Concurrent left ventricular myocardial diffuse fibrosis and left atrial dysfunction strongly predicts incident heart failure and all-cause mortality

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Academy of Medical Sciences

Background

LV myocardial interstitial fibrosis has been reported to influence LA morphology and function via LV remodelling and diastolic dysfunction. However, this association, as well as their combined influence on clinical outcomes remains poorly characterised.

Aim

To evaluate the relationship between left ventricular (LV) fibrosis quantified by native T1 times and left atrial (LA) global and phasic function and their impact on clinical outcomes.

Methods

A total of 40,818 UK Biobank participants with cardiovascular magnetic resonance data were included. Native T1 mapping was performed using Shortened Modified Look-Locker Inversion recovery sequence with global myocardial T1 estimated by an automatic segmentation framework. Ten parameters of LA phasic function were calculated from normalised LA volume-time curves derived by a three-dimensional sparse active shape model. LV parameters (mass, end-diastolic volume, and ejection fraction) were extracted by a fully convolutional neural network. Multivariable regression models were used to assess the associations between T1 and LA parameters. Lastly, survival analysis was performed to assess the interplay between T1, LA function and incident heart failure, atrial fibrillation, major adverse cardiovascular event (MACE) and all-cause mortality.

Results

The mean age of study population was 64.0 ± 7.7 years; 47.8% were men. Higher T1 values were associated with larger LA minimum size (Beta= 0.89ml per 100ms; 95% confidence interval (CI) = 0.62, 1.17), and lower LA global emptying fraction (Beta= -0.012 per 100ms; CI= -0.015, -0.010), LA reservoir function (Beta= -0.060 per 100ms; CI= -0.083, -0.037) and LA booster function (Beta= -0.014 per 100ms; CI= -0.017, -0.011). Among LA phasic functional parameters, LA booster function is most strongly associated with T1. Survival analysis revealed concurrent high T1 and low LA function had a significant influence on incident heart failure (Hazard Ratio [HR] = 2.99; CI=1.91,2.01), atrial fibrillation (HR = 4.86; CI=3.51-6.54), MACE (HR = 1.86; CI = 1.36-2.54) and all-cause mortality (HR = 1.86; CI=1.22-2.82) compared to either parameter alone, even after accounting for LV parameters (Figure 1).

Conclusion

This is the first study to robustly demonstrate the associations between myocardial diffuse fibrosis and reduced LA global and phasic functional measurements. We reveal the independent prognostic role of high T1 values accompanied by low LA function in predicting adverse clinical outcomes in a general population. These findings advance our understanding of the relationships between myocardial fibrosis and LA biomechanics at an early, subclinical stage, and highlight the additive value of incorporating these biomarkers into clinical decision making.

Cardiac magnetic resonance radiomics for prediction of incident heart failure: a feasibility study in the UK Biobank Imaging cohort

Background

Cardiac magnetic resonance (CMR) radiomics is a novel image quantification technique with the potential to improve image-based disease diagnosis and prediction.

Purpose

In this proof-of-concept study, we aimed to evaluate the utility of CMR radiomics in the prediction of incident heart failure (HF).

Methods

We studied 32,121 UK Biobank participants with CMR. Incident HF was defined from linked Hospital Episode Statistics. To create a balanced cohort, we identified as comparators an equal number of randomly selected subjects who did not develop the outcome of interest during this period. Radiomics shape, first-order and texture features were extracted from short-axis cine images (left and right ventricle, left ventricular myocardium) using the Pyradiomics toolbox. Vascular risk factors (VRFs) were considered as additional predictors. Feature selection was conducted using the sequential forward selection technique and modelling was performed using Support Vector Machine (SVM) methods with 5-fold cross-validation. Models were developed using 1) VRFs alone, 2) radiomics alone, and 3) VRFs and radiomics. We determined model performance using receiver operating characteristic (ROC) curve and area under the curve (AUC) scores.

