Volumetric BMD and vascular calcification in middle-aged women: the Study of Women's Health Across the Nation

Association between bone mineral density and coronary plaque burden in patients with coronary artery disease: a cross-sectional study using quantitative computed tomography

PURPOSE

To evaluate the association between osteoporosis and coronary calcification and coronary plaque burden in patients with atherosclerosis and coronary artery disease (CAD).

METHODS

This study included 290 men and 177 postmenopausal women with angiography-confirmed atherosclerosis or CAD who underwent chest multidetector row computed tomography covering L1-L2 between September 2020 and October 2021. Quantitative computed tomography was used to measure the lumbar vertebra's bone mineral density (BMD). The coronary artery calcium score (CACS) and total coronary plaque burden were quantified using the Agatston and modified Gensini scores, respectively. Associations between BMD and CACS and modified Gensini scores were assessed using multivariate regression analysis. Lasso regression was used in model selection.

RESULTS

In men, BMD was inversely associated with CACS [ β  = -0.24; 95% confidence interval (CI), -0.35 to -0.13; P  < 0.001) and coronary artery calcification (CAC) presence [odds ratio (OR) = 0.71; 95% CI, 0.52-0.96; P  = 0.03) in the unadjusted model. After adjusting for age, modified Gensini score, prior percutaneous coronary intervention and hypertension, BMD was inversely associated with CACS ( β  = -0.11; 95% CI, -0.22 to -0.01; P  = 0.04). In postmenopausal women, BMD was inversely associated with CACS ( β  = -0.24; 95% CI, -0.39 to 0.10; P  < 0.001) and CAC presence (OR = 0.66; 95% CI, 0.47-0.92; P  = 0.01) in the unadjusted model but no other models ( P  > 0.05). In both sexes, BMD did not correlate with the modified Gensini score or CAD prevalence (all P  > 0.05).

CONCLUSION

In patients with coronary atherosclerosis and CAD, BMD of the lumbar vertebra correlated inversely with CACS in men but not postmenopausal women. Additionally, BMD did not correlate with the modified Gensini score in both sexes.

ENPP1 in Blood and Bone: Skeletal and Soft Tissue Diseases Induced by ENPP1 Deficiency

The enzyme ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) codes for a type 2 transmembrane glycoprotein that hydrolyzes extracellular ATP to generate pyrophosphate (PPi) and adenosine monophosphate, thereby contributing to downstream purinergic signaling pathways. The clinical phenotypes induced by ENPP1 deficiency are seemingly contradictory and include early-onset osteoporosis in middle-aged adults and life-threatening vascular calcifications in the large arteries of infants with generalized arterial calcification of infancy. The progressive overmineralization of soft tissue and concurrent undermineralization of skeleton also occur in the general medical population, where it is referred to as paradoxical mineralization to highlight the confusing pathophysiology. This review summarizes the clinical presentation and pathophysiology of paradoxical mineralization unveiled by ENPP1 deficiency and the bench-to-bedside development of a novel ENPP1 biologics designed to treat mineralization disorders in the rare disease and general medical population.

Novel Associations of Dyslipidaemia with Vitamin D and Bone Metabolism in Elderly Patients with Diabetes: A Cross-Sectional Study

Objective

Little is known about whether diabetic dyslipidaemia contributes to increased bone fragility in patients with diabetes. This study aimed to explore the potential effects of dyslipidaemia on vitamin D and bone metabolism in elderly subjects with type 2 diabetes (T2D).

Methods

A total of 1479 male patients and 1356 female patients 50 years or older with T2D were included in Shanghai, China. Lipid profiles, 25-hydroxyvitamin D (25(OH)D), serum procollagen type I N-terminal propeptide (P1NP), β-C-terminal telopeptide (β-CTX) and other parameters were measured. Principal component regression (PCR) and mediation analysis were used to estimate the associations of lipid profile, 25(OH)D and bone turnover levels.

Results

Female patients presented with higher blood lipids, lower 25(OH)D, and higher P1NP and β-CTX levels than male patients with T2D. TC was associated with P1NP in males and females (β=0.056, P<0.05; β=0.095, P<0.01, respectively), and 25(OH)D fully mediated the associations in males and mediated approximately 17.89% of the effects in females. LDL-C was associated with P1NP in males and females (β=0.072 and 0.105 respectively, all P<0.01), and 25(OH)D mediated the relationships approximately 20.83% in males and 14.29% in females. TG was negatively associated with P1NP (in males, β= -0.063, P<0.05; in females, β= -0.100, P<0.01) and β-CTX (in males, β= -0.108; in females, β= -0.128, all P<0.01) independent of 25(OH)D, while HDL-C was not associated with P1NP or β-CTX in diabetic patients.

Conclusion

Hypercholesterolemia and hypertriglyceridaemia might affect bone metabolism by distinguishing pathways in diabetes patients. Ameliorating lipid control in elderly diabetes patients, especially female patients, will benefit both vitamin D and bone metabolism.

The Association of Coronary Artery Calcium Score and Osteoporosis in Postmenopausal Women: A Cross-Sectional Study

BACKGROUND

The association between osteoporosis, a common metabolic bone disorder, and atherosclerosis has been reported in different studies. In this study, we aimed to investigate the association between the coronary artery calcium score (CACS) and bone mineral density (BMD) at different sites and bone biomarkers in postmenopausal women.

METHODS

A total of 184 participants were enrolled in this study. The CACS and BMD at different sites, including the spinal, total hip, and femoral neck, were measured using computed tomography angiography and dual energy X-ray absorptiometry, respectively. Serum levels of osteocalcin, β-C-terminal telopeptide (β-CTX), parathyroid hormone, and 25-hydroxy-vitamin D were measured.

RESULTS

A negative association between CACS and bone biomarker levels (osteocalcin, P=0.021; β-CTX, P=0.013) was noted. The univariable model showed an association between CACS and osteoporosis of the femoral neck (P=0.03). It was found that with an increase of 10 U in CACS, the odds of osteoporosis at the femoral neck escalates by 2% (odds ratio=1.02, 95% confidence interval, 1.002-1.03) using the multivariate logistic regression model, while such an association with osteoporosis could not be found at the spinal site. The best cutoff point of the calcium score was estimated to be 127.

CONCLUSIONS

The results suggest that in postmenopausal women, coronary atherosclerosis is independently associated with osteoporosis of the femoral neck, but such an association could not be detected with spinal osteoporosis. The importance of screening for osteoporosis in patients with cardiovascular disease and the implications of preventive measures in the primary care setting were highlighted considering the common risk factors.

Risk of earlier atherosclerotic cardiovascular disease in women with low bone mineral density

Low bone mineral density (BMD) is associated with higher risk of atherosclerotic cardiovascular disease (ASCVD) in women. We investigated whether the association between low BMD and ASCVD differs according to the age at ASCVD occurrence. We retrospectively analyzed 7932 women aged 50–65 years who underwent dual-energy X-ray absorptiometry. ASCVD was defined as a composite of ASCVD death, myocardial infarction, and ischemic stroke. When we classified participants into no event (n = 7803), early ASCVD (< 70 years) (n = 97), and late ASCVD (≥ 70 years) (n = 32) groups, age gradually increased across groups (median, 58, 60, and 63 years, respectively). However, the estimated BMD T-score at the age of 65 years was lowest in the early ASCVD group (median − 0.9, − 1.1, and − 0.5, respectively). Lower BMD was an independent predictor for early ASCVD (adjusted hazard ratio [95% confidence interval]: 1.34 [1.08–1.67] per 1-SD decrease in T-score), but not for late ASCVD (0.88 [0.60–1.30]). The inverse trend between early ASCVD risk and BMD T-score was consistent regardless of the number of accompanied clinical risk factors. Thus, low BMD is an independent predictor for early ASCVD in women. BMD evaluation can provide prognostic benefit for risk stratification for early ASCVD.

Nephrolithiasis: A Red Flag for Cardiovascular Risk

Epidemiological evidence shows that nephrolithiasis is associated with cardiovascular (CV) morbidities. The association between nephrolithiasis and CV disease is not surprising because both diseases share conditions that facilitate their development. Metabolic conditions, encompassed in the definition of metabolic syndrome (MS), and habits that promote nephrolithiasis by altering urine composition also promote clinical manifestations of CV disease. By inducing oxidative stress, these conditions cause endothelial dysfunction and increased arterial stiffness, which are both well-known predictors of CV disease. Furthermore, the subtle systemic metabolic acidosis observed in stone formers with CV disease may have a pathogenic role by increasing bone turnover and leading to reduced mineral content and osteoporosis/osteopenia. Heart valves and/or coronary artery and aortic calcifications are frequently associated with reduced mineral density. This is known as the 'calcification paradox' in osteoporosis and has also been observed in subjects with calcium nephrolithiasis. Evidence supports the hypothesis that osteoporosis/osteopenia is an independent risk factor for the development of CV calcifications. In the long term, episodes of renal stones may occur from the onset of metabolic derangements/MS to arterial stiffness/atherosclerosis and CV morbidities. These episodes should be considered a warning sign of an ongoing and silent atherosclerotic process. The evaluation of cardiometabolic risk factors and MS components should be routine in the assessment of renal stone formers. This would allow for treatment and prevention of the development of CV complications, which are much more severe for the patient and for public health.

