A large international study has found that 99% of heart attacks, strokes, and major cardiovascular events are linked to four common health risk factors: high blood pressure, high cholesterol, high blood sugar, and tobacco use.
Researchers examined data from over 9 million adults in the United States and South Korea, making it one of the most comprehensive studies of its kind. The results, published in 2025, underline the importance of early prevention and lifestyle changes.
Even among younger women under 60, who are typically at lower risk, over 95% of cardiovascular events were tied to one or more of these four factors.
High blood pressure (hypertension) emerged as the most significant contributor, present in more than 93% of individuals who experienced a heart attack, stroke, or heart failure.
"We think the study shows very convincingly that exposure to one or more nonoptimal risk factors before these cardiovascular outcomes is nearly 100%," said senior author Dr Philip Greenland, professor of cardiology at Northwestern University Feinberg School of Medicine.
"The goal now is to work harder on finding ways to control these modifiable risk factors rather than to get off track in pursuing other factors that are not easily treatable and not causal."
The findings highlight the critical need for early detection, regular screening, and better management of these common conditions to prevent life-threatening heart issues in the future.
Greenland and his co-authors highlight that their findings challenge recent reports suggesting an increase in cardiovascular events occurring without risk factors. They believe earlier studies may have missed some diagnoses or overlooked risk factors that were below clinical thresholds. In a related editorial, Duke University cardiologist Neha Pagidipati, who was not involved in the study, emphasizes the critical importance of managing health risks early to prevent serious and potentially fatal outcomes.
"We can and must do better," she states. The study was published in the Journal of the American College of Cardiology.
