A study of more than 4,200 adults published in Circulation: Cardiovascular Imaging, an American Heart Association journal, reveals that women face increased cardiovascular risk at lower levels of artery plaque than men, despite typically having less plaque overall. The research, which analyzed health data from participants with stable chest pain and no prior coronary artery disease history, found that while fewer women had plaque in their coronary arteries (55% of women vs. 75% of men) and women had lower plaque volume (median 78 mm³ vs. 156 mm³ in men), women were just as likely as men to experience major cardiac events.
The study's key finding indicates that women's cardiovascular risk begins to rise at 20% plaque burden, while men's risk starts at 28%. With increasing plaque levels, risk escalates more sharply for women than for men, particularly after menopause. This challenges the assumption that lower plaque volume provides protection for women against heart disease, which remains the leading cause of illness and death both in the United States and worldwide according to the American Heart Association's 2026 Heart Disease and Stroke Statistics available at https://www.heart.org/en/research/statistics.
"Our findings underscore that women are not 'protected' from coronary events despite having lower plaque volumes," said senior author Borek Foldyna, M.D., Ph.D., an assistant professor in radiology at Harvard Medical School. "Because women have smaller coronary arteries, a small amount of plaque can have a bigger impact. Moderate increases in plaque burden appear to have disproportionate risk in women, suggesting that standard definitions of high risk may underestimate risk in women."
The research analyzed data from the PROMISE trial, which followed adults with stable chest pain from 193 clinical sites in the U.S. and Canada for approximately two years. The analysis included 4,267 adults with an average age of 60, 51% of whom were women. According to the American Heart Association's statistics, cardiovascular disease caused 433,254 female deaths across all ages in 2026, representing 47.3% of cardiovascular disease deaths.
Stacey E. Rosen, M.D., FAHA, volunteer president of the American Heart Association, emphasized the importance of recognizing biological differences in cardiovascular disease manifestation. "These findings are another important example of why it is imperative to recognize that cardiovascular disease can impact men and women so differently," Rosen stated. "There is an overdue recognition of fundamental, biological differences in the way health conditions manifest in women vs. men, and these differences can influence everything from risk factors to symptoms to treatment response."
The study's implications extend to clinical practice, suggesting current risk assessment models may need adjustment to account for sex-specific differences in plaque impact. For business and technology leaders in healthcare, this research highlights opportunities for developing more precise diagnostic tools and personalized treatment approaches. The findings also underscore the importance of continued investment in sex-specific medical research to improve outcomes across populations. Additional information about cardiovascular disease in women is available through the American Heart Association's scientific statement on acute coronary syndromes in premenopausal women at https://www.ahajournals.org/doi/10.1161/CIR.0000000000001135.
