A study published in Circulation: Cardiovascular Imaging reveals women face heart attack and chest pain risks at significantly lower levels of artery plaque than men, challenging assumptions about cardiovascular protection in women. The research, involving over 4,200 adults, found that while women had less plaque volume than men, their risk of cardiovascular events increased more rapidly with plaque accumulation, particularly after menopause.
The study analyzed data from the PROMISE trial, which included adults with stable chest pain and no prior coronary artery disease history. Participants underwent coronary computed tomography angiography and were followed for approximately two years. Results showed 55% of women had plaque in their coronary arteries compared to 75% of men, with women having a median plaque volume of 78 mm³ versus 156 mm³ in men. Despite these differences, women were just as likely as men to experience death from any cause, non-fatal heart attacks, or hospitalization for chest pain.
"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 identified specific thresholds where risk begins to increase: women's risk rose at 20% plaque burden, while men's risk started at 28%. With increasing plaque levels, risk escalated more sharply for women than for men. This finding has significant implications for cardiovascular risk assessment and treatment guidelines, which have historically been based primarily on male physiology.
Stacey E. Rosen, M.D., FAHA, volunteer president of the American Heart Association, emphasized the importance of recognizing biological differences in cardiovascular disease manifestation. "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," said Rosen, who also serves as executive director of the Katz Institute for Women's Health.
According to the American Heart Association's 2026 Heart Disease and Stroke Statistics, cardiovascular disease remains the leading cause of death worldwide, responsible for 433,254 female deaths in the U.S. alone. The study's findings highlight the need for sex-specific approaches to cardiovascular risk assessment and prevention strategies.
The American Heart Association provides educational resources about cardiovascular health, including information on atherosclerosis and heart attack symptoms in women. The organization has also published scientific statements addressing cardiovascular disease in women, including an advisory on cardiovascular disease in women that calls for improved awareness and equitable healthcare delivery.
This research contributes to growing evidence that cardiovascular disease manifests differently in women and men, with implications for diagnosis, treatment, and prevention. As cardiovascular disease continues to be the leading cause of death globally, understanding these sex-based differences becomes increasingly critical for developing effective public health strategies and clinical interventions.
