Current heart attack screening tools are not optimal and fail to identify half the people who are at risk

Current cardiac screening tools used to prevent heart attacks fail to identify nearly half of the people who are actually at risk of having one, according to a new study led by Mount Sinai researchers. The results, published in a brief report on November 21, in the Journal of the American College of Cardiology: Advances, expose a major flaw in patient care: that following current screening guidelines may cause missed opportunities for early detection of heart attacks and prevention.

The researchers assessed the accuracy of a widely used tool, the atherosclerotic cardiovascular disease (ASCVD) risk score, and of a newer measure, called PREVENT, which adds variables and is intended to provide a more comprehensive estimate of cardiovascular risk along with symptomatic screening .

“Our research shows that population-based risk tools often fail to reflect the true risk for many individual patients,” says corresponding author Amir Ahmadi, MD, Clinical Associate Professor of Medicine (Cardiology) at the Icahn School of Medicine at Mount Sinai. “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.

"This study suggests that the current approach of relying on risk scores and symptoms as primary gatekeepers for prevention is not optimal,” Dr. Ahmadi continued. “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.”

In current practice, doctors calculate a patient’s ASCVD risk score during annual primary care visits. This is typically done for people between 40 and 75 years old without known heart disease. This score estimates a person’s 10-year risk of having a heart attack or stroke using factors such as age, sex, race, blood pressure, cholesterol, diabetes, and smoking status. Physicians use the ASCVD or PREVENT calculators to guide decisions about preventive treatment, including whether to start statin therapy.

Cardiologists also rely on these same risk calculators as a guideline. Patients with intermediate or high scores are typically prescribed cholesterol-lowering medication and may be referred for additional testing. Those with low or borderline scores, especially if they have no symptoms like chest pain or shortness of breath, are often reassured and sent home without further evaluation. However, this study found that if patients who had their first heart attack had been evaluated two days earlier, nearly half of them would have been labeled as low or borderline risk and not recommended for preventive therapy by ASCVD, and more than half of them would have been so labeled by PREVENT.

To assess the effectiveness of current screening tools, researchers did a retrospective analysis on data from 474 patients under age 66 with no known coronary artery disease. All patients were treated for their first heart attack at Mount Sinai Morningside and The Mount Sinai Hospital in New York City between January 2020 and July 2025. The team collected personal information including patient demographics, medical history, cholesterol levels, blood pressure, and when their symptoms, defined as chest pain or shortness of breath, first appeared. For each patient, the 10-year ASCVD risk was calculated and a simulated assessment was performed as if the patient had been evaluated two days before their heart attack. Patients were divided into four risk groups: low (under 5 percent), borderline (5-7.5 percent), intermediate (7.5-20 percent) and high (more than 20 percent).

The results focused on two main factors: who would have qualified for preventive treatment based on their risk score, and when symptoms began. Overall, 45 percent of patients would not have been recommended for preventive therapy or diagnostic testing under current ASCVD-based guidelines, and this number increased to 61 percent when using the newer PREVENT calculator. Most patients (60 percent) did not develop symptoms such as chest pain or shortness of breath until less than two days before their cardiac event, showing that symptoms often appear too late to help with changing the course of disease. Together, these findings reveal a critical gap in current prevention strategies: patients who appear healthy by standard measures may already have significant, silent heart disease. Relying solely on risk scores and symptoms delays diagnosis until it is too late for prevention.

“When we look at heart attacks and trace them backwards, most heart attacks occur in patients in the low or intermediate risk groups. 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,” says first author Anna Mueller, MD, an internal medicine resident at the Icahn School of Medicine at Mount Sinai. “Our study exposes a major flaw where tools effective for tracking large populations fall short when guiding individualized care. Instead, doctors should shift their focus from detecting symptomatic heart disease to detecting the plaque itself for earlier treatment, which could save lives.”

Researchers say more studies are needed to further this work, and future research should focus on optimizing strategies to enhance early detection and prevention including cardiovascular imaging.

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