First MI as the First Warning: Rethinking Cardiovascular Risk Assessment

Around half of the patients did not experience any antecedent symptoms prior to the first myocardial infarction (MI), 22% had not consulted a primary care physician and/or a cardiologist, and over 60% were not using cardiovascular medications, according to a study published in the European Heart Journal.^1,2

The aim of this study was to determine the standard modifiable risk factors of coronary artery disease (CAD), symptoms, healthcare utilization, and uptake of preventive therapy among US adults prior to experiencing their first MI between January 2017 and September 2022. For this, the researchers used data from the Clarivate Real-World Data Product that interconnects electronic health records, medical claims, and pharmacy claims from 98% of government and commercial insurance plans in the US.

Retrospective analysis of data showed that 4,657,412 patients had experienced a first MI in the study duration. Their median age of the participants was 70 years and 42.3% were women. About one-third (35.1%) had a ST-elevation MI (STEMI).

Analysis revealed that half (50.5%) of these patients had no previously documented cardiac symptoms. Furthermore, 18.0% had no standard modifiable risk factors including dyslipidemia, hypertension, smoking, family history of MI, diabetes, obesity, and excessive alcohol intake, documented 6 months before the event. Twenty-two percent had no documented physician visits before the MI, and 63.4% had not been prescribed any preventive therapy.

Even among patients with documented standard modifiable risk factors and a prior physician visit, 56.0% were not on any preventive medications, and 52.2% of those with documented symptoms and standard modifiable risk factors and a physician visit were not receiving any cardiovascular treatment before their MI.

Patients aged ≤60 years as well as men were less likely to have documented symptoms and standard modifiable risk factors; they had fewer primary care physician visits, and were less likely to be on preventive therapies compared to older patients and women. They also experienced a higher incidence of STEMI compared to women and those older than 60 years.

According to the authors, this is the largest study to date evaluating the prevalence of cardiac symptoms preceding an MI. These findings show significant gaps in cardiovascular risk detection and prevention in the duration leading up to a first MI highlighting “an unmet need for improved tools to identify patients at risk of MI who may benefit from preventive therapy.”

Many patients did not seek medical attention and the use of cardiovascular medication was low, regardless of symptoms, risk factors, or prior physician visits. Hence, there is an urgent need to shift from a symptom-based approach to a prevention-based approach in day to day clinical practice. The study further emphasizes the importance of primary prevention over secondary, as many patients may not survive their first MI. Efforts must be made to identify modifiable risk factors beyond the traditional ones.

References

1.  Eur Heart J. 2025 Jul 3:ehaf390. doi: 10.1093/eurheartj/ehaf390.

2.   https://www.tctmd.com/news/roughly-half-patients-dont-have-symptoms-prior-first-mi. Dated July 09, 2025. Accessed on July 31, 2025.s