What’s Really Causing Atherosclerosis in Older People?
What is actually causing atherosclerosis in older patients? Is it just cholesterol? Or is it a pre-diabetic/insulin resistant state or perhaps inflammation? What is the major contributor and how do these factors work together?
The question of whether age-related lipid changes (decreased HDL, increased LDL) are causative of atherosclerosis or merely correlated with it, occurring alongside age-associated atherosclerosis, is a critical one in cardiovascular research. As of March 9, 2025, the evidence does not provide a simple yes-or-no answer but suggests a nuanced relationship where lipids play a significant but not exclusive role, with inflammation and insulin resistance emerging as potentially more direct drivers in certain contexts. Below, I’ll review the evidence, address the correlation-versus-causation debate, and integrate the role of inflammation and insulin resistance.
Lipid Changes and Atherosclerosis: Correlation vs. Causation
- Traditional Lipid Hypothesis
- Premise: Elevated LDL cholesterol (LDL-C) and reduced HDL cholesterol (HDL-C) directly contribute to atherosclerosis by promoting lipid accumulation in arterial walls (LDL) and impairing cholesterol removal (HDL).
- Evidence Supporting Causation:
- Epidemiology: Decades of data (e.g., Framingham Heart Study) show strong associations between high LDL-C, low HDL-C, and increased atherosclerosis risk, especially after age 40.
- Genetic Studies: Mendelian randomization studies (e.g., Voight et al., 2012) demonstrate that lifelong exposure to elevated LDL-C (due to PCSK9 or LDLR mutations) causally increases coronary artery disease (CAD) risk, independent of age.
- Interventional Trials: Statins, which lower LDL-C, consistently reduce atherosclerosis progression and cardiovascular events (e.g., 4S Trial, 1994; JUPITER, 2008), suggesting a causal link. PCSK9 inhibitors (e.g., FOURIER trial, 2017) further reinforce this by showing plaque regression with aggressive LDL-C reduction.
- Mechanistic Data: LDL particles penetrate the arterial intima, oxidize (oxLDL), and trigger foam cell formation, a hallmark of early atherosclerosis.
- Limitations: These studies establish LDL-C as a causal factor in atherosclerosis population-wide, but they don’t fully clarify if age-related lipid changes (post-40) are independently causative or simply amplify an ongoing process driven by other factors.
- Age-Related Lipid Changes: Correlation Evidence
- Observation: As people age, LDL-C tends to rise and HDL-C falls (due to mechanisms outlined previously: reduced LDL-R, impaired RCT, etc.), while atherosclerosis prevalence increases concurrently.
- Evidence for Correlation:
- Cross-Sectional Data: Studies like the National Health and Nutrition Examination Survey (NHANES) show that lipid profiles worsen with age alongside atherosclerosis, but this doesn’t prove causation—both could reflect aging’s broader effects (e.g., endothelial dysfunction, oxidative stress).
- Autopsy Studies: Older individuals often have advanced plaques without extreme lipid abnormalities, suggesting other factors (e.g., inflammation) dominate in late-stage disease.
- HDL Paradox: Raising HDL-C pharmacologically (e.g., with CETP inhibitors like torcetrapib) hasn’t consistently reduced atherosclerosis (ILLUMINATE trial, 2007), questioning HDL’s direct protective role in aging populations.
- Interpretation: Age-related lipid shifts may be epiphenomena—markers of metabolic decline—rather than primary drivers, especially if atherosclerosis is already underway.
- Conclusive Evidence?
- No Definitive Proof: While LDL-C is causally linked to atherosclerosis initiation and progression in general (via genetics and trials), no study isolates age-related lipid changes (post-40) as the sole cause in aging cohorts. The temporal overlap with atherosclerosis suggests correlation, but causation is confounded by co-occurring factors like inflammation and insulin resistance.
Inflammation and Insulin Resistance as Driving Factors
Emerging data increasingly spotlight inflammation and insulin resistance as central drivers of atherosclerosis, potentially relegating lipids to a facilitating or secondary role, especially in aging.
