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New research suggests that widely used cardiovascular risk scores may fail to flag a large share of people who go on to have a heart attack within days. The findings raise questions about whether population-level screening tools are adequate for identifying short-term, individual risk and whether more direct testing for atherosclerosis should play a greater role in prevention.
Study snapshot: what the researchers found
Researchers in the US and Canada analyzed medical records for 465 people aged 65 or younger who were treated for a first heart attack between January 2020 and July 2025 at two US medical centers. The dataset included standard clinical measurements captured at routine visits — blood pressure, cholesterol, past medical history and other factors used to estimate cardiovascular risk.
Using those records, the team calculated two commonly discussed risk measures as they would have appeared two days before each patient’s event. The atherosclerotic cardiovascular disease (ASCVD) 10-year risk score categorized 45 percent of these patients as low or borderline risk. The newer PREVENT score performed worse on this sample, labeling 61 percent of patients as low or borderline risk.
The implication is stark: a substantial fraction of people who had imminent heart attacks would not have been triaged for further testing or preventive therapy, such as statin treatment, based on existing guideline-driven risk cutoffs.
Why population-based scores can miss individual danger
ASCVD and similar scores were designed to estimate long-term, population-level risk (for example, the chance of a heart attack or stroke within 10 years) using factors such as age, sex, race, blood pressure and lipid levels. They are cost-effective tools for guiding preventive measures, especially in primary care.
But population tools trade individual granularity for broad applicability. As cardiologist Amir Ahmadi of Mount Sinai notes, population-based risk tools often fail to reflect the true risk for many individual patients. In practice, a lower predicted 10-year risk does not guarantee short-term safety — a person with subclinical atherosclerosis may still be very near an acute event despite a modest ASCVD score.
The ASCVD score could be missing people who will soon experience a heart attack. (Mueller et al., JACC Adv., 2025)
Anna Mueller, an internal medicine resident and co-author, points out that many heart attacks occur in people classified as low or intermediate risk. She adds that lacking classic symptoms like chest pain or breathlessness (which is common) can further delay detection and prevention.
Scientific background and clinical implications
Atherosclerosis is the buildup of fatty plaques inside arterial walls. When a plaque ruptures, it can trigger a clot that abruptly blocks blood flow — the mechanism behind most heart attacks. Traditional risk scores estimate probability indirectly by tracking risk factors associated with plaque development, but they don't detect plaques directly.
That gap helps explain why some patients with modest risk-factor profiles still suffer acute coronary events. Direct tests for arterial plaque — coronary artery calcium (CAC) scoring by CT, carotid ultrasound, or advanced biomarkers — can identify subclinical atherosclerosis and reclassify patients into higher-risk categories, enabling preventive therapies sooner.
However, adding routine imaging to screening programs raises questions about cost, radiation exposure, downstream testing and equitable access. The new study is retrospective and limited to a few hundred cases; PREVENT and other scores have shown utility in larger cohorts. Still, the analysis reinforces an important message: risk estimation that relies solely on population models and classic symptom checks may miss many at imminent risk.
What could change in practice?
Possible responses include broader use of coronary calcium scanning for people in intermediate-risk bands, more frequent reassessment of risk in younger adults with risk factors, and development of hybrid models that combine traditional risk scores with imaging or novel biomarkers. Policymakers and clinicians will need to balance the benefits of earlier detection against costs and potential harms from overtesting.
The paper, published in JACC: Advances, stops short of prescribing a single solution, instead calling for efforts to personalize prevention so heart disease can be detected and treated earlier in individuals who would otherwise slip through current screening nets.
Expert Insight
Dr. Laura Chen, a cardiologist and science communicator, comments: "Risk calculators are invaluable, but they're not crystal balls. For patients with family history, unusual lipid patterns, or atypical presentations, a low 10‑year score shouldn't end the conversation. Targeted imaging or biomarker testing can be the difference between prevention and crisis — the challenge is implementing those tools where they'll do the most good."
Conclusion
The study highlights a critical limitation of widely used risk scores: they can underestimate near-term, individual risk for heart attack. Improving detection will likely require combining population-based prediction with targeted, individualized testing for atherosclerosis. For clinicians and patients, the take-home is clear — risk assessment should be dynamic and, when indicated, include tools that look directly for disease rather than only for the risk factors that predict it.
Source: sciencealert
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