Results

Over average follow-up time of 3.7 (±1.3) years, 209 participants experienced incident HF. Among vascular risk factors, age, body size, hypertension, diabetes, high cholesterol were chosen for the incident HF predictive model (Accuracy: 0.66, AUC: 0.73) by the SVM methods. The model based on radiomics features reached a marginal improvement compared to vascular risk factors alone (Accuracy: 0.71, AUC: 0.75). The combination of VRFs and radiomics features significantly improved the performance of the model to predict incident HF compared to VRFs alone (Accuracy: 0.77; AUC: 0.83; p<0.05)

Conclusion

We demonstrate the feasibility of CMR radomics features to predict incident HF and illustrate their added value over vascular risk factors.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding.

The association between native myocardial T1 relaxation times and left atrial phasic structure and function: the UK Biobank Imaging Enhancement study

Introduction

Left ventricular (LV) myocardial fibrosis is posited to result in left atrial (LA) changes via LV remodelling and diastolic dysfunction, though the association remains poorly characterised. Native myocardial T1 mapping is a non-invasive modality that quantifies diffuse myocardial fibrosis. This study examines the relationship between LV fibrosis (quantified by native T1 times) and LA function, drawing upon data from the UK Biobank.

Methods

40,818 participants underwent cardiovascular magnetic resonance (CMR) using steady-state free precession imaging at 1.5 Tesla. Native T1-mapping was performed using the Shortened Modified Look-Locker Inversion recovery technique (ShMOLLI), with global myocardial T1 estimated by an automatic segmentation framework. Nine parameters of LA phasic function were calculated (representing global, reservoir, conduit and booster components) from normalised LA volume-time curves. LV parameters (LV Mass, end-diastolic volume and ejection fraction) were extracted by a convolutional neural network. Multivariable logistic regression models were used to assess the association between T1 (exposure) and LA function (outcome). Mediation analysis was performed to assess the role of LV parameters as a mediator for the association between T1 and LA function. Lastly, potential non-linear relationships between T1 and LA function were investigated using Restrictive Cubic Spline (RCS) modelling, with model fit assessed via the Akaike Information Criterion (AIC).

Results

Higher T1 values were positively associated with larger LA volumes, and negatively associated with markers of LA global, reservoir and booster function. In the fully adjusted model, T1 was positively associated with larger LA minimum size (Beta: +0.034 SD per T1 SD; Confidence Interval (CI): 0.024, 0.045), and negatively associated with LA emptying volume (Beta: −0.017; CI: −0.027, −0.006), LA booster volume (Beta: −0.019; CI: −0.030, −0.008), LA emptying fraction (Beta: −0.052; CI: −0.062, −0.041), and LA reservoir function (Beta: −0.028; CI: −0.039, −0.017). Though adjustment for LV parameters did not fully attenuate the above relationships, LV parameters were consistent mediators between T1 and LA function, with proportional mediative effects ranging from 15% to 75%. Lastly, there is evidence of an inverted J-shaped relationship between T1 and LA function, with the associations becoming more apparent in the upper half of T1 ranges (turning points within 925–950 ms, median T1 = 930 ms) (p<0.05).

Conclusion

This study demonstrates a consistent association between higher native T1 values (as a marker of myocardial fibrosis) and lower LA global and phasic functions. We also highlighted an interplay between T1 values, LV remodelling and LA dysfunction. These findings will facilitate our understanding of the disease processes underlying cardiac dysfunction and myocardial remodelling at an early, subclinical stage.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This work was part of the portfolio of translational research of the National Institute for Health Research Biomedical Research Centre at Barts and The London School of Medicine and DentistryDr Nay Aung is supported by a Wellcome Trust Research Training Fellowship (203553/Z/16/Z)

Patterns and outcomes of cardiovascular emergency department encounters for men and women in the USA

Aims

We described sex-differential disease patterns and outcomes of over 20.6 million cardiovascular emergency department (ED) encounters in the USA.

Methods and results

We analysed primary cardiovascular encounters from the Nationwide Emergency Department Sample (between 2016–2018). We grouped the documented cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; average age was 67 [54,78] years. Men had greater overall baseline co-morbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common ED encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation (AF)/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (AMI, 10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, AF/flutter, supraventricular tachycardia, pulmonary embolism, or ischaemic stroke. Men were more likely to present with AMI or cardiac arrest. In logistic regression models adjusted for baseline covariates, women with intracranial haemorrhage had higher risk of hospitalisation and death. Women with ischaemic stroke had higher risk of hospitalisation and death in ED. Women presenting with pulmonary embolism were less likely to be hospitalised but were more likely to die. Women with aortic aneurysm/dissection had higher risk of hospitalisation and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, AF/flutter, AMI, or cardiac arrest.

