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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
No takes yet. Share an insight, caveat, or question.
Where experts stand
Experts uniformly read REACT as a wake-up call that silent atherosclerosis is far more common and begins far earlier than traditional risk scores suggest, reinforcing demands for imaging-based prevention strategies.
Cardiologists reacting to REACT are struck by how widespread silent plaque is across adulthood and how poorly conventional risk tools like SCORE2 detect it. There is broad agreement that the findings support earlier, imaging-driven approaches to primary prevention. The open question is whether these prevalence data will translate into guideline-level changes that recommend routine vascular imaging in younger, apparently healthy adults.
Agreement
Multiple clinicians emphasize that atherosclerosis begins much earlier than conventional practice assumes and that traditional risk scores miss the majority of people who already harbor plaque.
5 clinicians say this directly
2 takes classified by contention axis so far — the map appears as more land.
Still unclear
Whether the high prevalence of imaging-detected plaque in young adults should prompt guideline changes recommending routine vascular imaging for primary prevention remains unanswered. It is also unclear how much of the detected silent atherosclerosis will progress to clinical events and what intervention thresholds should apply in younger, low-risk populations.
Key expert perspectives
SCORE2 has near-zero sensitivity for silent plaque, showing 10-year risk and disease burden are not the same construct
Fogacci highlights that SCORE2 achieved 99.8% specificity but only 1.9% sensitivity for silent atherosclerosis, arguing that 10-year risk and actual plaque burden are fundamentally different constructs. She notes that atherosclerosis becomes increasingly multiarterial and systemic before it becomes symptomatic, and that prevention must focus on slowing burden, not only detecting plaque.
REACT is a real-world demonstration that silent atherosclerosis is already present in over half of adults
Spring frames REACT as a real-world confirmation that silent atherosclerosis was present in over half of adults without known disease, detectable in early adulthood, and increasingly extensive with age.
Distilled from their postX post
Atherosclerosis starts earlier than we think, and multimodal imaging now proves it
Corral emphasizes that REACT provides a striking picture of silent atherosclerosis across adult life using multimodal imaging, underscoring that the disease begins earlier than clinicians generally assume.
Distilled from their postX post
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.