Myocardial Infarction Without Standard Modifiable Risk Factors From 2025-2040

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Acute Myocardial Infarction (AMI). Intervention: SMuRF-less status (absence of standard modifiable risk factors) vs. Temporal baseline (2025) and overall AMI population. Primary outcome: Prevalence of SMuRF-less AMI among total AMI cases in Singapore (2040 forecast) (Projected increase from 5.8% to 8.5%, 95% CI 6.2%-10.8%).

Q: What does this research mean for the field?

By 2040, the proportion of acute myocardial infarction cases occurring without standard modifiable risk factors is projected to increase to 8.5% in Singapore and 16.9% in the United Kingdom, disproportionately shifting toward younger men with overweight or obesity. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Grace Cao; Nicholas Weight; Silingga Metta Jauhari; Bryan Chong; Muhammad Rashid; Yiming Chen; Yip Han Chin; Haryo Raden Himan; Mingshi Cai; Si Min Kuo; Hui Wen Sim; Sara Moiz Tyebally; Xinyi Seow; Bryan Neo; Jayanth Jayabaskaran; Lynette Li San Teo; Mark Muthiah; Zhan Yun Lim; Syed Saqib Imran; David Foo; Hee Hwa Ho; Jonathan Yap; Jiang Ming Fam; Zijuan Huang; Weien Chow; Siang Chew Chai; Liang Zhong; Lohendran Baskaran; Jack Wei Chieh Tan; Khung Keong Yeo; Andie Hartanto Djohan; Christopher Koo; Jason Chen; Gavin Ng; K A Chan; Poay Huan Loh; Adrian F. Low; Chi Hang Lee; Ping Chai; James Yip; Tiong Cheng Yeo; Huay Cheem Tan; Derek J. Hausenloy; Gemma A. Figtree; A. Mark Richards; Mark Yan-Yee Chan; Mamas A. Mamas; Nicholas WS Chew

doi:10.1016/j.jacasi.2026.01.027

Figures

Graphical abstract published by JACC Asia — Graphical abstract · Published by JACC Asia · CC BY

Key Points

To forecast trends in the prevalence and case fatality rate of acute myocardial infarction in patients presenting without standard modifiable risk factors between 2025 and 2040 in Singapore and the United Kingdom.
Extracted patient data from the Singapore Myocardial Infarction Registry and the UK Myocardial Ischemia National Audit Project.
Constructed Poisson regression models to project the proportion of SMuRF-less AMI cases and case fatality rates through 2040 across demographic and clinical subgroups.
The proportion of SMuRF-less cases among all AMI events is projected to increase from 5.8% (95% CI: 5.2%-6.4%) to 8.5% (95% CI: 6.2%-10.8%) in Singapore and from 13.8% (95% CI: 13.0%-14.6%) to 16.9% (95% CI: 15.1%-18.7%) in the United Kingdom by 2040.
SMuRF-less AMI mortality as a share of total AMI mortality is predicted to rise from 6.3% (95% CI: 5.7%-6.9%) to 13.3% (95% CI: 10.9%-15.6%) in Singapore, but fall from 11.3% (95% CI: 10.5%-12.1%) to 9.5% (95% CI: 7.7%-11.4%) in the United Kingdom.
The fastest prevalence increases are expected in young adults in Singapore (CAGR 8.1%; 95% CI: 7.5%-8.7%), middle-aged adults in the United Kingdom (CAGR 2.3%; 95% CI: 1.5%-3.1%), and individuals with overweight or obesity (CAGR 3.9%; 95% CI: 3.3%-4.5%).

Study Design

Type

Observational

Multicenter

Yes

Structured PICO

P

Population

Nationwide registry-based forecast study projecting the prevalence and case fatality rates of acute myocardial infarction without standard modifiable risk factors (SMuRF-less AMI) in Singapore and the United Kingdom from 2025 to 2040.

