European Journal of Cardiovascular Medicine

Osteoporosis is a systemic skeletal disorder characterized by reduced bone strength and an increased risk of fragility fractures. It represents a significant public health concern, particularly among older adults, because osteoporotic fractures may cause disability, loss of independence, and increased healthcare requirements. Bone mineral density (BMD), commonly measured using dual-energy X-ray absorptiometry (DXA), is an important component of osteoporosis diagnosis and fracture-risk assessment. Measurements at the lumbar spine and femoral neck help identify individuals with normal bone mass, osteopenia, or osteoporosis. The prevalence of osteoporosis varies according to age, sex, population characteristics, and the skeletal site assessed [1,2].

Sex-related differences are important in understanding the epidemiology of osteoporosis. Women generally experience accelerated bone loss following menopause, whereas men may develop osteoporosis later in life and may be less likely to receive timely diagnosis and treatment. Cawthon reviewed differences in osteoporosis and fracture outcomes between men and women, while Dy and colleagues highlighted sex-specific considerations in the recognition and management of osteoporosis in men [3,4]. Differences in osteoporosis prevalence and fracture outcomes may also be influenced by ethnicity, healthcare access, and disparities in screening and treatment [5,6]. Therefore, reporting osteoporosis prevalence separately for male and female patients is important when evaluating populations with chronic medical conditions.

Ischaemic heart disease (IHD) is a major cardiovascular disorder commonly associated with coronary atherosclerosis. Its risk factors include increasing age, smoking, hypertension, diabetes mellitus, and dyslipidaemia. Several of these factors may also influence skeletal health, providing a possible explanation for the coexistence of cardiovascular disease and osteoporosis. A systematic review by den Uyl and colleagues reported evidence of an association between cardiovascular disease, subsequent bone loss, and fracture risk, although the included studies differed in design and population characteristics [7]. A prospective study by Wiklund and colleagues also investigated the association between BMD and myocardial infarction in men and women [8]. These findings support further investigation of the relationship between cardiovascular and skeletal disorders but do not establish that IHD directly causes osteoporosis.

Potential biological links include shared inflammatory pathways and mechanisms involved in vascular calcification and bone remodelling. Vascular calcification is a regulated process involving signalling molecules and proteins that also participate in skeletal metabolism. Sage and colleagues reviewed the regulatory mechanisms underlying vascular calcification, while Thompson and Towler discussed interactions between vascular and skeletal physiology through the bone–vascular axis [9,10]. Szulc further reviewed the evidence connecting cardiovascular disease and osteoporosis, emphasizing that the association remains complex and that causal relationships are not fully established [11].

Studies examining coronary atherosclerosis and BMD have not produced entirely consistent findings. Lin and colleagues investigated coronary artery calcification and BMD in middle-aged men and women and found that the association was not statistically significant after adjustment for relevant risk factors [12]. Hajsadeghi and colleagues also examined BMD in relation to coronary atherosclerosis, while Aronow reviewed evidence concerning osteoporosis, osteopenia, and atherosclerotic vascular disease [13,14]. These findings suggest that age, sex, comorbidities, and study methodology may influence the observed relationship between cardiovascular disease and skeletal health.

Despite growing interest in this association, the prevalence and severity of osteoporosis among patients with established IHD may differ between men and women. Population-based osteoporosis research has demonstrated the importance of age and sex in identifying individuals with low BMD, while studies of bone density and cardiovascular risk indicate that these conditions may coexist in the same population [15]. However, evidence directly comparing osteoporosis severity between male and female patients with established IHD remains an important area for investigation. Therefore, this study aims to compare the prevalence and severity of osteoporosis between male and female patients with IHD, providing information that may support improved recognition of coexisting skeletal disease in cardiovascular clinical practice.

Objectives

The main objective was to compare the prevalence and severity of osteoporosis between male and female patients with ischaemic heart disease (IHD).

The cross-sectional study was conducted in the Department of Medicine, Comilla Medical College Hospital, Comilla, Bangladesh. The study was carried out over six months, from January 2012 to June 2012.

Inclusion Criteria:

• Patients diagnosed with ischaemic heart disease (IHD).
• Male and female patients eligible for bone mineral density (BMD) assessment.
• Patients for whom relevant clinical information and BMD measurements were available.
• Patients who provided informed consent to participate in the study.

Exclusion Criteria:

• Patients with incomplete clinical or bone mineral density assessment data.
• Patients with conditions or receiving medications that substantially affect bone metabolism, if excluded according to the original study protocol.
• Patients who did not consent to participate in the study.

