A groundbreaking study led by researchers at the Icahn School of Medicine at Mount Sinai has unveiled a concerning reality: the standard diagnostic tools used by physicians to gauge heart attack risk are failing to identify nearly half of the individuals who are at imminent danger of a cardiac event. The findings, published on November 21 in the Journal of the American College of Cardiology: Advances, suggest that current medical guidelines are inadvertently leaving millions of "low-risk" patients vulnerable to silent, progressive heart disease.
The research calls into question the long-standing reliance on population-based risk scores—specifically the Atherosclerotic Cardiovascular Disease (ASCVD) risk score and the newer PREVENT tool—arguing that these calculators, while useful for public health trends, are fundamentally inadequate for individual patient care.
The Foundation of Current Prevention: How We Assess Risk Today
To understand the scope of the study, one must first understand the "gatekeeper" model of modern cardiology. For decades, primary care physicians have utilized the ASCVD risk score to determine the necessity of preventive interventions, such as statins or blood pressure medication. This tool calculates a patient’s 10-year probability of suffering a heart attack or stroke by aggregating key demographic and physiological variables: age, sex, race, systolic blood pressure, cholesterol levels, diabetes status, and smoking history.
The PREVENT tool was introduced more recently to provide a more nuanced outlook, incorporating additional biomarkers and social determinants of health to offer a broader cardiovascular risk profile.
In clinical practice, these scores dictate the trajectory of patient care. If a patient scores as "intermediate" or "high," physicians typically initiate aggressive cholesterol-lowering therapies and order further diagnostic testing. However, for the millions of adults aged 40 to 75 who fall into the "low" or "borderline" categories—particularly those who report no classic symptoms like chest pain or shortness of breath—the clinical response is frequently one of reassurance. These patients are often discharged from their check-ups with a clean bill of health, unknowingly harboring the very plaque that will eventually trigger a cardiac event.
Chronology of the Investigation: Tracking the "Silent" Patient
The Mount Sinai research team, led by corresponding author Amir Ahmadi, MD, Clinical Associate Professor of Medicine (Cardiology), conducted a retrospective analysis designed to "stress-test" these risk calculators against real-world outcomes.
The study reviewed 474 patients, all under the age of 66, who had no prior diagnosis of coronary artery disease. Every patient in the cohort had been treated for a first-time heart attack at either The Mount Sinai Hospital or Mount Sinai Morningside between January 2020 and July 2025.
The investigative team performed a "reverse-simulation" on each patient. By collecting their medical history, cholesterol panels, and blood pressure readings from their last visit prior to the cardiac event, the researchers calculated what their ASCVD and PREVENT scores would have been just two days before their heart attack.
The results were stark:
- 45 percent of patients would have been categorized as low or borderline risk under the ASCVD guidelines.
- 61 percent of patients would have been categorized as low or borderline risk under the newer PREVENT tool.
Because these patients were classified as low-risk, they would not have been candidates for preventive treatment under current standard-of-care guidelines. Effectively, the medical system would have "missed" them entirely until the moment their heart attack occurred.
Supporting Data: Why Symptoms Are a Lagging Indicator
One of the most critical findings of the study concerns the timing of symptoms. Conventional medical advice encourages patients to seek help if they experience chest pain or shortness of breath. However, the Mount Sinai study highlights that this reliance on symptoms is a dangerous delay tactic.
The data revealed that 60 percent of the study participants did not experience any symptoms until fewer than two days before their heart attack. For the vast majority, the disease was entirely "silent" until the moment of acute rupture.
"When we look at heart attacks and trace them backwards, most heart attacks occur in patients in the low or intermediate risk groups," notes first author Anna Mueller, MD, an internal medicine resident at Icahn Mount Sinai. "Our study exposes a major flaw where tools effective for tracking large populations fall short when guiding individualized care."
The data demonstrates that for most patients, the clinical manifestation of a heart attack is not the start of the illness, but rather the end-stage of a long process of silent plaque accumulation. By the time a patient experiences pain, the pathology is already advanced, and the window for primary prevention has largely closed.
Official Responses and Clinical Perspectives
The medical community has long debated the efficacy of risk calculators, but this study provides empirical weight to the argument that we are over-relying on statistical averages at the expense of individual health.
Dr. Amir Ahmadi is clear about the implications of these findings: "If we had seen these patients just two days before their heart attack, nearly half would not have been recommended for further testing or preventive therapy guided by current risk estimate scores and guidelines."
According to Dr. Ahmadi, the strategy of using risk scores as the sole "gatekeeper" for prevention is no longer optimal. The medical establishment, he argues, must undergo a paradigm shift. "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," he states.
The study emphasizes that a "low risk" score is not a guarantee of safety. Because the current calculators are based on population-wide statistics, they are inherently prone to missing the unique, individual physiological risks that result in sudden, first-time cardiac events.
Implications: Moving Toward a New Era of Cardiovascular Imaging
The Mount Sinai study acts as a clarion call for the integration of more direct diagnostic methods into routine check-ups. The authors suggest that the future of cardiology lies not in better calculators, but in better visualization.
The Case for Imaging
By moving away from purely probabilistic models and toward objective imaging—such as coronary artery calcium (CAC) scoring or CT angiography—physicians could see the disease before it triggers a crisis. Unlike blood pressure or cholesterol numbers, which only provide indirect clues about arterial health, imaging allows a physician to see the presence, extent, and nature of plaque directly.
Rethinking Risk Thresholds
The findings also imply that the current thresholds for "low" and "intermediate" risk may need to be adjusted or supplemented by additional screening, especially for patients with a family history of heart disease, even if their traditional risk factors appear normal.
A Call for Future Research
The researchers acknowledge that their study is a starting point. While they have identified a significant failure in the current system, they emphasize that more work is needed to determine the most effective ways to implement widespread imaging without overwhelming the healthcare system. Future studies are expected to explore how to scale these imaging technologies effectively and how to identify which "low-risk" patients are the best candidates for more advanced diagnostic screening.
Conclusion: Bridging the Gap in Prevention
The Mount Sinai study paints a sobering picture of modern preventive cardiology. By relying on tools designed to estimate the risk of large populations, clinicians are consistently underestimating the individual danger faced by patients who appear healthy on paper.
As medicine moves forward, the "silent" nature of atherosclerosis must be met with more aggressive, direct detection methods. The transition from risk-based assessment to plaque-based detection represents the most viable path toward reducing the incidence of first-time heart attacks. For the thousands of individuals who believe they are safe because their cholesterol is stable and their blood pressure is within range, this study serves as a vital reminder that the current standard of care is not enough. To truly prevent heart attacks, we must stop waiting for the symptoms to appear and start looking for the disease where it lives: in the silent, hidden development of arterial plaque.
