Authors: Aaron L. Troy, Timothy S. Anderson, Alexander C. Razavi, Stacey L. Schott, Jared A. Spitz, Roger S. Blumenthal
Categories: Commentary, Cardiovascular aging, Preventive cardiology, Hypertension, Dyslipidemia, Guidelines, Geriatric cardiology, Risk estimation, Cognition
Source: American Journal of Preventive Cardiology
Authors: Aaron L. Troy, Timothy S. Anderson, Alexander C. Razavi, Stacey L. Schott, Jared A. Spitz, Roger S. Blumenthal
Advances in cardiovascular disease (CVD) prevention have increased longevity among adults with hypertension and dyslipidemia [1]. These successes, alongside other factors driving global population aging, have expanded the number of older adults with cardiovascular risk factors and disease, a group historically underrepresented in both clinical trials and society guidelines [2,3]. The field of geriatric cardiology has grown in response to this need, generating and incorporating evidence to guide personalized CVD prevention and management in this high-risk population [4].
Some of this evidence has been incorporated in three recent major preventive the 2024 European Society of Cardiology (ESC) Guidelines for the Management of Elevated Blood Pressure and Hypertension (ESC BP Guideline), the 2025 American Heart Association (AHA)/American College of Cardiology (ACC)/Multisociety Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (AHA/ACC BP Guideline), and most recently the 2025 Focused Update of the 2019 ESC/European Atherosclerosis Society Guidelines for the Management of Dyslipidemias (ESC/EAS Dyslipidemia Guideline) [[5], [6], [7]]. Geriatric cardiology has embraced the American Geriatrics Society’s framework for core competencies in aging care, the Geriatric 5Ms: Mind, Mobility, Medications, What Matters Most, and Multicomplexity [8]. Developed to distill the volume of geriatric assessments and interventions into an easily applicable approach, this tool has been embraced across medical specialties and health systems, including the Age-Friendly Health Systems Initiative [4]. In this article, we will use the Geriatric 5Ms framework to spotlight key updates and evidence from the recent guidelines that support personalized preventive care for healthy cardiovascular aging (Fig. 1).Fig. 15Ms for Healthy Cardiovascular Aging. A framework applying the Geriatric 5Ms to tailor preventive strategies to promote healthy cardiovascular aging, adapted with permission from Tinetti et al. J Am Geriatr Soc, 2017. Created in BioRender. https://BioRender.com/u6l67fc.Fig 1
Cognition is a key patient-centered outcome that is amenable to preventive cardiovascular interventions including BP and lipid lowering. Hypertension is the primary risk factor for small vessel cerebral ischemia and cortical white matter abnormalities that are highly predictive of dementia [7,9]. The AHA/ACC BP Guideline includes a new class 1A recommendation for a systolic BP goal <130 to help prevent mild cognitive impairment and dementia, reflecting the robust supporting evidence; a recent meta-analysis and subsequent large trials demonstrated a 12-19 % reduction in dementia incidence with relative systolic BP reductions of 7-21 mmHg [10]. In SPRINT-MIND, systolic BP reduction with a target of <120 mmHg reduced the incidence of early cognitive decline, with decreased risk of mild cognitive impairment over a median follow-up of 7 years [11].
Although the ESC/EAS Dyslipidemia Guideline does not explicitly discuss cognitive impairment, the benefit of lipid-lowering therapy for prevention of stroke, a key dementia driver, is emphasized throughout. Future guidelines should consider doing so in light of a recent comprehensive meta-analysis, including 55 studies and more than 7 million patients, that found statin use to be linked with lower risks of dementia (HR 0.86 [95 % CI 0.80-0.88]. ) and Alzheimer’s disease (HR 0.82 [95 % CI 0.74-0.90]. ) [12]. The message is statins and LDL-reduction lower dementia risk, and healthy vascular aging supports healthy cognitive aging. This patient-centered benefit should be central to shared decision-making conversations with patients [13].
Maximizing physical activity is a high-benefit, low-risk approach to support healthy cardiovascular aging, with demonstrated blood pressure and lipid-lowering benefits. The ESC/EAS Dyslipidemia guideline newly mentions physical inactivity as a key risk modifier to guide preventive therapy. In the older hypertensive population, unfortunately, fear of falling is common and contributes to physical and social inactivity [14]. The ACC/AHA and ESC Blood Pressure Guidelines include new sections on orthostatic hypotension, with differing recommendations around this condition that affects 7-10 % of community-dwelling hypertensive older adults and can limit mobility, promote falls, and complicate treatment.
