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Maximo Agustin Schiavone: What Does ‘Risk-Factor-Free MI’ Really Mean in Practice?
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Feb 3, 2026, 15:52

Maximo Agustin Schiavone: What Does ‘Risk-Factor-Free MI’ Really Mean in Practice?

Maximo Agustin Schiavone, Head of Clinical Research – Bariatric and Metabolic Surgery Department at Hospital Universitario Austral, shared a post on LinkedIn about a recent article by Daniel G. Brieger et al, published in Atherosclerosis:

“A ‘risk-factor-free’ heart attack is one of the most uncomfortable truths in preventive cardiology.

Because it exposes a category error we keep making: we treat risk factors as if they were the disease. But the disease is coronary atherosclerosis—and it can be present, active, and dangerous even when the usual checklist looks ‘clean.’

This review puts numbers on it: 14–25% of MI patients present without standard modifiable risk factors (SMuRFs), and SMuRFs explain only ~53–56% of incident CVD events globally. And the inequity signal is loud: SMuRF-less women with MI have nearly a threefold higher early mortality risk compared with men who have at least one risk factor.

So what does ‘risk-factor-free MI’ really mean in practice?

It often means ‘we missed the atherosclerosis’—because our prevention model is built to estimate risk, not to detect disease. The authors explicitly argue for moving beyond probability scores to directly detect the causal disease (atherosclerosis) before symptoms arise.

That framing matters: if you’re ‘SMuRF-less’ the correct clinical reflex shouldn’t be reassurance. It should be better phenotyping and a pathway that stops confusing ‘absence of classic risk factors’ with ‘absence of coronary disease.’

And yes, sex needs to be treated as a biological variable in the whole pipeline, because the performance gaps are most evident in women.”

Title: Coronary artery disease in the absence of standard modifiable risk factors (SMuRFs): The impact of sex

Authors: James Amamoo, Lin Xie, Andrea Steffens, Erin Buysman, Caroline Swift, Sherif Mehanna, Noelle N. Gronroos, Marc P. Bonaca

Read the Full Article  on Atherosclerosis

Maximo Agustin Schiavone: What Does 'Risk-Factor-Free MI' Really Mean in Practice?

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Andrea Steffens Atherosclerosis Caroline Swift Erin Buysman Health Hematology Hemostasis Today James Amamoo Lin Xie Marc P. Bonaca Maximo Agustin Schiavone Medicine Noelle N. Gronroos preventive cardiology Risk Factors Sherif Mehanna
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