Abstract
To determine if the revised US FRAX can identify those at high risk for fractures at any skeletal site, we studied 250 women and 249 men ≥40 years old from an age-stratified random sample of Rochester, MN residents. At baseline, femoral neck (FN) bone density was assessed, as were the clinical risk factors included in FRAX, along with additional fracture risk factors such as bone turnover markers and fall history. Fracture ascertainment through periodic interviews and comprehensive medical record review was performed over 10 years of followup. In both women and men, a higher FRAX probability at baseline was associated with greater subsequent likelihood of a major osteoporotic fracture. However, a relative 10% increase in the FRAX 10-year fracture probability was also associated with a 1.4-fold increase (95% confidence interval (CI) 1.1–1.7) in other fractures in women and a 1.7-fold increase (95% CI 0.8–3.1) in men. Furthermore, FRAX predicted asymptomatic vertebral fractures and fractures generally in both sexes. The addition of risk factors not currently included in FRAX did not appear to improve the accuracy of fracture risk prediction. FRAX may provide a conservative estimate of risk for major osteoporotic fractures, but it also predicts fractures generally.
Highlights
Most fractures arise in the intermediate-risk “osteopenic” population rather than among those classified as having osteoporosis by dual-energy X-ray absorptiometry (DXA) [1]
Potential changes were recently suggested to improve the accuracy of fracture prediction by FRAX, including incorporation of information about falls, additional causes of secondary osteoporosis, biochemical markers of bone turnover, bone mineral density (BMD) measurements at the lumbar spine (LS), and concurrent osteoporosis treatment [5]
The revised United States version of FRAX (US FRAX) provided a conservative estimate of fracture probability, but much of the discrepancy between the major osteoporotic fractures predicted and those observed could be accounted for by unusually complete ascertainment of symptomatic vertebral fractures in this population
Summary
Most fractures arise in the intermediate-risk “osteopenic” population rather than among those classified as having osteoporosis by dual-energy X-ray absorptiometry (DXA) [1]. To increase the assessment gradient-of-risk, and thereby improve both sensitivity and specificity [2], bone mineral density (BMD) has been combined with clinical risk factors in the World Health Organization’s fracture risk assessment tool, FRAX [3], which calculates a 10-year fracture probability (%). Like most such scoring systems, discordant results inevitably arise whereby some patients at predicted low risk will fracture and vice versa [4]. We examined whether other risk factors (e.g., bone turnover markers, fall history) add further predictive accuracy to FRAX
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