Catalysis-Independent ENPP1 Protein Signaling Regulates Mammalian Bone Mass

Biallelic ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) deficiency induces vascular/soft tissue calcifications in generalized arterial calcification of infancy (GACI), and low bone mass with phosphate-wasting rickets in GACI survivors (autosomal hypophosphatemic rickets type-2). ENPP1 haploinsufficiency induces early-onset osteoporosis and mild phosphate wasting in adults. Both conditions demonstrate the unusual combination of reduced accrual of skeletal mineral, yet excess and progressive heterotopic mineralization. ENPP1 is the only enzyme that generates extracellular pyrophosphate (PPi), a potent inhibitor of both bone and heterotopic mineralization. Life-threatening vascular calcification in ENPP1 deficiency is due to decreased plasma PPi; however, the mechanism by which osteopenia results is not apparent from an understanding of the enzyme's catalytic activity. To probe for catalysis-independent ENPP1 pathways regulating bone, we developed a murine model uncoupling ENPP1 protein signaling from ENPP1 catalysis, Enpp1T238A mice. In contrast to Enpp1asj mice, which lack ENPP1, Enpp1T238A mice have normal trabecular bone microarchitecture and favorable biomechanical properties. However, both models demonstrate low plasma Pi and PPi, increased fibroblast growth factor 23 (FGF23), and by 23 weeks, osteomalacia demonstrating equivalent phosphate wasting in both models. Reflecting findings in whole bone, calvarial cell cultures from Enpp1asj mice demonstrated markedly decreased calcification, elevated transcription of Sfrp1, and decreased nuclear β-catenin signaling compared to wild-type (WT) and Enpp1T238A cultures. Finally, the decreased calcification and nuclear β-catenin signaling observed in Enpp1asj cultures was restored to WT levels by knockout of Sfrp1. Collectively, our findings demonstrate that catalysis-independent ENPP1 signaling pathways regulate bone mass via the expression of soluble Wnt inhibitors such as secreted frizzled-related protein 1 (SFRP1), whereas catalysis dependent pathways regulate phosphate homeostasis through the regulation of plasma FGF23. © 2022 American Society for Bone and Mineral Research (ASBMR).

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.

Associations between bone mineral density and coronary artery calcification: a systematic review and meta-analysis

Background:

The studies about the correlation between bone mineral density (BMD) and coronary arterial calcification (CAC) were still controversial. The aim of this study was to conduct a meta-analysis to evaluate the association between BMD and CAC.

Methods:

We systematically searched PubMed, Embase, Google scholar and Cochrane library for observational studies. We pooled odds ratio (OR) or correlation coefficient, and 95% confidence interval (CI) of the studies. Continuous data were pooled by mean difference (MD). Sub-group analysis was applied to investigate sources of heterogeneity. Funnel plots for publication bias was also performed.

Results:

Seventeen studies met the inclusion criteria. Pooled ORs for the prevalence of CAC in patients with low BMD versus patients with normal BMD was 2.11 (95% CI: 1.11 - 4.02, P = 0.02). The data pooled for comparing CAC score of low BMD and normal BMD patients is 33.77 (95% CI: 23.77 - 43.77, p = 0.000). The pooled ORs of multivariate logistic regression to predict the association were 1.00 (95% CI: 0.92 - 1.10, p = 0.95, age-adjusted), and 0.95 (95% CI: 0.86 - 1.05, p = 0.33, multivariable-adjusted). Cohort category and BMD assessment method were the main sources of heterogeneity.

Conclusions:

Low BMD is associated with higher prevalence and severity of CAC, especially in postmenopausal women. But the relation is not significant after adjusting age and other confounding variables. Low BMD and CAC may be two independent processes with aging. More large-scale studies with high-quality design are still needed to increase the understanding of them.

Is dual-energy absorptiometry accurate in the assessment of bone status of patients with chronic kidney disease?

Several patients with chronic kidney disease (CKD) have deteriorated bone status. Estimation of bone status using DXA has limitations especially in patients with CKD accompanying aortic calcifications. Quantitative CT and the trabecular bone score could be more accurate methods to estimate bone status for patients with CKD and vascular calcifications.

INTRODUCTION

It remains unclear whether dual-energy absorptiometry (DXA) is appropriate for the assessment of bone status in patients with chronic kidney disease (CKD), a disease that impacts bone health. The aims of this study were to compare DXA and central quantitative computed tomography (cQCT) and to evaluate bone status in patients with pre-dialysis CKD.

METHODS

This retrospective study included 363 healthy control subjects whose bone mineral density (BMD) was evaluated with DXA and 117 CKD patients whose BMD was evaluated using both cQCT and DXA. Diagnostic discordance was assessed between the lumbar spine (LS) and femur neck (FN) from DXA or between two modalities. The trabecular bone score (TBS) was extracted from DXA images. The volume of abdominal aortic calcification (AAC) was calculated using CT images from cQCT.

RESULTS

Using LS DXA T-score, osteoporosis was less common in the CKD group than in controls. Patients with normal LS BMD using DXA were reclassified into osteopenia or osteoporosis using cQCT in CKD patients. Among discordant subjects between FN and LS in DXA, a higher BMD of LS was more common in CKD patients than in controls. CKD patients had lower TBS than controls despite having the same diagnosis using DXA. AAC volume negatively correlated with BMD from cQCT and with TBS but not with BMD from DXA.

CONCLUSIONS

TBS and cQCT could accurately assess bone status in CKD patients since DXA may overestimate LS BMD, likely due to an increased AAC volume.

Effect of Denosumab or Alendronic Acid on the Progression of Aortic Stenosis: A Double-Blind Randomized Controlled Trial

BACKGROUND

Valvular calcification is central to the pathogenesis and progression of aortic stenosis, with preclinical and observational studies suggesting that bone turnover and osteoblastic differentiation of valvular interstitial cells are important contributory mechanisms. We aimed to establish whether inhibition of these pathways with denosumab or alendronic acid could reduce disease progression in aortic stenosis.

METHODS

In a single-center, parallel group, double-blind randomized controlled trial, patients >50 years of age with calcific aortic stenosis (peak aortic jet velocity >2.5 m/s) were randomized 2:1:2:1 to denosumab (60 mg every 6 months), placebo injection, alendronic acid (70 mg once weekly), or placebo capsule. Participants underwent serial assessments with Doppler echocardiography, computed tomography aortic valve calcium scoring, and 18F-sodium fluoride positron emission tomography and computed tomography. The primary end point was the calculated 24-month change in aortic valve calcium score.

RESULTS

A total of 150 patients (mean age, 72±8 years; 21% women) with calcific aortic stenosis (peak aortic jet velocity, 3.36 m/s [2.93-3.82 m/s]; aortic valve calcium score, 1152 AU [655-2065 AU]) were randomized and received the allocated trial intervention: denosumab (n=49), alendronic acid (n=51), and placebo (injection n=25, capsule n=25; pooled for analysis). Serum C-terminal telopeptide, a measure of bone turnover, halved from baseline to 6 months with denosumab (0.23 [0.18-0.33 µg/L] to 0.11 µg/L [0.08-0.17 µg/L]) and alendronic acid (0.20 [0.14-0.28 µg/L] to 0.09 µg/L [0.08-0.13 µg/L]) but was unchanged with placebo (0.23 [0.17-0.30 µg/L] to 0.26 µg/L [0.16-0.31 µg/L]). There were no differences in 24-month change in aortic valve calcium score between denosumab and placebo (343 [198-804 AU] versus 354 AU [76-675 AU]; P=0.41) or alendronic acid and placebo (326 [138-813 AU] versus 354 AU [76-675 AU]; P=0.49). Similarly, there were no differences in change in peak aortic jet velocity or 18F-sodium fluoride aortic valve uptake.

CONCLUSIONS

Neither denosumab nor alendronic acid affected progression of aortic valve calcification in patients with calcific aortic stenosis. Alternative pathways and mechanisms need to be explored to identify disease-modifying therapies for the growing population of patients with this potentially fatal condition. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02132026.

