A new study by Mount Sinai researchers shows that current guidelines to screen for individuals at risk of heart attack fail to identify nearly half of patients who are actually at risk. These findings, published today in the Journal of the American College of Cardiology: Advances, highlight the need for integrating imaging biomarkers in routine screening to improve cardiovascular risk assessments.
“Our research shows that population-based risk tools often fail to reflect the true risk for many individual patients,” says Amir Ahmadi, MD, clinical associate professor of medicine at the Icahn School of Medicine at Mount Sinai.
Doctors often rely on the atherosclerotic cardiovascular disease (ASCVD) risk score during yearly checkups to estimate the 10-year risk of a patient suffering a heart attack. This risk score is based on multiple factors including age, sex, race, blood pressure, cholesterol levels, diabetes, and smoking.
To evaluate the accuracy of this screening tool, Ahmadi and colleagues did a retrospective analysis using data from 474 patients under the age of 66 who were treated for their first heart attack at two Mount Sinai hospitals between January 2020 and July 2025. The patient’s personal information was collected to perform a simulated risk assessment as if they had been evaluated two days before their heart attack.
Based on their risk score, patients were divided into low, borderline, intermediate and high risk groups. In total, 45% of patients were classified as low or borderline risk, which do not qualify for preventive treatment or further testing under current guidelines.
“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,” said Ahmadi.
The study also evaluated the accuracy of the predicting risk of cardiovascular disease events (PREVENT) calculator, a newer tool that includes a higher number of variables compared to ASCVD. However, this tool classified 61% of patients who had a heart attack two days later as belonging to the low or borderline risk groups.
“This study suggests that the current approach of relying on risk scores and symptoms as primary gatekeepers for prevention is not optimal,” said Ahmadi. “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.”
The researchers also looked at when these patients first reported experiencing symptoms preceding their heart attack, such as chest pain or shortness of breath. They found that 60% of patients did not develop any symptoms until less than two days before the heart attack, highlighting that symptoms often appear too late to prevent or change the course of disease.
“When we look at heart attacks and trace them backwards, most heart attacks occur in patients in the low or intermediate risk groups,” says Anna Mueller, MD, internal medicine resident at the Icahn School of Medicine at Mount Sinai and first author of the study. “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.”
Based on these findings, the research team stressed the importance of developing and implementing new tools for early detection and prevention of cardiovascular events, including imaging techniques. “Our study exposes a major flaw where tools effective for tracking large populations fall short when guiding individualized care,” said Mueller. “Instead, doctors should shift their focus from detecting symptomatic heart disease to detecting the plaque itself for earlier treatment, which could save lives.”
