From the Guidelines
A 70-year-old male former smoker has a 15% ASCVD risk primarily due to his age and smoking history, despite having a normal lipid profile and controlled blood pressure. Age is one of the strongest risk factors for cardiovascular disease, with risk increasing substantially after age 65 1. His history of smoking, even though he has quit, continues to contribute significantly to his cardiovascular risk as smoking damage to blood vessels persists for years after cessation. While his lipid profile (LDL 81, Total Cholesterol 150, HDL 61) is favorable and his blood pressure is well-controlled at 130/80, these positive factors cannot fully counterbalance the impact of age and smoking history. The ASCVD risk calculator weighs these non-modifiable risk factors heavily in its assessment. For this patient, preventive measures might include:
- Daily aspirin (81mg)
- Continued blood pressure management
- Possibly statin therapy despite normal lipids, given his overall risk profile, as the 2013 ACC/AHA guideline recommends statin therapy for individuals with a 10-year risk for ASCVD ≥7.5% 1
- Regular exercise
- Heart-healthy diet
- Continued smoking abstinence The 15% risk score indicates that without intervention, he has a 15% chance of experiencing a cardiovascular event in the next 10 years. Given his age and smoking history, statin therapy is reasonable to consider, despite his normal lipid profile, as it may help reduce his ASCVD risk 1.
From the Research
ASCVD Risk Assessment
The 70-year-old male in question has a 15% ASCVD risk despite having a normal lipid profile (LDL 81, Total Cholesterol 150, HDL 61) and controlled blood pressure (130/80). Several factors contribute to this risk assessment:
- Age: As people get older, their risk of developing ASCVD increases 2
- Former smoker: Although the individual quit smoking over 15 years ago, their history of smoking still contributes to their ASCVD risk 3
- Other potential risk factors: Although not explicitly mentioned, other risk factors such as family history, diabetes, or kidney disease may also contribute to the individual's ASCVD risk
Lipid Profile and ASCVD Risk
The individual's lipid profile is within normal limits, with an LDL of 81, Total Cholesterol of 150, and HDL of 61. However, research suggests that even with normal lipid profiles, individuals can still be at risk for ASCVD 4. The 2018 Cholesterol Management Guidelines recommend risk stratification of secondary prevention patients to identify those at very high-risk of ASCVD events 5.
Risk Assessment Models
The Pooled Cohort Equations (PCE) are commonly used to estimate 5-year ASCVD risk. However, studies have shown that the PCE may overestimate ASCVD risk in certain populations 2. The use of cohort-derived models or other risk assessment tools may provide a more accurate estimate of ASCVD risk.
Management of ASCVD Risk
The management of ASCVD risk involves a combination of lifestyle modifications and pharmacological interventions. Statins are commonly used to reduce LDL-C levels and prevent ASCVD events 6, 5. Other medications, such as ezetimibe and PCSK9 inhibitors, may also be used in certain cases 6, 5. Lifestyle modifications, such as a healthy diet, regular exercise, and smoking cessation, are also essential for reducing ASCVD risk 3.