Below is the full podcast episode and a shortened blog summary. I encourage you to listen to the full podcast for depth and inspiration from my human (non-AI) voice. It’s also available on your favorite podcast apps here (Apple, Spotify, etc.).
Background
I’m finding more and more patients plugging numbers into an online calculator or using AI to estimate their risk of having a heart attack or stroke. Those tools—built on huge population datasets—do a good job in people who are clearly high risk (older age, smokers, diabetics, hypertensives, etc.) or healthy. What they don’t see is the vast “metabolic middle”: lean, often younger adults (many South Asian, Filipino, etc.) whose arteries have dangerous plaque even though the risk calculator and AI label them as “low risk.”
How today’s scores fall short
Pooled-Cohort Equations (PCE) and the more recent PREVENT risk calculator rely on inputs like age, cholesterol, blood pressure, smoking, diabetes, etc. Helpful…but they ignore:
Aerobic fitness signals: VO₂ max, 1-mile walk time, heart-rate recovery
Psychosocial and emotional load: sustained stress, depression, short sleep
Ethnic nuance: South Asians, Filipinos, etc. typically are under-risked.
The result? Patients in my clinic can have high plaque scores on their coronary artery calcium scan (read my blog post here on heart scans) or come see me after a heart attack, yet when I check their PCE or PREVENT risk score, it often falls under 5% (low risk).
This means many high risk individuals, falsely rated as low risk, aren’t being put on statins, and they are also not being told to aggressively intensify lifestyle changes because they score low on these risk calculators or are being told by AI that they are low risk.
Brief Hidden Risk Checklist
Below are a list of some of the additional risk metrics you should consider assessing to avoid these potentially deadly blindspots:
Additional Lipid metrics: Elevated Apo B, High Lp(a), Presence of excess type B small dense LDL
Fitness metrics: Read this post for details on assessing your VO2 max and other aerobic metrics. Cardiopulmonary fitness is arguably the single greatest metric for longevity and reduced heart disease risk, yet it’s not on any of these calculators.
Heart-rate recovery < 12 bpm at one minute post-exercise
Emotional health: High stress, mood disorders, poor sleep
High risk ethnic groups: South Asian, Filipino, Asian Pacific Islander, etc.
To be fair, the American Heart Association, has added what they call risk enhancing factors which you can find here. However, these are not part of the core inputs and I don’t see them being routinely used to adjust risk in most patients.
Taking Action
If you have any of the above hidden risks, consider the following after discussing with your health care provider:
Imaging: You may need to consider getting a heart scan. If you’re not familiar with that test, read about it here.
Medication therapy: I try to avoid medications in my patients whenever possible. However, many of my patients rated as “low risk” are definitely high risk based on the hidden risk factors listed above. I would put these patients on statin therapy to drive down their Apo B and LDL.
Lifestyle changes: Don’t get lulled into false security because AI or a risk calculator rates you as “low risk.” Pay attention to hidden risks (see checklist above) and then double down on nutrition, exercise, stress, and sleep.
