DETECTion of the Prevalence of Silent Atherosclerosis Across Adult Life and Development of a Risk Calculator to Predict Its Presence — Phase I of the REACT (Early Cure of Atherosclerosis) Project

doi:10.1056/nejmoa2609059

REACT

Patient / Population Intervention / Exposure Comparison Outcome

In 16,808 adults aged 18–70 years without known cardiovascular disease, whole-body imaging for atherosclerosis was studied for the age- and sex-specific prevalence of silent atherosclerosis.

N

16,808patients

Design

Prospective multicenter observational cohort in Denmark and Spain, adults 18-70 years without known ASCVD enrolled in five prespecified age strata balanced for sex and country; cross-sectional baseline multimodality imaging (3D vascular ultrasound of carotid and femoral arteries, coronary CT angiography, non-contrast CT calcium); study follow-up to 2032

Endpoint

Prevalence of silent atherosclerosis, defined as atherosclerotic plaque in at least one examined territory (carotid, femoral or coronary), at the baseline imaging visit

Relevance

2Important — one of several pillars.

ResultSilent atherosclerosis in 57.1% of participants overall: about 1 in 13 aged 18-29 and 9 of 10 aged 60-70. Men were affected 5-10 years earlier than women, who showed a steep rise around menopause. SCORE2 classified only a small minority of those with plaque as high risk, and almost none of the young.

Bundgaard H, Ibanez B, et al. N Engl J Med. 2026; published online 29 August. 10.1056/nejmoa2609059

Discussion & critique

A prevalence map, not a treatment trial: multimodality imaging of 16,808 adults shows plaque long before any risk score calls the person high risk. The gap between 57% with disease and the handful SCORE2 flags is the finding, and it cuts both ways — it may mean the score misses people, or that plaque at 25 is common enough to be near-normal. Nothing here shows that imaging these people and treating what is found prevents an event; the cohort runs to 2032, and that is the study that will answer it.