The AHA/ACC BP Guideline emphasizes the benefits of intensive treatment, recommending improved BP control to reduce risk of orthostatic hypotension based on a robust meta-analysis of 31,043 participants across hypertension trials, maintaining systolic BP <130 in asymptomatic orthostatic hypotension, and assessing for symptomatic orthostatic hypotension to detect other chronic conditions [15]. The ESC BP Guideline explicitly recommends testing for orthostatic hypotension by having the patient sit or lay down for 5 minutes then measuring BP after 1 and/or 3 minutes after standing before starting or intensifying any BP lowering medication. It also includes a class 1A recommendation for nonpharmacological approaches including maximally tolerated physical activity and time upright, changing position slowly, hydrating adequately, avoiding alcohol and large meals, and considering a switch to alternative lower-orthostatic risk antihypertensive medications for first line management of orthostatic hypotension based on smaller randomized studies and post-hoc analyses [6].
The ACC/AHA and ESC guidelines agree that patients with orthostatic hypotension should be assessed for neurogenic drivers such as neurodegenerative diseases, diabetes, and B12 deficiency and non-neurogenic drivers such as renal failure, dehydration, deconditioning, and medications. Specifically, ACE-inhibitors, angiotensin-receptor blockers, and dihydropyridine calcium channel-blockers are favored over alpha blockers, beta blockers, diuretics, and nitrates in this population. Deprescribing antihypertensive therapy is not recommended, as intensive BP-lowering did not increase orthostatic hypotension in major trials. However, facility-dwelling older adults and those with moderate-severe frailty were underrepresented and have higher risks of falls, meriting further research.
Overall, the AHA/ACC and ESC recommendations on orthostatic hypotension are complementary, together offering a patient-centered approach to maximize both functional and cardiovascular benefit, targeting BP <130/80 in community-dwelling older adults using lower-risk medications while treating reversible causes and maximizing nonpharmacologic measures. And, across the BP and dyslipidemia guidelines, maximizing mobility and physical activity is a top priority to support healthy cardiovascular aging.
Polypharmacy (>5 medications), and hyperpolypharmacy (>10 medications) are associated with decreased functional capacity and quality of life in older adults with CVD, driven by increased risk of adverse effects, interactions, and nonadherence [16]. However, rather than hesitation to initiate indicated therapy, polypharmacy should trigger thoughtful medication optimization, prioritizing therapies with evidence-based risk-benefit ratios in the older population over those for which risks equal or outweigh benefits. Although only the ESC BP Guideline mentions polypharmacy explicitly, all three guidelines offer insights to support refined medication management in older adults. The AHA/ACC and ESC BP Guidelines emphasize single-pill combinations rather than stepped-care therapy for patients requiring multiple BP-lowering agents. Single-pill combinations reduce pill burden, improve adherence and BP control, and are associated with fewer cardiovascular and non-cardiovascular events [17].
The ESC/EAS Dyslipidemia Guideline includes a strong focus on trials of non-statin lipid-lowering therapies; however, many of these lacked adequate older adult representation. Two exceptions are the EWTOPIA 75 and OMEMI Trials, which together represent the nascent randomized literature-base for non-statin therapies in this population. In the open-label EWTOPIA 75, 3,795 adults aged >75 years with elevated LDL-C (mean 161 mg/dL), without coronary artery disease and mostly on concurrent statin therapy, were randomized to receive vs. not receive ezetimibe [18]. Ezetimibe was associated with a 26 % reduction in LDL-C and an improvement in four-point major adverse cardiovascular events over approximately 4 years of follow-up from 7.8 % in the control group to 5.2 % in the ezetimibe group (p=0.002), as well as very low risk of adverse events but no difference in the secondary outcomes of all-cause and cardiovascular mortality. The OMEMI Trial found that adding omega-3 fatty acids for 1,027 patients age 70-82 with recent myocardial infarction did not reduce the composite of nonfatal myocardial infarction, unscheduled revascularization, stroke, all-cause death, and heart failure hospitalization after 2 years [19].