Patients with abnormal microarchitecture have an increased risk of early complications after spinal fusion surgery

Spine fusion is one of the most common orthopedic surgeries, with more than 400,000 cases performed annually. While these procedures correct debilitating pain and deformities, complications occur in up to 45%. As successful fusion rests upon early stability of hardware in bone, patients with structural skeletal deficits may be at particular risk for complications. Few studies have investigated this relationship, and none have used higher order imaging to evaluate microstructural mechanisms for complications. Standard DXA measurements are subject to artifact in patients with spinal disease and therefore provide limited information. The goal of this prospective study was to investigate pre-operative bone quality as a risk factor for early post-operative complications using high resolution peripheral QCT (HR-pQCT) measurements of volumetric BMD (vBMD) and microarchitecture. We hypothesized that patients with low vBMD and abnormal microarchitecture at baseline would have more skeletal complications post-operatively. Conversely, we hypothesized that pre-operative DXA measurements would not be predictive of complications. Fifty-four subjects (mean age 63 years, BMI 27 kg/m²) were enrolled pre-operatively and followed for 6 months after multi-level lumbar spine fusion. Skeletal complications occurred in 14 patients. Patients who developed complications were of similar age and BMI to those who did not. Baseline areal BMD and Trabecular Bone Score by DXA did not differ. In contrast, HR-pQCT revealed that patients who developed complications had lower trabecular vBMD, fewer and thinner trabeculae at both the radius and tibia, and thinner tibial cortices. In summary, abnormalities of both trabecular and cortical microarchitecture were associated the development of complications within the first six months following spine fusion surgery. Our results suggest a mechanism for early skeletal complications after fusion. Given the burgeoning number of fusion surgeries, further studies are necessary to investigate strategies that may improve bone quality and lower the risk of post-operative complications.

Association of Bone Mineral Density and Coronary Artery Calcification in Patients with Osteopenia and Osteoporosis

The aim of this study was to investigate the association between bone mineral density (BMD) and coronary artery calcification (CAC) in adults with osteopenia or osteoporosis. A retrospective medical review study was conducted in a regional hospital in southern Taiwan. Medical records of patients who underwent both a coronary computed tomography scan and a BMD measurement were identified. Multinomial logistic regression analyses were used to assess the association between BMD and CAC levels in patients with osteopenia or osteoporosis. Of the 246 patients, 119 were female and 42.3% had CAC. For patients with osteopenia, after adjusting for the significant factors of CAC, no significant association was observed between BMD with either moderate CAC (0 < CAC score ≤ 100) or high CAC (CAC score > 100). However, in patients with osteoporosis, after adjusting for the significant factors of CAC, BMD in the lumbar spine was inversely associated with moderate CAC (odds ratio = 0.38, p = 0.035). In conclusion, a lower BMD in the lumbar spine was associated with an increased risk of moderate CAC in patients with osteoporosis. It is crucial to take action to maintain bone health, particularly in those who already have osteoporosis, to reduce the risk of developing CAC and its associated morbidity and mortality.

Breast artery calcification and osteoporosis in postmenopausal woman: a case report and opinion on the problem

Mammography is one of the most common screening test in the female population. In addition to identifying breast cancer, vascular calcification is clearly visualized on the mammogram, which is associated with an increased risk of cardiovascular disease, atherosclerosis, and a number of other chronic non-communicable diseases. The article presents a case report of a postmenopausal woman with breast artery calcification and osteoporosis. Identification of women at risk of non-cancer diseases significantly expands the prospects of using mammography for screening.

Cross-sectional association of bone mineral density with coronary artery calcification in an international multi-ethnic population-based cohort of men aged 40-49: ERA JUMP study

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Significant association of atherosclerosis and bone mineral density has been reported.

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The association has been reported in postmenopausal women and elderly men.

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This study reported the association in an international cohort of middle-aged men.

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Coronary artery calcification was used as a biomarker of coronary atherosclerosis.

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Vertebral bone density was used as a surrogate marker of bone mineral density.

Introduction

Inverse associations of cardiovascular disease (CVD) and atherosclerosis with osteoporosis and bone mineral density (BMD) have been reported in post-menopausal women and elderly men. We aimed to investigate an association between vetebral bone density (VBD) and coronary artery cacification (CAC) in an international multi-ethnic cohort of middle-aged men in the EBCT and Risk Factor Assessment among Japanese and US Men in the Post-World-War-II birth cohort (ERA JUMP).

Methods

ERA JUMP examined 1134 men aged 40–49 (267 white, 84 black, and 242 Japanese Americans, 308 Japanese in Japan, and 233 Koreans in South Korea) free from CVD for CAC, and VBD, biomarkers of coronary atherosclerosis and BMD, respectively, with electron-beam computed tomography, and other risk factors. CAC was quantified with the Agatston method and VBD by computing the mean Hounsfield Unit (HU) value of the T12 to L3 vertebrae. To examine multivariable-adjusted associations of CAC with VBD, we used robust linear and logistic regressions.

Results

The mean VBD and median CAC were 175.4 HU (standard deviation: 36.3) and 0 (interquartile range: (0, 4.5)), respectively. The frequency of CAC was 19.0%. There was no significant interaction by race. VBD had a significant inverse association with CAC score (β = −0.207, p-value = 0.005), while a 10-unit increase in VBD was significantly associated with the frequency of CAC (odds ratio (95% confidence interval) = 0.929 (0.890–0.969)). Both associations remained significant after adjusting for covariates.

Conclusions

VBD had a significant inverse association with CAC in this international multi-ethnic cohort of men aged 40–49.

Bone mineral density and mortality in end-stage renal disease patients

Osteoporosis characterized by low bone mineral density (BMD) as assessed by dual-energy X-ray absorptiometry (DXA) is common among end-stage renal disease (ESRD) patients and associates with high fracture incidence and high all-cause mortality. This is because chronic kidney disease-mineral bone disorders (CKD-MBDs) promote not only bone disease (osteoporosis and renal dystrophy) but also vascular calcification and cardiovascular disease. The disturbed bone metabolism in ESRD leads to 'loss of cortical bone' with increased cortical porosity and thinning of cortical bone rather than to loss of trabecular bone. Low BMD, especially at cortical-rich bone sites, is closely linked to CKD-MBD, vascular calcification and poor cardiovascular outcomes. These effects appear to be largely mediated by shared mechanistic pathways via the 'bone-vascular axis' through which impaired bone status associates with changes in the vascular wall. Thus, bone is more than just the scaffolding that holds the body together and protects organs from external forces but is-in addition to its physical supportive function-also an active endocrine organ that interacts with the vasculature by paracrine and endocrine factors through pathways including Wnt signalling, osteoprotegerin (OPG)/receptor activator of nuclear factor-κB (RANK)/RANK ligand system and the Galectin-3/receptor of advanced glycation end products axis. The insight that osteogenesis and vascular calcification share many similarities-and the knowledge that vascular calcification is a cell-mediated active rather than a passive mineralization process-suggest that low BMD and vascular calcification ('vascular ossification') to a large extent represent two sides of the same coin. Here, we briefly review changes of BMD in ESRD as observed using different DXA methods (central and whole-body DXA) at different bone sites for BMD measurements, and summarize recent knowledge regarding the relationships between 'low BMD' and 'fracture incidence, vascular calcification and increased mortality' in ESRD patients, as well as potential 'molecular mechanisms' underlying these associations.

Low volumetric bone density is a risk factor for early complications after spine fusion surgery

This study aims to investigate lumbar spine (LS) volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion.

INTRODUCTION

Lumbar spine (LS) fusion surgery is increasingly performed worldwide. Complications after fusion result in significant morbidity and healthcare costs. Multiple factors, including osteoporosis, have been suggested to contribute to risk of complications and re-operation. However, most studies have used DXA, which is subject to artifact in patients with spine pathology, and none have investigated the relationship between BMD and timing of post-operative complications. This study aims to investigate LS volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion.

METHODS

We evaluated a cohort of 359 patients who had initial LS fusion surgery at our institution, had pre-operative LS CTs and post-operative imaging available for review. Demographic factors, smoking status, vBMD, and details of surgical procedure were related to likelihood and timing of post-operative complications.

RESULTS

Mean age was 60 ± 14 years, vBMD 122 ± 37 g/cm³. Median follow-up was 11 months. Skeletal complications occurred in 47 patients (13%); 34 patients (10%) required re-operation. Low vBMD (directly measured and estimated using HU) and smoking were associated with increased risk of skeletal complications. Each increase in baseline vBMD of 10 g/cm³ decreased the complication hazard and increased the complication-free duration in time-to-event analysis (hazard ratio 0.91, 95% CI 0.83-0.98, p < 0.02).

CONCLUSIONS

Low vBMD was a significant risk factor for early post-operative complications in patients undergoing LS fusion. Prospective studies are needed to confirm these findings and to elucidate the optimal timing for follow-up and strategies for prevention of post-operative complications in this population.

Relationship of volumetric bone mineral density by quantitative computed tomography with abdominal aortic calcification

OBJECTIVE

This multicenter study aimed to evaluate the association between volumetric bone mineral density (vBMD) and abdominal aortic calcification (AAC) in a Chinese population.

METHODS

Quantitative computed tomography (QCT) and Agatston score (AS) were used to measure vBMD and AAC, respectively, in 3457 participants during 2013-2017. The association between vBMD and AAC was assessed using multivariate regression analysis, adjusted for age, residence, education, body mass index, and other cardiovascular risk factors.

