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Prevalence of Silent Atherosclerosis across Adult Life
Key result
Silent atherosclerosis affects ~57% of adults without known CVD, with plaque volume increasing with age.
- 95% CI 56.3-58.0
- n=16,808
Why the trial?
Atherosclerosis develops silently for decades before causing events, but how prevalent subclinical disease is across adult life — and how well standard risk scores identify the people who harbour it — had not been systematically mapped in a broad asymptomatic population.
Population
16,808 adults 18-70 without known ASCVD (mean age 45, 51.4% women)
Comparison
No comparator - cross-sectional imaging (three-dimensional carotid/femoral ultrasound + coronary CTA)
Design
Prospective cohort in Denmark and Spain, five sex-balanced age strata
Follow-up
Baseline imaging assessment (cross-sectional readout)
Authors
Discussion
Key questions
No takes yet. Share an insight, caveat, or question.
Where experts stand
Experts read REACT as a striking confirmation that silent atherosclerosis is far more common and starts far earlier than conventional risk scores suggest, raising urgent questions about whether imaging-based screening should reshape primary prevention.
The reaction is overwhelmingly one-directional: clinicians are struck by how much plaque exists in apparently healthy adults, especially by midlife, and how poorly traditional risk tools detect it. Several voices highlight the disconnect between SCORE2 sensitivity and actual disease burden. The live question is whether these findings will push guidelines toward earlier imaging-based screening and, if so, what the downstream treatment implications would be.
Agreement
Multiple clinicians emphasize that atherosclerosis begins much earlier than commonly assumed and that SCORE2 fails to identify the majority of individuals who already harbor silent plaque, calling into question the adequacy of risk-score-only approaches to primary prevention.
4 clinicians say this directly
2 takes classified by contention axis so far — the map appears as more land.
Still unclear
Whether demonstrating high prevalence of silent plaque will translate into guideline-level recommendations for earlier or broader vascular imaging in asymptomatic adults. No data yet on whether detecting and treating this plaque earlier actually improves clinical outcomes. The role of sex-specific thresholds and age-tailored screening strategies also remains open.
Key expert perspectives
Risk scores and disease burden are not the same construct, and imaging reveals what SCORE2 misses
Fogacci stresses that SCORE2 had 99.8% specificity but only 1.9% sensitivity for silent atherosclerosis, meaning imaging may reveal disease long before estimated short-term risk rises. She notes that in younger adults plaque was usually peripheral and single-territory, but with age it became increasingly multiarterial, making the case that prevention is also about slowing burden, not only detecting plaque.
REACT is a real-world demonstration that silent atherosclerosis is detectable in early adulthood
Spring views the trial as confirmation that silent atherosclerosis was present in over half of adults without known ASCVD and that it was detectable in early adulthood, becoming more prevalent and extensive with age.
Distilled from their postX post
By age 40, half of men and a third of women already had silent plaque
Gouda highlights the sex-stratified prevalence at age 40 as the striking finding and emphasizes that atherosclerosis is often already established by midlife. He also flags SCORE2's limited sensitivity, noting that a lot of plaque exists below traditional risk thresholds.
Implication
Silent atherosclerosis is common from early adulthood without known disease; extends prevalence mapping but leaves open whether imaging changes primary prevention.
Key Points
- To determine the age- and sex-specific prevalence, arterial distribution, and plaque volume of silent atherosclerosis across the adult lifespan.
- Enrolled 16,808 adults aged 18 to 70 years without established cardiovascular disease in Denmark and Spain across five prespecified, sex-balanced age strata (51.4% women; NCT06692127).
- Evaluated subclinical atherosclerosis using three-dimensional vascular ultrasonography of carotid and femoral arteries and coronary computed tomographic angiography.
- Silent atherosclerosis was present in 57.1% of participants (95% CI, 56.3 to 58.0), including 8.7% of men and 6.7% of women in the 18-to-29 age stratum.
- Prevalence increased with age with a steeper midlife rise in women, showing exponential plaque volume growth and frequent multiarterial involvement, whereas isolated coronary disease remained rare (≤9.3% in men and ≤5.0% in women).
Evidence details
What drove the result?
| Outcome | All | Men | Women |
|---|---|---|---|
| Any silent atherosclerosis | 57.1% | - | - |
| 95% CI 56.3-58.0; sex-specific overall rates not reported in abstract | |||
| Atherosclerosis at age 18-29 | - | 8.7% | 6.7% |
| Youngest stratum; prevalence rose with age with a later, steeper midlife rise in women | |||
| Isolated coronary atherosclerosis | - | <=9.3% | <=5.0% |
| Uncommon in every age stratum; early disease was mostly peripheral and single-territory | |||
Limitations & tradeoffs
Design limitations
cross-sectional prevalence data with no outcome follow-up, and plaque detection is an imaging surrogate, not a clinical event.
Representation
conducted in Denmark and Spain, which may limit generalizability to other populations.
Structured PICO
P
Population
16,808 adults aged 18 to 70 years without known atherosclerotic cardiovascular disease, assessed for the prevalence of silent atherosclerosis.
O
Outcome
Prevalence of silent atherosclerosis assessed by three-dimensional vascular ultrasonography of the carotid and femoral arteries and coronary computed tomographic angiographysurrogate
Silent atherosclerosis is highly prevalent (57.1%) in adults without known cardiovascular disease and is detectable even in early adulthood.
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Bundgaard et al. (2026) conducted a cohort in Silent atherosclerosis (n=16,808). Age was evaluated on Presence of silent atherosclerosis (95% CI 56.3-58.0). Silent atherosclerosis was present in 57.1% (95% CI 56.3-58.0) of adults aged 18 to 70 without known cardiovascular disease, with prevalence and plaque volume increasing with age.