Dr. Juan Carlos Vargas Decamps

Dr. Juan Carlos Vargas Decamps

VIII Congreso Nacional de Osteoporosis

VIII Congreso Nacional de Osteoporosis

Consejo PanameConsejo Panameño de Osteoporosis

ño de Osteoporosis

Hard Rock, PanamaHard Rock, Panama, 19 de Julio 2013

, 19 de Julio 2013

The osteoporosis/arterial calcification syndrome. Computed tomography demonstrating severe aortic calcification (arrow) in a 71- year-old man with an osteoporotic hip fracture (T score by DEXA:−3.1 at the spine and −2.6 at the proximal femur). His risk profile includes type 2 diabetes mellitus, arterial hypertension and a 60-packyear history of cigarette smoking

Riesgo CardiovascularEs la probabilidad que tiene un individuo de contraer una enfermedad cardiovascular en los próximos 10 años, basado en el número de factores de riesgo presentes en el mismo individuo (riesgo cualitativo) o teniendo en cuenta la magnitud de cada uno de ellos (riesgo cuantitativo)

Riesgo Cardiovascular y

Osteoporosis

•La enfermedad cardiovascular es la principal causa de muerte en el mundo occidental.

•90% de los casos puede ser explicado por la combinación de factores de riesgo

•El estudios Interheart avalaría la universalidad de los factores de riesgo

•Factores de riesgo donde podemos actuar ( dislipemia, tabaquismo, diabetes, obesidad, sme metabólico, dieta aterogenica, sedentarismo, estrés)

Tabaquismo HTA HDL < 40 Hx Fliar de EC prematura ( < 55 en hombres,

< 65 mujeres) Edad ( ≥45 en hombres/ ≥55 en mujeres)

HDL ≥60 ( resta un factor)

FRC

CT, HDL, LDL, TG a todos a partir de los 20ª; repetir cada 5ª si son normales ( NCEP III)

Hombres a los 40 y mujeres a los 50; antes si hay algun FRC, pedir CT, HDL, TG ( TWG)

Hombres a los 35 y mujeres a los 45; antes si hay algun FRC , pedir CT y HDL ( Task Force)

Rastreo

La osteoporosis y las enfermedades cardiovasculares (ECV) son de las principales preocupaciones de salud, así como responsables de una gran proporción de la morbilidad y la mortalidad entre los ancianos. La baja densidad mineral ósea (DMO), especialmente entre las mujeres posmenopáusicas, se asocia con una mayor mortalidad debido a las fracturas osteoporóticas , derrames cerebrales y enfermedades cardiovasculares La relación entre la osteoporosis y las enfermedades cardiovasculares en las mujeres ha sido reconocida por más de 30 años. Boukhris R, Becker KL “Calcification of the aorta and osteoporosis. A roentgenographic study”. JAMA , 1972: 219:1307–1311

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Riesgo Cardiovascular y

Osteoporosis

De hecho, se ha estimado que las mujeres con masa ósea en el cuartil más bajo (medida en la posmenopausia temprana) tienen el doble de riesgo de muerte por ECV que los del cuartil más altovon der Recke P, Hansen MA, Hassager C “The association between low bone mass at the menopause and cardiovascular mortality” . Am J Med 106:273–278, 1999.

Riesgo Cardiovascular y

Osteoporosis

Se especula que el mecanismo (s) que une la osteoporosis y la aterosclerosis actúa a través de factores de riesgo comunes1. Varios estudios epidemiológicos, han informado de la asociación entre perfil de lípidos y la DMO. Adami et al, “Relationship between lipids and bone mass in 2 cohorts of healthy women and men. Calcif Tissue Int 74:136–142, 2004.

2. El papel de la inflamación en la salud vascular y ósea también ha sido estudiado. Se cree que la aterosclerosis se asocia con una respuesta inflamatoria en curso, y la disminución de la DMO se ha visto en individuos con diferentes condiciones inflamatorias crónica que incluye enfermedades reumáticas, el lupus eritematoso, la enfermedad periodontal y la enfermedad inflamatoria intestinal. Schett G, “Inflammation-induced bone loss in the rheumatic diseases”. 2006.

Riesgo Cardiovascular y

Osteoporosis

Current data, described above, support the hypo thesis that a common metabolic pathway links osteoporosis and vascular calcification1. These two conditions develop gradually with progression of age, suggesting an inevitable and age dependent association2. A possible explanation for this connection is that vascular calcification affects bone metabolism by reducing blood flow or by limiting physical activity, leading in turn to bone loss3. Studies in rats demonstrated that bisphosphonates, at doses comparable to those that inhibit bone resorption, inhibit calcification of arteries and valves without affect ing serum levels of calcium or phosphate4.This effect is attributable to the protective action of BIS on the vessel wall; that is, by sensitizing macrophages to undergo apoptosis and by preventing the formation of foam cells via inhibition of LDL cholesterol uptake.5. In hypertensive rats, bisphosphonates reduced atherosclerosis and vascular SMC proliferation.

