Artery scans detect “silent atherosclerosis” in 1 in 13 adults under 30

By Vijay Kumar MalesuReviewed by Susha Cheriyedath, M.Sc.Nov 10 2026

What can detailed arterial scans reveal about the earliest stages of cardiovascular disease, and how do patterns of plaque accumulation differ between men and women?

Study: Prevalence of Silent Atherosclerosis across Adult Life. Image Credit: Explode / Shutterstock

In a recent study published in The New England Journal of Medicine, researchers estimated the age- and sex-specific prevalence, vascular distribution, and plaque burden of silent atherosclerosis among adults aged 18–70 years.

Background

Cardiovascular disease remains the leading cause of illness and death globally, largely because of atherosclerosis, which underlies conditions such as coronary heart disease, ischemic stroke, and peripheral artery disease. Atherosclerotic plaque can develop years before symptom onset, and imaging studies have shown evidence of “silent atherosclerosis” in 40–80% of middle-aged and older adults. The accumulation of plaque is linked to an increased risk of cardiovascular events and death. Evidence remains limited among younger adults, especially regarding age- and sex-based differences in plaque distribution and accumulation. Large-scale imaging studies are needed to address this knowledge gap.

About the study

The research was conducted by the REACT Investigators, an international team led by scientists from Copenhagen University Hospital and the University of Copenhagen in Denmark, alongside Spain's National Centre for Cardiovascular Research (CNIC), with collaborators from other institutions in Denmark, Spain and the United States.

The researchers analyzed baseline data from REACT, a multicenter prospective cohort study conducted in Denmark and Spain. Participants were adults between 18 and 70 years of age without established clinical atherosclerotic cardiovascular disease or prior coronary revascularization. Symptoms such as angina or leg pain during walking did not exclude participation. Recruitment was done in five age groups: 18–29, 30–39, 40–49, 50–59 and 60–70 years. There was balanced representation by sex and country. Participants from Denmark were recruited using stratified random sampling, and participants from Spain were recruited using public advertisements.

Investigators assessed atherosclerosis in the carotid, femoral and coronary arteries at baseline. Three-dimensional vascular ultrasonography evaluated carotid and femoral plaque, whereas coronary computed tomography angiography assessed coronary atherosclerosis. Noncontrast coronary computed tomography was used to assess coronary calcification.

The primary outcome was silent atherosclerosis, defined as plaque in at least one examined vascular territory. Secondary outcomes included territory-specific plaque prevalence, plaque volume, total peripheral plaque volume, coronary plaque volume, and coronary artery calcium scores. Cardiovascular risk was estimated using the Systematic Coronary Risk Evaluation 2 (SCORE2) risk model, which predicts cardiovascular events within 10 years in European adults aged 40–69. Regression models evaluated associations among age, sex, cardiovascular risk factors, and plaque characteristics.

Study results

The study involved 16,808 adult participants, 51.4% of whom were women. The mean age was 45 years. About half were recruited in Spain and half in Denmark. Complete imaging from all three vascular territories was available for 13,186 participants, and this population was used for the prevalence analysis.

Silent atherosclerosis was seen in 57.1% of participants with complete imaging. Because recruitment was stratified by age, sex and country, this estimate does not represent population-wide prevalence. The prevalence was higher in men (63.4%) than in women (50.9%). Silent atherosclerosis was seen in 8.7% of men and in 6.7% of women aged 18–29 years. Among those aged 30–39 years, prevalence increased to 34.6% in men and 21.3% in women.

Among men, prevalence increased from the 30–39-year age group and began to plateau by midlife. In women, the steepest increase occurred after age 40, narrowing the difference between sexes. This later rise broadly overlaps with the menopausal transition, but the study did not assess menopause as a cause. By ages 60–70, nearly all men and more than nine in ten women had detectable plaque in at least one examined artery.

In younger participants, plaque was seen in peripheral arteries, especially in the carotids. In these participants, plaque usually involved a single vascular territory. With increasing age, combined carotid and femoral involvement became more frequent. Coronary atherosclerosis and calcification also increased with age in both sexes. Yet isolated coronary atherosclerosis remained uncommon, affecting no more than 9.3% of men and 5.0% of women across the age groups.

Of those aged 30–39 years with coronary plaque, approximately four in ten men and five in ten women had a coronary artery calcium score of zero. A zero score did not exclude noncalcified coronary plaque, particularly in younger adults. This finding was also observed among older participants.

Of those with coronary plaque, 82.0% also had peripheral plaque, compared with 41.5% of those without coronary plaque. Increasing peripheral plaque volume was associated with progressively higher odds of coronary atherosclerosis.

Among participants with detectable plaque, median plaque volume was greatest in the coronary arteries (74.7 mm³), compared with 44.8 mm³ in the femoral arteries and 23.9 mm³ in the carotid arteries. Carotid and coronary plaque volumes increased more steeply with age in men, while femoral plaque volumes followed similar age-associated patterns between sexes.

SCORE2 identified only a minority of participants with established silent atherosclerosis. The high-risk category captured fewer than 2% of participants with detectable plaque, while the moderate-to-high-risk category captured about one third. SCORE2 estimates cardiovascular event risk rather than diagnosing plaque and is not calibrated for adults younger than 40. Risk scores and imaging provided different information, particularly in younger adults.

“These data from multiple locations support the concept of silent atherosclerosis as a systemic, progressive disease process with men showing an approximately 5-to-10-year earlier atherosclerotic trajectory than women,” commented Professor Henning Bundgaard of the REACT Initiative and Rigshospitalet - Copenhagen University Hospital

Conclusions

Silent atherosclerosis is detectable during early adulthood. Prevalence and burden were greater in older age groups, and men showed higher prevalence and burden at younger ages than women. Plaque affected multiple arterial territories more frequently in older adults. These findings do not establish that routine vascular imaging improves cardiovascular outcomes. Because this analysis used cross-sectional baseline data, it could not evaluate the rate of disease development or progression within individuals. The age-stratified sample was not population-weighted, and incomplete imaging could have introduced selection bias. Further longitudinal research is needed to determine how early imaging findings relate to subsequent cardiovascular outcomes.