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Broken hearts and bones: new insights or falling for unmeasured confounding?
  1. Joshua, R. Lewis1,2,3,
  2. Pawel Szulc4
  1. 1School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
  2. 2School of Public Health, The University of Sydney, Centre for Kidney Research, Sydney Medical School, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
  3. 3Medical School, University of Western Australia, Perth, Australia
  4. 4INSERM UMR 1033, University of Lyon, Hospices Civils de Lyon, Lyon, France
  1. Correspondence to Dr Joshua and R. Lewis, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia ; joshua.lewis{at}ecu.edu.au

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Most minimal trauma or osteoporotic fractures are due to low bone mass and/or quality combined with a fall from standing height or less. Osteoporosis is common in older men and women and combined with increased falls propensity during ageing leads to the dramatic rise in the risk of minimal trauma fracture in older men and women. Causes of falls in older men and women are often complex and can be due to loss of skeletal muscle mass and strength, acute and chronic illnesses, cardiovascular causes, medications, nutritional deficiencies and environmental hazards, either individually, or in combination.

While cardiovascular disease and minimal trauma fractures are generally thought of as independent diseases of old age, low bone mass and osteoporotic fracture are associated with cardiovascular events and deaths.1 The mechanism(s) underpinning this relationship are yet to be fully explained. However, there are shared genetic and modifiable risk factors, comorbid conditions and common signalling pathways regulating bone homeostasis and vascular wall repair. In particular, low bone mass is associated with greater abdominal aortic calcification, which is a marker of advanced atherosclerosis and future cardiovascular disease risk.2

The evidence linking cardiovascular disease to the long-term risk of minimal trauma fracture is conceptually similar to that of low bone mass and fracture with cardiovascular disease. However, there are subtle differences: (i) the skeleton is dependent on the vasculature for blood and nutrient supply with vascular disease and occlusion potentially leading to increased bone loss, (ii) the skeletal muscles are also dependent on the vasculature for blood and nutrient supply with vascular disease and occlusion potentially leading to decreased muscle function, (iii) cardiovascular disease can cause falls and increased falls propensity by mechanisms such as neurally mediated disorders and cardiac abnormalities of structure and function,3 (iv) abdominal aortic calcification is associated with decreased …

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