Heart Attack Prediction Tools Miss the Warning in Half of Cases

Existing Prediction Models Are Not Reliable, Suggests a New Study

November 26, 2025

A new study by medical researchers in the United States has revealed a serious limitation in how doctors currently try to predict and prevent heart attacks. It shows that the tools most commonly used by physicians, namely the ASCVD risk score and the newer PREVENT calculator, are failing to identify a large number of individuals who are actually at risk.

India carries a heavy burden of heart disease, with many people developing it at younger ages than in Western countries. Cardiovascular disease remains one of the country’s leading causes of death. Actress-model Shefali Jariwala and bodybuilder Varinder Singh Ghuman are among the public figures who recently died of heart attacks at a young age. Though the study is based in the United States, its findings are highly relevant in this context, as early detection of silent heart disease could help prevent thousands of avoidable deaths.

According to the study conducted by Mount Sinai Health System, nearly half of those who went on to have a heart attack would not have been flagged for preventive treatment under the current system, even if they had been evaluated just two days before the event.

During regular checkups, doctors use calculators like ASCVD to estimate a person’s risk of having a heart attack or stroke over the next 10 years. These calculators factor in age, sex, race, blood pressure, cholesterol levels, diabetes and smoking status. People identified as having medium or high risk are generally offered preventive treatments, including cholesterol-lowering drugs, and may be sent for further heart tests. Those with low or borderline risk scores, and who don’t have symptoms like chest pain or shortness of breath, are typically told they are safe and are not given any further testing or treatment. The study tested how reliable those risk scores actually are.

Researchers looked at data from 474 people under the age of 66 who had their first heart attack between 2020 and 2025 and had no prior history of coronary artery disease. They calculated each person’s risk score based on their health status two days before their heart attack. Shockingly, 45 percent of them would not have qualified for preventive treatment based on the ASCVD score. Even more, 61 percent would not have qualified under the PREVENT score, which is designed to be a more thorough screening tool.

What makes this finding even more concerning is that most of the people in the study didn’t experience any warning symptoms until it was nearly too late. About 60 percent only developed signs like chest pain or breathlessness in the two days before their heart attack. This suggests that waiting for symptoms to appear before acting is a poor strategy because the disease has often already progressed by that point.

One of the lead authors of the study, Dr. Amir Ahmadi, explains that these risk scores are designed for use at the population level. That means they work reasonably well for identifying trends across large groups of people. But on an individual level, they are blunt tools. A person may score as “low risk” according to the formula, yet still have dangerously clogged arteries that could cause a heart attack without warning. In fact, the study found that the majority of heart attacks happened in people labelled low or intermediate risk.

The ASCVD risk score is used only occasionally in India, and the newer PREVENT calculator has not yet been adopted or tested in Indian settings at all. The Lipid Association of India has noted the absence of any fully validated ASCVD-based risk model for Indians. This makes the findings of the study all the more relevant. If current tools miss nearly half of at-risk patients even in the U.S., the mismatch could be greater in India, where no locally tailored risk calculator exists. 

The study suggests that by depending so heavily on risk scores and symptoms as the basis for whether to take action, doctors may be missing the chance to prevent heart attacks in patients who seem healthy on paper.

According to the researchers, it may be time to rethink how heart disease is detected. Instead of waiting for symptoms or depending on formulas, they suggest a stronger focus on imaging techniques that can detect atherosclerosis, or the buildup of plaque in the arteries, before it causes damage. These silent plaques are what rupture and cause heart attacks, often without warning.

Detecting plaque buildup before it causes symptoms or damage can be done through imaging tools like coronary artery calcium (CAC) scans, which use CT technology to identify hardened deposits in the arteries, or coronary CT angiography, which maps both soft and calcified plaque using contrast dye. Ultrasound-based tests, such as carotid intima-media thickness measurement, can also detect early thickening of artery walls.

However, these imaging tests are not routinely done for most people.

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