A total of 250 patients diagnosed with IHD were included in the study, comprising 150 males and 100 females. Participants were selected using the sampling technique applied during the study period. Baseline demographic and clinical information, including age, sex, body mass index (BMI), residence, educational status, duration of IHD, hypertension, diabetes mellitus, dyslipidaemia, smoking status, family history of IHD, antiplatelet medication use, and statin therapy, was recorded using a structured data collection form. Bone mineral density measurements of the lumbar spine and femoral neck were recorded in g/cm², along with the corresponding T-scores. Based on the diagnostic criteria adopted in the original study protocol, participants were classified into three categories: normal BMD, osteopenia, and osteoporosis. The severity of osteoporosis was further categorized as mild, moderate, or severe according to the classification criteria used in the study. The participants were categorized by sex to assess differences in BMD measurements, the prevalence and severity of osteoporosis, and the association between selected clinical risk factors and osteoporosis. The prevalence of osteoporosis was calculated separately for males and females. Associations between osteoporosis and age group, hypertension, diabetes mellitus, dyslipidaemia, current smoking, and family history of IHD were also evaluated.

Statistical Analysis: All data were recorded systematically using a preformed data collection form and analyzed using the Statistical Package for the Social Sciences (SPSS), with the software version specified according to the original study records. Quantitative variables were expressed as mean ± standard deviation, while qualitative variables were presented as frequencies and percentages. Continuous variables were compared between males and females using the independent-samples t-test or an appropriate non-parametric test, depending on the distribution of the data. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. The odds ratio (OR) with a 95% confidence interval (CI) was used to assess the association between sex and osteoporosis. A p-value of less than 0.05 was considered statistically significant.

Ethical Considerations: Ethical approval was obtained from the relevant institutional ethics committee before commencement of the study, according to the original study records. Informed consent was obtained from the participants, and the confidentiality of their personal and clinical information was maintained throughout the study. The collected data were used exclusively for research purposes.

The cross-sectional study was conducted in the Department of Medicine, Comilla Medical College Hospital, Comilla, Bangladesh. The study was carried out over six months, from January 2012 to June 2012.

Inclusion Criteria:

• Patients diagnosed with ischaemic heart disease (IHD).
• Male and female patients eligible for bone mineral density (BMD) assessment.
• Patients for whom relevant clinical information and BMD measurements were available.
• Patients who provided informed consent to participate in the study.

Exclusion Criteria:

• Patients with incomplete clinical or bone mineral density assessment data.
• Patients with conditions or receiving medications that substantially affect bone metabolism, if excluded according to the original study protocol.
• Patients who did not consent to participate in the study.

A total of 250 patients diagnosed with IHD were included in the study, comprising 150 males and 100 females. Participants were selected using the sampling technique applied during the study period. Baseline demographic and clinical information, including age, sex, body mass index (BMI), residence, educational status, duration of IHD, hypertension, diabetes mellitus, dyslipidaemia, smoking status, family history of IHD, antiplatelet medication use, and statin therapy, was recorded using a structured data collection form. Bone mineral density measurements of the lumbar spine and femoral neck were recorded in g/cm², along with the corresponding T-scores. Based on the diagnostic criteria adopted in the original study protocol, participants were classified into three categories: normal BMD, osteopenia, and osteoporosis. The severity of osteoporosis was further categorized as mild, moderate, or severe according to the classification criteria used in the study. The participants were categorized by sex to assess differences in BMD measurements, the prevalence and severity of osteoporosis, and the association between selected clinical risk factors and osteoporosis. The prevalence of osteoporosis was calculated separately for males and females. Associations between osteoporosis and age group, hypertension, diabetes mellitus, dyslipidaemia, current smoking, and family history of IHD were also evaluated.

Statistical Analysis: All data were recorded systematically using a preformed data collection form and analyzed using the Statistical Package for the Social Sciences (SPSS), with the software version specified according to the original study records. Quantitative variables were expressed as mean ± standard deviation, while qualitative variables were presented as frequencies and percentages. Continuous variables were compared between males and females using the independent-samples t-test or an appropriate non-parametric test, depending on the distribution of the data. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. The odds ratio (OR) with a 95% confidence interval (CI) was used to assess the association between sex and osteoporosis. A p-value of less than 0.05 was considered statistically significant.

Ethical Considerations: Ethical approval was obtained from the relevant institutional ethics committee before commencement of the study, according to the original study records. Informed consent was obtained from the participants, and the confidentiality of their personal and clinical information was maintained throughout the study. The collected data were used exclusively for research purposes.

This cross-sectional study compared the prevalence and severity of osteoporosis between 150 male and 100 female patients with ischaemic heart disease (IHD). Osteoporosis was present in 26.0% of all patients and osteopenia in a further 46.0%, so fewer than three in ten had normal bone mineral density (BMD). Osteoporosis was significantly more frequent in women than in men (35.0% vs 20.0%; OR 2.15, 95% CI 1.21–3.82), and BMD and T-scores at both the lumbar spine and femoral neck were lower in women. The severity of osteoporosis did not differ significantly between the sexes.

Low bone mass was common in our patients: 72% had osteopenia or osteoporosis. A comparable pattern was reported by Hajsadeghi et al. in 119 Iranian patients undergoing coronary angiography, of whom only 21% had normal BMD, 32.7% had osteopenia and 46.2% had osteoporosis [13]. Their osteoporosis figure is higher than ours, which may reflect differences in patient selection, age and the population studied. In a large Indian study of 1,600 apparently healthy adults aged over 50 years, osteoporosis was present in 35.1% (24.6% of men and 42.5% of women) [16]. That study also found a higher prevalence in women, as we did. Its absolute prevalence was higher than ours, which is plausible because it excluded people younger than 50, whereas 20% of our patients were aged 40–49 years. The same study found that prevalence rose with age in women but not in men [16]. Our age analysis (Table 7) pooled both sexes, so we could not test whether the age gradient differs by sex; this deserves examination in future work.

