Abstract-Cardiovascular disease and osteoporosis together account for most of the morbidity and mortality in our aging population despite significant improvements in treatment. Recently, converging lines of evidence suggest that these 2 diseases share an etiologic factor -that hyperlipidemia contributes not only to atherosclerotic plaque formation, but also to osteoporosis, following a similar biologic mechanism involving lipid oxidation. In vitro studies indicate that lipid products of oxidation promote osteoblastic differentiation of vascular cells and inhibit such differentiation in bone cells. [1][2][3][4][5][6][7][8][9] Although this association is often dismissed as a consequence of aging, the relationship remains significant after age adjustment in some 1,9 but not all 10 studies. Osteoporotic postmenopausal women are at significantly greater risk for cardiovascular disease than agematched controls. 11 Patients with lower bone density and osteoporosis also have higher lipid levels, more severe coronary atherosclerosis, and have a greater risk of stroke death. 2,3,[12][13][14][15] The common finding of simultaneous vascular calcification and osteoporosis in individual patients suggests that local tissue factors govern regulation of biomineralization.Bone and vascular tissue share several features at the molecular and cellular levels. Bone and marrow both contain endothelial cells, preosteoblasts, and monocyte-derived osteoclasts, all of which have counterparts in the artery wall. Both bone and atherosclerotic arteries contain osteopontin, bone morphogenetic protein, matrix Gla protein, collagen I, osteonectin, osteocalcin, nitric oxide, and matrix vesicles. Atherosclerosis and osteoporosis both involve recruitment and differentiation of monocytic cells that differentiate into macrophage-foam cells in artery and osteoclasts in bone. Each cylindrical unit of bone, the osteon, contains a central vessel lined with endothelial cells and a subendothelial matrix. Osteoblast progenitor cells are located immediately outside this matrix.The artery wall contains cells capable of differentiation into osteoblasts, following the same stages of differentiation as occur in bone-derived osteoblasts, and ultimately producing bone mineral. 16 The same oxidized lipids that induce atherosclerosis also induce mineralization and differentiation of the osteoblastic cells in the artery wall. 16 Consistent with this finding, hyperlipidemia is associated with vascular calcification in mice. 17 However, in bone and bone osteoblasts, osteoblastic differentiation is inhibited by oxidized lipids and hyperlipidemia. 16,18 Lipids have been shown to accumulate in bones of mice and around bone vessels in patients with osteoporosis. 19,20 Because the immature osteoblasts are located immediately adjacent to the subendothelial matrix of bone vessels, lipid accumulation in subendothelial matrix would be expected to inhibit differentiation of the bone-forming cells. In addition, because oxidized lipids induce endothelial expression of monocyte ...