Arterial hypertension and hip fracture, a story of "dangerous friendships"

It is already known that starting a hypotensive treatment in the elderly constitutes a risk factor for falls, however the relation that it can have with the presence of hip fractures is not well known.

In this population study (*), with a retrospective longitudinal design in which cases are selected from a pharmacological database in Canada, elderly patients with new hypotensive treatments, recording as the main variable the appearance of a femoral fracture in the first 45 days, over a decade (from 2000 to 2009).

The sample size reached is 301,591 people, analyzing 1463 hip fractures, observing that those who start hypotensive treatment increase by 43% the risk of femoral fracture, mainly ACEI and beta-blockers, maintaining the risk despite the withdrawal of psychoactive drugs. The fracture incidence rate is 1.43 (IC95% 1.19-1.72), with the highest risk on days 15-44.

The fall is the main etiological factor of femoral fractures in more than 90% of cases, influencing the orthostatic hypotension in its production mechanism.

In another study (**) that analyses the risk of falls in the first three weeks after starting hypotensive treatment, it was found to be greater with thiazide diuretics and beta-blockers, not so much with ACE inhibitors, ARA II or calcium antagonists, with the beta-blockers being the same in both studies.

The conclusions that can be drawn from this study are several. On the one hand, the initiation of a pharmacological hypotensive treatment must be accompanied by a multifactorial intervention plan in the prevention of falls, detecting early the possible orthostatic hypotension and educating patients on how to detect and prevent it. In the selection of antihypertensive drugs in the elderly, the comorbidities, previous functional level and the relationship of the different mechanisms with falls and especially with femoral fractures must be taken into consideration. Paradoxically, ACEi and beta-blockers, the main interventions together with antiaggregation in the management of ischemic cardiopathy and heart failure, are the most related to fractures.

The need for adequate blood pressure control, which is clearly shown to reduce the incidence of cardiovascular events over a period of 5 to 10 years, must be balanced with the short-term risk of a hip fracture in the elderly, whose severity and level of disability may be greater than that of an acute myocardial infarction.

"Ignorance affirms or denies outright; science doubts. Voltaire (1694-1778)

(*) Butt D, Mamdani M, Austin P et al.The Risk of Hip Fracture After Initiating Antihypertensive Drugs in the Elderly. Arch Intern Med. 2012;172(22):1739-1744.

(**) Gribbin J, Hubbard R, Gladman J, Smith C, Lewis S. Risk of falls associated with antihypertensive medication: self-controlled case series. Pharmacoepidemiol Drug Saf. 2011;20(8):879-884.