Findings support cardiovascular safety of alendronate as a first-line choice for osteoporosis treatment.

• In this propensity-matched cohort study and meta-analysis, patients were taken from the SIDIAP or CPRD database to assess the risk of acute myocardial infarction in patients taking osteoporosis medication.

• Relative to alendronate users, a 10% elevated risk of acute myocardial infarction was found in users of other bisphosphonates within CPRD.

• A 9% elevated risk in users of other bisphosphonate vs alendronate users was shown by the findings of meta-analysis of CPRD and SIDIAP.

• In the sensitivity analysis, an increased risk was found in selective oestrogen receptor modulators users with diabetes and chronic kidney disease.