RESULTS

The mean age of women and men was 61.4 and 62.7 years, respectively. In total, 30.4% of women and 37.7% of men were found to have AAC. After full adjustment, higher vBMD was associated with lower AAC score (β, -0.095; 95% confidence interval [CI], -0.167 to -0.024; P = 0.0087) and lower AAC prevalence (odds ratio [OR], 0.873; 95% CI, 0.824 to 0.924; P < 0.0001) in men. Inverse trends were also observed in the association of vBMD quartile with AAC severity (lowest vs highest quartile; β = 0.235; 95% CI, 0.011 to 0.459; P_trend < 0.0001) and AAC prevalence (lowest vs highest quartile; OR = 1.329; 95% CI, 1.087 to 1.625; P_trend < 0.0001) in men. However, no significant result was obtained in women, except for the association between quartiles of vBMD and AAC score.

CONCLUSIONS

In our study, vBMD was inversely associated with AAC among men independent of age and shared risk factors. However, the association was not significant among women.

Vitamin D and Abdominal Aortic Calcification in Older African American Women, the PODA Clinical Trial

Abdominal aortic calcification (AAC) detected on lateral vertebral fracture assessment is associated with increased cardiovascular risk. Vitamin D deficiency and toxicity have been linked with vascular calcification. The objective of this study was to determine the effect of high-dose vitamin D on the progression of AAC. The Physical Performance, Osteoporosis and vitamin D in African American Women (PODA) is a randomized, clinical trial examining the effect of vitamin D. There were 14.7% subjects with AAC in the vitamin D group, compared to 12.1% in the placebo group at baseline. The prevalence of extended AAC at baseline was 6.4% in the vitamin D group and 3.5% in the placebo group. The extended calcification scores over time were not different between groups. There was no association between AAC and serum 25(OH)D. However, PTH was associated with an increase in AAC in the placebo group.

Association of bone mineral density and trabecular bone score with cardiovascular disease

Traditionally, osteoporosis and cardiovascular disease (CVD) are considered as separate chronic diseases. Increasing evidence now links osteoporosis with hypertension, abnormal lipid metabolism, atherosclerosis, vascular calcification (VC), and congestive heart failure. VC coexists with bone loss, and aortic calcification is a strong predictor of low bone mineral density (BMD) and fragility fractures. The same holds true for coronary artery calcification (CAC): the lower the BMD, the higher the CAC. Trabecular bone score (TBS) iNsight software can analyze the existing BMD database to obtain the bony microstructure score (TBS). Many TBS-related studies include fracture risk, normal aging, diabetes, potential genes, obesity, and asthma severity prediction. The inverse relationship of TBS to VC may provide insight into bone–vascular interactions in chronic kidney disease. A higher TBS has been associated with moderate, but not high, CAC. One explanation is that bone microstructural remodeling becomes more active during early coronary calcification. Increased risk of 10-year likelihood of hip fracture and major osteoporotic fracture as estimated by the fracture risk assessment tool FRAX^® is significantly and independently associated with more severe CAC scores. Dual-energy X-ray absorptiometry and FRAX^® can be used to predict fracture risk and CAC scores, identifying patients who may benefit from early intervention. This review will discuss the relationship and possible mechanism of BMD, TBS, and FRAX^® with CVD and VC or CAC.

The relationship between volumetric thoracic bone mineral density and coronary calcification in men and women - results from the Copenhagen General Population Study

BACKGROUND

The association between low bone mineral density (BMD) and the presence of coronary artery calcium (CAC) as a marker of atherosclerosis is unclear. The aim of this study was to assess the potential relationship between volumetric thoracic bone mineral density and coronary calcification in a large population of men and women.

METHODS

Participants from the Copenhagen General Population Study underwent multidetector computed tomography. Volumetric thoracic BMD and CAC were assessed in the same scan. CAC was measured using calibrated mass score (cMS). cMS was dichotomized as cMS = 0 or cMS > 0. The association between BMD and cMS was analyzed using multiple logistic regression in men, premenopausal and postmenopausal women. The model was adjusted for age, BMI, hypertension, hypercholesterolemia, diabetes, known cardiovascular disease and smoking.

RESULTS

Of 2548 eligible participants, 1163 men and 1385 women, mean age 61 ± 10 were included in the study. Mean BMD was 138 ± 46 mg/cm³ for men and 151 ± 49 mg/cm³ women. In 696 men (67%) and 537 women (41%) cMS was found to be above zero. For men, a decrease in BMD of 100 mg/cm³ was associated to an odds ratio of 1.49 for cMS > 0 (95% confidence interval: 1.04-2.13, P = 0.03). In postmenopausal women, a decrease in BMD of 100 mg/cm³ was associated to an odds ratio of 1.47 for MS > 0 (95% confidence interval: 1.04-2.08, P = 0.03). For premenopausal women, no significant association was found between BMD and cMS (odds ratio = 0.74, 95% confidence interval: 0.36-1.52, P = 0.4).

CONCLUSION

Bone mineral density and coronary calcification are inversely related in both men and postmenopausal women, supporting the hypothesis that a direct relation between bone loss and development of atherosclerosis exists irrespective of gender.

Differences in association of lower bone mineral density with higher coronary calcification in female and male end-stage renal disease patients

Background

Risk of cardiac events and cardiovascular disease (CVD) in end-stage renal disease (ESRD) patients are predicted by coronary artery calcification (CAC) independently. It is not clear to what extent low bone mineral density (BMD) is associated with higher risk of CAC and if sex interacts. We investigated the sex-specific associations of CAC score with total body BMD (tBMD) as well as with BMD of different skeletal sub-regions.

Methods

In 174 ESRD patients, median age 57 (10th–90th percentiles 29–75) years, 63% males, BMD (measured by dual-energy X-ray absorptiometry; DXA), CAC score (measured by cardiac CT) and circulating inflammatory biomarkers were analysed.

Results

A total of 104 (60%) patients with CAC > 100 AUs were older, had higher prevalence of both clinical CVD and diabetes, higher level of high sensitivity C-reactive protein, tumour necrosis factor, interleukin-6 and lower T-score of tBMD. Female patients had significantly lower tBMD and BMD of all skeletal sub-regions, except head, than male patients. Female patients with high CAC (> 100 AUs) had significantly decreased T-score of tBMD, and lower BMD of arms, legs than those low CAC (≤ 100 AUs); elevated CAC score were associated with tBMD, T-score, Z-score of tBMD and BMD of arms and legs, while no such differences was observed in males. Multivariate generalized linear model (GLM) analysis adjusted for age, diabetes and hsCRP showed that in females per SD higher CAC score (1057 AUs) was predicted by either per SD (0.13 g/cm²) lower tBMD or per SD (0.17 g/cm²) lower BMD at legs. No such associations were found in male ESRD patients.

Conclusions

In female, but not male, lower BMD, in particular sub-regions of legs, was associated with higher CAC score independently. Low BMD has the potential to identify increased risk for high CAC score in ESRD patients.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1235-z) contains supplementary material, which is available to authorized users.

Lower femoral neck bone mineral density (BMD) in elderly women not on statins

Coronary artery disease (CAD) and osteoporosis, the two most frequently occurring chronic diseases of aging populations, share many risk factors including lack of estrogen, smoking, and low physical activity. CAD and low bone mineral density (BMD) are strongly associated. Statins, (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors), are used to prevent and treat CAD and have been associated with high BMD. This cross-sectional study examined associations of BMD with statin use and nonuse in elderly women with or without CAD. Multivariate regression analyses were conducted on 185 women aged ≥60 years who were referred between October 2010 and March 2015 to a geriatric osteoporosis clinic in Houston, Texas, for compromised skeletal health. Compared to the control group (without CAD and without statin use), patients with CAD and no statin use were more likely to have lower femoral neck BMD (β: -0.46, 95% confidence interval: -0.75 to -0.18). The BMD of patients taking statins, regardless of presence of CAD, was similar to that of the control group. Statins may be protective in preventing bone loss in elderly women suffering from CAD. Prospective trials are warranted to determine if continued use of statins in them would help prevent both CAD and bone loss.

Lower Spine Volumetric Bone Density in Patients With a History of Epidural Steroid Injections

CONTEXT

Epidural steroid injections (ESIs) are a common, effective treatment of lumbar radiculopathy and sciatica. Although the negative skeletal effects of oral glucocorticoids are well established, little is known about the impact of ESI on bone quality.

OBJECTIVE

To investigate the relationship between ESI exposure and volumetric bone mineral density (vBMD) at the lumbar spine (LS) using central quantitative CT.

DESIGN

Retrospective study.

SETTING

University hospital outpatient facility.

PATIENTS

All patients had CT scans of the LS between 2011 and 2016. Cases received at least three ESIs prior to the date of CT (n = 121). Controls were matched for age and sex (n = 121).