Research around deprescribing remains a key priority to support optimal balance of CVD prevention and polypharmacy. A Danish cohort study including over 67,000 long-term statin users with median age 79 found statin discontinuation to be associated with higher rate of major adverse cardiovascular events compared with statin continuation in both primary and secondary prevention populations [20]. However, for patients without recent cardiovascular decompensation and estimated prognosis of 1 month to 1 year, a randomized controlled trial found statin discontinuation improved quality of life and provided costs savings without significant differences in mortality [21]. For antihypertensive therapy, the recently published RETREAT-FRAIL randomized controlled trial of an antihypertensive treatment step-down strategy among nursing home residents in France age >80 receiving 2 or more antihypertensive drugs and systolic BP <130 found no change in mortality or adverse events between the arms [22].
Medication optimization, with consideration of single-pill combinations, deprescription of lower net benefit cardiovascular and non-cardiovascular therapies, and selection of medications like ezetimibe with demonstrated benefit in older populations over other adjunct lipid-lowering therapies, represent a guideline-supported approach to reduce polypharmacy and support healthy cardiovascular aging.
As individuals age chronologically and biologically, the risks of both cardiovascular and non-cardiovascular diseases and adverse treatment outcomes increase. Moreover, heterogeneity in cardiovascular and non-cardiovascular multimorbidity increase with age as individuals accrue risk along divergent lifetime exposure trajectories [23]. This amplifies the importance of shared decision-making when initiating or intensifying BP or lipid-lowering therapy in an older patient, an approach emphasized across recent preventive guidelines. Shared decision-making (SDM) requires a collaborative, iterative experience between individuals, particularly patients and clinicians, that allows patients to compare the individualized benefits and risks of available therapies and select an approach that best fits their values and preferences [24]. Advances in cardiovascular risk assessment enable more precise estimation of patient-centered benefits related to BP and lipid-lowering, and risk assessment tools can be incorporated into a SDM model to ensure elicitation of what matters most.
The AHA/ACC BP Guideline incorporates the PREVENT Equations, developed and validated in a population of ∼6.6 million US adults between ages 30-79, that provide high-fidelity risk estimates of both atherosclerotic CVD events (myocardial infarction and fatal coronary heart disease) and incident heart failure [25]. Although recently demonstrated to have improved accuracy compared with the Pooled Cohort Equations in adults age >79, the PREVENT equations were not developed and validated for this age group [26]. In contrast, the ESC BP Guideline and ESC/EAS Dyslipidemia Guideline recommend using the SCORE2-OP (Systematic Coronary Risk Evaluation 2-Older Persons) models to estimate risk of cardiovascular mortality and non-fatal myocardial infarction or stroke for people age 70-89.
The model coefficients for SCORE2-OP were derived in the Cohort of Norway study (n = 28,503) and then recalibrated to four geographical risk regions across and beyond Europe. SCORE2-OP was then validated in prospective cohorts across risk regions (n = 211,184 total), adjusting for competing risk and age-interactions for all risk factors. Although SCORE2-OP was not developed in a US cohort, three of the six studies included in the validation cohort are US-based (ARIC, MESA, SPRINT). And, in contrast to PREVENT, SCORE2-OP does not estimate risk of incident heart failure.
For many decisions, the benefits of BP and lipid-lowering therapies are clear. The ESC BP Guideline emphasizes that for adults age <85 without moderate to severe frailty the benefits of BP lowering are evidence-based and that standard guideline recommendations apply. The AHA/ACC BP Guideline recommends medication initiation for adults with BP >140/90 mmHg to reduce risk of dementia and orthostatic hypotension, as well as coronary artery disease, heart failure, atrial fibrillation, stroke, and chronic kidney disease. The ESC/EAS Dyslipidemia Guideline emphasizes lipid-lowering therapy in all patients at “very high risk” with LDL-C >70 to reduce risk of atherosclerotic CVD events and mortality.
For older patients in whom the benefit-to-risk ratio of preventive therapies is uncertain, PREVENT and SCORE-2 OP can help refine CVD risk estimation and individualize decision- making about BP and lipid lowering. The AHA/ACC BP Guideline recommends medical therapy for adults with stage II HTN or stage I HTN and diabetes, CKD, predicted 10-year CVD risk of >7.5 % by PREVENT, or <7.5 % if BP is not at goal after 3-to-6-months of lifestyle modification. The ESC BP Guideline correspondingly considers SCORE2-OP >10 % to represent elevated risk. Similarly, the ESC/EAS Dyslipidemia Guideline considers individuals with SCORE2-OP between 10 and 20 % to be high risk and recommends a target LDL-C <100.
