In the past several years, there have been reports that many patients who develop ischemic heart disease don’t have standard modifiable risk factors, often referred to as SMuRFs. In one Australian study, for example, the proportion of STEMI patients without SMuRFs increased from 11% to 27% between 2006 and 2014 and those without modifiable risk factors fared worse in follow-up than those with conventional risk factors. “Several recent studies claimed that coronary heart disease can often develop without traditional risk factors like high blood pressure, high cholesterol, diabetes, or smoking,” Lee told TCTMD via email. Nathan Wong“Surprisingly, the results were almost identical between the Korean and US cohorts in that traditional risk factors were universally present before CVD events in both cohorts,” said Lee. Jeffrey BergerBerger noted that patients in MESA and KNHIS who didn’t develop cardiovascular disease also had very poor optimization of risk factors.