MAIN OUTCOME MEASURES

Cumulative ESI dose was calculated. vBMD was measured at T12 through L5 using QCT Pro phantomless software (MindWays).

RESULTS

Mean age of subjects was 65 ± 14 years, and 49% were women. Median number of ESIs was 4 (range: 3 to 16). Median cumulative ESI dosage was 340 mg of triamcinolone or equivalent (range: 150 to 1400 mg). Compared with controls, ESI subjects had lower vBMD at each vertebral level. Higher cumulative dose was associated with lower mean vBMD at T12 to L5 (r = -0.22, P = 0.02).

CONCLUSIONS

Greater cumulative ESI dose was related to lower vBMD at the LS. To our knowledge, this is the first study to measure vBMD in patients treated with ESIs. Prospective studies are needed to confirm these findings and to help identify the best strategies for preventing bone loss in this population.

Inflammatory and metabolic mechanisms underlying the calcific aortic valve disease

Although calcific aortic stenosis is a very common disease with major adverse cardiovascular events and healthcare costs, there are no effective medical interventions to delay or halt its progression. Cardiometabolic risk factors, including smoking and male sex, are linked to aortic stenosis. Emerging studies have identified important regulatory roles for immunological and inflammatory responses, including oxidized lipids, various cytokines, and biomineralization. Recent clinical and experimental studies in atherosclerosis and osteoporosis have demonstrated that oxidative stress and oxidized lipids decrease bone formation in the skeletal system while they increase bone formation in the cardiovascular system. Multidisciplinary factors contribute to vascular calcification, including inflammation and metabolic regulation of osteogenesis in the cardiovascular system via similar signaling pathways as bone formation. Calcific aortic valve disease (CAVD) is no longer considered a simple passive process of calcium deposition that occurs with advanced age. Biomineralization in CAVD is a complex, regulated process that involves valvular, circulating, bone marrow-derived cells, macrophage heterogeneity and genetic factors along with biochemical and mechanical factors. The current review will discuss the recently discovered important role of inflammation, metabolic risk factors, and molecular and cellular mechanisms that promote CAVD, as well as the link between osteogenic signals in the skeletal and cardiovascular systems. This may inform future therapeutic strategies for CAVD progression.

Oxidized phospholipids are ligands for LRP6

Low-density lipoprotein receptor-related protein 6 (LRP6) is a co-receptor for Wnt signaling and can be recruited by multiple growth factors/hormones to their receptors facilitating intracellular signaling activation. The ligands that bind directly to LRP6 have not been identified. Here, we report that bioactive oxidized phospholipids (oxPLs) are native ligands of LRP6, but not the closely related LRP5. oxPLs are products of lipid oxidation involving in pathological conditions such as hyperlipidemia, atherosclerosis, and inflammation. We found that cell surface LRP6 in bone marrow mesenchymal stromal cells (MSCs) decreased rapidly in response to increased oxPLs in marrow microenvironment. LRP6 directly bound and mediated the uptake of oxPLs by MSCs. oxPL-LRP6 binding induced LRP6 endocytosis through a clathrin-mediated pathway, decreasing responses of MSCs to osteogenic factors and diminishing osteoblast differentiation ability. Thus, LRP6 functions as a receptor and molecular target of oxPLs for their adverse effect on MSCs, revealing a potential mechanism underlying atherosclerosis-associated bone loss.

Abdominal aortic calcification and the risk of bone fractures: a meta-analysis of prospective cohort studies

The relationship between abdominal aortic calcification (AAC) and bone fracture has been examined by some observational studies, but the results remain discordant. Therefore, we aimed to assess the link between them by conducting a meta-analysis of prospective studies. Relevant studies were identified by searching PubMed and EMBASE databases until the end of December 2016. Summary relative risks (RRs) and 95% confidence intervals (CIs) for associations between AAC and fracture risk were estimated with fixed- or random- effects models. Seven prospective studies were included in the final analysis. The summarized RRs of any type of fractures for the highest compared with the lowest category of AAC were 1.64 (95% CI 1.30-2.07, P = 0.000) with mild heterogeneity (I ² = 30.1%, P = 0.188). Subgroup analysis showed that the association between AAC and fracture was not significantly modified by gender and follow-up length. Risks were similar when analyses were restricted to the studies with adjustment for bone mineral density (BMD) (RR = 1.76, 95% CI 1.31-2.38, P = 0.000, I ² = 49.1%). For the specific type of fracture, severe AAC was significantly related with hip fracture (RR = 1.64, 95% CI 1.22-2.20, P = 0.001, n = 5), but not with vertebral (RR = 1.45, 95% CI 0.81-2.58, P = 0.213, n = 3) or non-vertebral fracture (RR = 1.35, 95% CI 0.96-1.88, P = 0.081, n = 3). There was no evidence of publication bias. Our findings demonstrated that AAC was significantly and independently associated with a higher fracture risk, especially for hip fracture.

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.

Oxidation-specific epitopes restrain bone formation

Atherosclerosis and osteoporosis are epidemiologically linked and oxidation specific epitopes (OSEs), such as phosphocholine (PC) of oxidized phospholipids (PC-OxPL) and malondialdehyde (MDA), are pathogenic in both. The proatherogenic effects of OSEs are opposed by innate immune antibodies. Here we show that high-fat diet (HFD)-induced bone loss is attenuated in mice expressing a single chain variable region fragment of the IgM E06 (E06-scFv) that neutralizes PC-OxPL, by increasing osteoblast number and stimulating bone formation. Similarly, HFD-induced bone loss is attenuated in mice expressing IK17-scFv, which neutralizes MDA. Notably, E06-scFv also increases bone mass in mice fed a normal diet. Moreover, the levels of anti-PC IgM decrease in aged mice. We conclude that OSEs, whether produced chronically or increased by HFD, restrain bone formation, and that diminished defense against OSEs may contribute to age-related bone loss. Anti-OSEs, therefore, may represent a novel therapeutic approach against osteoporosis and atherosclerosis simultaneously.

The Role of Secondary Calciprotein Particles in the Mineralisation Paradox of Chronic Kidney Disease

Mineralisation paradox is prevalent in chronic kidney disease and ageing where increased vascular calcification is accompanied by reduced bone mineralisation and osteopenia. Secondary calciprotein particles (CPP2), colloidal nanoparticles containing hydroxyapatite crystal stabilised by a protein shell, have been implicated in vascular calcification in chronic kidney disease. Here, we describe the effect of CPP2 on osteoblasts and vascular smooth muscle cells (VSMC) mineralisation in an in vitro model system. The mineralisation paradox can be simulated in vitro by the addition of phosphate ions (Pi, 3 mM) and CPP2 (10 µg/ml of Ca equivalent). Pi alone induced osteoblast mineralisation but had no effect on VSMC mineralisation. CPP2 alone had no effect on mineralisation in either cell line, but when combined with elevated Pi, reduced osteoblast-like mineralisation (P < 0.001) whilst induced VSMC mineralisation (P < 0.001). These results suggest that in an in vitro system the synergistic interaction between Pi and CPP2 could mimic the mineralisation paradox, and may provide a potential mechanistic link to explain these clinical observations.

Coronary Artery Calcification (CAC) and Post-Trial Cardiovascular Events and Mortality Within the Women's Health Initiative (WHI) Estrogen-Alone Trial

BACKGROUND

Among women aged 50 to 59 years at baseline in the Women's Health Initiative (WHI) Estrogen-Alone (E-Alone) trial, randomization to conjugated equine estrogen-alone versus placebo was associated with lower risk of myocardial infarction and mortality, and, in an ancillary study, the WHI-CACS (WHI Coronary Artery Calcification Study) with lower CAC, measured by cardiac computed tomography ≈8.7 years after baseline randomization. We hypothesized that higher CAC would be related to post-trial coronary heart disease (CHD), cardiovascular disease (CVD), and total mortality, independent of baseline randomization or risk factors.

METHODS AND RESULTS

WHI-CACS participants (n=1020) were followed ≈8 years from computed tomography scan in 2005 (mean age=64.4) through 2013 for incident CHD (myocardial infarction and fatal CHD, n=17), CVD (n=69), and total mortality (n=55). Incident CHD and CVD analyses excluded women with CVD before scan (n=89). Women with CAC=0 (n=54%) had very low age-adjusted rates/1000 person-years of CHD (0.91), CVD (5.56), and mortality (3.45). In comparison, rates were ≈2-fold higher for women with any CAC (>0). Associations were not modified by baseline randomization to conjugated equine estrogen-alone versus placebo. Adjusted for baseline randomization and risk factors, the hazard ratio (95% confidence interval) for CAC >100 (19%) was 4.06 (2.11, 7.80) for CVD and 2.70 (1.26, 5.79) for mortality.

