Front Cardiovasc Med. 2026 Aug 6;13:1785553. doi: 10.3389/fcvm.2026.1785553. eCollection 2026.
ABSTRACT
BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in Middle East. Some patients sustain events in the absence of the four standard modifiable risk factors (SMuRFs): hypertension, type 2 diabetes, dyslipidemia and cigarette smoking (SMuRF-less patients). Two other modifiable RFs, obesity and physical inactivity, although highly prevalent, are not included in SMuRF-less definition.
AIM: To study the prevalence and clinical profiles of SMuRF-less patients in a large Middle Eastern ASCVD cohort using an expanded definition includes obesity and physical inactivity vs. the traditional four RFs definition.
METHODS: We analysed data from the Jordan SMuRF-less study, to compare between expanded and traditional definitions and SMuRF-less vs. SMuRFs groups.
RESULTS: An initial analysis that included 5,540 ASCVD patients [mean age 57.5 ± 11.6 years, and 1,333 (24.1%) were women] showed that 214 (3.9%) patients were SMuRF-less with none of the four RFs. A subgroup of 1,121 patients had available data on their body mass index and physical activity. Of this subgroup, only 11 (1.0%) patients were SMuRF-less with none of the six RFs were present. The 6-RF SMuRF-less patients were younger than those with ≥ 1 SMuRF. These patients also had higher median high-density lipoprotein cholesterol levels and lower median triglycerides serum levels compared with those who have 4-6 RFs.
CONCLUSIONS: Including obesity and physical inactivity to the original four RFs lowered the prevalence of "SMuRF-less" by 74.4%. ASCVD prevention strategies need to give more attention to lifestyle-related parameters to avoid misclassifying any modifiable risk factor.Clinical Trial Registration: ClinicalTrials.gov, identifier NCT06199869.
PMID:42625571 | PMC:PMC13489840 | DOI:10.3389/fcvm.2026.1785553