Many Italians Underestimate Their Own Heart Risk, Major Trial Finds

Cardiovascular disease remains the leading cause of death worldwide, and yet the people who stand to lose the most from it often fail to see themselves as being in danger. A new analysis from the Italian INNOPREV trial, published in BMC Public Health, offers one of the most detailed portraits to date of how adults at moderate-to-high cardiovascular risk actually perceive that risk, and the results reveal a striking gap between clinical reality and personal belief. Among nearly one thousand middle-aged Italians with elevated cardiovascular risk profiles, the average level of perceived risk was only moderate, suggesting that a substantial share of the population is living with a threat they do not fully appreciate.

The study, led by Chiara de Waure of the University of Perugia and colleagues spanning institutions in Perugia, Rome, Palermo and Catania, drew its participants from the INNOPREV randomized controlled trial, a project funded by the Italian Ministry of Health under the National Recovery and Resilience Plan. The trial, registered at ClinicalTrials.gov as NCT05883878, is designed to test innovative, personalized strategies for cardiovascular disease prevention in high-risk adults. Before any randomization took place, the researchers asked participants aged 40 to 69 a deceptively simple question: how much do you believe cardiovascular disease threatens you personally? The answer came through a validated instrument called the Health Beliefs Related to Cardiovascular Disease Scale, or HBCVD, a 25-item questionnaire built on the Health Belief Model, one of the most influential psychological frameworks in preventive medicine.

The Health Belief Model holds that whether people adopt protective behaviors depends on four interconnected perceptions: their susceptibility to a condition, the severity it would have if it struck, the benefits of taking preventive action, and the barriers standing in the way of that action. The HBCVD scale translates these constructs into four subscales, each scored out of 100. When the researchers analyzed the 988 returned questionnaires from the 1,019 enrolled participants, they found a mean overall score of 61.10, with a standard deviation of 6.61. In other words, on average these adults, all of whom had been clinically assessed as being at moderate-to-high cardiovascular risk, perceived their risk as barely more than moderate.

To understand what shaped these perceptions, the team compared HBCVD scores across a battery of socio-demographic and clinical characteristics, including sex, age, marital status, education, employment, smoking status, body mass index, family history of cardiovascular conditions, the SCORE2 risk algorithm, and Life’s Essential 8, the American Heart Association’s composite measure of cardiovascular health covering diet, physical activity, nicotine exposure, sleep, body weight, blood lipids, blood glucose and blood pressure. Because the analysis involved many simultaneous comparisons, the researchers applied the Benjamini-Hochberg procedure to control the false discovery rate, a statistical safeguard that reduces the risk of spurious findings when testing many hypotheses at once. Effect sizes were reported as rank-biserial correlations or epsilon-squared values, allowing readers to judge not just statistical significance but practical magnitude.

After this correction, two factors stood out as consistently associated with overall risk perception: body mass index category and Life’s Essential 8 score. Participants with higher BMI perceived greater risk, an association confirmed in multivariable linear regression models fitted with heteroskedasticity-consistent standard errors. Compared with participants of normal weight, those who were overweight scored 1.13 points higher on the overall HBCVD scale, while those with obesity scored 2.94 points higher, the latter difference highly statistically significant. The direction makes intuitive sense: people carrying excess weight may receive more frequent warnings from clinicians, or may themselves sense the physical burden, and this awareness translates into stronger perceived vulnerability.

The association with cardiovascular health ran in the opposite direction, and this is where the findings become genuinely thought-provoking. Participants with moderate cardiovascular health scored 2.63 points lower on risk perception than those with low cardiovascular health, and those with high cardiovascular health scored 3.80 points lower. On the surface this seems logical, since healthier people genuinely face lower risk. But the effect sizes were small, and the pattern raises a subtle concern for prevention science: people who already behave well may feel insulated from cardiovascular disease, and that sense of safety could erode their motivation to maintain healthy habits over the long term. Prevention programs that ignore this psychological dynamic risk losing participants precisely when those habits have begun to pay off.

