Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review

Gemma A. Figtree, Stephen T. Vernon, Jason A. Harmer, Michael P. Gray, Clare Arnott, Eric Bachour, Giannie Barsha, David Brieger, Alex Brown, David S. Celermajer, Keith M. Channon, Nicholas W.S. Chew, James J.H. Chong, Clara K. Chow, Peter A. Cistulli, Patrick T. Ellinor, Stuart M. Grieve, Tomasz J. Guzik, Emil Hagström, Alicia JenkinsGarry Jennings, Anthony C. Keech, Katharine A. Kott, Leonard Kritharides, Mamas A. Mamas, Roxana Mehran, Peter J. Meikle, Pradeep Natarajan, Kazuaki Negishi, John O'Sullivan, Sanjay Patel, Peter J. Psaltis, Julie Redfern, Philippe G. Steg, David R. Sullivan, Johan Sundström, Birgit Vogel, Andrew Wilson, Dennis Wong, Deepak L. Bhatt, Jason C. Kovacic, Stephen J. Nicholls, on behalf of the CRE for CAD Collaborators

Research output: Contribution to journalReview ArticleResearchpeer-review

12 Citations (Scopus)


Reducing the incidence and prevalence of standard modifiable cardiovascular risk factors (SMuRFs) is critical to tackling the global burden of coronary artery disease (CAD). However, a substantial number of individuals develop coronary atherosclerosis despite no SMuRFs. SMuRFless patients presenting with myocardial infarction have been observed to have an unexpected higher early mortality compared to their counterparts with at least 1 SMuRF. Evidence for optimal management of these patients is lacking. We assembled an international, multidisciplinary team to develop an evidence-based clinical pathway for SMuRFless CAD patients. A modified Delphi method was applied. The resulting pathway confirms underlying atherosclerosis and true SMuRFless status, ensures evidence-based secondary prevention, and considers additional tests and interventions for less typical contributors. This dedicated pathway for a previously overlooked CAD population, with an accompanying registry, aims to improve outcomes through enhanced adherence to evidence-based secondary prevention and additional diagnosis of modifiable risk factors observed.

Original languageEnglish
Pages (from-to)1343-1359
Number of pages17
JournalJournal of the American College of Cardiology
Issue number13
Publication statusPublished - 26 Sept 2023


  • atherosclerosis
  • cardiovascular risk
  • clinical pathway
  • coronary artery disease
  • primary prevention
  • secondary prevention

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