Conclusion

In this large nationally representative sample of cardiovascular ED presentations, we demonstrate significant sex differences in disease distribution, hospitalisation, and death.

Funding Acknowledgement

Type of funding sources: None.

Protocol design and preliminary evaluation of the REAL-Health Triple Aim, an open-cohort CVD-care optimisation initiative

Introduction

Effective treatment of cardiovascular disease (CVD) in primary care could be improved. We aim to assess the efficacy of a scalable treatment optimisation programme in unselected community populations in South East England, with the triple aim of improved blood pressure control in people with hypertension, increased high-intensity statin use in people with CVD and reduced gastrointestinal bleeding in patients on antithrombotic medication.

Method

This observational study comprises an open cohort of approximately 200,000 adults at high cardiovascular risk registered with general practitioners in five South East England Clinical Commissioning Groups (CCGs). An intervention programme is planned in four of these CCGs with a further non-intervention CCG acting as a control group. The intervention will consist of: clinical guidelines and educational outreach; virtual patient-reviews software; peer-performance “dashboards” and, where available, financial incentives.

The study will examine 3 primary outcomes: 1. Diagnosed hypertension with a blood pressure <140/90mmHg; 2. Diagnosed CVD on a high-intensity statin; 3. A cardiovascular indication for antithrombotic therapy with one or more factors for increased risk of gastrointestinal bleeding (e.g. age ≥65) on gastroprotection. A further 17 secondary outcomes related to these three aims will be assessed.

Analysis

We will use an interrupted time series analysis over 18 months, representing the pre-implementation, implementation and the post-implementation phases with comparison to the control CCG and applicable national Quality and Outcomes Framework and national prescribing statistics (e.g. OpenPrescribing). Secondary outcomes include an equity impact analysis with results stratified by age, gender, ethnic group and index of deprivation.

Preliminary data

We present preliminary data on Key Performance Indicators (KPIs) collected from 191 GP practices including [percentage achievement on 01/09/2019, on 01/09/2020]: 1. Patients with hypertension and most recent blood pressure ≤140/90mmHg [68.7%, 60.6%]. 2. Patients eligible for treatment with a high-intensity statin on such treatment [53.8%, 55.8%]. 3. Patients on antithrombotics with ≥1 risk factors for gastrointestinal bleeding on gastroprotection [59.0%, 60.1%]. We also present our virtual patient-review software tool and outcome visualisation dashboard.

Conclusion

The REAL-Health Triple Aim initiative is a large-scale primary care cardiovascular risk reduction initiative which was launched almost contemporaneously with the United Kingdom's first SARS-CoV-2 related lockdown. Preliminary data justify the need for the Triple Aim initiative and give us an insight on the impact of the pandemic on its implementation.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Barts CharityBritish Heart Foundation

Association of daily coffee consumption with cardiovascular health – results from the UK Biobank

Background

There are conflicting reports on the association of coffee consumption with cardiovascular (CV) health. The UK Biobank is a prospective cohort study including data for half a million middle-aged individuals.

Purpose

We studied the association of daily coffee consumption with all-cause and CV mortality, and incidence of the major CV diseases in the UK Biobank. In a subgroup of participants who underwent cardiovascular magnetic resonance (CMR), we evaluated the association between regular coffee intake and cardiac structure and function parameters.

Methods

UK Biobank cohort of participants without clinically manifested heart disease at the time of recruitment were included. Regular coffee intake was categorized into 3 groups: zero, light-to-moderate (0.5–3 cups/day) and high (>3 cups/day) coffee drinkers. We estimated association of daily coffee consumption with incident outcomes using multivariable Cox-regression models (median follow-up of 11 years) and, in the subset with CMR data, with left and right ventricular (LV, RV) end-systolic and end-diastolic volumes, LV mass, and LV/RV stroke volume using multivariable linear regression. Models were adjusted for potential confounders and mediators, including: age, sex, non-European ethnicities, body mass index, smoking, physical activity, Townsend deprivation index, alcohol, meat, fruit and vegetable intake, hypertension, diabetes mellitus, and cholesterol level.

