Preventing the first myocardial infarction: from reaction to action

This commentary refers to ‘First myocardial infarction: risk factors, symptoms, and medical therapy’, by N.S. Nurmohamed et al., https://doi.org/10.1093/eurheartj/ehaf390 and the discussion piece ‘First myocardial infarction: incorporating non-traditional risk factors to bridge the prevention gap’, by B. Zhang et al., https://doi.org/10.1093/eurheartj/ehaf851. We thank Zhang et al. for their interest in our analysis of over 4.5 million patients from the US with a first myocardial infarction (MI) that demonstrated approximately half were asymptomatic and one in five had no identified traditional cardiovascular risk factors.1 Most importantly, many patients with a first MI had standard modifiable cardiovascular risk factors (SMuRFs) that were left untreated: 56% of patients with documented SMuRFs and a physician visit did not receive preventive medication.1 Several prior studies have documented undertreatment of hypertension and hyperlipidaemia in the primary care setting, either due to physician inertia or due to patient non-adherence. Evolving evidence also plays an important role, as what was used to be considered a ‘normal’ blood pressure or cholesterol level might be considered above target according to recent guidelines. Finally, there are patients presenting with an MI who truly do not have any SMuRFs present.2 We completely agree with Zhang et al. that well-done studies have shown non-traditional risk factors such as pollution, sleep disturbances, and other stressors contribute to MI risk.3,4 Indeed, greater efforts are needed to identify and treat such non-traditional risk factors.