How to predict the risk of Cardiovascular Disease (CVD) events?

Predicting Risk of Cardiovascular Disease Events

The most effective approach to predict cardiovascular disease (CVD) risk is to use the ACC/AHA Pooled Cohort Equations, which calculate 10-year risk of atherosclerotic cardiovascular disease based on age, sex, total cholesterol, HDL cholesterol, systolic blood pressure, antihypertensive treatment, diabetes status, and smoking status. 1, 2

Primary Risk Assessment Tools

• The ACC/AHA Pooled Cohort Equations are the recommended standard in the United States for calculating 10-year risk of atherosclerotic cardiovascular disease (ASCVD) events, including heart attack, stroke, and cardiovascular death 1, 2
• In Europe, the Systematic Coronary Risk Evaluation (SCORE) system is recommended for estimating 10-year CVD mortality risk using age, sex, total cholesterol, HDL cholesterol, smoking status, and systolic blood pressure 1
• The ACC/AHA risk calculator is the only US-based CVD risk prediction tool with published external validation studies in US populations 2

Risk Categories and Treatment Implications

• High-risk category: Patients with existing CVD, 10-year ASCVD risk ≥10%, diabetes mellitus, chronic kidney disease stages 3-5, or grade 3 hypertension 1
• Intermediate-risk category: Patients with 10-year ASCVD risk between 7.5% and 10% 1, 2
• Lower-risk category: Patients with 10-year ASCVD risk <7.5% 1

Risk-Enhancing Factors to Consider

• Family history of premature ASCVD 1, 2
• LDL-C ≥160 mg/dL or HDL-C <40 mg/dL 1, 2
• Metabolic syndrome, chronic kidney disease 1, 2
• History of preeclampsia or premature menopause in women 2
• Chronic inflammatory disorders 2
• High-risk ethnicity (e.g., South Asian ancestry) 2
• Elevated triglycerides (>175 mg/dL) 2
• Elevated high-sensitivity C-reactive protein (≥2 mg/L) 1, 2
• Elevated lipoprotein(a) (>50 mg/dL) 2
• Reduced ankle-brachial index (<0.9) 2
• Heart rate >80 beats/min 1

Refinement Tools for Risk Assessment

• Coronary Artery Calcium (CAC) scoring is recommended to refine risk assessment for adults with intermediate risk (7.5-19.9%) who are uncertain about statin benefit 2
• A CAC score of 0 Agatston units suggests statin therapy may be withheld or delayed 2
• A CAC score of 1-99 units favors statin therapy 2
• A CAC score ≥100 Agatston units or ≥75th percentile strongly indicates statin therapy 2

Special Populations

• For patients with diabetes, diabetes-specific tools like the ADVANCE-risk engine may provide more accurate estimations by incorporating factors such as hemoglobin A1c, albuminuria, retinopathy, atrial fibrillation, and diabetes duration 1
• For patients with existing vascular disease, the SMART risk score accounts for number of vascular disease locations, kidney function, high-sensitivity CRP, and years since first diagnosis 1
• For elderly patients (>75-80 years), specialized tools that account for competing non-vascular mortality should be used, such as the JBS3 risk calculator or elderly risk algorithms available in the U-Prevent tool 1

Important Limitations and Pitfalls

• The Pooled Cohort Equations may overestimate risk in contemporary cohorts, especially at the lower end of the risk spectrum 2
• Risk calculation is heavily influenced by age, with 41% of men and 27% of women aged 60-69 years having a calculated risk ≥10% even without other risk factors 2
• The recently developed PREVENT equations (2023) tend to estimate lower 10-year ASCVD risk compared to the Pooled Cohort Equations, which could reduce the number of adults meeting criteria for primary prevention statin therapy 3
• Risk prediction tools may be less accurate for patients with extreme risk factor levels or life-limiting comorbidities 1
• Geographic differences in lifestyle, environmental factors, and healthcare quality may affect the accuracy of risk predictions, necessitating recalibration for specific populations 1

Implementation Algorithm

1. Calculate 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations for adults aged 40-75 1, 2
2. Categorize patients by risk level (high: ≥10%, intermediate: 7.5-10%, low: <7.5%) 1
3. Consider risk-enhancing factors for borderline or intermediate-risk patients 2
4. Consider CAC scoring for intermediate-risk patients (7.5-19.9%) uncertain about statin benefit 2
5. Update risk assessment every 4-6 years to improve short- and long-term risk prediction 1
6. For younger adults (20-39 years), consider lifetime risk assessment 1

By systematically applying these evidence-based risk assessment tools and considering additional risk factors, clinicians can more accurately predict CVD risk and guide appropriate preventive interventions to reduce morbidity and mortality.