Summary: A large international study finds that virtually all heart attacks, strokes, and cases of heart failure occur in people who already had at least one known cardiovascular risk factor. Researchers tracked more than 9 million adults in South Korea and nearly 7,000 adults in the United States, and found that over 99% had nonoptimal blood pressure, cholesterol, blood sugar, or a history of tobacco use years before their first cardiovascular event.
Hypertension was the most common contributor, present in more than 93% of patients in both cohorts. These findings emphasize the importance of early prevention and sustained management of modifiable cardiovascular risk factors to reduce heart attack, stroke, and heart failure risk.
Key Facts
- Near-universal risk: More than 99% of cardiovascular events were preceded by at least one nonoptimal risk factor.
- Multiple risks common: Over 93% of people who developed disease had two or more elevated risk factors.
- Hypertension dominant: High blood pressure was the leading risk factor across both populations.
Source: Northwestern University
Overview
A major study led by Northwestern Medicine and Yonsei University demonstrates that heart attacks, strokes and heart failure rarely occur without prior warning signs in the form of modifiable cardiovascular risk factors. By analyzing repeated health screening records over more than a decade, investigators could assess blood pressure, cholesterol, fasting glucose and tobacco exposure in the years leading up to patients’ first cardiovascular events.
Cardiovascular disease remains the leading cause of death globally and in the United States. The study, to be published in The Journal of the American College of Cardiology, provides strong population-level evidence that detection and control of traditional, modifiable risk factors must remain a public health priority.
“Our analysis shows very convincingly that exposure to one or more nonoptimal risk factors before these cardiovascular outcomes is nearly 100%,” said senior author Dr. Philip Greenland, professor of cardiology at Northwestern University Feinberg School of Medicine. The authors argue that efforts should prioritize controlling blood pressure, cholesterol, blood sugar and tobacco use early in life.
The risk factors examined
Researchers focused on four widely recognized cardiovascular risk factors, using the American Heart Association’s definitions for ideal cardiovascular health. They defined nonoptimal levels as:
- Blood pressure ≥ 120/80 mm Hg or receiving antihypertensive treatment
- Total cholesterol ≥ 200 mg/dL or on lipid-lowering treatment
- Fasting glucose ≥ 100 mg/dL, a diagnosis of diabetes, or glucose-lowering treatment
- Past or current tobacco use
The team also performed secondary analyses using clinically elevated thresholds commonly used for diagnosis: blood pressure ≥ 140/90 mm Hg, total cholesterol ≥ 240 mg/dL, fasting glucose ≥ 126 mg/dL, and current smoking.
Study design and populations
The researchers evaluated repeated health screening data from more than 9.3 million Korean adults and nearly 7,000 U.S. adults who were followed for up to two decades. Because the cohorts included serial measurements over time, the analysis could determine whether individuals had evidence of nonoptimal blood pressure, cholesterol, glucose, or tobacco exposure long before their first diagnosis of coronary heart disease, heart failure, or stroke.
Major findings
Across both Korean and U.S. cohorts, more than 99% of people who developed coronary heart disease, heart failure, or stroke had at least one nonoptimal risk factor prior to the event. More than 93% had two or more elevated risk factors. Hypertension was the most prevalent risk factor, present in over 95% of affected patients in South Korea and more than 93% in the United States.
The pattern held across age and sex groups. Even among women under 60 years old — a subgroup often considered lower risk — over 95% had at least one nonoptimal factor before experiencing heart failure or stroke. When analyses used the higher clinically elevated thresholds, at least 90% of patients still had at least one major risk factor preceding their first cardiovascular event.
Implications for prevention
These results reinforce that most cardiovascular events are predictable and largely preventable through early detection and consistent management of modifiable risk factors. Public health strategies, clinical screening programs, and individual preventive care that prioritize blood pressure control, cholesterol management, glycemic control, and tobacco cessation can substantially reduce the burden of heart attacks, strokes, and heart failure.
Funding: This research, titled “Very High Prevalence of Nonoptimally Controlled Traditional Risk Factors at the Onset of Cardiovascular Disease,” was supported by the National Research Foundation of Korea (grant 2022R1F1A1066181) from the Korea Ministry of Science and ICT.
Key Questions Answered
A: No. The study found that more than 99% of people who experienced a first heart attack, stroke, or heart failure had at least one elevated risk factor beforehand.
A: The principal modifiable risk factors identified were high blood pressure (hypertension), elevated cholesterol, high blood sugar (or diabetes), and tobacco use.
A: Most cardiovascular events are preceded by modifiable risks, so early detection, sustained treatment, and lifestyle changes are crucial to prevent heart attacks, strokes, and heart failure.
About this cardiovascular health and neurology research news
Author: Ben Schamisso
Source: Northwestern University
Contact: Ben Schamisso – Northwestern University
Image: The image is credited to Neuroscience News
Original Research: Findings to appear in Journal of the American College of Cardiology