On behalf of the authors of the Strategic Plan for Cardiovascular Health in Portugal of the Portuguese Society of Cardiology1,2 we appreciate the recognition of its importance as a key reference for action in this field.

This plan sets out an overarching national vision for cardiovascular health. Far from being limited to prevention, health education, and psychosocial determinants, it embraces the entire continuum of care: from primordial and primary prevention (explicitly including psychosocial determinants of health), to secondary prevention, cardiac rehabilitation, and long-term management of cardiovascular disease. In addition, it highlights critical issues such as timely access to care, equity, and the need for sustained system-level interventions. Its scope is, therefore, intentionally comprehensive, reflecting the complexity of cardiovascular health and the multiple layers of action required to achieve meaningful progress, in both the short and the long term.

The assertion that older adults were overlooked in the plan is misplaced. Its scope necessarily covers the entire population across the life span, and singling out one age group would not be consistent with its purpose. Importantly, the document directly addresses the growing demographic weight of older adults in Portugal and the burden this imposes on the healthcare system across the different levels of care, from prevention to rehabilitation.

Moreover, the claim that a single and specific psychological factor was left out is unfounded, as such a focus would have been unduly narrow. The plan explicitly addresses psychological well-being as part of its primordial prevention objectives, framed broadly to encompass a wide range of scenarios rather than isolated concepts. In this regard, constructs such as ikigai may provide complementary perspectives on psychosocial well-being, yet they remain outside the remit of a national strategic plan, which must be guided by a broader population-based approach.

Nevertheless, highlighting psychological and social dimensions is both pertinent and timely, as cardiovascular risk is increasingly recognized as inherently multifactorial, shaped not only by traditional biomedical factors but also by a wide range of socio-psychological and economic determinants, as rightly underscored in the Letter to the Editor.

Growing evidence points to the role of factors such as chronic psychological stress, subjective social status, job strain, perceived discrimination, loneliness or social isolation,3 and a lack of purpose in life, as relevant contributors to cardiovascular health,4 prompting a broader understanding of risk beyond conventional parameters. Conversely, protective psychological traits and overall motivation, within which ikigai can be framed, have been associated with beneficial effects on cardiovascular outcomes.5 However, these associations, whether adverse or positive, may not necessarily reflect causality, and further investigation is warranted to clarify underlying mechanisms. Accordingly, this represents a complex and multifaceted relationship that is not yet fully understood. Nonetheless, research suggests that ikigai may contribute to cardiovascular protection by fostering preventive health behaviors, as shown by Hajek et al. in a German cohort of 5000 individuals,6 a particularly relevant observation given the strong influence of lifestyle on cardiovascular risk. As such, exploring innovative concepts may complement emerging frontiers in the fight against cardiovascular disease, particularly in promoting healthy aging.

The reflections brought forward in the Letter to the Editor reinforce the need to continue exploring forward-thinking approaches to inform future cardiovascular health strategies. Far from a missed opportunity, the plan establishes a solid foundation on which these complementary perspectives may build.