Diagnostic Gaps in ASCVD and PREVENT Risk Calculators for First Myocardial Infarction

Article Impact Level: HIGH
Data Quality: STRONG
Summary of Journal of the American College of Cardiology  https://doi.org/10.1016/j.jacadv.2025.102361 
Dr. Anna S. Mueller  et al.

Points

Researchers analyzed 474 patients under age 66 to evaluate the accuracy of standard cardiovascular risk assessments in predicting first-time heart attacks relative to actual clinical outcomes.
The study determined that forty-five percent of patients would not have qualified for preventive statin therapy or testing based on their calculated ASCVD risk scores prior to the event.
Application of the newer PREVENT calculator resulted in an even higher failure rate by classifying sixty-one percent of the subsequent heart attack patients as low or borderline risk.
Data regarding symptom onset revealed that sixty percent of individuals did not experience warning signs like chest pain or shortness of breath until forty-eight hours before presentation.
The authors recommend shifting focus from population-based risk scores toward direct atherosclerosis imaging to better identify silent plaque and initiate early preventive treatment for subclinical disease.

Summary

This retrospective study published in JACC: Advances assessed the diagnostic accuracy of the atherosclerotic cardiovascular disease (ASCVD) risk score and the newer PREVENT calculator in predicting first myocardial infarction (MI). Current guidelines utilize these population-based tools to guide statin therapy for individuals aged 40 to 75, yet their sensitivity at the individual level remains questioned. The researchers analyzed data from 474 patients under age 66 presenting with a primary MI at Mount Sinai facilities between January 2020 and July 2025 to determine if guideline-directed assessments would have indicated preventive intervention just two days prior to the cardiac event.

The analysis stratified patients into low (<5%), borderline (5–7.5%), intermediate (7.5–20%), and high (>20%) risk categories. Simulation results revealed that 45% (209/465) of patients would not have qualified for preventive therapy or testing under ASCVD guidelines. The PREVENT calculator demonstrated lower sensitivity, classifying 61% (285/465) of the cohort as low or borderline risk despite their subsequent MI. Furthermore, regarding symptom onset, 60% (279/474) of patients did not experience warning signs such as chest pain or dyspnea until within 48 hours of presentation, rendering symptom-based gating ineffective for early prevention.

These findings highlight significant limitations in using multivariable risk calculators and symptom presentation as primary gatekeepers for cardiovascular prevention. The data indicates that relying on these metrics delays diagnosis, as a majority of patients presenting with MI fall into low or intermediate risk categories without prodromal symptoms. The authors suggest a paradigm shift away from population-based probability models toward direct atherosclerosis imaging to identify silent plaque and initiate earlier treatment for subclinical disease.

Link to the article: http://jacc.org/doi/10.1016/j.jacadv.2025.102361

References

Mueller, A. S., Leipsic, J., Tomey, M., Argulian, E., Narula, J., & Ahmadi, A. (2025). Limitations of risk- and symptom-based screening in predicting first myocardial infarction. JACC: Advances, 4(12), 102361. https://doi.org/10.1016/j.jacadv.2025.102361