From the Guidelines
The Pooled Cohort Equations (PCE) are the recommended tool for 10-year cardiovascular risk assessment, estimating the probability of experiencing a first atherosclerotic cardiovascular disease event within the next 10 years. This risk calculator incorporates several key variables: age, sex, race (Black or non-Black), total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension, diabetes status, and smoking status 1. To use this tool, healthcare providers input these variables into the equation or use an online calculator, with results typically categorized as low risk (<5%), borderline risk (5-7.4%), intermediate risk (7.5-19.9%), or high risk (≥20%) 1.
Key Variables
- Age
- Sex
- Race (Black or non-Black)
- Total cholesterol
- HDL cholesterol
- Systolic blood pressure
- Treatment for hypertension
- Diabetes status
- Smoking status Risk assessment guides preventive interventions, particularly statin therapy decisions, with treatment generally recommended for those with ≥7.5% 10-year risk 1. The PCE was developed from multiple large cohort studies and provides more accurate risk prediction than previous models by accounting for race and sex differences in cardiovascular risk factors. For optimal patient care, risk calculation should be performed every 4-6 years in adults aged 40-75 without known cardiovascular disease 1.
Recommendations for Statin Therapy
- 10-year risk of 7.5% or higher does not result in automatic statin assignment, but rather consideration of additional risk-enhancing factors 1
- Presence of risk-enhancing factors in patients at intermediate risk favors statin therapy
- Coronary artery calcium (CAC) scoring may be considered to improve risk stratification in adults with uncertain risk status 1
From the Research
Equation for 10-Year Cardiac Risk Assessment
The equation for 10-year cardiac risk assessment is typically based on the Pooled Cohort Equations (PCEs) or other risk scores such as the Framingham Risk Score (FRS) or the Systematic Coronary Risk Evaluation (SCORE).
- The PCEs estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) events, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke 2, 3.
- The PCEs take into account various risk factors, including age, sex, race, total cholesterol, high-density lipoprotein (HDL) cholesterol, systolic blood pressure, diabetes status, and smoking status 2, 3.
- Other risk scores, such as the FRS and SCORE, also estimate the 10-year risk of ASCVD events, but may use slightly different risk factors or weighting schemes 3.
- The choice of risk score may depend on the specific population being assessed, as well as the clinical context and available data 2, 3.
Performance of Risk Scores
The performance of risk scores can be evaluated using various metrics, including discrimination (e.g., area under the curve (AUC) or Harrell C statistic) and calibration (e.g., mean calibration or calibration slope) 2, 3, 4.
- Studies have shown that the PCEs have acceptable discrimination and calibration for estimating 10-year ASCVD risk in various populations, including those with different body mass index (BMI) categories 2, 4.
- However, the PCEs may overestimate ASCVD risk in certain populations, such as those with moderate or severe obesity 4.
- Other risk scores, such as the FRS and SCORE, may also have acceptable performance, but may not be as well-calibrated as the PCEs in certain populations 3.
Clinical Practice and Recommendations
Accurate ASCVD risk assessment is crucial for the appropriate targeting of preventive therapies to reduce ASCVD risk 5, 6.
- Clinicians should use global risk scores, such as the PCEs, to estimate 10-year ASCVD risk, and consider additional risk-enhancing factors, such as family history, social determinants of health, and novel biomarkers 5.
- Treatment should aim to reduce ASCVD risk to the lowest possible level, using a combination of lifestyle modifications and pharmacologic therapies, and should begin earlier in life 6.
- Regular screening for subclinical atherosclerosis, such as coronary calcium screening, can further inform treatment decisions 5.