Cardiovascular disease does not appear suddenly. Heart attacks or strokes occur after many years of accumulated damage that neither hurts nor is noticed, which is why it is important to eat healthily, exercise, not smoke, and manage blood pressure. Now, an analysis involving more than 16,800 healthy adults in Spain and Denmark suggests that silent atherosclerosis, the buildup of atheroma plaques in the arteries that hinder blood flow but cause no symptoms, begins much earlier than previously thought and affects more people than expected.
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In the study, named REACT, funded by the Novo Nordisk Foundation and led from the National Center for Cardiovascular Research in Madrid, advanced 3D ultrasound and tomography were used in three parts of the body: the carotids in the neck, the femorals in the groin, and the coronaries in the heart. Thus, the authors observed that 57.1% of these adults aged between 18 and 70, with no history of heart attack or stroke, had atheroma plaques. The most striking fact is that the problem begins to appear from youth, a stage in which this type of risk was not usually studied. One in 13 participants between 18 and 29 years old already had atherosclerosis in some artery. Afterwards, the proportion progressively increases to reach 90% in people over 60 years old.
The work, presented today at the Congress of the European Society of Cardiology in Munich and simultaneously published in the journal The New England Journal of Medicine, also confirms that men and women suffer cardiovascular disease differently. The prevalence is higher in men, at 63.4%, than in women, at 50.9%. Additionally, in men, plaques appear between five and ten years earlier, while in women they surge between 40 and 60, coinciding with menopause.
Atherosclerosis is the progressive accumulation of fat and cholesterol plaques in the walls of the arteries and is behind most heart attacks or strokes. Almost a third of all deaths worldwide are attributed to cardiovascular diseases, a percentage that is somewhat higher in regions like Europe. The World Health Organization and the World Heart Federation estimate that up to 80% of premature heart attacks and strokes could be prevented if risk factors were addressed in time, and that is what REACT aims to map precisely.
The authors propose replacing the current risk calculation systems, which measure indirect parameters such as age, blood pressure, or cholesterol, with direct detection of plaque, starting from an early age and adapting the strategy to the patient’s sex. A risk calculation system like the European SCORE2 did not identify most people who already had atherosclerosis according to imaging tests. A high-risk score in this method identified only 1.9% of people who already had silent disease, and including moderate risk left 66% undetected. Traditional methods also exclude younger people who, as this study shows, are already beginning to have plaques.
The study leader, Borja Ibáñez, estimates that the benefits of changing the prevention strategy would be enormous: “We have conducted preliminary studies with very conservative estimates and estimate that we could prevent more than 50% of ischemic events that occur today: heart attacks, strokes, and sudden death, with savings of billions of euros per year in Europe.” Ibáñez, who is the scientific director of CNIC and a cardiologist at the Jiménez Díaz University Hospital Foundation, co-directed the project with Henning Bundgaard, Professor of Cardiology at Rigshospitalet in Copenhagen (Denmark).
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To better assess the need for change, the researchers will conduct a second phase of the REACT study to answer a question not addressed in this first phase: does detecting atherosclerosis before symptoms appear and acting on it prevent more heart attacks and strokes than conventional cardiovascular prevention?
Ibáñez clarifies that it would not be necessary to carry out the full tests as in the trial, which require expensive equipment, trained personnel, and, as with coronary CT, exposure to radiation. “It is not necessary to do tomography on everyone; simply with a quick vascular ultrasound using low-cost equipment on the arteries of the neck and legs, the carotids and femorals, we can reliably identify subjects who already have the process started,” he explains. 82% of those with coronary plaque also have it in carotids or femorals.
Ibáñez is aware of the risk of suddenly labeling millions of very young people without symptoms as sick, but believes the way of viewing atherosclerosis must change. “It is very important to raise awareness among the population that this will not be a short-term problem, but it will be in the long term and something must be done,” he points out. Ibáñez makes an analogy with diabetes: “Fifty or sixty years ago, a perfectly normal person would go to the doctor, have a blood glucose test, get 180, and be prescribed insulin, and it was not accepted until that person already looked ill. Now, the diagnosis is received and accepted without it being a terrible drama, and we want to do the same with this disease,” he continues. If that is achieved, it will be possible “to make an intervention, even a mild one, at 30 years old, which will have much more benefit than if you start the intervention at 50.”
Cardiovascular risk measurement with the method tested in REACT would also alert a portion of the population without apparent risk. People who exercise, are not overweight, and eat well, but who, when measured, are accumulating plaque. “There are risk factors that are not related to lifestyle and are more biochemical, such as cholesterol or blood pressure. Much of the elevated cholesterol is due to hepatic production, for example,” says Ibáñez.
Ignacio Fernández Lozano, president of the Spanish Society of Cardiology, states that this study does not change anything for now, but “it is a cornerstone that will probably change everything over time.” That change will occur if in the second phase of REACT it is confirmed that the information obtained with the new methods helps save lives and prevent cardiovascular problems. Among the main findings, for Fernández Lozano, who did not participate in the study, is seeing that the scales used today, such as SCORE2, “do not work very well to detect asymptomatic atherosclerosis” and that it is necessary “to start considering the patient diagnosed with coronary disease as a patient with global atherosclerosis, and not focus only on the heart.”
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