Introduction
A growing population of individuals with atherosclerotic cardiovascular disease (ASCVD) has been identified who lack standard modifiable risk factors, also known as SMuRF-less patients. These individuals constitute about 1.5% to 26% of ASCVD cases and have shown a rising trend over the past two decades in studies conducted across different regions.
Recent research, particularly in Middle Eastern countries, emphasizes the need to address this unique group due to varying outcomes and the lack of tailored management guidelines. The first study to evaluate SMuRF-less patients in a large Middle Eastern cohort provides insights into their demographics, clinical features, and long-term prognosis.
Prevalence and Demographics
The study, conducted in Jordan, involved a total of 5540 patients with ASCVD. Among them, 214 (3.9%) were identified as SMuRF-less. The prevalence was slightly lower compared to studies in other regions but highlights the importance of regional differences in cardiovascular risk factors.
Key demographic findings include a younger average age (57.5 ± 11.6 years) and a higher proportion of men. The study also noted that young people (≤45 years) made up 15.6% of the cohort, similar to findings in other studies.
Clinical Profiles and Risk Factors
The clinical profiles of SMuRF-less patients showed significant differences compared to those with standard modifiable risk factors (SMuRFs). They had fewer comorbid diseases, including heart failure, chronic kidney disease, and metabolic syndrome. Additionally, their risk factor profile was notably different, with lower prevalence of obesity, family history of premature ASCVD, and physical inactivity.
Table 1 highlights the comparison of clinical profiles, risk factors, serum lipoprotein levels, and comorbid diseases among the three patient groups. SMuRF-less patients had lower LDL-C and triglyceride levels while showing higher HDL-C levels, indicating a more favorable lipid profile.
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Table 1 Clinical Features, Cardiovascular Risk Factors and Serum Lipoprotein Levels in SMuRF-Less and SMuRFs Patients |
Management and Medication Use
The utilization of evidence-based secondary cardiovascular prevention medications was notably lower in SMuRF-less patients. This includes aspirin, statins, beta blockers, and renin angiotensin system blockers. Table 2 and Figure 2 demonstrate the lower prescription rates of these medications in the SMuRF-less group compared to those with SMuRFs.
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Table 2 Pharmacotherapy Across the Three Groups of Patients According to the Number of SMuRFs |
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Figure 2 Forest plot showing the use of cardiovascular medications according to the number of the standard modifiable risk factors. Abbreviations: DAPs, dual antiplatelet agents; RAAS, renin angiotensin aldosterone system; SMuRFs, standard modifiable risk factors. |
Prognosis and Survival Rates
One-year survival rates were an important aspect of the study. Among patients who had a cardiovascular event at least one year prior to enrollment, SMuRF-less patients had a slightly higher one-year mortality rate (2.3%) compared to those with 1–2 SMuRFs (1.6%) or 3–4 SMuRFs (1.7%).
Multivariable analysis revealed that young age, absence of heart failure, and use of certain medications were independently associated with better survival. These findings suggest the importance of personalized treatment approaches based on individual patient characteristics.
Discussion
The study underscores the complexity and variability in the clinical profiles of SMuRF-less ASCVD patients. Their unique characteristics, including younger age and fewer comorbidities, challenge traditional risk factor-based management strategies. The diverse prevalence rates reported in different regions highlight the need for regional-specific research and clinical guidelines.
The lower medication use among SMuRF-less patients is a significant observation. It emphasizes the need for targeted interventions and possibly new strategies to manage this low-risk factor subgroup effectively.
Limitations and Future Directions
Despite the significant findings, the study has limitations, including a limited sample of young women and the heterogeneity of the patient cohort. Future research should focus on expanding the sample size, particularly in the young female population, to better understand the burden, clinical profiles, and long-term outcomes of SMuRF-less patients.
An international, multidisciplinary team is currently developing an evidence-based clinical pathway to address the unique needs of SMuRF-less CAD patients, suggesting a promising direction for future clinical practice.
Conclusion
In conclusion, this study provides important insights into the demographic and clinical characteristics of SMuRF-less ASCVD patients in the Middle East. These findings underscore the need for tailored management strategies and highlight the importance of regional-specific research to improve outcomes in these unique patients.
Call to Action
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