Silent artery disease starts far earlier than medical textbooks suggest. The REACT study, presented at ESC Congress 2026 and published simultaneously in the New England Journal of Medicine, scanned 16,808 adults aged 18 to 70 in Denmark and Spain who had no known cardiovascular disease. Its headline finding: about one in thirteen adults under thirty already carries plaque in an artery wall, and overall 57.1 percent of participants had silent atherosclerosis somewhere in their vessels.
The methods are what make this study hard to dismiss. Every participant underwent coronary computed tomographic angiography for the heart arteries plus three-dimensional vascular ultrasound of the carotid arteries in the neck and the femoral arteries in the leg. Recruitment used stratified random sampling from the Danish civil register and open public advertisement in Spain, balanced across five age bands and both sexes. According to SciTechDaily's coverage of the release, this is the largest multimodal imaging survey of silent plaque ever conducted. The press release ESC published via escardio confirms the REACT results were presented in a Hot Line session at ESC Congress 2026 and published simultaneously.
The age curve is the study's most dramatic result. In the 18-to-29 group, 8.7 percent of men and 6.7 percent of women had plaque; by ages 30 to 39 the figures reached 34.6 and 21.3 percent; and among 60-to-70-year-olds roughly nine in ten carried disease. As the NIH's PubMed record of the paper details, plaque volume grows exponentially with age and the disease turns from single-territory to multi-territory involvement as decades pass.
Sex differences are sharp and clinically meaningful. In men, prevalence climbs from the thirties and plateaus by midlife; in women the steepest rise lands between 40 and 60, overlapping menopause, narrowing the gap with age. In younger adults the disease sits almost entirely in peripheral arteries, usually one territory, most often the carotids. Isolated coronary plaque is uncommon at every age, and strikingly, more than four in ten young adults with coronary plaque had a calcium score of zero.
The uncomfortable finding concerns the calculators doctors actually use. SCORE2 estimates ten-year cardiovascular risk from age, blood pressure, cholesterol and smoking, yet REACT showed it classifies only a small minority of people with confirmed silent plaque as high risk, with the miss rate worst in the young. Medscape's commentators framed the message bluntly: prevention may be starting too late, because risk estimation without any knowledge of the disease itself overlooks plaque built up years earlier.
From Periphery to Heart: One Scan, Two Signals
That gap motivates the study's practical proposal. Because peripheral plaque predicts coronary plaque, with odds rising across plaque-volume quartiles, a handheld ultrasound of neck and leg arteries could become a front-line triage tool. The ClinicalTrials registry entry for REACT-DETECT describes exactly this ambition: a precision-prevention pipeline that finds candidates for early therapy long before overt disease, rather than waiting for risk scores to catch up.
Scores Fall Short, Precision Prevention Is Next
What comes next is already funded and scheduled. The Novo Nordisk Foundation committed 23 million euros to the first phase, and the second phase, REACT-PROTECT, will run randomized trials from 2027 to 2032 testing whether imaging-guided precision medicine actually reduces heart attacks and strokes. The team has also begun collaborations in India, Singapore, Tanzania and Mexico to extend findings beyond European populations.
AI commentary
"I read the NEJM paper behind this story in full, and what struck me most is how badly our risk calculators miss young patients. My take: imaging-guided prevention is coming, but the cost and radiation questions are real and unresolved."
AI assessment
The strongest counter-view says early imaging creates more problems than it solves. A coronary CT means radiation and contrast dye, full-body knowledge of silent plaque in a healthy 25-year-old invites overdiagnosis, statins for decades on the basis of a screening finding, and anxiety without proven benefit. Until REACT-PROTECT reports, treating images instead of patients is speculation, however precise the pictures look.
A second limitation is design and population. REACT-DETECT is cross-sectional: one snapshot per person, no proof yet that finding plaque early and acting on it prevents heart attacks. Recruitment was Danish registry sampling plus Spanish open advertisement, overwhelmingly European ancestry, and the team itself says expansion to India, Singapore, Tanzania and Mexico is only beginning.
My practical takeaway is narrower than the headlines. If you are over 40, male, a smoker, or have a family history of early heart disease, ask your doctor whether a carotid or femoral ultrasound makes sense for you; Medscape's commentators frame this as prevention starting too late, not too early. If you are young and healthy, the actionable message is boring and free: blood pressure, lipids, smoking and exercise still drive most of the risk the scanners reveal.
Sources
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react study · silent atherosclerosis · nejm · score2 · early prevention · ccta