This research is Trending!
REACTPreventionNew England Journal of Medicine
Prevalence and Vascular Distribution of Silent Atherosclerosis Across Adult Life
Prevalence of Silent Atherosclerosis across Adult Life
View Full PaperWhy 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)
Key result
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.
Authors
Discussion
Key questions
Member takes
Where experts stand
Experts are broadly struck by how early and how common silent atherosclerosis is in apparently healthy adults, with several flagging that traditional risk scores like SCORE2 miss the vast majority of people who already have plaque.
REACT mapped subclinical plaque across the adult lifespan and found it far more prevalent and far earlier than conventional risk frameworks assume. Clinicians see the results as a call to rethink prevention strategy, particularly for younger adults whose short-term risk looks low but who already harbor disease. The live question is whether and how imaging-based screening should be folded into primary prevention guidelines.
Agreement
Multiple clinicians highlight the same central point: atherosclerosis is already established well before midlife, meaning a low 10-year risk score does not equal a plaque-free artery. Several also note that SCORE2 has very poor sensitivity for detecting people who already have silent disease.
4 clinicians say this directly
2 takes classified by contention axis so far — the map appears as more land.
Still unclear
Experts have not addressed whether these prevalence data should change screening guidelines or trigger earlier pharmacotherapy. It remains open whether detecting silent plaque in young adults translates into better outcomes, and whether population-level imaging is feasible or cost-effective enough to act on.
Key expert perspectives
SCORE2 has near-zero sensitivity for silent plaque, and imaging reveals disease before short-term risk rises
Fogacci stresses that 10-year risk and atherosclerotic burden are not the same construct, noting SCORE2 had 99.8% specificity but only 1.9% sensitivity for silent atherosclerosis. She adds that in younger adults plaque was typically peripheral and single-territory, becoming multiarterial with age, meaning atherosclerosis is often systemic before it becomes symptomatic. Prevention, she argues, is also about slowing burden, not only detecting plaque.
By age 40, half of men and a third of women already had silent plaque, and SCORE2 missed most of it
Gouda highlights that by age 40 roughly 50% of men and 30% of women had silent atherosclerosis, calling this the striking finding. He notes that SCORE2 had limited sensitivity: only 1.9% at the high-risk threshold and 34.1% at moderate-to-high risk. A lot of plaque, he says, exists below traditional risk thresholds.
These findings are striking but not entirely new, and the real question is what changes next
Marzouka calls REACT a landmark study and flags the 57.1% overall prevalence and detectable plaque in 1 in 13 young adults, but notes this is not entirely new and points toward questions about what should come next.
Distilled from their postX post
Overview
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.