortality is rising in the elderly population. Falling is one of the causes of the murderous and non-murderous injuries in the elderly population which can lead to disability, dependence and decline of quality of life. Fractures constitute a major part of the fall-related injuries. The present study is designed to investigate the prevalence of fall-related risk factors of fractures in the Iranian elderly population.

METHODS

This descriptive study was performed on 240 elderly adults (aged 72.24±8.81 years) referred to Tehran hospitals in 2011 with wrist, femoral and proximal humeral fractures, using a questionnaire designed for this purpose.

RESULTS

Ninety four (39.2%) cases were males and 146 (60.8%) were females. Slipping was the most prevalent mechanism of falling with the rate of 26.9% followed by falling from height and falling outdoors. Femur was the most frequently injured site (57.5%) while wrist and humerus were the next sites to be injured. Only 7.5% of the cases lived in a safe environment while in 37.2% and 55.2% cases, home environment was partly safe and non-safe, respectively.

CONCLUSION

Fall-related fractures in the studied population is related to cardiovascular and musculoskeletal disorders, low level of physical activity and ignorance of safety principles but, the prevalence of neurologic diseases and drug and alcohol abuse, which have been mentioned as relevant risk factors in some studies, was very low in this population.

Risk of major osteoporotic fracture after cardiovascular disease: a population-based cohort study in Taiwan

Background

We investigated the association between cardiovascular disease (CVD) and the risk of major osteoporotic fracture in Taiwan.

Methods

Using the Taiwan National Health Insurance Database for the period 2000–2007, we classified 43 874 patients aged 50 years or older with newly diagnosed CVD (coronary artery disease, heart failure, cerebrovascular disease, or peripheral atherosclerosis) as the CVD group and 43 874 subjects without CVD (frequency-matched by sex, age, and date selected) as the non-CVD group. Incidence and hazard ratios (HRs) for major osteoporotic fracture of the spine, hip, humerus, and forearm/wrist were estimated for the period until the end of 2010.

Results

After adjustment for confounders, the overall HRs for major osteoporotic fracture were 1.24 (95% CI = 1.13, 1.36) in men with CVD and 1.18 (95% CI = 1.11, 1.25) in women with CVD, as compared with the non-CVD group. As compared with the non-CVD group, the adjusted HR for major osteoporotic fracture was highest among subjects with cerebrovascular disease (HR 1.31; 95% CI 1.23, 1.39), followed by those with heart failure (HR 1.18; 95% CI 1.11, 1.27), peripheral atherosclerosis (HR 1.12; 95% CI 1.04, 1.20), and coronary artery disease (HR 1.07; 95% CI 1.01, 1.12).

Conclusions

CVD is associated with risk of major osteoporotic fracture in men and women in Taiwan.

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.

Aortic calcification and femoral bone density are independently associated with left ventricular mass in patients with chronic kidney disease

Background

Vascular calcification and reduced bone density are prevalent in chronic kidney disease and linked to increased cardiovascular risk. The mechanism is unknown. We assessed the relationship between vascular calcification, femoral bone density and left ventricular mass in patients with stage 3 non-diabetic chronic kidney disease in a cross-sectional observational study.

Methodology and Principal Findings

A total of 120 patients were recruited (54% male, mean age 55±14 years, mean glomerular filtration rate 50±13 ml/min/1.73 m²). Abdominal aortic calcification was assessed using lateral lumbar spine radiography and was present in 48%. Mean femoral Z-score measured using dual energy x-ray absorptiometry was 0.60±1.06. Cardiovascular magnetic resonance imaging was used to determine left ventricular mass. One patient had left ventricular hypertrophy. Subjects with aortic calcification had higher left ventricular mass compared to those without (56±16 vs. 48±12 g/m², P = 0.002), as did patients with femoral Z-scores below zero (56±15 vs. 49±13 g/m², P = 0.01). In univariate analysis presence of aortic calcification correlated with left ventricular mass (r = 0.32, P = 0.001); mean femoral Z-score inversely correlated with left ventricular mass (r = −0.28, P = 0.004). In a multivariate regression model that included presence of aortic calcification, mean femoral Z-score, gender and 24-hour systolic blood pressure, 46% of the variability in left ventricular mass was explained (P<0.001).

Conclusions

In patients with stage 3 non-diabetic chronic kidney disease, lower mean femoral Z-score and presence of aortic calcification are independently associated with increased left ventricular mass. Further research exploring the pathophysiology that underlies these relationships is warranted.

Reno-protective mechanisms of epoxyeicosatrienoic acids in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, and it is well known that end-stage renal disease (ESRD) is a profound consequence of the progression of CVD. Present treatments only slow CVD progression to ESRD, and it is imperative that new therapeutic strategies are developed to prevent the incidence of ESRD. Because epoxyeicosatrienoic acids (EETs) have been shown to elicit reno-protective effects in hypertensive animal models, the current review will focus on addressing the reno-protective mechanisms of EETs in CVD. The cytochrome P-450 epoxygenase catalyzes the oxidation of arachidonic acid to EETs. EETs have been identified as endothelium-derived hyperpolarizing factors (EDHFs) with vasodilatory, anti-inflammatory, antihypertensive, and antiplatelet aggregation properties. EETs also have profound effects on vascular migration and proliferation and promote angiogenesis. The progression of CVD has been linked to decreased EETs levels, leading to the concept that EETs should be therapeutically targeted to prevent end-organ damage associated with CVD. However, EETs are quickly degraded by the enzyme soluble epoxide hydrolase (sEH) to their less active diols, dihydroxyeicosatrienoic acids (DHETs). As such, one way to increase EETs level is to inhibit their degradation to DHETs by using sEH inhibitors. Inhibition of sEH has been shown to effectively reduce blood pressure and organ damage in experimental models of CVD. Another approach to target EETs is to develop EET analogs with improved solubility and resistance to auto-oxidation and metabolism by sEH. For example, stable ether EET analogs dilate afferent arterioles and lower blood pressure in hypertensive rodent animal models. EET agonists also improve insulin signaling and vascular function in animal models of metabolic syndrome.

Is the Western diet adequate in copper?

Copper has been known to be essential for health for more than three quarters of a century. Myriad experiments with animals reveal that the cardiovascular, musculoskeletal and nervous systems are most sensitive to deficiency. Copper in the Western diet has been decreasing at least since the 1930s; half of the adult population consumes less than the amount recommended in the European Communities and the United Kingdom. At least one fourth of adults consume less than the estimated average requirement published for the United States and Canada. Hundreds of people have been reported in journals about medicine and neurology rather than nutrition to have impaired copper nutriture based on the criteria of low copper concentrations and low activities of enzymes dependent on copper in various fluids and tissues. In contrast, only 46 people have participated in depletion/repletion experiments needed to define requirements. Almost 1000 people have benefited from supplements containing copper in controlled trials. People deficient in copper are being identified increasingly; it is unknown if unusually high requirements or unusually low diets are causal. Alzheimer's disease, ischemic heart disease and osteoporosis are the most likely human illnesses from low copper intakes.