8/25/2026
I have been sharing my thoughts on Super Agers: An Evidence-Based Approach to Longevity by Eric Topol since August 14. Before I move on from this book, I want to share one more thing that caught me completely by surprise in Chapter 5, “Cardiovascular Disease.”
I was shocked when I saw the following data, from a study examining the prevalence of coronary atherosclerosis in asymptomatic teenagers and young adults using intravascular ultrasound.
The graph at the bottom clearly shows something I had never thought about this way before:
Coronary atherosclerosis can begin much earlier in life than most people assume.
What does the graph show?
The y-axis represents the percentage of people with coronary atherosclerosis, and the x-axis represents age.
The researchers used two thresholds for defining an atherosclerotic lesion:
| Age | 0.5 mm threshold | 0.3 mm threshold |
|---|---|---|
| 13–19 | 17% | 21% |
| 20–29 | 37% | 66% |
| 30–39 | 60% | 75% |
| 40–49 | 71% | 85% |
| ≥50 | 85% | 91% |
The pattern is striking. Even among teenagers aged 13–19, 17% met the 0.5-mm threshold and 21% met the 0.3-mm threshold.
Among people in their 20s, the numbers rose to 37% and 66%.
By the 30s, they reached 60% and 75%.
By age 40–49, the figures were 71% and 85%.
And among people 50 and older, they were 85% and 91%.
The most shocking part for me
The 20–29 age group really caught my attention. These are still very young people. Yet even using the stricter 0.5-mm threshold, more than one-third already showed coronary atherosclerosis. Using the 0.3-mm threshold, the figure was two-thirds.
And among people in their 30s—still young by any ordinary definition—the numbers were already 60% and 75%.
I used to think of coronary atherosclerosis primarily as a disease of old age. Now I understand it differently:
Atherosclerosis can be a lifelong process that begins early and accumulates over decades.
The graph shows the presence of atherosclerotic changes according to specific anatomical thresholds. But it does not tell us how severe the plaque is, whether an artery is significantly narrowed, whether the person has symptoms, or whether that person will eventually suffer a heart attack.
So having detectable atherosclerosis is not the same as having clinically significant coronary artery disease. But the finding is still eye-opening.
Why does it become more common with age?
There are several reasons that make sense.
1. It is cumulative.
Our arteries are exposed year after year to factors such as LDL cholesterol, blood pressure, elevated blood glucose, smoking, inflammation, and other metabolic stresses.
A 50-year-old has had decades of exposure that a 20-year-old has not.
2. The process can go on silently.
Atherosclerosis does not suddenly appear when someone has a heart attack. Arterial changes can develop silently for years or even decades before they cause symptoms.
A heart attack may be the first obvious sign of a disease process that has been developing for a very long time.
3. Risk factors can accelerate the process.
Smoking, high LDL or ApoB, hypertension, diabetes, obesity, poor diet, and physical inactivity can all contribute to the progression of cardiovascular disease.
This is why waiting until middle age to start thinking about healthy lifestyle and cardiovascular prevention may be too late to prevent the beginning of the process. By then, it may already have been developing for decades.
4. The threshold matters.
The 0.3-mm threshold is more sensitive than the 0.5-mm threshold, which explains why the percentages are consistently higher with the smaller threshold.
So these numbers should not be interpreted as saying that two-thirds of people in their 20s have serious heart disease. They indicate that detectable atherosclerotic changes are surprisingly common.
5. This is not just an “old people's disease”
We often think about healthy aging as something that becomes important when we reach our 60s or 70s.
But many processes associated with age-related disease begin much earlier.
The same principle applies to cardiovascular disease:
A heart attack may happen at 65, but the underlying disease process may have started decades earlier.
The absence of symptoms does not necessarily mean that everything is fine inside the body.
That gives a different meaning to the lifestyle factors Topol discusses throughout Super Agers: diet, exercise, not smoking, maintaining healthy blood pressure and cholesterol, getting adequate sleep, and maintaining good metabolic health.
These habits are important not only because they help us feel better today. They influence the trajectory of disease accumulation over the decades ahead.
The message I take away
This graph gave me a completely different perspective on prevention.
You are shaping and influencing what is happening inside your arteries right now.
And perhaps that is one of the most important lessons of healthy aging:
You don't start preparing for healthy aging when you become old. You start young.
