**8.1 Pathophysiological mechanisms for increased fracture risk in patients with hypertension**

According to recent studies, both disorders may have the same etiopathology [75]. Additionally, some hypotensive medications may influence bone mineral density and exacerbate osteoporosis. There are several genetic and etiological similarities between osteoporosis and hypertension. Aging, menopause, and physical inactivity are risk factors for both hypertension and osteoporosis. Human and animal studies have shown that elevated blood pressure is linked to aberrant calcium metabolism, which increases urine calcium loss [76–79]. These hypertension-related anomalies may ultimately attribute to increased bone loss and decreased bone mineral density (BMD). The overall cumulative incidence of any fracture, hip fracture, and clinical vertebral fracture for men with hypertension was16.3, 3.3, and 5.7 per 1000 personyears compared with 11.3, 2.8, and 4.5 per 1000 person-years for those without hypertension, respectively [80–84].

In women, additionally, the cumulative total fracture incidence was greater in the hypertensive group compared to the non-hypertensive group (27.6 vs. 21.6 per 1000 person-years for any fracture; 5.7 vs. 1.1 for hip fracture, and 9.3 vs. 8.8 for vertebral fracture) [85].

In contrast to the non-hypertensive group, the cumulative incidence of any hip fracture in women was significantly higher in the hypertensive group [86].

There is a physiologic basis for the association between hypertension and osteoporosis. High blood pressure is linked to increased urinary calcium loss, which impairs the calcium balance necessary for bone remodeling. In fact, an epidemiological study discovered that elevated blood pressure was associated with an increased rate of mineral loss from the bone [87]. Furthermore, high levels of the parathyroid hormone are linked to hypertension and accelerated bone turnover, reducing bone mass, and bone quality. Finally, high blood pressure may gradually harm brain regions involved in balance and gait regulation, which could increase the risk of falls and consequent fractures. These findings imply that appropriately managed blood pressure may potentially promote bone health and protection against fragility fracture given those two closely associated medical problems [88–90].
