Prevalence of silent atherosclerosis in healthy adults
ESC Congress 2026 – In the cross-sectional REACT study, silent atherosclerosis was already detectable in 1 in 13 adults without known ASCVD aged 18–29 years, increasing sigmoidally to 9 in 10 by age 60–70 years.
This summary is based on the presentation of Henning Bundgaard, MD, PhD (Copenhagen, Denmark) at the ESC Congress 2026 - REACT - Prevalence of silent atherosclerosis across adult life.
Introduction and methods
Atherosclerosis can remain clinically silent for years before cardiovascular disease becomes apparent. This silent phase may provide a window of opportunity for earlier detection and more effective preventive strategies.
The aim of the REACT trial was to establish the cross-sectional prevalence, territorial distribution, and plaque volume of silent atherosclerosis across adult life.
REACT was a prospective cohort study conducted in Denmark and Spain. A total of 16,808 adults aged 18–70 years without known clinical ASCVD were enrolled in 5 prespecified age strata, with balanced representation of women and men. Participants underwent deep phenotyping, including assessment of biomarkers, clinical variables, anthropometrics, genomics, retinal imaging, questionnaires and wearable-derived data. Silent atherosclerosis was assessed across three vascular territories using 3D vascular ultrasound of the carotid and femoral arteries and coronary CT angiography.
The main outcome was the presence of silent atherosclerosis, defined as plaque in at least one examined vascular territory, and plaque volume.
Main results
- Silent atherosclerosis was already detectable in the youngest age group (18–29 years), affecting approximately 1 in 13 participants. Its prevalence increased sigmoidally with age, reaching 9 in 10 participants in both sexes by age 60–70 years.
- By age 40, approximately 50% of men and 30% of women had developed silent atherosclerosis.
- Men developed atherosclerosis approximately 5–10 years earlier than women. In women, the prevalence of silent atherosclerosis increased steeply after midlife.
- In women, atherosclerosis appeared first in the carotid arteries, followed by the femoral arteries and, lastly, the coronary arteries. In men, atherosclerosis developed more uniformly across the three vascular territories.
- Plaque volume increased exponentially with age in all three vascular territories, with a more pronounced increase in men.
- Conventional risk assessment showed substantial discordance with imaging findings. A high SCORE2 risk had a sensitivity of only 1.9% for detecting silent atherosclerosis, while moderate-to-high SCORE2 risk had a sensitivity of 34.1%.
Conclusion
The REACT study showed that silent atherosclerosis is already detectable in early adulthood and increases markedly in prevalence and plaque burden with age. Atherosclerosis developed 5–10 years earlier in men than in women, with differences in the age-related patterns and vascular distribution between sexes. Conventional SCORE2-risk assessment identified only a minority of individuals with silent atherosclerosis.
- Our reporting is based on the information provided at the ESC Congress 2026 -