Biological Age, Frailty and Cardiovascular Care: A Pakistan-Focused Editorial Comment

Cognitive impairment, frailty, and cardiovascular disease (CVD) are often approached as separate clinical problems. However, the recent American College of Cardiology (ACC) Scientific Statement presents a more integrated perspective, emphasizing their convergence in older adults and their close relationship with biological aging [1]. This framework is particularly relevant to Pakistan, where cardiovascular services increasingly encounter older patients with multimorbidity, delayed presentation, limited access to rehabilitation, and reduced functional reserve. The central message is important: chronological age alone is an inadequate measure of cardiovascular vulnerability, treatment tolerance, and recovery potential. Clinical assessment should increasingly consider biological age—the cumulative physiological and functional consequences of health and disease across the life course [1-3]. The Central Illustration, “Impact of Health Trajectory on Biologic Age,” provides a useful framework for translating geroscience into cardiovascular practice. Two individuals of the same chronological age may have markedly different biological ages because of differences in lifelong exposure to hypertension, diabetes, obesity, physical inactivity, poor diet, inflammation, vascular injury, and other adverse health determinants [2-5]. Biological aging therefore reflects more than the passage of time; it represents the progressive accumulation of molecular, cellular, physiological, and functional changes that influence resilience and vulnerability [2,3]. From a cardiovascular perspective, successful prevention should consequently extend beyond avoiding myocardial infarction or stroke to preserving cognition, mobility, muscle strength, independence, and functional capacity. Cardiovascular disease, cognitive decline, and frailty share several important upstream determinants, including hypertension, diabetes, dyslipidemia, obesity, smoking, sedentary behavior, poor dietary quality, vascular dysfunction, chronic inflammation, and loss of skeletal-muscle reserve [3-6]. Frailty is particularly relevant because it reflects declining physiological resilience and can substantially modify the risks and benefits of cardiovascular interventions [1,7,8]. Similarly, cognitive impairment may influence medication adherence, informed decision-making, rehabilitation participation, and post-discharge recovery [1]. Cardiovascular care in older adults must therefore move beyond a disease-centered model toward a function-centered approach in which survival, cognition, mobility, independence, and quality of life are considered alongside conventional cardiovascular outcomes [1,6-8]. Why This Matters for Pakistan The biological-aging framework assumes particular importance in Pakistan because cardiometabolic risk factors frequently emerge long before patients enter specialist cardiovascular care. The Pakistan STEPS survey demonstrated a substantial burden of modifiable risk factors: 96.5% of adults consumed fewer than five servings of fruits and vegetables per day, 41.5% had low physical activity, 26.3% were overweight, 14.9% were obese, while stage I and stage II hypertension affected 37% and 15.9%, respectively [9]. These findings indicate that adverse cardiovascular and biological-aging trajectories may begin decades before overt cardiovascular disease becomes clinically apparent. Pakistan is also experiencing a rapid nutrition and lifestyle transition. Traditional dietary patterns increasingly coexist with greater consumption of commercially prepared and energy-dense foods, refined carbohydrates, fats, salt, and added sugars, particularly in urban populations [10]. This transition is occurring alongside reduced habitual physical activity and changing occupational and urban lifestyles. Such exposures are not merely conventional cardiovascular risk factors; accumulated over decades, they may contribute to vascular injury, metabolic dysfunction, inflammation, loss of physiological reserve, and ultimately accelerated biological aging [2-5]. This is where Pakistan differs importantly from many high-income healthcare settings. While geriatric cardiology increasingly incorporates frailty assessment, rehabilitation, cognitive evaluation, exercise, and shared decision-making, Pakistan must simultaneously address more fundamental barriers to healthy aging. These include delayed detection of hypertension and diabetes, fragmented preventive care, out-of-pocket healthcare expenditure, limited availability of cardiac rehabilitation, and minimal routine assessment of cognition and frailty. Consequently, cardiovascular disease may become clinically evident only after considerable physiological and functional reserve has already been lost. From Cardiovascular Prevention to Preservation of Biological Reserve The implications for prevention are substantial. Blood-pressure control, diabetes prevention, smoking cessation, regular physical activity, healthier dietary patterns, and maintenance of healthy body weight should not be viewed solely as strategies for reducing myocardial infarction and stroke. They should also be understood as interventions that may help preserve vascular, cognitive, metabolic, and functional reserve across the life course [4,5,11]. The INTERHEART study demonstrated the major contribution of modifiable risk factors to myocardial infarction across diverse populations [4], while the PURE study reinforced the importance of modifiable metabolic and behavioral factors for cardiovascular disease and mortality across countries at different income levels [5]. These findings are highly relevant to Pakistan: preventing cardiovascular disease earlier in life may also contribute to healthier aging later in life. For clinicians, implementation of this concept does not require sophisticated biomarkers or expensive biological-age testing. A practical approach could begin with brief assessment of frailty, cognition, mobility, nutrition, medication burden, and social support alongside conventional cardiovascular evaluation [1,7,8]. Simple measures such as gait speed, chair-rise performance, or validated frailty scales may provide clinically meaningful information about physiological reserve. Older adults admitted with acute coronary syndrome, heart failure, valvular heart disease, or arrhythmias should therefore be assessed not only according to ejection fraction, angiographic anatomy, and traditional risk scores, but also according to whether they can walk independently, understand and adhere to treatment, tolerate rehabilitation, manage polypharmacy, and recover function after discharge [1,7,8]. These dimensions may profoundly influence whether technically successful cardiovascular treatment translates into meaningful patient-centered recovery. The same principle extends beyond hospitals. Population-level interventions addressing hypertension, unhealthy diet, physical inactivity, obesity, and other major modifiable risk factors can influence the health trajectory long before biological reserve is depleted [11]. In a country with a large population exposed to cardiometabolic risks, preservation of healthy aging should therefore become part of cardiovascular prevention rather than being considered exclusively a geriatric concern. A Broader Definition of Cardiovascular Success The major contribution of the ACC Scientific Statement is its ability to connect cardiology with geroscience, cognition, frailty, and functional health [1]. It challenges cardiovascular medicine to look beyond procedural success and short-term event reduction toward outcomes that matter deeply to older adults: preserved cognition, mobility, independence, functional recovery, and quality of life. For Pakistan, this perspective has particular urgency. If health trajectories influence biological age, then hypertension, diabetes, poor diet, physical inactivity, rapid lifestyle transition, and gaps in preventive healthcare are not simply background public-health problems; they are determinants of how rapidly cardiovascular and functional reserve may decline. The next decade of cardiovascular prevention in Pakistan should therefore broaden its objective from preventing cardiovascular events to preserving biological and functional reserve across the life course. This requires earlier risk-factor detection, stronger primary prevention, greater access to rehabilitation, and routine consideration of frailty and cognition in older cardiovascular patients. Ultimately, the success of cardiovascular care should be judged not only by how many years are added to life, but also by how much cognitive, physical, and functional health is preserved within those years. 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