Redefining atherosclerotic cardiovascular disease patients with no standard modifiable risk factors "SMuRF-less": six rather than four risk factors. Analysis from the Jordan SMuRF-less Study.

Authors

Ayman Hammoudeh, Mo'men Aldalal'ah, Fakhri Al-Malkawi, Enad Haddad, Aseel Rizik, Omar Shadeed, Samia Sulaiman, Mayar Abughosh, Lamia Marouf, Qossay Abu Khalil, Zaid Shbita, Ahmed Alhaj, Jamal M Hammoudeh, Mohammad Araidah

Published in

Frontiers in cardiovascular medicine. Volume 13. Pages 1785553. Epub Aug 06, 2026.

Abstract

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.
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.
We analysed data from the Jordan SMuRF-less study, to compare between expanded and traditional definitions and SMuRF-less vs. SMuRFs groups.
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.
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
Bibliographic data and abstract were imported from PubMed on 21 Aug 2026.

Read full publication at:
Please sign in to see all details.

Stats

1-terrible, 9-excellent. How would you rate this publication? Sign in in to submit your rating.

Post a comment

You need to be signed in to post comments. You can sign in here.

Comments

There are no comments yet.