Results

We included 468,629 individuals (mean age 56.2±8.1 years, 44.2% male). Among them, 22.1% did not consume coffee on a regular basis, 58.4% had 0.5–3 cups per day and 19.5% had >3 cups per day. After adjustment for potential confounders and mediators, compared to non-coffee drinkers, light-to-moderate coffee drinking was associated with lower risk of all-cause mortality (HR=0.88, p<0.001), CV mortality (HR=0.83, p=0.006), and incident stroke (HR=0.79; p=0.037). CMR data were available in 30,650 participants. In multivariable analysis, compared to non-coffee drinkers, both the light-to-moderate and high coffee consuming categories, were associated with significantly increased LV and RV ventricular end-systolic (β=0.91 and 1.64 for LV and 1.10 and 1.72 for RV), end-diastolic (β=2.21 and 3.28 for LV and 2.24 and 3.35 for RV) and stroke volumes (β=1.31 and 1.64 for LV and 1.15 and 1.63 for RV), as well as greater LV mass (β=0.78 and 1.64; all p<0.001).

Conclusion

In this large study of the UK Biobank population, regular coffee consumption of up to 3 cups per day was associated with favorable cardiovascular outcomes, in particular, decreased all-cause and CV mortality and stroke incidence. Regular coffee consumption was also associated with a pattern of CMR metrics in keeping with the reverse of age-related cardiac alterations.

Funding Acknowledgement

Type of funding sources: None.

Benefits from optimised antihypertensive and statin treatment in high risk people

Background

Hypertension and hypercholesterolaemia are major modifiable risk factors for cardiovascular diseases (CVD) with available effective and low-cost treatments. However, their suboptimal treatment remains widespread. We characterise treatment gaps in a large urban population and quantify the potential long-term health and economic impact with optimised use.

Methods

We studied 1 million UK urban residents served by 123 primary care practices in 2019. We categorised antihypertensive treatment in adults with diagnosed hypertension, and statin treatment in adults with diagnosed CVD, into optimal, suboptimal and not treated following UK clinical guidelines. A long-term CVD model was used to project cardiovascular events avoided, years of life and quality-adjusted life years (QALYs) gained, and healthcare costs saved with optimised treatments for individual patients accounting for their socio-demographic characteristics and risk factors.

Results

21,954 (24%, mean age 59 years; 49% female) of the 91,828 adults with hypertension were either suboptimally treated (20%) or untreated (4%) and 9,062 (38%, mean age 69 years; 43% female) of the 23,723 adults with CVD were either suboptimally treated (24%) or untreated (14%). Per 1000 patients (95% CI) optimised over lifespan, hypertension treatment would prevent 154 (72–230) major vascular events (MVEs, including heart attack, stroke or arterial revascularisation) and 69 (28–103) vascular deaths, and gain 769 (436–1038) QALYs for those sub-optimally treated, and prevent 138 (68–201) MVEs and 50 (21–76) vascular deaths, and gain 674 (386–920) QALYs for those not treated; statin treatment would prevent 68 (46–88) MVEs and 17 (12–21) vascular deaths, and gain 145 (113–178) QALYs for those sub-optimally treated, and prevent 260 (190–319) MVEs and 55 (40–68) vascular deaths, and gain 535 (412–651) QALYs for those not treated (Figure). Hospital cost savings net of medication costs were about £1100 per person over their remaining lifespan.

Conclusion

Optimising preventive cardiovascular treatments in UK primary care is likely to cost-effectively reduce cardiovascular risk and improve life expectancy, while reducing population inequalities.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Barts Charity, British Heart Foundation, and Health Data Research UK Predicted benefits from optimisation

Automated myocardial segmentation in native t1-mapping cardiovascular magnetic resonance images based on machine learning: a validation study in the UK biobank"s covid-19 subset

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Innovate UK

Background

 Regional assessment of septal native T1 values with cardiovascular magnetic resonance (CMR) is used to characterise diffuse myocardial diseases. Previous studies suggest its potential role in detecting early pathological alterations, which may help identify high-risk subjects at early disease stages. Automated analysis of myocardial native T1 images may enable faster CMR analysis and reduce inter-observer variability of manual analysis. However, the technical performance of such methodologies has not been previously reported.

