Bone mineral density in patients with chronic heart failure: a meta-analysis

Abstract

Objective: This study aimed to verify the existing relationship between bone mineral density (BMD) and chronic heart failure (CHF) by meta-analysis.

Methods: Databases, including PubMed, Web of Science, and Chinese National Knowledge Infrastructure, published in English or Chinese up to February 28, 2017, were searched for studies on the association between CHF and BMD. Two independent reviewers collected the relevant articles. The standard mean deviation (SMD) and 95% confidence interval were calculated for BMD with fixed- and random-effect models. Subgroup and sensitivity analyses were also conducted.

Results: A total of six studies (552 CHF and 243 non-CHF patients) were included. The results indicated that the patients with CHF had a lower total BMD compared with the non-CHF patients. Similar effects were also observed for femoral neck, arm, leg, and trunk BMD. However, no difference was observed in the lumbar spine BMD. The SMD of total BMD in New York Heart Association classes I or II (NYHA I or II) patients was -0.62, while that in NYHA III or IV patients was -0.87, and the SMD of femoral bone mineral density in NYHA I or II patients was -0.47, while that in NYHA III or IV patients was -1.07. Moreover, vitamin D and parathyroid hormone (PTH) were also found to be associated with CHF.

Conclusion: Patients with CHF had a lower total BMD and femoral neck, arm, leg, or trochanter BMD than patients with non-CHF. Vitamin D reduced, whereas PTH increased, with the severity of CHF. The clinical significance of the present findings remains uncertain and should be confirmed by future studies.

Keywords: bone mineral density; chronic heart failure; meta-analysis.

Figure 1

Flow diagram of the published data search. Abbreviation: CNKI, Chinese National Knowledge Infrastructure.

Figure 2

Meta-analysis of the differences in BMD of the total body in CHF. Notes: (A) Total body BMD. Terrovitis et al data shown in order of total group, NYHA I or NYHA II group, and NYHA III or IV group, respectively. Jankowska at al data shown in order of total group, NYHA I, NYHA II, NYHA III, and NYHA IV group, respectively. (B) Subgroup analysis of total body BMD by severity of CHF. For each study, the estimate of mean BMD difference and its 95% CI are plotted with a diamond and a horizontal line, respectively. Abbreviations: BMD, bone mineral density; CHF, chronic heart failure; CI, confidence interval; SMD, standard mean deviation.

Figure 3

Forest plots for (A) femoral neck BMD, (B) subgroup analysis of femoral neck BMD by severity of CHF, (C) lumbar spine BMD, and (D) lumbar spine BMD after removing the Abou-Raya and Abou-Raya study. Notes: For each study, the estimate of mean BMD difference and its 95% CI are plotted with a diamond and a horizontal line, respectively. Weights are from random-effects analysis. Terrovitis et al data shown in order of total group, NYHA I or NYHA II group, and NYHA III or IV group, respectively. Zhu et al data shown in order of NYHA I, NYHA II. NYHA III, and NYHA IV group, respectively (A) and NYHA III and NYHA IV group, respectively (B). Abbreviations: BMD, bone mineral density; CHF, chronic heart failure; CI, confidence interval; SMD, standard mean deviation.

Figure 4

Forest plots for (A) legs BMD, (B) subgroup analysis of legs BMD by severity of CHF, (C) arms BMD, and (D) subgroup analysis of legs BMD by severity of CHF. Notes: For each study, the estimate of mean BMD difference and its 95% CI are plotted with a diamond and a horizontal line, respectively. (A and C) Terrovitis et al data shown in order of total group, NYHA I or NYHA II group, and NYHA III or IV group, respectively. Jankowska at al data shown in order of total group, NYHA I, NYHA II, NYHA III, and NYHA IV group, respectively. Abbreviations: BMD, bone mineral density; CHF, chronic heart failure; CI, confidence interval; SMD, standard mean deviation.

Figure 5

Forest plots for (A) trunk BMD, (B) subgroup analysis of trunk BMD by severity of CHF, and (C) subgroup analysis of trunk BMD by sex. Notes: For each study, the estimate of mean BMD difference and its 95% CI are plotted with a diamond and a horizontal line, respectively. Weights are from random-effects analysis. (A and C) Terrovitis et al data shown in order of total group, NYHA I or NYHA II group, and NYHA III or IV group, respectively. Jankowska at al data shown in order of total group, NYHA I, NYHA II, NYHA III, and NYHA IV group, respectively (A), and NYHA III and NYHA IV, respectively (B). Zhu et al data shown in order of NYHA I, NYHA II. NYHA III, and NYHA IV group, respectively (A and C) and NYHA III and NYHA IV group, respectively (B). Abbreviations: BMD, bone mineral density; CHF, chronic heart failure; CI, confidence interval; SMD, standard mean deviation.

Figure 6

Forest plots for (A) PTH and (B) Vitamin D. Notes: For each study, the estimate of mean BMD difference and its 95% CI are plotted with a diamond and a horizontal line, respectively. Weights are from random-effects analysis. Terrovitis et al data shown in order of total group, NYHA I or NYHA II group, and NYHA III or IV group, respectively. Abbreviations: BMD, bone mineral density; CI, confidence interval; PTH, parathyroid hormone; SMD, standard mean deviation.