Abstract
While the fracture risk assessment tool (FRAX) is widely established for predicting fracture risk, its prognostic value is underexplored. This study aimed to investigate the association between FRAX scores and all-cause and cardiovascular mortality in a nationally representative cohort of older adults in the United States. We analyzed data from 1403 participants aged ≥60 years in the 2013 to 2014 cycle of the National Health and Nutrition Examination Survey, linked to mortality data up to December 31, 2019, from the National Death Index. Hip FRAX scores (for hip fracture probability) and Major FRAX scores (for major osteoporotic fracture probability) were calculated using Hologic version 3.05 FRAX. Survey-weighted Cox proportional hazards regression models were used to estimate the hazard ratio (HR) and confidence intervals (CI) for all-cause and cardiovascular mortality. During a median follow-up of 5.67 years, 207 (12.7%) participants died, including 72 (4.0%) due to cardiovascular causes. Time-dependent receiver operating characteristic curves indicated that Hip FRAX scores exhibited superior predictive accuracy compared with Major FRAX scores for both all-cause (area under the curve = 0.69 vs 0.61) and cardiovascular mortality (area under the curve = 0.74 vs 0.62; both P < .001). Restricted cubic spline analyses revealed significant dose-response relationships between Hip FRAX scores and all-cause mortality and cardiovascular mortality. After full adjustment, participants with high Hip FRAX scores (≥3%) had independently increased risks of all-cause (HR = 1.84; 95% CI: 1.10-3.07) and cardiovascular mortality (HR = 2.60; 95% CI: 1.42-4.75). Higher Hip FRAX scores are independently associated with increased risks of all-cause and cardiovascular mortality in older adults. Beyond its established role in fracture risk prediction, the Hip FRAX may serve as a valuable tool for broader health risk stratification in geriatric populations.