Nancy A. Melville

September 20, 2011

September 20, 2011 (San Diego, California) — Heart failure puts patients at a nearly 30% greater risk for major osteoporotic fractures than those without the condition, according to research presented here at the American Society for Bone and Mineral Research (ASBMR) 2011 Annual Meeting.

Researchers in Canada who previously reported an independent link between heart failure and fractures sought to further investigate bone mineral density (BMD) data on such patients.

They conducted a population-based study in Manitoba, Canada, of 45,509 adults who underwent initial BMD testing between 1998 and 2007. Participants were followed through 2009.

Of the total, 1841 (4%) participants had a diagnosis of heart failure. There were 2703 incident fractures over a median of 5 years in the entire cohort; as many as 10% of persons with heart failure sustained incident major fractures compared with 5% of those without heart failure (age-sex adjusted hazard ratio [HR], 1.64; 95% confidence interval [CI], 1.45 - 1.86).

Those with heart failure had higher rates of risk factors typically associated with fractures. They were older than those without heart failure (mean age, 74 years vs 66 years; P < .001), were more likely to be male (17% vs 7%), had more previous major osteoporotic fractures (21% vs 13%), and had lower total hip BMD (T-score, -1.3 ± 1.3 vs -0.9 ± 1.2; P < .001).

But adjustments for osteoporosis risk factors, comorbid conditions, and medications that might increase risk only attenuated and did not eliminate this association (adjusted HR, 1.33; 95% CI, 1.11 - 1.60), as was also seen with further adjustment for total-hip BMD (adjusted HR, 1.28; 95% CI, 1.06 - 1.53).

That finding was a surprise, according to lead author Sumit Majumdar, MD, an associate professor in the Division of General Internal Medicine at the University of Alberta, Canada.

"The main 'alternate' explanation for prior findings, including our own, was shared risk factors," Dr. Majumdar said. "But if you account for these — age, female sex, diabetes, etc., and the fact that most medications used to treat heart failure can affect fracture risk — especially Lasix, because it both lowers bone mineral density and predisposes to falls, adequate control of these factors would eliminate the association between heart failure and fracture if that was all there was to the story."

But with all else equal, BMD was still lower in patients with heart failure who presented for their first BMD test, Dr. Majumdar said.

"After accounting for shared risk factors, medications and BMD, there was still an increased risk."

Dr. Majumdar suggested that a reason for the lack of recognition of the risk for fracture and underdiagnosis is simply that clinicians aren't on the lookout for it.

"The focus for heart failure patients is always heart failure, and these patients are also underdiagnosed and undertreated for several other conditions because of the focus on heart failure," he said.

Patients may also be less likely to get mammograms, colon cancer screening, and other measures because of the single diagnosis, rather than the whole patient approach, he said.

"Patients will go, for instance, to heart failure clinics that do not deal with non-cardiac issues, but that often means family doctors are out of the loop."

Suzanne M. Cadarette, PhD, an assistant professor at the University of Toronto, Canada, and co-moderator for the session, noted that the study did have some limitations, including the patients' physical condition.

"As pointed out by the author, a limitation of the study is that some data is missing on potentially important confounders such as frailty," she said. "So I would say that more research is needed."

Responding to a question following the session, Dr. Majumdar noted that as many as 35% of patients were taking beta-blockers, but no association with the drugs were found.

"We specifically looked at the beta-blocker subgroup and we didn't find any relationship between beta-blockers and risk of fracture," he said.

Another audience member inquired about the potential role of osteoporosis treatment on heart failure. "We did look at that as well and we didn't see any association in terms of mortality, but we did see a trend toward a slight reduction in fracture," Dr. Majumdar said.

The bottom line for clinicians, Dr. Majumdar said, is that "heart failure should make you think about fracture."

"Patients with heart failure are less likely to tolerate or survive a major fracture, such as hip, so prevention is key."

The study was honored by the ASMBR as the meeting's "Highest-Rated Clinical Abstract." The authors have disclosed no relevant financial relationships.

American Society for Bone and Mineral Research (ASBMR) 2011 Annual Meeting; Abstract #1031. Presented September 17, 2011.

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