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Association between vertebral bone mineral density, myocardial perfusion, and long-term cardiovascular outcomes: A sex-specific analysis

  • Original Article
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Journal of Nuclear Cardiology Aims and scope

Abstract

Background

Sexual dimorphism in the manifestation of coronary artery disease (CAD) has unleashed a call to reconsider cardiovascular risk assessment. Alterations of bone mineral density (BMD) have been associated with congestive heart failure and appear to be modified by sex. However, the sex-specific association between BMD, myocardial perfusion, and cardiovascular outcomes is currently unknown.

Methods

A total number of 491 patients (65.9 ± 10.7 years, 32.4% women) underwent 13N-ammonia positron emission tomography/computed tomography for evaluation of CAD, and were tracked for major adverse cardiac events (MACEs).

Results

Event-free survival (median follow-up time of 4.3 ± 2.0 years) was significantly reduced in patients with low (≤ 100 Hounsfield units) compared to those with higher BMD (log-rank P = .037). Accordingly, reduced BMD was chosen as significant predictor of MACE in a fully adjusted proportional hazards regression model (P = .015). Further, a first-order interaction term consisting of sex and BMD was statistically significant (P = .007). BMD was significantly lower in patients with abnormal myocardial perfusion or impaired left ventricular ejection fraction (P < .05). This difference, however, was noticed in men, but not in women.

Conclusions

The association between low BMD and cardiovascular disease is sex dependent. Our data suggest that quantification of BMD during myocardial perfusion imaging for evaluation of CAD may be particularly useful in men.

Spanish Abstract

Antecedentes

El dimorfismo sexual en la enfermedad arterial coronaria (EAC) hace reconsiderar la evaluación del riesgo cardiovascular. Las alteraciones de la densidad mineral ósea (DMO) se han asociado con la presencia de falla cardíaca congestiva y parecen estar influenciadas por el sexo. Sin embargo, actualmente se desconoce la asociación específica por sexo entre la DMO, la perfusión miocárdica y el impacto en los resultados cardiovasculares.

Métodos

Un total de 491 pacientes (con edad de 65.9 ± 10.7 años y 32.4% mujeres) se sometieron a estudio de tomografía por emisión de positrones/tomografía computarizada (PET/TC) con 13N-amoníaco, para la evaluación de EAC y se dio seguimiento de eventos cardíacos adversos mayores (MACE).

Resultados

en un tiempo de seguimiento de 4.3 ± 2.0 años, la supervivencia libre de eventos se redujo significativamente en pacientes con DMO baja (≤ 100 Unidades Hounsfield) en comparación a aquellos con mayor DMO (P = .037). En consecuencia, se seleccionó la reducción de la DMO como predictor significativo de MACE en un modelo de regresión de riesgos proporcionales totalmente ajustado (P = .015). Además, un término de interacción de primer orden que consistía en sexo y DMO fue estadísticamente significativo (P = .007). La DMO fue significativamente menor en pacientes con perfusión miocárdica anormal o fracción de eyección del ventrículo izquierdo reducida (P < .05). Esta diferencia, sin embargo, se notó en hombres, pero no en mujeres.

Conclusiones

la asociación entre DMO reducida y la enfermedad cardiovascular depende del sexo. Nuestros datos sugieren que la cuantificación de la DMO durante la imagen de perfusión miocárdica para la evaluación de la EAC puede ser particularmente útil en los hombres.

Chinese Abstract

背景

冠状动脉疾病 (CAD) 表现中的性别差异, 促使人们重新考虑心血管风险的评估。骨矿物质密度 (BMD) 的改变与充血性心力衰竭有关并且存在性别差异。然而, BMD, 心肌灌注和心血管终点之间的性别特异性目前尚不清楚。

方法

共计 491 例患者 (65.9 ± 10.7 岁, 32.4% 女性) 接受 13N-氨正电子发射断层扫描/计算机断层扫描 (PET/CT) 来评估 CAD, 并随访记录主要不良心脏事件 (MACE)。

结果

与 BMD 较高的患者 (对数秩检验 P = .037) 相比, 低 BMD 患者 (≤ 100 Hounsfield 单位) 的无事件生存率 (随访时间为 4.3 ± 2.0 年) 显著降低。因此, 在完全调整的比例风险回归模型中, 下降的 BMD 被选为 MACE 的重要预测因子 (P = .015) 。此外, 由性别和 BMD 组成的一级相互作用项具有统计学意义 (P = 0.007) 。心肌灌注异常或左心室射血分数较小的患者的 BMD 显著较低 (P < .05) 。然而, 这种差异只在男性患者中显著存在, 在女性患者中没有。

结论

低 BMD 与心血管疾病的关联性有性别差异。数据表明, 用于评估 CAD 的心肌灌注成像期间 BMD 的量化可能对男性患者特别有用。

French Abstract

Contexte

le dimorphisme sexuel dans la manifestation de la maladie coronarienne a amené à reconsidérer l’évaluation du risque cardiovasculaire. Des altérations de la densité minérale osseuse (DMO) ont été observées en association à une insuffisance cardiaque congestive et semblaient être modifiée par le sexe. Néanmoins, le rôle spécifique du genre dans l’association entre la DMO, la perfusion myocardique et les maladies cardiovasculaires est actuellement inconnue.

