99% of Heart Attacks, Strokes, Heart Failures Have Cardiovascular Risk Factors Beforehand

Over 99% of individuals who suffer a heart attack, stroke, or heart failure (HF) had ≥1 risk factor above optimal level beforehand, refuting the widely accepted notion that these cardiac events strike without warnings.1

Cardiovascular disease (CVD) is still the leading cause of death in the US and worldwide. Recent studies have suggested that coronary heart disease (CHD) often occurs without traditional CVD risk factors. However, whether these data are based on missed clinical diagnoses or subthreshold nonoptimal risk factor exposure is unclear.2

“We think the study shows very convincingly that exposure to one or more nonoptimal risk factors before these cardiovascular outcomes is nearly 100%,” Philip Greenland, MD, professor of cardiology at Northwestern University Feinberg School of Medicine and senior study author, said in a statement. “The goal now is to work harder on finding ways to control these modifiable risk factors rather than to get off track in pursuing other factors that are not easily treatable and not causal.”1

Greenland and colleagues chose 4 major cardiovascular risk factors for the purpose of this study: blood pressure, tobacco use, blood sugar, and cholesterol. The team used the American Heart Association’s ideal cardiovascular health definitions, which describe “nonoptimal” levels as follows:1

• Blood pressure ≥120/80 mmHg or on treatment
• Total cholesterol ≥200 mg/dL or on treatment
• Fasting glucose ≥100 mg/dL, diagnosis of diabetes, or on treatment
• Past or current tobacco use

A secondary analysis also examined clinically elevated risk factors, such as blood pressure ≥140/90, cholesterol ≥240, glucose ≥126, and current smoking.1

Health data was collected from 2 population-based prospective cohorts: the Korean National Health Insurance Service (KNHIS), with 9,341,100 patients who had a baseline age of ≥20 years and follow-up from 2009-2022, and the Multi-Ethnic Study of Atherosclerosis (MESA), with 6803 patients who had a baseline age of 45-84 years and follow-up from 2000-2019.2

Investigators based their analyses on 601,025 and 1188 CVD events in KNHIS and MESA, respectively. The prevalence of ≥1 nonoptimal risk factor was high (99.7% and 99.6%) before CHD, with similar patterns before HF (99.4% and 99.5%) and stroke (99.3% and 99.5%) in both KNHIS and MESA, respectively. This prevalence was consistently high across all age groups and sexes, with the lowest proportion observed for HF and stroke (>95%) when occurring at ages <60 years in women. Additionally, the prevalence of ≥2 risk factors was also common (93.2-97.2%) before CVD events.2

“These results not only challenge claims that CHD events frequently occur without antecedent major risk factors but also demonstrate that other CVD events, including HF or stroke, rarely occur in the absence of nonoptimal traditional risk factors, highlighting the importance of primordial prevention efforts,” Greenland and colleagues wrote.2

References

1. Northwestern University. Over 99% have a risk factor before heart attack, stroke or heart failure. Eurekalert! September 29, 2025. October 3, 2025. https://www.eurekalert.org/news-releases/1098159

2. Lee H, Huang X, Khan SS, et al. Very High Prevalence of Nonoptimally Controlled Traditional Risk Factors at the Onset of Cardiovascular Disease. J Am Coll Cardiol. 2025;86(14):1017-1029. doi:10.1016/j.jacc.2025.07.014