How to keep your heart healthy well into old age

The heart works for a lifetime without us paying it much attention in our daily lives. With every beat, it supplies organs and tissues with oxygen and nutrients. But as we get older, the heart and blood vessels also change. Vessel walls lose elasticity, deposits can form, and certain diseases become more common.

However, how well the heart functions in old age does not depend on years of life alone. Genetic predispositions play a role, as do blood pressure, blood lipid levels, metabolism, exercise, diet, and sleep. Many of these factors can be influenced, even if you only start in the second half of life.

Heart health is therefore not a short-term project. It develops over decades and is shaped by the interplay of various influences.

Table of Contents

1. How the heart and blood vessels change over the course of life
2. Which risk factors particularly influence heart health
3. Exercise as a long-term factor for a healthy heart
4. Diet and heart health
5. Smoking, alcohol, and other avoidable stressors
6. Sleep, stress, and social relationships
7. Which screening tests are useful in old age
8. Why medical treatment is sometimes part of it
9. Heart health is a long-term task
10. Sources

How the heart and blood vessels change over the course of life

With increasing age, the structures that enable blood circulation change. This is particularly evident in the large arteries. Their elastic fibers often lose their resilience, causing the vessel walls to become stiffer. This means the heart has to work against greater resistance. Systolic blood pressure, i.e., the pressure during the heart's contraction, can rise.

The heart muscle can also become somewhat stiffer. This changes its ability to relax and fill with blood between two heartbeats. Such changes are part of the normal aging process, but can be exacerbated by diseases such as high blood pressure, diabetes, or coronary heart disease.

Atherosclerosis and its consequences

A key factor in heart health is atherosclerosis, a form of arteriosclerosis. In this condition, fats, cholesterol, immune cells, and connective tissue accumulate in the inner layer of the arterial wall. So-called plaques form, which can narrow the vessel and change its structure.

An important starting point is the deposition of LDL particles in the vessel wall. There, they can trigger inflammatory reactions. Immune cells take up the deposited lipids and partially develop into so-called foam cells. Over time, this can lead to the formation of an atherosclerotic plaque.

It becomes particularly problematic if a plaque ruptures or its surface is damaged. Then a blood clot can form, which severely restricts blood flow or completely closes a vessel. If this affects a coronary artery, a heart attack can occur. If blood supply to the brain is interrupted, an ischemic stroke can occur.

Atherosclerosis usually develops over many years. In addition to age, it is primarily influenced by elevated LDL cholesterol levels, high blood pressure, smoking, and elevated blood sugar levels.

Which risk factors particularly influence heart health

Cardiovascular diseases are rarely caused by a single trigger. Usually, several factors come together, which can reinforce each other. Among the most important modifiable risks are high blood pressure, elevated LDL cholesterol levels, smoking, diabetes, lack of exercise, and obesity.

High blood pressure and the strain on the vessels

High blood pressure is one of the most significant risk factors for cardiovascular diseases. If the pressure in the arteries remains permanently elevated, the heart and vessels have to work harder in the long term. The vessel walls can change, and the heart muscle has to pump against greater resistance.

Over time, the muscle of the left ventricle can thicken. This so-called left ventricular hypertrophy can initially help compensate for the increased strain. In the long term, however, it can impair the relaxation and filling of the heart.

High blood pressure often causes no noticeable symptoms. Therefore, it makes sense to have the values checked regularly. Individual measurements are not always sufficient for a reliable assessment. If the values are unusual, repeated measurements at home or a long-term blood pressure measurement can help.

The 2024 guidelines published by the European Society of Cardiology distinguish, in addition to normal blood pressure and high blood pressure, a range of elevated blood pressure values. This takes into account that cardiovascular risk does not increase only from a single threshold. Whether treatment is necessary depends not only on the measured values but also on other risk factors and the individual health situation.