Purpose

 We tested, in a subset of UK Biobank participants, the degree of agreement between CMR septal myocardial T1 values obtained from our machine learning (ML) algorithm and septal native T1 values computed from manual segmentations.

Methods

 We analysed the first 292 participants who were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and had CMR imaging (1.5 Tesla, Siemens MAGNETOM Aera). T1 mapping was performed in a single mid-ventricular short axis (SAX) slice using ShMOLLI (WIP780B) sequences. Three experienced CMR readers independently measured native T1 values by manually placing a single region of interest (ROI) covering half of the anteroseptal and half of the inferoseptal wall using cvi42 post-processing software (version 5.11). A mean T1 value for each participant was then calculated. A ML algorithm developed by Circle Cardiovascular Imaging Inc. was then applied to the same images to derive the myocardium T1 values automatically. The algorithm was previously trained to segment myocardium from SAX T1 and non-T1 mapping images on two external CMR datasets. We compared the mean septal ROI T1 values to the mean myocardium T1 values predicted by the ML algorithm.

Results

 Two studies were excluded after quality control. The ML-derived and the manually calculated mean T1 values were significantly correlated (r = 0.82, p < 0.001). The Bland-Altman analysis between the two methods showed a mean bias of 3.64 ms, with 95% limits of agreement of −38.88 to 53.46 ms, indicating good agreement (figure 1).

Conclusions

 We demonstrated strong correlation and good agreement between native T1 values obtained from our automated analysis method and manual T1 septal analysis in a subset of UK Biobank participants. This algorithm may represent a valuable tool for clinicians allowing for fast and potentially less operator-dependent myocardial tissue characterisation. However, validation of more extensive datasets and quality control processes are needed.

Higher consumption of red and processed meat is associated with adverse cardiovascular magnetic resonance morpho-functional phenotypes: A study of 19,408 UK Biobank participants

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship No. FS/17/81/33318 European Union’s Horizon 2020 research and innovation programme under grant agreement No 825903 (euCanSHare project).

Background

Multiple epidemiological studies link greater red and processed meat consumption with poorer cardiovascular outcomes. However, the impact of these exposures on directly measured cardiovascular phenotypes has not been examined in large cohorts. Limited existing studies suggest that the observed associations may be mediated by cardiometabolic diseases and/or novel mechanisms acting via the heart-gut axes. However, few studies systematically examine potential confounding and mediating mechanisms.

Purpose

We assessed, in the UK Biobank, the association between meat intake and cardiovascular structure and function incorporating a comprehensive range of confounders and mediators.

Methods

We studied 19,408 participants with cardiovascular magnetic resonance (CMR) data. We determined average daily red and processed meat intake using food frequency questionnaires. We used oily fish as a comparator linked to favourable cardiac health. We considered conventional CMR measures (ventricular volumes, left ventricular mass, ejection fraction, stroke volume), novel CMR radiomics features (shape, texture), and arterial stiffness metrics (arterial stiffness index, aortic distensibility). Multivariable linear regression models were used to investigate associations between meat/fish intake and cardiovascular phenotypes, adjusting for age, sex, deprivation, educational level, smoking, alcohol intake, and exercise. In separate models, we investigated the mediating role of cardiometabolic morbidities.

Results

Higher intake of red and processed meat was associated with an adverse overall pattern of right and left ventricular remodelling, poorer cardiac function, and higher arterial stiffness. Conversely, higher oily fish intake was associated with a healthy cardiovascular phenotype (better ventricular function, greater arterial compliance). Radiomics analysis showed association of the different dietary habits with unique overall geometry of the ventricles and myocardial texture. These associations were partially mediated by cardiometabolic morbidities.

Conclusions

Higher red and processed meat consumption is associated with adverse cardiovascular phenotypes. These relationships are not fully explained by mediation through cardiometabolic morbidities suggesting importance of alternative disease pathways. Understanding these potential novel disease mechanisms is important for optimising cardiovascular disease prevention strategies.

