The Surprising Gap in Heart Attack Prediction

Traditional atherosclerotic cardiovascular disease (ASCVD) risk- and symptom-based screening misses nearly half of patients under age 66 who go on to experience their first myocardial infarction (MI), revealing major shortcomings in current preventive strategies. In this US retrospective study of 465 adults presenting with a first type 1 MI, simulation of guideline-directed screening 2 days before the event showed that 45–61% would not have qualified for statin therapy or further evaluation using either the ASCVD Risk Estimator Plus or the newer PREVENT calculator, which classified even more individuals as low risk. Symptoms also provided little warning value: 60% of patients developed chest pain or dyspnea only within 48 hours of their MI, and this pattern persisted across all risk categories. These findings highlight the “MI paradox,” in which population-level risk tools fail to predict events in individuals, especially younger adults whose age-driven calculations underestimate true atherosclerotic burden. Because many culprit plaques progress silently and do not produce ischemic symptoms before rupture, relying on symptoms or short-term risk estimation is fundamentally flawed. In contrast, imaging-based assessment of atherosclerosis—such as coronary calcium scoring or coronary CT—more accurately identifies at-risk individuals across risk strata and may enable earlier intervention to halt plaque progression. Overall, this study suggests that current risk- and symptom-based screening strategies are inadequate and supports a shift toward lifetime, disease-focused prevention incorporating imaging, biomarkers, and novel risk factors to detect subclinical disease before catastrophic events occur. Source: https://www.jacc.org/