Rethinking cardiovascular risk assessment in women

Less artery-clogging plaque in women's arteries did not appear to protect them from heart disease compared to men, according to a study published in Circulation: Cardiovascular Imaging, an American Heart Association journal.

While heart disease is the leading cause of illness and death in the U.S. and worldwide, according to the American Heart Association's 2026 Heart Disease and Stroke Statistics, women tend to have a lower prevalence of artery plaque than men, according to previous research.

This study evaluated health data for more than 4,200 adults (more than half of whom were women) to compare how the quantity of plaque influenced the risk of major heart conditions. The study included people with stable chest pain and no prior history of coronary artery disease. Participants were randomized to undergo diagnostic evaluation via coronary computed tomography angiography (X-ray images of the heart and blood vessels) and followed for about two years.

Key findings of the study:

• Fewer women had plaque in their coronary arteries than men (55% of women vs. 75% of men). Women also had a lower volume of artery plaque than men (a median of 78 mm³ among women vs. 156 mm³ in men).
• Despite less plaque, women were just as likely as men to die from any cause, have a non-fatal heart attack or be hospitalized for chest pain (2.3% of women vs. 3.4% of men).
• In addition, women faced increased heart risk at lower levels of plaque compared to men. For total plaque burden, women's risk began to rise at 20% plaque burden, while men's risk started at 28%. With increasing plaque levels, risk rose more sharply for women than for men.

"Our findings underscore that women are not 'protected' from coronary events despite having lower plaque volumes," said senior author Borek Foldyna, M.D., Ph.D., an assistant professor in radiology at Harvard Medical School in Boston. "Because women have smaller coronary arteries, a small amount of plaque can have a bigger impact. Moderate increases in plaque burden appear to have disproportionate risk in women, suggesting that standard definitions of high risk may underestimate risk in women."

These findings are another important example of why it is imperative to recognize that cardiovascular disease can impact men and women so differently."

Stacey E. Rosen, M.D., FAHA, Volunteer President, American Heart Association

She is also the executive director of the Katz Institute for Women's Health and senior vice president of women's health at Northwell Health in New York City.

Rosen added, "There is an overdue recognition of fundamental, biological differences in the way health conditions manifest in women vs. men, and these differences can influence everything from risk factors to symptoms to treatment response. I'm heartened to see more research such as this emerging as we address ways to reduce cardiovascular disease burden among all people."

According to the American Heart Association's 2026 Heart Disease and Stroke Statistics, cardiovascular disease was the cause of death in 433,254 females of all ages, representing 47.3% of deaths from cardiovascular disease.

Study background, design, and details:

• The patients included in this study were a subset of participants from the PROMISE trial, a study of adults with stable chest pain and no prior history of coronary artery disease, treated at 193 clinical sites in the U.S. and Canada. PROMISE participants were followed for about two years
• The analysis included 4,267 adults (average age 60; 51% women)
• The study's lead author is Dr. Jan Brendel, M.D., research fellow at Massachusetts General Hospital and Harvard Medical School, both in Boston