{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T15:13:45Z","timestamp":1786115625686,"version":"build-2736575974"},"reference-count":34,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,6]],"date-time":"2026-08-06T00:00:00Z","timestamp":1785974400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We analysed data from the Jordan SMuRF-less study, to compare between expanded and traditional definitions and SMuRF-less vs. SMuRFs groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>An initial analysis that included 5,540 ASCVD patients [mean age 57.5\u2009\u00b1\u200911.6 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 \u2265 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\u20136 RFs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Including obesity and physical inactivity to the original four RFs lowered the prevalence of \u201cSMuRF-less\u201d by 74.4%. ASCVD prevention strategies need to give more attention to lifestyle-related parameters to avoid misclassifying any modifiable risk factor.<\/jats:p>\n                    <jats:p>\n                      <jats:bold>Clinical Trial Registration<\/jats:bold>\n                      :\n                      <jats:ext-link>ClinicalTrials.gov<\/jats:ext-link>\n                      , identifier NCT06199869.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fcvm.2026.1785553","type":"journal-article","created":{"date-parts":[[2026,8,6]],"date-time":"2026-08-06T04:25:09Z","timestamp":1785990309000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Redefining atherosclerotic cardiovascular disease patients with no standard modifiable risk factors \u201cSMuRF-less\u201d: six rather than four risk factors. Analysis from the Jordan SMuRF-less Study"],"prefix":"10.3389","volume":"13","author":[{"given":"Ayman","family":"Hammoudeh","sequence":"first","affiliation":[{"name":"Department of Cardiology, Istishari Hospital","place":["Amman, Jordan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mo\u2019men","family":"Aldalal\u2019ah","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Princess Basma Hospital, Ministry of Health","place":["Irbid, Jordan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fakhri","family":"Al-Malkawi","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Princess Basma Hospital, Ministry of Health","place":["Irbid, Jordan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Enad","family":"Haddad","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Jefferson Abington Hospital","place":["Abington, PA, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aseel","family":"Rizik","sequence":"additional","affiliation":[{"name":"Department of Medical Education, University of Jordan School of Medicine","place":["Amman, Jordan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Omar","family":"Shadeed","sequence":"additional","affiliation":[{"name":"Department of Medical Education, University of Jordan School of Medicine","place":["Amman, Jordan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samia","family":"Sulaiman","sequence":"additional","affiliation":[{"name":"Department of Medical Education, University of Jordan School of Medicine","place":["Amman, Jordan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mayar","family":"Abughosh","sequence":"additional","affiliation":[{"name":"Department of Medical Education, Arab American University School of Medicine","place":["Jenin, Palestinian Territory"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lamia","family":"Marouf","sequence":"additional","affiliation":[{"name":"Department of Medical Education, Arab American University School of Medicine","place":["Jenin, Palestinian Territory"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qossay","family":"Abu Khalil","sequence":"additional","affiliation":[{"name":"Department of Medical Education, Arab American University School of Medicine","place":["Jenin, Palestinian Territory"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zaid","family":"Shbita","sequence":"additional","affiliation":[{"name":"Department of Medical Education, Arab American University School of Medicine","place":["Jenin, Palestinian Territory"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmed","family":"Alhaj","sequence":"additional","affiliation":[{"name":"Department of Medical Education, Arab American University School of Medicine","place":["Jenin, Palestinian Territory"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jamal M.","family":"Hammoudeh","sequence":"additional","affiliation":[{"name":"Department of Medical Education, University of Szeged Albert Szent Gyorgyi Medical School","place":["Szeged, Hungary"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad","family":"Araidah","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Istishari Hospital","place":["Amman, Jordan"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,6]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1273","DOI":"10.1056\/NEJMOA2206916","article-title":"Global effect of modifiable risk factors on cardiovascular disease and mortality","volume":"389","author":"Magnussen","year":"2023","journal-title":"N Engl J Med"},{"key":"B2","doi-asserted-by":"publisher","first-page":"102341","DOI":"10.1016\/j.cpcardiol.2023.102341","article-title":"Cardiovascular disease burden in the Middle East and north Africa region","volume":"49","author":"Alhuneafat","year":"2024","journal-title":"Curr