Heart Failure Preliminarily Linked to Bone Fractures

October 21, 2008 — Patients who are newly diagnosed with heart failure (HF) in the emergency department are at least four times as likely to suffer serious bone fractures over the next year compared with patients presenting to the emergency department with other cardiovascular (CV) disorders, suggests a study based on hospital data from >16,000 patients [1].

“The main public-health message is that in addition to the risks heart-failure patients already have, here is another burden they could potentially face,” primary author Dr Justin A Ezekowitz (University of Alberta, Edmonton) told heartwire. Providers, he said, should see heart failure “as another red flag that the person needs to be screened [for osteoporosis] and treated appropriately.”

Ezekowitz cautioned, however, that the analysis merely shows an association between heart failure and fractures, one that hasn’t been made before, and so doesn’t demonstrate cause and effect. The finding has been met with skepticism in some quarters, he said, “and I think that’s good, because it will drive research to better understand it.”

The analysis, based on emergency-department admissions of 2041 patients aged ? 65 with a new heart-failure diagnosis and 14,253 with other CV conditions, with first author Dr Sean van Diepen (University of Alberta), is published online October 20, 2008, in Circulation and is expected to be in the journal’s November 4 issue.

Importantly, patients with osteoporosis or other conditions known to affect fracture or fall risk were excluded.

Rates of hospitalization for any orthopedic bone fracture within a year of the index emergency-department visit were 4.6% for the HF patients and only 1% for the non-HF group. Hospitalization rates for fracture of the hip were 1.3% and 0.1%, respectively. When age, sex, and medications that could influence bone density were controlled for, heart-failure patients had four times the risk of any fracture and more than six times the risk of hip fracture compared with non-HF patients.

Adjusteda odds ratio (95% CI), bone-fracture hospitalizations within a year of ED presentation for HF compared with other CV diagnosesbEnd point OR (95% CI)
Hospitalization for any bone fracture 4.0 (3.0 – 5.2)
Hospitalization for hip fracture 6.3 (3.4 – 11.8)
a. Adjusted for age, sex, medications, and comorbidities (hypertension, diabetes, atrial fibrillation, history of myocardial infarction (MI), cerebrovascular disease, other peripheral vascular disease, renal disease, cataracts, and chronic obstructive pulmonary disease).
b. Acute myocardial infarction (MI), arrhythmias, chest pain, stable angina, or unstable angina.

The findings were changed little in an analysis that excluded patients who were on bisphosphonates at the time of the index hospitalization.

Exactly how heart failure might promote bone fractures is unknown, according to Ezekowitz, but he pointed to animal studies conducted in the past decade suggesting that long-term heart failure may cause a secondary hyperparathyroidism. “That, by itself, can lead to bone loss,” he observed. “Hence, patients with heart failure may be more susceptible to hip fracture or any orthopedic fracture, much like they’re more susceptible to anemia or acute infections.”


van Diepen S, Majumdar SR, Bakal JA, et al. Heart failure is a risk factor for orthopedic fracture. A population-based analysis of 16 294 patients. Circulation. 2008; DOI: 10.1161/CIRCULATIONAHA.108.784009. Available at: http://circ.ahajournals.org.

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