O

Outcome

Forecasted prevalence and case fatality rate of SMuRF-less acute myocardial infarction from 2025 to 2040hard clinical

Main Result

Effect estimate: Projected increase from 5.8% to 8.5% (95% CI 6.2%-10.8%)

Absolute Event Rate: 8.5% vs 5.8%

Limitations

Use of Poisson regression models risks overdispersion and assumes a linear relationship without fully accounting for nonlinear metabolic interactions.
Assumes historical trends from 2010-2018 will remain consistent in the future without fully accounting for dynamic healthcare changes.
Use of Body Mass Index (BMI) as a surrogate measure for overweight/obesity rather than more precise anthropometric measures like waist-to-hip ratio.
Heterogeneity in risk factor definitions across the two national registries.
Small sample sizes in certain subgroups (e.g., young adults, STEMI) inflate forecast uncertainty.
Missing BMI data in the MINAP data set requiring imputation
Exclusion of 2019-2021 data to avoid pandemic-related distortions
Body mass index as a surrogate of overweight/obesity is a poor measure of high-risk body fat distribution

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Implication

The prevalence of acute myocardial infarction in patients without standard modifiable risk factors is projected to significantly increase by 2040 in both Eastern and Western populations, highlighting a growing demographic vulnerability that may be overlooked by current primary prevention screening guidelines.

Abstract

BACKGROUND: Standard modifiable risk factors (SMuRFs) are associated with increased risk of acute myocardial infarction (AMI). Patients with AMI in the absence of standard modifiable risk factors (SMuRF-less) have demonstrated excess mortality. OBJECTIVES: The study aims to forecast trends in prevalence and case fatality of SMuRF-less AMI in Singapore and United Kingdom. METHODS: Data from the Singapore Myocardial Infarction Registry and the UK Myocardial Ischemia National Audit Project were used to construct Poisson regression models to predict the prevalence and case fatality rate of SMuRF-less AMI from 2025 to 2040. RESULTS: From 2025 to 2040, SMuRF-less AMI cases are expected to contribute to larger proportions of total AMI cases in Singapore (5.8% [95% CI: 5.2%-6.4%] to 8.5% [95% CI: 6.2%-10.8%]) and United Kingdom (13.8% [95% CI: 13.0%-14.6%] to 16.9% [95% CI: 15.1%-18.7%]). The proportion of SMuRF-less AMI mortality of the total AMI mortality is set to decrease in the United Kingdom (11.3% [95% CI: 10.5%-12.1%] to 9.5% [95% CI: 7.7%-11.4%]), but increase in Singapore (6.3% [95% CI: 5.7%-6.9%] to 13.3% [95% CI: 10.9%-15.6%]). Men continue to bear the majority of SMuRF-less AMI prevalence, with the most rapid rise in young adults in Singapore (8.1%; 95% CI: 7.5%-8.7%) and middle-aged adults in the United Kingdom (2.3%; 95% CI: 1.5%-3.1%). The increase in SMuRF-less AMI prevalence is set to be more rapid in the overweight/obesity population (3.9%; 95% CI: 3.3%-4.5%). CONCLUSIONS: By 2040, SMuRF-less AMI will expand to a larger proportion of the AMI census in Western and Eastern populations. SMuRF-less AMI vulnerability will shift toward a younger, male-dominant demographic, with overweight/obesity as a dominant risk factor.

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Cite This Study

Cao et al. (2026) conducted an observational in Acute Myocardial Infarction (AMI). SMuRF-less status (absence of standard modifiable risk factors) vs. Temporal baseline (2025) and overall AMI population was evaluated on Prevalence of SMuRF-less AMI among total AMI cases in Singapore (2040 forecast) (Projected increase from 5.8% to 8.5%, 95% CI 6.2%-10.8%).

synapsesocial.com/papers/69c2294caeb5a845df0d3848 https://doi.org/10.1016/j.jacasi.2026.01.027

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Myocardial Infarction Without Standard Modifiable Risk Factors From 2025-2040

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Myocardial Infarction Without Standard Modifiable Risk Factors From 2025-2040

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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