A new global study demolishes the myth of the “out-of-nowhere” heart attack. According to new research, more than 99 percent of heart attacks, strokes, and heart failures are preceded by one or more of four familiar culprits: high blood pressure, high cholesterol, elevated blood sugar, or smoking (past or present).
“We think the study shows very convincingly that exposure to one or more nonoptimal risk factors before these cardiovascular outcomes is nearly 100 percent,” said cardiologist Philip Greenland of Northwestern University, one of the study’s authors.
Out of the Blue Heart Attack? Think Again
Cardiologists have been puzzled by cases of people who seemed perfectly healthy, only to collapse suddenly from a heart attack or stroke. Some earlier studies suggested that as many as one in four patients had no warning signs or major risk factors. But the new research, led by Hokyou Lee of Yonsei University in Seoul and colleagues from the United States and South Korea, suggests that most of these “mystery cases” weren’t mysteries at all.
The researchers analyzed two massive databases: one from South Korea’s National Health Insurance Service (over 9 million adults) and one from the U.S.-based Multi-Ethnic Study of Atherosclerosis. Together, they followed participants for up to 20 years, tracking who developed heart disease and what their health looked like before disaster struck.
Nearly every case (over 99 percent) had at least one nonoptimal risk factor before the first event. Even among women under 60, who had the lowest risk overall, more than 95 percent of heart attacks and strokes were linked to one of these four conditions.
The study even found that people didn’t need to have clinically “severe” disease to be at risk. Levels below diagnostic thresholds still mattered. For instance, a blood pressure above 120/80 mm Hg or total cholesterol above 200 mg/dL — levels that many doctors might consider close to borderline — were enough to raise long-term risk.
What This Means for Prevention
High blood pressure was by far the most common risk factor, showing up before more than 93 percent of cardiovascular events in both countries. That finding alone has enormous implications. Hypertension often goes undiagnosed or untreated, especially in younger adults who rarely check their blood pressure.
“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,” said Greenland.
The results reinforce the American Heart Association’s “Life’s Essential 8,” a framework that reframes prevention around maintaining ideal health. This includes keeping blood pressure, cholesterol, and blood sugar at optimal levels — not just “not bad” — and avoiding tobacco altogether.
As Lee and his colleagues wrote in their new study, “These results not only challenge claims that coronary heart disease events frequently occur without antecedent major risk factors but also demonstrate that other cardiovascular disease events, including heart failure or stroke, rarely occur in the absence of nonoptimal traditional risk factors.”
What ‘Healthy’ Looks Like
This study’s message is both sobering and empowering: heart disease is almost never random. For years, news stories and even medical case reports have painted heart attacks as lightning bolts striking from clear skies. The reality, Lee’s team argues, is closer to slow, predictable weather — one we can forecast and prevent.
Duke University cardiologist Neha Pagidipati, who was not involved in the research, wrote in an accompanying editorial, “We can — and must — do better.”
Better means rethinking what “healthy” really looks like. It means not settling for blood pressure that’s “just a little high” or cholesterol that’s “almost fine.” It means seeing prevention as something we start early, maintain daily, and monitor closely. That means long before we reach the cardiologist’s office.
The findings also come at a time when global rates of hypertension, diabetes, and obesity are climbing. If 99 percent of cardiovascular disease traces back to these modifiable factors, millions of lives are at stake.
The findings appeared in The Journal of the American College of Cardiology.
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