Clinical Implications

1. In a prospective clinical study, bisphosphonates inhibited the progression of plaques and abdominal aortic calcifica tion (AAC) score in women with osteoporosis whereas vascular calcification progressed in healthy women who did not receive treatment, suggesting a protective role for bisphosphonates against atherosclerosis.2. The MESA abdominal aortic calcium study, for example, showed that, after adjustment for age and risk factors, lower BMD is associated with greater coronary artery calcium score among women and with greater AAC score in both sexes3. In a 9 year study of 236 women, loss of bone mass during menopause was significantly greater in those with progression of aortic calcification than those without.4. In patients with renal failure undergoing haemodialysis, a significant negative correlation has been noted between the rate of bone turnover, as determined from bone biopsy samples, and cardiac calcification score

Clinical Implications

1.Low BMD in the hip seems to be a marker of advanced atherosclerosis in elderly women. 2. Carotid intima–media thickness (IMT), a well known cardiovascular risk factor, has been related to osteoporosis in many studies.3. Women with osteoporosis have impaired brachial arterial endothelial function compared with healthy individuals, as depicted by flow mediated vasodilatation after reactive hyperaemia.4. Arterial stiffness, measured by brachial– ankle pulse wave velocity, is associated with osteoporosis and coronary artery atherosclerosis, as determined by multidetector CT.5. A number of clinical studies have also demonstrated associations between vascular calcification and risk of osteoporotic fracture , and between osteoporosis and cardiovascular events 6. In the MINOS Study, which followed 781 men aged ≥50 years for 10 years, higher AAC scores were associated with a twofold to threefold increase in risk of fractures, regardless of BMD or history of falls.

Clinical Implications

1. In a group of 2,348 healthy postmenopausal women, degree of aortic calcification (as measured by use of CT) was significantly and age independently associated with bone loss; furthermore, women with calcification were five times more likely to experience a spine fracture and three times more likely to have a hip fracture than those without calcification.2. In a population based cohort study of 2,662 healthy post menopausal women, advanced aortic calcification was associated with lower BMD and a 2.3 fold increased risk of proximal femur fractures after 7.5 years of observa tion. An increased risk of fractures, especially vertebral fractures, and the rate of BMD decline have also been positively associated with progression of aortic calcifica tion.3. Women with osteoporosis have a 4.8 fold higher risk of stroke compared with women with normal BMD.4 In another study of the Framingham cohort, women with lower BMD had greater progression of AAC over a 25 year follow up period

Clinical Implications

A population based cohort study of 16,294 patients showed that heart failure is associated with factors that contribute to accelerated bone loss and an increased risk of fractures, in particular a fourfold increase of hip fracture.

Clinical Implications

Osteoporotic fractures and acute cardiovascular events remain the predominant contributors to morbidity and mortality among the elderly. Postmenopausal women with osteoporosis are at increased risk for acute cardiovascular events independent of their age and cardiovascular risk profile, and the increase in risk is proportional to the severity of osteoporosis at the time of the diagnosis. Bone mineral density (BMD) at the hip is inversely correlated with the severity of aorta calcification (AC) and hence low hip BMD can be a surrogate marker of the atherosclerotic burden in elderly women. Advanced AC is associated with increased risk of osteoporotic fractures. Collectively, numerous epidemiological observations document an overlap between the pathogenesis of the two diseases.Conclusions:Conclusion The contribution of serum lipids to the modulators of BMD seem to be via promotion of atherosclerosis, which in turn can affect bone metabolism locally, especially when skeletal sites supplied by end-arteries are concerned.

Using a population-based cohort of older men and women, we tested the hypothesis that the progression of vascular calcification of the abdominal aorta should be greatest in those individuals with the greatest amount of bone loss. From the original population-based Framingham Heart Study cohort, 364 women and 190 men had lateral lumbar spine and hand radiographs performed between 1966 and 1970 and repeated between 1992 and 1993. The lateral lumbar films were read for the presence of aortic calcification using a semiquantitative method, and the hand films were read for second metacarpal relative cortical area (MCA). Using multivariate regression techniques, the 25-year progression of the abdominal aortic calcification index was examined in relation to the change in the MCA, while adjusting for recognized risk factors for atheroscle rotic cardiovascular disease.

