Heart attacks and strokes seem like sudden disorders; sudden attacks that appear without warning and can be devastating. However, these problems are actually the result of damage to the arteries that has been developing silently over the years.
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Atherosclerosis, that accumulation of plaques inside blood vessels that causes their progressive narrowing and hardening, is a much more common phenomenon than previously thought and can already be detected in apparently healthy young adults, as recently demonstrated by a study led by scientists from the National Center for Cardiovascular Research (CNIC).
According to the data from this work, one in 13 young people between 18 and 29 years old has silent atherosclerosis in some artery of their body. “It is alarming that, as we have seen, almost 9% of the males analyzed in that age group and practically 7% of young women present silent atherosclerosis. In general, we have seen much higher percentages of affected individuals than previously thought,” explains Borja Ibáñez, scientific director of the CNIC and leader of this research whose conclusions are presented in one of the highlighted sessions of the European Society of Cardiology Congress and are simultaneously published in the journal The New England Journal of Medicine.
“Nowadays, atherosclerosis is diagnosed and treated when it is already very advanced. What the results of this work show is that we need to move towards a new way of preventing cardiovascular disease,” states Ibáñez, who is also a cardiologist at the Fundación Jiménez Díaz Hospital in Madrid and group leader at the CIBER of Cardiovascular Diseases (CIBERCV).
Together with Henning Bundgaard, professor of Cardiology at Rigshospitalet in Copenhagen (Denmark), Ibáñez has coordinated this ambitious research, called REACT, which analyzed the case of more than 16,000 patients aged between 18 and 70 years to map the existence of silent atherosclerosis in adulthood.
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The ultimate goal of the work, as Ibáñez explained to this newspaper when the trial was in its early stages, is to generate the necessary evidence to completely change the way cardiovascular prevention is done, redirecting it to act early.
“According to current clinical guidelines, the evaluation and treatment of atherosclerotic cardiovascular disease is mainly recommended in people over 40 years old, generally after many years of exposure to risk factors such as high cholesterol levels, high blood pressure, smoking, or obesity. But that prevention strategy is not working. A change is needed,” Ibáñez explained then.
The results of the first phase of the research have shown that silent atherosclerosis is very common. 57.1% of the people studied had atherosclerotic plaques in their arteries despite not showing symptoms or having a diagnosis of cardiovascular disease.
Conventional risk estimation methods are not enough
The percentages of atherosclerosis detected in people between 18 and 29 years old are striking, with 9% in males and almost 7% in females, but the proportion of affected individuals increased progressively with age, reaching 9 out of 10 people between 60 and 70 years old.
The study also detected significant differences between men and women. Thus, they found that in men the disease progresses quite rapidly in the first decades of adulthood and appears 5 to 10 years earlier than in women. In women, however, the most marked increase is observed between 40 and 60 years, a period that coincides with menopause. In the case of women, atherosclerosis progresses more slowly in the first decades of adulthood and then shows very significant growth. “We are going to carry out specific studies on the effects of hormonal changes on cardiovascular disease,” Ibáñez reveals, emphasizing another important point of the research.
“We have seen that more than 80% of subjects who have atherosclerosis in the coronaries also have it in the carotid or femoral arteries, so it is confirmed that with a study of these vessels, for example with an ultrasound, it is possible to detect if that person has coronary disease. This is a finding that is important at the screening level, because the study of carotid and femoral arteries with ultrasound is easy, quick, and non-invasive,” the researcher points out.
Additionally, the study also showed that the methods currently used to estimate cardiovascular risk—such as the SCORE2 risk scales—only allow identifying a small proportion of people who already have silent atherosclerosis.
“It is necessary to change the approach,” says the researcher, who clarifies that the second phase of the project, which will start in 2027, will take a further step and study whether a prevention strategy guided by imaging techniques is capable of more effectively reducing the occurrence of heart attacks, strokes, and other cardiovascular problems.
“Being able to intervene much earlier than is done now will probably result in a very significant reduction in cardiovascular disease,” concludes Ibáñez.
For Ignacio Fernández Lozano, president of the Spanish Society of Cardiology (SEC), this research “is the most relevant atlas of atherosclerosis we currently have. That is why it is published in The New England Journal of Medicine, which is the most prestigious medical journal. It will probably be one of the most referenced articles in the coming years regarding cardiovascular pathology because everyone will take this study as a reference atlas,” he points out.
“Fundamentally, what changes for us cardiologists today is the finding that coronary disease is rarely an isolated event and that most patients when they have atherosclerosis have it in several territories of their body. That should be a message not only for cardiologists but also for neurologists, vascular surgeons, or general practitioners who attend to this type of patients to carry out more active screening of atherosclerosis in various territories of the body,” he adds.
Furthermore, he continues, this study can also be a first approach for future changes in clinical practice. “The CNIC is considering conducting studies in the future that change the clinical treatment strategy and begin to assess whether searching for subclinical atherosclerosis and then treating it translates into an improvement in cardiovascular health and a reduction in the number of events. It could be a fundamental step to change the prevention strategy and implement a more aggressive strategy for detecting atherosclerotic disease in the general population,” he concludes.
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