Cardiovascular aging reflects the cumulative burden of decades of hypertension, dyslipidemia, inflammation, and subclinical atherosclerosis, processes that may be modified before overt disease develops. The late-breaking trials at ESC Congress 2026 examined prevention across a spectrum from healthy older adults to patients with atrial fibrillation (AFib) or acute coronary syndromes. STAREE tested lipid lowering beyond age 70, REACT used imaging techniques to detect silent atherosclerosis, CRHCP connected blood pressure (BP) control with cognitive health, DAN-RSV examined infection-related decompensation, and AFFIRMO considered how care should be individualized after disease emerges.

STAREE: Statin Therapy Reduces Major CV Events in Older Adults Without CVD

The STAREE double-blind primary-prevention trial randomized 9,971 community-dwelling adults aged ≥70 years without clinical cardiovascular disease, diabetes, or dementia to atorvastatin 40 mg once daily or placebo.¹ Its co-primary endpoints paired major cardiovascular events with disability-free survival, defined as survival free of dementia or persistent physical disability.

Over a median 5.9 years, major cardiovascular events occurred in 6.0% of the atorvastatin group vs. 8.3% for placebo (hazard ratio [HR], 0.70; 95% CI, 0.61-0.82), but disability-free survival did not differ (12.8% vs. 13.6%; HR, 0.94; 95% CI, 0.84-1.05). Serious adverse events were 2.7% in both groups, although muscle-, liver-, and diabetes-related events were more frequent with atorvastatin.

Why It Matters

STAREE fills an important evidence gap for primary-prevention statins in healthy older adults. The cardiovascular benefit suggests a role for atorvastatin for primary prevention of nonfatal myocardial infarction and coronary revascularization in older adults aged ≥70 years.

That statin therapy reduced cardiovascular events without improving disability-free survival is an important finding. Disability in late life is driven largely by dementia, frailty, and musculoskeletal decline, processes that a lipid-lowering intervention begun at age 70 might have little time and little biological reserve to reverse. Furthermore, the lack of participants with frailty and multimorbidity might have influenced the lack of effect on disability-free survival in this community cohort.

Overall, chronological age alone should not close the window for primary prevention. Decisions should incorporate other baseline cardiovascular risk, medication and multimorbidity burden, and life expectancy.

CRHCP: Long-Term Intensive BP Control Reduces Dementia Risk

The CRHCP cluster-randomized trial included 33,995 adults with hypertension from 326 rural villages in China (mean age, 63 years; 61% women).² Trained nonphysician community health care providers, supervised by primary care physicians, initiated and titrated antihypertensive therapy using a standardized protocol targeting BP below 130/80 mm Hg.

After four years of active intervention and three additional years of observation, systolic BP decreased by 17.6 mm Hg in the intervention group compared with 2.4 mm Hg under usual care. Dementia occurred in 8.85% vs. 10.55%, respectively (adjusted risk ratio, 0.85; 95% CI, 0.78-0.91), while cognitive impairment without dementia was reduced by 13%. Serious adverse events occurred in 47.15% and 49.78%, respectively.

Why It Matters

CRHCP shows that sustained BP control may protect cognitive as well as cardiovascular health. Its 1.7-percentage-point absolute reduction in dementia is meaningful at a population level, while the task-shared model is potentially scalable. While generalizability beyond rural settings requires consideration, the findings support structured long-term hypertension management in reducing the risk of dementia and cognitive impairment without dementia.

DAN-RSV: RSVpreF Vaccine Has Lower Incidence of Hospitalizations for RSV-Related Respiratory Illness vs. Placebo

The DAN-RSV pragmatic, randomized trial compared the bivalent RSV prefusion F (RSVpreF) vaccine with no vaccine, initially in Danish adults aged ≥60 years and subsequently in adults aged ≥18 years in Denmark and Spain.³

Among 513,358 randomized participants, RSV-related respiratory hospitalization rates were 0.16 vs. 0.55 per 1,000 person-years (vaccine effectiveness, 70.3%; 95% CI, 49.7-83.2). However, all-cause respiratory hospitalization was not significantly reduced (vaccine effectiveness, 7.1%; 95% CI, –0.3 to 13.9), indicating that the clearest signal was confined to confirmed RSV-related admissions.

In separate follow-up of the original older adult cohort, effectiveness against RSV hospitalization was 83.3% in season one and 56.2% in season two; the wide second season CI included no benefit (95% CI, –12.4 to 84.8). An apparent reduction in all-cause cardiorespiratory hospitalization in season one was not present in season two. This pattern is compatible with waning but could also reflect low event numbers or seasonal variation. Serious adverse events in the expanded trial were similar (2.0% vs. 2.2%).

