Abstract-HDL plasma concentrations decline with age in prospective studies. Decline in HDL concentration and function may occur secondary because of hormonal changes, inflammatory processes, and diabetes mellitus. Beyond these effects specific aging processes may be involved. Replicative aging, the telomere-driven loss of divisional capacity, is a species-specific aging mechanism that may decrease HDL concentration and function. Cross-sectionally, by contrast, HDL levels do not change much or even slightly increase with age, suggesting that only people with still high HDL concentrations survive. A selection bias by HDL lowering genetic variation may explain why HDL deficiency is extremely rare among centenarians. Vice versa, HDL may modulate the aging process, not only by its well-known antiatherogenic effects, eg, its ability to remove cellular lipids and by antiatherogenic pleiotropic effects on cell survival, but possibly also by direct interfering with aging signaling or survival factor KLOTHO. Most of the current findings, however, are based on cell culture and selected animal experiments and await further confirmation by appropriate in vivo models. T he influence of age on atherosclerosis is generally explained by the simple passage of time and a higher number and severity of risk factors with increasing age. However, the observation of senescence-like changes in atherosclerotic lesions, 1 the severe atherosclerosis in premature aging syndromes, 2 and the identification of age as by far the most predictive independent risk factor for atherosclerosis effective even in absence of other risk factors 3 suggests that atherogenesis is more directly related to the aging process than previously presumed.Aging is a complex process that (on the cellular level) includes cell cycle arrest, morphology remodeling with functional decline, chromatin silencing with profound gene expression changes, and changes in metabolism. As summarized in Figure 1, different triggers may act together in a cooperative fashion and use overlapping signaling pathways to induce and propagate the aging process. 4 Replicative aging results from the progressive shortening of telomeres (composed of conserved nucleotide sequences, TTAGGG in vertebrates) attributable to incomplete end replication during cell divisions. It may protect against increased cancer risk but may also contribute to atherosclerosis in later life, particularly at "atherosclerosis-prone areas" with high replication rates. 5 Next to age, a low high-density lipoprotein (HDL) cholesterol level is one of the strongest predictors of premature coronary heart disease and stroke. 6 In contrast to high low-density lipoprotein (LDL) cholesterol, low HDL cholesterol remains a powerful risk predictor into old age. HDL may directly influence specific aging processes and, vice versa, aging may influence HDL concentration and function. However, it is important to bear in mind the caveats of the current studies. First, most findings are based on cell culture and animal models and have not be...