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Joint Bone Spine 77 (2010) 519–520

esearch lectures

hat links vascular calcifications to osteoporotic fractures?

awel Szulcnité Inserm 831, université de Lyon, hôpital Édouard-Herriot, Pavillon F, place d’Arsonval, 69437 Lyon, France

r t i c l e i n f o

rticle history:ccepted 22 July 2010

vailable online 20 October 2010

Epidemiological studies have documented an associationetween osteoporosis and cardiovascular disease in both males andemales [1]. In these studies, individuals with severe cardiovascularisease were at increased risk for osteoporosis and vice versa.

. Osteoporosis risk in patients with cardiovascular disease

In large epidemiological studies, heart failure was associatedith a higher risk of hip fracture [2,5]. The risk of hip fracture was

lso elevated in patients with coronary artery disease, hyperten-ion, or peripheral occlusive arterial disease [3,6]. The fracture riskncreased with the severity of the cardiovascular disease. The haz-rd ratio of hip fracture was 4.4 in patients with heart failure and.3 in those with coronary artery disease [3]. The relative risk ofip fracture was increased 2-fold in patients with one hospitaliza-ion for cardiovascular disease and 6-fold in patients with six or

ore admissions for cardiovascular disease, compared to patientsever admitted for cardiovascular disease [4]. These results may bescribable in part to the lower areal bone mineral density (aBMD)alues seen in patients with cardiovascular disease [7,8].

. Cardiovascular risk in patients with osteoporosis

The cardiovascular risk is increased in patients who have boneetabolism abnormalities (diminished aBMD, fast bone turnover,

nd/or vitamin D deficiency). Women with postmenopausal osteo-orosis may be at increased risk for severe cardiovascular eventsmyocardial infarction or stroke) [9]. In a prospective study, lowerortical bone area values were associated with an increased risk oforonary artery disease in females but not in males [10]. Patients

ith elevated bone resorption markers are at high risk for myocar-ial infarction and stroke [11,12]. A 10-year prospective studyound that males with low 25-hydroxy vitamin D levels weret increased risk for myocardial infarction [13]. These data from

E-mail address: pawel.szulc@inserm.fr.

297-319X/$ – see front matter © 2010 Société francaise de rhumatologie. Published by Eoi:10.1016/j.jbspin.2010.09.003

prospective studies establish that cardiovascular disease is asso-ciated with a high risk of fracture and that bone metabolismabnormalities are associated with a high risk of cardiovascularevents. Two clinical situations deserve special attention.

3. Stroke and osteoporotic fractures

In prospective studies, low aBMD values and rapid bone resorp-tion were associated with an elevated risk of stroke [9,11,14]. Strokeleads to decreased mobility and to bone nerve supply alterationsthat cause accelerated bone loss, most notably on the paralyzedside. In addition, stroke patients have higher risk of fall. These fac-tors combine to substantially increase in the fracture risk after astroke, particularly within the first year [3,15]. Therefore, the bonestatus of stroke patients should be evaluated in depth and antire-sorption medications given if appropriate.

4. Aortic calcifications and osteoporosis

Several studies found an increased risk of osteoporosis inpatients with aortic calcifications. Postmenopausal women withabdominal aortic calcifications had lower volumetric BMD (vBMD)values at the lumbar spine and higher prevalences of vertebral andhip fractures compared to controls [16]. In postmenopausal out-patients evaluated for osteoporosis, aortic calcifications were alsoassociated with higher prevalence of vertebral and hip fractures[17]. In a prospective study of postmenopausal women, extensiveaortic calcifications were associated with low hip and lumbar spineBMD values, accelerated bone loss at the hip, and an increasedrisk of hip fractures [18]. Similar results were obtained in cohortsthat included men and women or only men. In a cohort of elderlymen and women, the extent of aortic calcifications was negatively

associated with trabecular bone vBMD at the lumbar spine [19].Extensive aortic calcifications were associated with an increasedprevalence of vertebral fractures [20]. In a cohort of elderly menfollowed up for 10 years in the MINOS study, extensive aortic cal-cifications were associated with an elevated risk of osteoporotic

lsevier Masson SAS. All rights reserved.

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20 P. Szulc / Joint Bone

ractures [21]. Among older men in the Strambo study, those havingxtensive aortic calcifications detected using VFA software (Hologiciscovery A) were more likely to have moderate or severe verte-ral fractures (according to the Genant’s semiquantitative score foren) and multiple vertebral fractures [22–24].

. Methodological limitations of available studies – possibleechanisms

The data reviewed above were obtained using multivariateodels adjusted for confounders (age, body weight, life style,

o-morbidities, and treatments). However, these confounders var-ed across studies, complicating the identification of mechanismshat might link osteoporosis and cardiovascular disease. A numberf risk factors predispose to both conditions, including smoking,ypertension, and diabetes. The effects of cardiovascular drugs onone metabolism may be favourable (statins, thiazide diuretics,nd spironolactone) or unfavourable (furosemide and vitamin Kntagonists). The association between cardiovascular disease andracture risk is not fully explained by the lower aBMD values seenn cardiovascular patients. Muscle mass may be lost as a result ofhronic disease, diminished physical activity, and immobility dur-ng repeated hospitalizations. Cardiovascular patients may haveisturbances in cerebral blood flow related to the disease (e.g.rrhythmia) or drugs (e.g. orthostatic hypotension). Both muscleoss and altered cerebral blood flow may cause balance disorders,hereby increasing the risk of falls.

The links between cardiovascular disease and osteoporosis haveajor practical relevance. Many patients seen in everyday clinical

ractice have severe cardiovascular disease (heart failure, stroke,nd/or extensive aortic calcifications). These patients, who are eas-ly identified, should be viewed as having a high risk of osteoporoticractures that requires an in-depth bone status assessment. Thispproach may diminish osteoporosis-related morbidity and mor-ality rates while limiting healthcare costs.

onflict of interest statement

The author declares no conflict of interest.

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[2] Carbone L, Buzková P, Fink HA, et al. Hip fractures and heart failure: findingsfrom the Cardiovascular Health Study. Eur Heart J 2010;31:77–84.

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