Exposomic Determinants in Heart Failure Among Older Adults - Mechanistic Links, Clinical Evidence, and Future Perspectives

Purpose of review: Heart failure (HF) in older adults emerges from the interplay between biological aging and the totality of environmental and behavioural exposures conceptualized as the exposome. Traditional cardiovascular risk factors and intrinsic cardiac pathology only partially explain HF burden, as chronic exposures to air pollution, traffic noise, temperature extremes, toxic metals and chemicals, artificial light at night, and adverse social environments, along with low greenness and walkability, substantially influence HF incidence, decompensations, and prognosis in older patients with multiple comorbidities.

Recent findings: Recently, epidemiological studies have associated many of the exposomic factors with HF incidence and morbidity. Age‑related impairments of the myocardium and vasculature make them particularly vulnerable to external stressors. Mechanistically, aging, HF, and environmental factors converge on shared pathways including, oxidative stress and mitochondrial dysfunction, inflammaging, impaired autophagy and proteostasis, genomic and epigenetic alterations, cellular senescence, dysregulated neurohormonal and circadian signalling, and fibrosis with maladaptive remodelling. Through these mechanisms exposome chronically accelerates cardiovascular aging and lowers the threshold for HF onset and progression. This review considers a shift from an organ‑centred view of HF in older adults to a systems‑level, life‑course perspective that explicitly incorporates exposomic determinants, and argues that reducing harmful exposures while promoting green space, physical activity, walkability, and healthy dietary patterns should be integral to HF prevention and management strategies in aging societies.