Middle East Fertility Society Journal (2012) 17, 181–186
Middle East Fertility Society
Middle East Fertility Society Journal www.mefsjournal.org www.sciencedirect.com
ORIGINAL ARTICLE
Relation between postmenopausal osteoporosis and coronary and peripheral arterial disease Mahmoud Shokry Ashraf A. Essa e
a,*
, Ayman A. Hassan b, Ghada Ibrahim c, Hisham M. Habib d,
a
Department of Obstetrics and Gynecology, Assiut University, Egypt Department of Vascular Surgery, Ain Shams University, Egypt c Department of Cardiology, Zagazig University, Egypt d Department of Rheumatology, Mansoura University, Egypt e Department of Radiology, Bani Sweef University, Egypt b
Received 23 January 2012; accepted 29 May 2012 Available online 29 June 2012
KEYWORDS Postmenopausal; Osteoporosis; Coronary artery disease; Peripheral arterial disease
Abstract Objectives: To study the relation between coronary artery disease (CAD) and peripheral arterial disease (PAD) with osteoporosis in postmenopausal women. Patients and methods: A 100 postmenopausal women were studied for evidence of osteoporosis by measurement of lumbar spine and femoral neck bone mineral density (BMD) and calculation of T score. From these cases; two groups were selected, group I included 30 cases with osteoporosis and group II included a matching 30 cases without osteoporosis or osteopenia as control group. Both groups were studied for prevalence of CAD using noninvasive tests including ECG, echocardiography and CT angiography, and prevalence of PAD using noninvasive tests including ankle brachial index (ABI) and color duplex study (CDS) of lower limb arteries. Results: Using CT angiogram, 17 cases (56.7%) had CAD in group I versus 6 cases (20%) in group II (p = 0.003). Prevalence of three vessel disease was significantly higher in group I than in group II (23.3% vs 3.3%, p = 0.022). In group I, there was a significant positive correlation between patients’ age with prevalence and severity of CAD in group I; and a significant negative
* Corresponding author. Tel.: +20 114 116 3619. E-mail address:
[email protected] (M. Shokry). Peer review under responsibility of Middle East Fertility Society.
Production and hosting by Elsevier 1110-5690 2012 Middle East Fertility Society. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.mefs.2012.05.003
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M. Shokry et al. correlation between T score with prevalence and severity of CAD. Presence of significant stenosis or occlusion in CDS of lower limb arteries was found in 6 cases (20%) in group I versus one case (3.3%) in group II (p = 0.044). Conclusion: Because of the increased prevalence of CAD and PAD in postmenopausal women with osteoporosis the severity of CAD and PAD in osteoporotic postmenopausal women is positively correlated to the severity of osteoporosis. Thus, in osteoporotic postmenopausal women, cardiovascular status evaluation should be done in order to identify candidate patients for preventive and therapeutic cardiovascular interventions. 2012 Middle East Fertility Society. Production and hosting by Elsevier B.V. All rights reserved.
1. Introduction Osteoporosis might develop in 1) consistent with current World Health Organization criteria. Participants with a vertebral fracture at baseline (Fig. 1A) were considered as having osteoporosis regardless of their BMD T score. Prevalent fractures were further characterized based on semi quantitative assessment (0, no fractures; 1, mild fracture (20–25% compression); 2, moderate fracture (25–40% compression); 3, severe fracture (>40% compression)) (10). From the 100 postmenopausal women who were scanned for bone density; using the T scorer value our patients categorized for: 44 case with T score > 1 fi (normal), 26 case with T score from 1 to 2.4 fi (osteopenia) and 30 cases of T score < 2.5 fi (osteoporosis) (Fig. 1B). Two groups of patients were chosen, Group I included 30 cases with osteoporosis and group II included a matching 30 normal cases (without osteoporosis or osteopenia) matched in age, prevalence of diabetes mellitus, hypertension, obesity (body mass index > 30 kg/m2), smoking, dyslipidemia and the use of hormone replacement therapy) as control group. Both groups were further investigated for the presence of CAD and PAD including. 3.1. Assessment for the presence of CAD using noninvasive tests
3. Patients and methods This study included 100 postmenopausal women with or without osteoporosis who were studied over the period between January 2009 and September 2011, in tertiary referral hospital in the eastern area of Saudi Arabia. Clinical evaluation including demographic characteristics and risk factors included age, body mass index, systolic and diastolic blood pressure, smoking habits, and previously diagnosed
3.1.1. Twelve lead resting surface ECG Twelve lead resting surface ECG for signs of ischemia. 3.1.2. Complete transthoracic echocardiographic study Complete transthoracic echocardiographic study using hp SONOS 5500 machine with 2.5 MHz transducer: including 2-D and M-mode measurements of the LV dimensions, wall thickness, LV systolic and diastolic functions and wall motion abnormalities. All the measurements were done according to
Postmenopausal osteoporosis and coronary and peripheral arterial disease
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Figure 1 This figure shows data of case number 9 in group (1); (A) shows CT with fracture of the L2 vertebrae, (B); shows DXA of femoral neck: the T score was 4.7. With (C) and (D) show the CT angiography of the same patient with 2VD, (E) color duplex study of right lower limb arteries shows near total occlusion of superficial femoral artery.