During the 25 years of follow up, the MCA decreased by 22.4% in women (from 79.6 ± 7.8 (SD) to 61.8 ± 10.3) and by 13.3% in men (from 80.6 ± 6.9 to 69.9 ± 8.3). The aortic calcification score increased over eightfold in women (from 1.2 ± 2.7 (SD) to 9.9 ± 6.7)and six fold in men (from 1.6 ± 2.8 to 9.6 ± 6.3). There was a significant association between percent change in MCA and change in aortic calcification index (P = 0.01) in women after controlling for all potential confounders. When we looked at the association between percent change in metacarpal cortical area and change in aortic cal cification index we observed that for each percent decline in metacarpal cortical area, the aortic calcification index in creased 7.3%. (P= 0.01) in women . No association was observed in men (P= 0.50), including the 50% of men with the greatest bone loss.

This is the first longitudinal study to show that women with the greatest magnitude of bone loss also demonstrate the most severe progression of abdominal aortic calcification, suggesting that the two processes may be related,

The associations of volumetric and areal bone mineral density (BMD) measures with incident cardiovascular disease (CVD) were studied in a biracial cohort of 2,310 older adults. BMD measures were inversely related to CVD in women and white men, independent of age and shared risk factors for osteoporosis and CVD.A decrease in femoral neck BMD by 1 SD below the mean was related to a 24% increased risk for incident CVD among the women as a group.In summary, we observed a longitudinal inverse association between BMD measures and incident CVD in older women and white men with no prior history of cardiovas- cular disease. These findings provide further support for a relationship between osteoporosis and CVD that is inde- pendent of age and shared risk factors.

In Black women , a 1 SD decrease in BMD of the total hip, femoral neck, and trochanter was related to an increased CVD risk in the order of 36%, 44%, and 34%, respectively.

The association between bone mineral density (BMD) and myocardial infarction (MI) was investigated in 6,872 men and women. For both men and women, lower BMD in the femoral neck and hip was associated with increased risk of MI largely independent of smoking, hypertension, hypertriglyceridemia, and diabetes.Lower BMD of the femoral neck and total hip was associated with increased risk of MI for both women [hazard ratio (HR) =1.33, 95% confidence interval (CI) 1.08–1.66 per SD decrease in FN BMD and men (HR = 1.74, 95% CI 1.34–2.28 per SD decrease in total hip BMD.

Conclusion Lower BMD was associated with an increase in MI risk for both men and women. Women had consistently lower HRs compared to men in all models. Adjusting for smoking, hypertension, hypertriglyceridemia, and diabetes did not distinctively weaken these associations

From February 2006 to January 2007, 17,033 women aged 50 years (mean 71.8, range 50–106) were recruited by 1,248 primary care practitioners and interviewed by trained nurses. For each woman, 10-year probability of a future major osteoporotic fracture was estimated using the World Health Organization Fracture Risk Assessment Tool (FRAX). The study showed that the 10-year probability of a major osteoporotic fracture was higher for 6,219 CVD women compared to 10,814 non CVD women after adjustment for age, BMI, current smoking, and alcohol useWith regard to high risk of fracture (i.e., 10-year probability 20%), the adjusted odds ratio for CVD was 1.23 (95% CI 1.13–1.35, P \ 0.001)

What are cardiovascular diseases?Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and they include:coronary heart disease – disease of the blood vessels supplying the heart muscle;cerebrovascular disease - disease of the blood vessels supplying the brain;peripheral arterial disease – disease of blood vessels supplying the arms and legs;rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;congenital heart disease - malformations of heart structure existing at birth;deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.Heart attacks and strokes are usually acute events and are mainly caused by a blockage that prevents blood from flowing to the heart or brain. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels that supply the heart or brain. Strokes can also be caused by bleeding from a blood vessel in the brain or from blood clots.

What are the risk factors for cardiovascular disease?The most important behavioural risk factors of heart disease and stroke are unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. Behavioural risk factors are responsible for about 80% of coronary heart disease and cerebrovascular disease .The effects of unhealthy diet and physical inactivity may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These “intermediate risks factors” can be measured in primary care facilities and indicate an increased risk of developing a heart attack, stroke, heart failure and other complications.Cessation of tobacco use, reduction of salt in the diet, consuming fruits and vegetables, regular physical activity and avoiding harmful use of alcohol have been shown to reduce the risk of cardiovascular disease.

What are the risk factors for cardiovascular disease?

The cardiovascular risk can also be reduced by preventing or treating hypertension, diabetes and raised blood lipids.Policies that create conducive environments for making healthy choices affordable and available are essential for motivating people to adopt and sustain healthy behavior.There are also a number of underlying determinants of CVDs, or "the causes of the causes". These are a reflection of the major forces driving social, economic and cultural change – globalization, urbanization, and population ageing. Other determinants of CVDs include poverty, stress and hereditary factors.