CONCLUSIONS

Among a subset of postmenopausal women aged 50 to 59 years at baseline in the WHI E-Alone Trial, CAC at mean age of 64 years was strongly related to incident CHD, CVD, and to total mortality over ≈8 years, independent of baseline randomization to conjugated equine estrogen-alone versus placebo or CVD risk factors.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00000611.

Bone mineral density of extremities is associated with coronary calcification and biopsy-verified vascular calcification in living-donor renal transplant recipients

Chronic kidney disease (CKD) mineral and bone disorders (CKD-MBD) may lead to low bone mineral density (BMD) and vascular calcification (VC), but links to the latter are unclear. Here we investigated associations between BMD, coronary artery calcium (CAC) scores, and histological signs of VC in end-stage renal disease (ESRD) patients undergoing living-donor kidney transplantation (LD-Rtx). In 66 ESRD patients (median age 45 years, 68% males), BMD (by dual-energy X-ray absorptiometry, DXA), CAC score (by computed tomography, CT; n = 54), and degree of VC score (graded by histological examination of epigastric artery specimens collected at LD-Rtx; n = 55) were assessed at the time of LD-Rtx. Of the patients, 26% had osteopenia and 7% had osteoporosis. Of those undergoing artery biopsy, 16% had extensive VC, and of those undergoing CT 28% had high CAC score (>100 Agatston units). CAC scores correlated with BMD of legs and pelvis. BMDs of leg and pelvic sub-regions were significantly lower in patients with extensive VC. In multivariate regression analysis adjusted for age and gender, lower BMD of leg sub-region was associated with CAC score >100 AUs and extensive VC, and patients with extensive VC had significantly higher CAC score. Both high CAC and extensive VC were independently predicted by low BMD of legs. Low BMD has the potential to identify ESRD patients at risk of vascular calcification.

Coronary Artery Calcium Score and Bone Metabolism: A Pilot Study in Postmenopausal Women

Background

Since 1991 many studies evaluated the link between cardiovascular diseases and osteoporosis, two age-related conditions, but the main common pathologic pathway has not been determined yet. The histological similarity between arterial calcified plaque and bone matrix and involvement of similar cells and mediators provide a special field of research. Therefore in the present study, we aimed to evaluate the relationship between coronary artery calcium score (CACS) as a surrogate marker of atherosclerosis and bone mediators and parameters in postmenopausal women.

Methods

Eleven postmenopausal women who had CACS higher than 80 were enrolled into the study and underwent bone densitometry. In addition, their serum and urine samples were taken for measuring osteoprotegerin, osteocalcin, and β cross laps. Patients' 10-year probability of fracture was calculated by the World Health Organization fracture-risk assessment tool (FRAX).

Results

The regression analysis of our results showed the association between CACS and OC (std β=0.66, 95% confidence interval [CI] 5.47-72.27, P=0.027), femoral bone density (std β=−0.6, 95% CI -6864.34-14.27, P=0.05) and T-score (std β=−0.6, 95% CI −773.08-1.28, P=0.05) which remained significant after adjustment for age, weight, years since menopause and body mass index. No association was found between CACS and osteoprotegerin, spinal bone density and FRAX score.

Conclusions

In conclusion, this pilot study with small sample size showed the potential association between CACS and osteocalcin, femoral bone density and T-score. However, the relationship between CACS and osteoprotegerin, receptor activator of nuclear factor-kappa B ligand, FRAX score and other bone parameters remain to be clarified in larger sample size studies.

Low Dentin Matrix Protein 1 Is Associated With Incident Cardiovascular Events in Peritoneal Dialysis Patients

Recent reports demonstrated that dentin matrix protein 1 (DMP1) acts as an inhibitor of vascular calcification and might be a potential biomarker for chronic kidney disease-mineral and bone disorder; however, no clinical investigations regarding DMP1 have been performed in dialysis patients. We investigated the prognostic value of DMP1 on cardiovascular outcomes in prevalent peritoneal dialysis patients. We recruited 223 prevalent peritoneal dialysis patients and divided them into high and low DMP1 groups according to log-transformed plasma DMP1 levels. Lateral lumbar spine radiographs were used for measurement of vascular calcification. Major cardiovascular events were compared between the two groups. A Cox proportional hazards analysis determined DMP1 was independently associated with cardiovascular outcomes. In vitro mouse osteocytes were cultured in media containing indoxyl sulfate (IS), and the expressions of DMP1 were examined. The mean age was 52.1 ± 11.8 years, and 116 (52.0%) patients were male. The median value of log DMP1 was 0.91 (0.32-2.81 ng/mL). The multiple logistic regression analysis indicated that DMP1 levels were independently associated with the presence of vascular calcification after adjustment for multiple confounding factors (odds ratio = 0.719; 95% confidence interval [CI] 0.522-0.989; p = 0.043). During a mean follow-up duration of 34.6 months, incident cardiovascular events were observed in 41 (18.4%) patients. A Kaplan-Meier plot showed that the low DMP1 group had a significantly higher rate of incident cardiovascular events compared with the high DMP1 group (log-rank test, p = 0.026). In addition, multiple Cox analysis showed that low DMP1 was significantly associated with incident cardiovascular events (log 1 increase: hazard ratio = 0.855; 95% CI 0.743-0.984; p = 0.029) after adjustment for multiple confounding factors. In IS-stimulated osteocytes, mRNA and protein expression levels of DMP1 were significantly decreased compared with control osteocytes. We showed that low DMP1 levels were significantly associated with presence of vascular calcification and were independently associated with the incident cardiovascular events in prevalent peritoneal dialysis patients. DMP1 might be a potential factor contributing to cardiovascular complications in dialysis patients. © 2016 American Society for Bone and Mineral Research.

Vertebral bone density associates with coronary artery calcification and is an independent predictor of poor outcome in end-stage renal disease patients

OBJECTIVE

Chronic kidney disease-mineral bone disorder (CKD-MBD) is a major complication of end-stage renal disease (ESRD). Reduced bone mineral density (BMD) is associated with vascular calcification. Here we investigated associations between vertebral bone density (VBD) and coronary artery calcification (CAC), quantified by cardiac computed tomography (CT), and BMD quantified by dual-energy X-ray absorptiometry (DXA), and their relations with mortality.

METHODS

In 231 ESRD patients (median age 56years, 63% males) comprising incident dialysis patients, prevalent peritoneal dialysis patients and recipients of living donor kidney transplant, VBD (Hounsfield units, HUs) and CAC scores (Agatston units, AUs) were quantified by cardiac CT, and, in 143 of the patients, BMD was measured by DXA of total body. Metabolic and inflammation biomarkers potentially linked to CKD-MBD were also analysed.

RESULTS

Patients with low tertile of VBD were older and had more often cardiovascular disease (CVD), and higher HbA1c (non-diabetics), interleukin-6 and CAC score. Low VBD was independently associated with higher CAC score (>100 AUs) after adjustment for age, gender, diabetes, CVD, inflammation and cohorts. In Cox proportional hazards analysis, low VBD was independently associated with all-cause mortality after adjustment for age, gender, diabetes, CVD, inflammation and subjective global assessment (SGA). The root mean-squared error of prediction (RMSE) showed a good degree of association between VBD and BMD evaluated from DXA. In receiver-operator characteristics curve (ROC) analysis, lower VBD was more strongly associated with higher CAC score and all-cause mortality than BMD evaluated from DXA.

CONCLUSIONS

While assessments of BMD by DXA and CT showed good degree of agreement, associations of high CAC, and mortality, with low VBD were stronger than those based on low BMD by DXA. The strong independent associations of low VBD with high CAC score and increased mortality risk suggest that VBD may serve as an important prognosticator in ESRD patients.

Lower leg arterial calcification assessed by high-resolution peripheral quantitative computed tomography is associated with bone microstructure abnormalities in women

In older women, the presence of lower leg arterial calcification assessed by high-resolution peripheral quantitative computed tomography is associated with relevant bone microstructure abnormalities at the distal tibia and distal radius.

INTRODUCTION

Here, we report the relationships of bone geometry, volumetric bone mineral density (BMD) and bone microarchitecture with lower leg arterial calcification (LLAC) as assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT).

METHODS

We utilized the Hertfordshire Cohort Study (HCS), where we were able to study associations between measures obtained from HR-pQCT of the distal radius and distal tibia in 341 participants with or without LLAC. Statistical analyses were performed separately for women and men. We used linear regression models to investigate the cross-sectional relationships between LLAC and bone parameters.

RESULTS

The mean (SD) age of participants was 76.4 (2.6) and 76.1 (2.5) years in women and men, respectively. One hundred and eleven of 341 participants (32.6 %) had LLAC that were visible and quantifiable by HR-pQCT. The prevalence of LLAC was higher in men than in women (46.4 % (n = 83) vs. 17.3 % (n = 28), p < 0.001). After adjustment for confounding factors, we found that women with LLAC had substantially lower Ct.area (β = -0.33, p = 0.016), lower Tb.N (β = -0.54, p = 0.013) and higher Tb.Sp (β = 0.54, p = 0.012) at the distal tibia and lower Tb.Th (β = -0.49, p = 0.027) at the distal radius compared with participants without LLAC. Distal radial or tibial bone parameter analyses in men according to their LLAC status revealed no significant differences with the exception of Tb.N (β = 0.27, p = 0.035) at the distal tibia.

