The findings suggest that this disease may begin to develop long before its first clinical signs appear, opening the door to new early detection and prevention strategies.
The research was directed by 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), together with Henning Bundgaard, professor of Cardiology at the Rigshospitalet in Copenhagen, Denmark.
The results were presented during a Hot Line session of the European Society of Cardiology Congress (ESC 2026) and published in The New England Journal of Medicine.
Of the more than 16,000 people analyzed, 57.1% had atherosclerosis plaques, despite the fact that none had been previously diagnosed with cardiovascular disease or presented associated symptoms.
A disease that can progress for decades
Atherosclerosis is characterized by the progressive accumulation of plaques on the walls of the arteries and is one of the main causes of cardiovascular disease. It is behind a good part of myocardial infarctions and strokes.
Cardiovascular diseases cause nearly 20 million deaths annually worldwide and a large proportion is related to atherosclerosis. One of the main problems in combating it is precisely its ability to advance silently for years or even decades.
The study proposes modifying the traditional way of approaching cardiovascular prevention. Currently, doctors calculate a person’s risk using factors such as age, blood pressure, cholesterol levels or tobacco use.
The researchers propose to complement that approach with imaging techniques capable of directly determining whether atherosclerotic plaques are already present, even when the patient has no symptoms.
This would allow preventive measures and treatment of risk factors to be guided based on evidence of existing disease and not exclusively through calculations on the possibility of developing it.
Atherosclerosis since before the age of 30
The results correspond to the first phase of REACT, an investigation designed to study how silent atherosclerosis appears and evolves during adulthood.
In this stage, 16,808 people between 18 and 70 years old with no known history of cardiovascular disease participated. The researchers used advanced imaging techniques to look for plaques in the carotid, femoral and coronary arteries.
They also collected information on cardiovascular risk factors, blood biomarkers, samples intended for omics studies and retinal images, forming an extensive database on the development of the disease.
One of the most striking results is the presence of atherosclerosis at very early ages. About one in 13 participants between the ages of 18 and 29 already had signs of the disease in at least one artery.
The prevalence increased progressively with age until it reached approximately nine out of 10 people between 60 and 70 years of age.
The scientists also found that a large part of those who had atherosclerosis in the coronary arteries also had plaques in the carotid arteries, located in the neck, or in the femoral arteries, in the legs.
This finding could facilitate future screening programs, because the carotid and femoral arteries can be examined using relatively simple, rapid, and non-invasive ultrasound.
“In our paradigm, portable ultrasound machines, which can be used by any health professional, will be implemented as a standard for screening for cardiovascular disease from early stages of life,” said Ibáñez.
Men develop the disease earlier
The research also identified relevant differences in the evolution of atherosclerosis between men and women.
In men, the prevalence began to increase at younger ages. According to the results, their atherosclerotic profile was between five and ten years ahead of that observed in women.
Among them, the most pronounced increase appeared between the ages of 40 and 60, a period that approximately coincides with the transition to menopause.
The researchers consider that these differences could justify the development of preventive strategies that take into account both the sex and the stage of life of each patient.
The CNIC also develops a complementary line of research specifically dedicated to the behavior of atherosclerotic disease in women.
Towards more personalized prevention
Another relevant fact is that the tools commonly used to calculate cardiovascular risk, including scales such as SCORE2, only identified a small portion of people in whom imaging tests revealed silent atherosclerosis.
For Ibáñez, the results support the need to move towards prevention methods capable of identifying the disease before it triggers serious complications.
“For decades we have estimated cardiovascular risk based on factors such as age, blood pressure or cholesterol. This work shows that we can now go one step further and directly detect the disease before it causes a heart attack or stroke,” he said.
The researcher believes that this possibility could transform the way we decide who needs preventive intervention.
“Cardiovascular prevention in the future must be more precise and personalized. If we identify atherosclerosis in its initial phases, we will be able to intervene earlier, better adapt treatments and reduce the burden of cardiovascular disease,” said Ibáñez.
Bundgaard agrees that the findings offer an opportunity to rethink current prevention models.
“Until now, preventive decisions were based on an estimate 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 complete atlas of the evolution of this disease throughout adult life,” he explained.
However, the researchers point out that it is still necessary to verify through prospective studies whether detecting these lesions through imaging and acting on them early effectively translates into better outcomes for patients.
“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 that evaluate 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 to the most common cardiovascular disease,” Bundgaard concluded.
