What is the relationship between cardiovascular risk score and Atherosclerotic Cardiovascular Disease (ASCVD) prevention?

From the Guidelines

The relationship between cardiovascular risk score and Atherosclerotic Cardiovascular Disease (ASCVD) prevention is that a higher risk score indicates a greater need for intensive preventive interventions, including lifestyle modifications and medications, to reduce the risk of ASCVD events and mortality. According to the 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease 1, prevention strategies must include a strong focus on lifestyle optimization, such as improvements in diet, physical activity, and avoidance of tobacco use and exposure to secondhand smoke, to minimize the risk of future ASCVD events. The guideline also emphasizes the importance of a comprehensive patient-centered approach that addresses all aspects of a patient’s lifestyle habits and estimated risk of a future ASCVD event.

Key factors that contribute to the development of ASCVD include age, gender, blood pressure, cholesterol levels, and smoking status, which are incorporated into risk calculators such as the Systematic COronary Risk Evaluation (SCORE) and the ASCVD risk calculator (also known as the Pooled Cohort Equations) 1. These calculators provide a percentage risk that guides clinicians in determining appropriate preventive measures based on established risk thresholds. For example, the 2024 International Lipid Expert Panel (ILEP) recommendations suggest that patients at very high risk of ASCVD, including those with familial hypercholesterolaemia (FH), those with an ASCVD pre-event, and those who have already experienced an acute coronary syndrome (ACS), may benefit from upfront lipid-lowering combination therapy, including statins, ezetimibe, bempedoic acid, and monoclonal antibody/small interference RNA (siRNA) targeting proprotein convertase subtilisin/kexin type 9 (PCSK9) 1.

The choice of prevention strategies should be based on the individual's risk score, with those at higher risk requiring more intensive interventions. For instance, patients with a high risk score may require medications like statins (such as atorvastatin 10-80mg daily or rosuvastatin 5-40mg daily), antihypertensives, or aspirin (usually 81mg daily) in addition to lifestyle modifications. The goal of these interventions is to reduce the risk of ASCVD events and mortality, and to improve overall quality of life. As emphasized in the 2024 ILEP recommendations, achieving treatment targets is crucial, and higher-intensity lipid-lowering therapy results in fewer ASCVD events than less-intensive treatment 1.

Some of the key points to consider when using risk scores to guide ASCVD prevention include:

• The importance of lifestyle optimization, including diet, physical activity, and avoidance of tobacco use and exposure to secondhand smoke
• The use of risk calculators, such as SCORE and the ASCVD risk calculator, to estimate an individual's risk of developing ASCVD
• The need for intensive preventive interventions, including medications, for individuals at high risk of ASCVD
• The importance of achieving treatment targets, including lipid-lowering therapy, to reduce the risk of ASCVD events and mortality
• The consideration of new agents, such as bempedoic acid and monoclonal antibody/small interference RNA (siRNA) targeting PCSK9, for patients at very high risk of ASCVD.

From the FDA Drug Label

In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), the effect of atorvastatin calcium on fatal and non-fatal coronary heart disease was assessed in 10,305 patients with hypertension, 40 to 80 years of age (mean of 63 years; 19% female; 95% White, 3% Black or African American, 1% South Asian, 1% other), without a previous myocardial infarction and with total cholesterol (TC) levels ≤251 mg/dL 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%) Atorvastatin calcium significantly reduced the rate of coronary events [either fatal coronary heart disease (46 events in the placebo group vs. 40 events in the atorvastatin calcium group) or non-fatal MI (108 events in the placebo group vs 60 events in the atorvastatin calcium group)] with a relative risk reduction of 36% [(based on incidences of 1.9% for atorvastatin calcium vs. 3% for placebo), p=0. 0005

The relationship between cardiovascular risk score and Atherosclerotic Cardiovascular Disease (ASCVD) prevention is that reducing cardiovascular risk factors with atorvastatin calcium can significantly decrease the rate of coronary events, including fatal coronary heart disease and non-fatal myocardial infarction.

• Key factors that contribute to the cardiovascular risk score 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 The use of atorvastatin calcium can help reduce the risk of ASCVD in patients with multiple cardiovascular risk factors, as seen in the ASCOT trial 2.

From the Research

Relationship Between Cardiovascular Risk Score and Atherosclerotic Cardiovascular Disease (ASCVD) Prevention

The relationship between cardiovascular risk score and ASCVD prevention is crucial for targeted use of aggressive therapies in those most likely to benefit, while guiding a conservative approach in those who are low risk 3, 4.

• ASCVD Risk Assessment: ASCVD risk assessment begins with the use of a traditional 10-year risk calculator, with further refinement through the consideration of risk-enhancing factors and subclinical atherosclerosis testing 4.
• Risk Scores: Risk scores, including the ASCVD pooled cohort equation (PCE), the multiethnic study of atherosclerosis (MESA) risk equation, and the coronary artery calcium score (CACS), can be used to predict the need for revascularization and incident major adverse coronary events (MACE) in symptomatic patients 5.
• Extreme ASCVD Risk: Extreme ASCVD risk can be defined as a 30% or greater 10-year ASCVD risk, and is associated with greater morbidity and mortality 6.
• Importance of Accurate Risk Assessment: Accurate ASCVD risk assessment is crucial for the appropriate targeting of preventive therapies to reduce ASCVD risk, and for identifying those at extreme risk who require aggressive primary prevention 3, 6.
• Role of Coronary Calcium Screening: Coronary calcium screening can be used to further inform treatment decisions and predict ASCVD risk, especially in those at borderline or intermediate risk 3, 7, 5.