# Stop Predicting Atherosclerosis. Start Looking for It. We have spent decades estimating who is *at risk* of developing atherosclerosis. The REACT study asks a more fundamental question: **How many apparently healthy adults already have the disease?** The answer is striking. Among **16,808 adults aged 18–70 years without known ASCVD**, systematically evaluated with carotid and femoral 3D ultrasound plus coronary CT angiography, **57.1% had silent atherosclerosis**. And it starts remarkably early: - **18–29 years:** 8.7% of men and 6.7% of women - **30–39 years:** 34.6% of men and 21.3% of women By age 60–70, only **1.9% of men and 8.1% of women** had no detectable plaque in any of the three territories. ## The Critical Point The most provocative result may be the disconnect between **predicted risk and actual disease**. High SCORE2 risk had a sensitivity of only **1.9%** for detecting silent atherosclerosis. Even moderate-to-high SCORE2 reached only **34.1% sensitivity**. And CAC alone does not tell the whole story. Among 30–39-year-olds with coronary plaque, **41.8% of men and 48.4% of women had CAC = 0.** Risk factors predict disease. **Imaging shows disease.** They are not the same thing. ## My Take This study should make us reconsider the foundations of primary prevention. Atherosclerosis is not something that suddenly appears when someone crosses a risk threshold. It begins early, progresses silently, becomes increasingly multiterritorial, and plaque volume rises dramatically with age. The question is therefore not whether risk scores are useful. They are. The question is whether **estimating the probability of disease should remain our endpoint when we can increasingly visualize and quantify the disease itself.** ## Where PCCT Fits REACT used CCTA to demonstrate something crucial: **CAC = 0 does not mean plaque = 0.** Photon-Counting CT could push this concept considerably further—toward lower-dose, higher-resolution assessment of early coronary plaque and increasingly detailed characterization of plaque burden and phenotype. The future of prevention may therefore move from: **risk-factor → risk-score → treatment** toward: **detect disease → quantify disease → characterize disease → treat disease.** Because ultimately: **Atherosclerosis is the disease. Risk is only its probability.** #Atherosclerosis #CardiacCT #CCTA #PhotonCountingCT #PCCT #PreventiveCardiology #CoronaryPlaque #CAC #PrecisionMedicine #TreatThePlaque