LDL cholesterol and vessel deposits

Cholesterol fulfills important tasks in the body. It is a component of cell membranes and serves as a starting material for certain hormones and bile acids. A permanently high concentration of LDL cholesterol in the blood is particularly problematic.

LDL particles can penetrate the vessel wall and contribute to the formation of atherosclerotic plaques there. The longer the vessels are exposed to elevated LDL, the greater the cumulative strain can be. Therefore, not only a single cholesterol value is relevant, but also the duration over which elevated values persist.

The causal role of LDL in the development of atherosclerotic cardiovascular diseases is well documented by genetic studies, observational studies, and randomized clinical trials. How much LDL should be lowered depends on the individual risk. People with pre-existing vascular disease generally require a different assessment than people with no known prior illnesses.

Blood sugar, insulin resistance, and metabolism

Metabolism also influences vessel health. With permanently elevated blood sugar levels, the inner walls of the blood vessels can be damaged. At the same time, a disrupted sugar metabolism promotes inflammatory processes and changes in lipid metabolism.

A key role is played by insulin resistance. Body cells respond less sensitively to insulin, so the pancreas initially has to secrete more of it to regulate blood sugar. Over time, this compensation can reach its limits. Type 2 diabetes can develop.

Diabetes is often accompanied by other risk factors, such as high blood pressure, unfavorable blood lipid levels, and visceral fat. This fat is located in the abdominal cavity and surrounds internal organs. It is metabolically active and can release messenger substances that are associated with chronic inflammatory processes and impaired insulin action.

Blood pressure, blood lipids, and blood sugar should therefore always be considered together.

Exercise as a long-term factor for a healthy heart

Regular physical activity is one of the best-studied influencing factors for cardiovascular health. Exercise supports blood pressure regulation, improves insulin sensitivity, and influences lipid metabolism. It also helps maintain muscle mass and physical performance.

Combining endurance and strength training sensibly

Walking, cycling, swimming, or dancing are examples of endurance activities that can be easily integrated into everyday life. The World Health Organization recommends that adults engage in at least 150 to 300 minutes of moderately intense or 75 to 150 minutes of intense endurance activity per week. In addition, the major muscle groups should be trained at least two days a week.

For people aged 65 and over, the WHO also recommends varied exercise at least three days a week that trains balance and functional strength. Such exercises are important for maintaining mobility and independence.

The key is not to immediately implement an extensive training program. Regular walks, short exercise sessions, and breaking up long periods of sitting also count. Those who have been inactive until now can start with small sessions and gradually increase the volume and intensity. If cardiovascular diseases are present, the appropriate level of exertion should be discussed with a doctor if necessary.

Diet and heart health

Diet influences lipid and sugar metabolism, blood pressure, and body weight. Here, individual foods matter less than the overall dietary pattern over a longer period.

The Mediterranean diet is particularly well studied. It focuses on vegetables, fruit, legumes, whole grains, nuts, seeds, and plant oils. Fish is eaten regularly, while red and processed meat are less common on the menu. Olive oil is an important source of fat.

Why the quality of fats is important

Fats differ in their composition. Saturated fatty acids are found in butter, high-fat dairy products, and certain meat products, among others. Monounsaturated and polyunsaturated fatty acids can be found in olive oil, rapeseed oil, nuts, seeds, and fish, for example.

Replacing some of the saturated fatty acids with unsaturated ones can influence LDL cholesterol. However, a single oil or food cannot compensate for an overall unhealthy diet.

Fiber and whole grains

Fiber is found mainly in whole grains, legumes, vegetables, fruit, nuts, and seeds. It contributes to longer satiety and can help prevent blood sugar levels from rising too sharply after eating. Oats, beans, lentils, vegetables, and whole-grain bread are therefore useful components of a heart-healthy diet.

Salt intake is also relevant. A high sodium intake can increase blood pressure. Those who frequently eat ready-made meals, highly processed foods, or salty snacks often consume more salt than they realize. Cooking yourself and seasoning with herbs, spices, and lemon can help reduce salt consumption.

