Roughly Half of Patients Don’t Have Symptoms Prior to a First MI

Many patients don’t have any documented symptoms or coronary artery disease risk factors in the months leading up to a first MI, but even among those who do, most aren’t taking any preventive medications, findings from a large US cohort show.

Roughly half of patients didn’t have symptoms documented 6 months prior to MI, 22.2% hadn’t seen a primary care physician and/or a cardiologist, and 63.4% were not using cardiovascular medications, lead author Nick Nurmohamed, MD, PhD (Amsterdam UMC, the Netherlands), and colleagues report.

The findings, published last week in the European Heart Journal, highlight “an unmet need for improvement of identification and adequate treatment of those at risk for myocardial infarction,” the researchers write. “These data demonstrate the urgency to shift the primarily symptom-based approach in present clinical practice to a prevention-based approach.”

That’s an important message to both physicians and the general population, senior author Deepak Bhatt, MD (Icahn School of Medicine at Mount Sinai, New York, NY), told TCTMD.

“We screen for many diseases like colon cancer and breast cancer. Probably with something where half the patients don’t even know that they’re potentially at risk for a heart attack, it’d be good to have some sort of screening as well,” he said, adding that it’s unclear what that should entail.

“But it certainly does point to the fact that if we just approach things from a secondary prevention perspective—that is, once patients have had a heart attack—that’s not a great approach,” Bhatt said. Many patients, he added, will not survive a first MI.

Commenting for TCTMD, Colin Berry, MBChB, PhD (University of Glasgow, Scotland), said the study “highlights a cause for concern, a missed opportunity,” adding that it raises questions about “what types of screening would be appropriate, proportionate, to prevent onset of MI or to delay its onset.”

Age, Sex Differences Observed

For the study, the researchers looked at data from the Clarivate Real-World Data Product, which links electronic health records, medical claims, and pharmacy claims from about 98% of government and commercial health insurance plans in the United States. The analysis included more than 4.6 million patients (median age 70 years; 42.3% women) who had a first MI between January 2017 and September 2022. About one-third (35.1%) had a STEMI.

At 6 months before the event, 18.0% of patients didn’t have any standard modifiable risk factors (SMuRFs)—including dyslipidemia, hypertension, smoking, family history of MI, diabetes, obesity, and alcohol abuse—recorded, although Bhatt noted that it’s possible some of these patients did, in fact, have risk factors that didn’t make it into the medical record.

Nonuse of cardiovascular medications was common irrespective of the presence or absence of symptoms and/or risk factors and physician visits. Among patients who had documented SMuRFs and a prior physician visit, for example, 56.0% were not taking any preventive medications. Even among those with standard risk factors, symptoms, and a prior physician visit, 52.2% were not on any cardiovascular drugs leading up to their MI.

Patients 60 years and younger as well as men were less likely than older patients and women, respectively, to have documented symptoms and SMuRFs, to have visited a physician, and to be using preventive medical therapy. Younger patients and men were more likely to have STEMI versus NSTEMI.

What Can Be Done

Though a sizeable minority of patients didn’t have any documented SMuRFs, most did have risk factors that could be addressed, and that highlights an opportunity to improve primary prevention efforts in that group, Bhatt said. Primary care physicians should be focused on identifying these modifiable risks, even among patients without physical complaints, and managing them with lifestyle changes and preventive medications according to the guidelines, he said.

“That’s something that’s tough to do in real-world practice, and this study shows that, but in terms of potential solutions, that’s a relatively low-cost, low-tech solution,” said Bhatt.

Other potential ways to address the gaps uncovered in this study still need to be investigated and there are efforts underway. Those include the TRANSFORM trial, for which Bhatt is the study chair. TRANSFORM includes asymptomatic patients with an elevated atherosclerotic CVD risk who are being randomized to usual care based on risk factors or management guided by coronary CT angiography. A variety of medical therapies will be used to tailor treatment.

Other strategies for identifying those at increased risk for MI may involve use of biomarkers or genetic screening, Bhatt indicated. Having a better way to find at-risk patients “would be really good in terms of public health,” he said.

For Berry, the study shows MI can occur even at younger ages and in individuals who don’t have any cardiovascular risk factors, which argues against “the characterization that individuals with heart attack smoke cigarettes and have high blood pressure and diabetes.”

He said that healthcare practitioners and researchers must do more to identify modifiable risk factors beyond the traditional ones, perhaps by focusing more on issues relevant to women’s health, like hypertension in pregnancy, stillbirth, and polycystic ovary syndrome, as well as genetics.

“I think we need to be thoughtful about how to be effective in screening and prevention at a population level,” Berry said, cautioning that screening interventions can sometimes have negative impacts.