Why It Matters

DAN-RSV reinforces RSV vaccination for eligible older adults to prevent severe RSV disease. Its main clinical message is prevention of RSV-specific hospitalization rather than sustained cardiovascular protection, given that the broader respiratory endpoint was neutral, and the cardiorespiratory signal was neither consistent nor durable across seasons. Protection appeared lower during the second season after a single dose, raising the possibility of waning immunity.

The findings support existing RSV vaccination recommendations but do not yet warrant changes to cardiovascular management while the durability of protection and optimal timing of revaccination remain unresolved.

REACT: Early Imaging of Atherosclerosis Identifies Silent Disease

The REACT study reported a cross-sectional baseline analysis of a prospective, multicenter, observational cohort of 16,808 adults aged 18-70 years without known ASCVD in Denmark and Spain, using three-dimensional carotid and femoral ultrasonography and coronary CT angiography.⁴

Among 13,186 participants with complete imaging, silent atherosclerosis was present in 57.1% (95% CI, 56.3-58.0), ranging from approximately one in 13 adults aged 18-29 years to nine in 10 adults aged 60-70 years. Each additional decade of age was associated with substantially higher odds of plaque in men (adjusted odds ratio [OR], 4.52; 95% CI, 4.21-4.87) and women (adjusted OR, 3.85; 95% CI, 3.61-4.12).

Age-related prevalence patterns suggested a five- to 10-year earlier onset in men, whereas women showed a later, steeper midlife increase. Younger adults predominantly had single-territory peripheral plaque, while older age was associated with exponentially greater plaque volume and more multiterritorial involvement; isolated coronary atherosclerosis remained uncommon. Among participants eligible for SCORE2 assessment, only 1.9% of those with silent atherosclerosis were classified as high cardiovascular risk.

Why It Matters

REACT highlights the long period during which atherosclerosis may be present before clinical events occur, with age- and sex- associated increases across arterial territories and plaque volume. A low 10-year risk estimate does not exclude established plaque, reinforcing the importance of addressing lipid levels, BP, and smoking earlier in life.

Although these cross-sectional findings do not establish individual disease progression or the benefit of imaging-guided treatment, they strengthen the rationale for earlier prevention and further evaluation of imaging to refine risk assessment.

AFFIRMO: Mobile Health Intervention Fails to Cut Hospitalizations in Older AFib Patients

The AFFIRMO open-label, cluster-randomized trial included 1,260 adults aged ≥65 years with AFib and multimorbidity across six European countries. It tested a mobile health-supported Atrial Fibrillation Better Care pathway combined with comprehensive geriatric assessment against usual care.⁵ Participants had a mean age of 74 years; 40.5% were prefrail and 13.7% were frail.

At 12 months, unplanned hospitalization occurred in 17.1% vs. 18.2% (adjusted OR, 0.95; 95% CI, 0.61-1.49); the usual-care event rate was substantially below the 30% assumed in the trial design. Approximately 97% received anticoagulation, while 68.5% of intervention participants used the application for no more than one-third of follow-up.

Why It Matters

AFFIRMO did not demonstrate additional hospitalization benefit from this digitally supported care strategy. The intervention was tested against well-managed usual care in a relatively well-preserved population, with high baseline guideline adherence, fewer hospitalizations than anticipated, and limited application engagement. These factors may have reduced both the opportunity and statistical power to show incremental benefit, but do not establish why the trial was neutral.

The findings therefore should not be interpreted as evidence against comprehensive geriatric assessment or integrated AFib care, particularly where guideline adherence is poorer or geriatric deficits are greater. Routine adoption of this specific digital package solely to reduce hospitalizations is not supported by these results.

References

1. Zoungas S, Wolfe R, Moran C, et al. Atorvastatin, cardiovascular events, and disability-free survival in older adults. N Engl J Med. Published online August 29, 2026. doi:10.1056/NEJMoa2607314
2. Sun G, Guo X, Zhao C, et al. Long-term effectiveness of intensive blood pressure management led by nonphysician community healthcare providers on cardiovascular events: 7-year follow-up of a cluster randomized trial. Circulation. Published online August 28, 2026. doi:10.1161/CIRCULATIONAHA.126.082511
3. Lassen MCH, Christensen SH, Yafasov M, et al. Bivalent RSV prefusion F vaccine to prevent hospitalizations in adults. NEJM Evid. 2026;5(10):EVIDoa2600272. doi:10.1056/EVIDoa2600272
4. Bundgaard H, García-Lunar I, Kofoed KF, et al. Prevalence of Silent Atherosclerosis across Adult Life. N Engl J Med. Published online August 29, 2026. doi:10.1056/NEJMoa2609059
5. Lip GYH, Proietti M, Ainsworth J, et al. Integrated care management and comprehensive geriatric assessment using a mHealth-based approach in older multimorbid patients with atrial fibrillation: the AFFIRMO cluster-randomised trial. Lancet Reg Health Eur. 2026 Aug 30. doi:10.1016/j.lanepe.2026.101832