- Inflammation
- Mechanism: Chronic low-grade inflammation, amplified by aging (inflammaging), damages the endothelium, recruits monocytes, and promotes plaque formation.
- Evidence:
- CANTOS Trial (2017): Canakinumab, an IL-1β inhibitor, reduced cardiovascular events in patients with residual inflammation (high CRP) but normal LDL-C, independent of lipid changes, proving inflammation’s causal role.
- oxLDL Role: Oxidized LDL (oxLDL), a product of inflammatory ROS, is more atherogenic than native LDL, suggesting inflammation amplifies lipid pathogenicity.
- Senescence: Senescent cells in aging arteries secrete pro-inflammatory cytokines (e.g., TNF-α, IL-6), driving plaque growth beyond lipid deposition.
- Implication: Inflammation may initiate and sustain atherosclerosis, with lipids as a substrate rather than the origin.
- Insulin Resistance
- Mechanism: Insulin resistance, common after 40, promotes endothelial dysfunction, inflammation, and dyslipidemia (high triglycerides, small dense LDL), accelerating atherosclerosis.
- Evidence:
- IRAS Study (1996): Insulin resistance independently predicts atherosclerosis (carotid intima-media thickness) even in normolipidemic individuals.
- Metabolic Syndrome: Clustering of insulin resistance, hypertension, and inflammation strongly correlates with CAD, often preceding severe lipid shifts.
- Small Dense LDL: Insulin resistance shifts LDL particles to a smaller, denser, more atherogenic form, which penetrates the endothelium more readily (Krauss, 1995).
- Implication: Insulin resistance may be a root cause, with lipid changes (e.g., increased small dense LDL) as downstream amplifiers.
- Integration with Lipids
- Synergy: Inflammation and insulin resistance likely interact with lipids in a vicious cycle:
- Insulin resistance increases VLDL and small dense LDL, which infiltrate arteries.
- Inflammation oxidizes these lipids, enhancing plaque formation.
- Reduced HDL functionality (from oxidative damage) fails to clear cholesterol, worsening the process.
- Evidence: Studies of diabetic patients show accelerated atherosclerosis despite LDL-C control, highlighting inflammation and insulin resistance as dominant drivers when lipids are managed.
Synthesis: Causative or Correlative?
- Lipids as Causal in Initiation: LDL-C is conclusively causative in early atherosclerosis (e.g., familial hypercholesterolemia patients develop plaques in their 20s), but this is less clear for age-related changes post-40. In aging, lipid shifts may exacerbate rather than initiate disease.
- Correlation in Aging: After 40, atherosclerosis often predates severe lipid changes, and plaques progress in individuals with normal lipids, suggesting age-related endothelial damage, inflammation, and insulin resistance are primary movers, with lipids as co-factors.
- Inflammation and Insulin Resistance as Drivers: Robust data (e.g., CANTOS, IRAS) position these as independent and potentially more direct causes, especially in older adults where inflammaging and metabolic decline dominate.
Conclusion
There is no conclusive evidence that age-related lipid changes (decreased HDL, increased LDL) are solely causative of atherosclerosis in aging populations. While LDL-C is causally linked to atherosclerosis broadly (via genetics, trials, and mechanisms), its role in age-specific progression is less clear—likely a strong correlation amplified by concurrent processes. Inflammation and insulin resistance have stronger, more direct evidence as drivers, particularly in older adults, where they initiate endothelial dysfunction and plaque growth, with lipids acting as facilitators or modifiers. The lipid hypothesis remains valid but incomplete; a modern view frames atherosclerosis as an inflammatory-metabolic disease where age-related lipid changes are significant but not the whole story. Future research (e.g., longitudinal studies isolating lipid effects in aging) could clarify this further, but current data tilt toward inflammation and insulin resistance as the dominant forces in age-associated atherosclerosis.
