Less artery-clogging plaque in women's arteries does not appear to protect them from heart disease compared to men, according to a study published today in Circulation: Cardiovascular Imaging, an American Heart Association journal. The research, which evaluated health data for more than 4,200 adults, found that despite having lower plaque volumes, women were just as likely as men to die from any cause, have a non-fatal heart attack, or be hospitalized for chest pain.
While heart disease is the leading cause of illness and death in the U.S. and worldwide, according to the American Heart Association’s 2026 Heart Disease and Stroke Statistics, women tend to have a lower prevalence of artery plaque than men, according to previous research. This study, however, indicates that this advantage may not translate into lower risk.
Key findings show that fewer women had plaque in their coronary arteries than men (55% of women vs. 75% of men), and women also had a lower volume of artery plaque (a median of 78 mm3 among women vs. 156 mm3 in men). Despite this, the incidence of major cardiovascular events was similar: 2.3% of women vs. 3.4% of men experienced death, non-fatal heart attack, or hospitalization for chest pain over about two years of follow-up.
Importantly, women faced increased heart risk at lower levels of plaque compared to men. For total plaque burden, women’s risk began to rise at 20% plaque burden, while men’s risk started at 28%. With increasing plaque levels, risk rose more sharply for women than 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., 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.”
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.”
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. The study included 4,267 adults (average age 60; 51% women) from the PROMISE trial, who had stable chest pain and no prior history of coronary artery disease. Participants were randomized to undergo diagnostic evaluation via coronary computed tomography angiography and followed for about two years.
The study’s lead author is Dr. Jan Brendel, M.D., research fellow at Massachusetts General Hospital and Harvard Medical School. The findings challenge the notion that lower plaque burden equates to lower risk in women, emphasizing the need for sex-specific risk assessment in cardiovascular disease.
