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928 renin ‐angiotensin ‐aldosterone system activation and dysregulation of osteoprotegerin. Consider‐ ation should also be given to increased oxidative stress as a common pathway to heart failure and osteoporosis. Population ‐based evidence shows increased oxidative stress is negatively associated with BMD11 and that antioxidants are decreased in women with postmenopausal osteoporosis.12 Likewise, oxidative stress is postulated to contrib‐ ute to atherosclerotic cardiovascular disease and cardiomyopathy risk,13 common causes of heart failure. Hyperparathyroidism, whether primary or secondary to another underlying cause such as vitamin D deficiency and / or renal disease, is another possible shared determinant.7,8 Vitamin D, known to be essential for calcium absorption and bone mineralization as well as cardiovascu‐ lar integrity as an antifibrotic and antihypertro‐ phic agent, is associated with both osteoporosis and heart failure incidence.7,8 However, the ab‐ sence of a benefit of vitamin D supplementation for heart failure prevention in the general popula‐ tion (including vitamin D–replete individuals) in randomized trials raises doubt about this mecha‐ nistic pathway,7 and further study is needed. Fi‐ nally, we would be remiss to neglect the fact that the association of osteoporosis and heart failure may be due entirely to shared risk factors. We noted a few limitations with this study. First, the study population was largely of Tai‐ wanese descent, thus limiting the generalizabil‐ ity of the findings to other races and ethnicities. The examined MESH terms did not include os‐ teoporotic fractures; in clinical practice, presence of a fragility fracture secures the diagnosis of os‐ teoporosis regardless of BMD. Thus, there may have been other published studies that were not included but might have shed more light on this important topic. One of the 3 cohort studies included14 was limited to persons with end ‐stage renal dis‐ ease (ESRD). This is problematic as the ESRD We were invited to comment on the systemat‐ ic review and meta ‐analysis by Gu et al1 exam‐ ining the risk of incident heart failure in per‐ sons with osteoporosis. Both heart failure and osteoporosis are prevalent disorders in the ag‐ ing population and cause substantial morbidi‐ ty, excess mortality, and considerable economic burden.2,3 Heart failure and osteoporosis or os‐ teoporotic fractures share some risk factors, in‐ cluding age,2,4 behavioral factors such as smok‐ ing and alcohol use,2,4 medication exposures such as systemic glucocorticoids,4,5 decreased exercise tolerance,4,6 hypovitaminosis D,4,7 re‐ nal disease,2,8 and diabetes.2,9 Whether there are common operative mechanisms underlying the development of heart failure and osteopo‐ rosis remains an area of study. Three cohort studies, 2 retrospective and 1 pro‐ spective, including 70 697 individuals, mainly of Taiwanese descent, were included in the sys‐ tematic review and meta ‐analysis by Gu et al.1 In these analyses, the authors report a modest in‐ creased risk of incident heart failure in persons with osteoporosis (HR, 1.17; 95% CI, 1.08–1.26), which remained significant in men (HR, 1.30; 95% CI, 1.05–1.62) but not in women (HR, 1.14; 95% CI, 0.94–1.37) in a gender ‐stratified anal‐ ysis. There was a significant association of in‐ creased risk of incident heart failure among pa‐ tients of Asian ethnicity with osteoporosis (HR, 1.18; 95% CI, 1.06–1.30), who comprised the ma‐ jority of the population included in the meta‐ ‐analysis. However, in the component prospec‐ tive study by Fohtung et al,10 there was an inverse association among Black men; lower total hip bone mineral density (BMD) was independently associated with a lower risk of heart failure (HR, 0.74; 95% CI, 0.59–0.94, for every 0.1 g/cm2 dec‐ rement in BMD). The pathophysiology of heart failure and os‐ teoporosis may share some common underpin‐ nings. Gu et al1 proposed 2 possible mechanisms: EDITORIAL

Heart failure and osteoporosis: an association that merits further study