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Are you old-old, young-young, young-old, or old-young?

Comment by Giuseppe Biondi-Zoccai, Population Science and Public Health Section

"No, that is the great fallacy: the wisdom of old men. They do not grow wise. They grow careful."
Ernest Hemingway

Preventive Cardiology

What defines healthy and happy old age, and especially being elderly without suffering from cardiovascular disease or risking cardiovascular events?(1) Several pieces of evidence support the importance of maintaining an active lifestyle, controlling risk factors (e.g. by avoiding cigarette smoking or other product of tobacco or nicotine-containing products), and preventing cardiovascular disease.(2) Patients are often given these recommendations, and they are commonly reinforced, but still many people cannot follow them duly.

Harb and colleagues, from the leading Cleveland Clinic, provide a compelling and 126,356-patient strong rationale for adopting and maintaining a healthy lifestyle, offering also physicians a uniquely useful tool to inform and motivate patients: age estimated from exercise testing (Figure 1).(3) In their carefully conducted and reported work, including patients undergoing exercise testing at their institution between 1991 and 2015, they highlight how prognosis was significantly predicted by chronological age, gender, history of coronary artery disease, diabetes mellitus, hypertension, statin use, end-stage renal disease, smoking, body mass index, peak exercise capacity, abnormal heart rate recovery, and chronotropic reserve index (all p<0.05). While this exercise in prognostic research is not novel in itself, and may miss important pieces of prognostic information,(4-6) it is still a useful reminder.

Most importantly though, Harb et al walk the extra mile and introduce an intriguing novel concept: age estimated by exercise testing (at odds from chronological age). Basically, exploiting readily available data from any exercise test (i.e. peak exercise capacity, abnormal heart rate recovery, and chronotropic reserve index), we can provide invidual patients an estimate of their age based on their stress-testing exercise performance (A-BEST). For instance, a 65-year-old lady with an A-BEST of 55 years will have a much better prognosis than a 50-year-old gentleman with an A-BEST of 60 years. Most importantly, A-BEST will be useful for supporting changes in a patient's lifestyle, and reinforce compliance (eg to diet and medication recommendations).

Despite the favorable implications of this work and similar ones, individual risk prediction remains challenging, and areas under the curve ranging around 0.80 still mean that 20% of patients will be inaccurately classfied. Accordingly, we should mantain a positive and constructive approach to patient risk-stratification and cardiovascular prevention, without falling into the trap of spurious precision. A beneficial adjunct could indeed be the addition of 95% confidence or credible intervals to individual point estimates of A-BEST.

In conclusion, while being young-young (i.e. young for chronological age as well as A-BEST) remains the best option, with the passing of time we should all aim to be and remain old-young (i.e. old for chronological age but young for A-BEST).

Figure 1. Secrets for healthy aging and improving age based on their stress testing exercise performance (A-BEST).




Giuseppe Biondi-Zoccai commented on this article:

3. Harb SC, Cremer PC, Wu Y, Xu B, Cho L, Menon V, Jaber WA. Estimated age based on exercise stress testing performance outperforms chronological age in predicting mortality. Eur J Prev Cardiol. 2019 Feb 13:2047487319826400. doi: 10.1177/2047487319826400. Epub ahead of print.

Other references:

1. Saglietto A, Manfredi R, Elia E, D'Ascenzo F, DE Ferrari GM, Biondi Zoccai G, Munzel T. Cardiovascular disease burden: Italian and global perspectives. Minerva Cardiol Angiol. 2021 Mar 11. doi: 10.23736/S2724-5683.21.05538-9. Epub ahead of print.
2. Roever L, Tse G, Biondi-Zoccai G. Walking or cycling to work to prevent myocardial infarction: Hope or hype? Eur J Prev Cardiol. 2020 May;27(8):820-821.
4. Nudi F, Iskandrian AE, Schillaci O, Nudi A, Di Belardino N, Frati G, Biondi-Zoccai G. Non-invasive cardiovascular imaging for myocardial necrosis, viability, stunning and hibernation: evidence from an umbrella review encompassing 12 systematic reviews, 286 studies, and 201,680 patients. Minerva Cardioangiol. 2020 Jul 8. doi: 10.23736/S0026-4725.20.05158-0. Epub ahead of print.
5. Xie X, Zhao Y, de Bock GH, de Jong PA, Mali WP, Oudkerk M, Vliegenthart R. Validation and prognosis of coronary artery calcium scoring in nontriggered thoracic computed tomography: systematic review and meta-analysis. Circ Cardiovasc Imaging. 2013 Jul;6(4):514-21.
6. Bombardini T, Zagatina A, Ciampi Q, Cortigiani L, D'andrea A, Borguezan Daros C, Zhuravskaya N, Kasprzak JD, Wierzbowska-Drabik K, De Castro E Silva Pretto JL, Djordjevic-Dikic A, Beleslin B, Petrovic M, Boskovic N, Tesic M, Monte IP, Simova I, Vladova M, Boshchenko A, Ryabova T, Citro R, Amor M, Vargas Mieles PE, Arbucci R, Dodi C, Rigo F, Gligorova S, Dekleva M, Severino S, Torres MA, Salustri A, Rodrìguez-Zanella H, Costantino FM, Varga A, Agoston G, Bossone E, Ferrara F, Gaibazzi N, Rabia G, Celutkiene J, Haberka M, Mori F, D'alfonso MG, Reisenhofer B, Camarozano AC, Salamé M, Szymczyk E, Wejner-Mik P, Wdowiak-Okrojek K, Kovacevic Preradovic T, Lattanzi F, Morrone D, Scali MC, Ostojic M, Nikolic A, Re F, Barbieri A, Di Salvo G, Colonna P, De Nes M, Paterni M, Merlo PM, Lowenstein J, Carpeggiani C, Gregori D, Picano E; Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging. Feasibility and value of two-dimensional volumetric stress echocardiography. Minerva Cardioangiol. 2020 Jul 10. doi: 10.23736/S0026-4725.20.05304-9. Epub ahead of print.

Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology