A study published in Circulation: Cardiovascular Imaging reveals that women face heart attack and chest pain risk at lower levels of artery plaque than men, despite typically having less plaque buildup. The research analyzed health data from more than 4,200 adults with stable chest pain and no prior coronary artery disease history, finding that while fewer women had plaque (55% versus 75% of men) and women had lower plaque volume (median 78 mm³ versus 156 mm³ in men), their cardiovascular risk manifested earlier and increased more rapidly.
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 challenge previous assumptions that lower plaque levels might protect women from heart events, showing instead that women's risk begins to rise at 20% plaque burden compared to 28% for men.
"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., 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 analyzed participants from the PROMISE trial who underwent coronary computed tomography angiography and were followed for approximately two years. The study's implications extend beyond clinical measurements to broader healthcare considerations, particularly as risk increased more sharply for women after menopause. Stacey E. Rosen, M.D., FAHA, volunteer president of the American Heart Association, noted that "these findings are another important example of why it is imperative to recognize that cardiovascular disease can impact men and women so differently."
Rosen emphasized the "overdue recognition of fundamental, biological differences in the way health conditions manifest in women vs. men" that influence "everything from risk factors to symptoms to treatment response." The American Heart Association provides additional health information through resources like What is Atherosclerosis? and Heart Attack Symptoms in Women to address these gender-specific concerns.
The study's methodology involved participants from 193 clinical sites across the U.S. and Canada, with an average age of 60 and 51% female representation. Lead author Dr. Jan Brendel, M.D., research fellow at Massachusetts General Hospital and Harvard Medical School, contributed to research that may influence how cardiovascular risk is assessed differently by gender. The findings suggest current diagnostic thresholds may need adjustment to account for women's increased vulnerability at lower plaque levels, potentially affecting screening protocols and preventive care approaches for millions of patients.
