A study published in Circulation: Cardiovascular Imaging reveals that women face heart attack and chest pain risks at substantially lower levels of artery plaque than men, challenging assumptions about gender differences in cardiovascular protection. The research, involving more than 4,200 adults, found that while women had less plaque volume than men, they experienced similar rates of adverse cardiovascular events, with their risk increasing more sharply as plaque levels rose.
The analysis showed that only 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 this apparent advantage, women were just as likely as men to die from any cause, experience non-fatal heart attacks, or require hospitalization for chest pain. More significantly, women's cardiovascular risk began to rise at 20% plaque burden, while men's risk didn't increase until 28% plaque burden, with risk escalating more rapidly for women as plaque levels increased.
"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 study's implications are particularly important given that cardiovascular disease remains the leading cause of death for both men and women in the United States and worldwide, according to the American Heart Association's 2026 Heart Disease and Stroke Statistics. The research adds to growing evidence that biological differences between sexes significantly influence how cardiovascular disease manifests, progresses, and should be treated.
Stacey E. Rosen, M.D., FAHA, volunteer president of the American Heart Association, emphasized the importance of these findings: "These results highlight 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 analyzed data from the PROMISE trial, which followed adults with stable chest pain and no prior history of coronary artery disease for approximately two years. Participants underwent diagnostic evaluation using coronary computed tomography angiography, providing detailed X-ray images of heart and blood vessels. The findings suggest current risk assessment models may need adjustment to account for women's heightened vulnerability at lower plaque levels, particularly after menopause when risk appears to accelerate.
This research has significant implications for clinical practice, potentially leading to revised screening protocols and treatment thresholds for women. It also underscores the need for increased awareness among both healthcare providers and patients about gender-specific cardiovascular risks. The American Heart Association provides educational resources about heart disease in women, including information on heart attack symptoms in women that differ from the classic symptoms more commonly seen in men.
As cardiovascular disease claimed the lives of 433,254 females of all ages in 2026, representing 47.3% of all cardiovascular deaths, this study's findings could help address persistent gender disparities in cardiovascular outcomes. The research contributes to ongoing efforts to develop more personalized, sex-specific approaches to cardiovascular prevention, diagnosis, and treatment that could ultimately reduce the global burden of heart disease for all populations.