When the researchers dissected the four subscales separately, each told a different story. Perceived susceptibility showed the strongest and most consistent relationships with objective risk factors, tracking closely with BMI, family history, and Life’s Essential 8 score. Perceived benefits, by contrast, varied mainly with socio-demographic characteristics, suggesting that beliefs about the value of prevention are shaped more by social context than by clinical status. Perceived barriers were linked both to education level and to cardiovascular health, hinting that people with less education may face more practical obstacles to preventive action, and that even health-conscious individuals encounter friction in sustaining it. Perceived severity differed significantly only by sex and age class, indicating that judgments about how bad a cardiovascular event would be are relatively uniform across the population, anchored more in personal demographics than in medical risk profiles.

The methodological choices in the study deserve attention. Because all variables were measured at a single pre-randomization time point, the authors are careful to note that no causal inference is possible; the analysis shows associations, not mechanisms. The cross-sectional design means that, for example, obesity might drive higher risk perception, or conversely that anxious people might gain weight, or that both could reflect some third factor. Yet even as a snapshot, the data are valuable precisely because they come from a trial population that was thoroughly phenotyped, with clinically validated risk scores and standardized health assessments, rather than from a self-selected survey sample. The modest effect sizes, with epsilon-squared values around 0.02, underscore that risk perception is a diffuse phenomenon shaped by many small influences rather than one dominant driver.

Why does all this matter? Because risk perception is the psychological gateway to prevention. Clinical guidelines can calculate a person’s ten-year cardiovascular risk to several decimal places, but that calculation changes nothing unless the person believes it applies to them. The concept of unrealistic optimism, well documented in health psychology, describes people’s tendency to believe their own risk is lower than that of their peers, and the moderate scores observed here, in a population selected specifically for elevated risk, are consistent with that bias. If the very people flagged by SCORE2 as needing intervention do not feel vulnerable, adherence to medications, lifestyle counseling and follow-up appointments may all suffer. The INNOPREV findings give clinicians and public health planners a map of where those perception gaps concentrate.

The authors argue that their results can support the development of tailored preventive strategies to enhance risk awareness and promote healthy behaviors, and the trial’s randomized phase will test exactly that idea. In an era when personalized prevention is moving from slogan to policy, this study is a reminder that personalization must begin with the mind as well as the body. A prevention program calibrated to a person’s cholesterol but not to their beliefs is working with half the information. As Italy and other countries grapple with the enormous burden of cardiovascular disease, the quiet insight from this analysis may prove to be among the most actionable: before we can persuade people to protect their hearts, we first have to convince them their hearts are worth protecting, and that task starts with understanding how they currently see the risk.

Subject of Research: Cardiovascular risk perception among Italian adults at moderate-to-high cardiovascular risk enrolled in the INNOPREV prevention trial

Article Title: Perceived risk of cardiovascular diseases in the Italian population: a baseline cross-sectional analysis of participants enrolled in the INNOPREV trial

Article References: de Waure, C., Valentini, I., Arcelli, M., Volpi, F., Scarsi, N., Gobbetti, C., Lolli, O., Russo, L., Proto, L., Galarducci, R., Pasciuto, T., Severino, A., Tuttolomondo, A., De Bella, D., Daidone, M., Morello, G., Muli, R. L., Previti, A., Pieri, A., … Boccia, S. (2026). Perceived risk of cardiovascular diseases in the Italian population: a baseline cross-sectional analysis of participants enrolled in the INNOPREV trial. BMC Public Health. https://doi.org/10.1186/s12889-026-29286-w

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29286-w

Keywords: cardiovascular disease, risk perception, INNOPREV trial, Health Belief Model, HBCVD scale, Life's Essential 8, body mass index, SCORE2, preventive behaviours, Italy, public health, BMC Public Health