the recommendations of the American society of echocardiography (11). 3.1.3. Coronary CT angiography Coronary CT angiography using Philips Brilliance 64 multislice CT machine. Images reconstructed with a slice thickness of 0.75 mm, 50% overlap between images (i.e., 0.4-mm increment), and a pixel matrix of 512 · 512. However in obese patients (body mass index > 30 kg/m2), an increase in slice
thickness to 1 mm was done to reduce image noise (12). Optimal reconstruction window in which the coronary arteries visualized nearly free of motion artifacts starts in mid-diastole (60–70% of the R–R interval) (13). Both axial images and multiplanar reformatted (MPR) images, for visualization of the coronary arteries in multiple orientations; orthogonal and perpendicular to the long axis of the vessel, are used for detecting the presence of significant coronary artery stenosis. Once a suggestive location with
184 luminal narrowing in the presence of calcified or uncalcified plaques has been identified on axial images, two long axis views of this location are created with 3–5 mm thin-slab maximum-intensity-projection (MIP) images, which project the information of 4–7 original slices onto 1 image. A comparison of the lumen at this narrowing with proximal and distal references enables a qualitative assessment of the degree of luminal narrowing. 3.2. Assessment for the presence of PAD using noninvasive tests 3.2.1. Ankle brachial index (ABI) ABI is a simple noninvasive method to assess the presence and extent of atherosclerosis in the lower leg. Participants were rested in the supine position for 5 min, after which a handheld Doppler flowmeter attached to a mercury sphygmomanometer cuff was used to measure the blood pressure in each arm (brachial artery) and leg (posterior tibial artery). Systolic blood pressure was recorded once for each arm and twice for each leg. The ABI was calculated for each leg by dividing the higher systolic pressure of the leg by the systolic blood pressure in the arm. The lower of these two ABIs was used to define participants with PAD. The sensitivity and specificity of an ABI > 0.9 for PAD are 80% and 95%, respectively (14). 3.2.2. Color duplex study (CDS) of lower limb arteries Color duplex study (CDS) of lower limb arteries using multibeam 3D ultrasound system (Sono Ace 9900 Prime, Medison, Korea) for detection of significant stenoses (>50% of luminal diameter) or occlusions was performed. 3.3. Statistical analyses Descriptive analysis expressed as mean (±SD) or percentages, was compared using the student t test or chi-square test as appropriate. Analysis of covariance was expressed in odds ratio(r) with statistical significance defined as p < 0.05. SPSS (SPSS Inc., SPSS Base 15 for Windows user’s Guide) and SAS (SAS Institute user’s Guide, version 8.2) were used for analysis. 4. Results This study included 100 postmenopausal women 45–75 years old for whom measurement of BMD and calculation of T scores were done in the lumbar spine and femoral neck. From these cases; two groups of patients were chosen, Group I included 30 cases with osteoporosis and group II included a matching 30 normal cases (without osteoporosis or osteopenia) as controls. Both the study and control groups were matched as regards the age, DM, HTN, Obesity, dyslipidemia and the use of hormone replacement therapy with no significant difference (Table 1). CT angiography found 17 cases (56.7%) with CAD in group I (patients with osteoporosis) versus 6 cases (20%) in group II (p = 0.003). Although there was no significant difference between both groups in the prevalence of single or two vessels disease (SVD & 2VD), there were significantly higher prevalence of three vessel disease (3VD) in group I than in group II (p = 0.022) as shown in Table 2.
