A recent study, encompassing health data from over 9 million adults in South Korea and the United States, indicates that nearly all individuals who develop heart disease and experience a major cardiovascular event have at least one of four primary risk factors beforehand. The study was published in the Journal of the American College of Cardiology in 2025.
Key Findings
These four risk factors are high blood pressure, high cholesterol, elevated blood sugar levels, and current or past tobacco smoking. Collectively, these factors preceded 99 percent of all cardiovascular events observed throughout the long-term study period.
Even within the demographic with the lowest risk of cardiovascular events, women under 60, more than 95 percent of heart attacks or strokes were linked to one of these existing risk factors.
High blood pressure was identified as the most frequently associated factor. In both the US and South Korea, over 93 percent of individuals who suffered a heart attack, stroke, or heart failure had pre-existing hypertension.
Expert Commentary
Senior author and cardiologist Philip Greenland from Northwestern University stated that the study convincingly shows "exposure to one or more nonoptimal risk factors before these cardiovascular outcomes is nearly 100 percent." He added that the focus should be on controlling these modifiable risk factors.
Greenland and his co-authors noted that their findings challenge claims regarding an increase in cardiovascular events occurring without identifiable risk factors, suggesting that previous studies might have overlooked diagnoses or sub-clinical risk factor levels.
Neha Pagidipati, a Duke University cardiologist not involved in the study, wrote in an accompanying editorial that the results underscore the critical importance of managing health risks to prevent serious health outcomes.