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APLAR Grand Round Blackboard: Beyond the Skeleton: Osteoporosis and Cardiovascular Health
Step
1
of
2
50%
Question 1
Which statement best reflects current evidence regarding the association between bone mineral density (BMD) and cardiovascular disease (CVD)?
Question 1
*
A. Low BMD is an established direct causal risk factor for cardiovascular disease.
B. Low BMD is associated with an increased risk of cardiovascular disease, but shared risk factors and biological pathways make direct causality difficult to establish.
C. The association between low BMD and cardiovascular disease is seen only in patients with chronic kidney disease.
D. Patients with cardiovascular disease generally have higher hip BMD because vascular calcification causes falsely elevated BMD measurements.
Answer with a detailed explanation
B. Low BMD is associated with an increased risk of cardiovascular disease, but shared risk factors and biological pathways make direct causality difficult to establish.
Your Answer is Incorrect
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Question 2
A 63-year-old female was evaluated in 2017 for osteoporosis, with a lumbar spine DXA showing a T-score of -3.5. She had no history of fragility fracture, chronic illnesses, no previous steroid use, no history of smoking, no family history of hip fracture, and no early menopause. BMI 25.22. She was offered anti-osteoporosis medication at that time but refused treatment.
She presented again in 2025 with new-onset back pain after pushing a sofa. Repeated DXA showed a markedly reduced L1-L4 T-score of -5.4, and spine MRI demonstrated a new T8 compression fracture with old wedging deformities at L5, L3, and L2. Secondary osteoporosis workup was unremarkable.
The assessment was very high-risk osteoporosis with fragility fracture. The patient agreed to start romosozumab. She had no history of coronary artery disease, diabetes mellitus, hypertension, or smoking. An echocardiogram performed 6 months earlier showed an ejection fraction of 50% with no segmental wall motion abnormalities.
Two months after starting romosozumab, she developed subacute shortness of breath and orthopnea, without chest pain. ECG showed no ischemic changes; however, echocardiography revealed an ejection fraction of 25% with global hypokinesia, and CT coronary angiography showed no obstructive coronary artery disease.
Question 2: What is the most appropriate interpretation of this case?
*
A. The heart failure is definitely caused by romosozumab
B. The temporal relationship is sufficient to establish causality
C. Romosozumab should be considered a possible contributing factor, but the temporal association alone does not establish causality
D. Romosozumab should not be considered a possible contributing factor because heart failure is not a recognized as cardiovascular side event
Answer with a detailed explanation
B. The temporal relationship is sufficient to establish causality
- Therefore, this case can reasonably be classified as a
suspected/possible adverse drug reaction
, rather than a definitively drug-induced cardiomyopathy.
Reference:
- Saag KG, Petersen J, Brandi ML, et al. Romosozumab or alendronate for fracture prevention in women with osteoporosis. N Engl J Med. 2017;377:1417-1427.
- Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab treatment in postmenopausal women with osteoporosis. N Engl J Med. 2016;375:1532-1543.
Answer with a detailed explanation
C. Romosozumab should be considered a possible contributing factor, but the temporal association alone does not establish causality
- Therefore, this case can reasonably be classified as a
suspected/possible adverse drug reaction
, rather than a definitively drug-induced cardiomyopathy.
Reference:
- Saag KG, Petersen J, Brandi ML, et al. Romosozumab or alendronate for fracture prevention in women with osteoporosis. N Engl J Med. 2017;377:1417-1427.
- Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab treatment in postmenopausal women with osteoporosis. N Engl J Med. 2016;375:1532-1543.
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