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Commentary

Does Heart Failure Relate to Bone Fractures?


August 01, 2017

Aging results in the accumulation over time of changes in physical, psychological and social changes. Two disorders of aging are heart failure and osteoporosis. Heart failure is a progressive debilitating disorder with a prevalence rate of 5.7 million and a high rate of morbidity and mortality1. Osteoporosis and low bone mineral density affect an estimated 53 million people, imparting high morbidity and mortality.2-3 Since heart failure and osteoporosis are related by advancing age the question could be asked: Is a link between the two?

A group of scientists from the Albert Einstein College of Medicine in New York examined this question. Using dual energy x-ray absorptiometry (DXA) in 1250 subjects ≥ 65 years old (59% women; 19% black)  who had previously been enrolled in the Cardiovascular Health Study an expert panel identified incident heart failure events over a median follow-up of 10.5 years.4 The study identified 35.4% (55% women) who developed heart failure during follow-up.  Women did not have hip or femoral neck bone mineral density associated with heart failure. In contrast, men showed a significant interaction between bone mineral density and race (total hip, P=001; femoral neck, P=0.009).  Lower bone mineral density was associated with higher heart failure risk in non-black men, but a lower risk of heart failure in black men.  These findings are limited by a small cohort who attended the 1994-1995 visits and were considered to be healthier by being able to undergo the DXA scan than the participants who did not.

We can now add osteoporosis to a growing list of comorbid conditions associated with the heart failure syndrome. This includes but is not limited to, renal and hepatic insufficiency, diabetes, sleep apnea, anemia, gout, thyroid disease, Parkinson’s disease, malnutrition, and peptic ulcer disease. All of these may result from low blood flow to various organ systems. Osteoporosis may result from the same low blood flow state, but also may be related to shared risk factors of both diseases, namely, advancing age, sedentary lifestyle, and kidney disease.

The important findings from this study are that in women, an association between total hip and femoral neck bone mineral density and heart failure was not found. In contrast, men have a significant association, especially shown in non-black men. Therefore, screening for bone mineral density should be aimed at white men for earlier detection and prevention of heart failure. Further studies are, of course needed to further elucidate sex- and race-based differences.

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy.

References:

1. Yancy CW, Jessup M, Bozkurt B, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.  Circulation 2016;134:DOI: 10.1161/CIR.0000000000000435.

2. Screening for osteoporosis: U.S. preventative services task force recommendation statement. Ann Intern Med 2011;154:356-64.

3. Office of the Surgeon General (US). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: Office of the Surgeon General (US); 2004. Available at: bcbu,nkm.ih.gov/books/NBK45513/. Accessed 07 25 2017.

4. Fohtung RB, Brown DL, Koh WJ, et al. Bone mineral density and risk of heart failure in older adults: the cardiovascular health study. J Am Heart Assoc. 2017; DOI: 10.1161/JAHA.116.004344.

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