Ageing and the Heart

​Cardiovascular health is a central tenet of our functional independence, and cardiovascular ageing perpetually affects us all, in one way or another.

By Dr Wong Jie Jun, Senior Cardiology Resident and Assoc Prof Angela Koh, Senior Consultant, Department of Cardiology

By 2030, it is estimated that one in four Singaporeans will be aged 65 years and above. In tandem, the prevalence of ageing-related cardiovascular diseases is rising rapidly, bringing about adverse consequences of our personal quality of life, life expectancy, and broader downstream complications on our societal health and economic prosperity. 

The conventional approach to cardiovascular disease prevention has traditionally been guided by what we were taught in schools: early detection of cardiometabolic risk factors – such as diabetes, hypertension, high cholesterol, and guideline-directed treatment approach that targets specific risk factors.

However, ageing should deserve the same attention as these traditional risk factors, and not simply viewed as a non-modifiable risk that inevitably happens to all. From a developmental perspective, the effect of ageing on the cardiovascular system may occur far earlier than anticipated. Fatty streaks in the coronary arteries have been found as early as the second decade of life, while discernible cardiac stiffness have been detected in the fourth decade of life among otherwise healthy adults. In the heart muscle, the cells can undergo changes and scar tissue can build up, making the heart stiffer and less able to relax to fill with blood properly. Heart valves can similarly wear out and harden with calcium deposits, resulting in the inability to function properly. The electrical system can gradually fail to generate or conduct impulses necessary for our hearts to beat in a coordinated manner, which can lead to heart rhythm disorders. All these changes in the cardiovascular system of men and women increase their susceptibility to developing ageing-related diseases. Therefore, given the enormous impact of ageing on the cardiovascular system, addressing cardiovascular ageing ought to start much earlier than we used to think.

Instead of waiting to tackle risk factors, one approach would be to encourage healthy lifestyle behaviours early on, way before any risk factors appear. Recently, the American Heart Association recommended “Life’s Essential 8” checklist¹, a list of lifestyle behaviours to improve heart health. The eight steps include:

Adhering to this checklist has recently been found to impact biological ageing, which refers to the age of the cells in the body². This implies that these lifestyle behaviours can slow down the body’s ageing process; not only reducing risk of heart disease but also improving life expectancy and lowering the risk of death.

Apart from general lifestyle advice, experts also recognise a critical need for tailored approaches for the ageing heart for instance, in women versus men because the hearts of women age differently from men. Older women who generally have longer life expectancies, experience poorer health span in their later years, living through heart failure and its complications. As women age, their heart chambers tend to become smaller and the walls thicken, which can contribute to heart failure. In contrast, men tend to experience sudden heart failure with larger chambers. Some of these alterations have occurred as early as the fourth decade of life among women³. Notably, these cardiac ageing changes correlated with substances that are produced during metabolism, which are crucial for energy production in cells. Older women who had better cellular function (such as when body breaks down fats to produce energy) had healthier hearts. These findings highlight the need for preventive strategies to start earlier, and shed light on the direction of how we might go about to do so.

To sum up, understanding how the heart ages is crucial for our ageing population. The science is exceedingly promising, with developments such as personalised strategies to combat heart ageing on the horizon. Better cardiovascular health contributes to better overall physical, mental, functional health and independence. We anticipate significant benefits for our current and future populations if we can move forward together to develop impactful strategies based on collective science.

REFERENCES
1. Lloyd-Jones DM, Allen NB, Anderson CAM, Black T, Brewer LC, Foraker RE, Grandner MA, Lavretsky H, Perak AM, Sharma G, Rosamond W; American Heart Association. Life's Essential 8: Updating and Enhancing the American Heart Association's Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association. Circulation. 2022 Aug 2;146(5):e18-e43. 
2. Carbonneau M, Li Y, Prescott B, Liu C, Huan T, Joehanes R, Murabito JM, Heard-Costa NL, Xanthakis V, Levy D, Ma J. Epigenetic Age Mediates the Association of Life's Essential 8 With Cardiovascular Disease and Mortality. J Am Heart Assoc. 2024 May 29:e032743.
3. Ho JS, Wong JJ, Gao F, Wee HN, Teo LLY, Ewe SH, Tan RS, Ching J, Chua KV, Lee LS, Koh WP, Kovalik JP, Koh AS. Adverse cardiovascular and metabolic perturbations among older women: 'fat-craving' hearts. Clin Res Cardiol. 2023 Nov;112(11):1555-1567.

This article is from Murmurs Issue 47. Click here to read other articles or issues.