Hidden heart-attack risks in young adults prompt doctors to broaden signs, Mayo Clinic study finds

A Mayo Clinic study spanning 15 years finds that more than half of heart attacks in people 65 and younger are triggered by nontraditional factors, challenging the view that plaque buildup alone drives these events. The findings, published in the Journal of the American College of Cardiology, show that many younger patients—especially women—experience heart attacks from causes that fall outside the classic artery-blockage model. The researchers say recognizing these hidden triggers is essential to guiding appropriate treatment and avoiding misdiagnosis when presentations do not fit the typical pattern. Dr Claire Raphael, an interventional cardiologist at Mayo Clinic and the study’s first author, said the research highlights causes that have historically been under-recognized, particularly in women, and cautioned that misunderstanding a heart attack’s root cause can lead to less effective or even harmful care.

To identify the nontraditional causes, investigators analyzed every resident of Olmsted County, Minnesota, aged 65 or younger, who between 2003 and 2018 experienced a cardiac event with elevated heart injury markers such as troponin. Each case was reviewed in detail and categorized into six potential causes of myocardial infarction: plaque rupture (atherothrombosis), spontaneous coronary artery dissection (SCAD), embolism, vasospasm, non-obstructive causes (MINOCA-U), or an oxygen supply-demand mismatch (Type 2 MI). Over the 15-year window, researchers reviewed 4,116 heart-injury events in 2,780 patients ranging from their early 40s to mid-60s.

The analysis found that 68 percent of events were due to plaque rupture, but the distribution differed notably by sex. Heart attacks caused by plaque were less common in women (47 percent) than in men (75 percent). Non-plaque-related causes accounted for the majority of events in women (53 percent) versus 25 percent in men. SCAD occurred in 11 percent of women compared with just 0.7 percent of men, and spontaneous artery tears were misdiagnosed initially in 55 percent of women. Across all groups, women tended to present with fewer traditional artery-blockage patterns, underscoring the need for clinicians to remain vigilant for alternative mechanisms.

The study also quantified outcomes by cause. The five-year mortality rate was highest after a supply-demand mismatch (33 percent) followed by plaque-related events (eight percent), with zero percent mortality reported for SCAD in that period. While plaque-related heart attacks remained a common cause for both sexes, they explained less than half of all cases in women (47 percent) compared with three-quarters in men (75 percent). The findings emphasize that non-plaque causes are a leading driver of heart attacks in younger women, with non-plaque etiologies accounting for 53 percent of their events compared with 25 percent in men. Dr Rajiv Gulati, chair of the Division of Interventional Cardiology and Ischemic Heart Disease at Mayo Clinic and the study’s senior author, said the results call for a reassessment of how heart attacks in younger patients are approached. “Our research highlights the larger need to rethink how we approach heart attacks in this patient population, and for younger adult women, in particular,” he said. “Clinicians must sharpen their awareness of conditions like SCAD, embolism and stress-related triggers, and patients should advocate for answers when something doesn’t feel right.” The study’s authors published their findings in the Journal of the American College of Cardiology.

Beyond the statistics, the report underscores a broader social shift: heart attacks are increasingly affecting younger people. Today, roughly one in five people with heart disease is under 40, and women are more likely to experience symptoms that do not align with the classic heart-attack presentation, which can delay diagnosis. The study notes that heart attacks among those aged 18 to 44 rose 66 percent between 2019 and 2023, signaling a growing public health concern. The research also references other contributing factors to nontraditional myocardial infarction, such as infections or major bleeding that overstress the heart, and other triggers that can occur without a persistent blockage.

The report’s personal dimension is illustrated by the case of Eve Walker, a 28-year-old professional dancer who survived a heart attack despite lacking obvious risk factors. She learned she has hypertrophic cardiomyopathy, a genetic condition that thickens the heart muscle and can disrupt blood flow. Walker’s symptoms began with extreme fatigue and a migrating, pinch-like sensation that moved from her leg to her face, prompting her to seek urgent care. Her diagnosis linked her event to a familial condition that had already claimed her sister’s life. The episode underscores how heart disease can strike seemingly healthy individuals and how genetic factors may play a critical role, particularly in younger patients who do not fit the traditional risk profile. The broader trend is reinforced by data showing rising heart attack rates among people under 40 from 2000 to 2016, increasing by about two percent each year.

The Mayo findings reinforce a need for heightened awareness among clinicians and patients alike. Experts urge that conditions such as SCAD, embolism and stress-related triggers be considered even when tests do not reveal a classic clogged artery. As Dr Gulati noted, the evidence supports a more nuanced approach to diagnosis and treatment for younger patients, especially women, and encourages patients to seek thorough explanations when symptoms arise that feel disproportionate to their activity level or risk factors. With the study published in a leading cardiology journal, the medical community is urged to incorporate these nontraditional pathways into clinical practice to reduce misdiagnosis and improve outcomes for a broader spectrum of heart-attack patients.