For CVD prevention in US older adults, the current evidence supports using a ≥7.5 % 10-year CVD risk by PREVENT to identify elevated risk through age 79. For patients age 80 and above, a ≥10 % risk threshold by SCORE2-OP can be used, calibrating to the US by selecting “High-Risk” region (150-299 age-adjusted CVD deaths per 100,000), given the age-adjusted CVD mortality in the US of 224.3 per 100,000 in 2022 [27]. Given the heavily age-weighted nature of both PREVENT and SCORE2-OP, these scores may overestimate risk for many older adults, necessitating additional risk modifiers to capture benefit heterogeneity and guide personalized therapy.
For older adults in whom benefits remain unclear after assessing for diabetes, chronic kidney disease, and predicted risk using PREVENT or SCORE2-OP, risk modifiers can help personalize assessment of potential gains from BP and lipid lowering. The ESC/EAS Guideline recommends assessing risk modifiers common in older adults such as social isolation, physical inactivity, and psychosocial stressors. Moreover, assessment for imaging evidence of cardiovascular aging using coronary artery calcium (CAC) scoring, a marker of vascular aging, and left ventricular hypertrophy, a marker of myocardial aging, can help capture patient heterogeneity. Specifically, CAC scoring is recommended in the European BP and Dyslipidemia Guidelines for patients in whom it is likely to change management [28]. For example, CAC scoring could impact management in older patients with polypharmacy and intermediate risk by PREVENT or SCORE2-OP, for whom a markedly elevated CAC score (>300) would reflect similar potential treatment benefit to secondary prevention and favor statin initiation. Alternatively, for patients who seem low-risk but have elevated predicted risk due to the equations’ age-weighting, a CAC score of 0 or low percentile for age could “de-risk” and support lifestyle over medical therapy [29,30]. The ESC and ACC/AHA BP Guidelines also recommend assessing for left ventricular hypertrophy for patients in whom further risk stratification could impact antihypertensive prescription [28]. PREVENTABLE and STAREE, ongoing landmark trials assessing benefits of statins for primary prevention in older adults, include robust assessment of risk modifiers including CAC to support individualized applications of their results [31,32].
Using a shared decision-making model with patients that incorporates PREVENT or SCORE2-OP, risk modifiers, and imaging evidence of cardiovascular aging can help estimate and communicate how BP or lipid lowering therapies might align with their personal health goals and assist in developing a treatment plan that clearly reflects what matters most.
Effective shared decision-making requires evaluation of patient-specific risks associated with BP and lipid-lowering therapies. With advancing age, patients face increasing and heterogeneous burdens of clinical and social multicomplexity that increase risk of adverse cardiovascular and non-cardiovascular events, epitomized by the frailty syndrome.
The ESC BP Guideline includes an in-depth section on “Very old age (>85 years), frailty, multimorbidity, and polypharmacy” that should serve as a blueprint for incorporating geriatric cardiology principles into future guidelines. The committee embraced the phenotypic definition of frailty as an age-associated biologic syndrome characterized by decreased reserves due to dysregulation of several physiologic systems [33]. Frailty is modifiable and has a robust bidirectional relationship with CVD [34]. The ESC BP Guideline recommends the clinical frailty scale, a quick and intuitive 9-point scale based on physical activity and functional status and recommends dividing patients into two 1-5 who are fit to mildly frail vs. 6-9 who are moderately to severely frail (Fig. 2) [35].Fig. 2Frailty assessment to support shared decision-making for cardiovascular prevention. Adapted with permission from “2024 ESC Guidelines for the Management of Elevated Blood Pressure and Hypertension [6,35]”. Created in BioRender. https://BioRender.com/0djgybz.Fig 2
The AHA/ACC BP Guideline specifically recommends clinician-patient assessment of potential benefits and harms of BP lowering therapy in older adults with frailty or limited life expectancy (can be estimated using ePrognosis.org, for example) to align care with patient goals. Similarly, the ESC BP Guideline recommends caution when initiating BP-lowering therapy in the setting of moderate-to-severe frailty, symptomatic orthostatic hypotension, and age >85, and clarifies that this caveat arises from lack of randomized evidence to support net benefit in this population. The ESC/EAS Dyslipidemia Guideline does not explicitly discuss frailty or advanced age; however, recent evidence has demonstrated CAC to be a powerful tool to stratify cardiovascular and competing non-cardiovascular risk in the setting of multimorbidity, with CAC score of 0 suggesting higher likelihood of non-cardiovascular than cardiovascular mortality [29,36].
