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Learning Objectives

  • Understand the basic conceptual similarities and differences between vascular aging and vascular disease.

  • Describe mechanisms by which vascular aging predisposes to atherosclerosis.

  • Understand the clinical manifestations of vascular aging versus atherosclerosis, including cognitive impairment, and systemic and functional manifestations.

  • Discuss the approach to managing vascular aging and age-related atherosclerosis.

Key Clinical Points

  1. Vascular aging is a distinct process that underlies the development of atherosclerosis and its clinical manifestations.

  2. Increased vascular stiffness is a consequence of vascular aging that leads to the development of age-associated conditions such as hypertension and heart failure.

  3. Emerging evidence points to potentially causal associations between vascular aging and geriatric syndromes such as cognitive impairment and frailty.

  4. Lifelong promotion of a healthy lifestyle is essential to delay and attenuate vascular aging and its complications.


A man is as old as his arteries.”

Thomas Sydenham, Father of English Medicine, 1624–1689

The notion, so succinctly expressed by Sydenham, that aging and cardiovascular pathology are intrinsically linked was first articulated thousands of years ago. Cardiac disease figures prominently in the Ebers papyrus from 1550 BC that describes medicine as practiced in ancient Egypt. Many cardiovascular syndromes can be recognized. For example, the following clearly describes angina pectoris: “If thou examinest a man for illness in his cardia and he has pains in his arms, and in his breast and in one side of his cardia … it is death threatening him.” Its accounts depict heart failure as a form of premature aging, and suggest apparent associations with cognitive impairment (in ancient Egypt, the heart was the center of knowledge and consciousness) and frailty: “His heart is overflooded. This means that his heart is forgetful like one who thinks something else,” and, “Weakness of old age…”

From the seventeenth to twentieth centuries, the work of Binswanger, Kraepelin, and Alzheimer established vascular disease as the major cause of senile dementia. Most recently, the contribution of vascular risk factors and disease to the development of the geriatric syndromes of frailty and dementia, including Alzheimer disease itself, has again come to the fore.

This chapter addresses vascular aging, and how changes in the structure and function of the arterial tree with age not only lead to atherosclerosis and its manifestations of coronary artery disease, peripheral vascular disease, and cerebrovascular disease, but also to the development of the important geriatric syndromes of frailty and cognitive impairment.


The development and progression of age-related atherosclerotic vascular disease results in most cases from a combination of genetic predisposition and cumulative chronic exposure to cardiovascular risk factors over the life course. With respect to genetic factors, it is important to note that a wide variety of genetic variants predispose to accelerated atherosclerosis ...

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