CONCLUSION

In the HCS, the presence of LLAC assessed by HR-pQCT was associated with relevant bone microstructure abnormalities in women. These findings need to be replicated and further research should study possible pathophysiological links between vascular calcification and osteoporosis.

Subfractions of High-Density Lipoprotein-Cholesterol and Carotid Intima-Media Thickness: The Northern Manhattan Study

BACKGROUND AND PURPOSE

Recent drug trials have challenged the high-density lipoprotein-cholesterol (HDL-C) antiatherosclerotic hypothesis, suggesting that total level of HDL-C may not be the best target for intervention. HDL-C subfractions may be better markers of vascular risk than total levels of HDL-C. The objective of this cross-sectional study was to investigate the relationship between HDL2-C and HDL3-C fractions and carotid intima-media thickness (cIMT) in the population-based Northern Manhattan Study.

METHODS

We evaluated 988 stroke-free participants (mean age, 66±8 years; 60% women; 66% Hispanic, and 34% non-Hispanic) with available data on HDL-C subfractions using precipitation method and cIMT assessed by a high-resolution carotid ultrasound. The associations between HDL-C subfractions and cIMT were analyzed by multiple linear regression models.

RESULTS

The mean HDL2-C was 14±8 mg/dL, HDL3-C 32±8 mg/dL, and the mean total HDL-C was 46±14 mg/dL. The mean cIMT was 0.90±0.08 mm. After controlling for demographics and vascular risk factors, HDL2-C and total HDL-C were inversely associated with cIMT (per 2 SDs, β=-0.017, P=0.001 and β=-0.012, P=0.03, respectively). The same inverse association was more pronounced among those with diabetes mellitus (per 2SDs, HDL2-C: β=-0.043, P=0.003 and HDL-C: β=-0.029, P=0.02). HDL3-C was not associated with cIMT.

CONCLUSIONS

HDL2-C had greater effect on cIMT than HDL3-C in this large urban population. The effect of HDL2-C was especially pronounced among individuals with diabetes mellitus. More research is needed to determine antiatherosclerotic effects of HDL-C subfractions and their clinical relevance.

Decreased Bone Mineral Density Is an Independent Predictor for the Development of Atherosclerosis: A Systematic Review and Meta-Analysis

Background

There is conflicting evidence regarding the association between decreased bone mineral density (BMD) and atherosclerosis. To this end, we performed a systematic review and meta-analysis to clarify the association.

Methods

To identify relevant studies, PubMed, Embase, and the Cochrane Library were systematically searched up to November 2015. All observational and comparative studies directly investigating the relationship between decreased BMD and clinical consequences of atherosclerotic vascular abnormalities, including carotid artery calcification (CAC), cardiovascular disease (CAD), and coronary artery disease (CAD) were obtained, without limitation of language or publication year.

Results

A total of 25 studies involving 10,299 patients were included. The incidence of atherosclerotic vascular abnormalities was significantly increased in low BMD patients, compared to patients with normal BMD (OR, 1.81, 95% CI [1.01, 2.19], p<0.00001)). Similar results were also observed for postmenopausal women (OR, 2.23, 95% CI [1.72, 2.89], p<0.00001). Subgroup analyses of osteopenia, osteoporosis, and normal BMD also revealed that the combined ORs for the incidence of atherosclerotic vascular abnormalities increased as BMD decreased. Of note, after adjusting for age, sex, body mass index (BMI) and other vascular risk factors, decreased BMD remained significantly associated with the incidence of atherosclerotic vascular abnormalities (OR, 2.96, 95% CI [2.25, 3.88], p < 0.00001).

Conclusions

Based on the results of this study, decreased BMD is an independent predictor for the development of atherosclerosis in elderly individuals. Moreover, the risk of atherosclerotic vascular abnormalities increased as BMD decreased. Future studies focusing on individuals with different severities of atherosclerosis and comorbidities are of interest.

Skeletal inflammation and attenuation of Wnt signaling, Wnt ligand expression, and bone formation in atherosclerotic ApoE-null mice

ApoE-null (ApoE-KO) mice fed a high-fat diet (HFD) develop atherosclerosis, due in part to activation of vascular inflammation by oxidized low-density lipoprotein. Since bone loss also occurs in these mice, we used them to investigate the impact of oxidized lipids on bone homeostasis and to search for underlying pathogenic pathways. Four-month-old female ApoE-KO mice fed a HFD for three months exhibited increased levels of oxidized lipids in bone, as well as decreased femoral and vertebral trabecular and cortical bone mass, compared with ApoE-KO mice on normal diet. Despite HFD-induced increase in expression of Alox15, a lipoxygenase that oxidizes LDL and promotes atherogenesis, global deletion of this gene failed to ameliorate the skeletal impact of HFD. Osteoblast number and function were dramatically reduced in trabecular and cortical bone of HFD-fed mice, whereas osteoclast number was modestly reduced only in trabecular bone, indicating that an imbalance in favor of osteoclasts was responsible for HFD-induced bone loss. These changes were associated with decreased osteoblast progenitors and increased monocyte/macrophages in the bone marrow as well as increased expression of IL-1β, IL-6, and TNF. HFD also attenuated Wnt signaling as evidenced by reduced expression of Wnt target genes, and it decreased expression of pro-osteoblastogenic Wnt ligands. These results suggest that oxidized lipids decrease bone mass by increasing anti-osteoblastogenic inflammatory cytokines and decreasing pro-osteoblastogenic Wnt ligands.

Osteoporosis and vascular calcification in postmenopausal women: a cross-sectional study

Objectives To estimate the correlation between osteoporosis and vascular calcification in postmenopausal women and the influence of calcium/vitamin D supplements on vascular calcification. Methods A cross-sectional study was performed including 29 women with osteoporosis (15 not taking supplements) and 18 age-matched, non-osteoporotic women. They were evaluated for cardiovascular risk factors and blood tests, lateral X-ray of lumbar spine (assessment of abdominal aorta calcification, AAC) and carotid ultrasound (increased intima media thickness (iIMT) or calcified plaques) were performed. Results In univariate analysis, osteoporotic women were 16 times more likely to develop AAC (odds ratio (OR) 15.8, 95% confidence interval (CI) 1.9-135.4) and seven times more likely to develop iIMT (OR 6.8, 95% CI 1.8-25.4) compared to normal individuals. The odds of developing AAC and iIMT were increased each year after menopause (OR 1.11, 95% CI 1.01-1.2 and OR 1.18, 95% CI 1.05-1.3, respectively) and with aging (OR 1.27, 95% CI 1.1-1.47 and OR = 1.17, 95% CI 1.04-1.3, respectively). Calcified plaques were significantly correlated with osteoporosis (p = 0.014). In multivariate analysis, osteoporosis was an independent risk factor for AAC (OR 13.3, 95% CI 1.3-134.4) and iIMT (OR 4.7, 95% CI 1.1-19.9). Low doses of supplements did not appear to affect vascular calcification (p = 0.6). Conclusions Osteoporosis is associated with increased calcification of the abdominal aorta and carotids. Low doses of supplements do not appear to cause any increase in vascular calcification in osteoporotic women.

Relationship between osteopenic syndrome and severity of coronary artery disease detected with coronary angiography and Gensini score in men

Background

Many studies have shown that evidence supporting the relationship between low bone mineral density (BMD) and coronary artery disease (CAD) has been increasing. There is a significant increase of myocardial infarction in men with low BMD.

Purpose

We aimed to detect the relationship between BMD and CAD in patients whose CAD was detected with coronary angiography, and its severity and prevalence was detected with Gensini score.

Methods

A total of 55 patients were selected who were found to have single or multiple infarctions through using coronary angiography in the cardiology clinic. The CAD severity was evaluated by calculating the Gensini score. These patients were divided into two groups: mild CAD and severe CAD groups. Femur bone mineral density (FBMD) was measured with dual energy X-ray absorptiometry. T score values were determined to be normal if the values were >−1.0 (n=22, 40%), and osteopenia–osteoporosis (osteopenic syndrome) if the T score values were ≤−1 (n=33, 60%).

Results

The FBMD of severe CAD according to the Gensini risk score was found to be significantly lower. FBMD values in patients decreased as their Gensini scores increased.

Conclusion

There was a significant relationship between CAD and osteopenic syndrome. FBMD level in men with severe CAD is significantly low when compared with patients who have mild CAD.

