For decades, the standard of care for cardiovascular health has relied on a predictable, arithmetic approach: physicians assess a patient’s age, blood pressure, cholesterol levels, and smoking status to generate a "risk score." This score, in turn, dictates whether a patient receives preventive medication, such as statins, or further diagnostic investigation. However, a groundbreaking study from Mount Sinai researchers, published November 21 in the Journal of the American College of Cardiology: Advances, suggests that this foundational pillar of modern cardiology may be failing the very people it is designed to protect.
According to the study, commonly used cardiac screening methods—including the widely utilized atherosclerotic cardiovascular disease (ASCVD) risk score and the newer PREVENT tool—fail to identify nearly half of all individuals who are at imminent risk of a heart attack. The findings suggest that millions of patients are currently being lulled into a false sense of security by "low-risk" labels, only to experience life-altering cardiac events without prior warning.
The Illusion of Safety: Analyzing the Risk Score Gap
In the landscape of modern preventive medicine, risk calculators are the primary gatekeepers. For adults aged 40 to 75 without a known history of heart disease, these tools provide a 10-year probability estimate of experiencing a major adverse cardiovascular event. If a patient’s score falls into the "low" or "borderline" category, they are typically reassured and sent home, provided they are not actively complaining of chest pain or shortness of breath.
The Mount Sinai research team, however, has exposed a dangerous disconnect between these statistical models and biological reality. By retrospectively analyzing the records of 474 patients who experienced their first heart attack, the investigators performed a "what if" simulation: they calculated what the patients’ risk scores would have been just 48 hours before their cardiac event.
The results were sobering. Nearly half (45 percent) of the patients would have been categorized as low or borderline risk by the standard ASCVD score, meaning they would not have qualified for aggressive preventive therapy or further diagnostic imaging under current guidelines. When the newer PREVENT tool—which was designed to be more comprehensive—was applied, the failure rate climbed even higher, with 61 percent of patients falling into the low- or borderline-risk categories.
Chronology of a Silent Crisis
The study examined patients younger than 66 years old who were treated for a first-time heart attack at The Mount Sinai Hospital or Mount Sinai Morningside between January 2020 and July 2025. To understand how the system failed these individuals, researchers mapped out the timeline of their care and symptom onset.
- Pre-Event Evaluation: Using comprehensive demographic, clinical, and laboratory data, the team simulated the clinical assessment of these patients two days prior to their heart attacks.
- The Symptom Window: The data revealed that 60 percent of the patients experienced no symptoms, or only negligible ones, until less than 48 hours before their heart attack.
- The Diagnostic Gap: Because the majority of these patients had low-to-intermediate risk scores and no "classic" symptoms (like crushing chest pain), they remained "under the radar" of the healthcare system. By the time they reached the emergency room, their atherosclerosis—the buildup of plaque in the arteries—had already reached a critical, often rupturable, stage.
This chronology highlights a systemic reliance on "symptom-driven" care. When medicine waits for a patient to report chest pain or fatigue, it is often waiting until the disease has already progressed to a dangerous, symptomatic state.
Supporting Data: Why Current Models Fail
The ASCVD and PREVENT calculators are effective at the population level. They can accurately predict that, out of a group of 10,000 people, a certain percentage will have heart attacks over the next decade. However, the study authors emphasize that these tools are not diagnostic instruments for the individual.
"Our research shows that population-based risk tools often fail to reflect the true risk for many individual patients," explains Dr. Amir Ahmadi, the study’s corresponding author and a Clinical Associate Professor of Medicine at the Icahn School of Medicine at Mount Sinai.
The failure stems from a fundamental limitation: these scores track risk factors—the things that cause plaque—rather than the plaque itself. An individual might have "normal" cholesterol and blood pressure, but still harbor "silent" atherosclerosis that has been accumulating for years. Because the current scoring systems do not look inside the arteries, they are blind to the actual physical damage that leads to a rupture.
Official Responses and Expert Perspective
The implications of this study are being discussed widely within the cardiology community, as they suggest a paradigm shift is necessary. Dr. Anna Mueller, the study’s first author and an internal medicine resident at Mount Sinai, noted the urgency of the findings.
"Most heart attacks occur in patients in the low or intermediate risk groups," Dr. Mueller stated. "This study highlights that a lower risk score, along with not having classic heart attack symptoms, is no guarantee of safety on an individual level."
The researchers argue that the medical community has become too reliant on these digital calculators as the sole arbiter of care. When a patient scores low, the current system effectively says, "You are fine." The Mount Sinai team suggests that the system needs to move away from this binary classification and toward a more proactive, personalized strategy.
Implications: A Call for Atherosclerosis Imaging
If the current risk-score model is not optimal, what should replace it? The study authors strongly advocate for a shift toward atherosclerosis imaging.
"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," Dr. Ahmadi says.
By using advanced imaging techniques (such as coronary artery calcium scoring or CT angiography), doctors can see exactly how much plaque has built up in a patient’s arteries. This approach moves the focus from statistical probability to biological reality. If a patient is found to have significant plaque, they can receive aggressive, life-saving interventions—such as high-dose statins, lifestyle modifications, or other targeted therapies—long before they ever experience a symptom.
Moving Forward: The Future of Prevention
The Mount Sinai study serves as a wake-up call for both patients and providers. While risk scores will likely remain a useful tool for general screening, they cannot be the "end-all-be-all" of cardiovascular health.
As the researchers acknowledge, more work is needed to integrate advanced imaging into routine, cost-effective primary care. The goal is not to abandon existing guidelines, but to refine them to ensure that those who are "statistically safe" but "biologically at-risk" are identified before it is too late.
For the average person, this study reinforces the importance of self-advocacy. If you have concerns about your heart health, relying solely on a risk score might not be enough. Engaging with a cardiologist about advanced imaging options, especially if you have a family history of heart disease or other concerns, could be the difference between a long life and a silent, preventable catastrophe.
In conclusion, the message from the Icahn School of Medicine is clear: to prevent the next generation of heart attacks, medicine must stop looking at the numbers on a chart and start looking at the arteries themselves. The "silent killer" is only silent if we refuse to look for it.
