A study published in Circulation: Cardiovascular Imaging, an American Heart Association journal, has found that women may experience heart attack risk at lower levels of artery-clogging plaque than men, despite having less overall plaque. The research, which analyzed data from over 4,200 adults with stable chest pain and no prior coronary artery disease, suggests that standard risk assessments may underestimate heart disease risk in women.
The study evaluated health data from participants (51% women) who underwent coronary computed tomography angiography and were followed for about two years. Key findings revealed that fewer women had plaque in their coronary arteries compared to men (55% vs. 75%), and women had a lower median volume of plaque (78 mm³ vs. 156 mm³). Despite this, women were just as likely as men to die from any cause, have a non-fatal heart attack, or be hospitalized for chest pain (2.3% of women vs. 3.4% of men). Notably, women's risk began to rise at a 20% plaque burden, while men's risk started at 28%, and risk increased more sharply for women as plaque levels rose.
“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.”
According to the American Heart Association’s 2026 Heart Disease and Stroke Statistics, cardiovascular disease was the cause of death in 433,254 females of all ages, representing 47.3% of deaths from cardiovascular disease. Stacey E. Rosen, M.D., FAHA, volunteer president of the American Heart Association, commented, “These findings are another important example of why it is imperative to recognize that cardiovascular disease can impact men and women so differently. 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 included participants from the PROMISE trial, which involved 193 clinical sites in the U.S. and Canada. The lead author is Dr. Jan Brendel, M.D., research fellow at Massachusetts General Hospital and Harvard Medical School. The findings highlight the need for sex-specific risk assessment tools to better identify women at risk for heart disease. The full manuscript is available here.