M. Shokry et al. There was a highly significant negative correlation between the women’s age with the T score (r = 0.79, p < 0.001), and there was a significant positive correlation between the age (Table 3) with prevalence and severity of CAD (r = 0.35, p < 0.05) (r = 0.43, p < 0.005), respectively. On the other hand, there was a highly significant negative correlation between the T score with prevalence and severity of CAD (r = 0.53, p< 0.05) (r = 0.59, p < 0.005) respectively (Table 3). An ABI < 0.9 denoting the presence of PAD (12) was detected in 9 cases (30%) in group I versus 2 cases (6%) in group II which was statistically significant (p = 0.019). The presence of significant stenoses or occlusions in CDS (Fig. 1E) of lower limb arteries was detected in 6 cases (20%) in group I versus one case (3.3%) in group II which was also statistically significant (p = 0.044) as shown in Table 4. 5. Discussion Coronary heart disease, often presents atypically in women, making clinical recognition difficult (15,16). More than twothirds of women who suddenly die of cardiovascular events had no prior sign of the disease (17). The main question to be answered in this study was: is osteoporosis associated with an increased prevalence of CAD and PAD in postmenopausal women and what are the related risk factors. In the present study, there was no significant difference between both groups in the age, incidence of DM, HTN, Obesity, dyslipidemia and the use of hormone replacement therapy. This was intended in our study to neutralize the effect of the risk factors on our study population. Also, in the studied 100 postmenopausal women, the T score was > 1 (normal) in 44 cases (44%), was from 1 to 2.4 (Osteopenia) in 26 cases (26%) and < 2.4 (Osteoporosis) in 30 cases (30%). These results are in disagreement with Ness and Aronow (18) who found that 66% to have normal T score, 18% to have osteopenia and 16% to have osteoporosis. These differences could be explained by the fewer number of cases in our study (100 vs 1000 cases in the other study) and the higher incidence of hormone replacement therapy in their community. CT angiography diagnosed 17 cases (56.7%) with CAD in group I versus 6 cases (20%) in the control group (p = 0.003). These results are in agreement with Ness and Aronow (18) who found the incidence of CAD in patients with osteoporosis to be about 60% and in those with osteopenia to be 35% while it was 22% in postmenopausal women with normal T score. Our study showed no statistically significant difference between both groups in the prevalence of SVD or 2VD, while, the prevalence of severe CAD (3VD) was significantly higher in group I than in group II. This means the increase in severity of CAD (assessed as the number of vessels affected from mild in SVD, to moderate in 2VD to severe in 3VD). These results are in agreement with Rhee et al. (19) and Tanko et al. (20) who stated that; Postmenopausal women with osteoporosis are at an increased risk for cardiovascular events that is proportional to the severity of osteoporosis at the time of the diagnosis. In the present study, there was a significant positive correlation between the age with prevalence and severity of CAD. This means that; with increasing in postmenopausal women’s age, the prevalence of osteoporosis increases and the T score
Postmenopausal osteoporosis and coronary and peripheral arterial disease Table 1
Differences in risk factors between both study groups.
Age (years) (mean ± SD) Menopause Duration (years) (mean ± SD) Diabetes (N&%) Hypertension (N&%) Obesity (N&%) Smoking (N&%) Dyslipidemia (N&%) Hormone replacement therapy (N&%)
Table 2
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Group I (osteoporosis) (N = 30)
Group II (controls) (N = 30)
p-value
63.9 ± 4.9 16.4 ± 4.9 11 (36.7%) 8 (26.7%) 9 (30%) 2 (6.7%) 12 (40%) 3 (10%)
62.3 ± 3.6 14.5 ± 3.9 10 (33.3%) 9 (30%) 7 (23.3%) 3 (10%) 13 (43.3%) 4 (13.3%)
0.463 0.071 0.786 0.774 0.559 0.640 0.793 0.687
The CT coronary angiography data of both groups.
CAD total SVD 2VD 3VD
Group I (osteoporosis) (N = 30)
Group II (controls) (N = 30))
p-value
17 (56.7%) 4 (13.3%) 6 (20%) 7 (23.3%)
6 (20%) 10 (33.3%) 2 (6.7%) 1 (3.3%)
0.003 0.067 0.129 0.022
CAD = coronary artery disease. SVD = single vessel disease. 2VD = two vessel disease. 3VD = three vessel disease.
Table 3 Correlation between age and T score with prevalence and severity of CAD. Variables
Age
CAD CAD severity
T score
r
p
r
p
0.35 0.43