The higher prevalence in women is consistent with the wider literature. Osteoporosis is more common in postmenopausal women, although older men still have poor outcomes after fracture [3]. Prevalence is lower in men partly because their BMD is higher and their bones are larger [17]. Sex differences in how the skeleton ages also matter: bone loss and fracture risk in men are linked to falling levels of bioavailable oestrogen, and men tend to fracture later in life than women [19]. The role of endogenous sex hormones in male osteoporosis has also been reviewed [18]. The mean age of our female patients was 60.5 years.

Several studies in cardiovascular populations point the same way. In 2,160 Korean adults over 50 years, the association between reduced BMD and coronary artery calcification was significant only in women (unadjusted OR 1.925) [20]. A review of epidemiological studies concluded that cardiovascular disease is associated with lower BMD and faster bone loss, with the association stronger in women, probably because bone loss is faster in postmenopausal women than in older men [11]. Likewise, older women with low BMD have been shown to have a higher prevalence of atherosclerotic vascular disease than those with normal BMD [14]. These studies mostly examine low BMD as a predictor of cardiovascular disease. Our cross-sectional design cannot establish the direction of any relationship.

A systematic review found that, in the six highest-ranked studies, prevalent subclinical cardiovascular disease was associated with a higher risk of bone loss and fracture (HR 1.5; OR 2.3–3.0), but it drew no firm conclusion on whether low BMD raises cardiovascular risk [7]. A cross-sectional study of 2,235 patients aged 65 years or older concluded that elderly patients with low BMD should be carefully evaluated for coronary artery disease [21]. The evidence is not uniform, however: Hajsadeghi et al. found no significant relationship between osteoporosis and coronary atherosclerosis [13]. Proposed shared mechanisms include the regulated, bone-like nature of vascular calcification [9]. Our data were not designed to test these mechanisms, and the results should not be read as showing that IHD causes osteoporosis.

Moderate and severe osteoporosis were proportionally more frequent in women (65.7%) than in men (50.0%), but the difference was not statistically significant (p = 0.413). With only 30 men and 35 women in the osteoporosis subgroup, the comparison had limited power, and a real difference cannot be excluded. To our knowledge, few studies of patients with IHD have reported osteoporosis severity separately for men and women, which limits direct comparison. One possible influence on severity is that osteoporosis in men is under-recognised and less often screened for, which may affect the stage at which it is detected [4]. Such reviews have called for sex-specific stratification of results in osteoporosis research, which our analysis supports [4].

Osteoporosis prevalence rose steadily with age, from 10.0% at 40–49 years to 44.4% at 70 years or older, in line with the age-related pattern described above [16]. Current smoking was the only clinical risk factor significantly associated with osteoporosis (38.5% vs 21.6%; p = 0.013). This agrees with longitudinal evidence that men who start smoking in young adulthood show poorer gains in BMD at the spine and hip [22]. Hajsadeghi et al., however, found no association between BMD and smoking in their coronary angiography cohort [13]. Smoking was far more common among our men (40.0% current smokers) than women (5.0%), yet osteoporosis was more common in women, so smoking cannot explain the female excess. Because smoking and sex are strongly linked in this sample, and we did not perform multivariable adjustment, their separate effects could not be disentangled.

Diabetes, hypertension, dyslipidaemia and family history of IHD were not associated with osteoporosis. A meta-analysis of 15 observational studies found that BMD was higher, not lower, in people with type 2 diabetes, with similar results in both sexes [23]; this is compatible with the numerically lower diabetes prevalence among our osteoporotic patients (30.8% vs 40.5%). The lack of association with diabetes, hypertension and lipids also matches the findings of Hajsadeghi et al. [13].

The high burden of low bone mass in this IHD cohort, and the doubled odds of osteoporosis in women, suggest that bone health deserves attention in cardiology practice. Case-finding by BMD measurement may be most useful in women, in older patients and in current smokers with IHD. Whether it would change outcomes needs to be tested prospectively.

Limitations of the study

This was a single-centre, cross-sectional study, so temporal and causal relationships cannot be inferred. There was no control group without IHD, so we cannot say whether osteoporosis is more common in IHD than in the general population. Associations were assessed with univariate tests only. Menopausal status, vitamin D and calcium status, physical activity and other medications were not analysed, and women were more likely to have had no formal education, which may reflect socioeconomic differences that also affect bone health. The severity subgroups were small.

Among patients with IHD, osteoporosis was more prevalent and BMD was lower in women than in men, whereas severity did not differ significantly between the sexes. Age and current smoking were associated with osteoporosis. Larger, multi-centre studies with control groups and multivariable analysis are needed to confirm these findings and clarify the mechanisms.

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