title: Heart failure is a clinically and densitometrically independent risk factor for osteoporotic fractures: population-based cohort study of 45,509 subjects.
abstract: OBJECTIVE
  The aim of the study was to determine whether heart failure is associated with an increased risk of major osteoporotic fractures that is independent of bone mineral density (BMD).
  
  
  METHODS
  We conducted a population-based cohort study in Manitoba, Canada, by linking a clinical registry of all adults 50 yr of age and older who underwent initial BMD testing from 1998-2009 with administrative databases. We collected osteoporosis risk factors, comorbidities, medications, and BMD results. Validated algorithms identified recent-onset heart failure before the BMD test and new fractures after. The main outcome was time to major osteoporotic fractures (i.e. clinical vertebrae, distal forearm, humerus, and hip), and multivariable proportional hazards models were used for analyses.
  
  
  RESULTS
  The cohort consisted of 45,509 adults; 1,841 (4%) had recent-onset heart failure. Subjects with heart failure were significantly (P < 0.001) older (74 vs. 66 yr) and had more previous fractures (21 vs. 13%) and lower total hip BMD [T-score, -1.3 (sd 1.3) vs. -0.9 (sd 1.2)] than those without. There were 2703 incident fractures over the 5-yr observation. Overall, 10% of heart failure subjects had incident major fractures compared with 5% of those without [unadjusted hazard ratio (HR), 2.45; 95% confidence interval (CI), 2.11-2.85]. Adjustment for osteoporosis risk factors, comorbidities, and medications attenuated but did not eliminate this association (HR, 1.33; 95% CI, 1.11-1.60), nor did further adjustment for total hip BMD (HR, 1.28; 95% CI, 1.06-1.53).
  
  
  CONCLUSIONS
  Heart failure is associated with a 30% increase in major fractures that is independent of traditional risk factors and BMD, and it also identifies a high-risk population that may benefit from increased screening and treatment for osteoporosis.
authors.affiliation: Department of Medicine, University of Alberta, 2F1.24 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112th Street, Edmonton, Alberta, Canada T6G 2B7. majumdar@ualberta.ca
authors.forename: Sumit R
authors.initials: SR
authors.lastname: Majumdar
authors.forename: Justin A
authors.initials: JA
authors.lastname: Ezekowitz
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Lix
authors.forename: William D
authors.initials: WD
authors.lastname: Leslie
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D015519:Bone Density; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D005260:Female; D006333:Heart Failure / Q000503:physiopathology*; D006801:Humans; D015994:Incidence; D008137:Longitudinal Studies; D008297:Male; D008350:Manitoba / Q000453:epidemiology; D008875:Middle Aged; D058866:Osteoporotic Fractures / Q000453:epidemiology / Q000209:etiology* / Q000503:physiopathology; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index