Early atheroma prevention: a cost-effective approach to healthy cardiovascular ageing.

# Early atheroma prevention: a cost-effective approach to healthy cardiovascular ageing *The Lancet 2026* Comment Early atheroma prevention: a cost-effective approach to healthy cardiovascular ageing As the global population ages, older adults with resilience, as more powerful, proximate, preventive Published Online atherosclerotic cardiovascular disease (ASCVD) are goals. March 16, 2026 https://doi.org/10.1016/ projected to drive a growing proportion of morbidity, In recent guidelines, cardiology has embraced risk S0140-6736(26)00419-8 mortality, and health-care spending in the coming estimators, such as SCORE2, to identify patients years.1,2 Annual deaths from ASCVD are projected to who would benefit from early preventive therapies, rise substantially, from 20·5 million deaths in 2025 which are an improvement but remain insufficient to 35·6 million in 2050.3,4 As an emerging generation to promote global healthy cardiovascular aging. of clinicians caring for an increasingly complex aging Although these tools are low-cost risk stratification population, we see an opportunity to re-examine modalities, 10-year risk prediction in young people with primary prevention with a focus on lifelong healthy modifiable risk factors, such as dyslipidaemia, often cardiovascular aging. Rather than waiting for anginal do not reflect their disproportionately high 30-year symptoms or relying on advanced, high-cost testing, a ASCVD risk, which is quantified in the American Heart proactive approach to preventing atheroma formation Association’s PREVENT equations.13,14 Moreover, high throughout the life course with consideration of earlier LDL-C is associated with increased myocardial infarction lipid-lowering therapy and judicious assessment of risk- risk even in individuals younger than 39 years who are modifiers could both improve clinical outcomes and excluded from current cardiovascular risk estimators.15 lower health-care costs. Excluding these individuals from strong diet and Vascular aging is a progressive process of arterial exercise recommendations and early lipid lowering stiffening and endothelial dysfunction that, with represents a missed opportunity to promote vascular prolonged exposure to high low-density lipoprotein resilience and bend the cardiovascular aging curve. cholesterol (LDL-C), can promote development Generic statin therapy in people with dyslipidaemia is of atheroma, atherosclerosis, and ultimately cost-effective even in patients younger than 39 years cardiovascular disease and dementia.5,6 Vascular aging with hyperlipidaemia and an additional risk factor, is both linked to and distinct from chronological aging, suggesting that earlier population-level lipid lowering occurring at different rates in different people, driven could improve both health outcomes and costs.16–18 primarily by exposures throughout the life course.7 For patients at lower risk uncertain about starting Conversely, vascular resilience refers to the arterial lipid-lowering therapy or those at borderline estimated system’s ability to resist and recover from atherogenic 30-year risk, coronary artery calcium (CAC) assessment stress: namely plaque initiation, inflammation, or can be a helpful tool to support early, cost-effective disruption.8 Starting to lower cumulative LDL-C primary prevention. With relatively low radiation and exposure early with lifestyle modification and generic cost, CAC scoring identifies patients with calcified lipid-lowering therapy can promote healthy vascular subclinical atherosclerosis who would benefit from aging and vascular resilience; even among patients lipid-lowering therapy.19 Unfortunately, however, it at lower risk of ASCVD, reducing LDL-C by 1 mmol/L misses patients with early developing non-calcified over 5 or more years can substantially reduce the atheroma who have elevated long-term risk.20 Coronary risk of major vascular events including myocardial CT angiography does detect non-calcified soft plaque infarction, stroke, limb ischaemia, and mortality.9–12 and has shown cost-effectiveness in diagnosing The evidence is clear: lower LDL-C is better for longer. atherosclerosis in patients with chest pain, but waiting Traditional disease and problem-based models of for symptoms represents a missed opportunity to care and reimbursement promote approaches that promote healthy cardiovascular aging at the subclinical do too little too late to curb the rising burden of stage.21 Alternately, expanding CT angiography to cardiovascular disease in older adults. Clinicians must support population-level primary prevention would aim to slow vascular aging and promote vascular risk additional harms and disparities, carrying higher Comment and deprescription in the setting of advanced age and multimorbidity, assessing patient priorities is foremost, weighing medication burden against longevity, cognitive health, and time at home, given the 33% increased risk of cardiovascular hospitalisation with statin deprescription.27 Non-pharmacological strategies, however, remain universally applicable with advancing biological age given salutary effects across cardiovascular and geriatric conditions, including maximising physical activity, optimising nutrition, and addressing health-related social needs.22 The healthy vascular aging paradigm aligns with the Lancet Commission on rethinking coronary artery disease, as well as recent guidelines.28 The 2025 European Society of Cardiology–European Atherosclerosis Society (ESC–EAS) Focused Update of the 2019 Guidelines for the management of Dyslipidaemias lowered the 10-year predicted ASCVD risk threshold for consideration of lipid-lowering therapy compared with the 2018 US guidelines. It recommends that lipid-lowering therapies be considered for patients with a 2% estimated 10-year risk of a cardiovascular event and LDL-C of 116 mg/dL rather cost, radiation, and renal risk than CAC.22 Shifting than the previous threshold of 190 mg/dL.29 Clinicians the focus from treating plaque to promoting healthy stewarding the next era of cardiovascular care should vascular aging offers clinicians a helpful paradigm to embrace these lower thresholds, leading a generational start preventive therapies early without unnecessary shift to a more cost-effective, atheroma-targeting testing; for patients with sufficient ASCVD risk to approach that promotes healthy vascular aging and warrant coronary imaging, why wait for imaging- resilience.29 detectable atheroma to maximise healthy lifestyle and At the patient level, clinicians should consider statin lower the cumulative lifetime exposure to LDL-C? therapy at the lower risk thresholds recommended in Focus on promoting vascular resilience also highlights the ESC–EAS focused update, guided by 30-year risk in the need for tailored preventive strategies that young patients. This proactive approach, paired with evolve from youth to older age.7 As risk of adverse early and intensive focus on the rest of Life’s Essential 8 cardiovascular events rises with vascular aging, the (diet, exercise, tobacco, sleep, weight, blood sugar, and number needed to treat to prevent stroke, myocardial blood pressure) will improve lifespan and healthspan as infarction, limb ischaemia, cardiovascular mortality, well as lowering health-care costs.30 At the population and dementia decreases.23,24 Statins and ezetimibe level, future global guidelines should emphasise early both have shown efficacy and safety beyond age LDL-C lowering and tailor recommendations across 75 years, and SCORE2-Older Persons has been the life course to promote lifelong vascular resilience. validated across European populations to predict At the policy and systems levels, addressing social risk in this cohort.23,25 However, risks of medication determinants of cardiovascular aging is essential to adverse effects and polypharmacy also increase with improve global cardiovascular outcomes and equity.22 age and frailty, and the likelihood of patient-centred By embracing early cost-effective assessments and benefit from statin reduces, with life expectancy of interventions, this generation of emerging clinicians less than 2 years.26 Therefore, for clinicians engaging has the opportunity to bend the cardiovascular aging in shared decision making around statin prescription curve by shifting the target from treating established 1490 segamI ytteG aiv snoitcudorP oMoM Comment atherosclerosis to preventing atheroma and promoting 14 Krishnan V, Huang X, Perak AM, et al. 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