Variation of cardiac magnetic resonance radiomics features by age and sex in healthy participants from the UK Biobank

Introduction

Cardiac magnetic resonance (CMR) radiomics use voxel-level data to derive quantitative indices of myocardial tissue texture, which may provide complementary risk information to traditional CMR measures.

Purpose

In this first stage of our work, establishing the performance characteristics of CMR radiomics in relation to disease outcomes, we aimed to elucidate differences in radiomic features by sex and age in apparently healthy adults.

Methods

We defined a healthy cohort from the first 5,065 individuals completing the UK Biobank Imaging Enhancement, limiting to white Caucasian ethnicity, and excluding those with major co-morbidities, or cardiovascular risk factors/symptoms. We created evenly distributed age groups: 45–54 years, 55–64 years, 65–74 years. Radiomics features were extracted from left ventricle segmentations, with normalisation to body surface area. We compared mean values of individual features between the sexes, stratified by age and separately between the oldest and youngest age groups for each sex.

Results

We studied 657 (309 men, 358 women) healthy individuals. There were significant differences between radiomics features of men and women. Different features appeared more important at different age groups. For instance, in the youngest age group “end-systolic coarseness” showed greatest difference between men and women, whilst “end-diastolic run percentage” and “end-diastolic high grey level emphasis” showed most variation in the oldest and middle age groups. In the oldest age groups, differences between men and women were most predominant in the texture features, whilst in the younger groups a mixture of shape and texture differences were observed. We demonstrate significant variation between radiomics features by age, these differences are exclusively in texture features with different features implicated in men and women (“end-diastolic mean intensity” in women, “end-systolic sum entropy in men”).

Conclusions

There are significant age and sex differences in CMR radiomics features of apparently healthy adults, demonstrating alterations in myocardial architecture not appreciated by conventional indices. In younger ages, shape and texture differences are observed, whilst in older ages texture differences dominate. Furthermore, texture features are the most different features between the youngest and oldest hearts. We provide proof-of-concept data indicating CMR radiomics has discriminatory value with regard to two characteristics strongly linked to cardiovascular outcomes. We will next elucidate relationships between CMR radiomics, cardiac risk factors, and clinical outcomes, establishing predictive value incremental to existing measures.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Union's Horizon 2020 research and innovation programme (825903),British Heart Foundation Clinical Research Training Fellowship (FS/17/81/33318)

Prior fragility fracture and risk of incident ischaemic cardiovascular events: results from UK Biobank

In the large UK Biobank population-based cohort, we found that amongst men, but not women, prior fragility fracture was associated with increased risk of admission with ischaemic heart disease.

INTRODUCTION

We aimed to investigate the relationship between prior fracture and risk of incident ischaemic cardiovascular events in a UK population-based cohort.

METHODS

UK Biobank is a large prospective cohort comprising 502,637 men and women aged 40-69 years, with detailed baseline assessment. History of fracture was self-reported, and details of hospital admissions for ischaemic heart disease (IHD) (ICD-10:I20-I25) were obtained through linkage to UK Hospital Episode Statistics. Cox proportional hazards models were used to investigate the prospective relationships between prior fracture and hospital admission for men and women, controlling for age, BMI, smoking, alcohol, educational level, physical activity, systolic blood pressure, calcium and vitamin D use, ankle spacing-width, heel BUA and HRT use (women).

RESULTS

Amongst men, a fragility fracture (hip, spine, wrist or arm fracture resulting from a simple fall) within the previous 5 years was associated with a 35% increased risk of IHD admission (fully adjusted HR 1.35; 95%CI 1.00, 1.82; p = 0.047), with the relationship predominantly driven by wrist fractures. Associations with hospitalisation for angina in men were similar in age-adjusted models [HR1.54; 95%CI: 1.03, 2.30), p = 0.037], but did not remain statistical significant after full adjustment [HR 1.64; 95%CI: 0.88, 3.07); p = 0.121]. HRs for admission with angina were lower in women, and neither age- nor fully adjusted relationships attained statistical significance.

CONCLUSIONS

Prior fragility fracture is an independent risk factor for incident ischaemic cardiovascular events in men. Further work may clarify whether this association is causal or represents shared risk factors, but these findings are likely to be of value in risk assessment of both osteoporosis and cardiovascular disease.