Centenarians delay, not dodge, cardiovascular disease, review finds

People who live to 100 and beyond are not spared cardiovascular disease so much as they postpone it, according to a review published in Nature Reviews Cardiology that synthesises what is known about the hearts, blood vessels, metabolism and immune systems of centenarians. The authors, led by Pedro Carrera-Bastos and Alejandro Lucia, argue that exceptional longevity offers a unique human model for understanding resilience to cardiovascular ageing, and that the centenarian phenotype is best understood as a composite of delayed pathology, adaptive compensation and survivorship selection rather than an outright escape from disease. The review’s central observation is a shift in timing rather than an absence of illness: conditions including hypertension, heart failure, atrial fibrillation and chronic kidney disease remain common among centenarians, but their onset is typically delayed relative to people aged 80 to 100 years. This distinction matters for interpretation, because many centenarians have survived to extreme age despite carrying cardiovascular risk factors, and the review cautions that diagnostic thresholds and treatment intensity developed for younger populations often require age-tailored interpretation in this group.

Structurally, centenarian hearts and vessels do show the expected marks of ageing. Studies summarised in the review describe concentric left ventricular remodelling, increased myocardial stiffness and vascular stiffening. What is striking, the authors note, is that these changes frequently occur without the burden of myocardial infarction or overt heart failure that such remodelling would predict in younger-old adults. Centenarians often display diastolic dysfunction alongside few overt clinical events, a pattern the review frames as adaptive compensation layered on top of genuine age-related change. The cardiometabolic profile of centenarian cohorts is generally favourable: the review reports preserved insulin sensitivity in cohorts with a low prevalence of diabetes mellitus, lipid levels in the mid-range, and a low prevalence of obesity compared with younger individuals. These characteristics, the authors suggest, may partly explain how structural cardiac ageing can progress without translating into the expected incidence of clinical events, although the review is careful to describe these as cohort-level observations rather than guarantees for any individual.

Beyond classical risk factors, the review highlights a distinctive inflammatory and gastrointestinal phenotype. Centenarians exhibit chronic low-grade inflammation, the phenomenon often called inflammageing, but this is counterbalanced by elevated anti-inflammatory signalling. Their gut microbiome composition more closely resembles that of younger adults, and intestinal barrier integrity appears preserved, features the authors describe as having cardioprotective characteristics. The persistence of inflammation alongside these compensatory adaptations is one of the clearest examples of the review’s central theme: resilience in extreme old age is not the absence of biological ageing but a rebalancing of it. Genetic and epigenetic findings reinforce that picture. The review concludes that exceptional longevity reflects highly polygenic contributions, with context-dependent genetic loci rather than single protective variants, alongside selective maintenance of genomic stability. Epigenetic clocks consistently indicate that centenarians’ biological age is markedly younger than their chronological age, and the authors characterise the regulatory maintenance underlying this as immune-centric, with immune system regulation occupying a central position in the longevity architecture.

The review also introduces an important interpretive caveat that shapes how all of these findings should be read. Survivorship selection means that centenarians are, by definition, a filtered population: individuals who died earlier from cardiovascular disease are absent from the cohort. Observations of favourable profiles in centenarians therefore reflect both genuine biological resilience and the statistical survival of resilient individuals, and the authors explicitly frame longevity observations through this lens of delayed pathology, adaptive compensation and survivorship selection rather than attributing everything to protective biology alone.

Looking forward, the review identifies two priorities for future research. The first is refining age-appropriate diagnostic thresholds, since criteria for hypertension and other cardiovascular conditions validated in younger populations may misclassify or overtreat the very old. The second is generating broader interventional data, because most current evidence in centenarians is observational, and the review notes that randomised or interventional studies in this population remain scarce. The authors suggest that understanding the biological, behavioural and environmental mechanisms underlying cardiovascular resilience in extreme longevity might ultimately inform strategies to extend cardiovascular healthspan across all ages, not only in centenarians themselves. For readers following the science of ageing, the review’s contribution is less a single discovery than a consolidated framework. It gathers evidence that centenarians carry structural cardiac and vascular ageing, delayed disease onset, favourable cardiometabolic and gut profiles, counterbalanced inflammation and younger epigenetic age into one integrated multilevel model of cardiovascular resilience. The practical implication, as the authors present it, is that the goal of cardiovascular medicine in extreme old age may need to shift from preventing every age-related change toward distinguishing which changes are tolerable adaptations and which warrant intervention, a distinction that current diagnostic criteria are not yet equipped to make.

Subject of Research: Cardiovascular resilience in centenarians

Article Title: Cardiovascular resilience in centenarians

Article References: Carrera-Bastos, P., Plaza-Florido, A., Pérez-Prieto, I., Radom-Aizik, S., Franceschi, C., Rodríguez-López, C., Serra-Rexach, J. A., Emanuele, E., & Lucia, A. (2026). Cardiovascular resilience in centenarians. Nature Reviews Cardiology. https://doi.org/10.1038/s41569-026-01348-x

Image Credits: AI Generated

DOI: 10.1038/s41569-026-01348-x

Keywords: ageing, cardiology, longevity, Cardiovascular, resilience, centenarians, scientific research