Current cardiac risk tools overlook a large share of impending first heart attacks
A closer look at why many low risk adults still experience major cardiac events
A new study suggests that common cardiovascular risk calculators may overlook a large group of adults who later experience a first heart attack. Many of these individuals would not have met criteria for statin therapy or further testing even 48 hours before their event.
Study Details
Researchers assessed how well widely used risk tools capture adults who ultimately present with a first myocardial infarction. The analysis focused on people aged 65 years or younger with no known coronary artery disease.
All participants were treated at two large US centers between 2020 and 2025. Risk categories were assigned using the ASCVD Risk Estimator Plus and the newer PREVENT tool. The study also evaluated when symptoms began and whether guideline-based care two days earlier would have triggered preventive treatment.
Methodology
This was a retrospective review of medical records from 465 adults with a first type 1 myocardial infarction. Researchers calculated each patient’s 10 year ASCVD risk using both ASCVD Risk Estimator Plus and PREVENT. They noted when symptoms such as chest pain or shortness of breath began and simulated which patients would have been advised to start a statin or undergo diagnostic imaging if they had been assessed 48 hours earlier under current clinical guidelines.
Key Findings
• ASCVD Risk Estimator Plus placed 33 percent of patients in the low risk group and 12 percent in the borderline group. Only 10 percent met statin indications based on LDL cholesterol above 190 mg/dL or diabetes.
• PREVENT placed 45 percent of patients in the low risk group and 16 percent in the borderline group. Only 13 percent met statin indications.
• Sixty percent of patients developed symptoms within 48 hours before their heart attack.
• If evaluated two days earlier, 45 percent would not have been considered for statin therapy or imaging based on ASCVD Risk Estimator Plus and 61 percent would not have been considered for these steps based on PREVENT.
Implications for Practice
For patients
Many adults who appear to have low or borderline cardiovascular risk may still harbor early atherosclerosis that routine calculators do not capture. Symptoms that arise suddenly within a day or two, especially chest discomfort or unexplained shortness of breath, remain important signals to seek care promptly. Understanding that risk scores are only one part of prevention may help more people discuss optional imaging or earlier screening with their clinicians.
For healthcare providers
The findings suggest that traditional risk models may miss a meaningful subset of younger adults who ultimately exhibit plaque rupture. Incorporating selective use of atherosclerosis imaging, such as coronary artery calcium scoring or coronary CT angiography, could help reveal silent plaque development. This approach may support more individualized preventive strategies, particularly for patients who score low on calculators but have persistent risk factors, concerning symptoms, or strong family histories.