More than 50 percent of apparently healthy young adults with no prior diagnosis of heart disease show silent atherosclerosis, responsible for most cardiovascular diseases, according to a new international study in which the Carlos III National Center for Cardiovascular Research (CNIC) has participated.
This international study confirms that atherosclerosis begins many years before the first clinical signs appear. The research is led by Dr. Borja Ibáñez, scientific director of the CNIC, cardiologist at the Jiménez Díaz Foundation University Hospital, and group leader at the CIBER of Cardiovascular Diseases (CIBERCV), along with Dr. Henning Bundgaard, professor of Cardiology at Rigshospitalet in Copenhagen (Denmark).
The findings, presented in a "Hot Line" session at the Congress of the European Society of Cardiology (ESC 2026) and published in "The New England Journal of Medicine," reveal that of the more than 16,000 analyzed volunteers, 57.1 percent had atherosclerosis plaques despite not showing symptoms or having been diagnosed with cardiovascular disease.
Atherosclerosis is the main cause of cardiovascular disease and is behind most heart attacks and strokes. Nearly 20 million people die each year from cardiovascular diseases worldwide, and a large part of these deaths is attributed to atherosclerosis. However, the process can silently progress for decades while atheroma plaques gradually accumulate in the arteries.
The work is based on a simple but transformative premise: to leave behind the classic model, which is based on calculating the probability of suffering cardiovascular disease from risk factors such as hypertension, cholesterol, or smoking, and move towards an approach in which the pathology is directly identified through imaging techniques before it manifests.
Thus, preventive measures and the approach to risk factors could be guided by the objective detection of silent atherosclerosis, instead of being limited to an indirect risk estimation.
The results belong to the initial phase of REACT, one of the largest projects developed so far to map silent atherosclerosis throughout adulthood.
In this first stage, 16,808 participants aged between 18 and 70 years have been included, all without a history of known cardiovascular disease. Advanced imaging tests were performed on each one to locate atherosclerotic plaques in the carotid, femoral, and coronary arteries.
At the same time, cardiovascular risk factors, blood biomarkers, samples for omics analysis, and retinal images were studied, resulting in one of the most comprehensive databases on atherosclerosis generated to date.
It also affects young people aged 18 to 29
The data released shows that the disease is already present in very young adults. About one in every 13 people aged between 18 and 29 had atherosclerosis in some artery, a figure that progressively increased with age until reaching 9 out of 10 individuals between 60 and 70 years old.
Moreover, most of those who present atherosclerosis in the coronary arteries also show it in the neck or leg arteries (carotid or femoral). This fact is key for screening, as carotid and femoral ultrasound is a simpler, faster, and non-invasive technique.
"In our paradigm, portable ultrasound devices, which can be used by any healthcare professional, will be implemented as standard for screening cardiovascular disease from early stages of life," Ibáñez.
Clear differences between men and women
The research also highlights marked differences by sex. In men, the prevalence of atherosclerosis increases from earlier ages, with a disease pattern five to ten years ahead compared to women.
In women, the most pronounced increase is observed between 40 and 60 years, an interval that generally coincides with the menopausal transition. These results point to the need to design specific preventive strategies according to sex and life stage.
In this line, the CNIC maintains an open parallel and complementary line of work focused on the study of atherosclerosis in women.
A new model of cardiovascular prevention
Another highlighted result is that conventional tools for calculating cardiovascular risk (such as SCORE2 scales) only manage to identify a limited fraction of people who already have silent atherosclerosis.
For Ibáñez, these conclusions highlight the urgency of moving towards a renewed model of cardiovascular prevention. "For decades we have estimated cardiovascular risk based on factors such as age, blood pressure, or cholesterol. This work demonstrates that we can now take a step further and directly detect the disease before it causes a heart attack or a stroke."
In his opinion, "the cardiovascular prevention of the future must be more precise and personalized. If we identify atherosclerosis in its early stages, we will be able to intervene earlier, better tailor treatments, and reduce the burden of cardiovascular disease."
Professor Bundgaard argues that the results open an exceptional opportunity to change prevention. "Until now, preventive decisions were based on an estimation of risk, but we did not know if the disease was already present. REACT demonstrates that atherosclerosis can be detected decades before clinical manifestations appear and provides the most comprehensive atlas of the evolution of this disease throughout adult life," he pointed out.
The researcher also emphasizes that this data lays the scientific foundations for evaluating a new preventive model. "Identifying and treating silent atherosclerosis as early as possible is essential to reduce the global burden of cardiovascular disease. Our results support the conduct of prospective studies to assess whether a preventive strategy guided by imaging techniques, even using portable ultrasound, can improve current standards. If confirmed, it will mean the incorporation of precision medicine into the most common cardiovascular disease," he concluded.