Current screening protocols for heart attacks, often based on symptoms, are not identifying nearly half the patients who are at risk, a new analysis shows. Anna S. Mueller, MD, from the Mount Sinai West/Morningside Department of Medicine, New York, and colleagues, reported these results in a manuscript published online Friday in JACC: Advances. “When we look at heart attacks and trace them backwards, most heart attacks occur in patients in the low or intermediate risk groups,” said Dr. Mueller in a Mount Sinai Fuster Heart Hospital press release on Friday. “This study highlights that a lower risk score, along with not having classic heart attack symptoms like chest pain or shortness of breath, which is common, is no guarantee of safety on an individual level.” Cardiovascular disease (CVD) is the leading cause of death for men and women worldwide. Risk calculators and symptom screening are used to evaluate patients for CVD risk, including the risk of cardiovascular events such as heart attack (myocardial infarction [MI]). Linking high atherosclerotic CVD (ASCVD) risk scores and symptoms to CVD risk may not be all-encompassing of the at-risk population. Investigators in this study examined the risk- and symptom-based analysis in the prevention of CVD. Patients included were under 66 years old and presented with their first acute coronary syndrome (ACS), and investigators looked at how guideline-directed tools would have worked if they were used two days prior to patients’ presentation. A total of 465 patients (19% women) who presented with their first heart attack at two U.S. hospitals were included in the study (January 2020 – July 2025), and the American College of Cardiology/Americah Heart Association (ACC/AHA) ASCVD Risk Estimator Plus calculated 10-year ASCVD risk. Investigators compared these results to the PREVENT calculator, which is a newer model for CVD risk reduction that integrates more variables (such as blood glucose levels). According to the ASCVD Risk Estimator Plus, 33% of patients were low-risk, 12% were borderline, 34% were intermediate and 10% were high-risk. Despite having been classified as lower risk for ASCVD, 10% of patients met statin indications because of high low-density lipoprotein (LDL) cholesterol (n=14) or diabetes (n=34). When the PREVENT calculator was used, 45% of patients were low-risk, 16% were borderline, 23% were intermediate and 3% were high-risk for ASCVD. Statin indications due to diabetes (n=51) or high LDL cholesterol (n=8) were also present (13%). Over half (53%) of patients reported chest pain or shortness of breath on the day they presented with their cardiovascular event, 7% of patients reported these symptoms within two days prior to the event and 23% had symptoms in the week prior to their event. Within the month before their event, 7% of patients had symptoms; within 1-3 months, 2% of patients had symptoms; and before the last three months, 11% had symptoms. The symptoms were analyzed with risk categories, and most patients developed symptoms before their cardiovascular event, indicating a limited value for the combined symptom-risk factor model. The ASCVD Risk Estimator Plus versus PREVENT showed similar results (low risk: 61% vs 65%, borderline risk: 61% vs 48%, intermediate risk: 60% vs 57%, high-risk: 60% vs 57%; patients with high LDL or diabetes: 58% vs 54%). Overall, if patients were evaluated two days before their event, 41% or 61% would not have been recommended to receive statins based on scoring from the ASCVD or PREVENT models. “This study suggests that the current approach of relying on risk scores and symptoms as primary gatekeepers for prevention is not optimal,” said Amir Ahmadi, MD, from the Icahn School of Medicine at Mount Sinai, and corresponding author of the paper, also during Friday’s press release. “It may be time to fundamentally reconsider this model and move toward atherosclerosis imaging to identify the silent plaque – early atherosclerosis- before it has a chance to rupture.” Source: Mueller AS, Leipsic M, Tomey M, et al. Limitations of risk- and symptom-based screening in predicting first myocardial infarction. JACC: Advances. 2025 November 21 (Article in Press). Image Credit: dragonstock – stock.adobe.com