There was a recent correspondence article in the New England Journal of Medicine by Henning Bundgaard et al, published on August 29, 2026, titled “Prevalence of Silent Atherosclerosis Across Adult Life. “ The article is attached in PDF format for your information and below is a summary for your convenience.
BACKGROUND
Atherosclerosis may begin in early adulthood and remain clinically silent for de cades before cardiovascular disease manifests. Although silent atherosclerosis is associated with cardiovascular events and death independent of traditional cardiovascular disease risk factors, its age- and sex-specific prevalence, vascular territory distribution, and plaque volume across adult life remain incompletely defined.
METHODS
We conducted a prospective cohort study in Denmark and Spain. Adults 18 to 70 years of age without known atherosclerotic cardiovascular disease were enrolled in five prespecified age strata that included balanced numbers of women and men. Silent atherosclerosis was assessed at baseline with three-dimensional vascular ultrasonography of the carotid and femoral arteries and with coronary computed tomographic angiography.
RESULTS
A total of 16,808 adults were enrolled in the study. The mean (±SD) age of the participants was 45±12 years, and 51.4% were women. Silent atherosclerosis was present in 57.1% of the participants (95% confidence interval, 56.3 to 58.0). In the youngest age stratum (18 to 29 years), atherosclerosis was present in 8.7% of the men and 6.7% of the women; prevalence increased with age, with a later, steeper midlife rise among women. Among participants in the younger age strata, atherosclerosis was most often peripheral and confined to a single vascular territory; with increasing age, plaque volume increased exponentially and the prevalence of multiarterial involvement became more frequent. Isolated coronary-artery atherosclerosis was uncommon in every age stratum (≤9.3% of men and ≤5.0% of women).
CONCLUSIONS
This study of silent atherosclerosis showed that the disease was detectable in early adulthood, with age- and sex-associated increases in prevalence across arterial territories and marked increases in plaque volume.
DISCUSSION
Cardiovascular disease remains the leading cause of illness and death worldwide. Atherosclerosis is the principal pathologic process underlying coronary heart disease, ischemic stroke, peripheral artery disease, sudden cardiac death, and other cardiovascular manifestations. Accordingly, prevention of the development and progression of atherosclerosis is central to efforts to reduce the global burden of atherosclerotic cardiovascular disease. However, contemporary primary prevention is guided largely by estimated event risk and risk-factor thresholds rather than by the presence, vascular distribution, or volume of established atherosclerosis. This distinction is important because atherosclerosis may be present for decades before clinical cardiovascular disease becomes manifest.
Imaging studies in asymptomatic adults have consistently shown that silent atherosclerosis is common, although the reported prevalence varies according to age, population characteristics, vascular territory, and imaging modality. In studies involving middle-aged and older adults, coronary-artery calcium scoring, coronary computed tomographic (CT) angiography, and carotid or femoral ultrasound imaging have detected silent atherosclerosis in approximately 40 to 80% of participants. Consistently, greater plaque burden has been associated with higher risks of subsequent atherosclerotic cardiovascular events and death. Longitudinal imaging studies have also shown that plaque burden may progress over time, with known modifiable risk factors particularly relevant to the progression of plaque burden at younger ages.
The results reported here have implications for detection strategies. Our findings suggest that imaging of the carotid arteries provided the highest diagnostic yield. In younger adults, coronary-artery plaque was frequently present despite the absence of calcification, indicating that calcium scoring alone does not exclude early coronary atherosclerosis.
This cross-sectional study provides a large-scale atlas of silent atherosclerosis across adult life in men and women. Silent atherosclerosis showed age- and sex-related increases in the cross-sectional prevalence and extent of systemic involvement. Most participants with silent coronary atherosclerosis had peripheral atherosclerosis. Conventional 10-year risk classification identified only a minority of participants with established silent atherosclerosis.