What is the preferred risk assessment tool for estimating 10-year cardiovascular risk, ASCVD (Atherosclerotic Cardiovascular Disease) risk calculator or PREVENT score?

ASCVD Risk Calculator vs PREVENT Score: Which is Preferred for Cardiovascular Risk Assessment?

The American College of Cardiology/American Heart Association ASCVD risk calculator (Risk Estimator Plus) remains the currently recommended tool for estimating 10-year cardiovascular risk in clinical practice, though the newer PREVENT equations may offer improved risk estimation in the future.

Current Guideline Recommendations

The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines endorse the ASCVD risk calculator (also called the Pooled Cohort Equations or PCE) as the standard tool for cardiovascular risk assessment:

• The ACC/AHA ASCVD risk calculator is specifically recommended in the 2020 American Diabetes Association Standards of Medical Care to estimate 10-year ASCVD risk 1
• It's available online at tools.acc.org/ASCVD-Risk-Estimator-Plus and is designed to guide therapy decisions based on risk stratification 1
• The calculator includes diabetes as a risk factor but doesn't account for diabetes duration or complications like albuminuria 1

Understanding the ASCVD Risk Calculator

The ASCVD risk calculator:

• Estimates 10-year risk of first "hard" ASCVD events (nonfatal MI, fatal coronary heart disease, nonfatal or fatal stroke) 2
• Is designed for adults aged 40-79 years without existing ASCVD 1
• Provides risk estimates specific to African Americans, which is an advantage over older calculators 1
• Categorizes 10-year risk as:
  • Low risk (<5%)
  • Borderline risk (5% to <7.5%)
  • Intermediate risk (7.5% to <20%)
  • High risk (≥20%) 1

The PREVENT Equations: Emerging Alternative

The PREVENT (Predicting Risk of Cardiovascular Disease Events) equations were developed in 2023 as an update to the 2013 Pooled Cohort Equations:

• They were derived from more contemporary cohorts 3
• Notable changes include:
  • Removal of race as a variable
  • Addition of kidney function and statin use as variables 3
• Recent research shows PREVENT equations generally estimate lower 10-year ASCVD risk compared to PCE:
  • Mean estimated risk of 4.3% vs 8.0% with PCE
  • Particularly large differences for Black adults (5.1% vs 10.9%) and older adults aged 70-75 (10.2% vs 22.8%) 3
• Using PREVENT could reduce the number of adults meeting criteria for primary prevention statin therapy by approximately 17.3 million 3

Clinical Application and Decision-Making

When using these risk calculators in practice:

1. For general population: Use the ACC/AHA ASCVD risk calculator as currently recommended by guidelines
2. Risk assessment frequency:
   • For low-risk individuals (<7.5%), repeat risk assessment every 4-6 years 1
   • For higher-risk individuals, assess cardiovascular risk factors annually 1
3. Risk-based treatment thresholds:
   • For patients with diabetes and hypertension with ASCVD risk ≥15%: target BP <130/80 mmHg 1
   • For patients with diabetes and hypertension with ASCVD risk <15%: target BP <140/90 mmHg 1

Limitations and Considerations

Both risk calculators have important limitations to consider:

• ASCVD Risk Calculator:

  • May overestimate risk in some populations 2
  • Does not account for all risk factors (e.g., chronic kidney disease) 2
  • Limited validation in non-US populations 4

• PREVENT Equations:

  • Newer with less extensive clinical validation
  • May result in fewer patients receiving preventive therapies 3
  • Not yet incorporated into major clinical guidelines

Conclusion

While the PREVENT equations represent a promising advancement in cardiovascular risk assessment with potentially improved accuracy, the ACC/AHA ASCVD risk calculator remains the guideline-recommended tool for clinical practice at this time. Clinicians should be aware that the PREVENT equations generally estimate lower risk and may change treatment recommendations for many patients if adopted in future guidelines.