From the Guidelines
Yes, you should check "yes" on the ASCVD risk score if the patient has a prior history of ASCVD, as this automatically categorizes them as high-risk and eligible for secondary prevention strategies. According to the 2019 guidelines on the management of blood cholesterol by the American College of Cardiology/American Heart Association task force on clinical practice guidelines 1, prior ASCVD events such as myocardial infarction, ischemic stroke, or symptomatic peripheral arterial disease are considered major ASCVD events that significantly increase the risk of future ASCVD events. Key points to consider in assessing ASCVD risk include:
- Major ASCVD events: recent acute coronary syndrome, history of myocardial infarction, history of ischemic stroke, symptomatic peripheral arterial disease
- High-risk conditions: age ≥65 years, heterozygous familial hypercholesterolemia, history of prior coronary artery bypass surgery or percutaneous coronary intervention, diabetes mellitus, hypertension, chronic kidney disease (eGFR 15-59 mL/min/1.73 m2), current smoking, persistently elevated LDL-C despite maximally tolerated statin therapy and ezetimibe Patients with established ASCVD are at a higher risk of recurrent events and typically require more aggressive management, including high-intensity statin therapy, antiplatelet therapy, blood pressure control, and lifestyle modifications, as outlined in the guidelines 1.
From the Research
ASCVD Risk Score Assessment
- The assessment of atherosclerotic cardiovascular disease (ASCVD) risk is crucial for primary prevention and guiding treatment decisions 2, 3.
- A prior history of ASCVD is a significant factor in determining the risk score, as it indicates a higher risk of future cardiovascular events 2, 4.
- The 2018 AHA/ACC cholesterol guideline recommends a maximally-tolerated statin with add-on lipid-lowering therapy for adults with very-high ASCVD risk to achieve a low-density lipoprotein cholesterol (LDL-C) <70 mg/dL 4.
- Patients with a history of ASCVD are considered high-risk and may require more aggressive treatment, including add-on lipid-lowering therapy 5, 4.
Determining ASCVD Risk Score
- The ASCVD risk score is determined using a traditional 10-year risk calculator, which takes into account factors such as age, sex, cholesterol levels, blood pressure, and smoking status 2, 3.
- Risk-enhancing factors, such as lipoprotein(a) and subclinical atherosclerosis testing, can further refine the risk assessment 3.
- A history of prior ASCVD events is a significant risk-enhancing factor, and patients with such a history should be considered high-risk 2, 4.
Implications for Treatment
- Patients with a history of ASCVD and high ASCVD risk score may require more aggressive treatment, including maximally-tolerated statin therapy and add-on lipid-lowering therapy 5, 4.
- The treatment goal for these patients is to achieve an LDL-C level <70 mg/dL, which can help reduce the risk of future cardiovascular events 4.
- Clinicians should consider the patient's prior history of ASCVD when assessing their risk score and guiding treatment decisions 2, 3.