Probl Cardiol"},{"key":"B3","doi-asserted-by":"publisher","first-page":"937","DOI":"10.1016\/S0140-6736(04)17018-9","article-title":"Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study","volume":"364","author":"Yusuf","year":"2004","journal-title":"Lancet"},{"key":"B4","doi-asserted-by":"publisher","first-page":"480","DOI":"10.1016\/j.hlc.2022.12.012","article-title":"Trends in modifiable risk factors amongst first presentation ST elevation myocardial infarction patients in a large longitudinal registry","volume":"32","author":"Kazi","year":"2023","journal-title":"Hear Lung Circ"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1085","DOI":"10.1016\/S0140-6736(21)00272-5","article-title":"Mortality in STEMI patients without standard modifiable risk factors: a sex-disaggregated analysis of SWEDEHEART registry data","volume":"397","author":"Figtree","year":"2021","journal-title":"Lancet"},{"key":"B6","doi-asserted-by":"publisher","first-page":"e002733","DOI":"10.1136\/OPENHRT-2024-002733","article-title":"Prevalence and outcomes of patients with SMuRF-less acute coronary syndrome undergoing percutaneous coronary intervention","volume":"11","author":"Ball","year":"2024","journal-title":"Open Hear"},{"key":"B7","doi-asserted-by":"publisher","first-page":"e027851","DOI":"10.1161\/JAHA.122.027851","article-title":"Mortality in patients hospitalised with acute myocardial infarction without standard modifiable risk factors: the ARIC study community surveillance","volume":"12","author":"Chunawala","year":"2023","journal-title":"J Am Heart Assoc"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/S12916-022-02418-W","article-title":"Number of standard modifiable risk factors and mortality in patients with first-presentation ST-segment elevation myocardial infarction: insights from China acute myocardial infarction registry","volume":"20","author":"Li","year":"2022","journal-title":"BMC Med"},{"key":"B9","doi-asserted-by":"publisher","first-page":"59","DOI":"10.5334\/GH.1341","article-title":"Atherosclerotic cardiovascular disease novel and traditional risk factors in Middle Eastern young women. The ANCORS-YW study","volume":"19","author":"Hammoudeh","year":"2024","journal-title":"Glob Heart"},{"key":"B10","doi-asserted-by":"publisher","first-page":"882","DOI":"10.1253\/CIRCJ.CJ-21-1041","article-title":"JCS 2022 Guideline focused update on diagnosis and treatment in patients with stable coronary artery disease","volume":"86","author":"Nakano","year":"2022","journal-title":"Circ J"},{"key":"B11","doi-asserted-by":"publisher","first-page":"432","DOI":"10.1016\/j.ijcard.2022.09.062","article-title":"Higher mortality in acute coronary syndrome patients without standard modifiable risk factors: results from a global meta-analysis of 1,285,722 patients","volume":"371","author":"Kong","year":"2023","journal-title":"Int J Cardiol"},{"key":"B12","doi-asserted-by":"publisher","first-page":"e013296","DOI":"10.1161\/JAHA.119.013296","article-title":"ST-Segment\u2013Elevation myocardial infarction (STEMI) patients without standard modifiable cardiovascular risk factors\u2014how common are they, and what are their outcomes?","volume":"8","author":"Vernon","year":"2019","journal-title":"J Am Heart Assoc"},{"key":"B13","doi-asserted-by":"publisher","first-page":"39","DOI":"10.2147\/VHRM.S499355","article-title":"Absence of standard modifiable risk factors in Middle Eastern patients with atherosclerotic cardiovascular disease. The Jordan absence of standard modifiable risk factors (SMuRF-less) study","volume":"21","author":"Hammoudeh","year":"2025","journal-title":"Vasc Health Risk Manag"},{"key":"B14","doi-asserted-by":"publisher","first-page":"726","DOI":"10.1186\/S12889-020-08715-4","article-title":"The association between physical activity with incident obesity, coronary heart disease, diabetes and hypertension in adults: a systematic review of longitudinal studies published after 2012","volume":"20","author":"Cleven","year":"2020","journal-title":"BMC Public Health"},{"key":"B15","doi-asserted-by":"publisher","first-page":"e0287218","DOI":"10.1371\/JOURNAL.PONE.0287218","article-title":"Body mass index and all-cause mortality in a 21st century U.S. Population: a national health interview survey analysis","volume":"18","author":"Visaria","year":"2023","journal-title":"PLoS One"},{"key":"B16","doi-asserted-by":"publisher","first-page":"2065","DOI":"10.1038\/S41366-022-01209-W","article-title":"Physical activity and fitness vs adiposity and weight loss for the prevention of cardiovascular disease and cancer mortality","volume":"46","author":"Lavie","year":"2022","journal-title":"Int J Obes (Lond)"},{"key":"B17","doi-asserted-by":"publisher","first-page":"818","DOI":"10.1056\/NEJMOA1311890","article-title":"Cardiovascular risk and events in 17 low-, middle-, and high-income countries","volume":"371","author":"Yusuf","year":"2014","journal-title":"N Engl J Med"},{"key":"B18","doi-asserted-by":"publisher","first-page":"1640","DOI":"10.1016\/S0140-6736(05)67663-5","article-title":"Obesity and the risk of myocardial infarction in 27 000 participants from 52 countries: a case-control study","volume":"366","author":"Yusuf","year":"2005","journal-title":"Lancet"},{"key":"B19","doi-asserted-by":"publisher","first-page":"869168","DOI":"10.3389\/FCVM.2022.869168","article-title":"Prognostic outcomes in acute myocardial