Women may have less artery-clogging plaque than men, yet this does not necessarily shield them from heart disease, according to new research published in Circulation: Cardiovascular Imaging, a journal of the American Heart Association. The findings challenge a long-held assumption that lower plaque levels automatically translate into lower cardiovascular risk. Instead, the study suggests that women can face comparable dangers even when the buildup within their arteries appears less severe.
Heart disease remains the leading cause of illness and death both in the United States and globally. Data from the American Heart Association’s 2026 Heart Disease and Stroke Statistics highlight the scale of the issue, affecting millions of people each year. Previous research has consistently shown that women tend to have a lower prevalence of arterial plaque than men, which has often been interpreted as a protective factor. However, the new study indicates that this difference may not provide the level of protection once believed.
To better understand how plaque levels relate to heart risk, researchers analysed health data from more than 4,200 adults, with women making up over half of the participants. All individuals had stable chest pain but no prior diagnosis of coronary artery disease. Participants were randomly assigned to undergo coronary computed tomography angiography, an imaging technique that uses X-rays to examine the heart and blood vessels. They were then monitored for approximately two years to track outcomes such as heart attacks, hospitalisations, or death.
The study revealed clear differences in plaque presence between men and women. About 55% of women had plaque in their coronary arteries compared to 75% of men. In addition, women had significantly lower volumes of plaque overall, with a median measurement of 78 mm³ versus 156 mm³ in men. Despite these differences, the likelihood of serious outcomes remained similar. Rates of death, non-fatal heart attack, or hospital admission for chest pain were 2.3% in women and 3.4% in men, indicating that lower plaque levels did not correspond to markedly lower risk.
Researchers also found that women began to face increased cardiovascular risk at lower plaque thresholds than men. For total plaque burden, women’s risk started to rise at around 20%, whereas men’s risk increased at approximately 28%. As plaque levels grew, the associated risk escalated more sharply in women. One possible explanation is that women typically have smaller coronary arteries, meaning even modest plaque accumulation can have a greater impact on blood flow and overall heart health.
Experts say the findings highlight important biological differences in how cardiovascular disease develops and affects men and women. These differences can influence everything from risk factors and symptoms to treatment outcomes. The study underscores the need for more tailored approaches to assessing and managing heart disease in women, as traditional definitions of “high risk” may underestimate their vulnerability. With cardiovascular disease accounting for 433,254 deaths among females of all ages—nearly half of all cardiovascular-related deaths—the research adds to growing evidence that improved awareness and targeted care are essential for reducing its impact.
More information: Jan Brendel et al, Risk in Women Emerges at Lower Coronary Plaque Burden Than in Men: PROMISE Trial, Circulation Cardiovascular Imaging. DOI: 10.1161/CIRCIMAGING.125.019011
Journal information: Circulation Cardiovascular Imaging Provided by American Heart Association
