A new study led by Mount Sinai researchers has revealed that nearly half of the individuals who go on to suffer a heart attack are not flagged as high-risk by current cardiac screening tools. Published on November 21 in the Journal of the American College of Cardiology: Advances, the findings raise serious concerns about the existing approach to heart attack prevention. According to the report, routine screening guidelines may create critical blind spots where early signs of heart disease are missed.
The investigation evaluated the performance of two widely used risk-assessment tools: the traditional ASCVD risk score and a newer model, PREVENT, which incorporates additional variables to estimate cardiovascular risk more comprehensively along with symptom-based screening.
“Population-level risk calculators often fail to reflect the true danger for many individual patients,” said corresponding author Amir Ahmadi, MD, Clinical Associate Professor of Medicine (Cardiology) at the Icahn School of Medicine at Mount Sinai. “If these patients had been assessed just two days before their heart attack, nearly half would not have qualified for further testing or preventive therapy under current guidelines.”
The findings indicate that relying primarily on symptoms and calculated risk scores may not be sufficient for preventing heart attacks. Researchers suggest that the model should shift toward early detection of atherosclerosis using imaging techniques, which can identify silent plaque long before it ruptures.
In current practice, physicians use ASCVD or PREVENT calculators during routine primary care visits—typically for adults aged 40 to 75 without diagnosed heart disease—to estimate a patient’s 10-year risk of heart attack or stroke. These assessments guide decisions about prescribing cholesterol-lowering medications such as statins. Patients with low or borderline risk scores, especially in the absence of symptoms like chest pain or breathlessness, are often reassured and discharged without additional evaluation.
However, the study showed a stark contrast: among patients who eventually suffered their first heart attack, nearly half would have been labeled low or borderline risk by ASCVD, and more than half by PREVENT, if they had been evaluated two days before their event.
The research analyzed data from 474 patients under age 66 with no known coronary artery disease who were treated for their first heart attack at Mount Sinai Morningside and The Mount Sinai Hospital between January 2020 and July 2025. Data collected included demographics, medical history, cholesterol levels, blood pressure, and the timing of symptom onset. Risk scores were calculated retrospectively as if assessments had been conducted two days prior to each patient’s heart attack.
Results showed that 45 percent of patients would not have qualified for preventive therapy under ASCVD guidelines, rising to 61 percent under PREVENT. Notably, 60 percent of patients did not experience classic symptoms—such as chest pain or shortness of breath—until less than two days before their cardiac event, underscoring that symptoms often appear too late to alter disease progression. The study emphasizes a serious gap in the current prevention strategy: many individuals who seem healthy by standard measures may already harbor advanced, silent plaque.
“Most heart attacks occur in individuals categorized as low or intermediate risk,” said first author Anna Mueller, MD, an internal medicine resident at the Icahn School of Medicine at Mount Sinai. “Our findings show that tools designed for population risk tracking do not translate well to personalized care. Instead of waiting for symptoms, clinicians should focus on detecting the underlying plaque early—this could be life-saving.”
The study concludes that further research is needed to refine early detection methods. Future work should emphasize improving screening strategies through advanced cardiovascular imaging to better identify at-risk patients before symptoms arise.
