Why Women's Hearts May Be at Greater Risk Than Standard Tests Suggest

Article: "Risk in Women Emerges at Lower Coronary Plaque Burden Than in Men: PROMISE Trial" (Brendel, Mayrhofer, Karády et al. — Circulation: Cardiovascular Imaging, 2026) 

A major new study published in Circulation: Cardiovascular Imaging, analyzing data from over 4,200 patients in the PROMISE trial, found that women face increased cardiovascular risk at substantially lower levels of coronary plaque burden compared to men — even after accounting for traditional risk factors. Using advanced quantitative analysis of coronary CT angiography (CCTA), researchers measured total plaque burden (the percentage of vessel volume occupied by plaque) and tracked major adverse cardiovascular events including heart attack, death, and hospitalization for unstable angina. Although women had lower total plaque volume than men, their total plaque burden — which accounts for their naturally smaller vessel size — was similar. Critically, elevated cardiac risk emerged at a total plaque burden of just 20% in women versus 28% in men, and the risk curve rose far more steeply in women. Put simply: a modest amount of plaque in a woman's coronary arteries may be just as dangerous as a much larger amount in a man's. 

These findings have important real-world implications for women's cardiovascular health. Current risk thresholds used in clinical practice are largely derived from male-dominated studies, and this research suggests those benchmarks may significantly underestimate risk in women. The authors propose that age- and sex-specific reference curves for coronary plaque burden — analogous to growth percentile charts — could enable more accurate, personalized risk assessment. Women in the study also showed higher rates of dyslipidemia yet similar rates of statin use compared to men, raising concerns about potential undertreatment. If you are a woman with chest pain, cardiovascular risk factors, or a family history of heart disease, a comprehensive coronary CT angiogram with quantitative plaque analysis may provide critical information that standard risk calculators miss. We encourage you to speak with our team about whether advanced cardiac imaging is right for you.