What studies on the Mediterranean diet show

An important study on the Mediterranean diet is the PREDIMED study. People with increased cardiovascular risk were followed for several years. A Mediterranean diet supplemented with extra virgin olive oil or nuts was compared with a control group.

The results showed fewer severe cardiovascular events in the groups with a Mediterranean diet. The original publication had to be withdrawn due to methodological problems with randomization and was republished in 2018 with revised analyses. The corrected publication confirmed the general direction of the results. The study provides important insights, but should be interpreted cautiously due to its methodological peculiarities.

Smoking, alcohol, and other avoidable stressors

Smoking is one of the most significant modifiable risk factors for cardiovascular diseases. The harmful substances in tobacco smoke impair the function of the inner vessel walls, promote inflammatory processes, and promote the formation of blood clots. Secondhand smoke is also relevant to health.

Those who quit smoking end the regular intake of these harmful substances. The body then begins to recover gradually. How quickly individual risk factors change depends, among other things, on the previous smoking history and individual health status.

Alcohol can also strain the cardiovascular system. Regular or heavy consumption can increase blood pressure and is associated with heart rhythm disorders, especially atrial fibrillation. Long-term high alcohol consumption can also damage the heart muscle. Alcohol should therefore not be recommended as a means to improve heart health. Those who do not drink alcohol do not need to start for health reasons.

In addition to tobacco and alcohol, air pollution can also strain the cardiovascular system. Fine particles can promote inflammatory reactions and changes in vessel function. When engaging in outdoor activities, it can be useful to avoid heavily trafficked roads and use routes with as little traffic as possible.

Sleep, stress, and social relationships

Sleep is an important part of physical recovery. During the night, heart rate, blood pressure, and the activity of the autonomic nervous system change. Consistently too short or highly irregular sleep is more frequently associated with high blood pressure, obesity, diabetes, and cardiovascular diseases in observational studies.

For most adults, about seven to nine hours of sleep per night is used as a guideline. Individual needs can vary. Regular bedtimes and a quiet sleep environment can help support a stable sleep rhythm.

Chronic stress can also influence heart health. If a strain is perceived as threatening, the autonomic nervous system activates the sympathetic nervous system, among others. Heart rate and blood pressure rise. A permanently high level of stress can also be associated with sleep problems, lack of exercise, and unhealthy eating habits. Exercise, relaxation techniques, and conscious periods of rest can help to cope better with strain.

Social relationships are also part of the bigger picture. A 2023 meta-analysis summarized 90 prospective cohort studies involving more than two million people. Social isolation was associated with higher cardiovascular mortality. This analysis showed no corresponding significant association between loneliness and cardiovascular mortality. The results do not prove that social contact alone prevents cardiovascular disease. However, they show that social factors can be relevant to health.

Which screening examinations are useful in old age

Many risk factors for cardiovascular disease cause no symptoms for a long time. High blood pressure, elevated blood lipid levels, or early-stage diabetes can therefore go unnoticed for years. Regular screening helps to detect such changes early and better assess personal risk.

Important examinations include:

• Blood pressure measurement: It indicates how much the heart and blood vessels are stressed by the pressure in the circulatory system.
• Blood lipid levels: LDL cholesterol in particular is relevant for assessing vascular risk.
• Blood sugar and HbA1c: The HbA1c value provides information about the average blood sugar over the past two to three months.
• Kidney function: Impaired kidney function can increase cardiovascular risk.

How often these values should be checked depends on age, pre-existing conditions, and personal risk profile. Not every examination is necessary at the same intervals for everyone.

Assessing individual cardiovascular risk

A single laboratory value only tells us a limited amount about long-term heart health. For a sound assessment, several factors are considered together. These include age, sex, blood pressure, cholesterol levels, and smoking status, among others.