TBS Predict Coronary Artery Calcification in Adults

Purpose. This study analyzes the association between the bony microarchitecture score (trabecular bone score, TBS) and coronary artery calcification (CAC) in adults undergoing health exams. Materials and Methods. We retrospectively collected subjects (N = 81) who underwent coronary computed tomography and bone mineral density studies simultaneously. CAC was categorized to three levels (Group 0, G0, no CAC, score = 0, N = 45; Group 1, G1, moderate CAC, score = 1–100, N = 17; Group 2, G2, high CAC, score ≧ 101, N = 19). Multinomial logistic regression was used to study the association between TBS and CAC levels. Results. CAC is present in 44.4% of the population. Mean TBS ± SD was 1.399 ± 0.090. Per 1 SD increase in TBS, the unadjusted odds ratio (2.393) of moderate CAC compared with no CAC was significantly increased (95% CI, 1.219–4.696, p = 0.011). However, there has been no association of TBS with high CAC (OR: 1.026, 95% CI: 0.586–1.797, p = 0.928). These relationships also existed when individually adjusted for age, sex, and multiple other covariates. Conclusions. Higher TBS was related to moderate CAC, but not high CAC; a possible explanation may be that bone microarchitecture remodeling becomes more active when early coronary artery calcification occurs. However, further researches are needed to clarify this pathophysiology.

Abdominal aortic calcification: A reappraisal of epidemiological and pathophysiological data

In men and women, there is a significant association between the risk of cardiovascular event (myocardial infarction, stroke) and risk of major fragility fracture (hip, vertebra). Abdominal aortic calcification (AAC) can be assessed using semiquantitative scores on spine radiographs and spine scans obtained by DXA. Severe AAC is associated with higher risk of major cardiovascular event. Not only does severe AAC reflect poor cardiovascular health status, but also directly disturbs blood flow in the vascular system. Severe (but not mild or moderate) AAC is associated with lower bone mineral density (BMD), faster bone loss and higher risk of major fragility fracture. The fracture risk remains increased after adjustment for BMD and other potential risk factors. The association between severe AAC and fracture risk was found in both sexes, mainly in the follow-ups of less than 10years. Many factors contribute to initiation and progression of AAC: lifestyle, co-morbidities, inorganic ions, dyslipidemia, hormones, cytokines (e.g. inflammatory cytokines, RANKL), matrix vesicles, microRNAs, structural proteins (e.g. elastin), vitamin K-dependent proteins, and medications (e.g. vitamin K antagonists). Osteogenic transdifferentiation of vascular smooth muscle cells (VSMC) and circulating osteoprogenitors penetrating into vascular wall plays a major role in the AAC initiation and progression. Vitamin K-dependent proteins protect vascular tunica media against formation of calcified deposits (matrix GLA protein, GLA-rich protein) and against VSMC apoptosis (Gas6). Further studies are needed to investigate clinical utility of AAC for the assessment of fracture and cardiovascular risk at the individual level and develop new medications permitting to prevent AAC progression.

Abdominal aortic calcification and risk of fracture among older women - The SOF study

Data concerning the link between severity of abdominal aortic calcification (AAC) and fracture risk in postmenopausal women are discordant. This association may vary by skeletal site and duration of follow-up. Our aim was to assess the association between the AAC severity and fracture risk in older women over the short- and long term. This is a case-cohort study nested in a large multicenter prospective cohort study. The association between AAC and fracture was assessed using Odds Ratios (OR) and 95% confidence intervals (95%CI) for vertebral fractures and using Hazard Risks (HR) and 95%CI for non-vertebral and hip fractures. AAC severity was evaluated from lateral spine radiographs using Kauppila's semiquantitative score. Severe AAC (AAC score 5+) was associated with higher risk of vertebral fracture during 4 years of follow-up, after adjustment for confounders (age, BMI, walking, smoking, hip bone mineral density, prevalent vertebral fracture, systolic blood pressure, hormone replacement therapy) (OR=2.31, 95%CI: 1.24-4.30, p<0.01). In a similar model, severe AAC was associated with an increase in the hip fracture risk (HR=2.88, 95%CI: 1.00-8.36, p=0.05). AAC was not associated with the risk of any non-vertebral fracture. AAC was not associated with the fracture risk after 15 years of follow-up. In elderly women, severe AAC is associated with higher short-term risk of vertebral and hip fractures, but not with the long-term risk of these fractures. There is no association between AAC and risk of non-vertebral-non-hip fracture in older women. Our findings lend further support to the hypothesis that AAC and skeletal fragility are related.

Vascular calcification and fracture risk

Osteoporosis and cardiovascular diseases are public health problems. Fragility fractures are associated with high risk of cardiovascular event and patients with cardiovascular diseases have higher risk of fracture. Severe abdominal aortic calcification (AAC) is associated with higher cardiovascular mortality and morbidity. Severe AAC is associated with higher risk of fracture. In cross-sectional studies severe AAC was associated with greater prevalence, higher number and greater severity of vertebral fractures after adjustment for confounders including bone mineral density (BMD). Prospective studies confirm the association between baseline AAC severity and prospectively assessed fracture risk in both sexes. Data on the link between AAC and BMD are discordant. Age, smoking, hypertension, diabetes mellitus, and low grade systemic inflammation are possible risk factors of severe AAC and fracture risk. However, in clinical studies, the link between AAC and fracture was significant after adjustment for these factors. Data on the association between calcification in other vascular beds and BMD are limited and discordant.

QCT Volumetric Bone Mineral Density and Vascular and Valvular Calcification: The Framingham Study

There is increasing evidence that bone and vascular calcification share common pathogenesis. Little is known about potential links between bone and valvular calcification. The purpose of this study was to determine the association between spine bone mineral density (BMD) and vascular and valvular calcification. Participants included 1317 participants (689 women, 628 men) in the Framingham Offspring Study (mean age 60 years). Integral, trabecular, and cortical volumetric bone density (vBMD) and arterial and valvular calcification were measured from computed tomography (CT) scans and categorized by sex-specific quartiles (Q4 = high vBMD). Calcification of the coronary arteries (CAC), abdominal aorta (AAC), aortic valve (AVC), and mitral valve (MVC) were quantified using the Agatston Score (AS). Prevalence of any calcium (AS >0) was 69% for CAC, 81% for AAC, 39% for AVC, and 20% for MVC. In women, CAC increased with decreasing quartile of trabecular vBMD: adjusted mean CAC = 2.1 (Q4), 2.2 (Q3), 2.5 (Q2), 2.6 (Q1); trend p = 0.04. However, there was no inverse trend between CAC and trabecular vBMD in men: CAC = 4.3 (Q4), 4.3 (Q3), 4.2 (Q2), 4.3 (Q1); trend p = 0.92. AAC increased with decreasing quartile of trabecular vBMD in both women (AAC = 4.5 [Q4], 4.8 [Q3], 5.4 [Q2], 5.1 [Q1]; trend p = 0.01) and men (AAC = 5.5 [Q4], 5.8 [Q3], 5.9 [Q2], 6.2 [Q1]; trend p = 0.01). We observed no association between trabecular vBMD and AVC or MVC in women or men. Finally, cortical vBMD was unrelated to vascular calcification and valvular calcification in women and men. Women and men with low spine vBMD have greater severity of vascular calcification, particularly at the abdominal aorta. The inverse relation between AAC and spine vBMD in women and men may be attributable to shared etiology and may be an important link on which to focus treatment efforts that can target individuals at high risk of both fracture and cardiovascular events.

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.

The lipid theory in the pathogenesis of calcific aortic stenosis

AIMS

Biologically active phenomena, triggered by atherogenesis and inflammation, lead to aortic valve (AV) calcification. Lipids play an important role in activating the cell signaling leading to AV bone deposition. This review, based on evidence from animal and human studies, mainly focused on the involvement of lipids and atherogenic phenomena in the pathogenesis of calcific aortic stenosis (AS).

DATA SYNTHESIS

The role of elevated low density lipoproteins for the risk of both vascular atherosclerosis and AS has been elucidated. Lipid disorders act synergistically with other risk factors to increase prevalence of calcific AS. Atherosclerosis is also involved in the pathogenesis of bone demineralization, a typical hallmark of aging, which is associated with ectopic calcification at vascular and valvular levels. Animal studies have recently contributed to demonstrate that lipids play an important role in AS pathogenesis through the activation of molecular cell signalings, such as Wnt/Lrp5 and RANK/RANKL/Osteprotegerin, which induce the transition of valvular myofibroblasts toward an osteogenic phenotype with consequent valvular bone deposition. Although all these evidence strongly support the lipid theory in AS pathogenesis, lipids lowering therapies failed to demonstrate in controlled trials a significant efficacy to slow AS progression. Encouraging results from animal studies indicate that physical activity may counteract the biological processes inducing AV degeneration.

CONCLUSIONS

This review indicates a robust interplay between lipids, inflammation, and calcific AS. This new pathophysiological scenario of such an emerging valvular disease paves the way to the next challenge of cardiovascular research: "prevent and care aortic valve stenosis".