Méthodes

Un nombre total de 491 patients (65,9 ± 10,7 ans, 32,4% de femmes) ont été évalués par tomographie à émission de positron (13N-PET/CT) pour l’évaluation de la maladie coronaire et ont été suivis pour éventuels accidents cardiaques (MACE).

Résultats

La survie sans accident cardiaque (temps de suivi de 4,3 ± 2,0 ans) s’est avérée significativement réduite chez les patients présentant une densité osseuse basse (≤ 100 unités Hounsfield) par rapport au patients ayant une DMO plus élevée (P = 0,037). En conséquence, le paramètre de DMO a été choisi comme facteur prédictif significatif des accidents cardiaques en utilisant un modèle de régression des risques proportionnels ajustés (P = 0,015). Une interaction de premier ordre composée du genre et de la DMO s’est révélée statistiquement significative (P = 0,007). Dans notre étude, la DMO est apparue significativement inferieure chez les patients présentant une perfusion myocardique anormale ou une diminution de fraction d’éjection ventriculaire gauche (P < 0,05). Cependant cette différence fut observée chez les hommes seulement et pas chez les femmes.

Conclusions

La relation entre une DMO basse et une maladie cardiovasculaire dépend du sexe. Nos données suggèrent que la quantification de la DMO au cours de l’imagerie de perfusion myocardique pour l’évaluation de la coronaropathie pourrait être particulièrement utile chez les hommes.

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Abbreviations

BMD:

Bone mineral density

CAD:

Coronary artery disease

CFR:

Coronary flow reserve

DXA:

Dual energy x-ray absorptiometry

HU:

Hounsfield units

LVEF:

Left ventricular ejection fraction

MACE:

Major adverse cardiovascular events

MBF:

Myocardial blood flow

MPI:

Myocardial perfusion imaging

PET/CT:

Positron emission tomography/computed tomography

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Acknowledgments

We would like to thank the Staff at the Department of Nuclear Medicine in the University Hospital of Zurich for their valuable contribution to this study.

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Authors and Affiliations

  1. Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland

    Michael Fiechter MD, PhD, Susan Bengs PhD, Andrea Roggo BSc, Ahmed Haider PhD, Monika Marędziak PhD, Angela Portmann MSc, Valerie Treyer PhD, Irene A. Burger MD, Michael Messerli MD, Dimitri Patriki MD, Elia von Felten MD, Dominik C. Benz MD, Tobias A. Fuchs MD, Christoph Gräni MD, PhD, Aju P. Pazhenkottil MD, Ronny R. Buechel MD, Philipp A. Kaufmann MD & Catherine Gebhard MD, PhD

  2. Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland

    Michael Fiechter MD, PhD, Susan Bengs PhD, Ahmed Haider PhD, Monika Marędziak PhD, Angela Portmann MSc & Catherine Gebhard MD, PhD

  3. Swiss Paraplegic Center, Nottwil, Switzerland

    Michael Fiechter MD, PhD

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  1. Michael Fiechter MD, PhD
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Correspondence to Michael Fiechter MD, PhD.

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The University Hospital of Zurich holds a Research Contract with GE Healthcare. CG has received Research Grants from the Novartis Foundation, Switzerland.

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JNC thanks Erick Alexanderson MD, Carlos Guitar MD, and Diego Vences MD, UNAM, Mexico, for providing the Spanish abstract; Zhuo He BS, Haipeng Tang MS, Zhixin Jiang MD, and Weihua Zhou PhD, for providing the Chinese abstract; and Jean-Luc Urbain, MD, PhD, CPE, Past President CANM, Chief Nuclear Medicine, Lebanon VAMC, PA, for providing the French abstract.

Funding

CG was supported by grants from The Swiss National Science Foundation (SNSF); The Olga Mayenfisch Foundation, Switzerland; The OPO Foundation, Switzerland; The Novartis Foundation, Switzerland; The Swissheart Foundation, and The Helmut Horten Foundation, Switzerland. MF was supported by the Swiss Paraplegic Center, Nottwil, Switzerland. MM was supported by The Iten-Kohaut Foundation, Switzerland.

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Fiechter, M., Bengs, S., Roggo, A. et al. Association between vertebral bone mineral density, myocardial perfusion, and long-term cardiovascular outcomes: A sex-specific analysis. J. Nucl. Cardiol. 27, 726–736 (2020). https://doi.org/10.1007/s12350-019-01802-z

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