In the SPRINT trial, rates of serious adverse events including hypotension, syncope, electrolyte abnormalities, and acute kidney injury were more common in the intensive treatment arm; however post-hoc analysis found no significant interaction between frailty and risks for serious adverse events with intensive treatment [37,38]. In the STEP trial of intensive BP lowering in Chinese adults age 60-80, there was no difference in adverse events between the two arms, aside from hypotension which was more common in the intensive arm [39]. Other meta-analyses, however, have suggested that the benefit to risk ratio may decrease with advanced age and frailty. A meta-analysis of nine observational studies including over 20,000 older adults found no mortality difference in BP <140 vs. >140 among frail patients, while a difference was seen for non-frail patients [40]. Additionally, a recent patient-level meta-analysis that included over 80,000 patients found treatment-related adverse events to be more common in adults age >65 and the net benefit of intensive BP lowering to decrease with advancing age [41].
Importantly, however, the potential harms of intensive BP lowering reflect medical rather than lifestyle interventions. Physical activity, including aerobic and resistance training, both lowers BP and cholesterol and improves frailty [42,43]. A diet low in saturated fat with a focus on whole grain products, vegetables, fruit, and fish is recommended across guidelines and, especially with an emphasis on natural sources of protein, can improve frailty as well [44]. Team-based care that addresses multicomplexity, including health-related social needs, is also an optimal approach for treating hypertension, dyslipidemia, and frailty [23].
Taken together, quantitative assessment of frailty and prognosis capture heterogeneity in biologic aging, helping individualize risk of adverse effects of BP and lipid lowering therapies. These personalized risk estimations should be included in shared decision-making conversations alongside potential benefits and elicitation of values to guide therapeutic selection. That said, intensive lifestyle and health-related social needs interventions should be emphasized for all patients to support healthy cardiovascular aging, and there is no evidence to support denying preventive pharmacotherapies to patients with advanced age and frailty.
Seen through the lens of geriatric cardiology, the ESC BP Guideline, AHA/ACC BP Guideline, and ESC/EAS Dyslipidemia Guideline provide excellent guidance to support personalized CVD prevention in older adults. BP and lipid lowering have clear cognitive benefits, supporting a healthy heart and Mind. BP lowering with medications that carry lower risk of orthostatic hypotension while optimizing non-pharmacologic therapies and secondary orthostasis workup can support patients’ Mobility. Single-pill combinations and both prescription and deprescription based on evidence in the geriatric population are essential to optimizing Medications and reducing polypharmacy.
SCORE2-OP, PREVENT, risk modifiers, and imaging assessment of cardiovascular aging can help assess benefits of BP and lipid-lowering therapies to achieve what Matters Most for our patients. And finally, assessing frailty using the simple Clinical Frailty Scale and targeting BP and frailty with lifestyle and health-related social needs interventions can address older patients’ Multicomplexity and inform shared decision-making. As the body of research grows across the 5Ms in geriatric cardiology, future guidelines should proactively incorporate this evidence, supporting healthy cardiovascular aging across the global population.
Dr. Troy was supported by the National Heart, Lung, and Blood Institute Ruth L. Kirschstein Institutional National Research Service Award T32-HL007227. Dr. Anderson is supported by the National Institutes on Aging Paul B. Beeson Emerging Leaders Career Development Award in Aging K76-AG074878. Dr. Razavi is supported by the National Heart, Lung, and Blood Institute grant L30-HL175751. Dr. Schott serves as a consultant to the American College of Preventive Medicine and was a Writing Committee Member for the 2025 AHA/ACC Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Dr. Spitz reports no pertinent funding or disclosures. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Department of Veterans Affairs.
Aaron L. Troy: Writing – review & editing, Writing – original draft, Conceptualization. Timothy S. Anderson: Writing – review & editing. Alexander C. Razavi: Writing – review & editing. Stacey L. Schott: Writing – review & editing. Jared A. Spitz: Writing – review & editing. Roger S. Blumenthal: Writing – review & editing, Conceptualization.
The authors declare the following financial interests/personal relationships which may be considered as potential competing
Aaron L. Troy reports financial support was provided by National Heart Lung and Blood Institute. Timothy S. Anderson reports financial support was provided by National Institute on Aging. Alexander C. Razavi reports financial support was provided by National Heart Lung and Blood Institute. Stacey L. Schott serves as a consultant to the American College of Preventive Medicine and was a Writing Committee Member for the 2025 AHA/ACC Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Roger S. Blumenthal is a Co-Chair of the 2026 ACC/AHA/Multisociety Dyslipidemia Guideline. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.