What Atherosclerotic Cardiovascular Disease (ASCVD) risk factors should be considered when starting?

From the Guidelines

When starting Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment, consideration should be given to major higher-risk categories, including patients with severe hypercholesterolemia (LDL-C levels ≥190 mg/dL), adults with diabetes, and adults 40 to 75 years of age, as well as "risk enhancers" such as family history of premature ASCVD, primary hypercholesterolemia, metabolic syndrome, and chronic kidney disease, as outlined in the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1.

Key ASCVD Risk Factors

• Severe hypercholesterolemia (LDL-C levels ≥190 mg/dL)
• Diabetes
• Age 40 to 75 years
• Family history of premature ASCVD
• Primary hypercholesterolemia (LDL-C 160–189 mg/dL)
• Metabolic syndrome
• Chronic kidney disease (eGFR 15–59 mL/min/1.73 m2 with or without albuminuria)

Assessment and Treatment

The 10-year ASCVD risk should guide therapeutic considerations, with high-intensity statin therapy recommended for those with established ASCVD, LDL cholesterol ≥190 mg/dL, or diabetes with high risk 1. For adults with diabetes, a moderate-intensity statin should be started, with consideration of high-intensity statin as additional risk factors accrue. Regular monitoring of lipid levels and liver function tests is necessary, with follow-up 4-12 weeks after starting therapy. The use of "risk enhancers" can help guide the decision to initiate or intensify statin therapy, particularly in cases where the 10-year ASCVD risk is uncertain 1.

From the FDA Drug Label

Additionally, all patients had at least 3 of the following cardiovascular risk factors: male gender (81%), age >55 years (85%), smoking (33%), diabetes (24%), history of CHD in a first-degree relative (26%), TC:HDL >6 (14%), peripheral vascular disease (5%), left ventricular hypertrophy (14%), prior cerebrovascular event (10%), specific ECG abnormality (14%), proteinuria/albuminuria (62%) In addition to diabetes, subjects had 1 or more of the following risk factors: current smoking (23%), hypertension (80%), retinopathy (30%), or microalbuminuria (9%) or macroalbuminuria (3%).

The Atherosclerotic Cardiovascular Disease (ASCVD) risk factors that should be considered when starting atorvastatin include:

• Male gender
• Age >55 years
• Smoking
• Diabetes
• History of CHD in a first-degree relative
• TC:HDL >6
• Peripheral vascular disease
• Left ventricular hypertrophy
• Prior cerebrovascular event
• Specific ECG abnormality
• Proteinuria/albuminuria
• Hypertension
• Retinopathy
• Microalbuminuria or macroalbuminuria 2 2

From the Research

Atherosclerotic Cardiovascular Disease (ASCVD) Risk Factors

When starting to assess ASCVD risk, several factors should be considered, including:

• Traditional 10-year risk calculator 3
• Risk-enhancing factors, such as lipoprotein(a) 3 and subclinical atherosclerosis testing, particularly coronary artery calcium (CAC) testing 3, 4, 5
• Population-appropriate risk equation, such as the ASCVD pooled cohort equations recommended by the American College of Cardiology/American Heart Association (ACC/AHA) 4
• 10-year ASCVD risk estimate, with a risk of 20% or higher considered high, and 7.5% to less than 20% considered intermediate 4
• CVD risk enhancers, such as coronary artery calcium assessed by computed tomography 4, 5
• Healthy lifestyle modifications to reduce CVD risk, as defined by the AHA's Life's Simple 7, including no tobacco use, ideal blood pressure, blood glucose, and cholesterol levels, adequate physical activity, weight management, and healthy diet 4
• Additional factors, such as female-specific risk enhancers, social determinants of health, and considerations for high-risk ethnic groups 5
• Presence of pre-existing ASCVD, with variable risk affected by the number of major ASCVD events, recent recurrent events, and other major risk factors or high-risk conditions 5
• Use of statins and other pharmacologic therapies, such as ezetimibe and PCSK9 inhibitors, to reduce ASCVD risk 6
• Diabetes status, with diabetes mellitus (DM) being a significant risk factor for ASCVD, and factors such as age, systolic blood pressure, total cholesterol level, HDL-C levels, and duration of diabetes being associated with ASCVD risk in DM patients 7

ASCVD Risk Assessment Tools

The following tools can be used to assess ASCVD risk:

• ASCVD Risk Calculator, which requires data such as age, sex, race, total cholesterol, HDL-C, systolic blood pressure, diastolic blood pressure, history of diabetes, history of hypertension treatment, smoking history, and use of statins for anti-hyperlipidemia 7
• Coronary artery calcium (CAC) testing, which can help inform the clinician-patient discussion and guide treatment decisions 3, 4, 5
• Subclinical atherosclerosis testing, which can help identify individuals at high risk of ASCVD events 3, 5