In Europe, risk models such as SCORE2 and SCORE2-OP are available for this purpose. They estimate the probability of certain cardiovascular events within the next ten years. SCORE2 is used for generally healthy adults under 70 years of age, while SCORE2-OP is used for people aged 70 and over. Neither model is suitable for everyone, for example not for those with known cardiovascular disease or certain pre-existing conditions such as diabetes or chronic kidney disease.

Such models are decision aids and not individual predictions. Especially in older people, risk assessment should also take into account physical fitness, life situation, and personal treatment goals.

Why medical treatment is sometimes part of the solution

A heart-healthy lifestyle is an important basis of prevention. In certain risk situations, however, it is not enough on its own. High blood pressure, severely elevated LDL cholesterol levels, or diabetes may make medication necessary.

Blood pressure-lowering medications reduce the strain on the cardiovascular system. Statins and other lipid-lowering active ingredients can lower LDL concentrations in the blood. For diabetes, medications are available that, in addition to controlling blood sugar, are also relevant for certain cardiovascular and kidney risks.

The decision to start treatment depends on individual risk and the expected benefit. Possible side effects, interactions with other medications, and personal life situation also play a role.

Blood pressure treatment in later life

The treatment of high blood pressure is also relevant for older people. An analysis of the SPRINT study specifically examined people aged 75 and over with high blood pressure but without diabetes. An intensive blood pressure treatment with a systolic target value below 120 mmHg was compared with standard treatment with a target value below 140 mmHg.

In the group receiving more intensive treatment, there were fewer major cardiovascular events and deaths during the study period. However, the participants were older adults living independently. The results therefore cannot easily be generalized to very old, frail, or dependent people.

Current European guidelines recommend a systolic target range of 120 to 129 mmHg for many treated adults, provided the treatment is well tolerated. For people aged 85 and over, those with severe frailty, symptomatic blood pressure drops when standing up, or limited life expectancy, less intensive targets may be appropriate.

The lowest possible blood pressure is not automatically the best blood pressure for everyone. Especially in later life, the benefits and possible risks must be weighed individually.

Heart health is a long-term task

How much the heart and blood vessels change with age does not depend on the year of birth alone. Blood pressure, LDL cholesterol, blood sugar, exercise, diet, sleep, and smoking shape cardiovascular health over many years.

What matters is a combination of regular exercise, a balanced diet, sufficient sleep, abstaining from tobacco, and appropriate medical screening. Social relationships and mental well-being are also part of this overall picture.

Heart health is not created by a single measure, but by the interplay of many factors. Those who know their risk factors, recognize changes early, and establish appropriate habits in the long term create a good foundation for cardiovascular health in old age.

Sources

• McEvoy, J. W. et al. (2024): 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. European Heart Journal, 45(38), 3912-4018. https://doi.org/10.1093/eurheartj/ehae178
• Visseren, F. L. J. et al. (2021): 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal, 42(34), 3227-3337. https://doi.org/10.1093/eurheartj/ehab484
• Ference, B. A. et al. (2017): Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. European Heart Journal, 38(32), 2459-2472. https://doi.org/10.1093/eurheartj/ehx144
• World Health Organization (2020): WHO Guidelines on Physical Activity and Sedentary Behaviour. https://www.who.int/publications/i/item/9789240015128
• Estruch, R. et al. (2018): Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. New England Journal of Medicine, 378(25), e34. https://doi.org/10.1056/NEJMoa1800389
• Williamson, J. D. et al. (2016): Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged 75 Years or Older: A Randomized Clinical Trial. JAMA, 315(24), 2673-2682. https://doi.org/10.1001/jama.2016.7050
• Wang, F. et al. (2023): A systematic review and meta-analysis of 90 cohort studies of social isolation, loneliness and mortality. Nature Human Behaviour, 7(8), 1307-1319. https://doi.org/10.1038/s41562-023-01617-6
• SCORE2-OP Working Group and ESC Cardiovascular Risk Collaboration (2021): SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions. European Heart Journal, 42(25), 2455-2467. https://doi.org/10.1093/eurheartj/ehab312