Imaging-Guided Screening Could Identify Silent Atherosclerosis Earlier

Atherosclerosis, the arterial plaque buildup that drives most cardiovascular disease, often develops silently for decades. Undetected plaques in young adults can lead to preventable heart attacks and strokes later in life, while current risk scores may miss early disease. Hospitals need practical strategies to identify subclinical disease before symptoms emerge. A new international study now maps the prevalence of silent atherosclerosis across adult life and points to imaging‑led screening pathways starting in early adulthood.

REACT, an international collaboration between Rigshospitalet in Denmark, other Danish hospitals, and the Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC) in Spain, examined apparently healthy adults using advanced vascular imaging. The findings were reported at ESC Congress 2026 and published in the New England Journal of Medicine on August 29, 2026. Phase 1 enrolled 16,808 adults ages 18–70 in Denmark and Spain, all without a known history of atherosclerotic cardiovascular disease.

Participants underwent imaging to detect plaques in the carotid, femoral, and coronary arteries, creating a comprehensive atlas of subclinical disease across vascular beds and age groups. Investigators also assessed traditional risk factors, blood biomarkers, samples for omics analyses, and retinal images to build a multidimensional database. The study design enables comparison of arterial territories and informs where noninvasive screening could be most efficient.

Plaques were detected in 57.1% of participants despite no prior diagnosis. Approximately one in 13 adults ages 18–29 already had disease in at least one artery, rising to nine in 10 among those ages 60–70. Coronary plaques usually coexisted with carotid or femoral lesions, highlighting the potential of ultrasound of neck and leg arteries as a practical screen compared with computed tomography (CT) scans. Men showed earlier onset by five to 10 years, while women had the sharpest increase between ages 40 and 60, broadly coinciding with the menopausal transition.

Conventional cardiovascular risk scores, including SCORE2, identified only a small proportion of people who already had silent atherosclerosis. REACT is planned over eight years in two phases, with REACT‑DETECT launched in 2024 and REACT‑PROTECT planned for 2027–2032. The next phase will test whether an imaging‑guided precision prevention strategy can slow systemic atherosclerosis and reduce events, with expansion to sites in India, Singapore, Tanzania, and Mexico.

“Identifying and treating silent atherosclerosis as early as possible is essential to reducing the global burden of cardiovascular disease. Our results support prospective studies evaluating whether a preventive strategy guided by imaging, including the use of portable ultrasound, can improve current standards. If confirmed, this would bring precision medicine to the most common cardiovascular disease,” said Henning Bundgaard, professor of cardiology at Rigshospitalet in Copenhagen, Denmark.

“PESA has shown us that atherosclerotic disease is present in many middle-aged people and is associated with lifestyle patterns. In REACT, we wanted to investigate how it emerges at much younger ages. For years, we have proposed that early intervention in atherosclerosis could not only prevent its progression but might even make it possible to cure the disease. REACT will answer this question,” said Valentin Fuster, director general of CNIC.

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