Atrial Fibrillation & Flutter

Matt Gayoso

Background

  • Definition: decreased bone mass leading to increased risk of fracture
  • Differential: malignancy (e.g., multiple myeloma), elder abuse (e.g., spiral fractures of long bones), hyperparathyroidism, Paget’s disease

Post-Menopausal Women

Pre-Menopausal Women
Risk Factors current smoker, >3 alcoholic drinks/day, chronic glucocorticoids (>4 weeks), previous fracture, parental history of fracture, RA, low-weight bearing status Female Athlete Triad (disordered eating, amenorrhea, bone loss)
Presentation height loss, fragility fracture (GLF, minor trauma) repetitive long bone stress fractures, atypical fractures (pubic ramus, femoral neck, non-metatarsal foot bones)
Screening all women 65yo+ (Grade B USPSTF) women<65yo w/ clinical risk factors via FRAX score (Grade B USPSTF)
Tests

Gold Standard: DEXA hip and lumbar spine

Labs: 25[OH]D, calcium, phos, albumin, total protein, LFTs (ALP), PTH
Diagnosis T score ≦ -2.5 at femoral neck or spine OR fragility fracture of vertebra, pelvis, wrist, humerus, rib
Management vitamin D supplementation, calcium if necessary, smoking cessation, weight bearing activity, Rx
Monitoring DEXA q 2 years (for osteoporosis), q 4 years (for osteopenia), q15 years (for normal BMD).

Evaluation

  • Interpretation of DEXA Score
    • Osteoporosis: T score ≦ -2.5
    • Osteopenia: -1.0 > T score > -2.5
    • Normal bone mineral density: T score  -1.0
  • Interpretation of FRAX (Fracture Risk Assessment Tool):
    • 10-year risk of major osteoporotic fracture (Google “FRAX tool.”)

Pharmacologic Management

  • Indications: T score ≦ -2.5 (osteoporosis) OR -1.0 > T score > -2.5 with FRAX>3% for hip fracture
  • First line: oral bisphosphonates (alendronate 10mg qd, at least 30min before food)
  • If eGFR<30: refer to endocrinology for IV zoledronic acid or IV denosumab
  • If severe (T score< -3.0): consider anabolic (e.g., teriparatide) as first line agent

Additional Information

  • There is currently no recommendation to screen men for osteoporosis.
  • Nodules that do not meet FNA criteria, US findings determine the timing for follow-up imaging:
    • High suspicion: 6-12mo
    • Low to intermediate suspicion: 12-24mo
    • Nodules >1cm with very ↓ suspicion OR pure cyst: >24mo if at all - Nodules <1cm with very ↓ suspicion OR pure cyst: no further imaging necessary
  • Nodules <1cm with very ↓ suspicion OR pure cyst: no further imaging necessary
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