infarction patients without standard modifiable risk factors: a multiethnic study of 8,680 Asian patients","volume":"9","author":"Kong","year":"2022","journal-title":"Front Cardiovasc Med"},{"key":"B20","doi-asserted-by":"publisher","first-page":"1343","DOI":"10.1016\/j.jacc.2023.06.045","article-title":"Clinical pathway for coronary atherosclerosis in patients without conventional modifiable risk factors: JACC state-of-the-art review","volume":"82","author":"Figtree","year":"2023","journal-title":"J Am Coll Cardiol"},{"key":"B21","doi-asserted-by":"publisher","first-page":"e081399","DOI":"10.1136\/BMJOPEN-2023-081399","article-title":"Body mass index and all-cause mortality in HUNT and UK biobank studies: revised non-linear mendelian randomisation analyses","volume":"14","author":"Burgess","year":"2024","journal-title":"BMJ Open"},{"key":"B22","doi-asserted-by":"publisher","first-page":"1167","DOI":"10.1016\/j.jcin.2022.03.036","article-title":"Clinical outcomes in patients with ST-segment elevation MI and No standard modifiable cardiovascular risk factors","volume":"15","author":"Figtree","year":"2022","journal-title":"JACC Cardiovasc Interv"},{"key":"B23","doi-asserted-by":"publisher","first-page":"1621","DOI":"10.1161\/CIRCULATIONAHA.123.065485","article-title":"Obesity and cardiovascular disease: a new Dawn","volume":"149","author":"Sattar","year":"2024","journal-title":"Circulation"},{"key":"B24","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1056\/NEJMoa2415879","article-title":"Global effect of cardiovascular risk factors on lifetime estimates","volume":"393","author":"Magnussen","year":"2025","journal-title":"N Engl J Med"},{"key":"B25","doi-asserted-by":"publisher","first-page":"725","DOI":"10.1097\/SLA.0000000000006588","article-title":"Metabolic surgery: progenitor of effective therapy for atherosclerotic cardiovascular disease, cancer, type 2 diabetes, and obesity","volume":"281","author":"Buchwald","year":"2025","journal-title":"Ann Surg"},{"key":"B26","doi-asserted-by":"publisher","first-page":"4063","DOI":"10.1093\/EURHEARTJ\/EHAE508","article-title":"Obesity and cardiovascular disease: an ESC clinical consensus statement","volume":"45","author":"Koskinas","year":"2024","journal-title":"Eur Heart J"},{"key":"B27","doi-asserted-by":"publisher","first-page":"2218","DOI":"10.1093\/EURJPC\/ZWAC187","article-title":"Obesity and cardiovascular disease: mechanistic insights and management strategies. A joint position paper by the world heart federation and world obesity federation","volume":"29","author":"Lopez-Jimenez","year":"2022","journal-title":"Eur J Prev Cardiol"},{"key":"B28","doi-asserted-by":"publisher","first-page":"100408","DOI":"10.1016\/j.ahjo.2024.100408","article-title":"Prevalence, predictors, and in-hospital outcomes of ST-elevation myocardial infarction among young adults without traditional cardiovascular risk factors in the United States","volume":"43","author":"Shamaki","year":"2024","journal-title":"Am Hear J Plus Cardiol Res Pract"},{"key":"B29","doi-asserted-by":"publisher","first-page":"e1077","DOI":"10.1016\/S2214-109X(18)30357-7","article-title":"Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1\u00b79 million participants","volume":"6","author":"Guthold","year":"2018","journal-title":"Lancet Glob Heal"},{"key":"B30","doi-asserted-by":"publisher","first-page":"729","DOI":"10.1186\/S12877-022-03414-8","article-title":"Cardiovascular disease risk and all-cause mortality associated with accelerometer-measured physical activity and sedentary time \u2012 a prospective population-based study in older adults","volume":"22","author":"L\u00e4nsitie","year":"2022","journal-title":"BMC Geriatr"},{"key":"B31","doi-asserted-by":"publisher","first-page":"1018460","DOI":"10.3389\/FPUBH.2022.1018460","article-title":"Association between sedentary behavior, physical activity, and cardiovascular disease-related outcomes in adults\u2014a meta-analysis and systematic review","volume":"10","author":"Liang","year":"2022","journal-title":"Front Public Heal"},{"key":"B32","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1016\/J.PCAD.2023.04.008","article-title":"Exercise and cardiovascular health: a state-of-the-art review","volume":"79","author":"Isath","year":"2023","journal-title":"Prog Cardiovasc Dis"},{"key":"B33","doi-asserted-by":"publisher","first-page":"5865","DOI":"10.3390\/JCM13195865","article-title":"Clinical insights into physical activity, fitness, and cardiovascular health","volume":"13","author":"Volis","year":"2024","journal-title":"J Clin Med"},{"key":"B34","doi-asserted-by":"publisher","first-page":"500","DOI":"10.1016\/j.jacasi.2024.02.005","article-title":"Patients with STEMI without standard modifiable risk factors","volume":"4","author":"Mizori","year":"2024","journal-title":"JACC Asia"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2026.1785553\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,6]],"date-time":"2026-08-06T04:25:11Z","timestamp":1785990311000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2026.1785553\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,6]]},"references-count":34,"alternative-id":["10.3389\/fcvm.2026.1785553"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2026.1785553","relation":{},"ISSN":["2297-055X"],"issn-type":[{"value":"2297-055X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,6]]},"article-number":"1785553"}}