Atherosclerotic cardiovascular disease risk assessment: An American Society for Preventive Cardiology clinical practice statement

Abstract

Risk for atherosclerotic cardiovascular disease (ASCVD) shows considerable heterogeneity both in generally healthy persons and in those with known ASCVD. The foundation of preventive cardiology begins with assessing baseline ASCVD risk using global risk scores based on standard office-based measures. Persons at low risk are generally recommended for lifestyle management only and those at highest risk are recommended for both lifestyle and pharmacologic therapy. Additional "risk enhancing" factors, including both traditional risk factors and novel biomarkers and inflammatory factors can be used to further assess ASCVD risk, especially in those at borderline or intermediate risk. There are also female-specific risk enhancers, social determinants of health, and considerations for high-risk ethnic groups. Screening for subclinical atherosclerosis, especially with the use of coronary calcium screening, can further inform the treatment decision if uncertain based on the above strategies. Persons with pre-existing ASCVD also have variable risk, affected by the number of major ASCVD events, whether recurrent events have occurred recently, and the presence of other major risk factors or high-risk conditions. Current guidelines define high to very high risk ASCVD accordingly. Accurate ASCVD risk assessment is crucial for the appropriate targeting of preventive therapies to reduce ASCVD risk. Finally, the clinician-patient risk discussion focusing on lifestyle management and the risks and benefits of evidence-based pharmacologic therapies to best lower ASCVD risk is central to this process. This clinical practice statement provides the preventive cardiology specialist with guidance and tools for assessment of ASCVD risk with the goal of appropriately targeting treatment approaches for prevention of ASCVD events.

Keywords: ACC, American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; ASPC, American Society for Preventive Cardiology; BMI, body mass index; CAC, coronary artery calcium, CCTA, coronary computed tomography angiography, CHD, coronary heart disease; CKD, chronic kidney disease; CRP, C-reactive protein; CVD, cardiovascular disease; Cardiovascular disease; DM, diabetes mellitus; EAS, European Atherosclerosis Society; ESC, European Society of Cardiology; Ethnicity; FH, familial hypercholesterolemia; GDM, gestational diabetes mellitus; IMT, intima media thickness; LDL, low density lipoprotein; MMP, matrix metalloproteinase; NHB, non-Hispanic Black; NHW, non-Hispanic White; PAD, peripheral arterial disease; PCE, pooled cohort equation; PCOS, polycystic ovary syndrome; POI, premature ovarian insufficiency; Primary prevention; Risk assessment; Risk factors inflammation; SDOH, social determinants of health; Secondary prevention; Sex; Subclinical atherosclerosis; VTE, venous thrombotic event.

Fig. 1

ASCVD Risk Estimator Plus (Pooled Cohort Equation Risk Score) tools.acc.org/ascvd-risk-estimator-plus. Provides 10-year ASCVD risk estimates for those aged 40-79 and lifetime ASCVD risk estimates for those aged 20-59.

Fig. 2

Refining Risk Estimates for Individual Patients: ASCVD Risk Categories, Risk Enhancing Factors, and Coronary Calcium Scoring. From Grundy et al. (15).

Fig. 3

Comparison of Novel Risk Markers for Improvement in Cardiovascular Risk Assessment in Intermediate Risk Individuals. From Yeboah et al. (210). Intermediate Risk MESA Subjects (n=1330) C-statistics: FRS alone 0.623; FRS+CAC 0.784 (p<0.001); FRS+CIMT 0.652 (p=0.01); FRS+FMD 0.639 (p=0.06); FRS+CRP 0.640 (p=0.03); FRS+FamHx 0.675 (p=0.001); FRS+ABI 0.650 (p=0.01)