How to manage patients at risk of atherosclerotic cardiovascular disease (ASCVD) using the ASCVD calculator?

Managing Patients at Risk of Atherosclerotic Cardiovascular Disease Using the ASCVD Calculator

The American College of Cardiology/American Heart Association ASCVD risk calculator is the recommended tool for estimating 10-year risk of cardiovascular events and guiding preventive therapy decisions in patients at risk for atherosclerotic cardiovascular disease. 1

Risk Assessment Process

Step 1: Calculate 10-Year ASCVD Risk

• Use the ACC/AHA ASCVD risk calculator (also called Pooled Cohort Equations or Risk Estimator Plus) available at tools.acc.org/ASCVD-Risk-Estimator-Plus 1
• Applicable for adults aged 40-79 years without existing ASCVD 2
• The calculator provides race- and sex-specific estimates of 10-year risk of first "hard" ASCVD event (nonfatal myocardial infarction, CHD death, fatal or nonfatal stroke) 1
• For adults 20-59 years with low short-term risk, also assess lifetime or 30-year risk 1, 2

Step 2: Risk Stratification

Categorize patients based on their 10-year ASCVD risk:

• Low risk: <5%
• Borderline risk: 5% to <7.5%
• Intermediate risk: 7.5% to <20%
• High risk: ≥20% 1, 2

Step 3: Risk Enhancement Factors

Consider optional variables that may refine risk assessment:

• Family history of premature ASCVD
• High-sensitivity CRP >2 mg/L
• Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity
• Ankle-brachial index 1
• Presence of albuminuria 1
• Chronic kidney disease 2

Management Based on Risk Assessment

1. Statin Therapy

The 2013 ACC/AHA guidelines identify four groups for statin therapy based on evidence:

• Individuals with clinical ASCVD
• Individuals with primary LDL-C ≥190 mg/dL
• Individuals 40-75 years with diabetes and LDL-C 70-189 mg/dL
• Individuals 40-75 years without clinical ASCVD or diabetes with LDL-C 70-189 mg/dL and estimated 10-year ASCVD risk ≥7.5% 1

For each risk group, recommend appropriate statin intensity (moderate or high) rather than dose titration to achieve specific LDL-C targets 1

2. Blood Pressure Management

Tailor blood pressure targets based on ASCVD risk:

• For patients with diabetes and hypertension at higher cardiovascular risk (existing ASCVD or 10-year ASCVD risk ≥15%): target BP <130/80 mmHg 1
• For patients with diabetes and hypertension at lower risk (10-year ASCVD risk <15%): target BP <140/90 mmHg 1

3. Risk Reassessment Frequency

• For low-risk individuals (<7.5%): repeat risk assessment every 4-6 years
• For higher-risk individuals: assess cardiovascular risk factors annually 2

Special Considerations

Coronary Artery Calcium (CAC) Scoring

• CAC scoring can help refine risk assessment, particularly in intermediate-risk patients 1
• CAC = 0 may favor deferring statin therapy in select patients
• CAC >0 or ≥100 generally favors statin therapy 1

Diabetes-Specific Considerations

• The ASCVD calculator includes diabetes as a risk factor but does not account for diabetes duration or complications 1
• For patients with diabetes, systematic assessment of cardiovascular risk factors should occur at least annually 1

Potential Pitfalls and Limitations

1. Risk Calculator Limitations:

   • May overestimate risk in some populations 3
   • Does not account for all risk factors (e.g., chronic kidney disease) 2
   • Does not consider duration of diabetes or presence of diabetes complications 1

2. New Developments:

   • The PREVENT equations (2023) may provide more accurate risk estimates than the PCEs but could result in fewer patients receiving preventive therapies 4
   • The PREVENT equations removed race and added variables for kidney function and statin use 4

3. Age Influence:

   • Age continues to be a major determinant of 10-year ASCVD risk 5
   • For younger patients with low short-term but high lifetime risk, consider lifetime risk assessment 2

By systematically applying the ASCVD risk calculator and following evidence-based management strategies, clinicians can effectively identify and treat patients at risk for atherosclerotic cardiovascular disease, ultimately reducing morbidity and mortality.