Cardiovascular Risk Assessment and Lipid-Lowering Therapy Recommendations in Primary Prevention

Abstract

Cardiovascular disease remains the leading cause of morbidity and mortality worldwide, underscoring the importance of effective primary prevention strategies. Current total cardiovascular disease (CVD) risk assessment tools, such as the Systematic Coronary Risk Evaluation 2 (SCORE2) in Europe and the Pooled cohort equations (PCEs) and Predicting Risk of CVD EVENTs (PREVENT) in the USA, aim to identify individuals at high CVD risk and guide clinical decision-making in the primary prevention setting. Statin therapy reduces cardiovascular events and is recommended as the first step for individuals with estimated CVD risk above specific thresholds. Moreover, the presence of risk modifiers, as well as the detection of asymptomatic atherosclerosis, reclassifies low-moderate CVD risk individuals into higher risk categories, contributing to tailored therapeutic decisions in primary prevention. However, differences in the performance of the available CVD risk assessment tools, the recommended thresholds for intervention, and the treatment targets by scientific societies introduce considerable inconsistency to the statin therapy practices. In addition, physicians' inertia and poor patients' adherence contribute to inadequate dyslipidemia control rates. This narrative review examines the available evidence on the current most used CVD risk assessment tools and the respective lipid-lowering recommendations, and highlights the role of targeted screening for asymptomatic atherosclerosis in terms of individualized therapy for primary prevention.

Keywords: PCE; PREVENT; SCORE2; cardiovascular disease; lipid-lowering therapy; primary cardiovascular prevention; risk tools; statin.

Figure 1

Cardiovascular disease risk categories based on the SCORE2, SCORE2-OP, PCE, and PREVENT scores. Footnote to Figure 1: For reasons of comparability, SCORE2 low-moderate, high and very high risk categories corresponded to the low and borderline, intermediate and high PCE/PREVENT risk categories, respectively.

Figure 2

Treatment decisions and LDL-cholesterol targets depending on CVD risk classification according to SCORE2, SCORE2-Diabetes, and SCORE2-OP.

Figure 3

Cardiovascular event rate with statins versus placebo in randomized primary prevention trials involving more than 10,000 participants [34,35,36]. Footnote to Figure 3: Numbers within each column correspond to the achieved mean LDL-cholesterol levels (mg/dL).